Davita Sherman Dialysis Center

“CFC-PHYSICAL ENVIRONMENT CFR(s): 494.60 This Condition is not met as evidenced by: 30377 Based on observation, review of policy and procedures, and staff interview the facility failed to ensure that all equipment, including dialysis machines are maintained and operated in accordance with the facilities policy and procedures and or manufacturer’s recommendations. The facility failed to ensure that a staff member not bypass safety alarms on the dialysis machine at time of treatment termination. This deficient practice has the likelihood to result in serious injury and harm, serious impairment, and or risk of death to patients at this ESRD facility. The findings were: (Cross Refer to Tag V0403)”

“CFC-PATIENT ASSESSMENT CFR(s): 494.80 This Condition is not met as evidenced by: 30377 Based on review of medical records and staff interview, the Interdisciplinary Team failed to ensure that patient #2’s current health status and medical conditions were evaluated and addressed, citing 1 of 4 patients (Patient #2). The Registered Nurse, the Nurse Practitioner, and the Attending Physician did not address Patient #2’s persistent severe hypertension. Based on review of hemodialysis flow sheets, policy and procedures, and staff interview the facility failed to ensure that direct patient care staff reported significant changes in patient health status while receiving hemodialysis to the charge nurse and or the charge nurse failed to reassess the patient when significant changes occurred during treatment and notify the physician when appropriate. (Cross Refer to Tag V0502 and V0504)”

“CFC-RESPONSIBILITIES OF THE MEDICAL DIRECTOR CFR(s): 494.150 This Condition is not met as evidenced by: 30377 Based on observation, review of policy and procedures, and staff interview the medical director failed to ensure that all equipment, including dialysis machines are maintained and operated in accordance with the facilities policy and procedures and or manufacturer’s recommendations. The facility failed to ensure that a staff member not bypass safety alarms on the dialysis machine at time of treatment termination. This deficient practice has the likelihood to result in serious injury and harm, serious impairment, and or risk of death to patients at this ESRD facility. Based on review of medical records and staff interview, the Interdisciplinary Team failed to ensure that patient #2’s current health status and medical conditions were evaluated and addressed, citing 1 of 4 patients (Patient #2). The Registered Nurse, the Nurse Practitioner, and the Attending Physician did not address Patient #2’s persistent severe hypertension. Based on review of hemodialysis flow sheets, policy and procedures, and staff interview the medical director failed to ensure that direct patient care staff reported significant changes in patient health status while receiving hemodialysis to the charge nurse and or the charge nurse failed to reassess the patient when significant changes occurred during treatment and notify the physician when appropriate. Based on review of medical record, policy and procedures, and staff interview the medical director failed to ensure that the attending physician record progress notes as soon as possible after its occurrence to provide other interdisciplinary team members with an up-to-date picture of the status of the patient. (Cross Refer to Tag V0403, V0502, V0504 and V0729)”

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 30377 Based on observation and interview, the facility failed to monitor and maintain a sanitary environment to minimize the transmission of infectious agents within the dialysis center. These findings have the likelihood to cause harm by increasing the risk of infection to all patients receiving care at the dialysis facility. Findings Include: During a tour of the facility on 06/02/25 at 4:35 PM the surveyor observed the following infection control issues: IN-CENTER TREATMENT AREA: Multiple supply cabinet drawers observed with dust buildup. Computer key pads observed with dust buildup Observed in isolation room on the countertop a black basket that contained a stethoscope, calculator and can of WD-40. This basket was stored next to a white basket that contained unopened dialyzers, blue pads and open box of large gloves. Three of three dialysis chairs designated as “clean” were inspected with the following observed: Three of the three chairs had grim build-up on the metal aspect of the chair frame. Three of the three chairs had reddish-brown build up that appeared to be rust on the metal aspect of the chair frame. One of three chairs observed had a dry reddish brown drip that appeared to be dried blood on the inside seat cushion. An interview with Staff #1 on 06/20/25 at 4:50 PM confirmed the infection contro issues found in the in-center treatment area”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 30377 Based on observation, review of policy and procedures, and staff interview the facility failed to ensure that all equipment, including dialysis machines are maintained and operated in accordance with the facilities policy and procedures and or manufacturer’s recommendations. The facility failed to ensure that a staff member not bypass safety alarms on the dialysis machine at time of treatment termination. This deficient practice has the likelihood to result in serious injury and harm, serious impairment, and or risk of death to patients at this ESRD facility. The findings were: Based on observation of the dialysis treatment floor on 06/04/2025 the following was observed: At 2:14 PM Patient care technician staff #4 was observed in the process of terminating a dialysis treatment at station 24. The patient care technician was observed bypassing the dialysis machine alarm by pressing down on the venous chamber lever during blood return which could potentially expose the patient to air and or blood clots. The surveyor requested that a member of the administrative team address the staff member. At 2:19 PM while communicating my findings to the administrator the patient care technician was observed at station 22 initiating termination of a second dialysis patient. The patient care technician was once again observed bypassing the dialysis machine alarm by pressing down on the venous chamber lever during blood return. Interview conducted with staff member #1 and staff member #3 on 06/04/25 at 2:19 PM at time of occurrence confirmed that they witnessed staff member #4 by passing the dialysis machine safety alarm by pressing down the venous chamber lever during rinse back. Staff member #1 stated this was not the normal practice and that the staff member’s actions would be addressed immediately.”

“PA-ASSESS CURRENT HEALTH STATUS/COMORBIDS CFR(s): 494.80(a)(1) The patient’s comprehensive assessment must include, but is not limited to, the following: (1) Evaluation of current health status and medical condition, including co-morbid conditions. This Standard is not met as evidenced by: 30377 Based on review of medical records and staff interview, the Interdisciplinary Team failed to ensure that patient #2’s current health status and medical conditions were evaluated and addressed, citing 1 of 4 patients (Patient #2). The Registered Nurse, the Nurse Practitioner, and the Attending Physician did not address Patient #2’s persistent severe hypertension. Findings included: Patient #2 Review of Fluid and Blood Pressure Management Report dated 04/02/25 to 06/02/25 on 06/03/25 and 06/04/25 in the facility conference room revealed persistent severe hypertension for patient #2.. The following was observed: 04/18/25 Pre Blood Pressure recorded as 187/88 with Post Blood Pressure recorded as 191/80. 04/21/25 Pre Blood Pressure recorded as 191/79 with Post Blood Pressure recorded as 202/77. 04/25/25 Pre Blood Pressure recorded as 172/80 with Post Blood Pressure recorded as 198/88. 04/28/25 Pre Blood Pressure recorded as 187/81 with Post Blood Pressure recorded as 206/88. 05/02/25 Pre Blood Pressure recorded as 197/87 with Post Blood Pressure recorded as 209/95. 05/05/25 Pre Blood Pressure recorded as 202/88 with Post Blood Pressure recorded as 190/83. 05/07/25 Pre Blood Pressure recorded as 200/89 with Post Blood Pressure recorded as 213/96. 05/16/25 Pre Blood Pressure recorded as 182/80 with Post Blood Pressure recorded as 205/90. 05/23/25 Pre Blood Pressure recorded as 195/91 with Post Blood Pressure recorded as 202/87. 05/26/25 Pre Blood Pressure recorded as 210/93 with Post Blood Pressure recorded as 226/102. 05/30/25 Pre Blood Pressure recorded as 221/96 with Post Blood Pressure recorded as 236/108. Review of the patient # 2’s 90-day care plan dated 05/09/25 on 06/03/25 and 06/04/25 in the facility conference room revealed that the patient’s ongoing severe hypertension was not addressed. The following documentation was observed: Category: Fluid/BP: Blood Pressure within range. Is post-dialysis blood pressure elevated? Answer was No. Review of physician and nurse practitioner’s progress notes on 06/03/25 and 06/04/25 in the facility conference room for patient #2 revealed that the patient’s persistent severe hypertension was not acknowledged or addressed. Physician Progress note dated 05/21/25 revealed that the physician did not acknowledge or address the persistent severe hypertension. The following documentation was observed: BP/Heart Rate: Current and last 2 Vitals provided for practitioner to review 06/02/25 Pre BP Sitting 190/81 with Pre BP Standing 196/81 05/30/25 Pre BP Sitting 221/96 with Pre BP Standing 218/104 Post BP Sitting 236/108 with Post BP Standing 227/112 05/26/25 Pre BP Sitting 210/93 with Pre BP Standing 223/98 Post BP Sitting 226/102 with Post BP Standing 215/96 Assessment and Plan: Fluid/BP: Reviewed, no comments entered BP Reviewed: Clinical assessment at goal unless otherwise documented. Blood Pressure: Blank Fluid/BP Comments: No comments added Nurse Practitioner Progress note dated 05/30/25 revealed that the nurse practitioner did not acknowledge or address the persistent severe hypertension. The following documentation was observed: BP/Heart Rate: Current and last 2 Vitals provided for practitioner to review 05/30/25 Pre BP Sitting 221/96 with Pre BP Standing 218/104 05/26/25 Pre BP Sitting 210/93 with Pre BP Standing 223/98 Post BP Sitting 226/102 with Post BP Standing 215/96 05/23/25 Pre BP Sitting 195/91 with Pre BP Standing 211/99 Post BP Sitting 202/87 with Post BP Standing 188/93 Assessment and Plan: Fluid/BP: Reviewed, no comments entered BP Reviewed: Clinical assessment at goal unless otherwise documented. Blood Pressure: Blank Fluid/BP Comments: No comments added Interview conducted with staff member #3 on 06/04/25 at 3:30 PM following her own review of the findings revealed she was unaware of the discrepancies found. Staff member #3 confirmed that the ongoing severe hypertension was not addressed in the patient’s physician progress notes, current comprehensive assessment and or care plan. At the time of the interview no evidence of compliance was presented where noncompliance was found”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 30377 Based on review of hemodialysis flow sheets, policy and procedures, and staff interview the facility failed to ensure that direct patient care staff reported significant changes in patient health status while receiving hemodialysis to the charge nurse and or the charge nurse failed to reassess the patient when significant changes occurred during treatment and notify the physician when appropriate. The findings included: Review of hemodialysis flow sheets on 06/03/25 and 06/04/25 in the facility conference room revealed an example of the following discrepancies: Patient #1 Flow Sheet dated 05/21/25 Dialysis Prescription Treatment Time: 4 hours Pre Treatment Vitals: Time: 09:43 AM Blood Pressure: 112/52 Heart Rate: 78 Post Treatment Vitals: Time: 1:40 PM Blood Pressure: 132/33 Heart Rate: 92 Treatment Initiated Time: 10:02 AM Blood Pressure: 133/52 Heartache 71. 10:29 AM Blood Pressure: 107/45 Heart Rate 39 with direct patient care technician documenting “Patient appears to be tolerating treatment well at this time. Patient awake: alert: and states no-complaints at this time.” There was no documentation presented at time of review that the direct patient care technician reported the severe bradycardia to the registered nurse and there was no documentation provided that the registered nurse addressed the severe bradycardia. 10:59 AM Blood Pressure: 105/48 Heart Rate 39 with direct patient care technician documenting “Patient appears to be tolerating treatment well at this time. Patient awake: alert and states no complaints at this time. There was no documentation presented at time of review that the direct patient care technician reported the severe bradycardia to the registered nurse and there was no documentation provided that the registered nurse addressed the severe bradycardia. 11:31 AM Blood Pressure: 78/29 Heart Rate 40 with direct patient care technician documenting “cuff adjusted: rechecking BP” There was no documentation presented at time of review that the direct patient care technician reported the severe hypotension and bradycardia to the registered nurse and there was no documentation provided that the registered nurse reassessed / reevaluated the severe hypotension and bradycardia. 11:44 AM Blood Pressure: 103/27 Heart Rate 54 with direct patient care technician documenting “Patient diastolic blood pressure low: Patient alert: no voiced c/o discomforts: CN notified: Continue to monitor” 12:00 PM Blood Pressure: 137/91 Heart Rate 72 with direct patient care technician documenting “Patient blood pressure improved: UF back on: CN notified: Continue to monitor. 12:30 PM Blood Pressure: 86/34 Heart Rate 47 with the Registered Nurse documenting “Blood Pressure down: UF off “There was no documentation provided at time of review that the registered nurse reassessed / reevaluated the severe bradycardia. 12:59 PM Blood Pressure: 100/38 Heart Rate 47 with direct patient care technician documenting “treatment terminated: 300ml normal saline rinseback: Patient sites clamped one at a time.” Treatment Ended Time: 12:59 PM Blood Pressure: 100/38 Heart Rate 47. Close Treatment Reason: Patient Choice (AMA, feels unwell/cramping, patient behavioral issue) Discharge Status: discharge/Transferred to SNF/Rehab/Other Institution Post Treatment Assessment: There was no documentation presented at time of review that the registered nurse addressed the severe bradycardia, the severe hypotension of 78/20 and the patient signing off the treatment early due to feeling unwell and cramping. Patient #2 Flow Sheet dated 05/30/25 Dialysis Prescription Treatment Time: 3 hours 30 minutes Pre Treatment Vitals: Time: 2:50 PM Blood Pressure: 221/96 Heart Rate: 84 Post Treatment Vitals: Time: 6:38 PM Blood Pressure: 236/108 Heart Rate: 71 Treatment Initiated Time: 3:05 PM Blood Pressure: 189/93 Heart Rate 79. Treatment initiated by a registered nurse via a dialysis catheter. The registered nurse documented the following “ .....CVC accessed without difficulty .....patient voices no complaint..” 5:01 PM Blood Pressure: 217/98 Heart Rate 77 5:02 PM Blood Pressure: 202/98 Heart Rate 77 with the registered nurse documenting “PCT did not chart on patient” There was no documentation presented at time of review that the registered nurse addressed the severe hypertension. There was no documentation presented at time of review that the patient was offered and or refused the PRN Clonidine for treatment of the severe hypertension. 5:31 PM Blood Pressure: 211/94 Heart Rate 72 with direct patient care technician documenting “rechecking BP” There was no documentation presented at time of review that the direct patient care technician reported the severe hypertension to the registered nurse and there was no documentation provided that the registered nurse reassessed / reevaluated the severe hypertension. There was no documentation presented at time of review that the patient was offered and or refused the PRN Clonidine for treatment of the severe hypertension. 5:58 PM Blood Pressure: 222/96 Heart Rate 72 with direct patient care technician documenting “BP trending up: patient put feet down: Continue to monitor” There was no documentation presented at time of review that the direct patient care technician reported the severe hypertension to the registered nurse and there was no documentation provided that the registered nurse reassessed / reevaluated the severe hypertension. There was no documentation presented at time of review that the patient was offered and or refused the PRN Clonidine for treatment of the severe hypertension. 6:01 PM Blood Pressure: 223/99 Heart Rate 71 with direct patient care technician documenting “rechecking BP” There was no documentation presented that the direct patient care technician reported the severe hypertension to the registered nurse and there was no documentation provided that the registered nurse reassessed / reevaluated the severe hypertension. There was no documentation presented at time of review that the patient was offered and or refused the PRN Clonidine for treatment of the severe hypertension. 6:03 PM Blood Pressure: 214/95 Heart Rate 70 with direct patient care technician documenting “bp remains elevated: patient keeping feet down: continue to monitor” There was no documentation presented at time of review that the direct patient care technician reported the severe hypertension to the registered nurse and there was no documentation provided that the registered nurse reassessed / reevaluated the severe hypertension. There was no documentation presented at time of review that the patient was offered and or refused the PRN Clonidine for treatment of the severe hypertension. Treatment Ended Time: 6:37 PM Blood Pressure: 233/101 Heartrate 67. Discharge Status: discharged home Post Treatment Assessment: the registered nurse documented “Patient no complaint at discharge. Patient blood pressure elevated. Patient no s/s. Patient states he will take BP meds as soon as he gets home. PCT did not notify the RN of elevated BP during treatment .....” There was no documentation presented at time of review that the registered nurse notified the physician of the severe hypertension during treatment and at time of discharge. There was no documentation presented at time of review that the patient was offered or refused PRN Medication to treat the severe hypertension. There was no documentation presented at time of review that patient was educated on consequences of untreated hypertension. An interview conducted with staff #3 on 06/04/25 following her own review of the findings revealed she was unaware of the discrepancies found in the flow sheets. Staff #3 confirmed the above findings.”

“MR-COMPLETE RECORDS PROMPTLY CFR(s): 494.170(b)(1) (1) Current medical records and those of discharged patients must be completed promptly. This Standard is not met as evidenced by: 30377 Based on review of medical record, policy and procedures, and staff interview the facility failed to ensure that the attending physician record progress notes as soon as possible after its occurrence to provide other interdisciplinary team members with an up-to-date picture of the status of the patient. Findings were: Review of Physician Progress notes on 06/04/25 revealed the following: Patient # 2 Physician Progress: Services rendered at Sherman Dialysis Center: 04/14/25. Disclaimer: This note was created on 05/09/2025. This documented visit occurred on 04/14/25. Please note that more recent lab data may have become available after the date of the visit and may have been displayed on the patient chart and included in this note. Patient # 2 Physician Progress: Services rendered at Sherman Dialysis Center: 04/21/25. Disclaimer: This note was created on 05/09/2025. This documented visit occurred on 04/21/25. Please note that more recent lab data may have become available after the date of the visit and may have been displayed on the patient chart and included in this note. Patient # 2 Physician Progress: Services rendered at Sherman Dialysis Center: 05/21/25 Disclaimer: This note was created on 06/04/25. This documented visit occurred on 05/21/25. Please note that more recent lab data may have become available after the date of the visit and may have been displayed on the patient chart and included in this note. An interview conducted with staff #6 on 06/04/25 following her own review of the findings revealed she was aware of the discrepancies found. Staff #6 stated that this has been addressed by the governing body in the past and continues to be an ongoing issue. At the time of the interview no evidence of compliance was presented where noncompliance was found”

“CFC-PATIENT ASSESSMENT CFR(s): 494.80 This Condition is not met as evidenced by: 48653 Based on record review and interview, A. the Registered Nurse failed to ensure the pre-treatment nursing assessments were completed and documented within (1) hour of treatment initiation on 4 (# 2, # 4, # 5, # 6) of 7 patient medical records reviewed. Also, the Registered Nurse failed to ensure the post-treatment nursing assessments were completed and documented before the patient was discharged on 6 (# 2, # 3, # 4, # 5, # 6, # 7) of 7 patient medical records reviewed. The facility staff failed to follow the facility policy “Pre-Intra-Post Treatment Data Collection Monitoring and Nursing Assessment”. (Cross Refer to Tag V 502) B. the facility staff failed to follow the physician’s prescribed orders for blood flow rate (BFR) and dialysate flow rate (DFR) in 4 (# 3, # 4, # 5, # 6) of 7 medical records reviewed. The facility staff failed to verify the ordered prescription matched the prescription the patient was receiving prior to treatment initiation. Also, the facility staff failed to follow the facility policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment”. (Cross Refer to Tag V 503) C. the facility staff failed to ensure direct care staff were reporting patient vital signs that fell outside of the facility’s set parameters to the CN (charge nurse) for further assessment and intervention on 3 (# 2, # 3, #7) of 7 patient charts reviewed. In addition, the facility staff removed more than the prescribed 13 ml/kg/hr (milliliters per kilogram per hour) on 2 (#6, #7) of 7 patient charts reviewed. The facility staff failed to follow the facility policy “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment”. (Cross Refer to Tag V 504) D. the Interdisciplinary Team (IDT) failed to ensure that the 90-day plan of care (POC) was completed for 1 (#6) of 8 patients. (Cross Refer to Tag V 517) E. the interdisciplinary team failed to do a comprehensive reassessment and revision to the plan of care on 1 (#5) of 8 patient where the plan of care was categorized as unstable. Also, the facility failed to follow its policy “INTERDISCIPLINARY TEAM (IDT) PATIENT ASSESSMENT AND PLAN OF CARE.” (Cross Refer to Tag V 520)”

“CFC-PATIENT PLAN OF CARE CFR(s): 494.90 This Condition is not met as evidenced by: 29191 Based on medical record review and staff interview: A. the facility’s interdisciplinary team members failed to complete an initial plan of care within 30 days of the start of treatment for the dialysis patient. There was no comprehensive assessment performed by the interdisciplinary team within 30 days of the start of dialysis to be used to implement a plan of care for 3 (#1, #2, and #6) of 8 patients. Also, the facility staff failed to follow the facility policy, “INTERDISCIPLINARY TEAM (IDT) PATIENT ASSESSMENT AND PLAN OF CARE.” Cross refer to tag V 557 B. Interdisciplinary Team (IDT) failed to ensure an assessment and a revised plan of care was completed for 4 (#1, #2, #6, and #7) of 8 patients within 15 days of the assessment date. Also, the facility staff failed to follow the facility policy, “INTERDISCIPLINARY TEAM (IDT) PATIENT ASSESSMENT AND PLAN OF CARE.” Cross refer to tag V 558”

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 48653 Based on observation and interview, the facility staff failed to promptly remove corrugated cardboard boxes from the in-center treatment floor. During a tour of the facility’s in-center treatment area on 11/29/23 at 11:45 AM, this surveyor observed 3 external shipping cardboard boxes sitting directly on the floor next to the charge nurse’s desk. In an interview with Staff # 9 on 11/29/23 at 11:45 AM, Staff # 9 was questioned on why the cardboard boxes were stored on the floor of the in-center treatment area. Staff # 9 stated, “The pharmacy delivery comes and brings them into the treatment area and they sit on the floor until we have time to put them away.” “External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material; serve as generators of and reservoirs for dust.” (AAM1 ST46-Section 5.2 Receiving items). An interview with Staff # 9 on 11/29/23 at 11:45 AM confirmed the presence of cardboard boxes stored on the in-center treatment floor.”

“IC-TRANSDUCER PROTECTORS-NOT WETTED/CHANGED CFR(s): 494.30(a)(1)(i) Use external venous and arterial pressure transducer filters/protectors for each patient treatment to prevent blood contamination of the dialysis machines’ pressure monitors. If the external transducer protector becomes wet, replace immediately and inspect the protector. If fluid is visible on the side of the transducer protector that faces the machine, have qualified personnel open the machine after the treatment is completed and check for contamination. This includes inspection for possible blood contamination of the internal pressure tubing set and pressure sensing port. If contamination has occurred, the machine must be taken out of service and disinfected using either 1:100 dilution of bleach (300-600 mg/L free chlorine) or a commercially available, EPA-registered tuberculocidal germicide before reuse. Change filters/protectors between each patient treatment, and do not reuse them. Internal transducer filters do not need to be changed routinely between patients. This Standard is not met as evidenced by: 48653 Based on observation, policy review, and staff interviews, the facility failed to ensure direct-care staff were competent in the facility’s process for changing wet external transducers. The staff failed to follow the facility’s policy titled, “CHANGING TRANSDUCER PROTECTORS”. This deficient practice had the likelihood to result in harm to all patients receiving care at the facility by introducing patient blood into the dialysis machine. This could cause contamination of the dialysis machine and allow other patients to become exposed to blood contamination. Findings include: During a tour of the facility’s in-center treatment area on 11/29/2023 at 2:30 PM with Staff # 1 and # 2, this surveyor observed Staff # 16 caring for Patient # 8 at station # 14. The surveyor noticed the hub of the external transducer on machine # 36 (the machine Patient # 8 was being treated on) was wet with blood. When questioned regarding the process for recognizing and changing the external transducer, Staff # 16 stated, “I have changed the transducer 4 times now. Blood keeps backing up into the tubing and hub but the transducer itself is not wet. I make sure to change the external transducer even if it seems like it could potentially be contaminated. I have taken a syringe and pushed saline into the line that connects to the transducer to try to push that blood back out of the line to avoid the transducer getting wet.” Staff # 16 did not state the appropriate process for inspecting the back of the external transducer and what should occur if the back of the external transducer became contaminated with blood or saline. Also, Staff # 16 stated a process for pushing saline into the dialysis line that was not noted in the policy. A review of the facility’s policy titled, “CHANGING TRANSDUCER PROTECTORS” dated April 2021, revealed, “PURPOSE: To provide guidance for changing transducer protectors and preventing cross-contamination. POLICY: 1. This policy is intended for all dialysis delivery systems that utilize blood tubing sets with external pressure transducer protectors in the arterial and venous pressure monitoring system. 2. During intradialytic treatment monitoring, the arterial and venous drip chamber levels should be observed and adjusted as needed. 3. External transducer protectors will be inspected for the presence of blood or saline every 30 minutes during patient treatment and included as part of the monitoring process. 4. The external transducer protector will be replaced: Prior to each patient’s use and whenever blood or saline is observed in contact with the patient side of the transducer protector. 5. If the external transducer protector becomes contaminated with blood or saline, the teammate will replace the external transducer protector and adjust the arterial and/or venous drip chamber as needed. After adjusting the arterial and/or venous drip chamber levels the patient’s arterial and venous pressures should be compared to previous treatment readings ... 7. The back of the wet external transducer protector and the delivery system pressure module luer locks will be visually inspected for blood or saline contamination prior to placing the new sterile external transducer protector on the delivery system. If blood or saline is noted on the back of the wet external transducer protector, strikethrough has occurred. The treatment can continue for this patient on this delivery system if accurate pressures are observed. Upon completion of treatment, the delivery system is to be removed from service and labeled with the date, time, description of the problem, and the name of the teammate reporting the problem ...” An interview with Staff # 1 and # 2 on 11/29/2023 at 2:45 PM confirmed the facility staff were not competent in the facility’s policy for inspecting and changing the external transducers on the dialysis machines. Staff # 2 stated another in-service would be conducted for facility staff.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 29191 Based on observation, record review, and interview, the facility failed to: A. ensure that staff followed the facility’s policy for bleach disinfection of 3 (#27, #28, and #31) of 28 patients’ dialysis machines. The clean and disinfect logs for September and October 2023 were reviewed. B. follow the correct procedure for cleaning and disinfecting contaminated dialysis surfaces in the in-center treatment area. The staff failed to follow the facility’s policy, “Infection Control For Dialysis Facilities”. A. This deficient practice had the likelihood of placing all patients being dialyzed on these machines at risk for potential harm due to the machines using bicarbonate during the dialysis process having a high potential for bacterial growth. Findings include: A review of the September 2023 daily disinfection log revealed the following: A review of the log titled, “Clean and Disinfect” Staff #12 failed to document on September 7, 2023, that bleach disinfection had been performed on dialysis machine #27. A review of the log titled, “Clean and Disinfect” Staff #12 failed to document on September 21, 2023, that bleach disinfection had been performed on dialysis machine #27. A review of the log titled, “Clean and Disinfect” Staff #18 failed to document on September 28, 2023, that bleach disinfection had been performed on dialysis machines #27 and #31. A review of the October 2023 daily disinfection log revealed the following: A review of the log titled, “Clean and Disinfect” Staff #15 failed to document on October 28, 2023, that bleach disinfection had been performed on dialysis machine #27. A review of the facility’s policy titled, “FRESENIUS DIALYSIS DELIVERY SYSTEM CLEANING AND DISINFECTION POLICY “ dated 10/2017 revealed the following: “EXAMPLES OF CLEANING/DISINFECTION PROCEDURES AND INTERVALS Weekly Bleach or Peracetic Acid Disinfection Operator Instructions for Use manuals for dialysis delivery systems currently in use are to be readily available to teammates performing cleaning and disinfection procedures. Refer to manufacturers’ procedures for the dialysis delivery system utilized.” Internally disinfect the dialysis machine as outlined below or per manufacturer guidelines: “* Heat disinfect after the last treatment each day the machine is used. * Bleach disinfect each week (at least every seven (7) days). Bleach disinfection can replace heat disinfection.” An interview with Staff #8 (Bio-Medical) on 11/30/2023 at 9:00 AM confirmed dialysis machines #27, #28, and #31 had not been bleach disinfected weekly as required by manufacturer guidelines. 48653 B. These findings had the likelihood to cause harm by increasing the risk of infection to all patients receiving care at the facility by allowing supplies and equipment to be used that had been exposed to microbial contamination and unclean surfaces. Findings include: During a tour of the facility’s in-center treatment area on 11/29/2023 at 11:00 AM, this surveyor observed 5 dialysis patients complete dialysis treatment and walk to the scale for post-treatment weight. All 5 of the patients touched the handrail and scale buttons without a staff member disinfecting the contaminated surfaces between each patient contact. Also, there were no disinfecting wipes located near the weight station for the patients or staff members to use. A review of facility’s policy titled, “Infection Control For Dialysis Facilities” with a revision date of April 2023, revealed the following: “PURPOSE: To minimize the spread of infections or bloodborne pathogens in the dialysis facility environment. POLICY: The Centers for Disease Control (CDC) Recommendations for Preventing Transmission of Infections among Chronic Hemodialysis Patients (Dialysis Precautions) will be followed when caring for all patients. Additional precautions recommended by the CDC are to be observed for patients with infectious hepatitis B and are included in the policy: Infection Control and Isolation Measures for Known or Suspected Hepatitis B Antigen Positive Patients ... DISINFECTION: 12. Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infectious materials (i.e. used or brought into the station) and prior to returning to clean/designated area or removal from treatment area. b. Use an appropriate disinfectant such as 1:100 (one to one hundred) bleach solution for routine disinfection of environmental surfaces. i. Disinfection should be completed by using a wiping motion with friction. ii. Sufficient disinfectant should be applied so that surfaces are visibly wet. iii. Surfaces should be allowed to air dry in order to provide sufficient disinfectant contact time. iv. Items disinfected via submersion will be fully submerged.” In an interview with Staff # 1 on 11/29/2023 at 11:00 AM, Staff # 1 confirmed the facility staff were not disinfecting the surfaces at the patient scale and there were no disinfecting wipes in the vicinity of the scale to be utilized by facility staff. Staff # 1 had to get disinfecting wipes from the supply to put near the patient scale for use.”

“MIXING SYSTEMS-LABELING CFR(s): 494.40(a) 5.4.4.1 Mixing systems: labeling Labeling strategies should permit positive identification by anyone using the contents of mixing tanks, bulk storage/dispensing tanks, and small containers intended for use with a single hemodialysis machine. Mixing tanks: Prior to batch preparation, a label should be affixed to the mixing tank that includes the date of preparation and the chemical composition or formulation of the concentrate being prepared. This labeling should remain on the mixing tank until the tank has been emptied. Bulk storage/dispensing tanks: These tanks should be permanently labeled to identify the chemical composition or formulation of their contents. Concentrate jugs: At a minimum, concentrate jugs should be labeled with sufficient information to differentiate the contents from other concentrate formulations used at the facility. This Standard is not met as evidenced by: 29191 Based on observation and interview, the facility staff failed to ensure the bicarbonate concentrate mixer was labeled appropriately with the contents. The facility staff failed to follow the facility’s policy “BICARB MIXING AND DELIVERY”. Findings include: There are two Bicarbonate mixing tanks. Tank #1 had a label stating bicarbonate was in the container, but Tank #2 had no label on the container. The tank was full of solution and did not identify the contents of the tank. There was no way to know what the solution was in tank #2 An interview with Staff #15 on 11/29/2023 at 12:39 PM verified the tank was not labeled as to what the solution was in the bicarbonate tank #2. A review of the facility policy titled, “BICARB MIXING AND DELIVERY” dated 10/2023 revealed the following: “Mixing tank #1 Label tank with contents. Verify that the tanks are labeled with contents in tank, date, time, and initials. Mixing tank #2 Label tank with contents. Verify that the tanks are labeled with contents in tank, date, time, and initials.” An interview with Staff #2 on 11/29/2023 at 12:39 PM confirmed that the Bicarbonate tank #2 was not labeled as to what the solution was in the container and that the staff failed to follow the facility’s policy.”

“DIALYS PROPORT-MONITOR PH/CONDUCTIVITY CFR(s): 494.40(a) 5.6 Dialysate proportioning: monitor pH/conductivity It is necessary for the operator to follow the manufacturer’s instructions regarding dialysate conductivity and to measure approximate pH with an independent method before starting the treatment of the next patient. This Standard is not met as evidenced by: 48653 Based on observation, staff interviews, and policy review, A. the facility’s direct care staff failed to test the dialysate solution with an independent meter for conductivity and pH before initiation of hemodialysis treatment on 1 (#9) of 1 patient observation. B. the facility’s direct care staff failed to test the dialysate solution with an independent meter for conductivity and pH after changing the potassium bath prescription mid-way through treatment on 2 (# 3 and # 4) of 2 patients. C. the facility staff failed to rinse the Myron L D-1 (independent device) with RO (reverse osmosis) water. D. the facility staff failed to empty the RO (reverse osmosis) bottles at the end of the treatment day on 11/29/2023. E. the facility’s bio-medical department failed to ensure the dialysate sample port on 24 of 24 dialysis machines was working correctly. Findings include: A. During a tour of the facility’s in-center treatment area on 11/29/2023 at 2:30 PM, the surveyor observed Staff # 9 perform a setup of dialysis machine # 48. Staff # 9 initiated dialysis treatment on Patient # 9 without performing a conductivity check with an independent device as required by facility policy. When questioned, Staff # 9 stated, “Conductivity was not performed with an independent device before imitating treatment on Patient # 9 and this testing should have been completed before treatment started.” B. In an interview with Staff # 16 on 11/29/2023 at 12:00 PM, Staff # 16 was questioned regarding the change in prescriptions for patients # 3 and # 4. Staff # 16 stated the physician was making rounds and was alerted to both patients having elevated potassium levels. The physician changed the potassium bath to a lower concentration mid-way through treatment. Staff # 16 stated, “I changed the prescription for potassium mid-way through treatment and did not check conductivity after making the change. I was worried about the patient’s potassium levels and did not think about checking the conductivity again after making the prescription change.” C. On 11/29/2023 at 2:45 PM, the surveyor observed Staff # 3 performing a conductivity check with an independent device before the initiation of treatment. Staff # 3 did not follow the correct process for checking conductivity according to the facility’s procedure and policy. Staff # 3 attempted to rinse the Myron L D-1 (independent device) with tap water as opposed to RO (reverse osmosis) water. This action could cause the result of the conductivity to be incorrect due to tap water and RO water have different conductivity levels. D. During a tour of the facility’s in-center treatment area on 11/30/2023 at 9:00 AM, the surveyor observed RO bottles filled with RO water from the day before. RO bottles are to be emptied at the end of the treatment day and inverted to drain. This clinic operates on Monday, Wednesday, and Friday. There were no patients being treated at the facility on 11/30/2023 (Thursday) the R/O had been left from the day before. The RO water must be emptied out of the bottles at the end of treatment day and inverted for drainage. A review of the facility policy titled, “TESTING pH AND CONDUCTIVITY OF PROPORTIONED DIALYSATE AND VERIFICATION OF TEMPERATURE OF PROPORTIONED DIALYSATE” with a revision date of April 2020 revealed, “PURPOSE: To provide guidance for testing and documenting pH, conductivity, and temperature of proportioned dialysate. POLICY: 1. Trained teammates will test pH and conductivity of final dialysate utilizing appropriate test strips and/or meters prior to each patient treatment. 2. Each facility will maintain a minimum of 2 approved devices to perform independent pH and conductivity readings of final dialysate, if applicable. 3. Document results in the electronic treatment record or dialysis system log, as applicable .... 5. When applicable, the final dialysate conductivity should be checked with an approved independent meter. The Independent meter reading should be plus/minus 0.4mS of the machine displayed conductivity based on your facility’s machine type. 6. Independent pH is required to be performed prior to each treatment...” An interview with Staff # 1 and # 2 confirmed Staff # 9 did not test the conductivity of the dialysate solution in machine # 48 before the initiation of treatment on Patient # 9 as required by facility policy. Staff # 3 did not use RO water to perform the rinsing of the Myron Meter. Also, Staff # 1 and # 2 confirmed Staff # 16 did not test the conductivity of the dialysate solution mid-way through treatment after a dialysate prescription change. 29191 E. This deficient practice had the likelihood of causing the conductivity to be incorrect when using the independent device. Findings include: During a tour of the in-center treatment floor on 11/29/2023 at 10:30 AM observed Patient Care Technicians #13 and #15 conducting the conductivity on the dialysis machines with the independent device. Each Patient Care Technician conducted the conductivity differently. Observed Patient Care Technician #13 tried to use the luer lock mechanism on the sample port of the Hanson connector to draw dialysate solution from the sample port. The dialysate sample port was not working. Patient Care Technician #13 had to obtain a dialysate solution from the Hansen connector; place the dialysate in a cup and then perform the conductivity test. Observed Patient Care Technician (PCT) #15 tried to use the dialysate sample port was not working. Patient Care Technician #15 had to obtain a dialysate solution from the dialyzer port with issues and then the Patient Care Technician #15 used the Hansen connector; placed the dialysate in a cup and then performed the conductivity test. The Patient Care Technicians had to obtain dialysate solution from the Hansen connector and place the dialysate in a cup and then perform the conductivity test. The sample ports were not working. A review of the facility policy titled, “MEASURING CONDUCTIVITY, TEMPERATURE, AND/OR pH USING THE PHOENIX CONDUCTIVITY METER” dated April 2022 revealed the following: *Dialysis quality water should be obtained fresh same day of use prior to use with this procedure. * The exterior of Phoenix meter should be cleaned with 1: 100 bleach solution prior to collecting a sample from another dialysis delivery system to prevent cross-contamination. * The Tri-Station along with drain line is a clean station and should be located in a clean area. Dialysate and the fluids used to disinfect, calibrate and store Phoenix meters are also considered clean. * Manufacturer’s drain line is limited to 5 feet and should be replaced by Biomed at least annually or sooner if drain line is discolored or contains evidence of buildup. *The outside of Phoenix meter must be disinfected after use prior to returning the meter to the storage location. Connects Phoenix Meter to dialysis machine dialysate sample port. Be sure to insert the adapter far enough into the port to depress the spring plate. Pull the syringe plunger and draw the solution through the cell. While the solution is flowing with no bubbles present, observe the reading on the meter display. When you are finished with the Phoenix meter, rinse the interior of the Phoenix meter thoroughly with dialysis-quality water. Disinfect the exterior of the meter with 1:100 bleach solution before taking it to a common clean area or using it at another station.” An interview with Staff #2 on 11/29/2023 at 11:45 AM confirmed the Patient Care Technicians were obtaining dialysate solution by disconnecting the Hansen connector and not obtaining the dialysate solution through the dialysate sample port per the facility’s policy.”

“PA-ASSESS CURRENT HEALTH STATUS/COMORBIDS CFR(s): 494.80(a)(1) The patient’s comprehensive assessment must include, but is not limited to, the following: (1) Evaluation of current health status and medical condition, including co-morbid conditions. This Standard is not met as evidenced by: 48653 Based on record review and interview, the Registered Nurse failed to ensure the pre-treatment nursing assessments were completed and documented within (1) hour of treatment initiation on 4 (# 2, # 4, # 5, # 6) of 7 patient medical records reviewed. Also, the Registered Nurse failed to ensure the post-treatment nursing assessments were completed and documented before the patient was discharged on 6 (# 2, # 3, # 4, # 5, # 6, # 7) of 7 patient medical records reviewed. The facility staff failed to follow the facility policy “Pre-Intra-Post Treatment Data Collection Monitoring and Nursing Assessment”. Findings Include: Patient # 2 A review of 2 of 6 treatment sheets for Patient # 2 revealed that pre-treatment nursing assessments were not completed within (1) hour of treatment initiation. A review of the treatment sheet dated 11/22/2023 revealed Staff # 9 did not complete the pre-treatment nursing assessment (documented at 8:03 AM) within 1 hour of the initiation of treatment. Treatment began at 6:08 AM. A review of the treatment sheet dated 11/27/23 revealed Staff # 9 did not complete the pre-treatment nursing assessment (documented at 7:50 AM) within 1 hour of the initiation of treatment. Treatment began at 6:04 AM. A review of 3 of 6 treatment sheets for Patient # 2 revealed that the post-treatment nursing assessments were not completed before the patient was discharged. A review of the treatment sheet dated 11/15/2023 revealed Staff # 19 did not complete the post-treatment nursing assessment (documented at 4:59 PM) before the patient was discharged. Treatment ended at 9:44 AM. A review of the treatment sheet dated 11/20/2023 revealed Staff # 16 did not complete the post-treatment nursing assessment (documented at 5:35 PM) before the patient was discharged. Treatment ended at 9:36 AM. A review of the treatment sheet dated 11/24/2023 revealed Staff # 20 did not complete the post-treatment nursing assessment (documented at 2:27 PM) before the patient was discharged. Treatment ended at 10:00 AM. Patient # 3 A review of 1 of 6 treatment sheets for Patient # 3 revealed that the post-treatment nursing assessments were not completed before the patient was discharged. A review of the treatment sheet dated 11/24/2023 revealed Staff # 20 did not complete the post-treatment nursing assessment (documented at 5:19 PM) before the patient was discharged. Treatment ended at 3:02 PM. Patient # 4 A review of 1 of 6 treatment sheets for Patient # 4 revealed that pre-treatment nursing assessments were not completed within (1) hour of treatment initiation. A review of the treatment sheet dated 11/27/2023 revealed Staff # 9 did not complete the pre-treatment nursing assessment (documented at 2:55 PM) within 1 hour of the initiation of treatment. Treatment began at 10:40 AM. A review of 1 of 6 treatment sheets for Patient # 4 revealed that the post-treatment nursing assessments were not completed before the patient was discharged. A review of the treatment sheet dated 11/24/2023 revealed Staff # 20 did not complete the post-treatment nursing assessment (documented at 5:37 PM) before the patient was discharged. Treatment ended at 1:49 PM. Patient # 5 A review of 1 of 6 treatment sheets for Patient # 5 revealed that pre-treatment nursing assessments were not completed within (1) hour of treatment initiation. A review of the treatment sheet dated 11/24/2023 revealed Staff # 20 did not complete the pre-treatment nursing assessment (documented at 4:49 PM) within 1 hour of the initiation of treatment. Treatment began at 3:24 PM. A review of 2 of 6 treatment sheets for Patient # 5 revealed that the post-treatment nursing assessments were not completed before the patient was discharged. A review of the treatment sheet dated 11/08/2023 revealed Staff # 9 did not complete the post-treatment nursing assessment (documented at 8:45 PM) before the patient was discharged. Treatment ended at 6:44 PM. A review of the treatment sheet dated 11/24/2023 revealed Staff # 16 did not complete the post-treatment nursing assessment (documented at 8:27 PM) before the patient was discharged. Treatment ended at 6:41 PM. Patient # 6 A review of 3 of 6 treatment sheets for Patient # 6 revealed that pre-treatment nursing assessments were not completed within (1) hour of treatment initiation. A review of the treatment sheet dated 11/13/2023 revealed Staff # 9 did not complete the pre-treatment nursing assessment (documented at 5:34 PM) within 1 hour of the initiation of treatment. Treatment began at 3:37 PM. A review of the treatment sheet dated 11/20/2023 revealed Staff # 9 did not complete the pre-treatment nursing assessment (documented at 6:03 PM) within 1 hour of the initiation of treatment. Treatment began at 3:37 PM. A review of the treatment sheet dated 11/22/2023 revealed Staff # 16 did not complete the pre-treatment nursing assessment (documented at 12:51 PM) within 1 hour of the initiation of treatment. Treatment began at 11:12 AM. A review of 2 of 6 treatment sheets for Patient # 6 revealed that the post-treatment nursing assessments were not completed before the patient was discharged. A review of the treatment sheet dated 11/06/2023 revealed Staff # 16 did not complete the post-treatment nursing assessment (documented at 8:44 PM) before the patient was discharged. Treatment ended at 7:32 PM. A review of the treatment sheet dated 11/08/2023 revealed Staff # 16 did not complete the post-treatment nursing assessment (documented at 5:08 PM) before the patient was discharged. Treatment ended at 2:05 PM. Patient # 7 A review of 3 of 6 treatment sheets for Patient # 7 revealed that the post-treatment nursing assessments were not completed before the patient was discharged. A review of the treatment sheet dated 11/15/2023 revealed Staff # 19 did not complete the post-treatment nursing assessment (documented at 4:42 PM) before the patient was discharged. Treatment ended at 2:42 PM. A review of the treatment sheet dated 11/20/2023 revealed Staff # 16 did not complete the post-treatment nursing assessment (documented at 5:51 PM) before the patient was discharged. Treatment ended at 2:10 PM. A review of the treatment sheet dated 11/22/2023 revealed Staff # 9 did not complete the post-treatment nursing assessment (documented at 4:38 PM) before the patient was discharged. Treatment ended at 3:11 PM. A review of the facility policy titled, “ Pre-Intra-Post Treatment Data Collection Monitoring and Nursing Assessment “ with a revision date of October 2023 revealed, “Purpose: To obtain and document baseline and ongoing information about the patient before, during, and after the dialysis treatment through data collection and nursing assessment. This information will be used in planning and documenting the patient’s dialysis treatment, monitoring during treatment, and for reviewing the patient’s response to the treatment and status prior to discharge. Policy: 2. The nursing assessment will be performed and documented by a licensed nurse; specifically, a Registered Nurse (RN) ... A physical assessment of the patient which includes, apical heart rate and rhythm, auscultation of the lungs, evaluation of volume status including edema, bruising, or bleeding, patient statement of well-being, level of pain or discomfort, and any other components which if observed/informed will be documented ... 3. Patient identity, prescription, and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment or as allowable by state law.” 4. Any abnormal findings or findings outside of any patient-specific physician-ordered parameters discovered during pre-treatment data collection will be documented and immediately reported to the licensed nurse. If an abnormal finding is reported to the licensed nurse pre-treatment, the nurse will assess the patient prior to the initiation of dialysis. 5. The assessment is a nursing responsibility. The nurse will assess the patient pre-treatment as warranted by the patient’s condition ... 8. The licensed nurse will round on those patients without reported abnormal findings and complete the nursing assessment without 1 hour of dialysis treatment initiation ... 16. If an abnormal finding(s) or concern is identified post-treatment, this needs to be reported to the licensed nurse. The licensed nurse will assess the patient prior to discharge.” An interview with Staff # 2 on 11/30/2023 at 9:00 AM confirmed the facility staff had not been consistently documenting pre-nursing and post-nursing assessment times within the required time frame among all patient medical records reviewed and the facility staff had not followed the facility policy, “ Pre-Intra-Post Treatment Data Collection Monitoring and Nursing Assessment “.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 48653 Based on record review and staff interview, the facility staff failed to follow the physician’s prescribed orders for blood flow rate (BFR) and dialysate flow rate (DFR) in 4 (# 3, # 4, # 5, # 6) of 7 medical records reviewed. The facility staff failed to verify the ordered prescription matched the prescription the patient was receiving prior to treatment initiation. Also, the facility staff failed to follow the facility policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment”. This deficient practice had the likelihood to harm patients by not following the physician’s dialysis orders which could negatively impact the effectiveness and adequacy of the dialysis treatment for all 66 in-center hemodialysis patients receiving care at this facility. Findings Include: Patient # 3 A review of 5 of 6 treatment sheets revealed facility staff did not follow the physician’s prescribed orders for BFR and DFR. A review of the treatment sheet dated 11/10/2023 revealed the following, “Dialysis Prescription: Blood Flow Rate: 450ml/min (milliliters per minute) Dialysate Flow Rate: 600.00 ml/min” Staff # 15 and # 16 documented the following BFR and DFR throughout the patient’s treatment, “11:28 AM: BFR- 200 DFR-500 11:32 AM-12:32 PM: BFR-400 DFR-500 12:32 PM-2:02PM: BFR-400 DFR-600” Staff # 16 documented the following on 11/10/2023 at 12:29 PM: “I verify that the patient’s prescription matches what is currently being delivered during the dialysis treatment” There was no documented order from the physician to adjust the BFR or DFR for this treatment date. A review of the treatment sheet dated 11/15/2023 revealed the following, “Dialysis Prescription: Blood Flow Rate: 450ml/min (milliliters per minute) Dialysate Flow Rate: 600.00 ml/min” Staff # 5 documented the following BFR throughout the patient’s treatment, “11:46 AM-3:05 PM: BFR-300” Staff # 19 documented the following on 11/15/2023 at 12:04 PM: “I verify that the patient’s prescription matches what is currently being delivered during the dialysis treatment.” There was no documented order from the physician to adjust the BFR for this treatment date. A review of the treatment sheet dated 11/20/2023 revealed the following, “Dialysis Prescription: Blood Flow Rate: 450ml/min (milliliters per minute) Dialysate Flow Rate: 600.00 ml/min” Staff # 3, # 5, and # 16 documented the following BFR throughout the patient’s treatment, “12:01 PM-3:01 PM: BFR- 350” Staff # 16 documented the following on 11/20/2023 at 1:03 PM: “I verify that the patient’s prescription matches what is currently being delivered during the dialysis treatment.” There was no documented order from the physician to adjust the BFR for this treatment date. A review of the treatment sheet dated 11/22/2023 revealed the following, “Dialysis Prescription: Blood Flow Rate: 450ml/min (milliliters per minute) Dialysate Flow Rate: 600.00 ml/min” Staff # 3 and # 5 documented the following BFR and DFR throughout the patient’s treatment, “11:20 AM-2:22PM: BFR- 400 DFR-500” Staff # 9 documented the following on 11/22/2023 at 12:24 PM: “I verify that the patient’s prescription matches what is currently being delivered during the dialysis treatment.” There was no documented order from the physician to adjust the BFR or DFR for this treatment date. A review of the treatment sheet dated 11/24/2023 revealed the following, “Dialysis Prescription: Blood Flow Rate: 450ml/min (milliliters per minute) Dialysate Flow Rate: 600.00 ml/min” Staff #5, # 12, and # 15 documented the following BFR and DFR throughout the patient’s treatment, “11:31 AM- 3:02 PM: BFR-400 DFR-500” Staff # 20 documented the following on 11/24/2023 at 12:34 PM: “I verify that the patient’s prescription matches what is currently being delivered during the dialysis treatment.” There was no documented order from the physician to adjust the BFR or DFR for this treatment date. Patient # 4 A review of 2 of 6 treatment sheets revealed facility staff did not follow the physician’s prescribed orders for BFR and DFR. A review of the treatment sheet dated 11/20/2023 revealed the following, “Dialysis Prescription: Blood Flow Rate: 500ml/min (milliliters per minute) Dialysate Flow Rate: 700.00 ml/min” Staff # 5 and # 16 documented the following BFR throughout the patient’s treatment, “11:30 AM-3:00 PM: BFR- 450” Staff # 16 documented the following on 11/20/2023 at 12:06 PM: “I verify that the patient’s prescription matches what is currently being delivered during the dialysis treatment.” There was no documented order from the physician to adjust the BFR for this treatment date. A review of the treatment sheet dated 11/22/2023 revealed the following, “Dialysis Prescription: Blood Flow Rate: 500ml/min (milliliters per minute) Dialysate Flow Rate: 700.00 ml/min” Staff # 5 documented the following BFR and DFR throughout the patient’s treatment, “10:10 AM- 11:00 AM: BFR-500 DFR- 500 11:30 AM-2:45 PM: BFR-350 DFR-500” Staff # 9 documented the following on 11/24/2023 at 10:17 AM: “I verify that the patient’s prescription matches what is currently being delivered during the dialysis treatment.” There was no documented order from the physician to adjust the BFR or DFR for this treatment date. Patient # 5 A review of 4 of 6 treatment sheets revealed facility staff did not follow the physician’s prescribed orders for BFR. A review of the treatment sheet dated 11/10/2023 revealed the following, “Dialysis Prescription: Blood Flow Rate: 400ml/min (milliliters per minute) Dialysate Flow Rate: 500.00 ml/min” Staff # 16 and # 17 documented the following BFR throughout the patient’s treatment, “4:01 PM-6:28 PM- BFR-200” Staff # 16 documented the following on 11/10/2023 at 4:12 PM: “I verify that the patient’s prescription matches what is currently being delivered during the dialysis treatment.” There was no documented order from the physician to adjust the BFR for this treatment date. A review of the treatment sheet dated 11/15/2023 revealed the following, “Dialysis Prescription: Blood Flow Rate: 400ml/min (milliliters per minute) Dialysate Flow Rate: 500.00 ml/min” Staff # 15 documented the following BFR throughout the patient’s treatment, “6:31 PM-7:33 PM: BFR-350” Staff # 19 documented the following on 11/15/2023 at 5:17 PM: “I verify that the patient’s prescription matches what is currently being delivered during the dialysis treatment.” There was no documented order from the physician to adjust the BFR for this treatment date. A review of the treatment sheet dated 11/20/2023 revealed the following, “Dialysis Prescription: Blood Flow Rate: 400ml/min (milliliters per minute) Dialysate Flow Rate: 500.00 ml/min” Staff # 3, # 5 and # 16 documented the following BFR throughout the patient’s treatment, “4:30 PM- 6:00 PM: BFR-350 6:30 PM- 7:13 PM: BFR-300” Staff # 16 documented the following on 11/20/2023 at 4:32 PM: “I verify that the patient’s prescription matches what is currently being delivered during the dialysis treatment.” There was no documented order from the physician to adjust the BFR for this treatment date. A review of the treatment sheet dated 11/24/2023 revealed the following, “Dialysis Prescription: Blood Flow Rate: 400ml/min (milliliters per minute) Dialysate Flow Rate: 500.00 ml/min” Staff # 12, # 16, and, # 20 documented the following BFR throughout the patient’s treatment, “4:33 PM-6:41 PM: BFR- 450” Staff # 20 documented the following on 11/24/2023 at 4:48 PM: “I verify that the patient’s prescription matches what is currently being delivered during the dialysis treatment.” There was no documented order from the physician to adjust the BFR for this treatment date. Patient # 6 A review of 1 of 6 treatment sheets revealed facility staff did not follow the physician’s prescribed orders for BFR and DFR. A review of the treatment sheet dated 11/22/2023 revealed the following, “Dialysis Prescription: Blood Flow Rate: 350ml/min (milliliters per minute) Dialysate Flow Rate: 500.00 ml/min” Staff # 12, #14 and # 16 documented the following BFR and DFR throughout the patient’s treatment, “11:12 AM-1:53 PM: BFR- 300 DFR-600” Staff # 16 documented the following on 11/22/2023 at 12:49 PM: “I verify that the patient’s prescription matches what is currently being delivered during the dialysis treatment.” There was no documented order from the physician to adjust the BFR or DFR for this treatment date. A review of facility policy, “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment” with a revision date of October 2023 revealed, “Purpose: To obtain and document baseline and ongoing information about the patient before, during, and after the dialysis treatment through data collection and nursing assessment. This information will be used in planning and documenting the patient’s dialysis treatment, monitoring during treatment, and for reviewing the patient’s response to the treatment and status prior to discharge. Policy: 2. The nursing assessment will be performed and documented by a licensed nurse; specifically, a Registered Nurse (RN) ... a. The assessment includes the following components: iii. Verification of prescription including machine parameters. v. Review of documentation for accuracy, completion, and patient data.” An interview with Staff # 2 on 11/30/2023 at 9:00 AM confirmed the facility staff were not consistently verifying prescriptions prior to initiation of treatment and did not follow the physician’s prescription on the patient’s treatments.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 48653 Based on record review and interview, the facility staff failed to ensure direct care staff were reporting patient vital signs that fell outside of the facility’s set parameters to the CN (charge nurse) for further assessment and intervention on 3 (# 2, # 3, #7) of 7 patient charts reviewed. In addition, the facility staff removed more than the prescribed 13ml/kg/hr (milliliters per kilogram per hour) on 2 (#6, #7) of 7 patient charts reviewed. The facility staff failed to follow the facility policy “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment”. Findings include: Patient # 2 A review of the treatment sheet dated 11/15/2023 for Patient # 2 revealed Staff # 5 did not alert the charge nurse (CN) of abnormal vital signs during treatment. Staff # 5 documented the following on 11/15/2023: “9:01 AM: BP (blood pressure): 154/137 9:31 AM: BP: 134/118; HR (heart rate): 167” There is no documentation from Staff # 5 to support the charge nurse being made aware of these abnormal vital signs during Patient # 2’s treatment on 11/15/2023. Patient # 3 A review of the treatment sheet dated 11/10/2023 for Patient # 3 revealed Staff # 5 did not alert the charge nurse (CN) of abnormal vital signs during treatment. Staff # 5 documented the following on 11/10/2023: “11:28 AM: HR: 53 11:32 AM: HR: 51 BP: 191/102 12:02 PM: HR: 50 12:32 PM: HR: 51 1:02 PM: HR: 49 1:32 PM: HR: 51 2:02 PM: HR: 53 2:30 PM: HR: 54” There is no documentation from Staff # 5 to support the charge nurse being made aware of these abnormal vital signs during Patient # 3’s treatment on 11/10/2023. Patient # 6 A review of the treatment sheet dated 11/06/2023 for Patient # 6 revealed Staff # 5 and # 21 did not alert the charge nurse of abnormal vital signs during Patient # 6’s treatment on 11/06/2023. Staff # 5, # 16 and # 21 documented the following vital signs on 11/06/2023: “4:24 PM: BP 181/110 4:32 PM: BP 169/115 5:01 PM: BP 165/113 5:31 PM: BP 175/113 6:02 PM: BP 165/113 6:32 PM: BP 158/109 7:02 PM: BP 174/123 7: 32 PM: 172/111” There is no documentation from Staff # 5 or # 21 to support the charge nurse being made aware of these abnormal vital signs during Patient # 6’s treatment on 11/06/2023. There is no documentation from Staff # 16 (RN) to support the physician being made aware of these abnormal vital signs during Patient #6’s treatment on 11/06/2023. A review of the treatment sheet dated 11/13/2023 for Patient # 6 revealed Staff # 5 and # 21 did not alert the charge nurse of abnormal vital signs during Patient # 6’s treatment on 11/06/2023. Staff # 9, # 13 and # 14 documented the following vital signs on 11/13/2023: “3:37 PM: BP 177/124; HR 111 4:03 PM: BP 190/130; HR 113 4:33 PM: BP 176/128; HR 125 5:03 PM: BP 183/122; HR 123 5:33 PM: BP 176/131; HR 118 6:03 PM: BP 176/127; HR 125 6:33 PM: BP 157/121; HR 124 7:03 PM: BP 132/104; HR 67 7:10 PM: BP 145/109; HR 133” There is no documentation from Staff # 13 to support the charge nurse being made aware of these abnormal vital signs during Patient # 6’s treatment on 11/13/2023. There is no documentation from Staff # 9 (RN) or # 14 (RN) to support the physician being made aware of these abnormal vital signs during Patient #6’s treatment on 11/13/2023. Also, the facility staff removed 14.35 ml/kg/hr (milliliters per kilogram per hour) of fluid on Patient # 6 for treatment date 11/13/2023. There was no order from the physician to remove more than 13.0 ml/kg/hr on this treatment date. A review of the treatment sheet dated 11/15/2023 revealed the facility staff removed 17.9 ml/kg/hr (milliliters per kilogram per hour) of fluid on Patient # 6 for treatment date 11/15/2023. There was no order from the physician to remove more than 13.0 ml/kg/hr on this treatment date. A review of treatment sheet dated 11/20/2023 revealed the facility staff removed 16.8 ml/kg/hr (milliliters per kilogram per hour) of fluid on Patient # 6 for treatment date 11/20/2023. There was no order from the physician to remove more than 13.0 ml/kg/hr on this treatment date. A review of the treatment sheet dated 11/27/2023 for Patient # 6 revealed Staff # 5 and # 21 did not alert the charge nurse of abnormal vital signs during Patient # 6’s treatment on 11/27/2023. Staff # 13 and # 16 documented the following vital signs on 11/27/2023: “5:04 PM: BP 142/103; HR 50 5:34 PM: BP 156/106; HR 50 6:05 PM: BP 145/107 6:35 PM: BP 142/107; HR 54 7:05 PM: BP 148/104 7:25 PM: BP 163/112” There is no documentation from Staff # 13 to support the charge nurse being made aware of these abnormal vital signs during Patient # 6’s treatment on 11/27/2023. There is no documentation from Staff # 16 (RN) to support the physician being made aware of these abnormal vital signs during Patient #6’s treatment on 11/27/2023. A review of the treatment sheet dated 11/27/2023 revealed the facility staff removed 19.1ml/kg/hr (milliliters per kilogram per hour) of fluid on Patient # 6 for treatment date 11/27/2023. There was no order from the physician to remove more than 13.0 ml/kg/hr on this treatment date. Patient # 7 A review of the treatment sheet dated 11/15/2023 revealed the facility staff removed 13.9 ml/kg/hr (milliliters per kilogram per hour) of fluid on Patient # 7 for treatment date 11/15/2023. There was no order from the physician to remove more than 13.0 ml/kg/hr on this treatment date. A review of the treatment sheet dated 11/17/2023 revealed the facility staff removed 16.9 ml/kg/hr (milliliters per kilogram per hour) of fluid on Patient # 7 for treatment date 11/17/2023. There was no order from the physician to remove more than 13.0 ml/kg/hr on this treatment date. A review of the treatment sheet dated 11/20/2023 revealed the facility staff removed 22.1 ml/kg/hr (milliliters per kilogram per hour) of fluid on Patient # 7 for treatment date 11/20/2023. There was no order from the physician to remove more than 13.0 ml/kg/hr on this treatment date. A review of the treatment sheet dated 11/22/2023 revealed the facility staff removed 15.7ml/kg/hr (milliliters per kilogram per hour) of fluid on Patient # 7 for treatment date 11/22/2023. There was no order from the physician to remove more than 13.0 ml/kg/hr on this treatment date. A review of the treatment sheet dated 11/24/2023 revealed the facility staff removed 17.8ml/kg/hr (milliliters per kilogram per hour) of fluid on Patient # 7 for treatment date 11/24/2023. There was no order from the physician to remove more than 13.0 ml/kg/hr on this treatment date. A review of the treatment sheet dated 11/27/2023 revealed the facility staff removed 16.4 ml/kg/hr (milliliters per kilogram per hour) of fluid on Patient # 7 for treatment date 11/27/2023. There was no order from the physician to remove more than 13.0 ml/kg/hr on this treatment date. A review of facility policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment” with a revision date of October 2023 revealed, “PURPOSE: To obtain and document baseline and ongoing information about the patient before, during, and after the dialysis treatment through data collection and nursing assessment. This information will be used in planning and documenting the patient’s dialysis treatment, monitoring during treatment, and for reviewing the patient’s response to the treatment and status prior to discharge. POLICY: 1. Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse. Data collection includes but is not necessarily limited to: *Measurement of patient temperature, measurement of blood pressure *Heart or pulse rate noting also if the beat is regular or irregular. *Patient weight *Patients report of well-being, level of pain or discomfort, complaints, hospitalization, and vascular access status. 2. The Nursing assessment will be performed and documented by a licensed nurse; specifically, a registered nurse (RN) ... a. The assessment includes the following components: i. Review of patient reports, data collection, complaints, and response to treatment. ii. Verification that machine safety checks have been completed and documented. iii. Verification of prescription including machine parameters. iv. Verification that the patient access is visible, and face is not covered ... 3. Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment ... Prescription components include but are not necessarily limited to: a. Dialyzer make and model b. Treatment time c. Target weight d. UFR and Max UFR e. UF profiling f. Blood Flow Rate g. Dialysate flow rate h. All access evaluated i. Correct dialysate composition (potassium, calcium, base sodium, and bicarb) and settings ... 4. Any abnormal findings pr findings outside of any patient specific physician ordered parameters discovered during pre-treatment data collection will be documented and immediately reported to the licensed nurse. If an abnormal findings is reported to the licensed nurse pre-treatment, the nurse will assess prior to the initiation of dialysis. 5. The assessment is nursing responsibility. The nurse will assess the patient pre-treatment as warranted by the patient’s condition. 6. The licensed nurse will use his/her clinical judgement based on individual patient needs to determine if ay clinical interventions are necessary. The physician will be notified of any concerns that may preclude the initiation of dialysis ... 12. The licensed nurse notified the physician as needed of changes in patient status ... 17. Licensed nurse will use their clinical judgement based on individual patient needs to determine if any clinical interventions or notification of physician is necessary prior to discharge of the patient from the facility ...” A review of facility documented titled, “NOTIFICATION PARAMETERS FOR SHERMAN DAVITA DIALYSIS #00923” revealed, “PCT reports to RN when: Heart rate: greater than 100, less than 55 or change greater than 30 bpm (beats per minute) Blood Pressure: SBP greater than 200 of less than 100 and DBP greater than 100 or less than 50 RN reports to MD when: Heart rate: greater than 100, less than 55 or change greater than 30 bpm (beats per minute) and symptomatic. Blood Pressure: Pre-Treatment: BP greater than 220/110 or less than 90/50 Treatment and Post Treatment: notify MD for persistent BP greater than 200/100 or less than 90/50” An interview with Staff # 2 on 11/30/2023 confirmed the facility staff were not consistently reporting out-of-parameter vital signs to the Charge Nurse. Also Staff # 2 confirmed the facility staff were removing more than the prescribed 13 ml/kg/hr.”

“PA-F/U REASSESSMENT-WITHIN 3 MO OF INITIAL CFR(s): 494.80(b)(2) A follow up comprehensive reassessment must occur within 3 months after the completion of the initial assessment to provide information to adjust the patient’s plan of care specified in §494.90. This Standard is not met as evidenced by: 29191 Based on record review and interview, the Interdisciplinary Team (IDT) failed to ensure that the 90-day plan of care (POC) was completed for 1(#6) of 8 patients. This deficient practice had the likelihood to cause harm to all patients by using outdated clinical assessments to complete the plan of care. A review of Patient #6’s Plan of Care revealed the 90-day plan of care had been conducted a month late dated 11/24/2023. The 90-day POC was due in October 2023. The initial Plan Of care was conducted 2 months late and the 90-day plan of care was conducted a month late. A review of the facility’s policy titled, “INTERDISCIPLINARY TEAM (IDT) PATIENT ASSESSMENT AND PLAN OF CARE” dated July 2023 revealed the following: “PURPOSE: To provide guidance for the development of patient assessment and plan of care for teammates. 1. The facility’s interdisciplinary team (IDT) consists of, at a minimum, the patient or the patient’s personal representative, a registered nurse, a physician or Non-Physician Practitioner (NPP), if allowed by state ESRD licensure regulations, treating the patient for ESRD, a social worker, and a dietitian. 2. The interdisciplinary team is responsible for providing each patient with an individualized and comprehensive assessment documenting his/her needs. The comprehensive assessment will be used to develop the patient’s treatment plan and expectations for care. 3. Assessment criteria will include, but not be limited to, evaluation of: Current health status and medical condition, including co-morbid conditions Dialysis prescription, blood pressure, and fluid management needs Laboratory results, immunization history and medication history Factors associated with anemia and potential treatment plans for anemia, including administration of erythropoiesis-stimulating agents Factors associated with renal mineral and bone disorder Nutritional status by a dietitian Psychosocial needs by a social worker Dialysis access type and performance Patient’s abilities, interests, preferences, and goals, including the desired level of participation in the dialysis care process; the preferred modality (hemodialysis or peritoneal dialysis), and setting, (for example, home dialysis), and the patient’s expectations for care outcomes Interest in transplant Family and other support systems Current patient physical activity level Referral to vocational and rehabilitation services 5. A follow-up 90-day re-assessment will be completed to evaluate the patient’s status and provide information to adjust the patient’s plan of care. In an interview with Staff #2 on 11/30/2023 at 1:00 PM confirmed the plan of care (POC) was not conducted within the 90-day timeframe with the patient.”

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 29191 Based on record review, and interview, the interdisciplinary team failed to do a comprehensive reassessment and revision to the plan of care on 1 (#5) of 8 patients where the plan of care was categorized as unstable. Also, the facility failed to follow its policy “INTERDISCIPLINARY TEAM (IDT) PATIENT ASSESSMENT AND PLAN OF CARE.” This deficient practice had the likelihood to cause harm to all patients by using outdated clinical assessments to complete the plan of care. Findings include: A review of Patient #5”s record revealed the plan of care was completed on 9/19/2023 after the patient had been missing treatments and the patient was categorized as unstable by the interdisciplinary team. A review of the record revealed no plan of care had been completed since 9/19/2023. There was no monthly Plan of Care completed for October of 2023. The patient remains unstable due to continuing to miss treatments without a plan of care being updated every 30 days until the Interdisciplinary team (IDT) considers the patient stable. A review of the facility’s policy titled, “INTERDISCIPLINARY TEAM (IDT) PATIENT ASSESSMENT AND PLAN OF CARE” dated July 2023 revealed the following: “A comprehensive re-assessment of each patient and a revision in the plan of care will be conducted: o At least annually for stable patients or semiannually when required by State Regulation o At least monthly for unstable patients including, but not limited to, patients with the following: o Extended or frequent hospitalizations o Marked deterioration in health status o Significant changes in psychosocial needs o Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis” An interview with Staff #2 on 11/30/2023 at 1:00 PM confirmed the October 2023 unstable plan of care for Patient #5 was not completed and the facility staff failed to follow the facility’s policy.”

“POC-INITIAL IMPLEMENTED-30 DAYS/13 TX CFR(s): 494.90(b)(2) Implementation of the initial plan of care must begin within the latter of 30 calendar days after admission to the dialysis facility or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session. This Standard is not met as evidenced by: 29191 Based on medical record review and staff interview, the facility’s interdisciplinary team members failed to complete an initial plan of care within 30 days of the start of treatment for the dialysis patient. There was no comprehensive assessment performed by the interdisciplinary team within 30 days of the start of dialysis to be used to implement a plan of care for 3 (#1, #2, and #6) of 8 patients. Also, the facility failed to follow the facility policy, “INTERDISCIPLINARY TEAM (IDT) PATIENT ASSESSMENT AND PLAN OF CARE.” This deficient practice had the likelihood to cause harm to all patients by using outdated clinical assessments to complete the plan of care. Findings included: A review of the medical record for Patient #1 revealed the patient was admitted on 1/30/2023. Comprehensive assessments were completed by the interdisciplinary team as follows: Social Worker, Dietitian, Registered Nurse, and physician. The initial Care Plan was not completed until 3/13/2023. The plan of care should have been completed by March 1, 2023. A review of the medical record for Patient #2 revealed the patient was admitted on 2/15/2023. Comprehensive assessments were completed by the interdisciplinary team as follows: Social Worker, Dietitian, Registered Nurse, and physician. There was no initial Care Plan found in the medical record. The plan of care should have been completed by March 15, 2023. A review of the medical record for Patient #6 revealed the patient was admitted on 6/09/2023. Comprehensive assessments were completed by the interdisciplinary team as follows: Social Worker, Dietitian, Registered Nurse, and physician. The initial Care Plan was not completed until 08/11/2023. The plan of care should have been completed by July 9, 2023. A review of the facility’s policy titled, “INTERDISCIPLINARY TEAM (IDT) PATIENT ASSESSMENT AND PLAN OF CARE” dated July 2023 revealed the following: “PURPOSE: To provide guidance for the development of patient assessment and plan of care for teammates. 1. The facility’s interdisciplinary team (IDT) consists of, at a minimum, the patient or the patient’s personal representative, a registered nurse, a physician or Non-Physician Practitioner (NPP), if allowed by state ESRD licensure regulations, treating the patient for ESRD, a social worker, and a dietitian. 2. The interdisciplinary team is responsible for providing each patient with an individualized and comprehensive assessment documenting his/her needs. The comprehensive assessment will be used to develop the patient’s treatment plan and expectations for care. 3. Assessment criteria will include, but not be limited to, evaluation of: Current health status and medical condition, including co-morbid conditions Dialysis prescription, blood pressure, and fluid management needs Laboratory results, immunization history and medication history Factors associated with anemia and potential treatment plans for anemia, including administration of erythropoiesis-stimulating agents Factors associated with renal mineral and bone disorder Nutritional status by a dietitian Psychosocial needs by a social worker Dialysis access type and performance Patient’s abilities, interests, preferences, and goals, including the desired level of participation in the dialysis care process; the preferred modality (hemodialysis or peritoneal dialysis), and setting, (for example, home dialysis), and the patient’s expectations for care outcomes Interest in transplant Family and other support systems Current patient physical activity level Referral to vocational and rehabilitation services 4. A comprehensive assessment will be conducted on all new patients within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis) beginning with the first outpatient dialysis treatment or per state guidelines” An interview with Staff #2 on 11/30/2023 at 11:00 AM confirmed the patient assessments and plan of care had not been completed by the interdisciplinary team within the 30-day timeframe.”

“POC-IMPLEMENT UPDATE-15 DAYS P PT ASSESS CFR(s): 494.90(b)(2) Implementation of monthly or annual updates of the plan of care must be performed within 15 days of the completion of the additional patient assessments specified in §494.80(d). This Standard is not met as evidenced by: 29191 Based on record review and interview, Interdisciplinary Team (IDT) failed to ensure an assessment and a revised plan of care was completed for 4 (#1, #2, #6, and #7) of 8 patients within 15 days of the assessment date. Also the facility staff failed to follow the facility policy, “INTERDISCIPLINARY TEAM (IDT) PATIENT ASSESSMENT AND PLAN OF CARE” This deficient practice had the likelihood to cause harm to all patients by using outdated clinical assessments to complete the plan of care. Findings include: Patient #1 A review of patient #1’s assessment by the Registered Dietician revealed the assessment was started on 05/05/2023. The assessment by the social worker revealed the assessment was conducted on 05/21/2023. The Registered Dietician and the Social Worker assessments were greater than 15 days from the Plan of Care. The Plan of Care (POC) was conducted with the interdisciplinary team on 06/26/2023. Patient #2 A review of patient #2’s assessment by the Registered Dietician revealed the assessment was started on 03/27/2023. The assessment by the social worker revealed the assessment was conducted on 03/29/2023. The Registered Nurse revealed the assessment was started on 04/20/2023. The Registered Dietician, Social Worker, and Registered Nurse assessments were greater than 15 days from the Plan of Care. The Plan of Care (POC) was conducted with the interdisciplinary team on 05/10/2023. Patient #6 A review of patient #6’s assessment by the Registered Dietician revealed the assessment was started on 11/03/2023. The assessment by the social worker revealed the assessment was conducted on 11/06/2023. The Registered Dietician and the Social Worker assessments were greater than 15 days from the Plan of Care. The Plan of Care (POC) was conducted with the interdisciplinary team on 11/24/2023. Patient #7 A review of patient #7’s assessment by the Registered Dietician revealed the assessment was started on 11/01/2023. The assessment by the social worker revealed the assessment was conducted on 11/03/2023. The Registered Dietician and the Social Worker assessments were greater than 15 days from the Plan of Care. The Plan of Care (POC) was conducted with the interdisciplinary team on 11/24/2023. A review of the facility’s policy titled, “INTERDISCIPLINARY TEAM (IDT) PATIENT ASSESSMENT AND PLAN OF CARE” dated July 2023 revealed the following: “PURPOSE: To provide guidance for the development of patient assessment and plan of care for teammates. 1. The facility’s interdisciplinary team (IDT) consists of, at a minimum, the patient or the patient’s personal representative, a registered nurse, a physician or Non-Physician Practitioner (NPP), if allowed by state ESRD licensure regulations, treating the patient for ESRD, a social worker, and a dietitian. 2. The interdisciplinary team is responsible for providing each patient with an individualized and comprehensive assessment documenting his/her needs. The comprehensive assessment will be used to develop the patient’s treatment plan and expectations for care. 3. Assessment criteria will include, but not be limited to, evaluation of: Current health status and medical condition, including co-morbid conditions Dialysis prescription, blood pressure, and fluid management needs Laboratory results, immunization history and medication history Factors associated with anemia and potential treatment plans for anemia, including administration of erythropoiesis-stimulating agents Factors associated with renal mineral and bone disorder Nutritional status by a dietitian Psychosocial needs by a social worker Dialysis access type and performance Patient’s abilities, interests, preferences, and goals, including the desired level of participation in the dialysis care process; the preferred modality (hemodialysis or peritoneal dialysis), and setting, (for example, home dialysis), and the patient’s expectations for care outcomes Interest in transplant Family and other support systems Current patient physical activity level Referral to vocational and rehabilitation services 10. An initial Plan of Care, based on the findings from the comprehensive assessment, will be completed on all patients new to dialysis within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis) beginning with the first outpatient dialysis treatment or per state guidelines. 11. After completion of the 90 Day re-assessment, the Interdisciplinary Team will conduct an IDT meeting to make adjustments to the Plan of Care. This meeting and initiation of the updated Plan of Care must occur within 15 days of completion of re-assessment. 12. Subsequent interdisciplinary re-assessments should be completed within the 30 days following the initiation of the re-assessment. The Plan of Care following re-assessments must be completed within 15 days of completing the re-assessment. This process would occur monthly for unstable patients and annually for stable patients.” An interview with Staff #2 on 11/30/2023 at 2:00 PM confirmed the plan of care (POC) was conducted greater than 15 days from the start of when the first assessment was completed for patients #1, #2, #6, and #7.”

“QAPI-COVERS SCOPE SERV/EFFECTIVE/IDT INVOL CFR(s): 494.110 The dialysis facility must develop, implement, maintain, and evaluate an effective, data-driven, quality assessment and performance improvement program with participation by the professional members of the interdisciplinary team. The program must reflect the complexity of the dialysis facility’s organization and services (including those services provided under arrangement), and must focus on indicators related to improved health outcomes and the prevention and reduction of medical errors. The dialysis facility must maintain and demonstrate evidence of its quality improvement and performance improvement program for review by CMS. This Standard is not met as evidenced by: 29191 Based on record review and interview, the facility failed to develop, implement, maintain, and evaluate an effective data-driven quality assessment and performance improvement program and to track, trend, and develop appropriate action and follow-up required. These findings have the likelihood to cause harm to all patients receiving care at the facility by allowing trends and medical errors to go unnoticed and by failure to reduce and prevent medical errors and adverse events. Findings include: A review of the Quality Assessment/Performance Improvement Program revealed the program was not robust and effective in identifying the numerous infection control issues, anemia, treatment flow sheet inaccuracies, safety, and mortality events found by the surveyor. A review of the Quality Assessment/Performance Improvement Program revealed the program did not effectively identify the numerous infection control issues, ensure treatment flow sheets were accurate and there were anemia and safety issues not addressed. The data collection for the infection control issues, anemia, treatment flow sheet inaccuracies, safety, and mortality events were collected and identified, but there was no action plan to solve the issues found. If there was a plan the quality program did not identify the outcomes of the action plan. An interview with Staff #2 on 11/30/2023 at 3:00 PM confirmed the facility’s Quality Assurance Improvement Program had not identified the numerous problems found during the survey with an action plan.”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 29191 Based on record review and interview, the facility’s governing body failed to ensure the medical record contained a comprehensive history and physical examination by the patient’s nephrologist completed within 30 days of admission and at least annually for 1 (#1) of 8 records reviewed. This deficient practice had the likelihood to cause harm to the dialysis patient not having a current comprehensive history and physical examination by the patient’s nephrologist. Findings include: A review of the medical record on 11/30/2023 at 11:00 AM revealed there were 1 (#1) of 8 patient’s medical records that did not have a comprehensive history and physical examination completed upon admission or at least annually by the patient’s nephrologist. The nurse Practitioner and Physician assistant had completed a comprehensive progress note for patient #1, but there was no notation from the nephrologist that addressed the current presentation and health status related to the kidney disease. An interview with Facility Administrator #1 on 11/30/2023 at 11:00 AM confirmed there was no History and Physical by the patient’s nephrologist.”