Davita Glenside Dialysis

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 40084 Based on the scope and severity of deficiencies related to infection control, the facility failed to substantially comply with this condition. See tags: V-0113 Based on nine (9) infection control observations, interviews and document review, it was determined the facility failed to follow infection control and prevention practices related to hand hygiene (HH) and glove changing. V-0115 Based on observation, interview and document review, it was determined the facility failed to ensure Personal Protective Equipment (PPE) was worn, per policy, to prevent contamination while in the patient treatment area. V-0116 Based on six (6) infection control observations, interview and document review, it was determined the facility staff failed to clean and disinfect non-disposable equipment prior to returning the equipment to a clean area. Additionally, the facility staff failed to maintain separation of clean and dirty areas by placing items that cannot be cleaned on top of the portable reverse osmosis (R.O.) system for six (6) of six (6) dialysis stations in the home hemodialysis (HHD) den at the skilled nursing facility (SNF). V-0122 Based on four (4) infection control observations, interviews and document review, it was determined the facility failed to ensure that dialysis stations and chairs were appropriately disinfected between patients. V-0143 Based on observations, interview and document review, it was determined the facility failed to ensure all expired medications are not available for patient use in the dialysis facility or evacuation kits and ensure that all predrawn medications are labeled appropriately and per policy. V-0147 Based on three (3) infection control observations, employee interviews and document review, it was determined the facility failed to follow appropriate infection control measures, per policy, when providing care to a central venous catheter (CVC). V-0178 Based on review of facility documents and interviews with staff, it was determined that the staff (EMP) failed to follow the facility’s policy when water cultures were at action or unacceptable levels at the home hemodialysis den at the skilled nursing facility (SNF) and the facility’s medical director failed to review water quality results. V-0401 Based on observations, review of facility policies, and interviews with staff (EMP), it was determined the facility failed to maintain a safe environment by failure to maintain sharps containers that would prevent anyone from reaching into the containers or that would prevent used sharps to fall out if the container was knocked over; failure to have a policy for linen handling as per the facility’s contract with the skilled nursing facility (SNF); and failure to remove expired supplies from the emergency cart. Based on observations, interview and document review, it was determined the facility failed to maintain a safe environment by not disposing of contaminated sharps at the point of use in two (2) out of three (3) observations when deaccessing a patient (MR) with a fistula or graft. V-0403 Based on observations, interviews and document review, it was determined the facility’s failed to ensure that patient treatment chairs are maintained to allow for effective cleaning and disinfection. Specifically, three (3) dialysis chairs currently in use on the treatment floor were observed to have torn/cracked upholstery. V-0550 Based on observations, interviews and document review, it was determined the facility failed to properly care for arteriovenous (AV) grafts/fistulas according to the facility’s policy. Specifically, in three (3) out of three (3) observations, facility staff touched the cannulation sites of arteriovenous (AV) fistulas after the areas were prepped with antiseptic.”

“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: 49355 Based on observation, facility document review and interviews with staff, it was determined the facility failed to ensure the evacuation kit included a physician contact roster. The findings: The “Facility Emergency Management Plan (ICHD, Home),” policy 4-07-01, revision April 2025, reads, in part: ... “Emergency Evacuation Kit ... 6. Each evacuation kit(s) should contain” ... d. A copy of the physician contact roster. Update information as needed.” Upon inspection of the In-Center Hemodialysis (ICHD) evacuation kit on July 14, 2025, at 11:40 A.M., the surveyor failed to find a physician contact roster in the binder with the kit. On July 16, 2025, employee (EMP) 2 and EMP28 confirmed that the ICHD evacuation kit did not contain a physician roster.”

“Methods for Sharing Information CFR(s): §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(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: (4) A method for sharing information and medical documentation for patients under the [facility’s] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility’s] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI’s care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4). This Standard is not met as evidenced by: 49355 Based on observation, interviews and document review, it was determined the facility failed to maintain an current updated copy of patients’ treatment orders in the in-center hemodialysis (ICHD) evacuation kit. The findings: The facility’s document, “Facility Emergency Management Plan (ICHD, Home),” policy 4-07-01, last revision date April 2025, reads, in part: ... “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.” The ICHD evacuation kit was inspected at 11:40 A.M. on July 14, 2025. The patient treatment orders included were dated June 2, 2025, or June 3, 2025. On July 16, 2025, employee (EMP) 2 agreed a current treatment order list for ICHD patients should be included in the evacuation kit and printed at least once monthly.”

“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: 42929 Based on review of facility documents and interviews with staff, it was determined that the home hemodialysis den in the skilled nursing facility (SNF) failed to provide documentation of participation in emergency preparedness testing based on the host SNF policy and procedures and facility EMP (Emergency Management Plan). Findings: Review of facility document “Facility Emergency Management Plan (DSD (Davita SNF Dialysis))” dated April 2024 reads in part: “... Emergency Drills. 1. The ROM (Regional Operations Manager), or designee, will maintain and participate in emergency preparedness and fire safety training and testing based on the host SNF policy and procedures and facility EMP. 2. Documentation of participation will be maintained with facility EMP.” Review of the facility’s emergency management binder provided by EMP16 revealed no documentation of the facility’s participation in emergency preparedness exercises for the home hemodialysis den at the SNF. EMP16 confirmed there was no documentation of emergency preparedness for the the home hemodialysis den at the SNF.”

“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: 49355 Based on nine (9) infection control observations, interviews and document review, it was determined the facility failed to follow infection control and prevention practices related to hand hygiene (HH) and glove changing. The findings: A review of the facility’s policy entitled, “Infection Control for Dialysis Facilities,” policy: 1-05-01, revision date April 2023, reads, in part: “Hand Hygiene 1. All teammates...will perform hand hygiene ... b. prior to gloving and immediately after removal of gloves, ... d. after patient and dialysis delivery system contact, ... g. before touching clean areas such as supplies, supply car and chairside keyboard/mouse ... PPE ... 7. Disposable gloves will be worn when caring for the patient or touching the patient’s equipment at the dialysis station.... a. Gloves should be changed when: ... ii. When going from a ‘dirty’ area or take to a ‘clean’ area or task.” On July 14, 2025, at 2:40 P.M., at the in-center hemodialysis (ICHD) location, employee (EMP) 9 partially donned a single glove to silence an alarm, removed the glove and did not perform HH before donning a new pair of gloves to attend to a patient at station #13. At 8:32 A.M. on July 15, 2025, at the facility’s skilled nursing facility (SNF) location, EMP20 did not remove gloves, perform HH or don clean gloves before disinfecting the CVC connections on patient (MR) 21 at station #3. At 6:10 P.M. on July 15, 2025, at the ICHD location, EMP32 removed gloves, touched the keyboard at the computer station, then performed hand hygiene. At 6:10 P.M. on July 15, 2025, at the ICHD location, EMP31 removed gloves after assessing a patient’s fistula at station #15, did not perform hand hygiene, then touched EMP31’s goggles. At 6:30 P.M. on July 15, 2025, at the ICHD location, EMP32 removed the dressing from the patient’s central venous catheter (CVC) at station #13, cleaned the exit site without removing gloves, performing hand hygiene, and donning new gloves prior to cleaning the exit site. At 6:40 P.M. on July 15, 2025, at the ICHD location, after EMP31 assessed the patient at the station by listening to the patient’s lungs and touching the patient’s legs and feet, EMP31 picked up the skin cleanser bottle from a clean area, reached into the clean draw and retrieved a gauze package, opened the top, pour the skin cleanser into the package, and handed the package to the PCT at station #11, then removed gloves. At 6:47 P.M. on July 15, 2025, at the ICHD location, EMP31 assessed the patient at station #9, removed one glove, did not perform hand hygiene, then retrieved gauze pads from a drawer at the clean area. At 7:03 P.M. on July 15, 2025, at the ICHD location, EMP5 removed the dressing from the patient’s CVC at station #6, then cleaned the exit site without removing gloves, performing hand hygiene and donning new gloves prior to cleaning the exit site. On July 16, 2025, at 8:48 A.M., at the SNF, EMP20 performed HH and then touched their nose, hair and a sharps container. EMP then donned gloves but failed to perform HH again. During an interview on July 14, 2025, EMP6 indicated that HH should always be performed after removing soiled gloves and prior to donning new gloves.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 49355 Based on observation, interview and document review, it was determined the facility failed to ensure Personal Protective Equipment (PPE) was worn, per policy, to prevent contamination while in the patient treatment area. The findings: A review of the facility’s policy titled, “ DSD Infection Control for Dialysis Facilities,” policy 1-12-17, revision date April 2024, reads, in part: ... “PPE (i.e. gown, gloves, eye protection, face shield) 5. Appropriate PPE will be worn whenever there is the potential for contact with body fluids, hazardous chemicals, contaminated equipment and environmental surfaces, for example, patient care areas. ... 6. Appropriate fluid resistant/fluid impervious gowns will be worn by all teammates, Physicians and Non-Physician (NPP) and visitors in the treatment area.” At 9:23 A.M. on July 15, 2025, at the facility’s skilled nursing facility (SNF) location, a SNF provider entered the patient treatment den but failed to don a gown. At 9:24 A.M. on July 15, 2025, at the SNF, a second SNF provider entered the patient treatment den but failed to don a gown. On July 16, 2025, EMP16 confirmed any provider or guest that enters the treatment floor should don a gown.”

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 49355 Based on six (6) infection control observations, interview and document review, it was determined the facility staff failed to clean and disinfect non-disposable equipment prior to returning the equipment to a clean area. Additionally, the facility staff failed to maintain separation of clean and dirty areas by placing items that cannot be cleaned on top of the portable reverse osmosis (R.O.) system for six (6) of six (6) dialysis stations in the home hemodialysis (HHD) den at the skilled nursing facility (SNF). The findings: Review of facility document “Incenter Hemodialysis Policies & Procedures DaVita Skilled Nursing Facility Dialysis (DSD)” dated April 2024 reads in part: “... 9. If a common supply cart is used to store clean supplies in the patient treatment den/bedside area, this cart is to remain in a designated area at a sufficient distance from patient stations to avoid contamination with blood.... 10. Unused supplies (syringes, alcohol swabs, tape, etc.) or medications (including multiple dose vials containing diluents) taken into the station should be used for that patient and should not be returned to a common clean area or used on other patients....” In the facility’s policy entitled, “Infection Control for Dialysis Facilities,” policy 1-05-01, revision date April 2023, reads, in part: ... “Supplies ... 11. Measures will be taken to prevent cross contamination between patients. ... b. Electronic thermometers...should not be placed on rotationally contaminated equipment such as the dialysis delivery systems. ... Disinfection ... 14. Non-disposable items are to be disinfected after each patient use, prior to removal from treatment area/station and if contaminated between uses. ... a. Stethoscopes will be disinfected with alcohol prep pad and/or 1:100 (one to one hundred) bleach solution and if they are visible contaminated with blood or body fluids should be disinfected with a 1:10 (one to ten) bleach solution. ... Facility Cheyenne 16. Clean areas should be clearly designated for...unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled.” On July 15, 2025, at 8:25 A.M., at the SNF location, employee (EMP) 21 returned the digital thermometer to the rolling desk, after obtaining a temperature on patient (MR) 20. EMP21 did not disinfect the thermometer prior to returning it to the clean desk. At 8:58 A.M., EMP21 returned the digital thermometer used to obtain a temperature on MR23 to the rolling desk without disinfecting it first. Observations on July 15, 2025, at the SNF location, at 8:25 A.M. and 8:43 A.M., revealed that the hoyer lift, used to transfer MR20 and MR21 to and from their wheelchair and into or out of the dialysis chair, was never disinfected after each use. The lift was stored to the side of the treatment area, within the den. Observations at the HHD den in the SNF on July 15, 2025, at 10:33 A.M., revealed six (6) dialysis stations, each with a portable R.O. system next to each dialysis machine. Each portable R.O. system had a box(es) of gloves, hand sanitizer bottle, and binder or clipboard containing daily R.O. paper logs stored on top of the portable R.O. system. Observation on July 15, 2025, at 6:17 P.M., at the in-center hemodialysis location, EMP5 sprayed numbing spray on the patient’s access site at station #7, and did not disinfect the numbing spray prior to placing it in a clean area. Observation on July 15, 2025, at 6:40 P.M., at the in-center hemodialysis location, EMP31 did not disinfect the stethoscope after assessing the patient at station #11. Observation on July 15, 2025, at 6:47 P.M., EMP31 did not disinfect the stethoscope after assessing the patient at station 9. Observation on July 15, 2025, at 7:01 P.M., EMP5 brought the thermometer to a patient to check the patient’s temperature, then proceeded to adjust the patient’s blanket while still holding the thermometer in hand which caused the thermometer to touch the blanket, then returned the thermometer back to the clean area without disinfecting. During an interview on July 15, 2025, EMP16 indicated that all non-disposable equipment should be disinfected after use. Interview on July 15, 2025, at 11:06 AM, EMP29 indicated that the portable R.O. (reverse osmosis) system used in the HHD den in the SNF are part of the dialysis station but are not disinfected with the dialysis machine and chair after each patient treatment. Interview on July 15, 2025, around 3:45 PM, EMP22 indicated that the portable R.O. systems used in the HHD den in the SNF are part of the dialysis station and should be disinfected between patients with the rest of the dialysis station.”

“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: 49355 Based on four (4) infection control observations, interviews and document review, it was determined the facility failed to ensure that dialysis stations and chairs were appropriately disinfected between patients. The findings: A review of the facility’s policy entitled, “Infection Control for Dialysis Facilities,” policy: 1-05-01, revision date April 2023, reads, in part: ... “Disinfection ... 13. At the end of each treatment, the dialysis station will be cleaned and disinfected. a. Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings (e.g. dialysis chair, tray tables, blood pressure cuffs)... ... i. The Wall box.... ... ii. Priming containers are to be emptied prior to disinfection.” On July 14, 2025, at 2:41 P.M., at the facility’s in-center hemodialysis (ICHD) facility, employee (EMP) 4 failed to disinfect the outside of the dialysis chair, underneath each side tray. On July 14, 2025, at 2:51 P.M., at the ICHD facility, EMP13 failed to disinfect the outside of the dialysis chair, underneath each side tray and failed to disinfect the inside and outside of the prime waste container. On July 15, 2025, at 8:28 A.M., at the facility’s skilled nursing facility (SNF), EMP21 failed to disinfect the outside of the dialysis chair, underneath each side tray. EMP21 also failed to disinfect the reverse osmosis (R.O.) unit. On July 15, 2025, at 8:49 A.M., at the facility’s SNF, EMP20 failed to disinfect the outside of the dialysis chair, underneath each side tray. EMP20 also failed to disinfect the R.O. unit. The surveyor observed several chair side tray tables with an accumulation of tape residue, which had not been removed during prior disinfections, to include the tray tables at station #6 and station #11. During an interview on July 15, 2025, at 7:47 A.M., employee (EMP) 16 indicated that the portable reverse osmosis (R.O.) machines used at the skilled nursing facility (SNF) location are part of the dialysis station. During an interview on July 16, 2025, EMP2 indicated that all surfaces of the dialysis chair should be disinfected, to include underneath the side trays. EMP2 also agreed that the inside and outside surfaces of the prime waste container should be disinfected as well.”

“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: 49355 Based on observations, interview and document review, it was determined the facility failed to ensure all expired medications are not available for patient use in the dialysis facility or evacuation kits and ensure that all predrawn medications are labeled appropriately and per policy. The findings: The facility’s policy entitled, “Medication Policy,” policy 1-06-01, revision date October 2023, reads, in part: ... “Policy: ... 20. ... 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 medication, date, time prepared, dose and initials of teammate preparing the medication. ... 30. All medications in the facility are checked monthly. All medications are checked monthly for expiration dates. ... 32. Disposal of expired medications, including all over the counter and nutritional product samples are removed from the treatment and inventory areas and disposed of per state/local regulations.” Review of facility policy “Facility Emergency Management Plan (ICHD, HOME)” last revised April 2025 reads in part: “ ... 7. FA [facility administrator] or designee will review the contents of the kit(s) and replace missing or expired supplies at least monthly ....” Observations on July 14, 2025, at 9:54 A.M., the following expired medications were observed in the home hemodialysis training program’s medication cabinets: three (3) vials of cefepime 2 grams expired April 2024; four (4) vials of vancomycin 500 mg expired June 1, 2025; one (1) vial of ceftriaxone 1 gram expired January 2025; one (1) bag of lactated ringers 500 mL expired April 2025; and one (1) bag of normal saline 1000 mL expired October 2024 located in the evacuation kit. Observations on July 14, 2025, at 11:44 A.M. in the facility’s in-center hemodialysis (ICHD) treatment area, revealed ten (10) 0.5 ml prefilled syringes of 2024-2025 influenza vaccine Flucelvax, NDC # 70461-0654-03, with an expiration date of May 29, 2025, and two (2) 0.5 ml prefilled syringes of 2024-2025 influenza vaccine Fluzone High-Dose, NDC # 49281-0124-65, had expired. In the ICHD’s evacuation kit, two (2) multidose vials of Heparin 1,000 units/ml, 30 ml vial, NDC # 00409-2720-32, with an expiration date of May 1, 2025, were discovered. On July 14, 2025, a labeled prefilled syringe of heparin 2,000 units for a patient was observed on the counter of the ICHD treatment area. The label did not contain the initials of the teammate that prepared the medication, the date or the time. Interview on July 14, 2025, at 10:22 AM, employee (EMP) 24 confirmed the expired medications and removed them from the medication cabinet and evacuation kit. EMP6 was present during the discovery of the expired medications on July 14, 2025, and confirmed expired medications should be removed from the treatment floor and the evacuation kit. EMP6 also indicated that the label for a prepared syringe of medication must include the initials of the teammate that prepared it, the date and the time.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 49355 Based on three (3) infection control observations, employee interviews and document review, it was determined the facility failed to follow appropriate infection control measures, per policy, when providing care to a central venous catheter (CVC). The findings: A review of facility’s policy entitled, “Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure,” procedure 1-04-02B, revision date April 2025, reads, in part: ... “Notes: ... Perform a 15 second hub scrub of the CVC during the process of connecting or disconnecting from the blood lines, including line reversal, or if the patient is disconnected during treatment for any reason. ... Procedure ... 9. Clean each CVC limb/cap with a new LARGE alcohol prep pad, starting close to the exit site and finishing with the cap. ... Upon completion of Dialysis ... 34. ...Scrub the sides, threads and end of the hub thoroughly with friction for 15 seconds.” During an observation on July 15, 2025, at 8:32 A.M., at the skilled nursing facility (SNF) location, employee (EMP) 20 wiped each CVC hub with an alcohol prep pad for approximately five (5) seconds after patient (MR) 21 completed the dialysis treatment. Observation on July 15, 2025, at 6:30 P.M., at the in-center hemodialysis (ICHD) location, EMP31 used a 2” x 2” alcohol prep pad to clean both CVC limbs and caps instead of using a 4” x 4” large alcohol prep pad as per the facility’s policy. Observation on July 15, 2025, at 7:03 P.M., at the ICHD location, EMP31 used a 2” x 2” alcohol prep pad to clean both CVC limbs and caps instead of using a 4” x 4” large alcohol prep pad as per the facility’s policy. During an interview on July 16, 2025, EMP2 indicated that the CVC hubs should be scrubbed for 15 (fifteen) seconds each with a large alcohol prep pad, as per policy.”

“BACT OF H20-MAXIMUM & ACTION LEVELS CFR(s): 494.40(a) 4.1.2 Bacteriology of water: max & action levels Product water used to prepare dialysate or concentrates from powder at a dialysis facility, or to process dialyzers for reuse, shall contain a total viable microbial count lower than 200 CFU/mL and an endotoxin concentration lower than 2 EU/mL The action level for the total viable microbial count in the product water shall be 50 CFU/mL, and the action level for the endotoxin concentration shall be 1 EU/mL. If those action levels are observed in the product water, corrective measures shall promptly be taken to reduce the levels. This Standard is not met as evidenced by: 42929 Based on review of facility documents and interviews with staff, it was determined that the staff (EMP) failed to follow the facility’s policy when water cultures were at action or unacceptable levels at the home hemodialysis den at the skilled nursing facility (SNF) and the facility’s medical director failed to review water quality results. Findings: Review of facility document “Water Culture Policy For The Acute Portable Reverse Osmosis (RO) System” dated April 2025 reads in part: “... Policy: 1. The Hospital Services Administrator (HSA) or designee is responsible for verifying that cultures are obtained, results recorded, reviewed and necessary actions taken, as applicable. 4. ... The medical Director, if applicable reviews all water culture results monthly.... 11. Required responses to action or unacceptable culture results: Single site at or above the action level (all other results in acceptable range): Notify Medical Director, if applicable of result(s) within 48 hours of receiving the result(s). Reculture of the site within 7 days of the original sample collection date. If repeat sampling result is below the action level, no further action is required. If repeat sampling result is at or above the action level, notify HSA/designee and Biomed Services and enter Troubleshooting Mode. See Troubleshooting-Elevated Bacteria/Endotoxin Policy....” Review of the facility’s culture and endotoxin results for six (6) dialysis machines and six (6) portable R.O. water system at the home hemodialysis den at the SNF from January 2025 through July 2025 revealed the following. January 2025, portable R.O. system #533616: Water cultures collected on January 17, 2025, resulted as “Action” level. There was no documentation of a reculture of the site as per facility’s policy. Endotoxin sample collected on January 17, 2025, resulted as “Unacceptable”. The redraw was not completed within seven (7) days of the original sample collection date, as per the facility’s policy. January 2025, portable R.O. system #565737: Water cultures collected on January 13, 2025, resulted “Action” level. There was no documentation of a reculture of the site as per facility’s policy. March 2025, portable R.O. system #565735: Water cultures collected on March 20, 2025, resulted “Unacceptable” level. There was no documentation of a reculture of the site as per facility’s policy. May 2025, portable R.O. system #565737: Water cultures collected on May 20, 2025, resulted “Action” level. There was no documentation of a reculture of the site as per facility’s policy. May 2025, portable R.O. system #565738: Water cultures collected on May 20, 2025, resulted “Unacceptable” level. There was no documentation of a reculture of the site as per facility’s policy. The culture and endotoxin results for February, March, April, May, June, and July 2025 were not signed by the medical director indicating the results were reviewed by the medical director, as per the facility’s policy. Interview on July 15, 2025, around 3:45 PM, EMP22 indicated that actions were not implemented as per the facility’s policy for cultures and endotoxins that were at or above the action level. EMP22 indicated that there was no redraw or the redraw was not done within 7 days as per the facility’s policy. EMP22 confirmed that the culture and endotoxin results were not signed by the medical director for those months.”

“CARBON ADSORP-MONITOR, TEST FREQUENCY CFR(s): 494.40(a) 6.2.5 Carbon adsorption: monitoring, testing freq Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours. Results of monitoring of free chlorine, chloramine, or total chlorine should be recorded in a log sheet. Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. On-line monitors can be used to measure chloramine concentrations. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels described in [AAMI] 4.1.1 (Table 1) [which is a maximum level of 0.1 mg/L]. Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly. This Standard is not met as evidenced by: 42929 Based on observations, review of facility documents, and interviews with staff (EMP), it was determined the facility staff failed to ensure expired chlorine test strips were not available for use. Findings: Review of facility document “Daily Water System Total Chlorine Monitoring” last revised October 2024 reads in part: “... 7. Verify that all supplies used for total chlorine testing have not expired. Discard any expired supplies....” Observations on July 14, 2025, around 9:30 AM, revealed two (2) expired E-Z Check Chloramine Test Strips bottles, with an expiration date of May 31, 2025, on the cart with the home hemodialysis machines in rooms five (5) and eight (8) in the home hemodialysis training area. Interview on July 14, 2025, in the morning, EMP24 confirmed that expired chlorine test strips should be discarded and not available for use.”

“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: 42929 Based on observations, review of facility policies, and interviews with staff (EMP), it was determined the facility failed to maintain a safe environment by failure to maintain sharps containers that would prevent anyone from reaching into the containers or that would prevent used sharps to fall out if the container was knocked over; failure to have a policy for linen handling as per the facility’s contract with the skilled nursing facility (SNF); and failure to remove expired supplies from the emergency cart. Findings: Review of the “Home Hemodialysis Coordination Agreement” between the SNF and the dialysis facility signed May 12, 2021, revealed “... Company [dialysis facility] Obligations ... F. Company will maintain direct responsibility for the safety and quality of the Renal Dialysis Services provided to the HHD [home hemodialysis] Patients admitted to the Facility [SNF], consistent with ESRD CFC requirements, the ESRD Prospective Payment System rules, as well as the terms of the Agreement. Company is responsible for the safe delivery of dialysis to the HHD patient ... Y. Company shall provide or arrange for the equipment and supplies for performance of Services. For the avoidance of doubt, the parties acknowledge that such equipment and supplies shall consist of the items set forth on Exhibit B attached hereto.... Operator [SNF] Obligations ... X. Operator will provide janitorial, laundry, and environmental services, all as related to the Services including, without limitation, medical and hazardous waste removal.... H. In accordance with CMS requirement, Company has developed dialysis-specific policies and procedures, which Company and Operator will work together during the Term to amend, update, and improve as necessary, that address the following: ... (xvii) Housekeeping and laundry policies for cleaning and sanitizing the locations where treatments are provided, including linen handling and waste disposal ...” Observations in the home hemodialysis den in the SNF on July 16, 2025, at 10:33 a.m., the facility had six (6) sharps containers in carts with wheels that had very large openings, approximately 6 inches by 8 inches, that would not prevent anyone from reaching into the containers, and would cause the sharps to fall out of the container if the container was knocked over. The surveyor observed three uncovered blankets in the small storage room containing other water related and dialysis supplies, and an expired 18 gauge IV catheter, expired February 28, 2025, and 8 inch IV set, expired April 13, 2025, in the emergency cart. Interview on July 16, 2025, in the morning, EMP16 and EMP29 indicated that the sharps containers are provided by the SNF as per the facility and SNF contract. EMP16 indicated that the home hemodialysis den must use sharps containers provided by the SNF as per the contract. Later in the day, EMP29 indicated that the SNF has few options for sharps containers including one sharps container that has a large opening, that anyone could still reach into the container, but has a slide cover that does not lock, that anyone can open and close. EMP16 indicated that the home hemodialysis den cannot use the safer sharps containers that are used at the in-center hemodialysis, because they are not supplied by the SNF as per the contract. EMP16 and EMP29 indicated that the blankets in the storage area are clean blankets for patients who need an extra blanket during treatment. EMP16 indicated that expired supplies should be removed from the code cart so they are not available for use. Interview on July 17, 2025, EMP16 indicated that the facility does not have a linen policy. Later in the day EMP29 indicated that the uncovered blankets had been addressed. 49355 Based on observations, interview and document review, it was determined the facility failed to maintain a safe environment by not disposing of contaminated sharps at the point of use in two (2) out of three (3) observations when deaccessing a patient (MR) with a fistula or graft. The findings: A review of the facility’s policy entitled, “Post Dialysis Vascular Access Care: Fistula/Graft Using Safety Fistula Needles,” procedure 1-04-01B, revision April 2023, reads, in part: ... “Procedure ... 8. With safety device engaged, dispose of safety fistula needle in the sharps container.” On July 14, 2025, at 9:33 A.M., employee (EMP) 9 deaccessed MR2’s fistula at station #16 and placed the contaminated needle on the chair side tray table. After applying gauze to the exit site, EMP9 disposed of the needle in a sharps container two stations away. EMP9 repeated the above process after removing the second contaminated fistula needle. On July 14, 2025, at 2:51 P.M., EMP4 deaccessed MR3’s fistula at station #11 and placed the contaminated needle on the chair side tray table. EMP4 then removed the second fistula needle, placing it on the chair side tray table. Once EMP4 had completed dressing the fistula exit sites, EMP4 then placed both contaminated needles in the sharps container. During an interview on July 16, 2025, EMP2 confirmed each contaminated fistula needle should immediately be disposed into a sharps container after removal.”

“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: 49355 Based on observations, interviews and document review, it was determined the facility’s failed to ensure that patient treatment chairs are maintained to allow for effective cleaning and disinfection. Specifically, three (3) dialysis chairs currently in use on the treatment floor were observed to have torn/cracked upholstery. The findings: The facility’s policy entitled, “Infection Control for Dialysis Facilities,” policy 1-05-01, revision April 2023, reads, in part: ... “Disinfection ... 13. At the end of each treatment, the dialysis station will be cleaned and disinfected. a. Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings (e.g. dialysis chair...)....” During observations on the in-center hemodialysis (ICHD) treatment floor on July 14, 2025, three (3) dialysis chairs were noted to have upholstery tears/cracks. The treatment chairs at station #7 and station #9 had a tear/crack in the seats and the chair at station #11 had a tear/crack in the seat in addition to a tear/crack in the right arm rest. During observations on the ICHD on July 15, 2025, at 6:00 P.M., a different surveyor observed the same three (3) treatment chairs with tears/cracks in the upholstery. At interviews on July 16, 2025, EMP2, EMP3 and EMP28 acknowledged dialysis chairs with torn upholstery were in use on the ICHD treatment floor. An estimate dated July 10, 2025, to replace the torn/cracked areas was provided to this surveyor.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 49355 Based on observations, interviews and document review, it was determined the facility failed to ensure access sites were visible during the dialysis treatment for four (4) dialysis patients (MR). The findings: The facility’s policy entitled, “Arteriovenous Fistula (AVF) and Arteriovenous Graft (AVG) Vascular Access Care,” policy 1-04-01, revision April 2025, reads, in part: ... “Policy: ... 16. Cannulation sites and blood tubing connections will be verified for accurate, patent and secure connections, and remain visible throughout the treatment.” During observations on July 14, 2025, at 9:52 A.M., the access site of MR3 was covered at station #12. At 10:57 A.M., the site was still covered. During observations on July 15, 2025, the access site of the patient at station #7 was covered at 12:29 P.M. At 12:30 P.M., the access site of the patient at station #11 was covered and at 12:32 P.M., the access site of the patient at station #3 was covered. During interviews on July 16, 2025, employee (EMP) 2 and EMP 28 indicated that access sites should remain visible at all times while the patient is receiving dialysis treatment.”

“PR-RIGHTS POSTED,STATE/NW ONTACT INFO CFR(s): 494.70(c) The dialysis facility must prominently display a copy of the patient’s rights in the facility, including the current State agency and ESRD network mailing addresses and telephone complaint numbers, where it can be easily seen and read by patients. This Standard is not met as evidenced by: 42929 Based on observations and interviews with staff (EMP), it was determined that the home dialysis program failed to have patient rights prominently displayed where it could be easily seen and read by patients, as per the regulation. Findings: Observations on July 14, 2025, at 10:33 AM, the home dialysis program is located on the second floor with a dedicated entrance and waiting room. The in-center program is located on the first floor with a dedicated entrance and waiting room. There was no patient rights prominently displayed where it could be easily seen and read by patients in the waiting area or treatment area of the home dialysis program. Interview on July 14, 2025, around 2:30 PM, EMP24 confirmed that patient rights was not posted in the home dialysis program, and they would work on getting it posted.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 49355 Based on medical record reviews, document review and interviews, it was determined the facility failed to document a completed nursing assessment within policy guidelines in one (1) out of six (6) in-center hemodialysis (ICHD) medical records reviewed. The facility also failed to document abnormal findings and notify the charge nurse, per facility policy, of unmet target weights (TW) compared to post treatment weights (PTW) in four (4) out of eight (8) ICHD and skilled nursing facility (SNF) medical records reviewed, and/or blood pressure (BP) measurements outside of facility guidelines in two (2) out of six (6) ICHD medical records reviewed. The findings: The facility’s policy entitled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” policy 1-03-08, revision date April 2024, reads, in part: ... “Pre-Treatment Data Collection/Assessment ... 5. The assessment is a nursing responsibility. ... 8. The licensed nurse will round on those patients without reported abnormal findings and complete the nursing assessment within one (1) hour of dialysis treatment initiation.... ... 11. Abnormal finding or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately (refer to “Abnormal Findings” section in this policy). The licensed nurse will use his/her clinical judgement based on individual patient needs to determine if any clinical interventions are necessary. ... 13. All findings, interventions and patient response will be documented in the patient’s medical record. ... Abnormal Findings Unless other abnormal parameters are established by the facility Governing Body and documented in the Governing Body Meeting minutes, the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record. ... Fluid Status: ... Post-treatment: If patient is above or below 1 kg from the target weight ... Blood Pressure-Intradialytic: * Systolic greater than 180 mm/Hg or less than 90 mm/Hg * Diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg A review of the following medical records revealed: Patient (MR) 6: Flowsheet dated July 5, 2025: PTW was 4.6 kg below TW of 91.5 kg. No documentation was noted in the flowsheet. MR7: Flowsheet dated July 4, 2025: PTW was 4.5 kg above TW of 106 kg. No documentation was noted in the flowsheet. MR13: Flowsheet dated July 3, 2025: BP reading at 11:58 A.M. recorded as 210/99 mm/Hg; at 12:02 P.M. recorded as 194/95 mm/Hg; at 12:32 P.M. recorded as 193/96 mm/Hg; at 1:02 P.M. recorded as 184/94 mm/Hg; at 2:32 P.M. recorded as 192/102 mm/Hg; and at 2:54 P.M. recorded as 193/100 mm/Hg. No additional documentation was noted in the flowsheet. MR14: Flowsheet dated June 23, 2025: PTW was 2.6 kg above TW of 130 kg. No documentation was noted in the flowsheet. Flowsheet dated June 27, 2025: treatment start time was 10:45 A.M., documented nursing pre-assessment note completion was 12:10 P.M., a difference of 1 hour 30 minutes. Flowsheet dated July 9, 2025: PTW was 1.7 kg above TW of 130 kg. No documentation was noted in the flowsheet. Flowsheet dated July 11, 2025: PTW was 1.3 kg above TW of 130 kg. No documentation was noted in the flowsheet. MR15: Flowsheet dated July 13, 2025: PTW was 1.8 kg below TW of 75 kg. No documentation was noted in the flowsheet. MR17: Flowsheet dated July 11, 2025: PTW was 1.1 kg above TW of 84.5 kg. No documentation was noted in the flowsheet. BP ranged reading at 12:14 P.M. recorded as 204/80 mm/Hg; at 12:40 P.M. recorded as 193/81 mm/Hg; at 1:37 P.M. recorded as 204/86 mm/Hg; at 2:33 P.M. recorded as 219/83 mm/Hg and at 3:10 P.M. recorded as 187/67 mm/Hg. No additional documentation was noted in the flowsheet. During an interview at 1:42 P.M. on July 14, 2025, employee (EMP) 6 indicated that pre-assessment nursing notes should be completed within one (1) hour from the start of treatment and any unmet target weights or abnormal BP readings should be documented in the flowsheet and the charge nurse notified. EMP6 added that sometimes things are busy on the treatment floor so sometimes the paperwork is late. During an interview at 12:59 P.M. on July 15, 2025, EMP30 indicated that all policies concerning nursing assessments and abnormal findings should be followed. EMP30 continued that documentation of those findings and notification to the charge nurse should be included in the flowsheets.”

“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: 49355 Based on medical record reviews, interviews and document review, it was determined the facility failed to document the reason for the deviation from prescribed blood flow rate (BFR) and/or dialysate flow rate (DFR) for six (6) out of eight (8) in-center hemodialysis (ICHD) and skilled nursing facility (SNF) medical records reviewed. The findings: The facility’s policy entitled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” policy 1-03-08, revision date April 2024, reads, in part: ... “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.... Prescription components include but are not necessarily limited to: ... b. Treatment time ... f. Blood flow rate g. Dialysate flow rate ... 10. If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed. ... 12. The licensed nurse notifies the physician (or NPP if applicable) as needed of changes in patient status. 13. All findings, interventions and patient response will be documented in the patient’s medical record.” The facility’s policy entitled, “Prescribed Treatment Time Not Met, policy 1-01-09, revision date April 2024, reads, in part: ... “A. Completion of the Early Termination of Treatment Against Medical Advice Form 1. The Registered Nurse (RN) will verify that a patient signs the Early Termination of Treatment Against Medical Advice form any time the patient requests to terminate their treatment earlier than the prescribed run time. ... 3. The RN will obtain the patient’s signature on the Early Termination of Treatment Against Medical Advice form prior to the patient being rinsed back from their treatment. If unable to obtain the patient’s signature prior to rinse-back, the RN will obtain the patient’s signature on the form prior to the patient’s departure from the facility. 4. A RN must countersign all Early Termination of Treatment Against Medical Advice forms. A witness signature is required only if the patient refuses to sign the form. 5. If a patient refuses to sign the Early Termination of Treatment Against Medical Advice form, the RN will document the patient’s refusal with the words “patient refused” in the patient signature box along with the date. Under such circumstances, the RN will sign the form and will also obtain a witness’ signature on the form. 6. This applies only to shortened treatments. ... B. Prescribed Treatment Time Not Met 1. If the shortened/early termination of treatment time exceeds 30 or more minutes, the RN will notify the patient’s attending nephrologist to discuss the appropriate intervention (if any), including what additional medical orders may be necessary to address the patient’s specific needs. NOTE: Shortened/Early Termination of dialysis treatment includes all reasons the prescribed dialysis time is not met by 30 or more minutes. ... 3. If a patient’s treatment is shortened/early terminated, the RN will document the event in the patient’s electronic health record. Documentation will include, as appropriate: * The amount of time by which the treatment was shortened * A description of why the treatment was shortened * Whether the patient’s nephrologist was notified * A description of the follow-up medical orders provided by the patient’s attending nephrologist (if any) * A description of all other interventions planned to address the shortened treatment, including recommendation to the patient. ... 4. A completed copy of the Early Termination of Treatment Against Medical Advice form will be kept in the patient’s health record. ... 5. Additionally, if the patient’s dialysis treatment is terminated 30 or more minutes prior to the ordered treatment length, the reason must be documented in the patient electronic health record at the time the treatment was terminated while reconciling the treatment times. ... 6. The Facility Administrator (FA)/Designee will verify that all shortened treatments are recorded and trended, and the FA/Designee shall verify that such records are reviewed and discussed at the Facility Health Meetings (FHM), as appropriate.” A review of the following medical records revealed: Patient (MR) 6: Flowsheet dated July 10, 2025: Prescribed DFR 600 ml/min, from 10:34 A.M. to 12:40 P.M. DFR ran at 800 ml/min. No documentation noted in the flowsheet. MR 7: Flowsheet dated July 14, 2025: Prescribed BFR 600 ml/min, from 11:30 A.M. to 1:30 P.M. DFR ran at 500 ml/min. No documentation noted in the flowsheet. MR 13: Flowsheet dated July 3, 2025: Prescribed BFR 350 ml/min, entire 240 minute treatment ran at 400 ml/min. No documentation noted in the flowsheet. MR 15: Flowsheet dated July 1, 2025: Prescribed BFR 300 ml/min, entire 360 minute treatment ran at 350 ml/min. No documentation noted in the flowsheet. MR17: Flowsheet dated June 30, 2025: Prescribed BFR 400 ml/min, entire 210 minute treatment ran at 200 ml/min. No documentation noted in the flowsheet. MR 18: Flowsheet dated July 4, 2025: Prescribed DFR 600 ml/min, entire 210 min treatment ran at 500 ml/min. No documentation noted in the flowsheet. During an interview at 1:42 P.M. on July 14, 2025, Employee (EMP6) indicated that the charge nurse should be notified anytime a patient’s BFR or DFR is not running as prescribed. EMP6 expects the technicians to document any changes and the reason those changes were made in the flowsheet. EMP6 also states the charge nurse should be notified when a patient is requesting a shortened treatment time so they can go discuss the request with the patient. EMP6 indicated that an AMA form should be completed for any amount of shortened time. During an interview at 12:59 P.M. on July 15, 2025, EMP30 indicated it is their expectation that the treatment prescription be followed as written and that includes any deviation from the prescribed DFR/BFR or any time a patient’s prescribed length of treatment is shortened. EMP30 expects the nurses to notify EMP30 of any issues. Interview on July 15, 2025, around 2:00 P.M., EMP16 indicated staff should document the reason the BFR and DFR were not run as per prescription.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 49355 Based on observations, interviews and document review, it was determined the facility failed to properly care for arteriovenous (AV) grafts/fistulas according to the facility’s policy. Specifically, in three (3) out of three (3) observations, facility staff touched the cannulation sites of arteriovenous (AV) fistulas after the areas were prepped with antiseptic. The findings: The facility’s procedure entitled, “AV Fistula or Graft Cannulation with JMS Sysloc (R) Mini Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose,” procedure 1-04-01E, revision date April 2025, reads, in part: ... “Procedure: ... 13. Do not palpate insertion site once area has been prepped. Once the access site has been prepped, touching it will contaminate the site and possible allow for the introduction of bacteria during contamination.” On July 14, 2025, at 9:39 A.M., at the facility’s in-center hemodialysis (ICHD) facility, employee (EMP) 8 palpated patient (MR) 1’s AV fistula cannulation site at station #15 after cleansing the area with antiseptic and did not recleanse the area before accessing the site. On July 14, 2025, at 11:16 A.M., at the facility’s ICHD facility, EMP9 palpated MR 14’s AV fistula cannulation site at station #16 after cleansing the area with antiseptic and did not recleanse the area before accessing the site. On July 15, 2025, at 9:25 A.M., at the facility’s skilled nursing facility (SNF), EMP21 palpated MR 22’s AV graft cannulation site at station #4 after cleansing the area with antiseptic and did not recleanse the area before accessing the site. On July 15, 2025, at 6:44 PM, the PCT cleaned a patient’s access site, held the patient’s arm touching the top access site to access the bottom site with a needle, and did not reclean the top access site prior to accessing that site with a needle. During an interview on July 14, 2025, at 1:42 P.M., EMP6 indicated the AV fistula/graft site should be recleansed after palpating and before cannulating and not touched again.”

“POC-INITIAL IMPLEMENTED-30 DAYS/13 TX CFR(s): 494.90(b)(2) Implementation of the initial plan of care must begin within the latter of 30 calendar days after admission to the dialysis facility or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session. This Standard is not met as evidenced by: 42929 Based on review of medical records (MR), review of facility documents, and interviews with staff (EMP), it was determined the facility failed to implement the initial plan of care (POC) within the latter of thirty (30) calendar days after admission to the dialysis facility or thirteen (13) outpatient hemodialysis sessions beginning with the first outpatient dialysis session, for three (3) of fifteen (15) patient’s medical records reviewed, MR4, MR5 and MR7. Findings: Review of the facility’s policy titled “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care” last revised October 2024 states in part: “... 10. An initial Plan of Care, based on the findings from the comprehensive assessment, will be completed on all patients new to dialysis within [thirty] 30 calendar days (or [thirteen] 13 outpatient dialysis sessions for hemodialysis) beginning with the first outpatient dialysis treatment or per state guidelines.... New Patient: ... Plan of Care: Within [thirty] 30 days of admission to facility (or within [thirteen] 13 treatments) for new patients to dialysis ... Plan of Care: Complete patient plan of care meeting within 15 days of the completion of the re-assessment and POC....” Review of medical record for MR4, peritoneal dialysis (PD) patient, revealed MR4 was admitted to the facility on February 5, 2025. The patient’s initial POC was completed March 20, 2025, not within thirty (30) calendar days of admission to the facility. Review of medical record for MR5, PD patient, revealed MR5 was admitted to the facility on April 14, 2025. The patient’s initial POC was completed May 30, 2025, not within thirty (30) calendar days of admission to the facility. Review of medical record for MR7, home hemodialysis (HHD) patient in the SNF, revealed MR7 was admitted to the facility on May 26, 2025. The patient’s initial POC was to be completed July 15, 2025, not within thirty (30) calendar days of admission to the facility. Interview on July 16, 2025, in the afternoon, EMP28 indicated that PD patients’ dialysis admission begins after the patient has completed training, so the thirty (30) days would not start until after training is completed. EMP28 indicated that the facility’s policy stating “beginning with the first outpatient dialysis treatment” means “outpatient” refers to when the PD patient has completed training. EMP28 indicated that the facility’s medical record system prompts the POC due date, so the POC needs to be completed by that date. Review of the regulation states, “Implementation of the initial plan of care must begin within the latter of 30 calendar days after admission to the dialysis facility or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session.” The “13 outpatient hemodialysis sessions” is specific to hemodialysis, not PD.”

“QAPI-MONITOR/ACT/TRACK/SUSTAIN IMPROVE CFR(s): 494.110(b) The dialysis facility must continuously monitor its performance, take actions that result in performance improvements, and track performance to ensure that improvements are sustained over time. This Standard is not met as evidenced by: 40084 Based on interview and record review, it was determined the facility’s Quality Assurance and Performance Improvement (QAPI) program failed to take action to ensure sustained improvement over time. Specifically, the QAPI program failed to correct known issues related to expired medications, abnormal findings and dialysis prescription adherence. The findings include: V-0143 Current Recertification survey Based on observations, interview and document review, it was determined the facility failed to ensure all expired medications are not available for patient use in the dialysis facility or evacuation kits and ensure that all predrawn medications are labeled appropriately and per policy. Recertification survey ending April 21, 2022 Based on observation and facility policy review, it was determined the facility staff failed to ensure expired medications were not available for patient use. V-0543 Current Recertification survey Based on medical record reviews, document review and interviews, it was determined the facility failed to document a completed nursing assessment within policy guidelines in one (1) out of six (6) in-center hemodialysis (ICHD) medical records reviewed. The facility also failed to document abnormal findings and notify the charge nurse, per facility policy, of unmet target weights (TW) compared to post treatment weights (PTW) in four (4) out of eight (8) ICHD and skilled nursing facility (SNF) medical records reviewed, and/or blood pressure (BP) measurements outside of facility guidelines in two (2) out of six (6) ICHD medical records reviewed. Recertification survey ending April 21, 2022 Based on medical record and policy review, it was determined that the facility staff failed to: document notification to the registered nurse of abnormal blood pressure for two (2) of seven (7) patients sampled; document notification to the registered nurse or physician of target weight not being met for five (5) of seven (7) patients sampled; and documentation of post-treatment data on each patient post dialysis for four (4) of seven (7) patients sampled. V-0544 Current Recertification survey Based on medical record reviews, interviews and document review, it was determined the facility failed to document the reason for the deviation from prescribed blood flow rate (BFR) and/or dialysate flow rate (DFR) for six (6) out of eight (8) in-center hemodialysis (ICHD) and skilled nursing facility (SNF) medical records reviewed. Recertification survey ending April 21, 2022 Based on medical record and policy review, it was determined that the facility staff failed to: document the reason and notification to the registered nurse of the change in blood flow rate (BFR) for four (4) of seven (7) patients sampled.”