Davita Victory Lakes Dialysis

“Policies/Procedures for Sheltering in Place CFR(s): §403.748(b)(4), §416.54(b)(3), §418.113(b)(6)(i), §441.184(b)(4), §460.84(b)(5), §482.15(b)(4), §483.73(b)(4), §483.475(b)(4), §485.68(b)(2), §485.542(b)(4), §485.625(b)(4), §485.727(b)(2), §485.920(b)(3), §491.12(b)(2), §494.62(b)(3). (b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(4) or (2),(3),(5),(6)] A means to shelter in place for patients, staff, and volunteers who remain in the [facility]. *[For Inpatient Hospices at §418.113(b):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (i) A means to shelter in place for patients, hospice employees who remain in the hospice. This Standard is not met as evidenced by: 26190 Based on record review, and interviews, the facility failed to provide policies and procedures for how to shelter in place for patients, staff and volunteers who remain in the facility. This failure had the possibility to negatively impact all 56 patients currently dialyzing at the facility due to facility not being prepared to shelter patients in place. Findings include: Review of the facility’s emergency management plan, “Facility Emergency Management Plan (ICHD [In Center Hemodialysis], HOME)” revised April 2025 indicated, “ ...Facility Evacuation Plan ...2. The scope of any evacuation can change dependent on the nature and course of the event. Evacuation may not be possible in some events. Options for evacuation include: a. Shelter in place - remain in facility during event ...” During an interview on 12/11/25 at 9:01 AM with the Facility Administrator, confirmed he/she was not aware of a policy and procedure for sheltering in place. The Facility Administrator stated he/she did not have a process for sheltering in place for the facility’s staff and patients.”

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 26190 Based on record review and interview, the facility failed to conduct exercises to test the emergency plan on an annual basis, specifically during 2024. This failure had the possibility to negatively impact all 56 patients dialyzing at the facility due to not being fully prepared for an emergency. Findings include: Review of a form titled, “Community Exercise Participation Evaluation” dated 2024 indicated, the emergency preparedness exercises completed on 05/30/24 and 03/25/25 were both desk top exercises not community based exercises. During an interview on 12/11/25 at 9:01 AM with the Facility Administrator, he/she confirmed that the two exercises were not community based. The Facility Administrator was not aware that a community based exercise needed to be completed every two years. Review of the facility’s plan titled, “Facility Emergency Management Plan (ICHD [In Center Hemodialysis], Home) revised 04/25 indicated, “ ...Training and Education Emergency Management Plan ...Emergency Drills ...e. Frequency: i. The facility will conduct and/or participate in one (1) exercise to test the facility EMP (Emergency Plan) at least ANNUALLY, conducted on OPPOSITE years (one year full scale exercise, next year facility-based/exercise of choice): 1. Full-scale exercise that is community based ...b. Defined as an operations-based exercise that typically involves multiple agencies, jurisdictions, and disciplines performing functional ...and integration of operational elements involved in the response to a disaster event, i.e. “boots on the ground” response activities ...2. Individual facility-based exercise: a. Tabletop exercise that includes a group discussion led by the FA (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: 22676 Based on observation, interview, and policy review, the facility failed to ensure proper hand hygiene was performed by one of four staff members observed (Certified Clinical Hemodialysis Technician (CCHT)13) Failure to perform proper hand hygiene has the potential to place all patients and visitors at risk for cross contamination, resulting in increased infections to all 56 patients receiving dialysis at the facility. Findings include: During observation on the treatment floor 12/10/25 at 2:00 PM and 3:30 PM, CCHT13 was observed numerus times removing gloves and redo13nning gloves without cleaning hands by washing or using hand sanitizer. CCHT13 was observed holding a Patient (P) 9’s access site at Station 9. CCHT13 removed gloves and went to station 11 to assist another patient. CCHT13 returned to Station 9 when P9’s fistula began to bleed and held the site with gloves, without cleaning hands prior to donning the gloves. CCHT13 then removed the gloves, went to the storage area, and obtained packages of 4x4 gauze, he/she then returned to Station 9, donned new gloves, opened the gauze, and placed them on P9’s’ access without cleaning hand. During an interview on 12/10/25 at 3:45 PM CCHT13, confirmed the above findings. During an interview on 12/10/25 at 41:15 PM, Registered Nurse (RN) 7 confirmed that the staff should use hand sanitizer or wash hands with soap and water when removing gloves and before donning new gloves. Review of the facility’s policy titled “Infections Control for Dialysis Facilities” dated April 2023 indicated, “All teammates, Physician and Advanced Providers (APP) will perform hand hygiene, prior to gloving and immediately after removal of gloves ...””

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 22676 Based on observation, interview, and policy review, the facility failed to maintain the dialysis treatment floor in a safe and clean condition to ensure the safety of the patients and staff and reduce the risk of infection during one of three survey days. These findings had the likelihood of causing harm to all 56 patients by increasing the risk of infection by failure to keep the building clean and in good repair. Findings include: During observation on the treatment floor on 12/10/25 at 2:30 PM the treatment floor between Station 9 and 19 was observed to have floor tiles broken exposing an area of about 3 inches by approximately 1 foot of porous concrete. The dialysis machine at station 10 was covering part of the porous concrete floor. Further observation the floor under the chase wall (that holds the Dialysate piping) was observed to be dirty with a build up of white crystals around the whole treatment floor. During an interview on 12/10/25 at 2:30 PM the Facility Administrator and the Registered Nurse (RN) 7 confirmed the above findings. Review of the facility policy titled “Physical Environment” dated April 2018, States “ The dialysis facility will be designed, constructed, equipped, and maintained to provide dialysis patients, teammates, the public a safe, functional, and comfortable treatment environment ...”

“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: 22676 Based on review of glucometer logs, interview, review of glucometer policy, and manufacturer’s instructions, the facility failed to ensure the glucometer was in the control range and follow manufacturer’s instructions for one of one glucometer used in the facility. This deficient practice had the potential to provide incorrect blood glucose results and could result in inaccurate glucose level results for all 56 patients receiving care at the facility. Findings included: Review of electronic “Blood Glucose Logs” for the treatment unit, from 11/01/25 through 12/09/25 revealed the following: On 11/27/25, the recorded acceptable low control range was 90-120, and the recorded low control was 128. During an interview on 12/10/25 at 1:15 PM, Registered Nurse (RN) 7, confirmed the findings and agreed the staff did not repeat the low-level and high-level control as required by the manufacturer’s instruction. Review of the facility’s policy titled, “Embrace pro Blood Glucose Monitor Quality Control,” 09/23, revealed, under “16” section revealed, “If control falls outside the acceptable range, the test must be repeated.” Review of the “Embrace Pro” blood glucose monitoring system manufactures instruction revision date 09/2020 revealed, “ ...p. eleven, if the “test fall outside the range printed on the test strip vial, repeat the test ...””

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 22676 Based on record review, interview, and policy review, the facility failed to follow the individualized dialysis plan (an artificial means of kidney function that removes the waste and excess fluid from the blood by passing through a filter) by following the physician prescription as determined by the medical provider for one of seven sampled in-center dialysis patients (Patient (P4). Failure to follow the medical providers’ dialysis prescription had the potential to negatively impact on the effectiveness of the prescribed dialysis treatments for all 56 patients receiving in-center dialysis treatments at this facility. Findings include: Review of P4’s “Treatment Detail Report” in the electronic medical record (EMR) revealed a prescribed Dialysate Flow Rate (DFR) of 800 milliliters per minute (ml/min). Review of two of six flow sheets from 11/28/25 through 12/08/25 indicated the following: On 11/28/25 from 3:47 PM until 7:15 PM, the BFR was documented at 500 ml/min. On 12/03/25 from 3:38 PM until 7:27 PM, the BFR was documented at 500 ml/min. There was no documentation for the change to the prescribed BFR. During an interview on 12/11/25 at 02:315 PM, Registered Nurse (RN) 7, confirmed the above findings, and that staff did not follow the physician’s order for dialysis treatment. Review of the facility’s policy titled, “Pre-Intra-Posttreatment Data, Collection, Monitoring and Nursing Assessment” dated April 2024, state’s identity, prescription, and machine settings are verified by teammate ... g. Dialysis flow rate ...””