Brazoria County Dialysis, LLP

“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: 48020 Based on observation, interview and record review, the facility governing body failed to: ensure all staff participated in quarterly fire drill in the facility in 3 of 7 staffs’ file reviewed: Registered Dietitian (F), Social Worker (I), Facility Technical Manager (K) Findings: Review of the facility’s current policy and procedure EPM-20 Patient Training & Preparedness directs staff as follows: “POLICY: 2. Fire Drills All staff and patients are required to participate in quarterly fire drills. (Fire drills must be done every 3 months) ... Employees, who participate in the drill, must sign the Fire/Emergency Drill form. Drills are to be kept in the back of this Emergency Preparedness Manual. Patient’s names should be written on the form or a patient schedule attached.” Personnel Fire Drills Registered Dietitian (J) Observation on 03/18/2025 - 03/20/2025 revealed Registered Dietitian (J) in her office documenting on the computer. Review of Registered Dietitian (J’s) personnel file revealed Registered Dietitian (J) was hired on 02/19/2020. Review of the facility’s Fire/Emergency Drill form on 03/20/2025 revealed documentation which indicated a fire drill was last held at the facility on March 2025. The log did not include Registered Dietitian (J’s) signature. Review of the facility’s Fire/Emergency Drill form on 03/20/2025 revealed documentation which indicated a fire drill was held at the facility on December 2024. The log did not include Registered Dietitian (J’s) signature. Review of the facility’s Fire/Emergency Drill form on 03/20/2025 revealed documentation which indicated a fire drill was held at the facility on September 2024. The log did not include Registered Dietitian (J’s) signature. Interview with Registered Dietitian (J) on 03/20/2025 at 12:25 p.m. revealed that Registered Dietitian (J) did not participate in the facility’s quarterly fire drills “since last year”. Social Worker (I) Observation on 03/18/2025 - 03/20/2025 revealed Social Worker (I) in her office documenting on the computer. Review of Social Worker (I’s) personnel file revealed Social Worker (I) was hired on 12/22/2018. Review of the facility’s Fire/Emergency Drill form on 03/20/2025 revealed documentation which indicated a fire drill was held at the facility on September 2024. The log did not include Social Worker (I’s) signature. Facility Technical Manager (K) Observation on 03/18/2025 - 03/20/2025 revealed Facility Technical Manager (K) was in the water room doing maintenance. Review of Facility Technical Manager (K’s) personnel file revealed Facility Technical Manager (K) was hired on 11/15/2010. Review of the facility’s Fire/Emergency Drill form on 03/20/2025 revealed documentation which indicated a fire drill was held at the facility on September 2024. The log did not include Facility Technical Manager (K’s) signature. Interview with Nurse Manager (A) on 03/20/2025 at 12:32 p.m. confirmed the findings.”

“ESRD Patient Orientation Training CFR(s): The dialysis facility must provide appropriate orientation and training to patients, including the areas specified in paragraph (d)(1) of this section. This Standard is not met as evidenced by: 48020 Based on observation, interview and record review, the facility governing body failed to ensure all patients participated in quarterly fire drill in the facility in 7 of 13 sampled patients: Patient #s 3, 6, 1, 2, 4, 7, 10 Findings: Review of the facility’s current policy and procedure EPM-20 Patient Training & Preparedness directs staff as follows: “POLICY: 2. Fire Drills All staff and patients are required to participate in quarterly fire drills. (Fire drills must be done every 3 months) ... Employees, who participate in the drill, must sign the Fire/Emergency Drill form. Drills are to be kept in the back of this Emergency Preparedness Manual. Patient’s names should be written on the form or a patient schedule attached.” Patient #3 Observation on 03/18/2025 at 7:39 a.m. revealed Patient #3 was seated at station #7 machine #14 receiving hemodialysis treatment at a blood flow rate of 450 mL/min and a dialysate flow rate of 500 mL/min via left lower arm vascular access. Review of the patient’s record revealed the patient participated in the quarterly fire drill on 02/10/2024, 06/25/2024 and 10/17/2024. There was no documentation that the patient participated in the fire drill every three months. There was no documentation of fire drill participation by the patient after 10/17/2024. Patient #6 Observation on 03/18/2025 at 7:40 a.m. revealed Patient #6 was seated at station #10 machine #1 receiving hemodialysis treatment at a blood flow rate of 350 mL/min and a dialysate flow rate of 500 mL/min via left upper arm vascular access. Review of the patient’s record revealed the patient participated in the quarterly fire drill on 05/31/2024 and 10/19/2024. There was no documentation that the patient participated in the fire drill every three months. There was no documentation of fire drill participation by the patient after 10/19/2024. Patient #1 Observation on 03/18/2025 at 7:43 a.m. revealed Patient #1 was seated at station #8 machine #11 receiving hemodialysis treatment at a blood flow rate of 350 mL/min and a dialysate flow rate of 500 mL/min via left upper arm vascular access. Review of the patient’s record revealed the patient participated in the quarterly fire drill on 02/08/2024, 06/22/2024 and 10/17/2024. There was no documentation that the patient participated in the fire drill every three months. There was no documentation of fire drill participation by the patient after 10/17/2024. Patient #2 Observation on 03/18/2025 at 7:45 a.m. revealed Patient #2 was seated at station #14 machine #4 receiving hemodialysis treatment at a blood flow rate of 400 mL/min and a dialysate flow rate of 600 mL/min via left upper arm vascular access. Review of the patient’s record revealed the patient participated in the quarterly fire drill on 02/08/2024, 06/22/2024 and 10/17/2024. There was no documentation that the patient participated in the fire drill every three months. There was no documentation of fire drill participation by the patient after 10/17/2024. Patient #4 Observation on 03/18/2025 at 11:44 a.m. revealed Patient #4 was seated at station #7 machine #14 receiving hemodialysis treatment at a blood flow rate of 350 mL/min and a dialysate flow rate of 500 mL/min via left upper arm vascular access. Review of the patient’s record revealed the patient participated in the quarterly fire drill on 03/05/2024, 06/22/2024 and 10/19/2024. There was no documentation that the patient participated in the fire drill every three months. There was no documentation of fire drill participation by the patient after 10/19/2024. Patient #7 Observation on 03/18/2025 at 2:14 p.m. revealed Patient #7 was seated at station #12 machine #76 receiving hemodialysis treatment at a blood flow rate of 350 mL/min and a dialysate flow rate of 700 mL/min via left upper arm vascular access. Review of the patient’s record revealed the patient participated in the quarterly fire drill on 03/14/2024, 06/22/2024 and 10/19/2024. There was no documentation that the patient participated in the fire drill every three months. There was no documentation of fire drill participation by the patient after 10/19/2024. Patient #10 Observation on 03/19/2025 at 2:00 p.m. revealed Patient #10 was seated at station #12 machine #7 receiving hemodialysis treatment at a blood flow rate of 450 mL/min and a dialysate flow rate of 700 mL/min via left lower arm vascular access Review of the patient’s record revealed the patient participated in the quarterly fire drill on 02/07/2024, 06/19/2024 and 10/16/2024. There was no documentation that the patient participated in the fire drill every three months. There was no documentation of fire drill participation by the patient after 10/16/2024. Interview with Nurse Manager (A) on 03/20/2025 at 12:32 p.m. confirmed the findings.”

“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: 48020 Based on observation, record review and interview the facility failed to ensure patient’s nephrologist round and assess patients every two weeks in 5 of 13 sampled patients and 4 closed records: Patient #s 6, 4, 5, 7, 10 Findings: Patient #6 Observation on 03/18/2025 at 7:40 a.m. revealed Patient #6 was seated at station #10 machine #1 receiving hemodialysis treatment at a blood flow rate of 350 mL/min and a dialysate flow rate of 500 mL/min via left upper arm vascular access. Review of the patient’s clinical record revealed the patient was admitted to the facility on 05/31/2024 with diagnoses of end stage renal disease and diabetes on insulin, tobacco use, on in-center hemodialysis three times weekly. Review of the patient’s clinical record on 03/19/2025 revealed was a physician progress note documented for 02/11/2025 and 03/06/2025. There was no documented physician note for 02/25/2025. There was no documented physician progress note every two weeks from 02/11/2025 - 03/06/2025 as required by the state regulations. Patient #4 Observation on 03/18/2025 at 11:44 a.m. revealed Patient #4 was seated at station #7 machine #14 receiving hemodialysis treatment at a blood flow rate of 350 mL/min and a dialysate flow rate of 500 mL/min via left upper arm vascular access. Review of the patient’s clinical record revealed the patient was admitted to the facility on 08/22/2023 with diagnoses of acute kidney injury, other hydronephrosis and disorder of kidney and ureter, on in-center hemodialysis three times weekly. Review of the patient’s clinical record on 03/19/2025 revealed was a physician progress note documented for 01/14/2025, 02/06/2025, 02/11/2025 and 03/06/2025. There was no documented physician note for 01/28/2025 and 02/25/2025. There was no documented physician progress note every two weeks from 01/14/2025 - 01/28/2025 and 02/11/2025 - 02/25/2025 as required by the state regulations. Patient #5 Observation on 03/18/2025 at 2:09 p.m. revealed Patient #5 was seated at station #6 machine #16 receiving hemodialysis treatment at a blood flow rate of 350 mL/min and a dialysate flow rate of 500 mL/min via right central venous catheter. Review of the patient’s clinical record revealed the patient was admitted to the facility on 12/19/2024 with diagnoses of end stage renal disease and hypertension, on in-center hemodialysis three times weekly. The patient has additional diagnoses of cardiomegaly, thrombocytopenia, hyperglycemia, epistaxis, and pericardial effusion. Review of the patient’s clinical record on 03/19/2025 revealed was a physician progress note documented for 02/11/2025 and 03/06/2025. There was no documented physician note for 02/25/2025. There was no documented physician progress note every two weeks from 02/11/2025 - 03/06/2025 as required by the state regulations. Patient #7 Observation on 03/18/2025 at 2:14 p.m. revealed Patient #7 was seated at station #12 machine #76 receiving hemodialysis treatment at a blood flow rate of 350 mL/min and a dialysate flow rate of 700 mL/min via left upper arm vascular access. Review of the patient’s clinical record revealed the patient was admitted to the facility on 05/31/2024 with diagnoses of end stage renal disease and hypertension, on in-center hemodialysis three times weekly. Review of the patient’s clinical record on 03/19/2025 revealed was a physician progress note documented for 02/11/2025 and 03/06/2025. There was no documented physician note for 02/25/2025. There was no documented physician progress note every two weeks from 02/11/2025 - 03/06/2025 as required by the state regulations. Patient #10 Observation on 03/19/2025 at 2:00 p.m. revealed Patient #10 was seated at station #12 machine #7 receiving hemodialysis treatment at a blood flow rate of 450 mL/min and a dialysate flow rate of 700 mL/min via left lower arm vascular access. Review of the patient’s clinical record revealed the patient was admitted to the facility on 02/05/2014 with diagnoses of end stage renal disease, type 2 diabetes, atherosclerotic heart disease, acute on chronic diastolic heart failure, and gastroparesis, on in-center hemodialysis three times weekly. Review of the patient’s clinical record on 03/19/2025 revealed was a physician progress note documented for 01/13/2025 and 02/07/2025. There was no documented physician note for 01/27/2025. There was no documented physician progress note every two weeks from 01/13/2025 - 02/07/2025 as required by the state regulations. Interview with Medical Director (N) on 03/20/2025 at 7:48 a.m. confirmed the findings for the dates in question.”

“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 encourage patients to wash/sanitize hands after removal of contaminated gloves in 2 of 6 staff observed: Patient Care Technician (C) and (B) and Patient #’s 3, 9, 8 Findings: Review of the facility’s current policy and procedure on G40 Infection Control directs staff as follows: “POLICY: GENERAL INFECTION CONTROL MEASURES 8. Hands are always washed after gloves are removed and between patient contacts, as well as after touching blood, body fluids, secretions, excretions and contaminated items. 17. Patients will be educated and encouraged to: “ Wear gloves when holding their access sites after needle removal “ Wash their hands before entering and leaving the patient treatment area” Patient Care Technician (C) Patient #2 Observation on 03/18/2025 at 9:07 a.m., revealed Patient #2 holding his vascular access with a gloved hand at station #14. After the bleeding ceased, Patient Care Technician (C) taped the patient’s vascular access site. The patient picked up his personal items, was weighed, and left the treatment floor without washing/sanitizing his hands. Random Patient #9 Observation on 03/18/2025 at 9:24 a.m., revealed Random Patient #9 holding his vascular access with a gloved hand at station #13. After the bleeding ceased, Patient Care Technician (C) taped the patient’s vascular access site. The patient picked up his personal items, was weighed, and left the treatment floor without washing/sanitizing his hands. The Surveyor notified Patient Care Technician (C) at 09:39 a.m. that Patient #s 2 and 3 washed/sanitized their hands after removal of contaminated gloves used to hold their vascular accesses. Patient Care Technician (C) said, “Okay.” Patient Care Technician (B) Random Patient #8 Observation on 03/18/2025 at 9:27 a.m., revealed Random Patient #8 holding her vascular access with a gloved hand at station #6. After the bleeding ceased, Patient Care Technician (B) taped the patient’s vascular access site. The patient picked up her personal items, got into her wheelchair, was weighed, and left the treatment floor without washing/sanitizing her hands. The Surveyor immediately notified Patient Care Technician (B) the patient did not wash/sanitize her hands after holding her access and removing his gloves. Patient Care Technician (B) said, “Okay.””

“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, per the TAC 117.33(b)(2)(B), the facility’s direct care staff failed to prevent cross contamination: by wiping the dialysate lines that were touching the floor and using the same towel to wipe the hemodialysis station in 1 of 6 staff observed: Patient Care Technician (B) B) by wiping the wall box and with the same gloves picking up new bleach towels to wipe the hemodialysis chair and television in 1 of 6 staff observed: Patient Care Technician (E) Findings: Review of the facility’s current policy and procedure on G40 Infection Control directs staff as follows: “POLICY: 1. Standard Precautions and infection control measures as outlined in this policy will be used by all associates at all times.” Review of the Center for Disease Control (CDC) Dialysis Safety: Dialysis Wall Boxes and Drains states: “ wall boxes need to be cleaned, disinfected, and properly maintained to decrease risk of patient infections. Wall boxes are part of the immediate patient care environment and are considered contaminated or dirty. Wipes or other supplies used to disinfect the wall box should be discarded after use and not used to disinfect other surfaces in the dialysis station.” Patient Care Technician (B) Station #7 Observation on 03/18/2025 at 9:15 a.m. revealed Patient Care Technician (B) terminally cleaning station #7 post hemodialysis treatment of a patient. Patient Care Technician (B) failed to prevent cross contamination by wiping the dialysate lines that were touching the floor and adding that contaminated bleach towel to a couple of clean bleach towels used to clean the rest of the station. Patient Care Technician (B) wiped the hemodialysis chair, blood pressure cuff, television and connecting arm, oxygen concentrator, chase and wall box with the wad of bleach towels. The Surveyor immediately notified Patient Care Technician (B) that he failed to prevent cross contamination by wiping the dialysate lines that were touching the floor and adding that contaminated bleach towel to a couple of clean bleach towels used to clean the rest of the station at station. Patient Care Technician (B0) said, “Okay.” Patient Care Technician (E) Station #9 Observation on 03/18/2025 at 9:41 a.m. revealed Patient Care Technician (E) terminally cleaning station #9 post hemodialysis treatment of a patient. Patient Care Technician (E) failed to prevent cross contamination by wiping the wall box and with the same gloves picking up new bleach towels to wipe the hemodialysis chair and television. The Surveyor immediately notified Patient Care Technician (E) that she failed to prevent cross contamination by wiping the wall box and with the same gloves picking up new bleach towels to wipe the hemodialysis chair and television. Patient Care Technician (E) said, “Okay.””

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 48020 Based on observation, interview and record review, the facility’s nurses failed to implement infection control measures by not using aseptic technique in dressing changes and connection of central venous catheters in 1 of 2 nurses observed: Registered Nurse (D), Patient #5 Findings: Review of the facility’s current policy and procedure on G40 Infection Control directs staff as follows: “POLICY: GENERAL INFECTION CONTROL MEASURES 8. Hands are always washed after gloves are removed and between patient contacts, as well as after touching blood, body fluids, secretions, excretions and contaminated items. 30. Aseptic technique will be used to prepare the access site prior to needle insertion and to clean the CVC exit site. 31. All blood line, fistula needle and CVC connections will be handled using proper aseptic technique. Registered Nurse (D), Patient #5 On 03/18/2025 at 11:20 a.m., Patient #5 was observed at station #6 receiving central venous catheter (CVC) care before the hemodialysis treatment. Registered Nurse (D) was observed to clean the CVC exit site with an antiseptic swabstick, removed her gloves, reached into the glove box and donned clean gloves without washing/sanitizing her hands. She applied the 2x2 to the exit site, scrubbed the hubs, connected a syringe to the arterial port to flush it and performed a glove change without washing/sanitizing her hands. She applied a syringe to remove indwelling solution from the venous port, applied a Heparin syringe, flushed it and performed a glove change with washing/sanitizing her hands. She applied a saline syringe to the venous port, flushed it, removed her gloves and began typing on the chairside computer without washing/sanitizing her hands. She donned clean gloves, clamped the blood lines, adjusted the settings on the hemodialysis machine, connected the patients CVC to the bloodlines and initiated the hemodialysis treatment. Registered Nurse (D) failed to perform aseptic technique in cleaning the CVC exit site and handling the CVC connections as per policy. The Surveyor notified Registered Nurse (D) at 11:39 a.m. of the break in infection control by failing to perform aseptic technique in cleaning the CVC exit site and handling the CVC. Registered Nurse (D) said, “Okay.””

“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: 48020 Based on observation, record review and interview, the facility’s Governing Body failed to ensure: the preventative maintenance at was completed least annually on patient care related equipment used in the facility. B) the staff completed the lab specimen refrigerator temperature check each working day. Review of the Baxter Flo-Gard 6201 Volumetric Infusion Pump Service Manual page 6-4 directs use as follows: “Table 6-2 Preventive Maintenance Procedures Schedule: Every 12 months or as required Back plate and safety clamp Door latch area Pole clamp Power cord Preventive maintenance tests Schedule: Every 6 months or as required Battery check” Treatment Floor: Observation on 12/01/2023 at 07:39 a.m. of the facility’s treatment floor revealed a Baxter Flo-Gard 6201 Volumetric Infusion Pump stored to the left of the emergency cart. Observation of the preventative maintenance sticker on the equipment revealed documentation that preventative maintenance was last done 4-17-2023. The sticker indicated the next preventative maintenance was due on 4-17-2024. There was no indication that preventative maintenance was done on the Baxter Flo-Gard 6201 Volumetric Infusion Pump. Walkthrough with Nurse Manager (A) and Facility Technical Manager (K) on 03/18/2025 at 2:35 p.m. verified the findings. Nurse Manager (A) said, “We have not used it but if we need to, we would.” She also confirmed the facility has IV tubing sets that they can attach to the hemodialysis machine to administer antibiotics. Lab Area: Observation of the lab area on 03/18/2025 at 10:15 a.m. revealed a refrigerator used to store laboratory specimens until they are picked up for processing. Review of the facility’s Laboratory Specimen Refrigerator Freezer Temperature Log directs the staff as follows: “Check the temperatures in both the freezer and refrigerator of your storage unit each working day. Place an “X” in the box that corresponds with the temperature, not the time and initial below each date the temperature is checked.” Review of the facility’s Laboratory Specimen Refrigerator Freezer Temperature Log dated Dec 2024 revealed missing documentation that the refrigerator temperature was checked on 12/19/2024. Review of the facility’s Laboratory Specimen Refrigerator Freezer Temperature Log dated Feb 2025 revealed missing documentation that the refrigerator temperature was checked on 02/21/2025 and 02/24/2025. The Surveyor notified Facility Technical Manager (K) of the missing documentation on the Laboratory Specimen Refrigerator Freezer Temperature Log on 03/18/2025 at 2:35 p.m. Facility Technical Manager (K) confirmed the missing documentation of the logs and said, “I’ll have to check on those dates.” No other documentation was provided by the facility.”

“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 and direct care staff failed to administer patients’ hemodialysis treatments based on physicians’ orders in 7 of 13 sampled patients and 4 closed records: Patient #s 4, 6, 2, 5, 14, 10, 15 Findings: Review of the facility’s current policy and procedure on IC08 Monitoring & Documentation of Patient Care During Treatment directs staff as follows: “POLICY: 4. The following must be documented before “starting” the patient’s treatment in the electronic documentation system: “ Machine checks “ Pre-treatment vital signs “ Treatment RX - indicating caregiver review and verification of all patient treatment data and machine set-up information “ Orders 7. Two signatures are required before “starting” the patient’s treatment in the electronic documentation system: “ First signature - person actually initiating the treatment “ Second signature - nurse who verifies the patient’s set-up matches the order, or o A non-nurse can verify that the patient’s set-up matches the order IF a nurse rounding note is documented within 1 hour of treatment initiation... 15. Information that must be entered manually includes, but is not limited to: “ Interventions for unexpected situations, such as slowing blood flow for access problem, target weight change, decease in UFR, etc. “ If the patient’s prescription was not met for any reason (A detailed progress note must be entered explaining why the prescription was not met and actions taken to address the situation.” Dialysate Composition Calcium Bath: Patient #4 Observation on 03/18/2025 at 11:44 a.m. revealed Patient #4 was seated at station #7 machine #14 receiving hemodialysis treatment at a blood flow rate of 350 mL/min and a dialysate flow rate of 500 mL/min via left upper arm vascular access. The patient was utilizing an Optiflux 180 non reuse dialyzer. The Surveyor asked Nurse Manager (A) who was chairside to reveal the dialysate settings on machine #14. The machine dialysate settings were: potassium 3.1 mEq/L, calcium 2.6 mEq/L, bicarbonate 33 mEq/L, sodium 141 mEq/L. The Surveyor next asked Nurse Manager (A) to pull up the patient’s hemodialysis order on the chair side computer. The hemodialysis orders revealed a physician’s order for Calcium 2.0 mEq/L. Interview during observation with Nurse Manager (A), the Surveyor informed Nurse Manager (A) that the dialysate calcium was not set on the hemodialysis machine as prescribed by the physician. Nurse Manager (A) said, “I am going to educate the team on it.” Machine Settings Patient #6 Observation on 03/18/2025 at 7:40 a.m. revealed Patient #6 was seated at station #10 machine #1 receiving hemodialysis treatment at a blood flow rate of 350 mL/min and a dialysate flow rate of 500 mL/min via left upper arm vascular access. The patient was utilizing an Optiflux 180 non reuse dialyzer. Treatment sheet review on 03/18/25 reveal the following documentation: Dialysate Flow Rate: Review of the patient’s treatment sheet dated 03/13/2025 revealed documentation which indicated the patient was prescribed a dialysate flow rate of 500 mL/min on the treatment sheet but received hemodialysis treatment at a dialysate flow rate of 800 mL/min from 10:56 a.m. - 14:32 p.m. There was no justification documented for the dialysate flow rate of 800 mL/min. Patient #2 Observation on 03/18/2025 at 7:45 a.m. revealed Patient #2 was seated at station #14 machine #4 receiving hemodialysis treatment at a blood flow rate of 400 mL/min and a dialysate flow rate of 600 mL/min via left upper arm vascular access. The patient was utilizing an Nipro Cellentia 15-H non reuse dialyzer. Treatment sheet review on 03/18/25 reveal the following documentation: Dialysate Flow Rate: Review of the patient’s treatment sheet dated 03/06/2025 revealed documentation which indicated the patient was prescribed a dialysate flow rate of 600 mL/min on the treatment sheet but received hemodialysis treatment at a dialysate flow rate of 500 mL/min from 5:20 a.m. - 9:06 a.m. There was no justification documented for the dialysate flow rate of 500 mL/min. Patient #5 Observation on 03/18/2025 at 2:09 p.m. revealed Patient #5 was seated at station #6 machine #16 receiving hemodialysis treatment at a blood flow rate of 350 mL/min and a dialysate flow rate of 500 mL/min via right central venous catheter. The patient was utilizing an Optiflux 160 non reuse dialyzer. Treatment sheet review on 03/18/25 reveal the following documentation: Blood Flow Rate: Review of the patient’s treatment sheet dated 03/13/2025 revealed documentation which indicated the patient was prescribed a blood flow rate of 350 mL/min on the treatment sheet but received hemodialysis treatment at a blood flow rate of 150 mL/min from 9:57 a.m. - 13:01 p.m. There was no justification documented for the blood flow rate of 150 mL/min. Patient #14 Review of the patient’s clinical record on 03/18/2025 revealed the patient was admitted to the facility 12/10/2019 with the diagnoses of end stage renal disease, hypertension, and type 2 diabetes, on hemodialysis three times a week. Treatment sheet review on 03/18/25 reveal the following documentation: Blood Flow Rate: Review of the patient’s treatment sheet dated 06/28/2023 revealed documentation which indicated the patient was prescribed a blood flow rate of 350 mL/min on the treatment sheet but received hemodialysis treatment at a blood flow rate of 300 mL/min from 10:26 a.m. - 11:00 a.m., 200 mL/min from 11:30 a.m. - 12:00 p.m., and 250 mL/min from 12:30 p.m. - 13:00 p.m., and 200 mL/min from 13:00 p.m. - 14:14 p.m. There was no justification documented for the blood flow rate of 200 - 250 mL/min. Patient #10 Observation on 03/19/2025 at 2:00 p.m. revealed Patient #10 was seated at station #12 machine #7 receiving hemodialysis treatment at a blood flow rate of 450 mL/min and a dialysate flow rate of 700 mL/min via left lower arm vascular access The patient was utilizing an Optiflux 200 non reuse dialyzer. Treatment sheet review on 03/19/25 reveal the following documentation: Blood Flow Rate: Review of the patient’s treatment sheet dated 01/17/2025 revealed documentation which indicated the patient was prescribed a blood flow rate of 450 mL/min on the treatment sheet but received hemodialysis treatment at a blood flow rate of 400 mL/min from 10:10 a.m. - 14:12 p.m. There was no justification documented for the blood flow rate of 400 mL/min. Dialysate Flow Rate: Review of the patient’s treatment sheet dated 05/15/2024 revealed documentation which indicated the patient was prescribed a dialysate flow rate of 800 mL/min on the treatment sheet but received hemodialysis treatment at a dialysate flow rate of 700 mL/min from 6:07 a.m. - 7:01 a.m. There was no justification documented for the dialysate flow rate of 700 mL/min. Review of the patient’s treatment sheet dated 05/08/2024 revealed documentation which indicated the patient was prescribed a dialysate flow rate of 800 mL/min on the treatment sheet but received hemodialysis treatment at a dialysate flow rate of 700 mL/min from 6:33 a.m. - 10 :01 a.m. There was no justification documented for the dialysate flow rate of 700 mL/min. Patient #15 Review of the patient’s clinical record on 03/18/2025 revealed the patient was admitted to the facility 12/10/2019 with the diagnoses of end stage renal disease, hypertension, and type 2 diabetes, on hemodialysis three times a week. Treatment sheet review on 03/18/25 reveal the following documentation: Blood Flow Rate: Review of the patient’s treatment sheet dated 05/02/2023 revealed documentation which indicated the patient was prescribed a blood flow rate of 350 mL/min on the treatment sheet but received hemodialysis treatment at a blood flow rate of 325 mL/min from 8:59 a.m. - 10:34 a.m. There was no justification documented for the blood flow rate of 325 mL/min. Interview during record review with Nurse Manager (A) and Facility Administrator (M) on 03/19/2025 confirmed the licensed nurses and direct care staff failed to administer patients’ hemodialysis treatments based on physicians’ orders for the patients above.”

“POC-MONITOR ESA RESPONSE CFR(s): 494.90(a)(4) The patient’s response to erythropoiesis-stimulating agent(s), including blood pressure levels and utilization of iron stores, must be monitored on a routine basis. This Standard is not met as evidenced by: 48020 Based on observation, interview and record review, the facility’s registered nurses failed to ensure total prescribed dosage of the medication (Venofer) was administered for management of anemia for patients receiving hemodialysis treatment in a 3 of 13 sampled patients: Patient #s 5, 6, 7 Findings: Review of the facility’s current protocol for Venofer administration directs staff as follows: “IRON MANAGEMENT GOALS Hemoglobin (hgb): 10.0 g/dL- 11.0 g/dL Ferritin: > 200 ng/ml and < 1200 ng/ml Transferrin Saturation (T-sat): > 30% Monitoring Iron: “ Monitor T-sat monthly, Ferritin quarterly “ Repeat T-sat no sooner than one week post load or at next monthly lab draw Initiation of Venofer Protocol T-sat <50%, 100mg IVP q Tx x 10, then 100mg IVP q week T-sat >50% and Ferritin <200ng/ml, 100mg IVP q Tx x 10 T-sat <30% and Ferritin >200ng/ml and <500ng/ml, 100mg IVP q Tx x 10 T-sat <30% and Ferritin 500ng/ml -1200ng/ml, 100mg IVP q Tx x 8, then 50mg IVP q week T-sat <30% and Ferritin>1200ng/ml, 50mg IVP q week for 5 weeks T-sat >50% and Ferritin>1200ng/ml, Hold all IV Fe Supplements T-sat <30% and Ferritin>1500ng/ml, Hold all IV Fe Supplements” Patient #5 Observation on 03/18/2025 at 2:09 p.m. revealed Patient #5 was seated at station #6 machine #16 receiving hemodialysis treatment at a blood flow rate of 350 mL/min and a dialysate flow rate of 500 mL/min via right central venous catheter. The patient was utilizing an Optiflux 160 non reuse dialyzer. Observation revealed residual Venofer was observed in the venous chamber medication Y-port. Review of the patient’s treatment sheet dated 03/18/2025 revealed documentation by Registered Nurse (D) that Venofer 100 mg IVP 1st, 2nd & 3rd tx of week, was administered at 14:06 p.m. although residual medication was left in the venous chamber medication Y-port. Review of the facility’s laboratory report on 03/19/2025 revealed the following hemoglobin results for Patient #5: 03/04/2024 hemoglobin 10.0 g/dL 03/06/2024 hemoglobin 9.8 g/dL 03/11/2024 hemoglobin 10.0 g/dL Patient #6 Observation on 03/18/2025 at 7:40 a.m. revealed Patient #6 was seated at station #10 machine #1 receiving hemodialysis treatment at a blood flow rate of 350 mL/min and a dialysate flow rate of 500 mL/min via left upper arm vascular access. The patient was utilizing an Optiflux 180 non reuse dialyzer. Subsequent observation of Patient #6 at 2:13 p.m. revealed residual Venofer was observed in the venous chamber medication Y-port. Review of the patient’s treatment sheet dated 03/18/2025 revealed documentation by Registered Nurse (D) that Venofer 100 mg IVP 1st, 2nd & 3rd tx of week, was administered at 14:08 p.m. although residual medication was left in the venous chamber medication Y-port. Review of the facility’s laboratory report on 03/19/2025 revealed the following hemoglobin results for Patient #6: 03/06/2024 hemoglobin 10.0 g/dL Patient #7 Observation on 03/18/2025 at 2:14 p.m. revealed Patient #7 was seated at station #12 machine #76 receiving hemodialysis treatment at a blood flow rate of 350 mL/min and a dialysate flow rate of 700 mL/min via left upper arm vascular access. The patient was utilizing an Optiflux 200 non reuse dialyzer. Observation revealed residual Venofer was observed in the venous chamber medication Y-port. Review of the patient’s treatment sheet dated 03/18/2025 revealed documentation by Registered Nurse (D) that Venofer 100 mg IVP 1st, 2nd & 3rd tx of week, was administered at 14:07 p.m. although residual medication was left in the venous chamber medication Y-port. Review of the facility’s laboratory report on 03/19/2025 revealed the following hemoglobin results for Patient #5: 03/06/2024 hemoglobin 9.1 g/dL 03/11/2024 hemoglobin 9.1 g/dL Interview during walkthrough with Nurse Manager (A) on 03/18/2025 starting at 2:09 p.m. confirmed the above findings.”

“POC-P/S COUNSELING/REFERRALS/HRQOL TOOL CFR(s): 494.90(a)(6) The interdisciplinary team must provide the necessary monitoring and social work interventions. These include counseling services and referrals for other social services, to assist the patient in achieving and sustaining an appropriate psychosocial status as measured by a standardized mental and physical assessment tool chosen by the social worker, at regular intervals, or more frequently on an as-needed basis. This Standard is not met as evidenced by: 48020 Based on observation, record review and interview, the facility’s social worker failed to evaluate, document progress towards the patient’s stated goals and discuss patient’s KDQOL-36 scores with the Interdisciplinary Team (IDT) in 3 of 13 sampled patients and 4 closed records: Patient #s 1, 4, 10 Findings: Review of the facility’s current policy and procedure on CR-SW-60 Common Psychosocial Issues in the ESRD Population directs staff as follows: “Documenting Patient Quality of Life Because an ESRD diagnosis impacts a patient’s daily life in many marked ways, it is important that the interdisciplinary team keep track of changes in the impact of the disease in various patient life spheres. The primary tool for this process is the KDQOL-36 survey. __’s KDQOL-36 Goal ____’s goal is that 100% of eligible patients take the KDQOL-36 survey, and score in every component average or above. Reporting and Documenting Results A patient’s KDQOL-36 results are integrated into the patient’s comprehensive assessment and plan of care and incorporated into facility-level data for reporting in the clinic’s monthly TQM meeting. Social work documentation should reflect progress towards the patient’s stated goals.” Patient #1 Observation on 03/18/2025 at 7:43 a.m. revealed Patient #1 was seated at station #8 machine #11 receiving hemodialysis treatment at a blood flow rate of 350 mL/min and a dialysate flow rate of 500 mL/min via left upper arm vascular access. Review of the patient’s clinical record revealed the patient was admitted to the facility on 09/19/2022 with diagnoses of end stage renal disease, type 2 diabetes and hypertension, on in-center hemodialysis three times weekly. Review of the patient’s KDQOL-36 survey dated 01/16/2025 reveals the following scores below average: Burden of Kidney Disease = 0.0 Below Average Mental Component Summary (MCS) = 27.2 Below Average There is no documented evaluation of the scores nor is it signed and dated by Social Worker (I). Review of the patient’s clinical record revealed social worker progress notes dated 01/16/2025. There is no documentation of the evaluation of the patient’s KDQOL-36 scores. There is no evidence the patient’s KDQOL-36 scores were discussed with the Interdisciplinary Team (IDT). There is no documentation reflecting progress towards the patient’s stated goals. Patient #4 Observation on 03/18/2025 at 11:44 a.m. revealed Patient #4 was seated at station #7 machine #14 receiving hemodialysis treatment at a blood flow rate of 350 mL/min and a dialysate flow rate of 500 mL/min via left upper arm vascular access. Review of the patient’s clinical record revealed the patient was admitted to the facility on 08/22/2023 with diagnoses of acute kidney injury, other hydronephrosis and disorder of kidney and ureter, on in-center hemodialysis three times weekly. Review of the patient’s KDQOL-36 survey dated 01/15/2025 reveals the following scores were flagged with a drop of more than 10 points since last survey: Burden of Kidney Disease = 50.0 Average Physical Component Summary (PCS) = 29.5 Average There is no documented evaluation of the scores nor is it signed and dated by Social Worker (I). Review of the patient’s clinical record revealed social worker progress notes dated 01/15/2025 and 02/13/2025. There is no documentation of the evaluation of the patient’s KDQOL-36 scores. There is no evidence the patient’s KDQOL-36 scores were discussed with the Interdisciplinary Team (IDT). There is no documentation reflecting progress towards the patient’s stated goals. Patient #10 Observation on 03/19/2025 at 2:00 p.m. revealed Patient #10 was seated at station #12 machine #7 receiving hemodialysis treatment at a blood flow rate of 450 mL/min and a dialysate flow rate of 700 mL/min via left lower arm vascular access. Review of the patient’s clinical record revealed the patient was admitted to the facility on 02/05/2014 with diagnoses of end stage renal disease, type 2 diabetes, atherosclerotic heart disease, acute on chronic diastolic heart failure, and gastroparesis, on in-center hemodialysis three times weekly. Review of the patient’s KDQOL-36 survey dated 02/10/2025 reveals the following score below average: Symptoms and Problems = 54.2 Below Average There is no documented evaluation of the scores nor is it signed and dated by Social Worker (I). Review of the patient’s clinical record revealed social worker progress notes dated 02/13/2025. There is no documentation of the evaluation of the patient’s KDQOL-36 scores. There is no evidence the patient’s KDQOL-36 scores were discussed with the Interdisciplinary Team (IDT). There is no documentation reflecting progress towards the patient’s stated goals. Interview with Social Worker (I) on 03/20/2025 at 11:16 a.m. confirmed that the KDQOL-36 surveys for the patients above were not evaluated, documented for the progress towards the patient’s stated goals, signed, dated or discussed with the IDT.”

“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: 48020 Based on observation, record review and interview: the facility’s registered nurses failed to conduct assessments when patients experienced a change in condition during hemodialysis treatment or after the treatment has ended per the facility’s policy in 5 of 13 sampled patients and 4 closed records: Patient #s 4, 3, 1, 5, 10 B) 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 per policy. Findings: Review of the facility’s current policy and procedure on IC07 Patient Assessment: Pre & Post Dialysis directs staff as follows: “POLICY: Patient care associates will report all patient complaints to the nurse responsible for the patient and will document the complaints in the patient’s treatment record. 8. The post-dialysis assessment will be done before discharge of the patient from the center, but after the treatment has ended and the patient’s blood has been rinsed back. 9. The nurse responsible for the patient will be immediately notified whenever the patient’s vital signs are not within normal limits for the patient or reach any alert values. Review of the facility’s current policy and procedure on IC08 Monitoring & Documentation of Patient Care During Treatment directs staff as follows: “POLICY: 15. Information that must be entered manually includes, but is not limited to: “ Any follow-care or arrangements made for follow-care after the patient’s treatment” EVENTS REPORTABLE TO THE CHARGE NURSE BY DIRECT PATIENT CARE STAFF PRE TREATMENT B/P Systolic > 200 OR < 90; Diastolic > 100 OR < 50 INTRADIALYTIC Blood Pressure Systolic > 200 or < 90 or any significant change in pressure POST TREATMENT Weight 1.0 kg < OR > EDW post treatment Blood Pressure SBP > 160 OR < 90; Diastolic BP > 100 OR < 50; Orthostatic BP changes - drops in SBP of > 25 pts or drops in DBP of > 15 pts ... ALWAYS REPORT ANY COMPLAINTS OR UNUSUAL SIGNS AND SYMPTOMS TO THE NURSE IN CHARGE AND DOCUMENT THAT THE CHARGE NURSE WAS NOTIFIED” Review of the facility’s current policy and procedure on IC08 Monitoring & Documentation of Patient Care During Treatment directs staff as follows: “POLICY: GENERAL INFECTION CONTROL MEASURES 25. No dialysis supplies or medications may be used after the manufacturer expiration date printed on the package label, or carton.” Intradialytic Assessment Patient #4 Observation on 03/18/2025 at 11:44 a.m. revealed Patient #4 was seated at station #7 machine #14 receiving hemodialysis treatment at a blood flow rate of 350 mL/min and a dialysate flow rate of 500 mL/min via left upper arm vascular access. The patient was utilizing an Optiflux 180 non reuse dialyzer. 10:31 a.m.: documented blood pressure of 118/74 mmHg and pulse rate of 58 beats per minute - patient care technician documented “blood flow at prescribed rate” 11:01 a.m.: documented blood pressure of 89/55 mmHg and pulse rate of 66 beats per minute - patient care technician documented “uf turned off due to low b/p” 11:02 a.m.: documented blood pressure of 93/61 mmHg and pulse rate of 64 beats per minute - patient care technician documented “pt taking b/p meds” 11:31 a.m.: documented blood pressure of 123/70 mmHg and pulse rate of 64 beats per minute - patient care technician documented “uf on; charge notified” 12:01 p.m.: documented blood pressure of 131/74 mmHg and pulse rate of 63 beats per minute - patient care technician documented “Patient alert, access visible” 12:31 p.m.: documented blood pressure of 130/78 mmHg and pulse rate of 66 beats per minute - patient care technician documented “Patient alert, access visible” 13:01 p.m.: documented blood pressure of 122/77 mmHg and pulse rate of 66 beats per minute - patient care technician documented “Patient watching tv, access visible” 13:31 p.m.: documented blood pressure of 124/69 mmHg and pulse rate of 67 beats per minute - patient care technician documented “Patient alert, access visible” 13:39 p.m.: documented blood pressure of 132/78 mmHg and pulse rate of 66 beats per minute - patient care technician documented “Treatment terminated, all blood returned” There was no nursing assessment performed by the registered nurse on the patient’s blood pressure and the ultrafiltration being turned off during the hemodialysis treatment. Post treatment documented before the end of treatment Patient #3 Observation on 03/18/2025 at 7:39 a.m. revealed Patient #3 was seated at station #7 machine #14 receiving hemodialysis treatment at a blood flow rate of 450 mL/min and a dialysate flow rate of 500 mL/min via left lower arm vascular access. The patient was utilizing an Optiflux 200 non reuse dialyzer. Review of the patient’s clinical record on 03/19/2025 revealed the following: Treatment sheet review: Review of treatment sheet dated 03/15/2025 revealed the following documentation: 08:50 a.m.: registered nurse documented the post treatment assessment which revealed Alert: Yes Oriented to: Time, Place, Person Cooperative: Yes Diarrhea: None Lungs: Clear AVF/AVG Hemostasis Achieved: Yes LE Edema: None Periorbital Edema: Not Facial Edema: No Pedal Edema: None Heart Rhythm: Regular Nausea/Vomiting: None Ambulatory Status: Cane Shortness of Breath: No Appetite Bleeding: Good Access Bleeding: < 20 min Pain: 0 08:51 a.m.: documented blood pressure of 157/81 mmHg and pulse rate of 81 beats per minute - registered nurse documented “Treatment terminated, all blood returned” The registered nurse documented the post treatment assessment prior to the end of treatment. The registered nurse documented the patient’s access hemostasis achieved and the access bleeding time while the patient was still receiving the hemodialysis treatment. Patient #1 Observation on 03/18/2025 at 7:43 a.m. revealed Patient #1 was seated at station #8 machine #11 receiving hemodialysis treatment at a blood flow rate of 350 mL/min and a dialysate flow rate of 500 mL/min via left upper arm vascular access. The patient was utilizing an Optiflux 180 non reuse dialyzer. Review of the patient’s clinical record on 03/19/2025 revealed the following: Treatment sheet review: Review of treatment sheet dated 03/11/2025 revealed the following documentation: 08:34 a.m.: registered nurse documented the post treatment assessment which revealed Alert: Yes Oriented to: Time, Place, Person Cooperative: Yes Diarrhea: None Lungs: Clear AVF/AVG Hemostasis Achieved: Yes LE Edema: None Periorbital Edema: Not Facial Edema: No Pedal Edema: None Heart Rhythm: Regular Nausea/Vomiting: None Ambulatory Status: Ambulates independently Shortness of Breath: No Appetite Bleeding: Good Access Bleeding: < 20 min Pain: 0 08:36 a.m.: documented blood pressure of 109/53 mmHg and pulse rate of 53 beats per minute - patient care technician documented “Treatment terminated, all blood returned” Review of treatment sheet dated 03/11/2025 revealed the following documentation: 08:37 a.m.: registered nurse documented the post treatment assessment which revealed Alert: Yes Oriented to: Time, Place, Person Cooperative: Yes Diarrhea: None Lungs: Clear AVF/AVG Hemostasis Achieved: Yes LE Edema: None Periorbital Edema: Not Facial Edema: No Pedal Edema: None Heart Rhythm: Regular Nausea/Vomiting: None Ambulatory Status: Ambulates independently Shortness of Breath: No Appetite Bleeding: Good Access Bleeding: < 20 min Pain: 0 08:42 a.m.: documented blood pressure of 89/48 mmHg and pulse rate of 53 beats per minute - patient care technician documented “Treatment terminated, all blood returned” The registered nurse documented the post treatment assessment prior to the end of treatment. The registered nurse documented the patient’s access hemostasis achieved and the access bleeding time while the patient was still receiving the hemodialysis treatment. Fluid Assessment Patient #5 Observation on 03/18/2025 at 2:09 p.m. revealed Patient #5 was seated at station #6 machine #16 receiving hemodialysis treatment at a blood flow rate of 350 mL/min and a dialysate flow rate of 500 mL/min via right central venous catheter. The patient was utilizing an Optiflux 160 non reuse dialyzer. Review of the patient’s clinical record on 03/19/2025 revealed the following: Treatment sheet review: Review of treatment sheet dated 03/11/2025 revealed the following documentation: 15:19 a.m.: registered nurse documented the post treatment assessment which revealed Post Dialysis Weight: 97.5 Dry Weight: 95 There was no mention of the patient being > 1 kg from the dry weight in the post treatment nurse assessment. Treatment sheet review: Review of treatment sheet dated 03/11/2025 revealed the following documentation: 15:19 a.m.: registered nurse documented the post treatment assessment which revealed Post Dialysis Weight: 96.9 Dry Weight: 95 There was no mention of the patient being > 1 kg from the dry weight in the post treatment nurse assessment. Patient #10 Observation on 03/19/2025 at 2:00 p.m. revealed Patient #10 was seated at station #12 machine #7 receiving hemodialysis treatment at a blood flow rate of 450 mL/min and a dialysate flow rate of 700 mL/min via left lower arm vascular access The patient was utilizing an Optiflux 200 non reuse dialyzer. Review of the patient’s clinical record on 03/19/2025 revealed the following: Treatment sheet review: Review of treatment sheet dated 01/15/2025 revealed the following documentation: 14:20 p.m.: registered nurse documented the post treatment assessment which revealed Post Dialysis Weight: 84.9 Dry Weight: 82 There was no mention of the patient being > 1 kg from the dry weight in the post treatment nurse assessment. Interview during record review with Nurse Manager (A) on 03/20/2025 starting at 1:29 p.m. confirmed the findings above. Expired Supplies Review of the Bemis “Expiration Information: Canisters & Liners” revealed: “All Bemis Canisters and Liners include an expiration date on the carton label and individual product. Expiration is three (3) years from the date of manufacture. Canisters and Liners should not be used past the labeled expiration date. Structural integrity can be compromised by factors such as, heat, time, and light exposure. Placing a negative vacuum on a compromised canister/liner can result in product failure.” Review of the package insert for TUBERSOL® Tuberculin Purified Protein Derivative (Mantoux) Solution, 5 Tuberculin units (TU) per 0.1 mL test dose, Intradermal injection Diagnostic Antigen to aid in the detection of infection with Mycobacterium tuberculosis ATC Code: V04CF01 Sanofi Pasteur Limited revealed: 11 STORAGE, STABILITY AND DISPOSAL Store at 2° to 8°C (35° to 46°F). Do not freeze. Discard product if exposed to freezing. At no time should TUBERSOL® be exposed to direct or indirect sunlight. Exposure to artificial light should also be kept to a minimum. A vial of TUBERSOL® which has been entered and in use for 30 days should be discarded. Treatment Area Observation of the hemodialysis treatment area on 03/18/2025 starting at 08:05 a.m. revealed the following expired supplies were co-mingled with stocks in use: Emergency cart: 1 - Bemis Hydrophobic 800 cc Suction Canister, Serial# 844-777, expiration date 2013-11 2 - Suture Removal Kit, Lot# 2020570, expiration date 2024-07-30 2 - 0.9% Sodium Chloride 250 mL IV bag, Lot# V22F220, expiration date Dec 23 Clean supply storage cabinets: Bay 3-4 (along the wall): 2 - Bemis Hydrophobic 800 cc Suction Canister, Serial# 844-777, expiration date 2013-11 3 - Criterion Powder-Free Nitrile Examination Gloves 200 count box, Lot# K07119602, expiration date 2022-11-06 Bay 1-2 (middle of bay): 1 - 0.9% Sodium Chloride 1000 mL IV bag, Lot# 23KG02078, expiration date Aug 24 Isolation Room: 1 - Criterion Powder-Free Nitrile Examination Gloves 200 count box, Lot# K07119602, expiration date 2022-11-06 Peritoneal dialysis training room Observation of the hemodialysis treatment area on 03/18/2025 starting at 1:03 p.m. revealed the following expired supplies were co-mingled with stocks in use: 1 - Tubersol Tuberculin Purified Protein Derivative (Mantoux) Solution, 5 Tuberculin units (TU) per 0.1 mL test dose, Intradermal injection Diagnostic Antigen, the vial was opened but had no open or discard date on the vial or the box 1 - Skin Prep 50 wipes, Lot# 64490, expiration date 2025-03-01 Walkthrough and interview with Nurse Manager (A) on 03/18/2025 starting at 8:05 a.m. confirmed the findings above.”

“GOV-GB RESP FOR MED STAFF CREDENTIALING CFR(s): 494.180(c)(1) The governing body- (1) Is responsible for all medical staff appointments and credentialing in accordance with State law, including attending physicians, physician assistants, nurse practitioners and clinical nurse specialists; This Standard is not met as evidenced by: 48020 Based on record review and interview, the facility’s Governing Body failed to ensure the delegation of medical responsibilities to the nurse practitioner was reviewed and signed annually in 1 of 2 medical staff personnel records reviewed: Nurse Practitioner (O) Findings: Nurse Practitioner (O) Review of Nurse Practitioner (O’s) personnel file on 03/20/2025 revealed Nurse Practitioner (O’s) most current credentials were approved by the facility’s governing body on 07/10/2024. Patient #4 Observation on 03/18/2025 at 11:44 a.m. revealed Patient #4 was seated at station #7 machine #14 receiving hemodialysis treatment at a blood flow rate of 350 mL/min and a dialysate flow rate of 500 mL/min via left upper arm vascular access. The patient was utilizing an Optiflux 180 non reuse dialyzer. Review of the clinical record for Patient #4 on 03/18/2025 revealed documentation that the patient was seen while on dialysis by Nurse Practitioner (O) on 02/18/2025. Patient #6 Observation on 03/18/2025 at 7:40 a.m. revealed Patient #6 was seated at station #10 machine #1 receiving hemodialysis treatment at a blood flow rate of 350 mL/min and a dialysate flow rate of 500 mL/min via left upper arm vascular access. The patient was utilizing an Optiflux 180 non reuse dialyzer. Review of the clinical record for Patient #4 on 03/18/2025 revealed documentation that the patient was seen while on dialysis by Nurse Practitioner (O) on 02/18/2025. Patient #7 Observation on 03/18/2025 at 2:14 p.m. revealed Patient #7 was seated at station #12 machine #76 receiving hemodialysis treatment at a blood flow rate of 350 mL/min and a dialysate flow rate of 700 mL/min via left upper arm vascular access. The patient was utilizing an Optiflux 200 non reuse dialyzer. Review of the clinical record for Patient #4 on 03/18/2025 revealed documentation that the patient was seen while on dialysis by Nurse Practitioner (O) on 02/18/2025. Review of Nurse Practitioner (O’s) personnel file revealed the most current delegation of medical responsibilities to the nurse practitioner was reviewed and signed on 02/25/2020. Interview with Facility’s Administrator (M) on 03/20/2025 at 12:30 p.m. confirmed the above findings.”