Usrc Weatherford

“ESRD EP Training Program CFR(s): §494.62(d)(1): Condition for Coverage: (d)(1) Training program. The dialysis facility must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. Staff training must: (iii) Demonstrate staff knowledge of emergency procedures, including informing patients of- (A) What to do; (B) Where to go, including instructions for occasions when the geographic area of the dialysis facility must be evacuated; (C) Whom to contact if an emergency occurs while the patient is not in the dialysis facility. This contact information must include an alternate emergency phone number for the facility for instances when the dialysis facility is unable to receive phone calls due to an emergency situation (unless the facility has the ability to forward calls to a working phone number under such emergency conditions); and (D) How to disconnect themselves from the dialysis machine if an emergency occurs. (iv) Demonstrate that, at a minimum, its patient care staff maintains current CPR certification; and (v) Properly train its nursing staff in the use of emergency equipment and emergency drugs. (vi) Maintain documentation of the training. (vii) If the emergency preparedness policies and procedures are significantly updated, the dialysis facility must conduct training on the updated policies and procedures. This Standard is not met as evidenced by: 50181 Based on record review and interview, the facility failed to ensure all patient care staff maintains current CPR (cardiopulmonary resuscitation) certification. Findings:Charge Nurse (Staff #4) CPR certification on file expired 07/31/2025 Certified Clinical Hemodialysis Technician (CCHT) (Staff #8)CPR (cardiopulmonary resuscitation) certification on file expired 06/2025 The above findings were confirmed by the Facility Administrator.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 50181 Based on observation and staff interview the facility failed to ensure expired medications were discarded on or before the expiration date and not available for patient use in the facility. The use of expired medications could negatively impact the health and well-being of the 49 in-center hemodialysis patients receiving dialysis treatments at the facility. Findings included: During a tour of the facility’s treatment floor on the morning of 08/28/2025, with the Clinical Specialist (Staff #3), the following expired medications were found in the designated medication area and available for patient use: 1 bottle of Benadryl tablets with a printed expiration date on the bottle of 07/2025 1 opened vial of multi-use Tubersol without an opened date resulting in the inability to determine the date of discard which is noted as 30 days after opening on the tubersol packaging The Clinical Specialist (Staff #3) confirmed the above findings at the time of the observations on the treatment floor the morning of 08/28/2025.”

“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: 50181 Based on record review, policy review, and staff interview, the facility failed to follow the patient’s ordered plan of care by not following the ordered blood flow rate (BFR) and/or dialysate flow rate (DFR) for one or more treatment records reviewed. The specific BFR/DFR ordered by the physician is needed to ensure that the blood pump is at constant speed to push the patient’s blood through the dialyzer and back into the patient’s body and is a part the patient’s dialysis prescription. Review of Patient #1 treatment record for 08/23/2025 revealed the BFR was ordered to run at 400mL/min. Review of the intradialytic records revealed the BFR ran at 357 mL/min from 10:27-11:25 and the BFR ran at 354 mL/min from 11:26-11:41 with no documentation reporting the variation in the BFR to the charge nurse by the patient care technician and no supporting documentation from the nurse related to the variation in hemodialysis orders for the treatment. Review of Patient #3 treatment record for 08/23/2025 revealed the BFR was ordered to run at 400mL/min and the DFR was ordered to run at 800mL/min. Review of the intradialytic records revealed the BFR ran at 300 mL/min and the DFR ran at 700 mL/min for the duration of the treatment (10:19-12:29) with no documentation reporting the variation in the BFR and/or DFR to the charge nurse by the patient care technician and no supporting documentation from the nurse related to the variation in hemodialysis orders for the treatment. Review of Patient #4 treatment record for 08/23/2025 revealed the BFR was ordered to run at 400mL/min. Review of the intradialytic records revealed the BFR ran at 300 mL/min from 09:57-10:27 with no documentation reporting the variation in the BFR to the charge nurse by the patient care technician and no supporting documentation from the nurse related to the variation in hemodialysis orders for the treatment. Review of Patient #5 treatment record for 08/23/2025 revealed the BFR was ordered to run at 400mL/min. Review of the intradialytic records revealed the BFR ranged from 296-352 mL/min from 10:57-14:07 with no documentation reporting the variation in the BFR to the charge nurse by the patient care technician and no supporting documentation from the nurse related to the variation in hemodialysis orders for the treatment. Review of Patient #6 treatment record for 08/23/2025 revealed the BFR was ordered to run at 400mL/min. Review of the intradialytic records revealed the BFR ranged from 348-356 mL/min from 06:30-09:26 with no documentation reporting the variation in the BFR to the charge nurse by the patient care technician and no supporting documentation from the nurse related to the variation in hemodialysis orders for the treatment. Review of Patient #7 treatment record for 08/23/2025 revealed the BFR was ordered to run at 400mL/min. Review of the intradialytic records revealed the BFR ranged from 346-354 mL/min from 04:55-08:54 with no documentation reporting the variation in the BFR to the charge nurse by the patient care technician and no supporting documentation from the nurse related to the variation in hemodialysis orders for the treatment. Review of Patient #8 treatment record for 08/23/2025 revealed the DFR was ordered to run at 500mL/min. Review of the intradialytic records revealed the DFR ran at 800mL/min from 06:46-10:04 with no documentation reporting the variation in the DFR to the charge nurse by the patient care technician and no supporting documentation from the nurse related to the variation in hemodialysis orders for the treatment. Review of Patient #9 treatment record for 08/23/2025 revealed the BFR was ordered to run at 300mL/min. Review of the intradialytic records revealed the BFR ranged from 349-357 mL/min from 06:20-10:22 with no documentation reporting the variation in the BFR to the charge nurse by the patient care technician and no supporting documentation from the nurse related to the variation in hemodialysis orders for the treatment. Review of Patient #10 treatment record for 08/23/2025 revealed the BFR was ordered to run at 400mL/min. Review of the intradialytic records revealed the BFR ranged from 375-378 mL/min from 05:28-09:08 with no documentation reporting the variation in the BFR to the charge nurse by the patient care technician and no supporting documentation from the nurse related to the variation in hemodialysis orders for the treatment. Review of Patient #11 treatment record for 08/23/2025 revealed the BFR was ordered to run at 400mL/min. Review of the intradialytic records revealed the BFR ranged from 349-354 mL/min from 07:57-08:57 with no documentation reporting the variation in the BFR to the charge nurse by the patient care technician and no supporting documentation from the nurse related to the variation in hemodialysis orders for the treatment. Review of Patient #12 treatment record for 08/23/2025 revealed the BFR was ordered to run at 250 mL/min. Review of the intradialytic records revealed the BFR ranged from 299-304 mL/min from 05:22-07:27 with no documentation reporting the variation in the BFR to the charge nurse by the patient care technician and no supporting documentation from the nurse related to the variation in hemodialysis orders for the treatment. Review of Patient #12 treatment record for 08/26/2025 revealed the BFR was ordered to run at 250 mL/min. Review of the intradialytic records revealed the BFR ranged from 296-301 mL/min from 04:53-07:23 with no documentation reporting the variation in the BFR to the charge nurse by the patient care technician and no supporting documentation from the nurse related to the variation in hemodialysis orders for the treatment. Review of Patient #13 treatment record for 08/25/2025 revealed the BFR was ordered to run at 400 mL/min. Review of the intradialytic records revealed the BFR ranged from 349-352 mL/min from 10:56-12:27 with no documentation reporting the variation in the BFR to the charge nurse by the patient care technician and no supporting documentation from the nurse related to the variation in hemodialysis orders for the treatment. Review of Patient #14 treatment record for 08/25/2025 revealed the BFR was ordered to run at 400 mL/min. Review of the intradialytic records revealed the BFR ranged from 303-314 mL/min from 11:26-15:21. The patient care technician (Staff #8) documented the following at 11:25, “pt bfr decreased to 300 due to high arterial pressure, charge nurse notified.” There is no supporting documentation from the nurse related to the variation in hemodialysis orders for the treatment.”

“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: 50181 Based on medical record review, policy review and staff interview the facility staff failed to ensure the direct patient care (DPC) staff reported patient status changes during treatment to the Registered Nurse (RN) to ensure a reassessment was performed and documented with appropriate interventions and/or physician notification, if required. Also, the facility staff failed to ensure timely documentation of the patient’s vital signs and the patient’s status during hemodialysis treatment. A review of the facility policy (Policy # C-ID-0010) titled, “Intradialytic Monitoring of Patient,” with an effective date of 01/2020, and revision date of 07/2024, includes the following guidance: “MONITORING: Direct patient care staff will monitor the following parameters during each dialysis treatment: PATIENT: 1. Must be in direct view of a staff member at all times ... 2. Vital signs: Obtained and documented at least every 30 minutes and reported to charge nurse if outside of standing orders and/or reportable parameters, refer to C-FORMS-0081 Reportable Parameters to CN. 3. Volume status: Indicated by changes in BP and HR parameters, lung sounds and presence or reduction of edema. 4. Vascular access: Site clean and dry; venous and arterial pressure monitoring; signs and symptoms of recirculation; signs and symptoms of infiltration. 5. ENSURE PATIENT’S ACCESS, BLOOD LINES AND FACE ARE VISIBLE AT ALL TIMES ... 6. Anticoagulation effectiveness ... 7. Well-being; level of consciousness: ask patient simple open-ended questions that cannot be answered with yes or no to determine LOC. 8. Delivery of dialysis prescription: review prescribed treatment orders against actual machine settings. 9. Response to treatment: evaluate vital signs and any patient complaints such as nausea, dizziness, restlessness, decreased responsiveness, shortness of breath, cramps, etc. 10. Comment regarding patient status and staff observation at least every 30 minutes ... DELIVERY SYSTEM MONITORING: ...3. Blood flow rate: any variance from prescribed order requires documentation of reason. 4. Dialysate flow rate: any variance from prescribed order requires documentation of reason ...” The following reportable parameters were provided by the Facility Administrator (Staff #2) on 08/26/2025: “PCT/CCHT/LPN Report to the Charge Nurse Pre-Dialysis Blood Pressure: Systolic>180 or <90 Diastolic >90 Pulse: <50 or >120 beats per minute NURSE MUST COMPLETE ASSESSMENT BEFORE TREATMENT INITIATED IF ANY PARAMETERS NOT MET Intra-Dialysis BP: Systolic>180 or <90 Diastolic>90 Pulse: <50 or >120 beats per minute ANY PATIENT COMPLAINT Post-Dialysis BP: Systolic>180 or <90 Diastolic>90 Pulse: <50 or >120 beats per minute” The findings include: Review of Patient #1 treatment record for 08/23/2025 revealed the following: Pre-Dialysis sitting blood pressure (BP): 161/103 recorded by patient care technician (PCT), Staff #11, at 10:07. There was no documentation indicating the out of parameter BP was reported to the registered nurse (RN), Staff #4, prior to treatment initiation at 10:12. The pre-dialysis RN assessment was completed at 12:01 by Staff #4. There was no documentation found that the RN addressed the out of parameter BP prior to treatment initiation. An intradialytic BP reading of 171/99 was recorded at 10:27. At 10:43, PCT (Staff #3) entered the following note, “Patient is tolerating treatment well. Sitting in chair with feet elevated and back of chair reclined. Access visualized and no problems noted. Machine/lines checked. Respirations regular.” There was no documentation identifying the out of parameter BP and no documentation indicating it was reported to the RN. There is no documentation found that the RN addressed the out of parameter BP. An intradialytic BP reading of 155/119 was recorded at 11:26. At 11:41, PCT (Staff #12) entered the following note, “Late Entry: Patient is tolerating treatment well. Sitting in chair with feet elevated and back of chair reclined. Access visualized and no problems noted. Machines/lines checked. Respirations regular. Patient resting and eyes closed. Dialysis in progress. Respirations regular. Access visualized and lines secure.” There was no documentation identifying the out of parameter BP and no documentation indicating it was reported to the RN. There is no documentation found that the RN addressed the out of parameter BP. Post-Dialysis sitting blood pressure (BP): 189/98 recorded by patient care technician (PCT), Staff #11, at 14:02. There was no documentation indicating the out of parameter BP was reported to the RN (Staff #4) after treatment termination at 13:41. The post-dialysis RN assessment was completed at 14:59 by Staff #4. The following post dialysis comments were entered by Staff #4, “Patient tolerated treatment well, voices no discomfort, UF goal reached, sites secured, discharged stable alert ambulatory via w/c back to NH.” There was no documentation found that the RN addressed the out of parameter BP post dialysis and prior to discharge from the facility. Review of Patient #3 treatment record for 08/23/2025 revealed the following: Pre-Dialysis sitting blood pressure (BP): 208/115 and pre-dialysis standing BP: 211/136 recorded by RN (Staff #4) at 10:19. There was no documentation indicating the out of parameter BP was addressed by the RN (Staff #4) prior to treatment initiation at 10:19. The pre-dialysis RN assessment was completed at 10:18 by Staff #4. There was no documentation found that the RN addressed the out of parameter BP prior to treatment initiation. The following pre-dialysis comments were entered by staff #4, “other: arrived stable, alert, ambulatory, tx started via pc, lines secured, resting.” An intradialytic BP reading of 211/136 was recorded at 10:19. At 10:20, RN (staff #4) entered the following note, “Pre-Dialysis Standing, using aseptic technique, catheter ports aspirated and flushed by nurse, treatment initiated without problems. Lines taped and secure. Saline line clamped. HemaClip device secure.” There is no documentation found that the RN addressed the out of parameter BP or notified the physician. An intradialytic BP reading of 217/109 was recorded at 11:05. At 11:06, PCT (Staff #11) entered the following note, “Patient resting and eyes closed. Dialysis in progress. Respirations regular. Access visualized and lines secure.” There was no documentation identifying the out of parameter BP and no documentation indicating it was reported to the RN. An intradialytic BP reading of 167/109 was recorded at 11:28. At 11:43, PCT (Staff #12) entered the following note, “Patient is tolerating treatment well. Sitting in chair with feet elevated and back of chair reclined. Access visualized and no problems noted. Machine/lines checked. Respirations regular. Patient is talking. Access visualized and lines secure.” There was no documentation identifying the out of parameter BP and no documentation indicating it was reported to the RN. Review of Patient #5 treatment record for 08/23/2025 revealed the following: Comments regarding patient status and staff observation documented by PCT (Staff #11) at 10:57. The next comments regarding the patient status and staff observation were documented by PCT (Staff #12) at 11:40 which exceeds every 30-minute documentation related to the patient status and staff observation. Review of Patient #7 treatment record for 08/23/2025 revealed the following: Post-Dialysis sitting blood pressure (BP): 205/73 and post-dialysis standing BP: 197/84 recorded by the PCT (Staff #12) at 09:08. There was no documentation indicating the out of parameter BP was reported to the RN (Staff #4) after treatment termination at 08:54. The post-dialysis RN assessment was completed at 11:52 by Staff #4. The following post dialysis comments were entered by Staff #4, “Other: Patient tolerated treatment well, voices no pain/discomfort, UF goal reached, sites secured, discharged stable alert ambulatory” There was no documentation found that the RN addressed the out of parameter BP post dialysis and prior to discharge from the facility. Review of Patient #9 treatment record for 08/23/2025 revealed the following: Comments regarding patient status and staff observation documented by PCT (Staff #11) at 07:34. The next comments regarding the patient status and staff observation were documented by PCT (Staff #11) at 08:29 which exceeds every 30-minute documentation related to the patient status and staff observation. Comments regarding patient status and staff observation documented by PCT (Staff #11) at 09:02. The next comments regarding the patient status and staff observation were documented by PCT (Staff #11) at 10:21 which exceeds every 30-minute documentation related to the patient status and staff observation. Review of Patient #15 treatment record for 08/23/2025 revealed the following: Pre-Dialysis sitting blood pressure (BP): 157/97 recorded by PCT (Staff #12) at 10:56. There was no documentation indicating the out of parameter BP was reported to the RN (Staff #4) prior to treatment initiation at 11:04. The pre-dialysis RN assessment was completed at 11:06 by Staff #4. There was no documentation found that the RN addressed the out of parameter BP prior to treatment initiation. An intradialytic BP reading of 182/105 was recorded at 11:02. At 11:07, RN (Staff #4) entered the following note, “Using aseptic technique, catheter ports aspirated and flushed by nurse. Treatment initiated without problems. Lines taped and secure. Saline line clamped. HemaClip device secure.” There was no documentation identifying the out of parameter BP by the RN initiating treatment and there is no documentation found that the RN addressed the out of parameter BP. Post-Dialysis sitting blood pressure (BP): 167/102 recorded by the RN, Staff #4, at 14:28. There was no documentation indicating the out of parameter BP was addressed by the RN (Staff #4) after treatment termination at 13:54. The post-dialysis RN assessment was completed at 14:29 by Staff #4. The following post dialysis comments were entered by Staff #4, “Patient tolerated treatment well, voices no discomfort, UF goal reached, sites secured, discharged stable alert ambulatory via w/c.” There was no documentation found that the RN addressed the out of parameter BP post dialysis and prior to discharge from the facility. Review of Patient #16 treatment record for 08/23/2025 revealed the following: Comments regarding patient status and staff observation documented by PCT (Staff #11) at 09:02. The next comments regarding the patient status and staff observation were documented by PCT (Staff #12) at 10:22 which exceeds every 30-minute documentation related to the patient status and staff observation. Review of Patient #17 treatment record for 08/23/2025 revealed the following: An intradialytic BP reading of 218/122 was recorded at 10:48. At 10:53, RN (Staff #4) entered the following note, “Using aseptic technique, catheter ports aspirated and flushed by nurse. Treatment initiated without problems. Lines taped and secure. Saline line clamped. HemaClip device secure.” At 10:54, RN (Staff #4) entered the following note, “cnr(charge nurse rounds): uf 1.5kg, 2k, f180, rx correct.” There was no documentation identifying the out of parameter BP by the RN initiating treatment and there is no documentation found that the RN addressed the out of parameter BP. Comments regarding patient status and staff observation documented by PCT (Staff #12) at 12:33. The next comments regarding the patient status and staff observation were documented by PCT (Staff #12) at 13:22 which exceeds every 30-minute documentation related to the patient status and staff observation. Review of Patient #18 treatment record for 08/23/2025 revealed the following: Comments regarding patient status and staff observation documented by PCT (Staff #12) at 09:38. The next comments regarding the patient status and staff observation were documented by PCT (Staff #12) at 10:34 which exceeds every 30-minute documentation related to the patient status and staff observation. Comments regarding patient status and staff observation documented by PCT (Staff #12) at 11:03. The next comments regarding the patient status and staff observation were documented by PCT (Staff #12) at 11:45 which exceeds every 30-minute documentation related to the patient status and staff observation. Review of Patient #19 treatment record for 08/23/2025 revealed the following: Pre-Dialysis sitting blood pressure (BP): 233/134 and pre-dialysis standing BP: 237/134 recorded by PCT (Staff #12) at 05:19. There was no documentation indicating the out of parameter BP was addressed by the RN (Staff #4) prior to treatment initiation at 05:19. The pre-dialysis RN assessment was completed at 05:31 by Staff #4. There was no documentation found that the RN addressed the out of parameter BP prior to treatment initiation. The following pre-dialysis comments were entered by staff #4, “Pain level: pain to left side of face Other: arrived stable alert ambulatory,pain from facial surgery, tx started via left AVF, lines secured, reclining resting.” An intradialytic BP reading of 227/130 was recorded at 05:20. There was no documentation identifying the out of parameter BP and no documentation indicating it was reported to the RN. An intradialytic BP reading of 211/128 was recorded at 05:30. There was no documentation identifying the out of parameter BP and no documentation indicating it was reported to the RN. An intradialytic BP reading of 225/123 was recorded at 05:57. There was no documentation identifying the out of parameter BP and no documentation indicating it was reported to the RN. An intradialytic BP reading of 201/116 was recorded at 06:42. At 06:44, PCT (Staff #11) entered the following note,”pt resting quietly, cn aware of bp. No s/s of distress.” There was no documentation that the RN addressed the BP. An intradialytic BP reading of 207/115 was recorded at 06:57. There was no documentation identifying the out of parameter BP and no documentation indicating it was reported to the RN. An intradialytic BP reading of 196/119 was recorded at 07:27. There was no documentation identifying the out of parameter BP and no documentation indicating it was reported to the RN. An intradialytic BP reading of 218/138 was recorded at 07:57. At 08:08, PCT (Staff #11) entered the following note,”pt is currently reading. Will continue to monitor. Access visualized and lines secure. CN aware of bp reading.” There was no documentation that the RN addressed the BP. An intradialytic BP reading of 187/111 was recorded at 08:27. There was no documentation identifying the out of parameter BP and no documentation indicating it was reported to the RN. An intradialytic BP reading of 224/96 was recorded at 08:51. There was no documentation identifying the out of parameter BP and no documentation indicating it was reported to the RN. Post-Dialysis sitting blood pressure (BP): 201/113 and post-dialysis standing BP: 178/109 recorded by the PCT (Staff #12). There was no documentation indicating the out of parameter BP was reported to the registered nurse (RN), Staff #4, after treatment termination at 08:51. The post-dialysis RN assessment was completed at 11:26 by Staff #4. The following post dialysis comments were entered by Staff #4, “Other: Patient tolerated treatment well, voices no pain/discomfort, UF goal reached, sites secured, discharged stable alert ambulatory Treatment duration: patient requested to sign-off” There was no documentation found that the RN addressed the out of parameter BP post dialysis and prior to discharge from the facility. Review of Patient #20 treatment record for 08/23/2025 revealed the following: Comments regarding patient status and staff observation documented by PCT (Staff #12) at 07:08. The next comments regarding the patient status and staff observation were documented by PCT (Staff #11) at 08:06 which exceeds every 30-minute documentation related to the patient status and staff observation. Comments regarding patient status and staff observation documented by PCT (Staff #12) at 08:28. The next comments regarding the patient status and staff observation were documented by PCT (Staff #12) at 10:19 which exceeds every 30-minute documentation related to the patient status and staff observation. Review of Patient #21 treatment record for 08/23/2025 revealed the following: Comments regarding patient status and staff observation documented by PCT (Staff #12) at 07:08. The next comments regarding the patient status and staff observation were documented by PCT (Staff #12) at 08:05 which exceeds every 30-minute documentation related to the patient status and staff observation. Comments regarding patient status and staff observation documented by PCT (Staff #12) at 08:28. The next comments regarding the patient status and staff observation were documented by RN (Staff #4) at 11:49 which exceeds every 30-minute documentation related to the patient status and staff observation. Treatment sheets findings were discussed throughout the survey with the Facility Administrator (Staff #2), Medical Director (Staff #1) and Clinical Specialist (Staff #3).”

“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: 50181 Based on record review and interview, the facility’s quality assessment performance improvement (QAPI) committee failed to develop, implement, maintain, and evaluate an effective, data-driven, QAPI program with participation by the professional members of the interdisciplinary team (IDT). The professional members of the facility’s IDT which must participate in the QAPI activities, must, minimally, consist of a physician, registered nurse, masters-prepared social worker, and registered dietitian. Findings:In review of the Facility Quality Management Meeting for the month of January Year 2025 Minutes the following list of attendees was provided: Medical DirectorFacility Administrator (non-registered nurse)Social WorkerDietitian Bio-Med Tech Unit Clerk There is no evidence of participation by a registered nurse for the January 2025 meeting. In review of the Facility Quality Management Meeting for the month of February Year 2025 Minutes the following list of attendees was provided: Medical Director Facility Administrator (non-registered nurse) Social Worker DietitianThere is no evidence of participation by a registered nurse for the February 2025 meeting. In review of the Facility Quality Management Meeting for the month of March Year 2025 Minutes the following list of attendees was provided: Medical Director Facility Administrator (non-registered nurse) Social Worker There is no evidence of participation by a registered nurse or dietitian for the March 2025 meeting. In review of the Facility Quality Management Meeting for the month of April Year 2025 Minutes the following list of attendees was provided: Medical Director Facility Administrator (non-registered nurse) Social Worker Dietitian There is no evidence of participation by a registered nurse for the April 2025 meeting. In review of the Facility Quality Management Meeting for the month of May Year 2025 Minutes there was no evidence of a meeting being held. The Facility Administrator reported that there was not a QAPI meeting held for the month of May 2025. In review of the Facility Quality Management Meeting for the month of June Year 2025 Minutes the following list of attendees was provided: Medical Director Facility Administrator (non-registered nurse) Social Worker Bio-Med Tech There is no evidence of participation by a registered nurse or dietitian for the June 2025 meeting. The above findings were confirmed by the Facility Administrator.”

“QAPI-INDICATOR-ADEQUACY OF DIALYSIS CFR(s): 494.110(a)(2)(i) The program must include, but not be limited to, the following: (i) Adequacy of dialysis. This Standard is not met as evidenced by: 50181 Based on review of Quality Assessment and Performance Improvement (QAPI) minutes and staff interview the facility failed to identify opportunities for improvement in addressing adequacy in patients with adequacy not meeting the minimum standards. The findings include: Review of QAPI meeting minutes for January 2025-June 2025 revealed the adequacy goal was not met for the months of February, April and May 2025. For the months not meeting goal the interdisciplinary team did not identify any commonalities among patients who did not reach the minimum expected targets, develop a plan to address those causes, monitor the effectiveness of the plan or adjust portions of the plan that were not successful. During interviews with the Facility Administrator and Medical Director the above findings were discussed and confirmed.”

“MD RESP-QAPI PROGRAM CFR(s): 494.150(a) Medical director responsibilities include, but are not limited to, the following: (a) Quality assessment and performance improvement program. This Standard is not met as evidenced by: 50181 Based on records review and interviews, the medical director failed to provide operational responsibility for the Quality Assessment and Performance Improvement (QAPI) program which includes review of quality indicators related to improved patient health outcomes and monitoring this data on a continual basis as is required by the Condition for QAPI; education of facility and medical staff in the QAPI objectives; reviewing the method of prioritizing the importance of improvement projects; inclusion/encouragement of all staff in participating towards achievement of QAPI goals; communication with the governing body regarding the needs identified by QAPI; and participating in the evaluation of the effectiveness of performance improvement plans/activities. The findings include: Review of QAPI meeting minutes for January 2025-June 2025 revealed the adequacy goal was not met for the months of February, April and May 2025. For the months not meeting goal the interdisciplinary team did not identify any commonalities among patients who did not reach the minimum expected targets, develop a plan to address those causes, monitor the effectiveness of the plan or adjust portions of the plan that were not successful.”

“MD RESP-STAFF ED, TRAINING & PERFORM CFR(s): 494.150(b) Medical director responsibilities include, but are not limited to, the following: (b) Staff education, training, and performance. This Standard is not met as evidenced by: 50181 Based on personnel file review and interview, the medical director failed to ensure that facility staff members received the appropriate education and training to competently perform their job responsibilities. Charge Nurse (Staff #4) Date of Hire: 01/20/2025 No initial Charge Nurse Skills Checklist completed CPR (cardiopulmonary resuscitation) certification on file expired 07/31/2025No facility orientationNo initial water test Charge Nurse (Staff #6) did not have a current technical skills checklist for the facility specific water system Staff #6 was acting as Charge Nurse in the facility on 08/28/2025 Charge Nurse/Supervising Nurse (Staff #7) annual clinical skills checklist was last completed on 01/18/2024 and annual technical skills checklist was last completed on 12/14/2022. Staff #7 worked in the facility as the supervising nurse until 03/21/2025 and completed clinical orientation skills checklists on facility employees during this timeframe. Certified Clinical Hemodialysis Technician (CCHT) (Staff #8) Annual clinical orientation skills checklist was last completed on 04/19/2024 CPR (cardiopulmonary resuscitation) certification on file expired 06/2025 Registered Dietician (staff #16) did not have a facility orientation specific to the facility. The above findings were confirmed by the Facility Administrator.”

“GOV-STAFF # & RATIO MEET PT NEEDS CFR(s): 494.180(b)(1) The governing body or designated person responsible must ensure that- (1) An adequate number of qualified personnel are present whenever patients are undergoing dialysis so that the patient/staff ratio is appropriate to the level of dialysis care given and meets the needs of patients; This Standard is not met as evidenced by: 50181 Based on record review and interview, the governing body failed to ensure a sufficient number of qualified and trained staff were on duty to meet the individualized needs of the patients receiving dialysis treatment in the facility.Also, the Governing Body failed to oversee the organization, management, control and operations of the facility. Findings: Review of the patient and staff schedule for 08/23/2025 revealed there were 12 patients scheduled for the first shift and 10 patients scheduled for the second shift. There were 3 direct patient care (DPC) staff and one charge nurse (CN) on the schedule; however, in review of the timesheets for the day, patient care technician (Staff #8) clocked out from 4:39 AM-10:17AM resulting in the facility not meeting the minimum staffing requirements for the care of 12 patients. During an interview with the Facility Administrator (Staff #2) on 08/26/2025, she confirmed Staff #8 was clocked out during this time and left the facility, leaving the facility with 2 DPC staff and 1 CN to care for 12 patients. The Facility Administrator (Staff #2) confirmed the facility did not meet minimum staffing requirements during this timeframe. Review of the Governing Body meeting minutes, from 03/21/2025, revealed the supervising nurse (Staff #7) resigned from the position. There is no evidence the Governing Body appointed a Supervising Nurse to assume the role after the resignation. During an interview with the Facility Administrator on 08/26/2025, it was reported that the previous Supervising Nurse (Staff #7) resigned as the supervising nurse in March 2025 but the new appointment of registered nurse (Staff #4) was not approved in the Governing Body.”

“GOV-GB RESP FOR STAFF ORIENTATION CFR(s): 494.180(b)(3) The governing body or designated person responsible must ensure that- (3) All staff, including the medical director, have appropriate orientation to the facility and their work responsibilities; This Standard is not met as evidenced by: 50181 Based on record review and staff interview, the governing body failed to ensure all staff, including the medical director, had appropriate orientation to the facility and up-to-date skills checklists and competencies required for the role. Findings: Charge Nurse (Staff #4) Date of Hire: 01/20/2025 No initial Charge Nurse Skills Checklist completed CPR (cardiopulmonary resuscitation) certification on file expired 07/31/2025 No facility orientation No initial water test No completed facility orientationNo signed job descriptionLack of evidence to support 80 hours of orientation was completed upon hire Charge Nurse (Staff #6) did not have a current technical skills checklist for the facility specific water system Staff #6 was acting as Charge Nurse in the facility on 08/28/2025 Charge Nurse/Supervising Nurse (Staff #7) annual clinical skills checklist was last completed on 01/18/2024 and annual technical skills checklist was last completed on 12/14/2022. Staff #7 worked in the facility as the supervising nurse until 03/21/2025 and completed clinical orientation skills checklists on facility employees during this timeframe. Certified Clinical Hemodialysis Technician (CCHT) (Staff #8) Annual clinical orientation skills checklist was last completed on 04/19/2024 CPR (cardiopulmonary resuscitation) certification on file expired 06/2025No signed job description Registered Dietician (staff #16) and medical director (staff #1) did not have a facility orientation specific to the facility. The above findings were confirmed by the Facility Administrator.”