Davita Avian Dialysis

“Names and Contact Information CFR(s): §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: 48020 Based on observation, record review and interview, facility’s governing body failed to ensure all patient information is updated and replaced at least monthly in 2 of 2 Emergency Evacuation Kits as per the facility’s emergency preparedness plan. Findings: Review of the facility’s current policy and procedure: FACILITY EMERGENCY MANAGEMENT PLAN (ICHD, HOME), policy # 4-07-01 directs the staff as follows: “Emergency Evacuation Kit ... 6. Each evacuation kit(s) should contain: a. Copy of each patient’s treatment orders and medication list. FA or designee will verify patient information is updated and replaced at least monthly.” Observation of the treatment area on 12/15/2025 at 8:34 AM revealed two emergency evacuation kits stored below 2 of the nursing stations. Review of the facility’s Patient Summary Reports inside of the kits revealed the most current reports stored in the Emergency Evacuation Kits were printed on 11/01/2025 and not monthly as required by the policy. Updated patient information was not available inside of the Emergency Evacuation Kits in the event of an emergency evacuation as per the emergency preparedness plan. Interview with Administrator Assistant (L) on 12/15/2025 at 8:38 AM confirmed updated Patient Summary Reports were not available inside of the Emergency Evacuation Kits. Administrator Assistant (L) said, “I had them printed but they were in my office.””

“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: 30124 Based on observation, interview and record review the facility failed to ensure: 1. All team members participated in its quarterly Emergency Preparedness Fire Drills. 2. Failed to ensure quarterly Emergency Preparedness Fire Drills were held. Policy: Review of the facility’s current Policy: 4-07-01, Titled: Facility Emergency Management Plan (ICHD, Home); Last Revision Date: October 2025. Goal: The Governing Body shall establish and maintain a facility specific Emergency Management Plan, as part of the Village Business Continuity Program, designed to manage the consequences of emergencies and disasters that may disrupt the facility’s ability to provide patient care. Purpose: 1. The goal of the Emergency Management Plan is to verify that mitigation, prepardness, response and recovery actions exist so patients and teammate welfare and safety is preserved. Fire Safety Preparedness: 1. FA, or designee, is responsible to: a. Maintain a fire safety preparedness program to prevent or minimize the likelihood of a fire that may result in death, injury, or property damage in accordance with CMS and OSHA regulations and National Fire Protection Association (NFPA) and applicable local and state life safety code requirements b. Conduct and review quarterly fire safety and evacuation training and drills for compliance, identify additional training and education needs Fire Safety Preparedness; Training and Education: 1. The FA, or designee, is responsible to provide training of EMP a.Teammates: ii. Quarterly 1. Fire Safety Preparedness iii. Upon Hire iv. Any changes/and/or updates to EMP or facility specific emergency procedures v. Document training in teammate file 1. Training/In-service Documentation Form Fire safety drills: a. Refer to policies: Fire Safety Preparedness, Facility Evacuation Plan, and Emergency Evacuation Device (as applicable). b. Required on a QUARTERLY basis c. One drill to be conducted for each shift of patients i. Utilize Emergency Exercise Template “FIRE WITHIN FACILITY” Emergency event drill template ii. Drill evaluation iii. Teammate attendance sheet On 12/16/2025 during the survey, the Facility’s Social Worker (O) was observed in the facility. Review of the facility’s Quarterly Emergency Fire Drill dated October 30 and 31, 2025 that was provided by the Facility’s Administrator (F) revealed no evidence the Social Worker(O) participated in the Emergency Preparedness Fire Drill at the facility. Surveyor requested documentation for August 2025 quarterly Emergency Fire Drills. No documentation was presented that the required quarterly fire drill was conducted. Interview with The Facility Administrator (F) confirmed there was no documentation the Social Worker (O) participated in the Emergency Preparedness Fire Drill for October 2025. Facility Administrator (F) confirmed he had no documentation for a quarterly Emergency Fire Drill held in August 2025.”

“COMPLIANCE WITH FED/STATE/LOCAL LAWS CFR(s): 494.20 The facility and its staff must operate and furnish services in compliance with applicable Federal, State, and local laws and regulations pertaining to licensure and any other relevant health and safety requirements. This Standard is not met as evidenced by: 30124 Based observation, interview and record review the facility’s Medical Director failed to have written physician standing orders specific to delegation of responsibility for the facility’s dietitian and failed to review and approve the standing orders at least annually. Record review along with the Facility Administrator (F) on 12/17/2025 at 14:00 PM of Dietitian (N) employee file documented no evidence of delegation of responsibilities or standing order review and approval by the Medical Director (Q). Interview with the Facility Administrator (F) confirmed the above finding and no additional information was received prior to exit.”

“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 remove contaminated gloves and perform hand hygiene in 1 of 6 staff observed: Patient Care Technician (C) B) failed to encourage patients to perform hand hygiene after removal of contaminated gloves in 2 of 6 staff observed: Patient Care Technician (C), (D) and Patient #s 2, 3, 6, 7 Findings: Review of facility’s current policy and procedure: Infection Control For Dialysis Facilities, Policy: 1-05-01, Revision Date: April 2023 directs staff as follows: “HAND HYGIENE 1. All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene a. upon entering and exiting the patient treatment area, b. prior to gloving and immediately after removal of gloves, c. after contamination with blood or other infectious material, d. after patient and dialysis delivery system contact, e. after interacting with wall boxes (i.e., plugging/unplugging acid/bicarb lines form dialysis machine, changing acid types, when exchanging a dialysis machine) f. between patients even if the contact is casual, g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse 2. Patients and caregivers will be encouraged to a. Wash their hands and access extremity upon entering the treatment area prior to the initiation of dialysis. b. Perform hand hygiene after treatment before leaving treatment area.” Staff Hand Hygiene: Patient Care Technician (C) Observation on 12/15/2025 at 9:15 AM, revealed Patient Care Technician (C) ) terminally cleaning station #6 post hemodialysis treatment of a patient. Patient Care Technician (C) picked up the red biohazard bag, walked to the large biohazard container near the nurse’s station, lifted the lid and disposed of the red biohazard bag. Patient Care Technician (C) then went to the bleach station, grabbed clean, white disposable towels, dipped them into the 1:100 bleach container and returned to station #6 and began wiping hemodialysis machine #11. Patient Care Technician (C) failed to remove his contaminated gloves and perform hand hygiene before touching the clean bleach towels. Observation on 12/15/2025 at 9:26 AM, revealed Patient Care Technician (C) terminally cleaning station #7 post hemodialysis treatment of a patient. Patient Care Technician (C) picked up the red biohazard bag, walked to the large biohazard container near the nurse’s station, lifted the lid and disposed of the red biohazard bag. Patient Care Technician (C) then went to the bleach station, grabbed clean, white disposable towels, dipped them into the 1:100 bleach container and returned to station #7 and began wiping the portable oxygen tank used by the previous patient. Patient Care Technician (C) failed to remove his contaminated gloves and perform hand hygiene before touching the clean bleach towels. The Surveyor notified Patient Care Technician (C) at 9:31 AM that he failed to remove his contaminated gloves and perform hand hygiene before touching the clean bleach towels. Patient Care Technician (C) said, “I thought it was disinfecting my gloves to put them in bleach.” Patient Hand Hygiene: Patient Care Technician (C) Patient #2 Observation on 12/15/2025 at 9:07 AM, revealed Patient #2 holding his vascular access with a gloved hand at station #7. After the bleeding ceased, Patient Care Technician (C) taped the patient’s vascular access site. The patient removed his glove, picked up his personal items, walked to the weigh scale where he was weighed by Patient Care Technician (C), and left the treatment area without being encouraged to perform hand hygiene. Patient #3 Observation on 12/15/2025 at 9:35 AM, revealed Patient #3 holding his vascular access with a gloved hand at station #9. After the bleeding ceased, Patient Care Technician (C) taped the patient’s vascular access site. The patient removed his glove, grabbed his walker, walked to the weigh scale where he was weighed by Patient Care Technician (C), and left the treatment area without being encouraged to perform hand hygiene. The Surveyor notified Patient Care Technician (C) at 10:10 AM that Patient #1 and #3 were not encouraged to perform hand hygiene after removal of the contaminated glove used to hold their vascular accesses. Patient Care Technician (C) said, “Thank you, ma’am.” Patient Care Technician (D) Random Patient #6 Observation on 12/15/2025 at 8:52 AM, revealed Random Patient #6 holding her vascular access with a gloved hand at station #12. After the bleeding ceased, Patient Care Technician (D) taped the patient’s vascular access site. The patient removed her glove walked to the weigh scale where she was weighed by Patient Care Technician (D), and left the treatment area without being encouraged to perform hand hygiene. Random Patient #7 Observation on 12/15/2025 at 10:46 AM, revealed Random Patient #7 holding his vascular access with a gloved hand at station #16. After the bleeding ceased, Patient Care Technician (D) taped the patient’s vascular access site. The patient removed his glove, picked up his belongings, walked to the weigh scale where he was weighed by Patient Care Technician (D), and left the treatment area without being encouraged to perform hand hygiene. The Surveyor notified Patient Care Technician (D) at 10:58 AM that Random Patient #6 and #7 were not encouraged to perform hand hygiene after removal of the contaminated glove used to hold their vascular accesses. Patient Care Technician (D) said, “Okay.””

“SOFTENERS: TESTING HARDNESS/LOG CFR(s): 494.40(a) 6.2.4 Softeners: Testing hardness/log Users should ensure that test accuracy and sensitivity are sufficient to satisfy the total hardness monitoring requirements of the reverse osmosis machine manufacturer. Total hardness of the water exiting the water softener should be measured at the end of each treatment day. Water hardness test results should be recorded in a water softener log. This Standard is not met as evidenced by: 48020 Based on observation, record review and interview, the staff assigned water room duties, failed to document the water hardness testing on the water softener as per the facility’s policy. Findings: Review of the facility’s current policy and procedure: HARDNESS TEST USING RPC WATER HARDNESS TEST STRIPS # 1-18-01 directs the staff as follows: “Procedure 7. Document test results on the Daily Water Treatment Log. Rationale 7. Hardness test results are recorded on the appropriate log.” Observation of the water treatment room on 12/15/2025 revealed a water softener in use for the hemodialysis treatments. Review of the facility’s log to document the “End of Day Hardness Test Result” on 12/17/2025 was missing for the following dates: 10/02/2025, 10/24/2025, 10/31/2025, 11/14/2025 and 11/15/2025. Interview with Biomedical Technician (M) on 12/17/2025 at 11:52 AM confirmed the water harness testing results were not documented for the dates in question. Biomedical Technician (M) said, “Okay.””

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 48020 Based on observation, record review and interview, the facility’s governing body failed to ensure expired supplies are not stored, and in use in the facility for care and services of patients beyond the manufacturer’s directions for use. Findings: Review of the Bemis “Expiration Information: Canisters & Liners” 6/2024 Rev 02 revealed: “All Bemis Canisters and Liners include an expiration date on the carton label and individual product. Expiration is three (3) years from the date of manufacture. Canisters and Liners should not be used past the labeled expiration date. Structural integrity can be compromised by factors such as, heat, time, and light exposure. Placing a negative vacuum on a compromised canister/liner can result in product failure.” Review of facility’s current policy and procedure: Infection Control For Dialysis Facilities, Policy: 1-05-01, Revision Date: April 2023 directs staff as follows: “SUPPLIES 8. Supplies will be stored in a manner that maintains their integrity ... b. Expiration date and package integrity will be verified prior to use.” Observation of the hemodialysis treatment area on 12/15/2025 beginning at 7:59 a.m. revealed the following: Emergency “crash” cart: 1- Bemis Hydrophobic 800 cc Suction Canister attached to the suction machine on top of the emergency “crash” cart reference #424410, expiration date 2025-05-01. Interview during observation with Group Facility Administrator (H) confirmed the suction canister was expired. Group Facility Administrator (H) said, “I will get them to change it.” Nursing Station clean supply drawers: 3rd nursing station from isolation room: 7- RPC Bloodline Connectors Lot #2200135, expiration date 2025-12-06 4th nursing station from isolation room: 16- RPC Bloodline Connectors Lot #2200135, expiration date 2025-12-06 Interview during observation at 11:19 AM with Clinical Coordinator (E) confirmed the above supplies were expired. 30124 Observation on 12/17/2025 at 12:30 PM along with the Group Facility Administrator (H) the following was observed in the clean supply room. 4 - Packages of Emergency Take Off Kits containing Curity All Purpose 4 x 4 sponges, Sterile, Lot # D20081036S, expiration date 07/31/2025. Interview with Staff (H) on 12/17/2025 at 12:30 PM confirmed the above findings.”

“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 and 8 closed records: Patient #s 1, 10 Findings: Review of the facility’s current policy and procedure on Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment, Policy 1-03-08, directs staff as follows: “POLICY 3. Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment or as allowable by state law. Prescription components include but are not necessarily limited to: a. Dialyzer make and model b. Treatment time c. Target weight d. UFR and Max UFR e. UF Profiling f. Blood flow rate g. Dialysate flow rate h. All accesses evaluated i. Correct dialysate composition (potassium, calcium, base sodium and bicarb) and settings j. Heparinization (intradialytic infusion setting)” Patient #1 On 12/15/2025 at 7:39 AM Patient #1 was observed on the treatment floor of the facility at station #2 machine #6. The patient was receiving hemodialysis treatment at a blood flow rate of 350 milliliters/minute (mL/min) and dialysate flow rate of 800 mL/min. The patient was utilizing an Elisio-17H non reuse dialyzer via a left central venous catheter. The Surveyor asked Patient Care Technician (B) who was chairside to reveal the dialysate settings on machine #6. The machine dialysate settings were: 2.1 potassium, 2.6 calcium, 30 bicarbonate, 137 sodium. The Surveyor next ask Patient Care Technician (C) to pull up the patient’s hemodialysis order on the chair side computer. The hemodialysis orders revealed physician’s order for Sodium 137 (mEq/L) and Bicarbonate 35.0 (mEq/L). The Surveyor notified Patient Care Technician (C) of the incorrect sodium and bicarbonate dialysate settings. Patient Care Technician (C) said, “I have to change it.” Review of the patient’s Treatment Details Report dated 12/15/2025 revealed the Registered Nurse (A) documented the dialysis prescription verification at 6:55 AM and the hemodialysis treatment started at 6:48 AM. The patient received sodium 137 (mEq/L) and bicarbonate 35.0 (mEq/L) for 51 minutes of the prescribed 4 hour (240 min) hemodialysis treatment. Patient #10 Review of the patient’s clinical record on 12/16/2025 revealed the patient was admitted to the facility on 11/05/2024 with diagnoses end stage renal disease, hypertension, peripheral vascular disease, non-renal congenital abnormality, systemic lupus erythematosus on in-center hemodialysis three times weekly. Treatment Details Report review: Blood Flow Rate Review of the patient’s Treatment Details Report dated 12/02/2025 revealed the Dialysis Prescription Blood Flow Rate of 300 mL/min but the patient received the hemodialysis treatment at a blood flow rate of 350 mL/min from 7:13 AM - 10:13 AM. The registered nurse documented the Nurse Prescription Verification at 7:19 AM. There was no justification documented for the blood flow rate of 350 mL/min. Dialysate Temperature Review of the patient’s Treatment Details Report dated 12/13/2025 revealed the Dialysis Prescription Dialysate Temperature of 37 degrees Celsius (C) but the patient received the hemodialysis treatment at a dialysate temperature of 36 C from 6:45 AM - 9:15 AM. The registered nurse documented the Nurse Prescription Verification at 6:47 AM. There was no justification documented for the dialysate temperature of 36 C. Review of the patient’s Treatment Details Report dated 12/06/2025 revealed the Dialysis Prescription Dialysate Temperature of 37 degrees Celsius (C) but the patient received the hemodialysis treatment at a dialysate temperature of 36 C from 7:04 AM - 10:20 AM. The registered nurse documented the Nurse Prescription Verification at 8:09 AM. There was no justification documented for the dialysate temperature of 36 C. Review of the patient’s Treatment Details Report dated 12/09/2025 revealed the Dialysis Prescription Dialysate Temperature of 37 degrees Celsius (C) but the patient received the hemodialysis treatment at a dialysate temperature of 36 C from 7:01 AM - 10:21 AM. The registered nurse documented the Nurse Prescription Verification at 7:06 AM. There was no justification documented for the dialysate temperature of 36 C. Review of the patient’s Treatment Details Report dated 12/06/2025 revealed the Dialysis Prescription Dialysate Temperature of 37 degrees Celsius (C) but the patient received the hemodialysis treatment at a dialysate temperature of 36 C from 6:55 AM - 10:00 AM. The registered nurse documented the Nurse Prescription Verification at 6:57 AM. There was no justification documented for the dialysate temperature of 36 C. Review of the patient’s Treatment Details Report dated 12/04/2025 revealed the Dialysis Prescription Dialysate Temperature of 37 degrees Celsius (C) but the patient received the hemodialysis treatment at a dialysate temperature of 36 C from 7:09 AM - 9:56 AM. The registered nurse documented the Nurse Prescription Verification at 7:39 AM. There was no justification documented for the dialysate temperature of 36 C. Review of the patient’s Treatment Details Report dated 12/02/2025 revealed the Dialysis Prescription Dialysate Temperature of 37 degrees Celsius (C) but the patient received the hemodialysis treatment at a dialysate temperature of 36 C from 7:13 AM - 10:13 AM. The registered nurse documented the Nurse Prescription Verification at 7:19 AM. There was no justification documented for the dialysate temperature of 36 C. Interview during record review on 12/16/2025 at 12:51 PM with Clinical Coordinator (E) confirmed Patient #10 did not receive the hemodialysis treatments as prescribed for the dates in question. Clinical Coordinator (E) said, “I’m sorry, we will have to do better.””

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 30124 Based on observation, interview and record review, the facility’s Medical Director failed to ensure staff followed the facility’s policy and procedures. 1. The facility staff failed to properly label medications and dispose of expired medications. 2. The facility failed to label glucose control solutions with the date opened and discard dates on the side of the bottles (low and high control solutions). 3. The facility failed to ensure initial nursing assessments were completed prior to initiation of hemodialysis treatments in 3 of 10 sampled patients and 8 closed records: Patient #s 9, 4, 1. Review of the facility’s current policy titled, “Medication Policy”, Policy: 1-06-01, Revision date November 2023. Purpose: To provide guidance for medication management in the facility and to provide guidance for the safe and aseptic preparation of medication. Policy: 1. The Facility Administrator/designee is responsible for supervising the handling, storing, disposing, administering, and controlling of medications and performs a monthly audit and inventory. 20. If medications are prepared and administered immediately, by the same licensed nurse teammate, the medications do not need to be labeled. If the medication is not immediately administered or is to be administered by another teammate, the medication must be labeled with the patient name, name of the medication, date, time prepared, dose and initials of the teammate preparing the medication. 30. All medications in the facility are checked monthly. Insulin and other medications with preservatives are dated and initialed once opened. All medications are checked monthly for expiration dates. Observation on 12/15/2025 at 10:28 AM along with Charge Nurse (A) the surveyor observed the following in the medication cabinet. 1 - pill cup containing two oral medications. The label identifying the patient along with the medication Cinacalcet HCL 30 Milligrams. The label included the date 12/15/2025 and the initials of the teammate preparing the medication. No time documented as to when the medication was prepared or the identification of the second medication in the medication cup as required. 1 - bottle of opened Clonidine Hydrochloride tablets, 0.2 milligrams with an expiration date of 11/2025. Interview on 12/15/2025 at 10:29 AM with the Charge Nurse (A) confirmed the above findings. Policy Review of the facility’s current policy titled, “EmbracePro Blood Glucose Monitor: Quality Control (QC)”; Procedure: 1-08-06C; Last Revision date: September 2020. 1. QC procedures are performed and documented every day the monitor is used or more often as required by state regulations. The first QC procedures of the ay are performed before the monitor is used for patient testing. 3. Verify the monitor is at room temperature. Check high and low control solutions expiration dates. Do not use control solutions past expiration date. Discard control solutions 90 days after opening or on the expiration date printed on the bottle, whichever comes first. When opening a new control solution, write the open and discard dates on the side of the bottle along with the teammate initials. Observation on 12/15/2025 at 10:00AM along with Charge Nurse (A) the surveyor observed the following in the laboratory area. 1 - bottle of opened Embrace Pro Control Solution 1, Lot # C24J02U2, Expiration date 10-02-26. Bottle was not labeled with the date opened nor the discard dates on the side of the bottle along the teammate initials as required. 1 - bottle of opened Embrace Pro Control Solution 2, Lot # C24J02U2, 2.5 mls; Expiration date 10-02-26. Bottle was not labeled with the date opened nor the discard dates on the side of the bottle along the teammate initials as required. Interview on 12/15/2025 at 10:15 AM confirmed the glucose high and low testing solution was not labeled properly. Review of the facility’s current policy and procedure titled; “Initial Patient Nursing Assessment for New Patients”; Policy # 1-03-07, Last revision April 2024. Purpose: Provide guidance for all patients to be evaluated by a registered nurse (RN) prior to the initiation of their first treatment at the facility. Policy: 1. A registered nurse (RN) as required by federal regulation will perform an initial pre-treatment evaluation of all patients prior to the initiation of their first treatment at the facility. Review of selected patient’s medical records along with the Facility Administrator (F) on 12/17/2025 documented the following findings: Patient ID (9) Review of Patient (9) medical records documents patient admitted to the facility on 9/23/2025, with first treatment initiated at 15:49 PM. Initial patient nursing assessment completed at 15:55 PM, after the start of treatment. Patient ID (4) Review of Patient (9) medical records documents patient admitted to the facility on 01/01/2021. Initial patient nursing assessment by the registered nurse documented date as 01/01/2021. No time of the initial patient nursing assessment completion was documented. Surveyor was unable to verify initial nursing assessment was completed prior to initiation of treatment. Interview 12/17/2025 with the Facility Administrator confirmed the above findings with no additional documentation received prior to exit. 48020 Patient #1 On 12/15/2025 at 7:39 AM Patient #1 was observed on the treatment floor of the facility at station #2 machine #6. The patient was receiving hemodialysis treatment at a blood flow rate of 350 milliliters/minute (mL/min) and dialysate flow rate of 800 mL/min. The patient was utilizing an Elisio-17H non reuse dialyzer via a left central venous catheter. Review of the patient’s clinical record (demographic data, history and physical) revealed the patient was admitted to the facility on 01/11/2023 with the diagnoses of end-stage renal disease, hypertension, coronary artery disease, on in-center hemodialysis three times a week. Review of the patient’s clinical record revealed an incomplete New Patient Pre-Treatment Initial Nurse Assessment. The Gastrointestinal, Fluid Status, Surgical Procedures, General Assessment, Personal (hygiene, alcohol, marital status), Language/Education and Wounds were left blank. The RN Signature and date were completed but the time of completion was left blank. Interview with Clinical Coordinator (E) on 12/16/2025 at 2:01 PM confirmed the incomplete admission nursing assessment. Clinical Coordinator (E) said, “We will get better.””

“MR-COMPLETE RECORDS PROMPTLY CFR(s): 494.170(b)(1) (1) Current medical records and those of discharged patients must be completed promptly. This Standard is not met as evidenced by: 48020 Based on record review and interview the facility failed to complete discharged summary within 30 days of discharge from the facility on 5 of 8 closed records of patients who transferred to another facility or expired patient #s 11, 12, 13, 17, 18 Findings: Review of facility’s current policy and procedure: Discharge Summary, Policy: 3-02-01B, Revision Date: October 2022 directs staff as follows: “POLICY: 1. A Discharge Summary will be completed in a maximum of 30 days from a patient’s discharge date or sooner according to state regulations ...” Patient #11 Review of the patient’s clinical record (incident report) on 12/16/2025 revealed the patient was admitted to the facility on 09/05/2022 with diagnosis of diabetes mellitus type 2, anemia, hypertension and end stage renal disease on in center hemodialysis three times weekly. Review of the clinical record revealed the following documentation: Reportable Incident: Death of a Patient Date of the incident: 08/06/25 Review of the clinical record revealed no discharge summary was completed by facility as to the disposition of the patient within 30 days of discharge. Patient #12 Review of the patient’s clinical record (incident report) on 12/16/2025 revealed the patient was admitted to the facility on 12/18/2023 with diagnosis of end stage renal disease, hypertension, anemia, and hyperkalemia on in center hemodialysis three times weekly. Review of the clinical record revealed the following documentation: Reportable Incident: Death of a Patient Date of the incident: 01/14/25 Review of the clinical record revealed no discharge summary was completed by facility as to the disposition of the patient within 30 days of discharge. Patient #13 Review of the patient’s clinical record (incident report) on 12/16/2025 revealed the patient was admitted to the facility on 09/14/2018 with diagnosis of end stage renal disease, congestive heart failure, chronic hypotension, anemia and dementia on in center hemodialysis three times weekly. Review of the clinical record revealed the following documentation: Reportable Incident: Death of a Patient Date of the incident: 10/02/24 Review of the clinical record revealed no discharge summary was completed by facility as to the disposition of the patient within 30 days of discharge. Patient #17 Review of the patient’s clinical record (incident report) on 12/16/2025 revealed the patient was admitted to the facility on 08/12/2024 with diagnosis of end stage renal disease, advanced heart failure, coronary artery disease, congestive heart failure, and malignant neoplasm of bladder and prostate on in center hemodialysis three times weekly. Review of the clinical record revealed the following documentation: Reportable Incident: Hospital Transfer Date of the incident: 11/14/25 The patient did not return to the facility after hospitalization. Review of the clinical record revealed no discharge summary was completed by facility as to the disposition of the patient within 30 days of discharge. Patient #18 Review of the patient’s clinical record (incident report) on 12/16/2025 revealed the patient was admitted to the facility on 04/03/2025. with diagnosis of end stage renal disease, hypertension, anemia, congestive heart failure, hypothyroidism on in center hemodialysis three times weekly. Review of the clinical record revealed the following documentation: Reportable Incident: Death of a Patient Date of the incident: 04/29/25 Review of the clinical record revealed no discharge summary was completed by facility as to the disposition of the patient within 30 days of discharge. Interview with Group Facility Administrator (H) on 12/17/2025 at 8:44 AM confirmed the facility failed to complete discharge summaries on the patients above. Group Facility Administrator (H) said, “The discharge summaries were not being done.””

“GOV-GB RESP FOR STAFF ORIENTATION CFR(s): 494.180(b)(3) The governing body or designated person responsible must ensure that- (3) All staff, including the medical director, have appropriate orientation to the facility and their work responsibilities; This Standard is not met as evidenced by: 30124 Based on interview and record review the governing body failed to ensure all staff, employees or contractors had been properly orientated, trained and demonstrated competencies to meet the needs of the patients. Review on 1/17/2025 of select employee files along with the Facility Administrator (F) the following was identified: Registered Dietitian (N) Record review along with the Facility Administrator (F) on 12/17/2025 at 14:00 PM of Dietitian (N) employee file documented no evidence of documented orientation to the facility. Medical Director (Q) Review of personnel records for the facility’s Medical Director (Q) found no documentation of a signed or dated orientation, and no evidence of water treatment education, training and competencies. Nurse Practitioner (P) Review of personnel records for Nurse Practitioner (P) found appointment by the Governing Body on 12/14/2017. No documentation of orientation to the facility was found. Interview on 12/17/2025 with the Facility Administrator (F) confirmed the above finding and no additional information was received prior to exit.”

“GOV-GB RESP FOR MED STAFF CREDENTIALING CFR(s): 494.180(c)(1) The governing body- (1) Is responsible for all medical staff appointments and credentialing in accordance with State law, including attending physicians, physician assistants, nurse practitioners and clinical nurse specialists; This Standard is not met as evidenced by: 48020 Based on record review and interview, the facility’s Governing Body failed to ensure the delegation of medical responsibilities to the nurse practitioner was reviewed and signed annually in 2 of 2 non-physician practitioners personnel records reviewed: Nurse Practitioner (P), (R) Findings: Nurse Practitioner (P) Review of Nurse Practitioner (P’s) personnel file on 12/17/2025 revealed Nurse Practitioner (P’s) most current credentials were approved by the facility’s governing body on 12/13/2017. The most current Physician’s Assistant/Nurse Practitioner Annual Agreement was signed and dated 04/5/2018. Nurse Practitioner (R) Review of Nurse Practitioner (R’s) personnel file on 12/17/2025 revealed Nurse Practitioner (R’s) most current credentials were approved by the facility’s governing body on 07/31/2023. There was no documentation of the current Physician’s Assistant/Nurse Practitioner Annual Agreement. Interview with Facility Administrator (F) on 12/17/2025 at 12:30 PM confirmed that he was unaware of the requirement for the Physician’s Assistant/Nurse Practitioner Annual Agreement to be reviewed and signed annually.”