Davita Loomis Road Dialysis

“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: 29972 Based on observation, interview, and record review staff failed to perform hand hygiene before donning gloves and immediately after removing gloves while providing patient care in 2 of 12 observations of care (Patient (Pt) #2, #11); failed to remove gloves and perform hand hygiene before donning a new pair of gloves in 1 of 2 staff observations of station cleaning (Station (St) 20); failed to remove gloves and perform hand hygiene when going from a “dirty” to a “clean” task in 1 of 4 observations of Central Venous Catheter (CVC) treatment initiation (Pt #2); and failed to ensure patients holding arteriovenous fistula/graft (AVF/G) post treatment perform hand hygiene after removing gloves in 2 of 2 observations of patient’s holding access site post treatment (Pt #8, #9), in a total sample of 12 observations of care. Findings Include: Review of policy and procedure #1-05-01 titled, “Infection control for Dialysis Facilities” last reviewed April 2023 revealed the following: 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 cart and chairside keyboard/mouse.” 2. “Patients...will be encouraged to...b. Perform hand hygiene after treatment before leaving treatment area.” 3. “Disposable gloves will be worn...when touching the patient’s equipment at the dialysis station...Gloves should be changed...when moving from a contaminated body site to a clean body site of the same patient...when going from a “dirty” area or task to a “clean” area or task...” Staff hand hygiene observations: On 01/22/2025 beginning at 11:00 AM, observed PCT H cleaning and disinfecting the equipment at St 20. PCT H removed her gloves then donned a new pair of gloves and proceeded to St 12 to silence the dialysis machine alarm; PCT H did not perform hand hygiene between glove changes. On 01/22/2025 beginning at 11:30 AM, observed PCT F initiating Pt #11’s dialysis treatment using an AVF/G. PCT F wrapped a glove around her index finger then proceeded to touch the dialysis machine; PCT F did not apply the glove to the whole hand before touching the dialysis equipment. On 01/23/2025 beginning at 10:08 AM, observed PCT G initiating Pt #2’s dialysis treatment using a Central Venous Catheter (CVC). PCT G cleansed the CVC exit site, then proceeded to scrub the CVC limbs/caps. After disinfecting the CVC limbs/caps, PCT G obtained a sterile dressing and placed it over the “clean” CVC exit site, using the same gloves used to disinfect the CVC limbs/caps. PCT G did not remove “dirty” gloves, perform hand hygiene, and don “clean” gloves before applying the clean sterile dressing. Patient hand hygiene observations: On 01/22/2025 beginning at 11:05 AM, observed Patient Care Technician (PCT) G performing Pt #9’s post dialysis access care using an AVF/G. Pt #9 held pressure on the AVF/G access site to achieve hemostasis (stopping of the flow of blood); Pt #9 removed his glove and PCT G did not offer Pt #9 hand sanitizer after glove removal. On 01/22/2025 beginning at 11:16 AM, observed Registered Nurse (RN) E performing Pt #8’s post dialysis access care using an AVF/G. Pt #8 held pressure on the AVF/G access site to achieve hemostasis; Pt #8 removed her glove and RN E did not offer Pt #8 hand sanitizer. Pt #8 then proceeded to touch the scale and door handle to exit the treatment room, allowing for potential cross contamination. Per interview with Facility Administrator (FA) A and Clinical Services Manager (CSM) I, while discussing the observations on 01/23/2025 beginning at 12:40 PM, FA A stated that staff should be offering hand sanitizer to patients after glove removal. FA A stated that staff should perform hand hygiene as per policy. FA A stated that gloves should cover the whole hand and staff should not wrap the glove around their finger. FA A confirmed that staff should don clean gloves before applying the clean dressing to the CVC exit site.”

“IC-HANDLING INFECTIOUS WASTE CFR(s): 494.30(a)(4)(i) [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- (i) Handling, storage and disposal of potentially infectious waste; This Standard is not met as evidenced by: 29972 Based on observations, interview, and record review staff failed to immediately dispose of potentially infectious waste in 1 of 12 patient care observations (Patient (Pt) #2), in a total sample of 12 patient observations of care. Findings Include: Review of policy and procedure #1-04-02B titled, “Central Venous Catheter (CVC)...” last revised October 2024 revealed to “Aseptically discard syringe containing indwelling solution from arterial limb...Repeat step for venous limb.” On 01/23/2025 beginning at 10:08 AM observed Patient Care Technician (PCT) G initiating Pt #2’s dialysis treatment using a CVC. PCT G aspirated 5 milliliter (ml) of blood/indwelling solution from the arterial limb and venous limb and placed both blood filled syringes on the tray table connected to the dialysis chair while continuing to initiate treatment. PCT G did not immediately discard the blood-filled syringes into the sharps container as per policy. During interview with Facility Administrator (FA) A and Clinical Services Manager (CSM) I on 01/23/2025 beginning at 12:40 PM, while discussing observations, FA A stated that blood filled syringes should be immediately discarded into the sharps container and not placed on the tray table.”

“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: 29972 Based on observation, record review, and interview staff failed to clean and disinfect all the equipment at the dialysis station between patients to prevent cross contamination in 2 of 2 observations of dialysis station cleaning (Station (St) 12, 3), in a total sample of 2 observations of station cleaning, Findings Include: Review of policy and procedure #1-05-01 titled, “Infection Control for Dialysis Facilities” last reviewed April 2023 revealed the following: - “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) and frequently contacted by healthcare personnel (e.g., control panel, top, front and sides of dialysis machine; touchscreens; countertops).” - “Hemostats (blood line clamps) should be in the open positions and fully submerged in an appropriate disinfectant solution.” On 01/22/2025 at 11:00 AM, observed Patient Care Technician (PCT) H cleaning and disinfecting St 12. PCT H did not clean and disinfect the following: -Basket attached to the dialysis machine -Extra blood pressure (BP) cuff in the basket -Blue emergency disconnect bag hanging from TV -Garbage can at the station -Bicarbonate lines and Hansen Connectors and hoses -Crevices in between the back rest and seat cushion -Crevices between the arm rest and tray table (did not fold down the tray table) -Did not soak the hemostat clamp as per policy. On 01/22/2025 at 11:27 AM, observed Registered Nurse (RN) E cleaning and disinfecting St 3. RN E did not clean the following: -Basket attached to the dialysis machine -Extra BP cuff in the basket -Dialysate lines and Hansen Connectors and hoses -Recline chair and clean in between the back rest and seat cushion -TV and arm and blue emergency disconnect bag hanging from TV -IV (intravenous) pole and hooks -Counter top at station -Garbage Can at the station During interviews with Facility Administrator (FA) A and Clinical Services Manager (CSM) I on 01/23/2025 beginning at 12:40 PM, while discussing observations, FA A stated that the above areas of the station should be cleaned between patients as per policy.”

“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: 29972 Based on record review, observation, and interview staff failed to ensure Central Venous Catheters (CVCs) are accessed in a manner to prevent potential cross contamination in 1 of 4 patients observed with a CVC (Patient (Pt) #2) in a total sample of 4 patients observed with a CVC. Findings include: Review of policy and procedures #1-04-02B titled, “Central Venous Catheter....” last reviewed October 2024 revealed the following: - “Verify patient’s clothing is secured away for the exit site/work area...Securing the patient’s clothing away from the work area minimizes the risk of cross contamination.” - “Clean each CVC limb/cap with a new Large alcohol prep pad...Remove gloves and discard perform hand hygiene...Place sterile 2 X 2 gauze over the catheter exit site...” On 01/23/2025 beginning at 10:08 AM, observed PCT G initiating Pt #2’s dialysis treatment using a Central Venous Catheter (CVC). After PCT G cleansed the CVC exit site, Pt #2’s clothing was touching the cleaned exit site allowing for potential recontamination; PCT G did not ensure Pt #2’s shirt was secured away from the CVC exit site. Per observation, PCT G cleansed the CVC limbs/caps and then obtained a sterile dressing and placed it over the “clean” CVC exit site, using the same gloves used to disinfect the CVC limbs/caps. PCT G did not remove “dirty” gloves, perform hand hygiene, and don “clean” gloves before applying the clean sterile dressing as per policy. During interview with Facility Administrator (FA) A and Clinical Services Manager (CSM) I on 01/23/2025 beginning at 12:40 PM, while discussing observations, FA A stated that staff should change gloves before applying the CVC exit site dressing. FA A stated that staff should ensure clothing is secure before performing the CVC exit site disinfection.”

“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: 29972 Based on observation, record review, and interview staff failed to ensure that all patient’s faces are visible during dialysis treatment in 1 of 20 patients observed (Patient (Pt) #13), in a total sample of 20 patients observed. Findings Include: Review of the policy and procedure #1-03-08 titled, “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment” last revised April 2024 revealed, “...the patient’s face should be visible throughout the dialysis treatment.” On 01/22/2025 between 12:30 PM to 3:00 PM, observed Pt #13 with dark sunglasses covering his eyes during dialysis treatment. Review of Pt #13’s Treatment Sheet for 01/22/2024 revealed “Patient Monitored eyes closed” is documented at 1:33 PM, 2:03 PM, 2:33 PM, 3:03 PM, and 3:33 PM, this documentation was inconsistent with the observations during these times. There was no documentation of staff addressing Pt #13 wearing sunglasses during treatment. During interviews with Facility Administrator (FA) A and Clinical Services Manager (CSM) I on 01/23/2025 beginning at 12:40 PM, while discussing observations, FA A stated that all patient’s faces including eyes, should be visible during the dialysis treatment as per policy.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 29972 Based on record review and interview staff failed to ensure Heparin is administered as per policy in 3 of 3 in-center hemodialysis patients with Heparin orders (Patients (Pt) #1, 2, 3), in a total sample of 7 medical records reviewed. Findings include: Review of policy and procedure #1-06-02 titled, “Anticoagulation” last reviewed September 2024 revealed the following: -“To anticoagulate (inhibit blood clotting) the patient, the initial loading dose of Heparin is administered through the venous fistula needle or venous port of the central venous catheter (CVC) as least 3 to 5 minutes prior to the initiation of the hemodialysis treatment.” Review of Pt #1’s Treatment Sheets revealed treatment orders for a Heparin loading dose of 2000 units. Review of Pt #1’s Treatment Sheets revealed the following: 01/20/2025: Treatment started at 7:58 AM and the Heparin loading dose was documented as given at 7:59 AM; 1 minute after treatment initiated (should be 3 to 5 minutes before treatment starts as per policy). 01/13/2025: Treatment started at 8:08 AM and the Heparin loading dose was documented as given at 8:11 AM; 3 minutes after treatment initiated. Review of Pt #2’s Treatment Sheets revealed treatment orders for a Heparin loading dose of 1500 units. Review of Pt #2’s Treatment Sheets revealed the following: 01/21/2025: Treatment started at 6:31 AM and the Heparin loading dose was documented as given at 6:31 AM(should be 3 to 5 minutes before treatment starts as per policy). Review of Pt #3’s Treatment Sheets revealed treatment orders for a Heparin loading dose of 1000 units. Review of Pt #3’s Treatment Sheets revealed the following: 01/21/2025: Treatment started at 11:24 AM and the Heparin loading dose was documented as given at 11:25 AM; 1 minute after treatment initiated (should be 3 to 5 minutes before treatment starts as per policy). During interview with Facility Administrator (FA) A and Clinical Services Manager (CSM) J on 01/24/2025 beginning at 12:39 PM, while discussing medical record findings, FA A stated that Heparin loading dose should be given 3 to minutes before treatment starts as per policy.”

“POC-IDT DEVELOPS PLAN OF CARE CFR(s): 494.90(a) The interdisciplinary team must develop a plan of care for each patient. This Standard is not met as evidenced by: 29972 Based on record review and interview the facility failed to ensure that all members of the interdisciplinary team (IDT) interact and discuss the findings of the IDT comprehensive patient assessments to facilitate in the development of a comprehensive patient plan of care in 3 of 5 staff interviews (Social Worker L, Registered Nurse B, Dietician M), in a total sample of 5 staff members interviewed; and 3 of 3 patient interviews (Patient (Pt) #7, #14, #15), in a total sample of 3 patients interviewed. Findings Include: Review of policy and procedure #1-14-01 titled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care” last revised October 2024 revealed the following: -“The facility’s interdisciplinary team (IDT) consists of, at a minimum, the patient or the patient’s personal representative, a registered nurse, a physician or non-physician practitioner...a social worker, and a...renal dietician...The interdisciplinary team is responsible for providing each patient with an individualized and comprehensive assessment documenting his/her needs. The comprehensive assessment will be used to develop the patient’s treatment plan and expectations for care.” Per interviews with Pt #14, and #15 on 01/22/2025 beginning at 3:00 PM and Pt #7 on 01/23/2025 beginning at 9:15 AM, when asked about meeting with the IDT to complete care plans, Pt #7, #14, and #15 denied receiving an invite to their care plan meetings; the patients stated that they had not met with the IDT as a team to discuss their care plans. Per interviews with Social Worker (SW) L on 01/22/2025 at 1:25 PM, Dietician (RD) M on 01/22/2025 at 1:50 PM, and Registered Nurse (RN) B on 01/23/2025 at 10:30 AM, the staff stated that the IDT does not meet as a team with the patient to complete the care plan meeting. Per SW L, she does not provide patients with a meeting/appointment invitation for their care plan meeting to ensure they are aware of their care plan date and time. SW L stated that they try and get the care plans done when staff is available so they are not always planned in advanced. Staff was unable to provide evidence of an effective process in place where the IDT meets to discuss and share information gathered from the comprehensive patient assessments to develop an effective plan of care for the patients.”

“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: 29972 Based on record review and interview, staff failed to ensure that nursing assessments and post treatment evaluations address fluid management needs in 7 of 7 records reviewed (Patients (Pt) #1, 2, 3, 4, 5, 6, 7); failed to ensure that nursing staff perform assessments when blood pressures (BP) and/or MAP (Mean Arterial Pressure) are out of parameters as per policy in 2 of 7 medical records reviewed (Pt #2, 6); and failed to ensure the comprehensive plan of care and comprehensive assessment are individualized and reflects the patient’s Fluid management needs in 1 of 7 records reviewed (Pt #5), in a total sample of 7 medical records reviewed. Findings Include: Review of policy and procedure #1-03-08 titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” last reviewed April 2024 revealed the following: - “Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately. The licensed nurse will use his/her clinical judgement based on individual patient needs to determine if any clinical interventions are necessary.” - “All findings, interventions and patient response will be documented in the patient’s medical record.” - Abnormal findings include, “If patient is above or below 1 kilogram from the target weight (TW);” “Systolic (blood pressure) greater than 180...or less than 90...Diastolic (blood pressure) greater than or equal to 100...” - “If an abnormal finding (s) or concern is identified post treatment, this needs to be reported to the licensed nurse. The licensed nurse will assess the patient prior to discharge. Fluid Assessment and Post Treatment Evaluations: Review of Pt #1’s Treatment Sheets revealed the following: -01/21/2025: Pt #1’s dialysis treatment ended at 11:42 AM and the nursing Post Treatment assessment was documented as being done at 2:54 PM; 3 hours and 24 minutes after Pt #1’s treatment ended. -01/17/2025: Pt #1’s dialysis treatment ended at 10:58 AM and the nursing Post Treatment assessment was documented as being done at 1:20 PM; 2 hours and 22 minutes after Pt #1’s treatment ended. Review of Pt #2’s Treatment Sheets revealed the following: -01/18/2025: Pt #2’s TW pre treatment was 118.0 kg and post weight was 120.5 kg; 2.5 kg above TW. There was no documentation of nursing interventions addressing Pt the post weight being >1 kg over the TW as per policy. -01/14/2025: Pt #2’s TW pre treatment was 118.0 kg and Post Weight was 119.9 kg; 1.9 kg above TW. There was no documentation of nursing interventions addressing the post weight being >1 kg over the TW as per policy. Review of Pt #3’s Treatment Sheets revealed the following: -01/21/2025: Pt #3’s dialysis treatment started at 9:30 AM and the nursing Post Treatment assessment was documented as being done at 11:36 AM; 2 hours and 6 minutes after Pt #3’s treatment ended. Review of Pt #4’s Treatment Sheets revealed the following: -01/20/2025: Pt #4’s dialysis treatment ended at 8:56 AM and the nursing Post Treatment assessment was documented as being done at 12:09 PM; 3 hours and 13 minutes after Pt #4’s treatment ended. Review of Pt #5’s Treatment Sheets revealed the following: -01/20/2025: Pt #5’s dialysis treatment ended at 9:25 AM and the nursing Post Treatment assessment was documented as being done at 12:11 PM; 3 hours and 13 minutes after Pt #5’s treatment ended. Review of Pt #6’s Treatment Sheets revealed the following: -01/22/2025: Pt #6’s TW pre treatment was 96.0 kg and post weight was 99.1 kg; 3.1 kg above TW. There was no documentation of nursing interventions addressing the post weight being >1 kg over the TW as per policy. -01/20/2025: Pt #6’s TW pre treatment was 96.0 kg and post weight was 100.8 kg; 4.8 kg above TW. There was no documentation of nursing interventions addressing the post weight being >1 kg over the TW as per policy. Review of Pt #7’s Treatment Sheets revealed the following: -01/16/2025: Pt #7’s TW pre treatment was 84.5 kg and post weight was 87.0 kg; 2.5 kg above TW. There was no documentation of nursing interventions addressing the post weight being >1 kg over the TW as per policy. -01/14/2025: Pt #7’s TW pre treatment was 84.5 kg and post weight was 89.7 kg; 5.2 kg above TW. There was no documentation of nursing interventions addressing the post weight being >1 kg over the TW as per policy. -01/10/2025 : Pt #7’s TW pre treatment was 84.5 kg and post weight was 88.1 kg; 3.6 kg above TW. There was no documentation of nursing interventions addressing the post weight being >1 kg over the TW as per policy. Blood Pressure/MAP Assessments and Monitoring: Review of Pt #2’s Treatment Sheet revealed the following: -01/21/2025: Pt #2’s Diastolic BP ranged from 104 to 127 (abnormal findings > 100 per policy) during dialysis treatment from 6:17 AM through 9:50 AM. There was no documentation of nursing assessments addressing signs and symptoms of high BP. -01/14/2025: Pt #2’s Diastolic BP ranged from 100 to 131 (abnormal findings > 100 per policy) during dialysis treatment from 7:31 AM through 9:31 AM. There was no documentation of nursing assessments addressing signs and symptoms of high BP. Review of Pt #6’s Treatment Sheet revealed the following: -01/22/2025: Pt #6’s treatment orders revealed staff is to use the MAP (Mean Arterial Pressure) parameter orders to monitor Pt #6 during treatment. The MAP should be greater than 50 (due to having a LVAD--Left Ventricular Assist Device). At 9:32 AM the MAP was 40 and there was no documentation of a RN addressing Pt #6’s MAP being less than the ordered parameters. -01/20/2025: At 10:32 AP Pt #6’s MAP was 48 and there was no documentation of a RN addressing Pt #6’s MAP being less than the ordered parameters. During interview with Facility Administrator (FA) A and Clinical Services Manager (CSM) J on 01/24/2025 beginning at 12:39 PM, while discussing medical record findings, FA A stated that the nurse should document the actual time patients are assessed post treatment. Per FA A, staff should notify the Provider and document interventions when the patient is more than 1.0 kg above dry weight post treatment. FA A stated that when blood pressure/MAP is out of parameters the nursing staff should document an assessment and interventions provided. Fluid Comprehensive Assessment and Plan of Care: Per review of Pt #5’s IDT Comprehensive Assessment Report dated 09/03/2024, the assessment addressing “Fluid/BP” category revealed “Excessive Post Weight above Target Weight...Yes,” “Excessive Intradialytic (between treatments) Weight Gain...Yes,” and “High Ultrafiltration (fluid removal) Rate...Yes.” Per review of Pt #5’s IDT Patient Plan of Care dated 09/25/2024, the plan addressing the “Fluid/BP” category revealed current goal to “Maintain actual Ultrafiltration Rate to avoid long-term risks of excessive fluid removal” and the long-term intervention to “Provide ongoing fluid management coaching.” The goals and interventions were not individualized to Pt #5’s specific needs. Pt #5’s plan of care did not discuss a specific individualized plan to address the excessive post weight above target weight and the excessive intradialytic weight gain that was identified on the Comprehensive Assessment.”

“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: 29972 Based on record review and interview staff failed to recognize and address shortened treatments as per policy in 1 of 7 medical records reviewed (Patients (Pt) #7), in a total sample of 7 medical records reviewed. Findings Include: Review of policy and procedure #1-01-09 titled, “Prescribed Treatment Time Not Met” last revised April 2024 revealed the following: - “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.” - “If shortened/early termination of treatment time exceeds 30 or more minutes, the RN will notify the patient’s attending nephrologist (Kidney Physician) to discuss the appropriate intervention including what additional medical orders may be necessary to address the patient’s specific needs.” - “...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 all other interventions planned to address the shortened treatment, including recommendation to the patient.” Shortened Treatments: Review of Pt #7’s Treatment Sheets revealed the following: -01/14/2025: Pt #7’s dialysis treatment time was ordered for 4 hours. Treatment started at 12:48 PM and ended at 3:31 PM, 77 minutes short. There was no documentation of an Early Termination of Treatment Against Medical Advice form completed as per policy. -01/10/2025: Pt #7’s dialysis treatment time was ordered for 4 hours. Treatment started at 4:27 PM and ended at 6:57 PM, 90 minutes short. There was no documentation of an Early Termination of Treatment Against Medical Advice form completed as per policy. During interview with Facility Administrator (FA) A and Clinical Services Manager (CSM) J on 01/24/2025 beginning at 12:39 PM, while discussing medical record findings, FA A confirmed findings and stated that staff should be documenting in the medical record the reason patient’s time was shortened, nursing interventions addressing shortened treatment, and notifying the physician.”

“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: 29972 Based on record review, observation, and interview staff failed to perform skin antisepsis as per policy when when using a Arteriovenous Fistula/Graft (AVF/G) in 2 of 2 observations of staff initiating treatment using an AVF/G (Patient (Pt) #11) in a total sample of 4 observations of patients using a AVF/G; and failed to assess, evaluate and develop a plan of care for vascular access for patients with a Central Venous Catheter (CVCs) in 2 of 2 records reviewed of patients with a CVC greater than 90 days (Pt #5, 6), in a total of 7 medical records reviewed. Findings Include: Review of policy and procedure #1-04-01D titled, “AV Fistula or Graft Cannulation...” last revised October 2024 revealed the following: -Povidone Iodine “Effective Contact Time” is 30 seconds and “Air Drying Time” is 2 minutes. - “While maintaining aseptic technique, cleanse the sites by applying skin antiseptic using a circular motion...and allow to dry.” - “Do not palpate insertion site once area has been prepped...Once the access site has been prepped touching it will contaminate the site and possibly allow for the introduction of bacteria during cannulation.” Review of policy and procedure #1-14-01 titled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care” last revised October 2024 revealed, “The facility interdisciplinary team will develop and implement a written, individualized comprehensive plan of care that specifies the services necessary to address the patient’s needs, as identified by the comprehensive assessment...and will include measurable and expected outcomes and estimated timetables to achieve these outcomes...The plan of care will address, but not limited to, the following:...When indicated, vascular access which addresses vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. All hemodialysis patients are evaluated for vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a candidate for arteriovenous fistula placement” AVF/G observations: On 01/22/2025 beginning at 11:30 AM, observed Patient Care Technician (PCT) F initiating Pt #11’s dialysis treatment using a AVF/G. PCT F cleansed the skin with Povidone Iodine antiseptic for 8 seconds and not 30 seconds as per policy. PCT F palpated the access sites immediately prior to cannulation allowing for potential cross contamination. PCT F allowed the site to dry for 1 minute and 45 seconds prior to cannulation and not 2 minutes as per policy. CVC greater than 90 days: Pt #6: Review of Pt #6’s Patient Plan of Care revealed Pt #6 currently had a CVC that was placed on 06/10/2024. Review of the Comprehensive Assessment completed by the nursing staff on 08/12/2024, revealed in the “Access” column there was, “No documentation Provided.” There was no document evidence of staff assessing and evaluating the function of Pt #6’s CVC access in RN K’s comprehensive assessment. Per review of Pt #6’s Patient Plan of Care document completed by the IDT on 08/27/2024, the “Access” section revealed to “Support placement, maintenance, and functioning of permanent dialysis access, with a 1 month time frame to “Implement Access Placement and CVC removal pathway steps as indicated.” Per interview with Medical Director (MD) D on 01/23/2025 beginning at 3:00 PM, MD D stated that Pt #6 was not a candidate for AVF/G placement due to having a LVAD (Left Ventricular Assist Device). There was no documentation in Pt #6’s plan of care addressing Pt #6 not being a candidate for an AVF and creating an individualize plan of care to address Pt #6’s specific vascular access goals and interventions. Pt #5: Review of Pt #5’s Patient Plan of Care revealed Pt #5 currently had a CVC that was placed on 11/18/2022. Review of the Comprehensive Assessment Report completed by the nursing staff on 08/29/2024, revealed in the “Access” column there was, “No documentation Provided.” There was no document evidence of staff assessing and evaluating the function of Pt #5’s CVC access in the nursing comprehensive assessment. Per review of Pt #5’s Patient Plan of Care document completed by the IDT on 09/25/2024, the “Access” section revealed goals to “Prevent treatment related complication related to non-permanent dialysis access” and Long term interventions to “Provide ongoing access related coaching.” Review of Pt #5’s Patient Plan of Care revealed there was no documented evidence of an individualized care plan to address Pt #5 having a CVC greater than 90 days, including measurable goals and individualized interventions addressing barriers that are preventing placement of a permanent vascular access. During interview with Facility Administrator (FA) A and Clinical Services Manager (CSM) J on 01/24/2025 beginning at 12:39 PM, while discussing medical record findings, FA A confirmed findings and stated that staff should perform AVF treatment initiation as per policy. FA A stated that the comprehensive assessment should include an evaluation and assessment of the vascular access site and function and the Plan of Care should include an individualized plan to address CVCs.”

“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: 29972 Based on record review and interview staff failed to ensure the initial Comprehensive Plan of Care (POC) is completed within 30 days of the first dialysis treatment in 1 of 2 medical records reviewed for new admissions less than 90 days (Patient (Pt) #2), in a total sample of 7 medical records reviewed. Findings Include: Review of policy and procedure #1-14-01 titled, Interdisciplinary Team (IDT) Patient Assessment and Plan of Care” last reviewed October 2024 revealed, “An initial Plan of Care, based on the findings from the comprehensive assessment, will be completed on all patients new to dialysis within 30 calendar days beginning the first outpatient dialysis treatment...” Review of Pt #2’s medical record revealed Pt #2’s first dialysis treatment was on 11/22/2024, as of the date of the review on 01/24/2025 (63 days), staff was unable to provide evidence that the IDT completed the initial Comprehensive POC. During interview with Facility Administrator (FA) A and Clinical Services Manager (CSM) J on 01/24/2025 beginning at 12:39 PM, while discussing medical record findings, FA A stated she was unable to find evidence that the IDT completed Pt #2’s initial Comprehensive POC. Per CSM J this should be completed within the first 30 days of dialysis treatment as per policy.”

“POC-IMPLEMENT UPDATE-15 DAYS P PT ASSESS CFR(s): 494.90(b)(2) Implementation of monthly or annual updates of the plan of care must be performed within 15 days of the completion of the additional patient assessments specified in §494.80(d). This Standard is not met as evidenced by: 29972 Based on record review and interview staff failed to ensure that the Comprehensive Interdisciplinary Plan of Care is completed within 15 days of the completion of the Comprehensive Interdisciplinary Patient Assessments in 2 of 7 medical records reviewed (Patient (Pt) #4, #6), in a total sample of 7 medical records reviewed. Findings Include: Review of policy and procedure #1-14-01 titled, Interdisciplinary Team (IDT) Patient Assessment and Plan of Care” last reviewed October 2024 revealed, “Complete patient plan of care and patient plan of care meeting within 15 days of the completion of the reassessment.” Review of Pt #4’s medical record revealed the Comprehensive IDT Plan of Care was completed on 05/29/2024. Review of the IDT Comprehensive Assessments revealed the dietician completed Pt #4’s assessment on 04/15/2024 (44 days before the Plan of Care meeting) and nursing completed Pt #4’s assessment on 04/29/2024 (30 days before the Plan of Care meeting); the IDT assessments were not within 15 days of the Plan of Care meeting as per policy. Review of Pt #5’s medical record revealed the Comprehensive IDT Plan of Care was completed on 09/25/2024. Review of the IDT Comprehensive Assessments revealed the dietician completed Pt #5’s assessment on 09/03/2024 (22 days before the Plan of Care meeting), nursing completed Pt #5’s assessment on 08/29/2024 (27 days before), and the social worker completed Pt #5’s assessment on 09/02/2024 (23 days before); the IDT assessments were not within 15 days of the Plan of Care meeting as per policy. During interview with Facility Administrator (FA) A and Clinical Services Manager (CSM) J on 01/24/2025 beginning at 12:39 PM, while discussing medical record findings, FA A stated that the IDT team has 15 days to complete the Plan of Care meeting after completing the IDT Comprehensive Patient Assessments.”

“QAPI-INDICATOR-INF CONT-TREND/PLAN/ACT CFR(s): 494.110(a)(2)(ix) The program must include, but not be limited to, the following: (ix) Infection control; with respect to this component the facility must- (A) Analyze and document the incidence of infection to identify trends and establish baseline information on infection incidence; (B) Develop recommendations and action plans to minimize infection transmission, promote immunization; and (C) Take actions to reduce future incidents. This Standard is not met as evidenced by: 29972 Based on record review and interview the facility failed to ensure the Monthly Infection Control Log was complete in 4 of 6 months reviewed (September 2024, October 2024, November 2024, and December 2024), in a total of 6 months of infection control logs reviewed. Findings Include: Per review of the Infection Control Log for September 2024 revealed the following: -Pt #4 is listed as having a CVC (Central Venous Catheter), but there is no documentation of the specific site of the infection and the “Antibiotic/Intervention” and “Resolution Date” columns are blank. Per review of the Infection Control Log for October 2024 revealed the following: -Pt #16 is listed as having a AVF (Arteriovenous Fistula) and “Sepsis” is documented, but the “Antibiotic/Intervention”, Culture results...” and “Resolution Date” columns are blank. Per review of the Infection Control Log for November 2024 revealed the following: -Pt #5 is listed as having a CVC and “Drainage” is documented in the “Catheter Access Infection” column, but the “Culture results...” and “Resolution Date” columns are blank. Per review of the Infection Control Log for December 2024 revealed the following: -Pt #15 is listed as having a CVC and there is a “X” documented in the “Catheter Access Infection” column, but the “Antibiotic/Intervention”, Culture results...” and “Resolution Date” columns are blank. Per interview with Facility Administrator (FA) A and Clinical Services Manager (CSM) I, while discussing the Infection Control Logs on 01/23/2025 beginning at 12:40 PM, FA A confirmed that the Infection Control Logs were not complete and stated that the nursing staff are responsible for completing the Infection Control Logs and that it should be completed as soon as the infection is identified and when follow up occurs. FA A stated that the Infection Control Logs are used in the Quality meetings to discuss infections.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 29972 Based on record review and interview, facility staff failed to ensure nursing staff verify medication orders prior to medication administration as per policy in 1 of 2 medication administration observations (Patient (Pt) #12), in a total of 2 medication administrations observed; and failed to ensure staff do not wear artificial nails while providing care to patients as per policy in 1 of 6 staff observations of care (Patient Care Technician (PCT) H), in a total of 6 staff observed. Findings Include: Review of policy and procedure #1-06-01 titled, “Medication Policy” last revised October 2023 revealed, “Prior to administration of medication, verify physician...order. Check for patient allergies when receiving or entering a medication order and prior to administering any medications.” On 01/22/2025 at 11:51 AM, observed Registered Nurse (RN) B administering an intravenous (IV) medication to Pt #12. RN B did not check the medication to the order in the electronic medical record prior to administering the IV medication. Review of policy and procedure #1-05-01 titled, “Infection Control for Dialysis Facilities” last revised April 2023 revealed, “It is a requirement for all...teammates whose primary location is working in a facility to have only natural nails...” Review of the “Artificial Nails & Health Care...A five-minute Homeroom Lesson” education signed by PCT H on 04/22/2024 revealed, “artificial fingernails, nail extenders, or nail enhancements including but not limited to nail jewelry, sculptor, acrylic or resin overlays or bonding, gels, tips, wraps, hybrid gels are not permitted.” On 01/22/2025 beginning at 10:30 AM, observed PCT H with artificial nails providing care to patients in the dialysis facility. During interviews with Facility Administrator (FA) A and Clinical Services Manager (CSM) I on 01/23/2025 beginning at 12:40 PM, while discussing observations, FA A stated that the nurse should check the medication order in the patients electronic medical record prior to administration. FA A confirmed that PCT H was wearing artificial nails and stated that staff should be following the policy.”