Davita Kent Dialysis Center

“Policies/Procedures for Sheltering in Place CFR(s): §403.748(b)(4), §416.54(b)(3), §418.113(b)(6)(i), §441.184(b)(4), §460.84(b)(5), §482.15(b)(4), §483.73(b)(4), §483.475(b)(4), §485.68(b)(2), §485.542(b)(4), §485.625(b)(4), §485.727(b)(2), §485.920(b)(3), §491.12(b)(2), §494.62(b)(3). (b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(4) or (2),(3),(5),(6)] A means to shelter in place for patients, staff, and volunteers who remain in the [facility]. *[For Inpatient Hospices at §418.113(b):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (i) A means to shelter in place for patients, hospice employees who remain in the hospice. This Standard is not met as evidenced by: 46647 . Based on document review and interview, the facility failed to develop and implement emergency preparedness policies and procedures that address a means to shelter in place for patients, staff, and volunteers who remain in the facility during a disaster or emergency. Failure to develop and implement emergency preparedness policies and procedures that address a means of sheltering in place for those who remain in the facility during a disaster or emergency could lead to adverse outcomes for patients, staff, and volunteers. Findings included: 1. Document review of the facility’s “Facility Emergency Management Plan (ICHD, HOME),” dated 10/24, showed no evidence of a policy addressing a means to shelter in place for patients, staff, and volunteers who remain in the facility during a disaster or emergency. 2. On 09/03/25 at 2:40 PM, Surveyor #6 interviewed the Facility Administrator (Staff #621) about the facility lacking a policy regarding a means to shelter in place during a disaster or emergency. Staff #621 confirmed that the facility lacks a policy for sheltering in place for patients, staff, and volunteers who remain in the facility during a disaster or emergency. .”

“Emergency Officials Contact Information CFR(s): §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(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: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This Standard is not met as evidenced by: 46647 . Based on document review and interview, the facility failed to track and document the contact information for tribal officials as a source of assistance in its emergency preparedness policies and procedures. Failure to maintain contact information of official agencies for use during an emergency places patients and staff at risk of harm due to ineffective communication. Findings included: 1. Document review of the facility’s “Facility Emergency Management Plan (ICHD, HOME),” dated 10/24, showed no evidence of the contact information for tribal officials as a source of assistance in its emergency preparedness policies and procedures. 2. On 09/03/25 at 2:40 PM, Surveyor #6 interviewed the Facility Administrator (Staff #621) regarding the facility’s emergency preparedness plan. Staff #621 confirmed that the plan failed to track and document the contact information for tribal officials as a source of assistance in its emergency preparedness policies and procedures. .”

“IC: HBV: TEST ALL,REV RESULTS/STATUS B4 ADMIT CFR(s): 494.30(a)(1)(i) Routine Testing for Hepatitis B The HBV serological status (i.e. HBsAg, total anti-HBc and anti-HBs) of all patients should be known before admission to the hemodialysis unit. Routinely test all patients [as required by the referenced schedule for routine testing for Hepatitis B Virus]. Promptly review results, and ensure that patients are managed appropriately based on their testing results. This Standard is not met as evidenced by: 46647 . Based on interviews and document review, the facility failed to routinely test all patients for the Hepatitis B Surface Antibody in accordance with the CDC guidelines in 1 of 6 medical records reviewed (Patient #603). Failure to routinely test all patients for the Hepatitis B Surface Antibody puts patients, staff, and visitors at risk of exposure to communicable diseases. Findings included: 1. Document review of facility policy titled, “Hepatitis B Surveillance, Vaccination, Infection Control Measures and Isolation Guidance,” revised 04/2024, showed Hepatitis B immune patients will have annual Hepatitis B Surface Antibody (HBsAb) testing. 2. Document review of Patient #603’s records showed no evidence of HBsAb level testing in the past 12 months. 3. On 09/03/25 at 2:15 PM, Surveyor #7 interviewed the Facility Administrator (Staff #621) regarding Patient #603’s HBsAb level testing. Staff #621 confirmed that Patient #603’s records showed no evidence of HBsAb level testing in the past 12 months. .”

“IC-HBV-ISOLATION-MACHINES/EQUIP/SUPPLIES CFR(s): 494.30(a)(1)(i) Isolation of HBV+ Patients To isolate HBsAg positive patients, ... dedicate machines, equipment, instruments, supplies, and medications that will not be used by HBV susceptible patients. This Standard is not met as evidenced by: 46647 . Based on observation, interview, and document review, the facility failed to dedicate equipment used for dialysis treatment of hepatitis B antigen (HBsAg) positive patients. Failure to dedicate equipment used for dialysis treatment of HBsAg-positive patients risks cross-contamination and use of the equipment by hepatitis B virus (HBV) susceptible (non-immune) patients. Findings included: 1. Document review of the facility policy “Hepatitis B Surveillance, Vaccination, Infection Control Measures, and Isolation Guidance,” dated 04/24, showed that a designated dialysis machine will be used for treatment in the isolation room. The dialysis machine should have a visible label on the front stating “Isolation Machine only” or “Temporary Isolation Machine.” 2. On 09/02/25 at 9:30 AM, Surveyor #6 observed that the dialysis machine in the isolation room was missing the isolation signage. 3. On 09/02/25 at 11:00 AM, Surveyor #6 interviewed the Biomed Manager (Staff #628) regarding the missing isolation machine signage. Staff #628 confirmed that the isolation signage was missing from the machine in the isolation room and from the back-up isolation machine located in the bio-med work area. .”

“IC-HBV-ISOLATION-STAFFING CFR(s): 494.30(a)(1)(i) Isolation of HBV+ Patients Staff members caring for HBsAg positive patients should not care for HBV susceptible patients at the same time, including during the period when dialysis is terminated on one patient and initiated on another. This Standard is not met as evidenced by: 46647 . Based on observation, interview, and document review, the facility failed to ensure staff did not simultaneously care for hepatitis B antigen (HBsAg) positive patients and hepatitis B virus (HBV) susceptible (non-immune) patients. Failure to prevent staff from simultaneously caring for hepatitis B antigen (HBsAg)-positive patients and hepatitis B virus (HBV) susceptible (non-immune) patients places susceptible patients at risk of contracting communicable diseases. Findings included: 1. Document review of facility policy titled, “Hepatitis B Surveillance, Vaccination, Infection Control Measures and Isolation Guidance,” revised 04/2024, showed that teammates caring for confirmed or suspected HBsAg-positive patients will only be assigned to simultaneously care for other HBsAb-positive (immune) patients 2. On 09/03/25 from 10:20 AM until 12:30 PM, Surveyor #7 observed a Patient Care Technician (Staff #623) delivering care to Patient #609, a Hepatitis B positive patient in the isolation room, and Patient #603 outside of isolation. 3. Document review of Patient #603’s records showed no evidence of current HBsAb level testing to ensure immunity. 4. Document review of the facility’s daily teammate and patient assignment sheet showed that Staff #623 was responsible for delivering care to Patient #609 and Patient #603. 5. On 09/03/25 at 2:15 PM, Surveyor #7 interviewed the Facility Administrator (Staff #621) regarding Staff #623’s patient care assignment. Staff #621 confirmed that Staff #623’s patient care assignment included Patient #609 (HBsAg-positive) and #603 (no evidence of a current HBsAb status). .”

“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: 46647 . Based on document review, observation, and interview, the facility failed to ensure staff demonstrated compliance with aseptic techniques when dispensing parenteral medications by failing to disinfect the medication vial rubber septum before accessing medications. Failure to adhere to aseptic techniques when dispensing parenteral medications places patients at risk of receiving contaminated medications that can result in patient harm. Reference: Centers for Disease Control and Prevention (CDC). “Injection Safety” (2019) - “Parenteral medications should be accessed in an aseptic manner ...the rubber septum [of the medication vial] should be disinfected with alcohol prior to piercing it.” Findings included: 1. Document review of the facility policy, “Preparation and Administration of Parenteral Medications (NON-ESA, NON-PARSABIV),” dated 04/24, showed that after removal of the vial cap, the rubber septum is to be cleaned with an alcohol prep pad. 2. On 09/03/25 at 11:30 AM, Surveyor #6 observed a Registered Nurse (RN) (Staff #624) preparing medications. The observation showed that after removing the cap from a new vial of Heparin (intravenous anticoagulation medication used to prevent clotting), Staff #624 failed to clean the rubber septum with an alcohol wipe before withdrawing medication from the vial. 3. On 09/03/25 at 11:35 AM, Surveyor #6 interviewed Staff #624 regarding the medication preparation observation. Staff #624 acknowledged the finding and reported being unaware that the rubber septum of new vials should be cleaned with an alcohol wipe before accessing the medication. 4. On 09/03/25 at 2:40 PM, Surveyor #6 interviewed the Facility Administrator (Staff #621) regarding the medication preparation observation. Staff #621 acknowledged the finding and confirmed that facility policy required the rubber septum of medication vials to be cleansed with an alcohol wipe before withdrawing medication from the vial. .”

“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: 46647 . Based on document review and interview, the facility failed to provide the necessary care and services to manage patients’ dose of dialysis by failing to follow physician’s prescribed dialysate temperature order for 5 of 8 medical records reviewed (Patient #601, #602, #603, #604, and #608) (1), and by failing to monitor patient post dialysis fluid volume status for 1 of 8 medical records reviewed (Patient #601) (2). Failure to provide the necessary care and services to manage the patients’ dose of dialysis places patients at risk for ineffective treatments and at risk for undetected complications. Findings Included: Item #1 - Dialysate Temperature Order 1. Document review of facility policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment,” revised 04/2024, showed patient prescription and machine settings are verified by teammate and the prescription components are confirmed by the licensed nurse. 2. Document review of facility policy titled, “Treatment Initiation Utilizing Fresenius 2008 Series Dialysis Delivery System with All Single Use Dialyzer Types and Streamline or Combiset or Nipro Blood Lines,” revised 04/2025, showed prescription components are verified during machine set up which include dialysate composition. 3. Document review of Patient #601’s prescription orders showed the dialysate temperature ordered at 37º Celsius (C). Treatment records reviewed showed the following: a. On 08/20/25 the Registered Nurse (RN) (Staff #624) lowered the patient’s dialysate temperature to 36ºC. There was no evidence in the record showing a physician’s order to change the dialysate temperature. b. On 08/22/25 the RN (Staff #624) lowered the patient’s dialysate temperature to 36ºC. There was no evidence in the record showing a physician’s order to change the dialysate temperature. c. On 08/25/25 the RN (Staff #624) lowered the patient’s dialysate temperature to 36ºC. There was no evidence in the record showing a physician’s order to change the dialysate temperature. d. On 08/27/25 the RN (Staff #624) lowered the patient’s dialysate temperature to 36ºC. There was no evidence in the record showing a physician’s order to change the dialysate temperature. e. On 08/29/25 the RN (Staff #624) lowered the patient’s dialysate temperature to 35.5ºC. There was no evidence in the record showing a physician’s order to change the dialysate temperature. 4. Document review of Patient #602’s prescription orders showed the dialysate temperature ordered at 37º Celsius (C). Treatment records reviewed showed the following: a. On 08/19/25 the Registered Nurse (RN) (Staff #625) lowered the patient’s dialysate temperature to 36ºC. There was no evidence in the record showing a physician’s order to change the dialysate temperature. b. On 08/23/25 the RN (Staff #625) lowered the patient’s dialysate temperature to 36ºC. There was no evidence in the record showing a physician’s order to change the dialysate temperature. c. On 08/26/25 the RN (Staff #625) lowered the patient’s dialysate temperature to 36ºC. There was no evidence in the record showing a physician’s order to change the dialysate temperature. d. On 08/28/25 the RN (Staff #625) lowered the patient’s dialysate temperature to 36ºC. There was no evidence in the record showing a physician’s order to change the dialysate temperature. e. On 08/29/25 the RN (Staff #625) lowered the patient’s dialysate temperature to 36ºC. There was no evidence in the record showing a physician’s order to change the dialysate temperature. 5. Document review of Patient #603’s prescription orders showed dialysate temperature ordered at 37º Celsius (C). Treatment records reviewed showed the following: a. On 08/18/25 the Registered Nurse (RN) (Staff #626) lowered the patient’s dialysate temperature to 35.5ºC. There was no evidence in the record showing a physician’s order to change the dialysate temperature. b. On 08/22/25 the RN (Staff #626) lowered the patient’s dialysate temperature to 36ºC. There was no evidence in the record showing a physician’s order to change the dialysate temperature. c. On 08/25/25 the RN (Staff #626) lowered the patient’s dialysate temperature to 36ºC. There was no evidence in the record showing a physician’s order to change the dialysate temperature. d. On 08/28/25 the Patient Care Technician (PCT) (Staff #623) lowered the patient’s dialysate temperature to 35.5ºC. There was no evidence in the record showing a physician’s order to change the dialysate temperature. e. On 08/27/25 the RN (Staff #626) lowered the patient’s dialysate temperature to 36ºC. There was no evidence in the record showing a physician’s order to change the dialysate temperature. f. On 08/27/25 the RN (Staff #626) lowered the patient’s dialysate temperature to 36ºC. There was no evidence in the record showing a physician’s order to change the dialysate temperature. 6. Document review of Patient #604’s prescription orders showed dialysate temperature ordered at 36.5º Celsius (C). Treatment records reviewed showed the following: a. On 08/19/25 the Registered Nurse (RN) (Staff #625) lowered the patient’s dialysate temperature to 35.5ºC. There was no evidence in the record showing a physician’s order to change the dialysate temperature. b. On 08/21/25 the RN (Staff #625) lowered the patient’s dialysate temperature to 36ºC. There was no evidence in the record showing a physician’s order to change the dialysate temperature. c. On 08/23/25 the Patient Care technician (PCT) (Staff #623) to 36ºC. There was no evidence in the record showing a physician’s order to change the dialysate temperature. d. On 08/26/25 the RN (Staff #625) lowered the patient’s dialysate temperature to 36ºC. There was no evidence in the record showing a physician’s order to change the dialysate temperature. e. On 08/28/25 the RN (Staff #625) lowered the patient’s dialysate temperature to 36ºC. There was no evidence in the record showing a physician’s order to change the dialysate temperature. 7. Document review of Patient #608 prescription orders showed dialysate temperature at 37º Celsius (C). Treatment records reviewed showed the following: a. On 08/18/25 the Registered Nurse (RN) (Staff #624) lowered the patient’s dialysate temperature to 36.5ºC. There was no evidence in the record showing a physician’s order to change the dialysate temperature. b. On 08/20/25 the RN (Staff #624) lowered the patient’s dialysate temperature to 36ºC. There was no evidence in the record showing a physician’s order to change the dialysate temperature. c. On 08/25/25 the RN (Staff #624) lowered the patient’s dialysate temperature to 36.5ºC. There was no evidence in the record showing a physician’s order to change the dialysate temperature. d. On 08/27/25 the RN (Staff #624) lowered the patient’s dialysate temperature to 36ºC. There was no evidence in the record showing a physician’s order to change the dialysate temperature. e. On 09/01/25 the RN (Staff #624) lowered the patient’s dialysate temperature to 35.5ºC. There was no evidence in the record showing a physician’s order to change the dialysate temperature. 8. On 09/04/25 at 11:30 AM, Surveyor #6 and Surveyor #7 interviewed the Facility Administrator (Staff #621) about the dialysate temperature being lowered without a physician’s order. Staff #621 acknowledged the findings and stated that the facility was unable to provide the missing documentation. Item #2 - Dry weight not achieved 1. Document review of facility policy, “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment,” revised 04/2024, showed that if the patient’s post-treatment weight is 1 kilogram (Kg) above or below the target weight, the licensed nurse should report to the physician and document the abnormal findings in the patient’s medical records. 2. Document review of the prescription orders for Patient #601 showed a target weight of 46.5 Kg. Treatment records reviewed showed the following: a. On 08/22/25, Patient #601’s post-treatment weight was 47.9 Kg, which was 1.4 Kg above the target weight. There was no evidence in the record to show that the licensed nurse (Staff #624) conducted a post-treatment assessment addressing the target weight or reported the abnormal post-treatment weight to the physician. b. On 08/25/25, Patient #601’s post-treatment weight was 49.2 Kg, which was 2.7 Kg above the target weight. There was no evidence in the record to show that the Patient Care Technician (PCT) (Staff #628) reported the abnormal post-weight to the licensed nurse. There was also no evidence in the record to show that the licensed nurse (Staff #624) assessed or reported the abnormal post-treatment weight to the physician. c. On 08/27/25, Patient #601’s post-treatment weight was 49.5 Kg, which was 3 Kg above the target weight. There was no evidence in the record to show that the PCT (Staff #627) reported the abnormal post weigh to the licensed nurse. There was also no evidence in the record to show that the licensed nurse (Staff #629) assessed or reported the abnormal post-treatment weight to the physician. 3. On 09/04/25 at 11:30 AM, Surveyor #7 interviewed the Facility Administrator (Staff #621) about the missing post-treatment nursing assessments and physician notifications for Patient #601. Staff #621 acknowledged the findings and stated that the facility was unable to provide the missing documentation. .”

“LAB-CLIA LABS/MEET NEEDS OF PTS CFR(s): 494.130 The dialysis facility must provide or make available, laboratory services (other than tissue pathology and histocompatibility) to meet the needs of the ESRD patient. Any laboratory services, including tissue pathology and histocompatibility must be furnished by or obtained from, a facility that meets the requirements for laboratory services specified in part 493 of this chapter. This Standard is not met as evidenced by: 46647 . Based on observation, document review, and interview, the facility failed to provide or make available laboratory services to meet the needs of the End Stage Renal Disease (ESRD) patients by failing to remove expired laboratory specimen tubes in accordance with facility policy. Failure to provide or make available laboratory services places the patients at risk of harm from receiving incorrect and harmful treatments based on inaccurate test results. Findings included: 1. Review of the facility’s policy, “Obtaining Patient Lab Specimens,” revised 10/2023, showed that expired laboratory specimen tubes are not to be used and are to be discarded. 2. On 09/02/25 at 12:00 PM, Surveyor #7 observed several bags of red top 6.0 mL laboratory specimen tubes with an expiration date of 06/30/25 and 07/31/25. 3. On 09/02/25 at 12:15 PM, Surveyor #7 interviewed and showed the covering Facility Administrator (Staff #622) the bags of expired laboratory specimen tubes in the lab processing area. Staff #622 confirmed the findings. .”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 46647 . Based on document review and interview, the facility failed to maintain complete and accurate medical records by failing to maintain physician orders when administering medications as needed for 1 of 8 medical records reviewed (Patient #603). Failure to ensure that complete and accurate medical records places patients at risk for harm or a delay in care delivery due to missing physician orders. Findings included: 1. Document review of the facility policy, “Medication Policy,” revised 10/2023, showed medications are to be administered as prescribed and that no medications will be given without an order from the physician or non-physician practitioner. 2. Document review of the in-center hemodialysis medication orders for Patient #603 showed Midodrine Hydrochloride (HCl) (a medication to treat low blood pressure) 5 milligrams (mg) three times a week orally (po) on Monday, Wednesday, and Friday. 3. Treatment records reviewed for Patient #603 showed the following: a. On 08/18/25 at 10:49 AM, a Registered Nurse (RN) (Staff #626) administered Midodrine HCl 5 mg by mouth (PO). At 12:04 PM, Staff #626 administered a second dose of Midodrine HCl 5 mg PO. There was no evidence in the record to show that Staff #626 obtained a physician’s order to administer the second dose of Midodrine HCl. b. On 08/22/25 at 9:59 AM, the RN (Staff #626) administered Midodrine HCl 5 mg PO. At 12:57 PM, Staff #626 administered a second dose of Midodrine HCl 5 mg PO. There was no evidence in the record to show that Staff #626 obtained a physician’s order to administer the second dose of Midodrine HCl. 4. On 09/04/25 at 11:30 AM, Surveyor #6 interviewed the Facility Administrator (Staff #621) regarding the missing physician’s order for the extra dose of Midodrine HCl for Patient #603. Staff #621 acknowledged the findings and stated that the facility was unable to provide documentation of the physician’s order. .”

“QAPI-INDICATOR-PT SATIS & GRIEVANCES CFR(s): 494.110(a)(2)(viii) The program must include, but not be limited to, the following: (viii) Patient satisfaction and grievances. This Standard is not met as evidenced by: 45034 . Based on document review and interview, the facility failed to follow their policies for grievances and patient satisfaction by failing to document investigation and follow up actions regarding negative patient satisfaction issues. Failure to assess and make necessary corrective actions to grievances and patient satisfaction issues places patients at risk of unresolved patient clinical or safety issues and patient harm. Findings Included: 1. Document review of the facility policy titled “Addressing Patient Grievances,” last revised 10/21, showed that all complaints/grievances should be documented on the facility patient grievance log. All details of patient grievances and discussion will be documented. If the grievance is not resolved, the patient should be invited to a grievance conference which should occur within 10 days of the receipt of the complaint. Record of the meeting should be documented during the meeting utilizing the Grievance Meeting Report. - Document review of the facility policy titled “Risk Event Reporting Policy,” last revised 04/19, showed that the Facility Administrator (FA) is responsible for documenting all additional information pertaining to the event in the Risk Event Management (REM) system. All events are to be trended and reviewed during the Facility Health Meeting (FHM). 2. Document review of the facility’s “REM Reports,” for the year 2022 showed staff entered event reports concerning Patient #420’s complaints of verbal and physical sexual misconduct by staff members on 05/02/22, 05/09/22, and 05/18/22. The documentation of follow up by the FA on 05/02/22 stated “Network notified. History of hostility and inappropriate behavior. Covering FA to reach out to Teammate Relations.” No evidence of investigation or follow up was found for the events reported on 05/09/22 and 05/18/22. 3. Document review of the facility’s “FHM Meeting Minutes,” dated 06/17/22, showed “2 patient complaints for May in review. See Facility Health tab for more details.” The Facility Health tab showed “2 patient complains and 2 patient behavior REMS for month in review. 3 from same patient complaint of staff inappropriate behavior towards him that are unfounded with investigation. Patient does not like male staff caring for him and acts out anytime a male staff member is around him.” -The facility failed to produce documentation of review of the FA’s investigation, IDT meeting minutes, communication with the patient or family by SW, FA, MD, or CC regarding concerns, meetings with the network, actions taken, or documentation that a grievance was created for the patients reported concerns. 4. Document review of Patient #420’s medical record showed the following: a. On 03/23/22, an annual Plan of Care (POC) meeting occurred with the patient, physician (MD), nurse, dietician (RD), and social worker (SW). The POC showed the patient was meeting all psychosocial goals which include “Maintain open communication between patient and clinical team.” b. On 05/02/22 at 12:04 PM, a Registered Nurse (RN) (Staff #406) documented, “This nurse was called to intervene due to patient getting upset. Patient deemed with behavioral issues, and refusal to certain caregivers due to their sexuality. This nurse spoke to patient in length regarding behavior, indecent exposure to RN and Patient Care Technician (PCT) while conversing with language hotline. To follow up with Interdisciplinary Team (IDT) meeting with SW, MD, and daughter to come up with a resolution regarding patient behavior and complaints.” c. On 05/02/22 at 2:04 PM, an RN (Staff #408) documented, “ ...patient started to talk rudely to the nurse ... Patient requested to cut time by 42 minutes ... patient is angry ...not talking to nurse ...seen by Clinical Coordinator (CC) for patient concern.” d. On 05/04/22 at 06:48 AM, an RN (Staff #407) documented, “2nd RN unable to verify due to patient conflict from last treatment. CC, MD, and SW aware of conflict.” e. On 05/09/22 at 11:30 AM, a SW (Staff #409) documented, “ ...patient reports he is unhappy when at dialysis due to feeling mistreated ...SW and IDT are working with the network to better assist the patient.” f. On 05/09/22 at 1:43 PM, an RN (Staff #408) documented, “ ...patient started shouting and being aggressive to the nurse attending to him. He is harassing and accusing the nurse that his private part was touched by the nurse and saying bad words ...CC informed.” g. On 05/18/22 at 4:22 PM, an RN (Staff #407) documented, “ ...patient stated he did not like when the males come into his room. Patient accused the male PCT and the male nurse working today of making advances towards him ...patient stated, “I don’t like homosexuals.” ...patient began accusing past male PCT and other male employees of sexually harassing him stating “They dance on me; they grab their balls.” ...patient used profane language repeatedly ...” h. On 04/10/23, an annual POC meeting occurred with the patient, physician (MD), nurse, dietician (RD), and social worker (SW). The POC shows the patient’s psychosocial goal is “Address patient’s needs/behavior to avoid involuntary discharge,” and includes a follow up note by SW. 5. On 01/23/24 at 2:00 PM, Investigator #4 interviewed the FA (Staff #401) about the facilities history with patient grievances or complaints regarding accusations of sexual misconduct by staff. Staff #401 stated that when they started in January of 2023, the staff had relayed a history of events by a patient over the past several years at more than one facility. Staff #401 stated that staff relayed to them that the police were involved at the end of the year 2022 and that the police stated the patient was “wasting everyone’s time” with these allegations. Staff #401 shared that upon their follow up during the first few months of employment, they discovered a lack of documentation regarding prior events involving this patient. Staff #401 provided education and set expectations for all staff regarding incident reporting. - Staff #401 shared that the same patient began making accusations in July, September, and October of 2023. They investigated each event by interviewing the patient, family, and staff, and found inappropriate behavior to be occurring by the patient and the allegations to be unfounded. The plan set in place was always to have the patient cared for by only female staff and to have a witness if female staff were unavailable. This plan was discussed with the patient and daughter. Staff #401 stated interventions were helpful periodically but when new staff were hired, the patient would demand to know their names and then started making the accusations against the new staff, including those that were not on shift at the time of the accusations. -Staff #401 had begun to implement the involuntary discharge process when the patient became unstable and was admitted to an acute care hospital. Staff #401 confirmed that all the investigation and follow up described occurred after they started in 2023, no staff from the 2022 events are currently employed at the facility, and they were unable to locate any further documentation from the 2022 events. 6. On 01/23/24 at 3:00 PM, Investigator #4 interviewed the Facility Administrator (Staff #401), Group Facility Administrator (Staff #402), and Manager of Clinical Services (Staff #403) regarding the facility’s documentation and response to patient grievance/satisfaction and reporting of events in 2022. Staff #401, #402, and #403 acknowledged the facility failed to document the investigation, communication, or action plans at that time as required by the REM and Grievance policies. .”