Quality Dialysis Two, Inc.

“COMPLIANCE WITH FED/STATE/LOCAL LAWS CFR(s): 494.20 The facility and its staff must operate and furnish services in compliance with applicable Federal, State, and local laws and regulations pertaining to licensure and any other relevant health and safety requirements. This Standard is not met as evidenced by: 30124 Based on observation and interview the facility failed to ensure that oxygen tanks were stored and identified according to the Federal and State laws that regulated medical gases according to “National Fire Protection Association (NFPA) 99, Standard for Health Care Facilities. Three oxygen tank cylinders observed in the patient treatment area. 2 - Oxygen cylinders were observed in the supply room unsecured by a rack or chain and not identified as full or empty. 1 - Oxygen cylinder was identified in the patient care area, seal had been broken with a regulator attached. Cylinder was not identified as full or empty. Record Reviewed: Review of “National Fire Protection Association (NFPA) 99, Standard for Health Care Facilities”(2005 edition): showed oxygen cylinders must be secured in racks or by chains, identified as full or empty and stored separately. NFPA 99 requires empty cylinders to be stored separately from full cylinders. This means partially full cylinders must be stored with the empty cylinders or stored separately from full or empty cylinders. “ A cylinder is considered “full” provided it still has its seal from the supplier. Once the seal has been removed, the cylinder is no longer considered full and cannot be stored with full cylinders. Findings: Observation on 08/11/2025 at !5:30 along with the Facility Administrator, (B) the following was observed: 2 - Oxygen cylinders were observed in the supply room unsecured by a rack or chin and not identified as full or empty. 1 - Oxygen cylinder was identified in the patient care area, seal had been broken with a regulator attached. Cylinder was not identified as full or empty. Interview on 08/11/2025 with Facility Administrator (B), confirmed that two oxygen cylinders were not secured and oxygen cylinders were not identified as full or empty. 48020”

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 48020 Based on observation, interview and record review, the facility’s direct care staff failed to perform hand hygiene after removal of contaminated gloves per the facility’s policy in 1 of 2 staff observed: Clinical Nurse Manager (A) Findings: Review of the facility’s current policy and procedure: Hand Hygiene directs the staff as follows: “This policy applies to all Quality Dialysis Two, LP employees. Hands will be washed prior to gloving, after removal of gloves, after contamination with blood or other infectious agents, between patients and at the close of the business day prior to leaving the facility or patients home. “Hand hygiene” includes either washing hands with soap and water, or using a waterless alcohol-based antiseptic hand rub with 60-90% alcohol content. Hands should be washed with soap and water if visibly soiled. If not visibly soiled, hand hygiene with alcohol-based hand rub may be used. The CDC recommends that hand washing incorporate rubbing hands together “vigorously” for 15 seconds, and that the use of alcohol-based rubs incorporate covering all surfaces of hands and fingers, until hands are dry. According to the CDC, even with glove use, hand hygiene is necessary after glove removal because hands can become contaminated through small defects in gloves and from the outer surface of gloves during glove removal.” Observation on 08/13/2025 at 8:52 a.m. revealed Clinical Nurse Manager (A) terminally cleaning the station post hemodialysis treatment of a patient. Clinical Nurse Manager (A) removed the hemodialysis bloodlines from the machine, removed her contaminated gloves, reached into the glove box, removed two clean gloves and donned them without performing hand hygiene. Subsequent observation revealed Clinical Nurse Manager (A) remove the bicarbonate jug used during the patient’s hemodialysis treatment, dumped the contents into the dirty sink, did a glove change without performing hand hygiene. Next, Clinical Nurse Manager (A) attached the acid jug to the hemodialysis machine for internal disinfection, did a glove change without performing hand hygiene. Clinical Nurse Manager (A) then cleaned and disinfected the hemodialysis machine and chair, did a glove change without performing hand hygiene. The Surveyor immediately notified Clinical Nurse Manager (A) that she failed to perform hand hygiene each time she removed her contaminated gloves. Clinical Nurse Manager (A) said, “Okay, I got you.””

“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: 48020 Based on observation, interview and record review, the facility’s direct care staff failed to clean and disinfect the intravenous pole rungs and wall box in 1 of 2 staff observed: Clinical Nurse Manager (A) Findings: Review of facility’s current policy and procedure: Cleaning & Disinfecting With 1:100 Bleach & Water directs staff as follows: “Purpose 1. To maintain clean hemodialysis equipment... Post dialysis the following procedure must be performed on all hemodialysis equipment. Procedure “ Add tap water to the specimen container to 1000 ml mark. “ Withdraw 10 ml of bleach with a syringe and add to 1000 ml of water, ensure mixing of the solution. “ Use the provided disposable wipe or wash cloth to wipe surface areas of the equipment. This solution may also be used for drain pans supporting the equipment. The idea is to keep the area clean not sterile...” Observation on 06/25/2025 at 10:45 a.m. revealed Clinical Nurse Manager (A) terminally cleaning the station post hemodialysis treatment of a patient. Clinical Nurse Manager (A) failed to remove a used face shield hanging from the intravenous (IV) pole and clean and disinfect the IV pole rungs. Clinical Nurse Manager (A) also failed to clean and disinfect the wall box that had dust buildup on it. The Surveyor notified Clinical Nurse Manager (A) at 9:15 AM that she failed to clean and disinfect the intravenous pole rungs and wall box. Clinical Nurse Manager (A) said, “Okay, we will clean it.””

“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: 30124 Based on observation, record review and interview, the facility’s governing body failed to ensure expired supplies are not stored, and in use in the facility for care and services of patients beyond the manufacturer ’ s directions for use. Policy Reviewed: Review on 08/13/2025 of the facility current policy and procedure titled, “Nursing Responsibilities”, Date January 1, 2024. Statement: It is the policy of Quality Dialysis Two, LP. That all licensed personnel check their dialysis supplies prior to initiation the dialysis procedure. Purpose: To Ensure that all clinical supplies used in the delivery of hemodialysis (HD) and peritoneal dialysis (PD) services are within their manufacturer-specified expiration dates, thereby ensuring patient safety, compliance with regulatory standards, and maintain quality of care. Procedure: 2. Monitoring Schedule “ Daily Checks: Staff verify expiration dates before opening any package for patient use. “ Weekly Checks: Designated staff review supplies in treatment rooms, carts, emergency kits, and PD storage areas. “ Monthly Inventory Audit: Comprehensive review of all clinical storage areas (including bulk storage) for expired or soon-to-expire items. 4. Removal of Expired Supplies “ Expired items must be removed immediately from patient care areas. Findings: Observation of the hemodialysis treatment area on 08/11/2025 beginning at 0:23 p.m. along with the Facility Administrator (B) the following expired supplies were co-mingled with stocks in use. Laboratory Area 9 - BD Vacutainer Multiple Sample Luer Adapter, Lot #2217247, Expiration date 07/31/2025. 32 - Sheer Adhesive Bandages 1x3 inches. Lot #58114, Expiration date 12/09/2021. 54 - Hema-Screen Slide Test for Fecal Occult Blood, Lot# 20783, Expiration date 06/30/2023. 100 - BD Vacutainer, Blood collection tubes, 4 ml, Lot 3289087, Expiration date 01/31/2025. Patient Room #1 34 - Baxter Mini Cap with Povidone Iodine solution, Lot# 24A15H15, Expiration date 06/28/2025. 1 - 16 fluid ounces Hydrogen Peroxide 3%, Lot # 61618, Expiration date 04/2024. Nurses Station 5 - Packages Dialysate Additive, Calcium Chloride 12.5 Grams, 1 mEq/L, Lot#14462/134, Expiration Date 03/23/2025. 1 - opened 32-ounce container of LiquaCel Watermelon Concentrated Liquid Protein. Container not labeled with an open date. Manufacturers instructions shelf life 90 days after opening. Supply Closet 13 - RPC Recirculation Connectors, Lot # 2100016, Expiration date 03/15/2024. Interview with Facility Administrator (B) confirmed the above expired supplies. 48020”

“PR-RECEIVE SERVICES OUTLINED IN POC CFR(s): 494.70(a)(12) The patient has the right to- (12) Receive the necessary services outlined in the patient plan of care described in §494.90; This Standard is not met as evidenced by: 48020 Based on observation, record review and interview, the facility’s licensed nurses failed to administer patients’ hemodialysis treatments based on physicians’ orders in 1 of 5 sampled patients: Patient #5 Findings: Review of the facility’s current Policy and Procedure on Nursing Responsibilities directs staff as follows: “EQUIPMENT SAFETY CHECKS: 5. Temperature 37-39 or as per manufacture recommendations VERIFICATION OF PATIENTS DIALYSIS ORDERS: 1. Right patient 2. Right dialyzer 3. Right dialysate 4. Right blood flow rate 5. Right dialysate flow rate 6. Right treatment time 7. Right UF calculations 8. Right heparinization/loading dose, and any other orders as prescribed by the nephrologist.” Patient #5 Review of the patient’s clinical record on 08/11/2025 revealed the patient was admitted to the facility on 02/28/2017 with the diagnoses of end stage renal disease and diabetes mellitus, on in-center hemodialysis three times a week. Review of the patient’s clinical record revealed a physician’s order dated 07/09/2025 for a dialysate temperature of 36 degrees Celsius, dialysate settings: potassium 2.0 mEq/L, calcium 2.5 mEq/L, sodium 140 mEq/L and machine bicarbonate of 37.0 mEq/L. Review of the patient’s treatment sheet dated 08/01/2025 revealed documentation which indicated the patient was prescribed a dialysate temperature of 36 degrees Celsius on the treatment sheet but received hemodialysis treatment at a dialysate temperature of 37 degrees Celsius from 5:05 AM - 8:35 AM. There was no justification documented for the dialysate temperature of 37 degrees Celsius. Review of the patient’s treatment sheet dated 08/04/2025 revealed documentation which indicated the patient was prescribed a dialysate temperature of 36 degrees Celsius on the treatment sheet but received hemodialysis treatment at a dialysate temperature of 37 degrees Celsius from 4:55 AM - 8:25 AM. There was no justification documented for the dialysate temperature of 37 degrees Celsius. Review of the patient’s treatment sheet dated 08/06/2025 revealed documentation which indicated the patient was prescribed a dialysate temperature of 36 degrees Celsius on the treatment sheet but received hemodialysis treatment at a dialysate temperature of 37 degrees Celsius from 4:59 AM - 8:30 AM. There was no justification documented for the dialysate temperature of 37 degrees Celsius. Review of the patient’s treatment sheet dated 08/08/2025 revealed documentation which indicated the patient was prescribed a dialysate temperature of 36 degrees Celsius on the treatment sheet but received hemodialysis treatment at a dialysate temperature of 37 degrees Celsius from 5:17 AM - 8:47 AM. There was no justification documented for the dialysate temperature of 37 degrees Celsius. Review of the patient’s treatment sheet dated 08/11/2025 revealed documentation which indicated the patient was prescribed a dialysate temperature of 36 degrees Celsius on the treatment sheet but received hemodialysis treatment at a dialysate temperature of 37 degrees Celsius from 5:17 AM - 8:48 AM. There was no justification documented for the dialysate temperature of 37 degrees Celsius. Observation on 08/13/2025 at 5:15 AM revealed Patient #5 receiving hemodialysis treatment on machine #4TOS-134847 at a blood flow rate of 350 mL/min and a dialysate flow rate of 600 mL/min via right lower arm vascular access. The patient was utilizing an Optiflux 160 non reuse dialyzer. The dialysate settings were: 2 potassium, 2.5 calcium, 36 bicarbonate, 140 sodium. Subsequent review of the physician’s order dated 07/09/2025 revealed machine bicarbonate of 37.0 mEq/L. Interview during observation with Clinical Nurse Manager (A), the Surveyor informed Clinical Nurse Manager (A) that the machine bicarbonate was not set on the hemodialysis machine as prescribed by the physician. Clinical Nurse Manager (A) said, “Okay.” The Surveyor also notified Clinical Nurse Manager (A) and Facility Administrator (B) at 6:15 AM that the patient did not receive the hemodialysis treatment at the prescribed dialysate temperature on 08/01/2025, 08/04/2025, 08/06/2025, 08/08/2025 and 08/11/2025. Clinical Nurse Manager (A) and Facility Administrator (B) reviewed the treatment sheets for the corresponding dates and said, “We lower the temperature to 36 when the patient’s blood pressure drops.””

“POC-PTS SEEN BY MED STAFF 1X/MO CFR(s): 494.90(b)(4) The dialysis facility must ensure that all dialysis patients are seen by a physician, nurse practitioner, clinical nurse specialist or physician’s assistant providing ESRD care at least monthly, as evidenced by a monthly progress note placed in the medical record, and periodically while the hemodialysis patient is receiving in-facility dialysis. This Standard is not met as evidenced by: 48020 Based on observation, interview and record review, patients’ attending nephrologists failed to complete monthly comprehensive progress notes on patients addressing adequacy, vascular access, anemia management, nutritional status, bone mineral metabolism and treatment response in 1 of 1 in-center hemodialysis sampled patients: Patient #s 5 Findings: Patient #5 Observation on 08/13/2025 at 5:15 AM revealed Patient #5 receiving hemodialysis treatment on machine #4TOS-134847 at a blood flow rate of 350 mL/min and a dialysate flow rate of 600 mL/min via right lower arm vascular access. Review of the patient’s clinical record on 08/11/2025 revealed the most current physician progress note was dated 06/02/2025. Review of the patient’s clinical record also revealed documentation which indicated that the patient’s nephrologist rounded on the patient on 04/07/2025, 04/21/2025, 05/05/2025 and 05/23/2025. There was no monthly comprehensive progress note documented for July 2025. Interview with Clinical Nurse Manager (A) 08/11/2025 at 3:05 PM confirmed the physician progress note was not completed by the attending nephrologist and she said the covering physician did not complete the progress note.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 30124 Based on observation, record review and interview, per the facility’s medical director failed to ensure staff followed the facility’s policy and procedures for labeling and identifying laboratory specimen containers in 3 of 3 specimen containers observed. Policy Reviewed: Review on 08/13/2025 of the facility current policy and procedure titled, “Nursing Responsibilities”, Date January 1, 2024. Responsibilities of the Hemodialysis Nurse: The dialysis nurse will provide patient care as mandated by professional standards of practice and in compliance with the organizations policy and procedures. Collection of PD (peritoneal dialysis) fluid: Adequacy: “ Obtain approximately 10 cc sample from 15-liter drain bag and place in sample cup for testing. PD (peritoneal dialysis) Effluent: “ Drain approximately 100 cc into sample cup, collect 10 cc for testing. “ Verify the proper name is on all test tubes/collection cups. “ Samples must be shipped on the day they are drawn but if the shipment cannot be sent the day of collection the samples should be refrigerated. Findings: Observation of the facility’s laboratory specimen refrigerator on 08/11/2025 beginning at 2:30 p.m. along with the Facility Administrator (B) the following was observed: 3 - specimen 100 ml containers were observed in the specimen refrigerator. Each of the containers appeared to have approximately 50 ml of a clear yellowish-white fluid. The specimen containers were not observed to have been labeled with patient identification information, specimen source nor the name, date, and time of collection. Interview on 08/11/2025 at 2:45 p.m. with Nurse Manager (A) confirmed that she had collected the three-specimen sample of peritoneal dialysis fluid from a patient last week and she should have labeled the samples properly with the patient information, time, and date the fluid was drawn.”

“GOV-ADM RESP FOR RELATIONSHIP W/ESRD NW CFR(s): 494.180(a)(3) The governing body or designated person responsible must appoint an individual who serves as the dialysis facility’s chief executive officer or administrator who exercises responsibility for the management of the facility and the provision of all dialysis services, including, but not limited to- (3) The relationship with the ESRD networks; This Standard is not met as evidenced by: 48020 Based on record review and interview, the facility failed to schedule the initial coaching call with End Stage Renal Disease Network 14 as requested. Findings: Pre- survey communication with the End Stage Renal Disease Network 14, revealed the facility has not scheduled the initial coaching call for May to meet the 80% pneumococcal vaccination rate goal. A notice of delinquency was sent July 7, 2025, and still no response was received from the facility. On 08/11/2025 at 3:59 p.m., Facility Administrator (B) was notified that the facility had not set up the coaching call with End Stage Renal Disease Network 14. Facility Administrator (B) said, “Let me dig into that.””