Fkc Clutch City

“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 2 of 10 sampled patients: Patient (D), (H) B) the registered nurses failed to document the review of patient treatment prescription and equipment parameters to verify correct settings, and if dialysis prescription is being followed in 9 of 10 sampled patients: Patient (A), (B), (C),(D), (G), (F), (H), (I), (J) Findings: Review of the facility’s current Policy and Procedure on Pre-Treatment Safety Checks; Policy #47798 directs staff as follows: Policy The clinician initiating treatment must verify the prescribed set up matches the patient: “ Patient’s identity per policy “ Prescription o Dialyzer o Dialysate composition o Dialysate flow rate o Time o Goal set o Needle size o Temperature “ Special attention orders are followed “ Na modeling (SVS) and/or UFR profiling if applicable “ Heparin dose. If a heparin pump is used check to see if it is primed, turned on and set at the proper prescribed infusion rate. “ OLC volume “ Blood pressure and parameters are set Review of the facility’s current Policy and Procedure on Nursing Supervision and Delegation; Policy #45265 directs staff as follows: Policy The registered nurse must evaluate each patient preferably within an hour or according to state requirements to: ... “ Review accuracy and completeness of treatment and patient data “ Review patient treatment prescription and equipment parameters to verify correct settings, and if dialysis prescription is being followed. Machine Settings Patient (D) Review of the patient’s clinical record on 12/31/2025 revealed the patient was admitted to the facility on 12/23/2021 with diagnoses of end stage renal disease and hypertension, on in-center hemodialysis three times weekly. Treatment sheet review: Review of the patient’s treatment sheet dated 12/30/2025 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 dialysate flow rate of 300 mL/min from 10:45 AM - 13:45 PM. There was no justification documented for the blood flow rate of 300 mL/min. Patient (H) Review of the patient’s clinical record on 12/31/2025 revealed the patient was admitted to the facility on 12/23/2021 with diagnoses of end stage renal disease, Type 1 diabetes mellitus and hypertension, on in-center hemodialysis three times weekly. Treatment sheet review: Review of the patient’s treatment sheet dated 12/22/2025 revealed documentation which indicated the patient was prescribed a dialysate flow rate of Manual 800 mL/min on the treatment sheet but received hemodialysis treatment at a dialysate flow rate of 500 mL/min from 12:13 PM - 15:30 PM. There was no justification documented for the dialysate flow rate of 500 mL/min. Interview during record review with Clinical Coordinator Staff ID #8 on 12/31/2025 confirmed the patients did not receive the hemodialysis treatment according to physicians’ orders. Clinical Coordinator Staff ID #8 said, “Okay.” RN Prescription Verification Patient (D) Review of the patient’s clinical record on 12/31/2025 revealed the patient was admitted to the facility on 12/23/2021 with diagnoses of end stage renal disease and hypertension, on in-center hemodialysis three times weekly. Treatment sheet review: Review of the patient’s treatment sheet dated 12/31/2025 revealed documentation which indicated the patient received the hemodialysis treatment from 9:30 AM - 12:36 PM. There was no documented review of the patient’s treatment prescription and equipment parameters to verify correct settings per the facility’s policy. Patient (F) Review of the patient’s clinical record on 12/31/2025 revealed the patient was admitted to the facility on 09/30/2024 with diagnoses of end stage renal disease and heart failure, on in-center hemodialysis three times weekly. Treatment sheet review: Review of the patient’s treatment sheet dated 12/20/2025 revealed documentation which indicated the patient received the hemodialysis treatment from 11:32 AM - 14:32 PM. There was no documented review of the patient’s treatment prescription and equipment parameters to verify correct settings per the facility’s policy. Patient (H) Review of the patient’s clinical record on 12/31/2025 revealed the patient was admitted to the facility on 12/23/2021 with diagnoses of end stage renal disease, Type 1 diabetes mellitus and hypertension, on in-center hemodialysis three times weekly. Review of the patient’s treatment sheet dated 12/30/2025 revealed documentation which indicated the patient received the hemodialysis treatment from 15:57 PM - 18:53 PM. There was no documented review of the patient’s treatment prescription and equipment parameters to verify correct settings per the facility’s policy. There was no documented review of the patient’s treatment prescription and equipment parameters to verify correct settings on 12/18/2025, 12/20/2025, 12/22/2025, 12/24/2025 and 12/27/2025. Patient (I) Review of the patient’s clinical record on 12/31/2025 revealed the patient was admitted to the facility on 07/14/2023 with diagnoses of end stage renal disease and hypertension, on in-center hemodialysis three times weekly. Review of the patient’s treatment sheet dated 12/30/2025 revealed documentation which indicated the patient received the hemodialysis treatment from 11:00 AM - 14:30 PM. There was no documented review of the patient’s treatment prescription and equipment parameters to verify correct settings per the facility’s policy. There was no documented review of the patient’s treatment prescription and equipment parameters to verify correct settings on 12/19/2025, 12/21/2025, 12/23/2025, 12/26/2025 and 12/28/2025. Patient (J) Review of the patient’s clinical record on 12/31/2025 revealed the patient was admitted to the facility on 05/01/2024 with diagnoses of end stage renal disease and hypertension, on in-center hemodialysis three times weekly. Review of the patient’s treatment sheet dated 12/30/2025 revealed documentation which indicated the patient received the hemodialysis treatment from 16:53 PM - 20:03 PM. There was no documented review of the patient’s treatment prescription and equipment parameters to verify correct settings per the facility’s policy. There was no documented review of the patient’s treatment prescription and equipment parameters to verify correct settings on 12/19/2025, 12/21/2025, 12/23/2025, 12/26/2025 and 12/28/2025. Interview during record review with Clinical Coordinator Staff ID #8 on 12/31/2025 confirmed the registered nurses did not complete the prescription verification according to policy. Clinical Coordinator Staff ID #8 said, “They are not consistent in completing them.” 30124 Record Review: Patient A Record review of Patient (A) records revealed the patient was admitted to the facility on 5/13/2025 with diagnosis of end stage renal disease and on in-center hemodialysis three times a week. There was no documentation by the registered nurse the patient’s treatment prescription and equipment parameters were verified to be at the correct setting per the facility’s policy for the following dates. 12/11/2025 12/20/2025 12/22/2025 12/24/2025 12/27/2025 12/29/2025 Patient B Record review of Patient (B) records revealed the patient was admitted to the facility on 4/04/2024 with diagnosis of end stage renal disease and on in-center hemodialysis three times a week. There was no documentation by the registered nurse the patient’s treatment prescription and equipment parameters were verified to be at the correct setting per the facility’s policy for the following dates. 12/16/2025 12/18/2025 12/20/2025 12/27/2025 Patient C Record review of Patient (C) records revealed the patient was admitted to the facility on 7/11/2023 with diagnosis of end stage renal disease and in-center hemodialysis three times a week. There was no documentation by the registered nurse the patient’s treatment prescription and equipment parameters were verified to be at the correct setting per the facility’s policy for the following dates. 12/20/2025 12/22/2025 12/24/2025 12/27/2025 Patient G Record review of Patient (G) records revealed the patient was admitted to the facility with a diagnosis of end stage renal disease and on in-center hemodialysis three times a week. There was no documentation by the registered nurse the patient’s treatment prescription and equipment parameters were verified to be at the correct setting per the facility’s policy for the following dates. 12/12/2025 12/15/2025 12/19/2025 12/28/2025”

“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 before or during hemodialysis treatment per the facility’s policy in 4 of 10 sampled patients: Patient (D), (F), (G), (H) Findings: Review of the facility’s current Policy and Procedure on Patient Assessment and Monitoring; Policy # 45284, published 05/01/2023 directs staff as follows: Data Collection Direct patient care staff may collect data such as weight, BP, pulse, respirations, temperature, general observations, access, and complaints reported by the patient. If the PCT/LPN note any changes or abnormal findings in the patient’s condition or vascular access are observed or reported by the patient, or the patient was hospitalized, the registered nurse must assess the patient. o The RN will notify the patient’s physician/physician extender of any abnormal findings, if necessary, based on clinical judgment for additional instruction. The Registered Nurse will assess/re-assess any findings addressed pre or during treatment as needed. Patient (D) Review of the patient’s clinical record on 12/31/2025 revealed the patient was admitted to the facility on 12/23/2021 with diagnoses of end stage renal disease and hypertension, on in-center hemodialysis three times weekly. Review of the patient’s clinical record on 12/31/2025 revealed the following: Treatment sheet review: Review of treatment sheet dated 12/30/2025 revealed the following documentation: 11:18 AM: registered nurse documented the pretreatment assessment which revealed Lungs: Decreased breath sounds Lower Leg - Severity: 2+: 2-4 mm indent, disappears in 10-15 seconds Lungs - Sound Location: Bilateral Edema Lower Leg - Location: Left 14:19 PM: registered nurse documented the post treatment assessment which revealed “Notes: Tx completed as ordered. Patient AOx3. Needles removed and sites secured with sterile gauze. Access site without bleeding or swelling. No complaints post tx. Left unit and in stable condition.” The registered nurse did not document a reassessment of edema and lung sounds found during the pretreatment assessment. Review of treatment sheet dated 12/24/2025 revealed the following documentation: 11:49 AM: registered nurse documented the pretreatment assessment which revealed Lungs: Decreased breath sounds Lower Leg - Severity: 1+: 2 mm or less, disappears rapidly Edema Lower Leg - Location: Right Lungs - Sound Location: Bilateral The registered nurse did not document a reassessment of edema and lung sounds found during the pretreatment assessment. Patient (F) Review of the patient’s clinical record on 12/31/2025 revealed the patient was admitted to the facility on 09/30/2024 with diagnoses of end stage renal disease and heart failure, on in-center hemodialysis three times weekly. Review of the patient’s clinical record on 12/31/2025 revealed the following: Treatment sheet review: Review of treatment sheet dated 12/28/2025 revealed the following documentation: 12:49 PM: registered nurse documented the pretreatment assessment which revealed General Assessment- Cardiovascular Associated Symptoms: SOB, Received 2LO2, Treatment General Assessment- Respiratory Associated Symptoms: Shortness of Breath Fluid Assessment Symptoms: Shortness of Breath Lungs: Decreased breath sounds, Rales (Crackles) Lower Leg - Severity: 3+: 4-6 mm indent, noticeably deep, last more than 1 minute, extremity swollen Ankle - Severity: 3+: 4-6 mm indent, noticeably deep, last more than 1 minute, extremity swollen Edema Ankle - Location: Bilateral Lungs - Sound Location: Bilateral Edema Lower Leg - Location: Bilateral “Notes: Pt arrived with walker. Pt c/o fall from yesterday 3 times. 1 time head hit in the floor. Small bruised present in the back of the head. Pt denies pain/vomiting. Notified MD. Per MD hold heparin. Tx started per MD order.” 16:58 PM: registered nurse documented the post treatment assessment which revealed “Notes: Tolerated well tx, denied chest pain, dizziness, headache, weakness, no n/v no sob noted, no nvd, access intact, no sign of infection, pt left fluid overload, aaox3 and stable, educated on salt and fluid restriction intake, declined extra tx.” The registered nurse did not document a reassessment of edema and lung sounds found during the pretreatment assessment. Patient (H) Review of the patient’s clinical record on 12/31/2025 revealed the patient was admitted to the facility on 12/23/2021 with diagnoses of end stage renal disease, Type 1 diabetes mellitus and hypertension, on in-center hemodialysis three times weekly. Treatment sheet review: Review of treatment sheet dated 12/28/2025 revealed the following documentation: 16:30 PM: documented blood pressure of 176/94 and pulse rate of 76 beats per minute - patient care technician documented “Denies Complaints” 17:00 PM: documented blood pressure of 199/100 and pulse rate of 80 beats per minute - patient care technician documented “Denies Complaints; Patient Alert” 17:33 PM: documented blood pressure of 192/104 and pulse rate of 80 beats per minute - patient care technician documented “Denies Complaints” 18:02 PM: documented blood pressure of 192/104 and pulse rate of 80 beats per minute - patient care technician documented “Denies Complaints; UF Off, Patient Alert; pt uf off, pt cramping” 18:31 PM: documented blood pressure of 190/109 and pulse rate of 85 beats per minute - patient care technician documented “Denies Complaints” 18:53 PM: documented blood pressure of 151/90 and pulse rate of 91 beats per minute - patient care technician documented “Denies Complaints; Treatment Discontinued Without Problem” The patient care technician failed to report the above parameter blood pressure to the registered nurse thus the registered nurse did complete an assessment. Interview during record review with Clinical Coordinator Staff ID #8 on 12/31/2025 at 2:54 PM confirmed the registered nurses did not conduct assessments when patients experienced a change in condition before or during hemodialysis treatment. Clinical Coordinator Staff ID #8 said, “Okay, she’s not reassessing.” 30124 Patient (G) Review of the patient’s clinical record on 12/31/2025 revealed the patient was admitted to the facility with diagnoses of end stage renal disease, on in-center hemodialysis three times weekly. Treatment sheets review: Review of treatment sheet dated 12/15/2025 revealed the following documentation: 17:34 PM: documented blood pressure of 145/77 and pulse rate of 75 beats per minute - patient care technician documented “Denies Complaints”. 18:03 PM: documented blood pressure 90/54 and pulse rate 71 beats per minute - patient care technician documented “UF off; RN notified of BP”. No documentation for reassessment of the patient by the registered nurse with blood pressure changes out of parameter reported during hemodialysis treatment. Review of treatment sheet dated 12/19/2025 revealed the following documentation: 15:40 PM: documented blood pressure of 160/51 and pulse rate 77 beats per minute - patient technician documented “Denies complaints; Patient alert”. 16:00 PM: documented blood pressure of 187/57 and pulse rate 78 beats per minute - patient technician documented “Denies complaints; Patient alert”. 16:30 PM: documented blood pressure of 189/52 and pulse rate 75 beats per minute - patient technician documented “Denies complaints; Patient alert”. The patient care technician failed to report the above parameter blood pressure to the registered nurse thus the registered nurse did complete an assessment.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 48020 Based on observation, interview, and record review, the facility’s staff failed to maintain a clean, sanitary environment based on the facility’s policy. Findings: Review of the facility’s current policy and procedure: General Cleanliness and Infection Control Guidelines 11/04/2024, reference number 47685, version 7 directs the staff as follows: “Policy “ All areas must be kept clean and organized, including but not limited to treatment areas, water/supply rooms and offices. Walkways must be kept clear of debris and free of clutter. “ Facility staff are accountable for cleaning rooms/areas not assigned to contracted cleaning staff. Such cleaning should be done regularly using a schedule developed by the facility.” Observation of the facility’s treatment area on 10/13/2025 beginning at 7:15 AM revealed the following: 1) Between Stations #21 and #23: white buildup on the floor near the chase cabinet 2) Between Station #23 and isolation room: white fluid on the floor near the chase cabinet leaking into the isolation room 3) Isolation room near Station #23: white powdery build up on the floor along the bottom of the windowed wall, white fluid and white build up on the floor 4) Right aisle in front of sinks and emergency cart: white wax build up on the floor 5) Station #5: clear fluid on the back bottom ledge of the machine and on the floor behind the machine Interview with Patient Care Technician (C) at 7:25 AM revealed he said, “We have leaks off and on.” Interview during a walk-through of the treatment area with Facility Administrator (F) at 7:47 AM verified the findings above. She said, the leak into the isolation room is from the wall box and when we they clean it up the white spots do not come up. She also said, “The cleaning crew waxed our floors and whatever they used created white spots all over the floor.””

“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 at the prescribed dialysate flow rate in 3 of 9 sampled patients: Patient #s 5, 6, 9. B) failed to administer patients’ hemodialysis treatments at the prescribed treatment time in 3 of 9 sampled patients: Patient #s 2, 4, 5. Findings: Review of the facility’s current Policy and Procedure on Pre-Treatment Safety Checks; Policy #47798 directs staff as follows: Policy The clinician initiating treatment must verify the prescribed set up matches the patient: “ Patient’s identity per policy “ Prescription o Dialyzer o Dialysate composition o Dialysate flow rate o Time o Goal set o Needle size o Temperature “ Special attention orders are followed “ Na modeling (SVS) and/or UFR profiling if applicable “ Heparin dose. If a heparin pump is used check to see if it is primed, turned on and set at the proper prescribed infusion rate. “ OLC volume “ Blood pressure and parameters are set Review of the facility’s current Policy and Procedure on Nursing Supervision and Delegation; Policy #45265 directs staff as follows: Policy The registered nurse must evaluate each patient preferably within an hour or according to state requirements to: ... “ Review accuracy and completeness of treatment and patient data “ Review patient treatment prescription and equipment parameters to verify correct settings, and if dialysis prescription is being followed. DIALYSATE FLOW RATE: Patient #5 Observation on 10/13/2025 at 7:43 AM revealed Patient #5 was seated at station #16 machine #26 receiving hemodialysis treatment at a blood flow rate of 300 mL/min and a dialysate flow rate of 700 mL/min via right lower arm vascular access. The patient was utilizing an Optiflux F-160 non-reuse dialyzer. Review of the patient’s treatment sheet dated 10/08/2025 revealed documentation which indicated the patient was prescribed a dialysate flow rate of Manual 700 mL/min on the treatment sheet but received hemodialysis treatment at a dialysate flow rate of 500 mL/min from 8:32 AM - 10:30 AM. There was no justification documented for the dialysate flow rate of 500 mL/min. Patient #6 Observation on 10/13/2025 at 7:53 AM revealed Patient #6 was seated at station #17 machine #25 receiving hemodialysis treatment at a blood flow rate of 400 mL/min and a dialysate flow rate of 600 mL/min via right central venous catheter. The patient was utilizing an Optiflux F-180 non-reuse dialyzer. Review of the patient’s treatment sheet dated 10/03/2025 revealed documentation which indicated the patient was prescribed a dialysate flow rate of Autoflow 1.5 (600 mL/min) on the treatment sheet but received hemodialysis treatment at a dialysate flow rate of 700 mL/min from 7:50 AM - 11:27 AM. There was no justification documented for the dialysate flow rate of 700 mL/min. Review of the patient’s treatment sheet dated 09/29/2025 revealed documentation which indicated the patient was prescribed a dialysate flow rate of Autoflow 1.5 (600 mL/min) on the treatment sheet but received hemodialysis treatment at a dialysate flow rate of 800 mL/min from 8:06 AM - 10:37 AM. There was no justification documented for the dialysate flow rate of 800 mL/min. Patient #9 Review of the patient’s clinical record (demographic data) on 10/13/2025 revealed the patient was admitted to the facility 12/23/2021. Review of the patient’s treatment sheet dated 10/07/2025 revealed documentation which indicated the patient was prescribed a dialysate flow rate of Manual 800 mL/min on the treatment sheet but received hemodialysis treatment at a dialysate flow rate of 700 mL/min from 6:55 AM - 10:04 AM. There was no justification documented for the dialysate flow rate of 700 mL/min. Interview during record review with Clinical Coordinator (G) on 10/13/2025 confirmed that Patient #s 5, 6 and 9 did not receive the hemodialysis treatment at the prescribed dialysate flow rate. She said, “I found some of the same things on my audit.” TREATMENT TIME: Patient #2 Observation on 10/13/2025 at 7:36 AM revealed Patient #2 was seated at station #4 machine #4 receiving hemodialysis treatment at a blood flow rate of 350 mL/min and a dialysate flow rate of 800 mL/min via left lower arm vascular access. The patient was utilizing an Optiflux F-180 non-reuse dialyzer. Review of the patient’s treatment sheet dated 10/08/2025 revealed the Scheduled Hours of 03:45 hours. The patient’s hemodialysis treatment duration was from 6:44 AM - 9:42 AM. The Post-Dialysis Vitals and Evaluation documentation indicated the “HOURS ON” dialysis was 02:58 hours instead of the prescribed 03:45 hours. There was no documented justification of why the patient did not receive the hemodialysis treatment at the prescribed time nor whether the patient signed an early termination Against Medical Advice form. Review of the patient’s treatment sheet dated 10/06/2025 revealed the Scheduled Hours of 03:45 hours. The patient’s hemodialysis treatment duration was from 6:14 AM - 9:45 AM. The Post-Dialysis Vitals and Evaluation documentation indicated the “HOURS ON” dialysis was 03:31 hours instead of the prescribed 03:45 hours. There was no documented justification of why the patient did not receive the hemodialysis treatment at the prescribed time nor whether the patient signed an early termination Against Medical Advice form. Review of the patient’s treatment sheet dated 10/03/2025 revealed the Scheduled Hours of 03:45 hours. The patient’s hemodialysis treatment duration was from 6:25 AM - 9:32 AM. The Post-Dialysis Vitals and Evaluation documentation indicated the “HOURS ON” dialysis was 03:06 hours instead of the prescribed 03:45 hours. There was no documented justification of why the patient did not receive the hemodialysis treatment at the prescribed time nor whether the patient signed an early termination Against Medical Advice form. Review of the patient’s treatment sheet dated 10/01/2025 revealed the Scheduled Hours of 03:45 hours. The patient’s hemodialysis treatment duration was from 6:56 AM - 9:33 AM. The Post-Dialysis Vitals and Evaluation documentation indicated the “HOURS ON” dialysis was 02:36 hours instead of the prescribed 03:45 hours. There was no documented justification of why the patient did not receive the hemodialysis treatment at the prescribed time nor whether the patient signed an early termination Against Medical Advice form. Review of the patient’s treatment sheet dated 10/06/2025 revealed the Scheduled Hours of 03:45 hours. The patient’s hemodialysis treatment duration was from 6:20 AM - 9:31 AM. The Post-Dialysis Vitals and Evaluation documentation indicated the “HOURS ON” dialysis was 03:10 hours instead of the prescribed 03:45 hours. There was no documented justification of why the patient did not receive the hemodialysis treatment at the prescribed time nor whether the patient signed an early termination Against Medical Advice form. Patient #4 Observation on 10/13/2025 at 7:41 AM revealed Patient #4 was seated at station #12 machine #3 receiving hemodialysis treatment at a blood flow rate of 350 mL/min and a dialysate flow rate of Autoflow 600 mL/min via left upper arm vascular access. The patient was utilizing an Optiflux F-180 non-reuse dialyzer. Review of the patient’s treatment sheet dated 10/06/2025 revealed the Scheduled Hours of 03:15 hours. The patient’s hemodialysis treatment duration was from 7:11 AM - 10:09 AM. The Post-Dialysis Vitals and Evaluation documentation indicated the “HOURS ON” dialysis was 02:57 hours instead of the prescribed 03:15 hours. There was no documented justification of why the patient did not receive the hemodialysis treatment at the prescribed time nor whether the patient signed an early termination Against Medical Advice form. Review of the patient’s treatment sheet dated 10/03/2025 revealed the Scheduled Hours of 03:15 hours. The patient’s hemodialysis treatment duration was from 7:07 AM - 10:00 AM. The Post-Dialysis Vitals and Evaluation documentation indicated the “HOURS ON” dialysis was 02:53 hours instead of the prescribed 03:15 hours. There was no documented justification of why the patient did not receive the hemodialysis treatment at the prescribed time nor whether the patient signed an early termination Against Medical Advice form. Review of the patient’s treatment sheet dated 10/01/2025 revealed the Scheduled Hours of 03:15 hours. The patient’s hemodialysis treatment duration was from 7:00 AM - 10:08 AM. The Post-Dialysis Vitals and Evaluation documentation indicated the “HOURS ON” dialysis was 03:06 hours instead of the prescribed 03:15 hours. There was no documented justification of why the patient did not receive the hemodialysis treatment at the prescribed time nor whether the patient signed an early termination Against Medical Advice form. Review of the patient’s treatment sheet dated 09/29/2025 revealed the Scheduled Hours of 03:15 hours. The patient’s hemodialysis treatment duration was from 7:04 AM - 10:00 AM. The Post-Dialysis Vitals and Evaluation documentation indicated the “HOURS ON” dialysis was 02:55 hours instead of the prescribed 03:15 hours. There was no documented justification of why the patient did not receive the hemodialysis treatment at the prescribed time nor whether the patient signed an early termination Against Medical Advice form. Patient #5 Observation on 10/13/2025 at 7:43 AM revealed Patient #5 was seated at station #16 machine #26 receiving hemodialysis treatment at a blood flow rate of 300 mL/min and a dialysate flow rate of 700 mL/min via right lower arm vascular access. The patient was utilizing an Optiflux F-160 non-reuse dialyzer. Review of the patient’s treatment sheet dated 10/08/2025 revealed the Scheduled Hours of 04:00 hours. The patient’s hemodialysis treatment duration was from 7:25 AM - 11:01 AM. The Post-Dialysis Vitals and Evaluation documentation indicated the “HOURS ON” dialysis was 03:06 hours instead of the prescribed 04:00 hours. There was no documented justification of why the patient did not receive the hemodialysis treatment at the prescribed time nor whether the patient signed an early termination Against Medical Advice form. Review of the patient’s treatment sheet dated 10/06/2025 revealed the Scheduled Hours of 04:00 hours. The patient’s hemodialysis treatment duration was from 7:29 AM - 11:14 AM. The Post-Dialysis Vitals and Evaluation documentation indicated the “HOURS ON” dialysis was 03:46 hours instead of the prescribed 04:00 hours. There was no documented justification of why the patient did not receive the hemodialysis treatment at the prescribed time nor whether the patient signed an early termination Against Medical Advice form. Review of the patient’s treatment sheet dated 10/03/2025 revealed the Scheduled Hours of 04:00 hours. The patient’s hemodialysis treatment duration was from 7:25 AM - 11:02 AM. The Post-Dialysis Vitals and Evaluation documentation indicated the “HOURS ON” dialysis was 03:36 hours instead of the prescribed 04:00 hours. There was no documented justification of why the patient did not receive the hemodialysis treatment at the prescribed time nor whether the patient signed an early termination Against Medical Advice form. Review of the patient’s treatment sheet dated 09/29/2025 revealed the Scheduled Hours of 04:00 hours. The patient’s hemodialysis treatment duration was from 9:00 AM - 11:00 AM. The Post-Dialysis Vitals and Evaluation documentation indicated the “HOURS ON” dialysis was 02:08 hours instead of the prescribed 04:00 hours. There was no documented justification of why the patient did not receive the hemodialysis treatment at the prescribed time nor whether the patient signed an early termination Against Medical Advice form. Interview during record review with Clinical Coordinator (G) and Facility Administrator (F) on 10/13/2025 confirmed that Patient #s 2, 4 and 5 did not receive the hemodialysis treatment at the prescribed treatment time. Facility Administrator (F) said, “We switched to a brand new schedule on the first of October and it caused delays.” She also said that on two of the days, the RN was late to work.”

“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 assess patients when patients experienced a change in condition during hemodialysis treatment or post treatment when abnormal findings were present pre-treatment per the facility’s policy in 3 of 9 sampled patients: Patient #s 1, 3, 4. Findings: Review of the facility’s current policy and procedure on Patient Assessment and Monitoring; Policy # 45284 directs staff as follows: “If the PCT/LPN note any changes or abnormal findings in the patient’s condition or vascular access are observed or reported by the patient, or the patient was hospitalized, the registered nurse must assess the patient ... o The RN will notify the patient’s physician/physician extender of any abnormal findings, if necessary, based on clinical judgment for additional instruction. The Registered Nurse will assess/re-assess any findings addressed pre or during treatment as needed ... During Treatment Follow the steps below for monitoring patient and machine parameters during treatment: 1. Blood Pressure Record blood pressure “ Recheck blood pressures after a drop that requires interventions such as administering normal saline. “ Reposition electronic cuff or use a manual cuff for aberrant blood pressure readings. Report to the nurse: “ Systolic blood pressures greater than 180 mm/Hg “ Diastolic blood pressure greater than 100 mm/Hg “ Blood Pressure less than or equal to 100 mm/Hg systolic ... Post-Treatment Lungs sounds Edema Heart sounds The registered nurse will assess/re-assess post treatment as indicated.” DURING TREATMENT: Patient #1 Observation on 10/13/2025 at 7:25 AM revealed Patient #1 was seated at station #12 machine #3 waiting to be cannulated before the hemodialysis treatment. Review of the patient’s treatment sheet dated 10/08/2025 revealed the following documentation: 07:01 AM: documented blood pressure of 176/68 mmHg sitting and heart rate of 63 bpm - Patient Care Technician (PCT) documented “Denies Complaints, Patient Alert, pt tx started” 07:33 AM: documented blood pressure of 146/67 mmHg sitting and heart rate of 62 bpm - PCT documented “Denies Complaints, Patient Alert” 08:05 AM: documented blood pressure of 115/55 mmHg sitting and heart rate of 65 bpm - PCT documented “Denies Complaints, Access Visible” 08:33 AM: documented blood pressure of 81/45 mmHg sitting and heart rate of 70 bpm - PCT documented “Uf off Rn notified Bp” 09:01 AM: documented blood pressure of 111/54 mmHg sitting and heart rate of 65 bpm - PCT documented “Denies Complaints, Patient Alert, pt uf back on, pt bp stable” 09:30 AM: documented blood pressure of 114/68 mmHg sitting and heart rate of 66 bpm - PCT documented “Denies Complaints, Patient Alert” 10:00 AM: documented blood pressure of 99/50 mmHg sitting and heart rate of 69 bpm - PCT documented “Denies Complaints, Patient Alert, pt bp below 100, pt stable” 10:15 AM: documented blood pressure of 99/50 mmHg sitting and heart rate of 69 bpm - PCT did not document a comment 10:31 AM: documented blood pressure of 116/58 mmHg sitting and heart rate of 68 bpm - PCT documented “Denies Complaints, Patient Alert” 11:05 AM: documented blood pressure of 125/71 mmHg sitting and heart rate of 55 bpm - PCT documented “ ...pt tx ended” There was no documented assessment on the reportable blood pressure by the registered nurse during the hemodialysis treatment. Patient #3 Observation on 10/13/2025 at 7:58 AM. revealed Patient #8 was seated at station #21 machine #27 receiving hemodialysis treatment at a blood flow rate of 400 mL/min and a dialysate flow rate of 800 mL/min via right upper arm vascular access. The patient was utilizing an Optiflux 180 non-reuse dialyzer. Review of the patient’s treatment sheet dated 10/08/2025 revealed the following documentation: 07:31 AM: documented blood pressure of 159/78 mmHg sitting and heart rate of 57 bpm - PCT documented “Denies Complaints, Patient Alert” 08:05 AM: documented blood pressure of 192/86 mmHg sitting and heart rate of 60 bpm - PCT documented “Denies Complaints, Access Visible” 08:32 AM: documented blood pressure of 189/87 mmHg sitting and heart rate of 62 bpm - PCT documented “Denies Complaints, Access Visible” 09:00 AM: documented blood pressure of 171/82 mmHg sitting and heart rate of 66 bpm - PCT documented “Denies Complaints, Access Visible” 09:32 AM: documented blood pressure of 173/90 mmHg sitting and heart rate of 66 bpm - PCT documented “Denies Complaints, Access Visible” 09:49 AM: documented blood pressure of 100/52 mmHg sitting and heart rate of 50 bpm - PCT documented “ ...Tx ended” There was no documentation that the above parameter blood pressure was reported to the registered nurse. There was no documented assessment on the above parameter blood pressure by the registered nurse during the hemodialysis treatment. Interview during record review with Clinical Coordinator (G) on 10/13/2025 at 2:50 PM confirmed the above findings. Clinical Coordinator (G) said, “Okay.” POST TREATMENT: Patient #8 Observation on 10/13/2025 at 7:58 AM. revealed Patient #8 was seated at station #21 machine #27 receiving hemodialysis treatment at a blood flow rate of 400 mL/min and a dialysate flow rate of 800 mL/min via right upper arm vascular access. The patient was utilizing an Optiflux 180 non-reuse dialyzer. Review of the patient’s treatment sheet dated 10/10/2025 revealed the following documentation: 6:14 AM: registered nurse documented the pretreatment assessment which revealed “Symptoms Lungs - Decreased breath sounds Ankle - Severity: 1+: 2 mm or less, disappears rapidly Lower Leg - Severity: 1+: 2 mm or less, disappears rapidly Edema Ankle - Location: Bilateral Edema Lower Leg - Location: Bilateral Lungs - Sound Location: Bilateral 9:33 AM: registered nurse documented the post treatment assessment which revealed Notes: Pt tolerated Tx. Access is + for bruit & thrill. Shows no signs of excess bleeding. Pt A&Ox3. VS are WNL for pt Hix. Tx sheet reviewed by RN. Pt left unit intact. Pt want come early chair for extra Tx, unfortunately no available chair at this time.” The RN did not document a reassessment of decreased lung sounds and edema found during the pretreatment assessment. Interview during record review with Clinical Coordinator (G) on 10/13/2025 at 2:50 PM confirmed that Patient #8 did not receive a reassessment by the registered nurse on the decreased lung sounds and edema found pretreatment. Clinical Coordinator (G) said, “Okay.””

“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, interview and record review, the facility failed to ensure patient’s nephrologist round and assess patient’s every two weeks in 6 of 11 sampled patients: Patient #s 2, 10, 6, 8, 9, 11 Findings: Patient #2 On 02/04/2025 at 7:42 a.m. Patient #2 was observed on the treatment floor of the facility at station #18 machine #20. The patient was receiving hemodialysis treatment at a blood flow rate of 400 mL/min and dialysate flow rate of 800 mL/min. The patient was utilizing an Optiflux 160 non reuse dialyzer via a left upper arm vascular access. Review of the patient’s clinical record on 02/04/2025 revealed physician progress note dated 08/15/2024, 08/20/2024, 09/10/2024, 09/26/2024, 10/03/2024, 10/22/2024, 11/07/2024, 11/21/2024, 12/05/2024, 12/19/2024, 01/08/2025 and 1/28/2025. There was no documented physician progress note every two weeks as required by the state regulations. Patient #10 On 02/05/2025 at 9:08 a.m. Patient #10 was observed on the treatment floor of the facility at station #3 machine #7. The patient was receiving hemodialysis treatment at a blood flow rate of 450 mL/min and dialysate flow rate of 800 mL/min. The patient was utilizing an Optiflux 160 non reuse dialyzer via a right upper arm vascular access. Review of the patient’s clinical record on 02/05/2025 revealed physician progress note dated 08/05/2024, 08/21/2024, 09/10/2024, 09/13/2024, 10/07/2024, 10/30/2024, 11/11/2024, 12/06/2024, 12/16/2024, 01/13/2025, and 01/24/2025. There was no documented physician progress note every two weeks as required by the state regulations. Patient #6 On 02/05/2025 at 9:14 a.m. Patient #6 was observed on the treatment floor of the facility at station #15 machine #25. The patient was receiving hemodialysis treatment at a blood flow rate of 400 mL/min and dialysate flow rate of 800 mL/min. The patient was utilizing an Optiflux 160 non reuse dialyzer via a left upper arm vascular access. Review of the patient’s clinical record on 02/05/2025 revealed physician progress note dated 10/09/2024, 10/23/2024, 11/20/2024, 12/06/2024, 01/08/2025, and 02/05/2025. There was no documented physician progress note every two weeks as required by the state regulations. Patient #8 On 02/05/2025 at 9:20 a.m. Patient #8 was observed on the treatment floor of the facility at station #21 machine #19. The patient was receiving hemodialysis treatment at a blood flow rate of 400 mL/min and dialysate flow rate of 800 mL/min. The patient was utilizing an Optiflux 180 non reuse dialyzer via a left lower arm vascular access. Review of the patient’s clinical record on 02/05/2025 revealed physician progress note dated 10/07/2024, 10/30/2024, 11/11/2024, 11/25/2024, 12/06/2024, 12/16/2024, 01/13/2025, and 01/24/2025. There was no documented physician progress note every two weeks as required by the state regulations. Patient #9 On 02/05/2025 at 9:51 a.m. Patient #9 was observed on the treatment floor of the facility at station #1 machine #23. The patient was receiving hemodialysis treatment at a blood flow rate of 350 mL/min and dialysate flow rate of 800 mL/min. The patient was utilizing an Optiflux 180 non reuse dialyzer via a left upper arm vascular access. Review of the patient’s clinical record on 02/05/2025 revealed physician progress note dated 08/05/2024, 08/16/2024, 09/16/2024, 10/07/2024, 11/08/2024, 11/11/2024, 12/06/2024, 01/06/2025 and 02/03/2025. There was no documented physician progress note every two weeks as required by the state regulations. Patient #11 Review of the patient’s clinical record revealed the patient was admitted to facility on 12/23/2021 with diagnosis of end-stage renal disease and hypertension, on three times a week hemodialysis. Review of the patient’s clinical record revealed physician progress note dated 08/28/2024, 09/27/2024, 10/25/2024, 11/22/2024, 12/20/2024 and 01/30/2025. There was no documented physician progress note every two weeks as required by the state regulations. Interview with Facility Administrator of Clinical Safety (H) during record review on 02/05/2025 at 2:35 p.m. verified the above findings.”

“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, record review and interview, the facility failed to ensure that infection control was maintained as evidenced by chair side tables that had tape and tape residue in 12 of 24 hemodialysis chairs. Findings: Review of the facility’s current policy and procedure: Cleaning and Disinfecting the Dialysis Station 09/05/2023, reference number 47806, version 14 directs the staff as follows: “The purpose of this policy is to provided guidelines to prevent the spread of infectious disease in accordance with appropriate regulations, and to maintain a clean, safe, and aesthetically pleasant environment for patients, staff, and visitors. The Centers for Medicare and Medicaid Services (CMS) has regulations that in order to prevent cross contamination, a dialysis station must be cleaned and disinfected between dialysis patients. The chair and dialysis equipment are used by multiple patients during a treatment day and it is critical that these items be thoroughly cleaned and disinfected between uses.” Observation of the hemodialysis treatment area on 02/04/2025 at 9:10 a.m. revealed dirty pieces of tape and tape residue on the tray tables and arms of the hemodialysis chairs at station #s 9, 10, 11, 12, 13, 15, 17, 18, 19, 20, 23, 24. Interview during the walkthrough with Facility Administrator (H) at 9:30 a.m. verified the findings.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 48020 Based on observation, record review, and interview, the facility’s staff failed to maintain a clean, sanitary environment based on the facility’s policy. B) Based on observation record review and interview the facility failed to ensure methods were in place to prevent and/or control the transmission of infections in that: (1) Multiple holes were in the walls of the medical supply storage room. (2) The Medical supply storage room was not maintained in a manner to ensure prevention of contamination by vermin. Findings: Review of the facility’s current policy and procedure: General Cleanliness and Infection Control Guidelines 11/04/2024, reference number 47685, version 7 directs the staff as follows: “Policy “ All areas must be kept clean and organized, including but not limited to treatment areas, water/supply rooms and offices. Walkways must be kept clear of debris and free of clutter. “ Facility staff are accountable for cleaning rooms/areas not assigned to contracted cleaning staff. Such cleaning should be done regularly using a schedule developed by the facility.” Observation of the facility’s water room on 02/04/2025 at 7:59 a.m. revealed dirt and debris behind and in between the mixers and storage tanks. There was white, crystalized buildup on the floor underneath the acid storage tank. The metal stand that holds the reverse osmosis system was rusted. Interview during a walk-through of the water room with Facility Administrator (H) at 8:20 a.m. verified the findings above. Observation of the emergency evacuation boxes revealed a stethoscope, yellow face mask and debris on the floor behind one of the emergency evacuation boxes. 43549 1. During a tour of the medical storage room 02/04/25 at 13:15 with Bio Technician, Staff P black cylindrical bits on the floor with both ends tapered to a point, like rodent excrement is was observed on the floor beneath stored boxes of supplies on elevated shelving. were multiple hard approximately 0.25-inch. During an interview 02/04/25 at 13:27 Staff P stated he had no idea what the bits were until seeing them up close. Staff P called Staff R an operations manager who was interviewed 2/44/05 at 13:35 and stated “We need to call the extermination company.” Staff P and staff R were present 02/04/25 at 13:40 when five evenly spaced holes, in the base of a wall next to the loading door were sited. The holes were spaced approximately the distance between where support boards on a pallet are. When asked about the holes Staff R stated they were probably from heavy supplies being placed too close and too hard against the wall. He stated the holes needed to be repaired and stated they would be repaired right away. During an interview 2/44/05 at 13:45 staff P stated he knew the supply room was being cleaned but was unsure of a schedule.”

“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 5 of 10 sampled patients: Patient #s 2, 4, 10, 6, 8 Findings: Review of the facility’s current Policy and Procedure on Nursing Supervision and Delegation; Policy #45265, published 11/06/2023 directs staff as follows: Policy The registered nurse must evaluate each patient preferably within an hour or according to state requirements to: ... “ Review accuracy and completeness of treatment and patient data “ Review patient treatment prescription and equipment parameters to verify correct settings, and if dialysis prescription is being followed. Patient #2 On 02/04/2025 at 7:42 a.m. Patient #2 was observed on the treatment floor of the facility at station #18 machine #20. The patient was receiving hemodialysis treatment at a blood flow rate of 400 mL/min, dialysate flow rate of 800 mL/min and dialysate temperature of 35.5 degrees Celsius. The patient was utilizing an Optiflux 160 non reuse dialyzer via a left upper arm vascular access. Review of the physician’s hemodialysis orders in the chairside computer with Patient Care Technician (C) revealed the patient was prescribed a dialysate temperature of 37 degrees Celsius. The Surveyor notified Patient Care Technician (C) that the patient was not receiving the hemodialysis treatment at the prescribed dialysate temperature. Patient Care Technician (C) said, “I will change it.” Patient #4 On 02/04/2025 at 7:53 a.m. Patient #4 was observed on the treatment floor of the facility at station #24 machine #6. The patient was receiving hemodialysis treatment at a blood flow rate of 400 mL/min and dialysate flow rate of 800 mL/min. The patient was utilizing an Optiflux 160 non reuse dialyzer via a left upper arm vascular access. Review of the patient’s clinical record on 02/04/2025 revealed the following: Treatment sheet review: Dialysate Flow Rate Review of the patient’s treatment sheet dated 02/04/2025 revealed documentation which indicated the patient was prescribed a dialysate flow rate of Manual 800 mL/min on the treatment sheet but received hemodialysis treatment at a dialysate flow rate of 500 mL/min from 9:53 a.m. - 10:04 a.m. There was no justification documented for the dialysate flow rate of 500 mL/min. Review of the patient’s treatment sheet dated 02/01/2025 revealed documentation which indicated the patient was prescribed a dialysate flow rate of Manual 800 mL/min on the treatment sheet but received hemodialysis treatment at a dialysate flow rate of 500 mL/min from 8:31 a.m. - 11:34 a.m. There was no justification documented for the dialysate flow rate of 500 mL/min. Patient #10 On 02/05/2025 at 9:08 a.m. Patient #10 was observed on the treatment floor of the facility at station #3 machine #7. The patient was receiving hemodialysis treatment at a blood flow rate of 450 mL/min and dialysate flow rate of 800 mL/min. The patient was utilizing an Optiflux 160 non reuse dialyzer via a right upper arm vascular access. Review of the patient’s clinical record on 02/05/2025 revealed the following: Treatment sheet review: Dialysate Flow Rate Review of the patient’s treatment sheet dated 01/27/2025 revealed documentation which indicated the patient was prescribed a dialysate flow rate of Manual 800 mL/min and treatment time of 3 hrs 30 min. on the treatment sheet but received hemodialysis treatment at a dialysate flow rate of 300 mL/min from 7:32 a.m. - 10:13 a.m. There was no justification documented for the dialysate flow rate of 300 mL/min. Treatment Time Review of the patient’s treatment sheet dated 01/31/2025 revealed the Dialysis Prescription Treatment Time of 3h 30m. The Post-Dialysis Vitals documentation indicated the Hours On was 3:21 instead of the prescribed 3h 30m. There was no documented justification why the patient did not receive the hemodialysis treatment at the prescribed time nor whether the patient signed an early termination Against Medical Advice form. Patient #6 On 02/05/2025 at 9:14 a.m. Patient #6 was observed on the treatment floor of the facility at station #15 machine #25. The patient was receiving hemodialysis treatment at a blood flow rate of 400 mL/min and dialysate flow rate of 800 mL/min. The patient was utilizing an Optiflux 160 non reuse dialyzer via a left upper arm vascular access. Review of the patient’s clinical record on 02/05/2025 revealed the following: Treatment sheet review: Dialysate Flow Rate Review of the patient’s treatment sheet dated 01/31/2025 revealed documentation which indicated the patient was prescribed a dialysate flow rate of Manual 800 mL/min on the treatment sheet but received hemodialysis treatment at a dialysate flow rate of 500 mL/min from 6:21 a.m. - 9:55 a.m. There was no justification documented for the dialysate flow rate of 500 mL/min. Review of the patient’s treatment sheet dated 01/27/2025 revealed documentation which indicated the patient was prescribed a dialysate flow rate of Manual 800 mL/min on the treatment sheet but received hemodialysis treatment at a dialysate flow rate of 300 mL/min from 7:33 a.m. - 9:42 a.m. There was no justification documented for the dialysate flow rate of 300 mL/min. Patient #8 On 02/05/2025 at 9:20 a.m. Patient #8 was observed on the treatment floor of the facility at station #21 machine #19. The patient was receiving hemodialysis treatment at a blood flow rate of 400 mL/min and dialysate flow rate of 800 mL/min. The patient was utilizing an Optiflux 180 non reuse dialyzer via a left lower arm vascular access. Review of the patient’s clinical record on 02/05/2025 revealed the following: Treatment sheet review: Blood Flow Rate: Review of the patient’s treatment sheet dated 01/24/2025 revealed documentation which indicated the patient was prescribed a blood flow rate of 400 mL/min on the treatment sheet but received hemodialysis treatment at a blood flow rate of 350 mL/min from 8:02 a.m. - 9:10 a.m. There was no justification documented for the blood flow rates of 350 mL/min. Record review and interview with Clinical Coordinator (A) on 02/05/2025 at 4:17 p.m. verified patients above did not receive their hemodialysis treatments as prescribed for the dates in question.”

“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 before or during hemodialysis treatment per the facility’s policy in 8 of 11 sampled and closed patients: Patient #s 2, 4, 10, 5, 6, 8, 9, 11 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 Patient Assessment and Monitoring; Policy # 45284, published 05/01/2023 directs staff as follows: Data Collection Direct patient care staff may collect data such as weight, BP, pulse, respirations, temperature, general observations, access, and complaints reported by the patient. If the PCT/LPN note any changes or abnormal findings in the patient’s condition or vascular access are observed or reported by the patient, or the patient was hospitalized, the registered nurse must assess the patient. o The RN will notify the patient’s physician/physician extender of any abnormal findings, if necessary, based on clinical judgment for additional instruction. The Registered Nurse will assess/re-assess any findings addressed pre or during treatment as needed. Pre-Treatment Follow the steps below for obtaining pre-treatment assessment data: Blood Pressure Record blood pressure. Verify: o Systolic blood pressures greater than 180 mm/Hg and / or diastolic blood pressures greater than 100 mm/Hg o Systolic blood pressures less than or equal to 100 mm/hg systolic during treatment. During Treatment Blood Pressure Record blood pressure. o Recheck blood pressures after a drop that requires interventions such as administering normal saline. o Reposition electronic cuff or use a manual cuff for aberrant blood pressure readings. Report to the nurse: o Systolic blood pressures greater than 180 mm/Hg o Diastolic blood pressure greater than 100 mm/Hg o Blood Pressure less than or equal to 100 mm/hg systolic Post-Treatment Lungs sounds Edema Heart sounds The registered nurse will assess/re-assess post treatment as indicated. Review of the facility’s current policy and procedure on Nursing Supervision and Delegation: Policy # 45265, published 11/06/2023 directs staff as follows: Non-Delegated Tasks The following tasks that may NOT be delegated: Assessment of each patient preferably within an hour (or according to state requirements) of treatment initiation in the clinic setting Review of the facility’s current policy and procedure on Storage of Supplies, published 04/05/2021 directs staff as follows: “Background Proper storage conditions are necessary to provide a safe environment and to ensure supplies are not expired, contaminated and damaged. Policy “ Supplies must be rotated First in-First Out (FIFO) to ensure products maintain quality and do not expire. Appropriately dispose of items that have reached the expiration date.” Review of the facility’s current policy and procedure Expiration Dates Sterile Supplies, published 07/04/2012 directs staff as follows: “Sterile items will be checked before use to ensure that they have not expired. Appropriately dispose of sterile items that have reached the expiration date.” Assessments Patient #2 On 02/04/2025 at 7:42 a.m. Patient #2 was observed on the treatment floor of the facility at station #18 machine #20. The patient was receiving hemodialysis treatment at a blood flow rate of 400 mL/min, dialysate flow rate of 800 mL/min and dialysate temperature of 35.5 degrees Celsius. The patient was utilizing an Optiflux 160 non reuse dialyzer via a left upper arm vascular access. Review of the patient’s clinical record on 02/04/2025 revealed the following: Treatment sheet review: Review of treatment sheet dated 01/23/2025 revealed the following documentation: 7:15 a.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms Ankle - Severity: 1+: 2 mm or less, disappears rapidly Edema Ankle - Location: Bilateral” 11:53 a.m.: registered nurse documented the post treatment assessment which revealed Notes: UFG achieved. Denies C/o. Lungs bil. clear. Hemostasis x2. Ambulatory. Pt stable.” The RN did not document a reassessment of edema found during the pretreatment assessment. Patient #4 On 02/04/2025 at 7:53 a.m. Patient #4 was observed on the treatment floor of the facility at station #24 machine #6. The patient was receiving hemodialysis treatment at a blood flow rate of 400 mL/min and dialysate flow rate of 800 mL/min. The patient was utilizing an Optiflux 160 non reuse dialyzer via a left upper arm vascular access. Review of the patient’s clinical record on 02/04/2025 revealed the following: Treatment sheet review: Review of treatment sheet dated 02/04/2025 revealed the following documentation: 05:55 a.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms Lower Leg - Severity: 1+: 2 mm or less, disappears rapidly Ankle - Severity: 1+: 2 mm or less, disappears rapidly Edema Lower Leg - Location: Bilateral Edema Ankle - Location: Bilateral Notes: 7.5 kg above Edw. UFg set at 5.5 L. Fluid restrictions reinforced. Pt verbalized understanding.” 14:52 p.m.: registered nurse documented the post treatment assessment which revealed Notes: Late entry- Denies C/o. Lungs bil. clear/diminished. UFG achieved. SOB unaltered. Pt not in any distress. Hemostasis x2. Exit via wheelchair. Pt stable.” The RN did not document a reassessment of edema found during the pretreatment assessment. Patient #10 On 02/05/2025 at 9:08 a.m. Patient #10 was observed on the treatment floor of the facility at station #3 machine #7. The patient was receiving hemodialysis treatment at a blood flow rate of 450 mL/min and dialysate flow rate of 800 mL/min. The patient was utilizing an Optiflux 160 non reuse dialyzer via a right upper arm vascular access. Review of the patient’s clinical record on 02/05/2025 revealed the following: 06:30 a.m.: documented blood pressure of 145/78 mmHg and pulse rate of 57 beats per minute - PCT documented, “Treatment Initiated Without Problem ... Denies Complaints; Patient Alert” 07:41 a.m.: registered nurse documented the pretreatment assessment which revealed “General Survey- Alert, Oriented Ambulation Status- Ambulates w/o assistance Cardiovascular, Respiratory, and Psychological- No Associated Symptoms Lungs- Clear No Edema Notes: bp stable, access intact, over edw. UFG at 4.5kg per Dr. Fluid restriction reinforced, ongoing bp monitor with fluid removal.” There was no justification documented by RN for failing to perform the pretreatment assessment within an hour of treatment initiation. Patient #5 On 02/05/2025 at 9:10 a.m. Patient #5 was observed on the treatment floor of the facility at station #8 machine #21. The patient was receiving hemodialysis treatment at a blood flow rate of 400 mL/min and dialysate flow rate of 800 mL/min. The patient was utilizing an Optiflux 160 non reuse dialyzer via a right central venous catheter. Review of the patient’s clinical record on 02/05/2025 revealed the following: Treatment sheet review: Review of treatment sheet dated 02/03/2025 revealed the following documentation: 07:21 a.m.: documented blood pressure of 160/96 mmHg and pulse rate of 81 beats per minute - Registered Nurse (RN) documented, “Treatment Initiated Without Problem ... Denies Complaints; Patient Alert” 07:32 a.m.: documented blood pressure of 164/98 mmHg and pulse rate of 81 beats per minute 07:32 a.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms: Lower Leg - Severity: 1+: 2 mm or less, disappears rapidly Ankle - Severity: 1+: 2 mm or less, disappears rapidly Edema Ankle - Location: Bilateral Edema Lower Leg - Location: Bilateral Notes: Patient arrived to tx amb without assistance. PT vital signs w/in parameters. PT denies SOB, HA, N/V, and chest pain. PT UF goal set to 3.3L. Tx rx verified.” 08:01 a.m.: documented blood pressure of 161/94 mmHg and pulse rate of 79 beats per minute 08:32 a.m.: documented blood pressure of 169/99 mmHg and pulse rate of 78 beats per minute 09:04 a.m.: documented blood pressure of 184/108 mmHg and pulse rate of 75 beats per minute - Patient Care Technician (PCT) documented, “Denies Complaints; bp high pt feet dwn r aware [sic] 09:31 a.m.: documented blood pressure of 193/116 mmHg and pulse rate of 73 beats per minute - PCT documented, “Denies Complaints; Patient Alert” 10:00 a.m.: documented blood pressure of 192/114 mmHg and pulse rate of 66 beats per minute - Patient Care Technician (PCT) documented, “Denies Complaints; Patient Alert” 10:31 a.m.: documented blood pressure of 199/117 mmHg and pulse rate of 73 beats per minute - PCT documented, “Denies Complaints; Patient Alert” 11:00 a.m.: documented blood pressure of 197/111 mmHg and pulse rate of 68 beats per minute - PCT documented, “Denies Complaints; Patient Alert; pt bp trending high pt took his meds” 11:28 a.m.: documented blood pressure of 160/87 mmHg and pulse rate of 73 beats per minute - RN documented, “Denies Complaints; Patient Alert; Treatment Discontinued” 19:20 p.m.: registered nurse documented the post treatment assessment which revealed “Notes: Late entry - Patient left tx amb without assistance. PT vital signs stable, even and non labored breathing. PT aaox3. PT has no complaints.” The RN did not document an assessment on the put of parameter blood pressure that occurred during the patient’s hemodialysis treatment. The RN did not document a reassessment of edema found during the pretreatment assessment. Patient #6 On 02/05/2025 at 9:14 a.m. Patient #6 was observed on the treatment floor of the facility at station #15 machine #25. The patient was receiving hemodialysis treatment at a blood flow rate of 400 mL/min and dialysate flow rate of 800 mL/min. The patient was utilizing an Optiflux 160 non reuse dialyzer via a left upper arm vascular access. Review of the patient’s clinical record on 02/05/2025 revealed the following: Treatment sheet review: Review of treatment sheet dated 01/31/2025 revealed the following documentation: 06:20 a.m.: documented blood pressure of 110/55 mmHg and pulse rate of 79 beats per minute - PCT documented, “Treatment Initiated Without Problem ... Denies Complaints; Patient Alert” 18:06 a.m.: registered nurse documented the pretreatment assessment which revealed “General Assessment Physical Exam- Calm, Pleasant; No Usual Finding Lungs- Clear No Edema Notes: Patient arrived to tx amb without assistance. PT vital signs w/in parameters. PT denies SOB, HA, N/V, and chest pain. PT UF goal set to 2L. Tx rx verified.” There was no justification documented by RN for failing to perform the pretreatment assessment within an hour of treatment initiation. Review of treatment sheet dated 01/29/2025 revealed the following documentation: 06:25 a.m.: documented blood pressure of 113/55 mmHg and pulse rate of 95 beats per minute - PCT documented, “Treatment Initiated Without Problem ... Denies Complaints; Patient Alert” 06:25 a.m. - 7:35 a.m.: systolic blood pressures were above 100 and diastolic blood pressures were below 60 08:03 a.m.: documented blood pressure of 106/53 mmHg and pulse rate of 90 beats per minute - PCT documented, “Denies Complaints; Patient Alert” 08:33 a.m.: documented blood pressure of 78/51 mmHg and pulse rate of 81 beats per minute - PCT documented, “Denies Complaints; Patient Alert” 09:05 a.m.: documented blood pressure of 94/47 mmHg and pulse rate of 87 beats per minute - PCT documented, “Denies Complaints; Patient Alert” 09:30 a.m.: documented blood pressure of 96/48 mmHg and pulse rate of 91 beats per minute - PCT documented, “Denies Complaints; Patient Alert” 09:42 a.m.: documented blood pressure of 98/42 mmHg and pulse rate of 89 beats per minute - PCT documented, “Denies Complaints; Patient Alert. Treatment Discontinued Without Problem” The PCT failed to recheck or report to the RN the patient’s out of parameter blood pressure. Patient #8 On 02/05/2025 at 9:20 a.m. Patient #8 was observed on the treatment floor of the facility at station #21 machine #19. The patient was receiving hemodialysis treatment at a blood flow rate of 400 mL/min and dialysate flow rate of 800 mL/min. The patient was utilizing an Optiflux 180 non reuse dialyzer via a left lower arm vascular access. Review of the patient’s clinical record on 02/05/2025 revealed the following: Treatment sheet review: Review of treatment sheet dated 02/05/2025 revealed the following documentation: 06:12 a.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms Ankle - Severity: 3+: 4-6 mm indent, noticeably deep, last more than 1 minute, extremity swollen Lower Leg - Severity: 2+: 2-4 mm indent, disappears in 10-15 seconds Edema Lower Leg - Location: Left Edema Ankle - Location: Left Notes: Patient arrived to tx with a walker. PT vital signs w/in parameters. PT denies SOB, HA, N/V, and chest pain. PT UF goal set to 3.5L. Left leg is chronically swollen. Lung fields clear. Tx rx verified.” 10:03 a.m.: registered nurse documented the post treatment assessment which revealed “Notes: Patient left tx using her walker. PT vital signs stable, even and non labored breathing. PT aaox3. PT has some cramping but no complaints otherwise.” The RN did not document a reassessment of edema found during the pretreatment assessment. Review of treatment sheet dated 01/24/2025 revealed the following documentation: 05:55 a.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms Ankle - Severity: 1+: 2 mm or less, disappears rapidly Edema Ankle - Location: Bilateral Notes: Patient arrived to tx with a walker. PT vital signs w/in parameters. PT denies SOB, HA, N/V, and chest pain. PT UF goal set to 4L. Tx rx verified.” 10:13 a.m.: registered nurse documented the post treatment assessment which revealed “Notes: Patient left tx using walker. PT vital signs stable, even and non labored breathing. PT aaox3. PT has no complaints.” The RN did not document a reassessment of edema found during the pretreatment assessment. Patient #9 On 02/05/2025 at 9:51 a.m. Patient #9 was observed on the treatment floor of the facility at station #1 machine #23. The patient was receiving hemodialysis treatment at a blood flow rate of 350 mL/min and dialysate flow rate of 800 mL/min. The patient was utilizing an Optiflux 180 non reuse dialyzer via a left upper arm vascular access. Review of the patient’s clinical record on 02/05/2025 revealed the following: Treatment sheet review: Review of treatment sheet dated 01/29/2024 revealed the following documentation: 09:58 a.m.: documented blood pressure of 178/95 mmHg and pulse rate of 81 beats per minute - PCT documented, “Treatment Initiated Without Problem ... Denies Complaints; Patient Alert” 12:05 a.m.: registered nurse documented the pretreatment assessment which revealed “General Survey- Alert, Oriented Ambulation Status- Ambulates w/o assistance Cardiovascular, Respiratory, and Psychological- No Associated Symptoms Lungs- Clear No Edema Notes: RN Evaluation - No Unusual findings noted.” There was no justification documented by RN for failing to perform the pretreatment assessment within an hour of treatment initiation. Patient #11 Review of the patient’s clinical record revealed the patient was admitted to facility on 12/23/2021 with diagnosis of end-stage renal disease and hypertension, on three times a week hemodialysis. Treatment sheet review: Review of treatment sheet dated 01/17/2025 revealed the following documentation: 10:53 a.m.: documented blood pressure of 102/48 mmHg and pulse rate of 81 beats per minute - PCT documented, “Treatment Initiated Without Problem ... RN notified; UF Off; Patient Alert” 11:00 a.m.: documented blood pressure of 104/48 mmHg and pulse rate of 82 beats per minute - PCT documented, “UF On; Resting Comfortably ... Denies Complaints” 11:30 a.m. - 12:00 p.m.: systolic blood pressures were above 100 and diastolic blood pressures were below 60 12:30 p.m.: documented blood pressure of 100/55 mmHg and pulse rate of 74 beats per minute - PCT documented, “Denies Complaints” 13:00 p.m.: documented blood pressure of 83/47 mmHg and pulse rate of 78 beats per minute - PCT documented, “RN Notified ... UF Off; pt bp dropped uf remains off” 13:05 p.m.: documented blood pressure of 112/41 mmHg and pulse rate of 76 beats per minute - PCT documented, “RN Notified ... UF Off; Denies Complaints” 13:30 p.m.: documented blood pressure of 126/72 mmHg and pulse rate of 76 beats per minute - PCT documented, “UF Off; Patient Alert” 13:47 p.m.: documented blood pressure of 105/54 mmHg and pulse rate of 77 beats per minute - PCT documented, “Treatment Discontinued” The RN failed to assess the patient’s out of parameter blood pressure and ultrafiltration being turned off by the PCT during the hemodialysis treatment. The RN did not document the assessment of the patient’s out of parameter blood pressure until 14:07 p.m. Review of treatment sheet dated 01/15/2025 revealed the following documentation: 10:06 a.m.: documented blood pressure of 105/50 mmHg and pulse rate of 68 beats per minute - PCT documented, “Treatment Initiated Without Problem ... Denies Complaints; Patient Alert” 11:22 a.m.: registered nurse documented the pretreatment assessment which revealed “General Assessment Physical Exam- Calm, Pleasant; No Usual Finding Lungs- Clear No Edema Notes: Patient arrived to tx amb without assistance. PT vital signs w/in parameters. PT denies SOB, HA, N/V, and chest pain. PT UF goal set to 1L. Tx rx verified.” There was no justification documented by RN for failing to perform the pretreatment assessment within an hour of treatment initiation. Record review and interview with Clinical Coordinator (A) on 02/05/2025 at 4:17 p.m. verified the registered nurses did not complete the pretreatment assessment within an hour of treatment initiation, assessment of abnormal parameters, or reassessments of edema post treatment for the patients above. Expired Supplies Observation of the hemodialysis treatment area on 02/04/2025 revealed the following expired supplies were co-mingled with stocks in use: Emergency cart: BD Vacutainer Safety-Lok Blood Collection Set Lot# 1M2111, expiration date 2024-12-31 = 2 sets Medication prep area (back of the hemodialysis treatment area): 1) Liquacel 32 fl oz (960 mL) bottle, Lot #M316, expiration date 11/23 = 3 bottles (1- opened bottle with two different open dates: 11/1/24 on the cap and 1/5/25 on the side of the bottle; 2 unopened bottles) 2) Covidien Magellan 1 mL Tuberculin Safety Syringe Lot#007635X, expiration date 2025-01-31, in the cabinet above the left sink = 32 syringes Interview with Registered Nurse (E) on 02/04/2025 at 10:29 a.m. verified that the facility uses the Covidien Magellan 1 mL Tuberculin syringes. Registered Nurse (E) said, “We use those to administer TB skin tests.” Clean supply carts in the center of the bays: Elcam Medical Italy SPA bloodline connectors Lot# 2100058, expiration date 2024-06-25 1) Bay 1-2 clean supply cart = 11 connectors 2) Bay 3-4 clean supply cart = 18 connectors 3) Bay 5-6 clean supply cart = 14 connectors All had the same lot number and expiration date. Interview with Facility Administrator (H) on 02/04/2025 at 11:34 a.m. verified the above findings.”

“EP Training and Testing CFR(s): §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: 48020 Based on observation, interview and record review, the facility’s governing body failed to ensure all staff participated in quarterly fire drill in the facility in 2 of 6 staff observed: Registered Dietitian (L) and Social Worker (J) Findings: Review of the facility’s current policy and procedure: Guidelines for Emergency Preparedness: published 07/03/2023, reference number 25907, version 11 directs the staff as follows: “Staff Training Staff will be trained on emergency disaster preparedness such as fire drills, emergency disconnection and emergency evacuation.” Registered Dietitian (L) On 01/25/2024 Registered Dietitian (L) was observed in the facility’s conference room being interviewed by one of the surveyors. Review on 01/25/2024 of the facility’s fire drill log revealed documentation which indicated fire drill was last held at the facility on December 5-6, 2023. The log did not include Registered Dietitian (L’s) signature. Review of the fire drill held on September 18-19, 2023, revealed the log did not include Registered Dietitian (L’s) signature. Social Worker (J) On 01/25/2024 Social Worker (J) was observed in her office being interviewed by one of the surveyors. Review on 01/25/2024 of the facility’s fire drill log revealed documentation which indicated fire drill was last held at the facility on December 5-6, 2023. The log did not include Social Worker (J’s) signature. Review of the fire drill held on September 18-19, 2023, revealed the log did not include Social Worker (J’s) signature. Interview on 01/25/2024 at 2:58 p.m. with the Facility’s Social Worker (J) revealed she said “I think I attended a couple of months ago, but I am unsure. I can ask the Facility Administrator.””

“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 wash/sanitize hands after touching contaminated objects in 3 of 6 staff observed: Patient Care Technician (D), (O), and (N) Findings: Review of the facility’s current policy and procedure: Hand Hygiene: published 11/06/2023, reference number 47664, version 8 directs the staff as follows: “Hands Will Be ... Decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water “ Entering and leaving the treatment area ... “ Immediately after removing gloves ... “ After contact with other objects within the patient station or treatment space” Patient Care Technician (D) Observation on 01/23/2024 at 10:04 a.m. revealed Patient Care Technician (D) removed her face shield from the top of her head and place it on over her face. Patient Care Technician (D) then walked over and grabbed clean gloves from the glove box, placed one of the gloves back into the glove box and donned the gloves without washing/sanitizing her hands. Interview with Patient Care Technician (D) at 10:11 a.m., the Surveyor notified Patient Care Technician (D) of the failure to wash/sanitize her hands after touching the dirty face shield and before grabbing clean gloves. Patient Care Technician (D) said, “Okay.” 10802 Patient Care Technician (O) On 01/23/2024 at 9:15 a.m. Patient Care Technician (O) was observed mopping the floor from a dialysate spill. Observation revealed Registered Nurse (E) asked the Patient Care Technician (O) to give him a bag of Normal Saline to hang on a patient. Patient Care Technician (O) removed her contaminated gloves, walked to the clean supply cabinet, located in the center of the hallway and picked up a clean bag of Normal Saline. Patient Care Technician (O) did not sanitize /wash her hands after removing her contaminated gloves used to mop the floor. The Surveyor immediately notified Patient Care technician (O) of her break in infection control technique of not washing / sanitizing her hands after removing her contaminated gloves. Patient Care Technician (O) states” I have so many things going on. I am sorry.” Patient Care (N) On 01/24/2024 at 9:45 a.m. Patient Care (Technician N) was observed terminally cleaning station # 13, post hemodialysis treatment of a patient. Observation revealed during terminal cleaning of the contaminated chair, the cleaning towel fell to the floor. Patient Care Technician (N) picked up the contaminated wash cloth, held it in his hand while cleaning and opening the sides of the chair with other towels which he commingled. The Patient care Technician did not discard the towel that fell to the floor, removed his contaminated gloves and wash/ sanitize his hands. The Surveyor immediately notified Patient Care Technician (N) of the observed break in infection control technique of him not discarding the towel that fell to the floor, removed his contaminated gloves and wash/ sanitize his hands. Patient Care Technician (N) states “ It was in this hand.’ He proceeded to demonstrate to the Surveyor that he held the contaminated towel in his right hand while opening and closing the sides of the chair and cleaning the chair with his left hand, which requires the use of both hands.”

“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: 48020 Based on observation, interview, the facility’s registered nurse failed to ensure oral medication liquids in bulk bottles are not stored and administered to patients beyond the maximum time period for use. Findings: Review of the facility’s current Policy and Procedure on Medication Preparation and Administration: Policy #45488, published 02/06/2023 directs staff as follows: Monitoring Expired Medications “ Expiration dates for all stored medications are to be monitored on a monthly basis “ Expired medications are to be discarded via Fresenius Kidney Care off-site return program or in accordance with local and/or state law. The following table includes expiration date of bulk type items or outpatient dialysis floor stock. Medication Product Category: Floorstock containers of oral solids and oral liquids in bulk bottles Expiration Date/Maximum Time Period for Use: Manufacturer’s expiration date Review of the Global Health Products manufacturer’s FAQs revealed the shelf life after opening LiquaCel is 3 months. Observation on 01/23/2024 of the medication prep area during tour of the facility revealed the following: 1 opened bottle Watermelon LiquaCel 32 fl oz (960 mL) Lot # G181A, expiration 06/24 that did not have the Date Opened and Nursing Initials documented. The bottle revealed the manufacturer recommendation for Storage: “May or may not be refrigerated. Do not use if safety seal is broken. Be sure to date when first opened. Use within 3 months of opening.” Interview on 01/23/2024 at 9:17 a.m. with Registered Nurse (B), the Surveyor showed her the bottle of LiquaCel with no open date and nursing initials documented. Registered Nurse (B) said, “okay, it should have been done.””

“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: 10802 Based on observation, record review and interview, the facility failed to ensure: Diasafe filters attached to 9 of 24 hemodialysis machines observed on the hemodialysis unit, were replaced based on manufacturer’s recommendation for use. Hemodialysis machine #s 1, 2, 3, 4, 5, 7, 8, 9, and 24. B) Expired supplies are not stored and in use for calibration and quality control testing of the blood glucose monitoring device. C) Annual preventative maintenance is completed for oxygen concentrators according to the manufacturer’s instruction for use. Findings: Review of the manufacturer’s direction for use manual, Chapter 6, page 275 of Fresenius 2008 T hemodialysis machine directs users as follows: “ The Diasafe plus us filter is intended for the preparation of ultra-pure dialysate. If the machine has a Diasafe Plus us filter it should be replaced at least 90 days. You must also replace the filter if the Diasafe test fails or shows an external leak.” Review of the facility’s policy and procedure on Diasafe Filter Replacement Policy # 47413 published 05/02/2022 directs staff as follows: “The Diasafe plus filters will be replaced in accordance to manufacturer’s IFU.” Review of the facility’s current policy and procedure: Blood Glucose Monitoring Device: published 11/06/2023, reference number 47803, version 5 directs the staff as follows: “Calibration and Quality Control Testing “ Monitor expiration date of calibration solution” Review of the Embrace Pro User Manual revealed: “Precautions for Test Strip - Do not use the test strip beyond the expiration date that is printed on the vial Control solution testing is used to check the performance of your meter and test strip ... The control solution test confirms that your meter and test strips are working correctly ... CAUTION - Check the expiration date on the control solution vial. Do not use if expiration date has passed. - Use control solution for only three months after the first use. When you open new vial of control solution, count three months forward and write the date on the label of the control solution vial for your convenience. Discard after three months.” Review of the facility’s current policy and procedure: Routine Administration of Oxygen: published 11/01/2021, reference number 47555, version 5 directs the staff as follows: Policy: Oxygen concentrators must be maintained in accordance with the manufacturer’s instruction for use. Review of the Respironics Millennium Oxygen Concentrators manufacturer’s instruction for use manual revealed the following: MAINTENANCE DEALER ANNUAL MAINTENANCE - MAINTENANCE - PAGE 1 Annual maintenance shall be performed by the Home Care Dealer, or at a Respironics service facility. Annual maintenance includes the following. o Checking the condition of the Filters (change if necessary). o Cleaning the cabinet. o Verifying the oxygen concentration with a calibrated oxygen analyzer. This procedure must be performed once a year or between patients. Refer to the Testing Section for more detail. o Perform a power interrupt alarm test and replace the 9-volt battery if necessary. Refer to the Testing Section for more detail. o Perform a start-up LED and audible alarm test. Refer to the Testing Section for more detail. Observation on 01/25/2024 at 11:30 a.m. of the following Fresenius 2008 T hemodialysis machines accompanied by the Facility’s Area Biomedical Technician revealed Diasafe filters plus in use at the back of the hemodialysis machines. Observation of labels on the Diasafe filters attached to these hemodialysis machines revealed they were last replaced on 10/2023: Fresenius 2000 T hemodialysis machine # 9 located at station # 3 Fresenius 2000 T hemodialysis machine #2 located at station # 5 Fresenius 2000 T hemodialysis machine #5 located at station # 6 Fresenius 2000 T hemodialysis machine #24 located at station # 8 Fresenius 2000 T hemodialysis machine #3 located at station # 10 Fresenius 2000 T hemodialysis machine #4 located at station # 16 Fresenius 2000 T hemodialysis machine #8 located at station # 20 Fresenius 2000 T hemodialysis machine #7 located at station # 17 Fresenius 2000 T hemodialysis machine #1 located in the storeroom. Review of the facility’s hemodialysis machines maintenance log revealed documentation which indicated the Diasafe filters were last replaced on October 9, 2023. Interview on 1/25/2024 at 11:30 a.m. with the Facility’s Area Biomedical Technician revealed he said the Diasafe filters are replaced in batches and the batch of 9 were missed. 48020 Observation on 01/23/2024 at 8:47 a.m. of the laboratory area revealed a container in the cabinet with an Embrace Pro Glucose Meter, opened quality control solutions and an opened vial of test strips with the following: Control 1 Solution: Lot C22G20U1 expiration 2024-01-20 Control 2 Solution: Lot C22G20U2 expiration 2024-01-20 Test Strips Lot A21L21271 expiration 2023-12-21 with an opened date of 01/19/2024 written on the outside of the bottle Review of the Glucose Meter v2 - 58013 Log revealed the Embrace Pro Control 1 and Control 2 solutions were used to confirm the meter was working correctly on 01/22/2024 and 01/23/2024. The Embrace Pro Test Strips were used on seven treatment days to confirm the meter was working properly from 01/16/2024 - 01/23/2024. On 01/23/2024 at 8:52 a.m., the Surveyor notified Facility Administrator (H) of the expired Embrace Pro Glucose Meter quality control testing solutions and test strips. Facility Administrator (H) said, “I’m going to get more solutions and strips.” Observation on 01/23/2024 at 7:59 a.m. of the hemodialysis treatment area revealed the following: 1 Respironics Millennium Oxygen Concentrator #1374404 with the following stickers attached to the top right corner: ISS Solutions Healthcare Technology Management Inspection Date: 11-22, Inspection Due: 11-23 and ISS Solutions 050510713 Subsequent observation at 8:03 a.m. revealed Clinical Coordinator (A) roll the Respironics Millennium Oxygen Concentrator #1374404 to station #12 to use on Patient #8, who was waiting for the hemodialysis treatment to be initiated. The Surveyor immediately notified Clinical Coordinator (A) of the expired annual preventative maintenance sticker, and she said “okay” and removed the Respironics Millennium Oxygen Concentrator #1374404 off the treatment floor. On 01/23/2024 at 10:35 a.m., the Surveyor notified the Area Biomedical Manager (K) of the expired Respironics Millennium Oxygen Concentrator #1374404. Area Biomedical Manager (K) said, “It looks like it may have been missed.””

“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 registered nurse failed to ensure patients’ hemodialysis treatments were administered based on the patients physicians’ prescriptions in 5 of 14 sampled patients: Patient #8, 3, 11, 6, and 13 Findings: Review of the facility’s current Policy and Procedure on Nursing Supervision and Delegation; Policy #45265, published 11/06/2023 directs staff as follows: Policy The registered nurse must evaluate each patient preferably within an hour or according to state requirements to: ... “ Review accuracy and completeness of treatment and patient data “ Review patient treatment prescription and equipment parameters to verify correct settings, and if dialysis prescription is being followed. Review of the facility’s current Policy and Procedure on Patient Assessment and Monitoring: Policy #45284, published 05/01/2023 directs staff as follows: Data Collection ... If the PCT/LPN note any changes or abnormal findings in the patient’s condition or vascular access are observed or reported by the patient, or the patient was hospitalized, the registered nurse must assess the patient. “ The RN will notify the patient’s physician/physician extender of any abnormal findings, if necessary, based on clinical judgement for additional instruction. Review of the facility’s current Policy and Procedure on Unable to Achieve Prescribed Blood Flow Rate: Policy #47334, published 11/01/2021 directs staff as follows: Policy Staff, patient and/or care partner will recognize and report to the nurse in charge the inability to achieve prescribed blood flow rate. Notification- Notify physician/extender if unable to achieve prescribed blood flow rate. Documentation- Document in patient’s treatment record what action taken to address the inadequate blood flow and if unable to resolve. The nurse shall document any physician orders. Patient #8 On 01/23/2024 at 08:32 a.m. Patient #8 was seated at station #12 machine #1 receiving hemodialysis treatment at a blood flow rate of 350 mL/min and a dialysate flow rate of 600 mL/min via right chest central venous catheter. The patient was utilizing an Optiflux 180 non reuse dialyzer. Observation of the patient’s physician’s order located in the chairside computer revealed an order for Optiflux 160 dialyzer. Review of the patient’s clinical record revealed a physician’s order dated 01/02/2024 for 160NRE Optiflux. The Surveyor immediately notified the Clinical Coordinator (A) assigned to the patient that the patient was using an incorrect dialyzer. The Clinical Coordinator (A) said, “Okay, I will get a one-time order for today.” Patient #3 Review of the patient’s clinical record (demographic data) on 01/23/2024 revealed the patient was admitted to the facility 03/24/2023. Review of the physician’s order dated 01/04/2024 revealed the prescribed blood flow rate of 350 mL/min. Treatment sheet dated 01/18/2024 Review of the patient’s treatment sheet dated 01/18/2024 revealed documentation which indicated the patient was prescribed a blood flow rate of 350 mL/min but received hemodialysis treatment at a blood flow rate of 400 mL/min from 6:18 a.m. - 9:20 a.m. here was no justification documented for the blood flow rate of 350 mL/min. Patient #11 On 01/24/2024 at 08:34 a.m., Patient #11 was seated at station #5 machine #2 receiving hemodialysis treatment at a blood flow rate of 500 mL/min and a dialysate flow rate of 800 mL/min via left lower arm vascular access. The patient was utilizing an Optiflux 180 non reuse dialyzer. The dialysate settings were: 2 potassium, 2.5 calcium, 35 bicarbonate, 137 sodium. Observation of the patient’s physician’s order located in the chairside computer revealed an order for bicarbonate 33.0 Review of the patient’s clinical record revealed a physician’s order dated 11/10/2023 for Bicarbonate setting: 33.0 (mEq/L). Subsequent review of the patient’s clinical record located in the chairside computer revealed the hemodialysis treatment began at 7:16 a.m. Interview on 01/24/2024 at 08:46 a.m. with Registered Nurse (M) assigned to the patient, the Surveyor informed her that the dialysate bicarbonate setting was not set on the hemodialysis machine as prescribed by the physician. Registered Nurse (M) said, “I think that is something we both missed.” Treatment sheet dated 01/10/2024 Review of the patient’s treatment sheet dated 01/10/2024 revealed documentation which indicated the patient was prescribed a blood flow rate of 500 mL/min but received hemodialysis treatment at a blood flow rate of 400 mL/min from 7:32 a.m. - 10:03 a.m. due to a high TMP. Then the blood flow rate was lowered to 350 mL/min from 10:35 a.m. - 11:07 a.m. There was no nurse notification documented of the inability to achieve prescribed blood flow rates. No intradialytic or post hemodialysis treatment documentation found from the nurse in charge, of the lowered blood flow rates. Treatment sheet dated 01/12/2024 Review of the patient’s treatment sheet dated 01/12/2024 revealed documentation which indicated the patient was prescribed a blood flow rate of 500 mL/min but received hemodialysis treatment at a blood flow rate of 450 mL/min from 9:35 a.m. - 11:02 a.m. There was no nurse notification documented of the inability to achieve prescribed blood flow rate. No intradialytic or post hemodialysis treatment documentation found from the nurse in charge, of the lowered blood flow rate. Interview on 01/25/2024 at 01:20 p.m. with Clinical Coordinator (A), the Surveyor informed her the nurses in charge are not being notified of the inability to achieve prescribed blood flow rates. Clinical Coordinator (A) said, “I know that the patient bleeds a lot and puts his arm above his head and has to be reminded to put his arm down.” 10802 Patient #6 On 01/23/2024 at 8:15 am Patient #6 was observed on the treatment floor of the facility at station # 17, Hemodialysis machine #7. The patient was receiving hemodialysis treatment at a blood flow rate of 400 mls/ minute and dialysate flow rate of 800 mls/ minute via a left upper arm vascular access. The patient was utilizing a dialyzer of Optiflux 180 non- reuse dialyzer. Review of the patient’s physician’s order, located in the computer attached to the hemodialysis machine revealed a physician’s order dated 1/6/2024 for Optiflux 160 non- reuse dialyzer. The Surveyor immediately informed Registered Nurse (B) assigned to patient that the patient was not utilizing the dialyzer prescribed by the patient’s physician. Interview with the Patient Care Technician ( C), assigned to the patient and in the presence of Registered Nurse (B), revealed he said he switched the patient’s hemodialysis machine and that is the reason why the patient was using the wrong dialyzer. Registered Nurse (B) said she was not aware of the switch in the patient’s prescribed dialyzer. Patient #13 Review on 01/25/2024 of Patient #13’s clinical record revealed a physician’s order dated 08/21/2023 for a blood flow rate of 500 mls/minute and dialysate flow rate of 800 mls/ minute via an arteriovenous fistula. Review of the patient’s treatment sheet for the following dates revealed the patient’s blood flow rate was not maintained at the prescribed rate. There was no justification documented by the registered nurse why the patient’s prescription was not followed: 1/5/2024: Documentation on the patient’s treatment sheet indicated the patient’s hemodialysis treatment was initiated by Patient Care Technician (D) at 11:43 a.m., at a blood flow rate of 300 mls/ minute. 12:09:Patient Care Technician (D) increased the patient’s blood flow rate to 450 mls/ minute. 13:02 - 13:33 :Patient Care Technician (D) decreased the patient’s blood flow rate to 400 mls/ minute. 14:00 :Patient Care Technician (D) documented “UF off bp dropped” 14:02 : The registered nurse documented “ Denies complaint 100 ns given for low bp. bp came up within parameters.” 1400 - 14:56 There is no documentation of blood flow or dialysate flow rate administered 14:57: documented blood flow rate 200 mls/ Minute and the patient’s hemodialysis treatment discontinued by the patient care technician. There was no justification documented by the registered nurse why the patient’s blood flow rate was not maintained at the prescribed rate. 12/29/2023: Documentation on the patient’s treatment sheet indicated the patient’s hemodialysis treatment was initiated by Patient Care Technician (C) at 12:12 p.m., at a blood flow rate of 350 mls/ minute. Patient Care Technician (C) documented “ pt keeps moving arm; BFR lowered to prevent infiltration. “ 13:03:Patient Care Technician (C) increased the patient’s blood flow rate to 400 mls/ minute. 13:31:Patient Care Technician (C) decreased the patient’s blood flow rate to 300 mls/ minute. 14:30:Patient Care Technician (D) decreased the patient’s blood flow rate to 200 mls/ minute. The patient’s hemodialysis treatment was discontinued by Patient Care Technician (D) at !5:07 p.m. Review of the Patients treatment sheet revealed a pre- treatment assessment was documented by the registered nurse at 14:20 p.m., approximately two hours after initiation of the patient’s hemodialysis treatment. There was no other intradialytic assessment by the registered nurse during the patients hemodialysis treatment.”

“POC-GOALS=COMMUNITY-BASED STANDARDS CFR(s): 494.90 The interdisciplinary team as defined at §494.80 must develop and implement a written, individualized comprehensive plan of care that specifies the services necessary to address the patient’s needs, as identified by the comprehensive assessment and changes in the patient’s condition, and must include measurable and expected outcomes and estimated timetables to achieve these outcomes. The outcomes specified in the patient plan of care must be consistent with current evidence-based professionally-accepted clinical practice standards. This Standard is not met as evidenced by: 10802 Based on observation, record review and interview, the facility’s interdisciplinary team failed to develop interdisciplinary comprehensive care plan for patient’s hospitalization and post surgical care, in 1 of 14 sampled patients. Patient #2 Findings: Patient #2 Interview on 1/24/2024 at 7:42 a.m. with the patient revealed he said he went to the hospital because he was sick, but he does not remember why. Review of Patient #2’s clinical record (CMS 2728) revealed he was admitted to the facility on 5/24/2023 with admitting diagnosis of arteriosclerotic heart disease, hypertension, hyperlipidemia, and end stage renal disease, on in center hemodialysis three times weekly. Reviewed Patient’s Hospitalization record. Review of the patient’s hospitalization record revealed he was admitted to the hospital on 7/28/2023 with history of vomiting and fever. The patient was diagnosed with acute febrile illness. The patient’s hospitalization record revealed he was readmitted to the hospital on 10/16/2023 - 10/31/2023 where he was diagnosed with leukocytosis, atrial flutter with rapid ventricular response, chest pain, renal mass and a nephrectomy performed. A stress test was performed which showed mild inferolateral ischemia and the patient was referred to the cardiologist post hospitalization. Review of the patient’s clinical record revealed the most current interdisciplinary comprehensive care plan was dated 09/27/2023, prior to the patient’s surgery and extended hospitalization. Interview on 01/24/2024 10:00 a.m. with the Facility’s Administrator, the Surveyor requested an updated interdisciplinary care plan on the patient. The Facility’s Administrator provided the Surveyor with the patient’s interdisciplinary care plan dated 09/27/2023 which was completed prior to the patient’s most current hospitalization and surgical intervention. The interdisciplinary care plan did not address the patient’s hospitalization and surgical intervention.”

“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: 10802 Based on observation, interview and record review, the facility’s registered nurse failed to document accurate and complete intradialytic and post treatment assessment to include patients who experienced a change in condition during hemodialysis treatment in 4 of 14 sampled and closed patients. Patient #1, 7, 5, and 14 Findings: Texas Board of Nursing RN Scope of practice. Rule 15.28. Assessment The comprehensive assessment is the first step, and lays the foundation for the nursing process. The comprehensive assessment is the initial and ongoing, extensive collection, analysis and interpretation of data. Nursing judgment is based on the assessment findings. The RN uses clinical reasoning and knowledge, evidence- based outcomes, and research as the basis for decision-making and comprehensive care. Based upon the comprehensive assessment the RN determines the physical and mental health status, needs, and preferences of culturally, ethnically, and socially diverse patients and their families using evidence-based health data and a synthesis of knowledge. Surveillance is an essential step in the comprehensive assessment process. The RN must anticipate and recognize changes in patient conditions and determines when reassessments are needed. Patient Diagnosis/Problem Identification/Planning The second step in the nursing process is analyzing data gathered during the assessment and problem identification. The role of the RN is to synthesize comprehensive assessment data to identify problems, formulate goals/outcomes, and develop plans of care for patients, families, populations, and communities using information from evidence-based practice and published research in collaboration with these groups and the interdisciplinary health care team, as appropriate for their educational background and scope. The third step in the nursing process is planning. The RN synthesizes the data collected during the comprehensive assessment to identify problems, participate in the patient diagnoses, and to formulate goals, teaching plans and outcomes. A nursing plan of care for patients is developed by the RN, who has the overall responsibility to coordinate nursing care for patients. Teaching plans address health promotion, maintenance, restoration, and prevention of risk factors. The RN utilizes evidence-based practice, published research, and information from patients and the interdisciplinary health care team during the planning process. Implementation Implementing the plan of care is the fourth step in the nursing process. The RN may begin, deliver, assign, or delegate certain nursing tasks within the plan of care for patients within legal, ethical, and regulatory parameters and in consideration of health restoration, disease prevention, patient independence, wellness, and promotion of healthy lifestyles. The RN ’ s duty to patient safety when making assignments to other nurses or when delegating tasks to unlicensed staff is to consider the education, training, skill, competence, and physical and emotional abilities of those to whom the assignments or delegation is made. The RN is responsible for reasonable and prudent decisions regarding assignments and delegation. The RN scope of practice may include the supervision of LVNs or other RNs. Supervision of LVN staff is defined as the process of directing, guiding, and influencing the outcome of an individual ’ s performance and activity. 5 The RN may have to directly observe and evaluate the nursing care provided depending on the LVN ’ s skills and competence, patient conditions, and level of urgency in emergent situations. The RN may determine when it is appropriate to delegate tasks to unlicensed personnel and maintains accountability for how the unlicensed personnel perform the tasks. The RN is responsible for supervising the unlicensed personnel when tasks are delegated. The proximity of supervision is dependent upon patient conditions and skill level of the unlicensed personnel. In addition, teaching and counseling are interwoven throughout the implementation phase of the nursing process. Evaluation and Re-assessment A critical and final step in the nursing process is evaluation. The RN evaluates and reports patient outcomes and responses to therapeutic interventions in comparison to benchmarks from evidence-based practice and research findings and plans any follow-up care and referrals to appropriate resources that may be needed. The evaluation phase is one of the times when the RN reassesses patient conditions and determines if interventions were effective and if any modifications to the plan of care are necessary. Review of the facility’s current Policy and Procedure on Nursing Supervision and Delegation Policy #45265, directs staff as follows: Review of the Facility’s current policy and procedure on post treatment evaluation directs staff as follows: “Prior to discharge, the RN must review the treatment record to: o Confirm patent is stable for discharge o Identity facility processes or supervision that could result in adverse events The record must be reviewed for: o Slow/fast/irregular heart rate o Low or high blood pressures o Whether patient is achieving dry weight and identifying reason for patient not achieving dry weight o Heart rate <50 or >120 addressed by the registered nurse with documentation present o Blood pressures < 100 systolic or greater than 180 systolic addressed by the registered nurse with or documentation Present. o Reported fall, and if heparin was held and MD notified.” Review of the facility’s current Policy and Procedure on Patient Assessment and Monitoring; Policy # 45284, published 05/01/2023 directs staff as follows: ’ “Lung sounds, edema, heart sounds. The registered nurse will assess/ reassess post treatment as indicated” Patient #1 On 01/23/2024 at 8:30 a.m. Patient #1 was observed on the treatment floor of the facility at station #15, hemodialysis machine # 24. The patient was alert and oriented to person, place, time, and situation. The patient was receiving hemodialysis treatment at a blood flow rate of 350 mls/ minute and dialysate flow rate of 800 mls/ minute via a right double lumen central venous catheter. Review of the patient’s clinical record revealed the patient was admitted to the facility on 5/25/2023 with admitting diagnosis of anemia, hypertension, heart failure, hyperlipidemia, hypothyroidism, hyperthyroidism, type 2 diabetes mellitus and end stage renal disease on in center hemodialysis three times weekly. Reviewed Patient’s treatment Sheet dated 1/6/2024. Review of the patient’s treatment sheet dated 1/6/2024 revealed the following documentation. The registered nurse conducted a pre- treatment assessment of the patient at 7:06 a.m. Review of the patient’s clinical record (treatment sheet) dated 1/06/2024 revealed the following documentation by the patient care technician: 08:30 a.m.: “pt complaint of dizzy uf, turn off will monitor.” 08:45 a.m.: “Pt feel better now, uf turn on.” 10:03 a.m.: Patient’s hemodialysis treatment ended. 10:24 a.m. Review of the registered nurse post treatment assessment revealed the following findings: “tx complete, tolerated fairly well, met decreased 1.3 ufg. post treatment no stated complaints, d/c via stretcher.” Review of the patient’s clinical record (treatment sheet, nurses’ notes.) revealed no intradialytic assessment documented by the registered nurse when the patient complained of dizziness and the patient care technician turned off the ultrafiltration. Review of the patient’s registered nurse post treatment assessment revealed no documentation of the patient’s change in condition (dizziness and turning off of the patient ultrafiltration) was not addressed. The registered nurse documented “Tx complete, tolerated fairly well. met decreased 1.3 ufg. post treatment no stated complaints, d/c via stretcher.” Patient #7 On 01/23/2024 at 8:00 a.m. Patient #7 was observed on the treatment unit of the facility at station #20. The patient was receiving hemodialysis treatment at a blood flow rate of 400 mls/ minute and dialysate flow rate of 600 mls/ minute. Review of the patient’s treatment sheet dated 01/09/2024 revealed the following findings: 08:00 a.m.: the registered nurse assigned to the patient documented “UF off. Patient alert, access visible; Pt passed out 3-5 seconds. C/o feeling warm. Received extra fluid. UF off. Pt alert, VS within norm range. Will continue to monitor Cramping relieved.” Review of the patient registered nurse’s post treatment assessment revealed the following documentation timed 09:15 a.m., “Pt aaox3, vss. Tolerated tx well. No problem post reinfusion. No complaints voiced or distress noted. Pt removed 2.4 L of fluid without difficulty. Left in stable condition; ambulating.” The record revealed the registered nurse post hemodialysis treatment documentation was inaccurate in that documentation intradialytic indicates the patient experienced cramping, had extra fluid administered “Pt passed out 3-5 seconds. C/o feeling warm. Received extra fluid. UF off.” 48020 Patient #5 Review of the patient’s clinical record on 01/24/2024 revealed the patient was admitted to the facility 02/28/2022. Review of the patient’s treatment sheet dated 12/11/2023 revealed the following documentation: 10:45 a.m.: blood pressure of 91/61, pulse of 92 beats per minute - Registered Nurse documented “Denies Complaints; Patient Alert; s/p hospital d/c. under edw. UFG at 500. BP noted. Pt c/o sob. Denies CP. O2 2L via NC. Will monitor closely” 11:30 a.m.: documented blood pressure of 91/44 and pulse rate of 102 beats per minute - Patient Care Technician documented “RN Notified; UF Off” 11:42 a.m.: documented blood pressure of 84/42 and pulse rate of 103 -Patient Care Technician documented “RN Notified; UF Off; Patient Alert; following up on patient, patient states she feels fine” 12:02 p.m.: documented blood pressure of 105/42 and pulse rate of 99 beats per minute - Patient Care Technician documented “uf off, pt bp low, rn aware, pt confused rn aware” 12:38 p.m.: documented blood pressure of 83/55 and pulse rate of 104 beats per minute - Patient Care Technician documented “ ...denies complaints” 13:30 p.m.: documented blood pressure of 88/47 and pulse rate of 97 beats per minute - Patient Care Technician documented “uf off, pt bp low, rn aware, pt resting” 14:13 p.m.: Registered Nurse documented “Denies Complaints; UF Off; Patient Alert; Treatment Discontinued An intradialytic assessment by the registered nurse in response to the hypotension and ultrafiltration being turned off, was not documented during the hemodialysis treatment. Patient #14 Review of the patient’s clinical record on 01/24/2024 revealed the patient was admitted to the facility 07/03/2023. Review of the patient’s treatment sheet dated 08/23/2023 revealed the following documentation: 11:40 a.m.: Registered Nurse documented “Treatment initiated ... Patient Alert; bp noted; pt asymptomatic, took bp prior to txt today, UFG at max, seq, d/t BUE and BLE edema, DR aware, extra txt schedule 8/24 ...” 11:56 a.m.: registered nurse documented the pretreatment assessment which revealed “Pt with no c/o n/v/d, c/o 4/10 pain to left foot and sob, aaox3, hr regular, vss, ankle/ble edema noted... uf goal set to max as tolerated Symptoms - Shortness of Breath Lungs - Decreased breath sounds Ankle - Severity: 2+: 2-4 mm indent, disappears in 10-15 seconds Lower Leg - Severity: 1+: 2 mm or less, disappears rapidly Edema Lower Leg - Location Bilateral Edema Ankle - Location: bilateral Pulse - Rhythm Regular Note RN Evaluation - No Unusual findings noted” 12:16 p.m.: documented blood pressure of 91/59 and pulse rate of 61 beats per minute - Registered Nurse documented “uf off, pt states he feels fine” 14:21 p.m.: documented blood pressure of 88/46 and pulse rate of 70 beats per minute - Patient Care Technician documented “Denies Complaints ... Uf remains off” 14:21 p.m.: documented blood pressure of 80/35 and pulse rate of 62 beats per minute - Registered Nurse documented “Denies Complaints; Uf Off; Patient Alert; pt states he feels fine” 14:21 - 15:46 p.m.: The ultrafiltration was turned off for the remainder of the treatment. 16:16 p.m.: Registered Nurse documented the post treatment assessment which revealed “RN Evaluation - No Unusual findings noted Notes: HD complete, tx tolerated post vss, aaox3, patient left clinic in stable condition, access dressing cdI. Pt states he feels better but still has some hypotn during tx, resolved post tx.” The lungs and edema reassessments were not documented.” Interview with Clinical Coordinator (A) on 01/25/2024 at 1:21 p.m., the Surveyor informed her the intradialytic assessments and post reassessments are not being completed. Clinical Coordinator (A) “Okay.””