Davita West Appleton Dialysis

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 29972 Based on record review, observation, and interview staff failed to perform hand hygiene before donning gloves, after removing gloves, between glove changes, and before touching “clean” equipment and/or obtaining clean supplies in 6 of 10 patient observations (Patient (Pt) #1, 2, 3, 5, 10, 15), in a total sample of 10 patients observed; and failed to ensure patients perform hand hygiene after dialysis treatment using an Arteriovenous Fistula/Graft (AVF/G) in 2 of 2 patients observed holding their access site post treatment (Pt #6, 7), in a total sample of 4 patients observed with an AVF/G; failed to wear personal protective equipment (PPE) appropriately to protect from potential blood splatter and contaminants in 2 of 6 staff observed (Patient Care Technician (PCT) K and Registered Nurse (RN) F), in a total of 6 staff observed; failed to ensure that equipment/supplies brought into the dialysis station is cleaned and disinfected before returning to a common “clean” area or used on another patient in 2 of 10 patient observations (Patient (Pt) #4, 6), in a total sample of 10 patients observed and 2 of 2 staff observations of machine pH and conductivity testing (Patient Care Technician (PCT) M, PCT K), in a total sample of 6 staff observations; failed to ensure that “clean” equipment and supplies are stored away from “dirty” areas in 1 of 3 areas observed (In-center hemodialysis treatment area), in a total sample of 3 areas observed; failed to clean and disinfect all the equipment at the dialysis station between patients to prevent potential cross contamination in 2 of 2 observations of dialysis station cleaning (Station (St) #4, 7), in a total sample of 2 observations of station cleaning; failed to ensure bleach solutions used to clean and disinfect equipment/supplies is stored and labeled as per policy to ensure effectiveness in 2 of 2 bleach solutions observed (clean and dirty counters) in a total sample of 2 containers of bleach solution observed; and failed to ensure that potentially contaminated supplies are not used for patient care in 1 of 10 patient care observations (Patient (Pt) #1), in a total sample of 10 patient care observations; failed to ensure that all staff are offered the Hepatitis B vaccination in 1 of 4 personnel files reviewed (Patient Care Technician (PCT) I), in a total sample of 4 personnel files reviewed; failed to administer medications using aseptic technique in 1 of 2 observations of medication administration (Patient (Pt) #17), in a total sample of 2 medication administrations observed; failed to ensure Central Venous Catheters (CVCs) are accessed in a manner to prevent potential cross contamination in 2 of 3 patients observed with a CVC (Patient (Pt) #2, #3) in a total sample of 3 patients observed with a CVC. Findings Include: Facility staff staff failed to perform hand hygiene before donning gloves, after removing gloves, between glove changes, and before touching “clean” equipment and/or obtaining clean supplies; and failed to ensure patients perform hand hygiene after dialysis treatment using an AVF/G. See V-Tag 0113. Facility staff failed to wear PPE appropriately to protect from potential blood splatter and contaminants. See V-Tag 0115. Facility staff failed to ensure that equipment/supplies brought into the dialysis station is cleaned and disinfected before returning to a common “clean” area or used on another patient. See V-Tag 0116. Facility staff failed to ensure that “clean” equipment and supplies are stored away from “dirty” areas. See V-Tag 0117. Facility staff failed to clean and disinfect all the equipment at the dialysis station between patients to prevent potential cross contamination; failed to ensure bleach solutions used to clean and disinfect equipment/supplies is stored and labeled as per policy to ensure effectiveness; and failed to ensure that potentially contaminated supplies are not used for patient care. See V-Tag 0122. Facility staff failed to ensure that all staff are offered the Hepatitis B vaccination. See V-Tag 0126. Facility staff failed to administer medications using aseptic technique. See V-Tag 0143. Facility staff failed to ensure CVCs are accessed in a manner to prevent potential cross contamination. See V-Tag 0147.”

“ESRD EP Training Program CFR(s): §494.62(d)(1): Condition for Coverage: (d)(1) Training program. The dialysis facility must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. Staff training must: (iii) Demonstrate staff knowledge of emergency procedures, including informing patients of- (A) What to do; (B) Where to go, including instructions for occasions when the geographic area of the dialysis facility must be evacuated; (C) Whom to contact if an emergency occurs while the patient is not in the dialysis facility. This contact information must include an alternate emergency phone number for the facility for instances when the dialysis facility is unable to receive phone calls due to an emergency situation (unless the facility has the ability to forward calls to a working phone number under such emergency conditions); and (D) How to disconnect themselves from the dialysis machine if an emergency occurs. (iv) Demonstrate that, at a minimum, its patient care staff maintains current CPR certification; and (v) Properly train its nursing staff in the use of emergency equipment and emergency drugs. (vi) Maintain documentation of the training. (vii) If the emergency preparedness policies and procedures are significantly updated, the dialysis facility must conduct training on the updated policies and procedures. This Standard is not met as evidenced by: 29972 Based on record review and interview facility staff failed to ensure that all patient care staff are certified in Cardiopulmonary Resuscitation (CPR) in 1 of 4 personnel files reviewed (Patient Care Technician (PCT) I), in a total sample of 4 personnel files reviewed. Findings Include: Review of policy and procedure #08-02-04 titled, “Cardiopulmonary Resuscitation Certification...” last reviewed April 2024 revealed, - “All direct patient care teammates (i.e., nurses and patient care technicians)...must have current BLS (basic life support) CPR...certification.” - “Documentation of BLS CPR...certification will be maintained in each patient care teammate’s personnel files.” Review of personnel files on 09/17/2025 beginning at 3:00 PM, revealed that PCT I’s personnel file did not have documentation of a CPR certification. Per observations on 09/17/2025 beginning at 10:00 AM, PCT I was assigned patients and working independently on the treatment floor. Per interview with Group Facility Administrator (FA) C on 09/17/2025 at 4:00 PM, FA C stated that PCT I does not have her CPR certification completed. FA C confirmed that this should have been completed.”

“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 record review, observation, and interview staff failed to perform hand hygiene before donning gloves, after removing gloves, between glove changes, and before touching “clean” equipment and/or obtaining clean supplies in 7 of 10 patient observations (Patient (Pt) #1, 2, 3, 5, 7, 10, 15), in a total sample of 10 patients observed; and failed to ensure patients perform hand hygiene after dialysis treatment using an Arteriovenous Fistula/Graft (AVF/G) in 2 of 2 patients observed holding their access site post treatment (Pt #6, 7), in a total sample of 4 patients observed with an AVF/G. Findings Include: Review of policy and procedure #1-05-01 titled, “Infection Control for Dialysis Facilities” last reviewed April 2023 revealed the following: -“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.” - “Patients and caregivers will be encouraged to...b. Perform hand hygiene after treatment before leaving treatment areas.” - “Disposable glove 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 task to a “clean” area or task...iv. After touching one patient or their dialysis delivery system and before arriving to care for another patient or touch another patient’s dialysis delivery system.” - “The chair side cart...monitor and keyboard are considered clean areas.” Staff observations: On 09/16/2025 beginning at 10:15 AM, observed (Patient Care Technician) PCT L discontinuing Pt #1’s dialysis treatment using a Central Venous Catheter (CVC). PCT L reinfused Pt #1’s blood then removed gloves and obtained clean supplies from the drawer without performing hand hygiene as per policy. On 09/16/2025 beginning at 10:45 AM, observed PCT I discontinuing Pt #7’s dialysis treatment using an Arteriovenous Fistula/Graft (AVF/G). PCT I donned gloves then grabbed the handle of a biohazard sharps container and rolled it over to the station. While wearing the same gloves, PCT I removed Pt #7’s needles. PCT I did not remove “dirty” gloves, perform hand hygiene, and don “clean” gloves to prevent potential cross contamination. On 09/16/2025 beginning at 11:10 AM, observed PCT M collect blood from Pt #10’s blood lines. PCT M placed Pt #10’s lab tubes in the lab area, and did not perform hand hygiene after removing gloves and before donning a new pair of gloves as per policy. On 09/16/2025 beginning at 11:45 AM, observed PCT M cleaning and disinfecting dialysis station 4. PCT M proceeded to silence Pt #15’s machine alarm at station 3, while wearing the same gloves used to clean station 4. PCT M did not remove gloves, perform hand hygiene, and don a clean pair of gloves before touching Pt #15’s dialysis machine as per policy. On 09/16/2025 beginning at 12:00 PM, observed PCT M at station 5, preparing to initiate Pt #5’s dialysis treatment using an AVF/G. PCT M touched the dialysis machine without wearing gloves to program the dialysis machine and then proceeded to type on “clean” computer keyboard without performing hand hygiene. PCT M donned gloves and assessed Pt #5’s vascular access site and wearing the same gloves, PCT M obtained a stethoscope from another dialysis station (station 2) (clean station), touched the computer cart at station 2, and obtained a cell phone from the computer cart at station 2. PCT M did not remove gloves and perform hand hygiene before touching “clean” equipment as per policy. On 09/16/2025 beginning at 12:39 PM, observed PCT I initiating Pt #2’s dialysis treatment using a Central Venous Catheter (CVC). PCT I missed 3 opportunities to perform hand hygiene after removing gloves while initiating Pt #2’s treatment; PCT I typed on the “clean” computer keyboard after removing gloves. On 09/17/2025 beginning at 10:40 AM, observed PCT K initiating Pt #3’s dialysis treatment using a CVC. PCT K missed 7 opportunities to perform hand hygiene between glove changes while initiating Pt #7’s treatment. Observed PCT K touch the dialysis machine (x2) without wearing gloves then touch the “clean” computer keyboard without performing hand hygiene. Patient observations: On 09/16/2025 beginning at 10:40 AM, observed PCT L discontinuing Pt #6’s dialysis treatment using an AVF/G. Pt #6 donned a glove and proceeded to hold pressure on the access site to achieve hemostasis (stop bleeding). Pt #6 did not perform hand hygiene after removing glove and before exiting the dialysis treatment area. On 09/16/2025 beginning at 10:50 AM, observed PCT I discontinuing Pt #7’s dialysis treatment using an AVF/G. Pt #7 donned a glove and proceeded to hold pressure on the access site to achieve hemostasis. Pt #7 did not perform hand hygiene after removing glove and before exiting the dialysis treatment area. During interview on 09/18/2025 beginning at 3:20 PM, while discussing observations with Facility Administrator (FA) B, Group FA C, and Clinical Services Manager (CSM) D, they stated that staff should be performing hand hygiene and glove changes as per policy, and that staff should ensure that patients who hold their vascular access sites are performing hand hygiene after glove removal. Per CSM D the computer cart keyboard is considered “clean” and staff should remove gloves and perform hand hygiene before touching the keyboard.”

“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: 29972 Based on record review, observation and interview the facility staff failed to wear personal protective equipment (PPE) appropriately to protect from potential blood splatter and contaminants in 2 of 6 staff observed (Patient Care Technician (PCT) K and Registered Nurse (RN) F), in a total of 6 staff observed. Findings Include: Review of policy and procedure #1-05-01 titled, “Infection Control for Dialysis Facilities” last reviewed April 2023 revealed the following: - “Appropriate PPE (gown, gloves, eye protection, face shield) will be worn whenever there is potential for contact with body fluids...” On 09/16/2025 beginning at 10:30 AM, observed RN F administering Pt #12’s intravenous medication via the blood lines attached to the dialysis machine. RN F’s face shield was on top of her head, not protecting her eyes, nose, and mouth from potential blood splatter. On 09/17/2025 beginning at 10:40 AM, observed PCT K initiating Pt #3’s dialysis treatment using a Central Venous Catheter (CVC). PCT K was not wearing a face shield to protect eyes, nose, and mouth from potential blood splatter. During interview on 09/18/2025 beginning at 3:20 PM, while discussing observations with Facility Administrator (FA) B, Group FA C, and Clinical Services Manager (CSM) D, FA C stated that staff should wear a face shield when there is a risk of blood exposure.”

“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: 29972 Based on observation, record review and interview, the facility staff failed to ensure that equipment/supplies brought into the dialysis station is cleaned and disinfected before returning to a common “clean” area or used on another patient in 2 of 10 patient observations (Patient (Pt) #4, 6), in a total sample of 10 patients observed and 2 of 2 staff observations of machine pH and conductivity testing (Patient Care Technician (PCT) M, PCT K), in a total sample of 6 staff observations. Findings Include: Review of policy and procedure #1-05-01 titled, “Infection Control for Dialysis Facilities” last revised April 2023 revealed, “Non disposable items are to be disinfected after each patient use, prior to removal from treatment area/station...” On 09/16/2025 beginning at 10:45 AM, observed Registered Nurse (RN) G at station 9 performing Pt #6’s nursing assessment. RN G obtained a stethoscope from station 11 and proceeded to use the stethoscope on Pt #6 without cleaning and disinfecting between patients. On 09/16/2025 beginning at 11:16 AM, observed Patient Care Technician (PCT) I obtain a temporal (forehead) thermometer from the computer cart to check Pt #4’s temperature. PCT I touched the thermometer to Pt #4’s knit hat covering his forehead, then placed the thermometer back onto the “clean” computer cart without cleaning and disinfecting. On 09/16/2025 beginning at 11:55 AM, observed PCT M checking the dialysis machine PH at station 5. PCT M obtained the bottle of pH test strips from a “clean” area and then brought the bottle into the station and proceeded to complete the testing at the dialysis machine with the bottle of test strips in his hands. After PCT M completed the testing he placed the bottle on the “clean” computer cart without first cleaning and disinfecting before returning to a “clean” area. On 09/17/2025 beginning at 11:27 AM, observed PCT K checking the dialysis machine pH and conductivity at station 6 and 7. PCT K obtained the Myron meter (tests conductivity) and bottle of pH test strips from a “clean” common area and then brought the equipment/supplies into station 6. PCT K placed the Myron meter on the counter and held the bottle of test strips in her hand while she completed the testing at the dialysis machine. PCT K then brought the equipment/supplies into station 7, repeating the previous observation, and then returned the equipment/supplies to the common area. PCT K did not clean the equipment between use and after removing from the station. During interview on 09/18/2025 beginning at 3:20 PM, while discussing observations with Facility Administrator (FA) B, Group FA C, and Clinical Services Manager (CSM) D, FA C stated that the Myron meter and bottle of test strips should not be brought into the station (clean equipment/supplies), staff should collect the dialysate from the machines and bring the sample to the common area to test the pH and conductivity. FA C stated that staff should clean stethoscopes before using on another patient.”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 29972 Based on observation, record review and interview, the facility staff failed to ensure that “clean” equipment and supplies are stored away from “dirty” areas in 1 of 3 areas observed (In-center hemodialysis treatment area), in a total sample of 3 areas observed. Findings Include: Review of policy and procedure #1-05-01 titled, “Infection Control for Dialysis Facilities” last revised April 2023 revealed, - “Clean areas should be clearly designated for the preparation, handling, and storage of medications and unused supplies and equipment. Clean area should be clearly separated from contaminated areas where used supplies and equipment are handled.” - “Clean supplies or equipment will not be placed adjacent to a sink unless a splash guard is in place.” - “The chair side cart...monitor and keyboard are considered clean areas...b. the chair side cart components will be cleaned at the end of each treatment day.” On 09/17/2025 beginning at 10:42 AM, observed the “clean” computer carts at station 6 and station 14 touching the the dialysis machine/equipment and within the dialysis station while Pt #3 and Pt #14 received dialysis treatment. On 09/16/2025 beginning at 2:15 PM observed 3 “clean” oxygen concentrators under/adjacent to “dirty” sinks. Per interview with Registered Nurse (RN) G at 2:15 PM, RN G stated that the oxygen concentrators are “clean” and should not be stored at or near a “dirty” sink. RN G stated that there is no designated “clean” area that the oxygen concentrators are stored. During interview on 09/18/2025 beginning at 3:20 PM, while discussing observations with Facility Administrator (FA) B, Group FA C, and Clinical Services Manager (CSM) D, FA C stated that the computer carts are considered clean and should not be within the dialysis station touching the equipment.”

“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, the facility staff failed to clean and disinfect all the equipment at the dialysis station between patients to prevent potential cross contamination in 2 of 2 observations of dialysis station cleaning (Station (St) #4, 7), in a total sample of 2 observations of station cleaning; failed to ensure bleach solutions used to clean and disinfect equipment/supplies is stored and labeled as per policy to ensure effectiveness in 2 of 2 bleach solutions observed (clean and dirty counters) in a total sample of 2 containers of bleach solution observed; and failed to ensure that potentially contaminated supplies are not used for patient care in 1 of 10 patient care observations (Patient (Pt) #3), in a total sample of 10 patient care observations. Findings Include: Review of policy and procedure #1-05-01 titled, “Infection Control for Dialysis Facilities” last reviewed April 2023 revealed: - “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)...the Wall box, drain, and water supply lines are considered part of the dialysis delivery system.” - “Non-disposable items are to be disinfected after each patient use, prior to removal from treatment area/station and if contaminated between uses. If item cannot be cleaned and disinfected it will be dedicated for use on a single patient.” Review of policy and procedure #1-05-08 titled, “Bleach Policy” last reviewed October 2023 revealed: - “Bleach solution needs to be covered with a secure lid...without a secure lid, the bleach solution is open to air causing the solution to degrade over time and become less effective.” Review of policy and procedure #1-05-08A titled, “Preparation of...Bleach Solution” last reviewed April 2025 revealed: - “...label container with expiration date, time and initials. The solution is good for 24 hours only...When the solution is not being used, place a lid on the bleach solution container.” Station Cleaning: On 09/16/2025 at 11:25 AM, observed Patient Care Technician (PCT) L cleaning and disinfecting station 7. PCT L did not clean the following: -Down the sides and back of the seat cushion -Counter tops at the station -TV arm and plastic evacuation bag hanging from the TV -Red laminated sign hanging from the IV (intravenous) pole -IV pole and hooks -Outside of chair under tray tables -Basket attached to the dialysis machine On 09/16/2025 at 11:45 AM, observed PCT M cleaning and disinfecting station 4. PCT M did not clean the following: -Basket attached to the dialysis machine -Acid and bicarbonate lines on the front of the dialysis machine -Hansen connectors and hoses -Counter tops at the station -TV arm and plastic evacuation bag hanging from the TV -Red laminated sign hanging from the IV (intravenous) pole -Venous Drip Chamber -Blood Pressure cuff cord -Outside of chair under tray tables Bleach Solution: On 09/16/2025 at 10:10 AM, observed two containers of bleach solution at the clean and dirty sink that were not covered with a lid to preserve its effectiveness as per policy. Per observations, the bleach solution at the dirty sink was dated 09/15/2025 (the day before) indicating that the bleach solution was expired. Supplies: On 09/16/2025 beginning at 12:45 PM, observed PCT K performing Pt #3’s CVC exit site care. PCT K accidentally dropped 2 unused packages of empty saline syringes onto the floor. PCT K picked up the packages off the floor, cleaned one side with an alcohol wipe, then placed the packages back onto the tray table with “clean” supplies potenitally contaminating the supplies used to initiatiate dialysis treatment. During interview on 09/18/2025 beginning at 3:20 PM, while discussing observations with Facility Administrator (FA) B, Group FA C, and Clinical Services Manager (CSM) D, FA C stated that staff should be cleaning and disinfecting all the areas of the dialysis station identified during the observations. FA C stated that the containers of bleach solution should be covered when not in use and should be labeled as per policy. FA C stated PCT K should have thrown away the supplies that fell on the floor and obtained “clean” supplies; FA C stated that it is not appropriate to use an alcohol wipe to clean the outside of supply packages that fall on the floor.”

“IC-HBV-VACCINATE PTS/STAFF CFR(s): 494.30(a)(1)(i) Hepatitis B Vaccination Vaccinate all susceptible patients and staff members against hepatitis B. This Standard is not met as evidenced by: 29972 Based on record reviews and interview the facility staff failed to ensure that all staff are offered the Hepatitis B vaccination in 1 of 4 personnel files reviewed (Patient Care Technician (PCT) I), in a total sample of 4 personnel files reviewed. Findings Include: Review of policy and procedure #4-06-03 titled, “Teammate Hepatitis B monitoring...” last reviewed April 2024 revealed: - “New teammates who are not able to provide documentation of hepatitis B surface antibodies of 10...or greater...will be screened for hepatitis B surface antigen and hepatitis B surface antibody within 10 days and offered the vaccination as indicated by their results.” - “Teammates that decline the hepatitis B vaccine series will be informed about the value of the vaccine and encouraged to take the series. They will sign Hepatitis B Vaccination Consent/Declination Form.” Review on 09/17/2025 beginning at 3:00 PM revealed that PCT I’s hire date was 06/02/2025. Review of PCT I’s personnel files revealed there was no documentation of PCT I having hepatitis B screening and being offered the hepatitis B vaccination if indicated as per policy. Per interview with Group Facility Administrator (FA) C on 09/17/2025 at 4:00 PM, FA C stated that she was unable to find documentation of PCT I being screened for hepatitis B and offered the hepatitis B vaccination if indicated.”

“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: 29972 Based on observation, record review, and interview the facility staff failed to administer medications using aseptic technique in 1 of 2 observations of medication administration (Patient (Pt) #17), in a total sample of 2 medication administrations observed. Findings Include: Review of policy and procedure #1-06-01 titled, “Medication Policy” reviewed October 2023 revealed, “All teammates administering medications must utilize aseptic technique.” On 09/16/2025 at 1:00 PM, observed Registered Nurse (RN) G drawing up intravenous (IV) medications to administer to Pt #17. RN G did not wipe the rubber stopper of the medication vial with an antiseptic before inserting the needle. RN G did not wipe the injection port with an antiseptic before administering Pt #17’s IV medication. During interview on 09/18/2025 beginning at 3:20 PM, while discussing observations with Facility Administrator (FA) B, Group FA C, and Clinical Services Manager (CSM) D, CSM D stated that staff should use an alcohol wipe to clean the rubber stopper of the medication vial before inserting the needle and should wipe the injection port with an alcohol wipe before administering patients IV medications.”

“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, the facility staff failed to ensure Central Venous Catheters (CVCs) are accessed in a manner to prevent potential cross contamination in 2 of 3 patients observed with a CVC (Patient (Pt) #2, #3) in a total sample of 3 patients observed with a CVC. Findings include: Review of policy and procedures #1-04-02B titled, “Central Venous Catheter....” last reviewed May 2025 revealed the following: - “Clean each CVC limb/cap with new large alcohol prep pad, starting close to the exit site and finishing with the cap. - “Using aseptic technique, remove each cap. One at a time, disinfect each CVC hub with a new alcohol prep pad. Scrub each CVC hub for 15 seconds...hold the limbs until the antiseptic has dried...verify open lumen is not placed on a non-sterile surface...” - “2% Chlorhexidine Gluconate/70% Isopropyl Alcohol (ChloraPrep)...Effective for CVC access exit site...Effective Contact Time 30 seconds back and forth motion...Air Drying Time 60 seconds.” - “Verify patient’s clothing is secured away from the exit site/work area...” On 09/16/2025 beginning at 12:39 PM, observed Patient Care Technician (PCT) I performing Pt #2’s CVC exit site care. PCT I held Pt #2’s shirt collar away from the exit site to cleanse the area, after performing the skin antisepsis, PCT I let go of Pt #2’s collar allowing the shirt to touch the skin surrounding the exit site; potentially contaminating the skin surrounding the CVC exit site. PCT I rested the uncleaned CVC limbs on a 4 x 4 gauze, then used an alcohol wipe to clean the length of the catheter limb from the exit site to the caps; PCT I proceeded to remove the caps and scrub the hubs with the same alcohol wipe used to clean the length of the CVC limbs, per policy staff should be using a new clean alcohol wipe to scrub the hubs. After cleaning the open hubs (no cap), PCT I laid the hubs back onto the same gauze that the uncleaned CVC limbs/caps rested on, allowing for potential contamination. On 09/16/2025 beginning at 12:45 PM, observed PCT K performing Pt #3’s CVC exit site care. PCT K scrubbed the skin surrounding the CVC exit site with ChloraPrep swab (antiseptic) for 19 seconds, should be 30 seconds as per policy. PCT K scrubbed the CVC hubs with an alcohol wipe for 12 seconds (venous) and 7 seconds (arterial), not 15 seconds per hub as per policy. During interview on 09/18/2025 beginning at 3:20 PM, while discussing observations with Facility Administrator (FA) B, Group FA C, and Clinical Services Manager (CSM) D, CSM D stated that staff should use a new alcohol wipe to scrub the CVC hub. FA C stated that staff should be following the CVC policy as it relates to scrubbing the hub and CVC exit care.”

“DIALYS PROPORT-MONITOR PH/CONDUCTIVITY CFR(s): 494.40(a) 5.6 Dialysate proportioning: monitor pH/conductivity It is necessary for the operator to follow the manufacturer’s instructions regarding dialysate conductivity and to measure approximate pH with an independent method before starting the treatment of the next patient. This Standard is not met as evidenced by: 29972 Based on observation, record review and interview facility staff failed to ensure that staff completed independent conductivity testing prior to dialysis treatment as per policy in 1 of 2 observations of machine alarm testing (independent conductivity), in a total sample of 2 observations of machine alarm testing. Findings Include: Review of policy and procedure #1-03-06V titled, “Machine Start Up and Priming a Single Use Dialyzer Utilizing Fresenius 2008 Series Dialysis Delivery Systems...” revealed, - “Perform pressure holding and alarm tests per procedure. These tests are to be performed after the new blood lines are placed on the dialysis delivery system. Verifies that dialysis delivery system is operating correctly and safely prior to initiation of each treatment.” - “Fresenius 2008T performs independent conductivity at the end of pressure holding and alarms test. A pass or fail will show on the screen...If the final dialysate conductivity is not within range, do not initiate treatment and investigate the reason the values are outside of the acceptable range.” On 09/16/2025 at 11:55 AM, observed Patient Care Technician (PCT) M setting up the dialysis machine at station 5 for Pt #5’s dialysis treatment. Per observations the machine alarm test failed for Independent Conductivity. PCT M did not repeat the alarm testing and did not perform an independent conductivity check. PCT J was helping out PCT M and initiated Pt #5’s dialysis treatment without checking to see if all the machine alarm tests had passed including independent conductivity. Per interview with PCT J on 09/16/2025 at 12:15 PM, PCT J stated she was not aware that the machine Independent Conductivity alarm test had failed and stated that an independent conductivity check should have been done using the Myron meter to confirm the conductivity was in an acceptable range before starting treatment.”

“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: 29972 Based on record review and interview facility staff failed to ensure eye wash stations are monitored and in functional working condition in case of an emergency in 3 of 5 monthly eyewash station logs reviewed (May 2025, August 2025, September 2025), in a total of 5 months of eyewash station logs reviewed. Findings Include: Review of policy and procedure #4-08-09 titled, “Eyewash Station...Checks” last revised October 2019 revealed, - “Plumbed eyewash stations...are to be activated weekly to flush the line and verify proper operation.” - “Inspections will be documented on the Weekly Eyewash...Inspection Log...” Eyewash Stations: Review on 09/17/2025 beginning at 2:00 PM of Eyewash station inspection logs revealed there was no documentation of staff checking the Eyewash stations to ensure functional working condition in May, August, and September 2025. Per interview with Clinical Services Manager (CSM) D on 09/17/2025 at 2:30 PM, CSM D stated that staff had not completed Eyewash Station logs for May 2025, August 2025, and September 2025. CSM D stated that Eyewash checks should be done weekly and documented on the Eyewash station inspection log.”

“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, the facility staff failed to ensure that all vascular access sites are visible during dialysis treatment and that patients are in view of staff at all times in 4 of 15 patients observed (Patient (Pt) #8, 11, 12, 13), in a total sample of 15 patients observed. Findings Include: Review of policy and procedure #1-03-08 titled, “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment” last revised April 2024 revealed, “The vascular access site...should be visible throughout the dialysis treatment.” On 09/16/2025 beginning at 10:08 AM observed Pt #8’s vascular access site covered with a blanket throughout dialysis treatment, not allowing staff to see the vascular access site connections. On 09/17/2025 beginning at 9:00 AM, observed Pt #11, 12, and 13 receiving dialysis treatment in POD 5. Patient Care Technician (PCT) H (assigned to POD 5) left the floor and there was no staff present in this POD for approximately 7 minutes. Staff from the other PODS were unable to see the patients due to the walls and pillars blocking the view. During interview on 09/18/2025 beginning at 3:20 PM, while discussing observations with Facility Administrator (FA) B, Group FA C, and Clinical Services Manager (CSM) D, FA C stated that staff should be within view of patients at all times and if the staff member needs to leave the floor they should have another staff member cover their POD. Per FA C the vascular access sites should not be covered during treatment.”

“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 physician orders in 2 of 5 in-center hemodialysis patients with Heparin orders (Patients (Pt) #20, 24), 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: - “Heparin is administered per physician’s order.” - “A Heparin pump is used to deliver a constant infusion of Heparin over the course of the hemodialysis treatment...” - “It is recommended that the heparin hourly infusion be discontinued 60 minutes prior to end of treatment for patients with arterio-venous (AV) fistulas and/or AV grafts per physician order. It is recommended that the heparin hourly infusion be continued for the entire treatment for patients with CVCs.” - “To anticoagulate the patient, the initial loading dose of heparin is administered...at least 3 to 5 minutes prior to initiation of the hemodialysis treatment.” Review of Pt #20’s medications revealed treatment orders for a Heparin infusion of 500 units per hour and stopped 60 minutes before treatment ends and Heparin 1000 units IV (intravenous) push (loading dose). Review of Pt #20’s Treatment Sheets revealed: -On 09/08/2025 Pt #20’s treatment ended at 9:22 AM and documentation revealed the Heparin infusion was stopped at 9:37 AM, 15 minutes after treatment ended (not 60 minutes before as per orders). -On 09/03/2025 Pt #20’s treatment started at 6:30 AM and the loading dose of Heparin was given at 6:32 AM, 2 minutes after treatment started (should be 3 to 5 minutes before per policy). Pt #20’s treatment ended at 9:27 AM and documentation revealed the Heparin infusion was stopped at 9:28 AM, 1 minute after treatment ended (not 60 minutes before as per orders). Review of Pt #24’s medications revealed treatment orders for Heparin 3000 units IV (intravenous) push (loading dose). Review of Pt #24’s Treatment Sheets revealed: -On 09/09/2025 Pt #24’s treatment started at 11:30 AM and the loading dose of Heparin was given at 1:03 PM, 1 hour and 33 minutes after treatment started (should be 3 to 5 minutes before per policy). During interview on 09/18/2025 beginning at 3:20 PM, while discussing medical record findings with Facility Administrator (FA) B, Group FA C, and Clinical Services Manager (CSM) D, CSM D confirmed the findings and stated that the Heparin loading dose should be given 3 to 5 minutes before treatment initiation and the actual time given should be reflected in the medical records. Per CSM D staff should follow physician orders for the Heparin infusion and the start and stop times should be accurately documented in the medical record.”

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 29972 Based on record review and interview, staff failed to ensure patients who are deemed unstable receive a monthly comprehensive re-assessment and plan of care revision to address the contributory factors in 1 of 1 unstable medical record reviewed (Patient (Pt) #24), 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 the following: -“A comprehensive re-assessment of each patient and a revision in the plan of care will be conducted: At least monthly for unstable patients...” Review of Pt #24’s Patient Plan of Care dated 06/26/2025 revealed that Pt #24 was deemed “Unstable” due to frequent hospitalizations. Per interview with Clinical Service Manager (CSM) E on 09/18/2025 at 2:45 PM, CSM E stated that no additional IDT re-assessments and plan of care revisions have been done since Pt #24 was deemed unstable (almost 3 months ago); CSM E stated that unstable assessments and care plans should be done monthly until the patient is deemed stable.”

“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, the facility staff failed to ensure that nursing staff perform nursing assessments when blood pressure (BP) and/or heart rate are out of parameters in 4 of 7 In-Center Hemodialysis medical records reviewed (Patient (Pt) #20, 21, 24, 26); and failed to perform fluid assessments and monitoring as per policy in 4 of 7 In-Center Hemodialysis medical records reviewed (Pt #21, 22, 23, 24), 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; - “If abnormal finding is reported to the licensed nurse pre-treatment, the nurse will assess the patient prior to the initiation of dialysis.” - “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.” - “If an abnormal finding 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.” - “All findings, interventions and patient response will be documented in the patient’s medical record.” - Abnormal findings include: Fluid Status Pre-Treatment...”Removal goal not to exceed maximum ordered by physician...Post-treatment: If patient is above or below 1 kilogram from the target weight (TW);” - Abnormal Findings include: Blood Pressure-Intradialytic (during treatment)...”Systolic (blood pressure) greater than 180...or less than 90...Diastolic (blood pressure) greater than or equal to 100 or less than 50...” - Abnormal Findings include: Blood Pressure Post Treatment... “Standing systolic BP greater than 140...Standing diastolic BP greater than 90...If patient is not able to stand, document the reason...” -Abnormal findings include: Heart or pulse rate of “Less than 60 beats per minute or greater that 100 beats per minute...” Blood Pressure/Heart Rate Assessments and Monitoring: Review of Pt #20’s Treatment Sheets revealed: -On 09/08/2025 Pt #20’s pre-treatment BP was 197/109 (systolic parameters <180)(diastolic parameters <100) and Pt #20’s dialysis treatment started at 6:20 AM. The nursing pre-treatment assessment was not documented as completed until 9:30 AM (3 hours and 10 minutes later); there was no documentation of the RN addressing Pt #20’s BP being out of parameters before initiating dialysis treatment as per policy. Pt #20’s BP was 210/103 at 7:35 AM, 194/98 at 8:00 AM, and 205/121 at 9:01 AM during dialysis treatment; there was no documentation of the RN assessing and addressing Pt #20’s abnormal BP findings as per policy. Pt #20’s post-treatment BP was 226/102 and there was no documentation of the RN assessing and addressing Pt #20’s abnormal BP post treatment as per policy. -On 09/05/2025 at 8:39 PM, Pt #20 complained of a headache and the patient care technician gave Tylenol documenting “RN aware,” at 9:01 AM Pt #20’s BP was 204/81; there was no RN assessment documented addressing Pt #20’s headache and abnormal BP findings. -On 09/02/2025 Pt #20’s pre-Treatment BP was 205/88 and dialysis treatment started at 6:30 AM. The nursing pre-treatment assessment was not documented as completed until 8:09 AM (1 hours and 39 minutes later); there was no documentation of the RN addressing Pt #20’s BP being out of parameters before initiating dialysis treatment as per policy. Review of Pt #21’s Treatment Sheets revealed: -On 09/17/2025 Pt #21’s BP was 188/113 at 8:31 AM (systolic parameters <180)(diastolic parameters <100), 198/118 at 9:01 AM, 203/110 at 9:59 AM, and 185/105 at 10:02 AM and there was no documentation of the RN assessing and addressing Pt #21’s abnormal BP findings as per policy. Review of Pt #24’s Treatment Sheets revealed: -On 09/13/2025 Pt #24’s pre-treatment heart rate was 120 (normal 60-100), there was no documentation of the RN assessing and addressing Pt #24’s abnormal heart rate findings in the Pre RN assessment. Pt #24’s heart rate ranged from 101 to 119 throughout treatment and there were no RN assessments and interventions documented throughout the treatment addressing Pt #24’s abnormal heart rate as per policy. Review of Pt #26’s Treatment Sheets revealed: -On 07/25/2025 Pt #26’s BP was 86/70 at 8:00 AM and 80/45 at 9:03 AM (systolic parameters >90), there was no RN assessment addressing Pt #26’s abnormal BP findings as per policy. Fluid Assessment and Monitoring: Review of Pt #21’s Treatment Sheets revealed: -On 09/17/2025 Pt #21’s Target Weight (TW) ordered was 57.0 kg (kilograms); Pt #21’s post treatment weight was 60.4 kg (3.4 kg more than TW). There was no documentation of the RN recognizing and addressing Pt #21’s abnormal findings of the post weight being more than 1.0 kg above TW as per policy, including interventions and physician notification. -On 09/17/2025 Pt #21’s ordered Maximum Ultrafiltration rate (UFR) (fluid removal) was 13 Milliliter per kilogram per hour (13 ml/kg/hr); Pt #21’s UFR during treatment was 19.5 ml/kg/hour (more than maximum ordered UFR). There was no documentation of the RN recognizing and addressing Pt #21’s UFR exceeding the prescribed rate. -On 09/12/2025 Pt #21’s TW ordered was 57.0 kg; Pt #21’s post treatment weight was 59.1 kg (2.1 kg more than TW). There was no documentation of the RN recognizing and addressing Pt #21’s abnormal findings of the post weight being more than 1.0 kg above TW as per policy, including interventions and physician notification. -On 09/12/2025 Pt #21’s ordered UFR was 13 ml/kg/hr; Pt #21’s UFR during treatment was 19 ml/kg/hour. There was no documentation of the RN recognizing and addressing Pt #21’s UFR exceeding the prescribed rate. -On 09/09/2025 Pt #21’s TW ordered was 57.0 kg; Pt #21’s post treatment weight was 58.5 kg (1.5 kg more than TW). There was no documentation of the RN recognizing and addressing Pt #21’s abnormal findings of the post weight being more than 1.0 kg above TW as per policy, including interventions and physician notification. -On 09/09/2025 Pt #21’s ordered UFR was 13 ml/kg/hr; Pt #21’s UFR during treatment was 44.3 ml/kg/hour. There was no documentation of the RN recognizing and addressing Pt #21’s UFR exceeding the prescribed rate. Review of Pt #22’s Treatment Sheets revealed: -On 09/06/2025 Pt #22’s ordered UFR was 13 ml/kg/hr; Pt #22’s UFR during treatment was 41.1 ml/kg/hour. There was no documentation of the RN recognizing and addressing Pt #22’s UFR exceeding the prescribed rate. -On 09/02/2025 Pt #22’s pre treatment weight was 82.2 kg and the Total Volume Removed was documented at 2.2 kg. Pt #22’s post weight was 82.2 kg, same as pre weight indicating there was no fluid removed during treatment or the weight documented was inaccurate. Review of Pt #23’s Treatment Sheets revealed: -On 08/29/2025 Pt #23’s TW ordered was 68.0 kg; Pt #23’s post treatment weight was 71.0 kg (3.0 kg more than TW). There was no documentation of the RN recognizing and addressing Pt #23’s abnormal findings of the post weight being more than 1.0 kg above TW as per policy, including interventions and physician notification. -On 08/27/2025 Pt #23’s TW ordered was 68.0 kg; Pt #23’s post treatment weight was 77.1 kg (9.1 kg more than TW). There was no documentation of the RN recognizing and addressing Pt #23’s abnormal findings of the post weight being more than 1.0 kg above TW as per policy, including interventions and physician notification. Review of Pt #24’s Treatment Sheets revealed: -On 09/13/2025 Pt #24’s TW ordered was 69.5 kg; Pt #24’s post treatment weight was 70.9 kg (1.4 kg more than TW). There was no documentation of the RN recognizing and addressing Pt #24’s abnormal findings of the post weight being more than 1.0 kg above TW as per policy, including interventions and physician notification. -On 09/09/2025 Pt #24’s TW ordered was 69.5 kg; Pt #24’s post treatment weight was 71.0 kg (1.5 kg more than TW). There was no documentation of the RN recognizing and addressing Pt #24’s abnormal findings of the post weight being more than 1.0 kg above TW as per policy, including interventions and physician notification. During interview on 09/18/2025 beginning at 3:20 PM, while discussing medical record findings with Facility Administrator (FA) B, Group FA C, and Clinical Services Manager (CSM) D, FA C and CSM D confirmed the findings and stated that RNs should be assessing patients when their vital signs (BP and Heart rate) are out of parameters before, during, and after treatment as per policy. Per CSM D staff should be following Provider orders related to Maximum UFR during treatment and if UFR is greater than 13 ml/kg/hr, there should be a physician order and RN documentation addressing the UFR not being within the prescribed rate. CSM B stated that RNs should be documenting interventions and contacting the Provider when a patient is >1.0 kg over TW post treatment as per policy.”

“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 6 of 7 medical records reviewed (Patients (Pt) #6, 20, 21, 22, 23, 24); and failed to follow prescribed blood flow rates (BFR) for 3 of 7 medical records reviewed (Pt #21, 23, 24), 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.” 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: -“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.” Shortened Treatments: Review of Pt #6’s dialysis treatment sheet dated 09/16/2025 revealed that Pt #6’s ordered dialysis treatment time was 3 hours and 30 minutes. On 09/16/2025 Pt #6 dialyzed for 2 hours and 59 minutes (31 minutes short). There was no documentation of an Early Termination of Treatment Against Medical Advice form signed and nursing assessment/interventions addressing the shortened treatment as per policy, including notifying the physician. Review of Pt #20’s dialysis treatment sheets revealed: -On 09/03/2025 Pt #20’s ordered dialysis treatment time was 3 hours and 30 minutes. Pt #20 dialyzed for 2 hours and 57 minutes (33 minutes short). There was no documentation of an Early Termination of Treatment Against Medical Advice form signed and nursing assessment/interventions addressing the shortened treatment as per policy, including notifying the physician. -On 08/29/2025 Pt #20’s ordered dialysis treatment time was 3 hours and 30 minutes; Pt #20 dialyzed for 3 hours and 7 minutes (23 minutes short). There was no documentation of an Early Termination of Treatment Against Medical Advice form signed and nursing assessment/interventions addressing the shortened treatment as per policy. -On 08/25/2025 Pt #20’s ordered dialysis treatment time was 3 hours and 30 minutes; Pt #20 dialyzed for 3 hours and 3 minutes (27 minutes short). There was no documentation of an Early Termination of Treatment Against Medical Advice form signed and nursing assessment/interventions addressing the shortened treatment as per policy. Review of Pt #21’s dialysis treatment sheets revealed: -On 09/17/2025 Pt #21’s ordered dialysis treatment time was 3 hours. Pt #21 dialyzed for 2 hours and 42 minutes (18 minutes short). There was no documentation of an Early Termination of Treatment Against Medical Advice form signed and nursing assessment/interventions addressing the shortened treatment as per policy. -On 09/12/2025 Pt #21’s ordered dialysis treatment time was 3 hours. Pt #21 dialyzed for 2 hours and 53 minutes (7 minutes short). There was no documentation of an Early Termination of Treatment Against Medical Advice form signed and nursing assessment/interventions documented addressing the shortened treatment as per policy. Review of Pt #22’s dialysis treatment sheets revealed: -On 09/02/2025 Pt #22’s ordered dialysis treatment time was 3 hours and 30 minutes. Pt #22 dialyzed for 3 hours and 12 minutes (18 minutes short). There was no documentation of an Early Termination of Treatment Against Medical Advice form signed and nursing assessment/interventions addressing the shortened treatment as per policy. -On 09/06/2025 Pt #22’s ordered dialysis treatment time was 3 hours and 30 minutes. Pt #22 dialyzed for 1 hour and 12 minutes (2 hours and 18 minutes short). There was no documentation of an Early Termination of Treatment Against Medical Advice form signed and nursing assessment/interventions addressing the shortened treatment as per policy, including notifying the physician. Review of Pt #23’s dialysis treatment sheets revealed: -On 09/02/2025 Pt #23’s ordered dialysis treatment time was 3 hours. Pt #23 dialyzed for 2 hours and 49 minutes (11 minutes short). There was no documentation of an Early Termination of Treatment Against Medical Advice form signed and nursing assessment/interventions addressing the shortened treatment as per policy. -On 08/25/2025 Pt #23’s ordered dialysis treatment time was 3 hours. Pt #23 dialyzed for 2 hours (60 minutes short). There was no documentation of an Early Termination of Treatment Against Medical Advice form signed and nursing assessment/interventions addressing the shortened treatment as per policy, including notifying the physician. Review of Pt #24’s dialysis treatment sheets revealed: -On 09/13/2025 Pt #24’s ordered dialysis treatment time was 3 hours and 30 minutes. Pt #24 dialyzed for 2 hours and 44 minutes (46 minutes short). There was no documentation of an Early Termination of Treatment Against Medical Advice form signed and nursing assessment/interventions addressing the shortened treatment as per policy, including notifying the physician. -On 09/06/2025 Pt Pt #24’s ordered dialysis treatment time was 3 hours and 30 minutes. Pt #24 dialyzed for 2 hours and 18 minutes (72 minutes short). There was no documentation of an Early Termination of Treatment Against Medical Advice form signed and nursing assessment/interventions addressing the shortened treatment as per policy, including notifying the physician. During interview on 09/18/2025 beginning at 3:20 PM, while discussing medical record findings with Facility Administrator (FA) B, Group FA C, and Clinical Services Manager (CSM) D, FA C and CSM D confirmed the 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. FA B confirmed there was no documentation of Early Termination of Treatment Against Medical Advice forms signed for the above shortened treatments. Dialysis Flow Rates and Blood Flow Rates: A review of Pt #21’s Treatment Sheets revealed orders for a BFR of 450. Review of Pt #21’s Treatment Sheets revealed the following: -On 09/12/2025 the BFR was set at 400 during dialysis treatment; there was no nursing assessment/intervention documented addressing why Pt #21 was not dialyzing at the prescribed BFR. A review of Pt #23’s Treatment Sheets revealed orders for a BFR of 400. Review of Pt #23’s Treatment Sheets revealed the following: -On 08/29/2025 the BFR was set at 350 during dialysis treatment; there was no nursing assessment/intervention documented addressing why Pt #23 was not dialyzing at the prescribed BFR. A review of Pt #24’s Treatment Sheets revealed orders for a BFR of 400. Review of Pt #24’s Treatment Sheets revealed the following: -On 09/13/2025 the BFR was set at 250 during dialysis treatment; there was no nursing assessment/intervention documented to address Pt #24 not dialyzing at the prescribed BFR. During interview on 09/18/2025 beginning at 3:20 PM, while discussing medical record findings with Facility Administrator (FA) B, Group FA C, and Clinical Services Manager (CSM) D, FA C stated that patients should be dialyzing at their prescribed BFR and if this is not possible, staff should be documenting the interventions completed and the reason why the patient is not dialyzing at the prescribed flow rates.”

“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 prior to cannulation as per policy in 2 of 2 observations of treatment initiation using an Arteriovenous Fistula/Graft (AVF/G) (Pt # 4, 5); in a total sample of 4 patients observed with an AVF/G. Findings Include: Review of policy and procedure #1-04-01D titled, “AV Fistula or Graft Cannulation...” last revised October 2024 revealed the following: - “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.” On 09/16/2025 beginning at 11:30 AM, observed Patient Care Technician (PCT) I initiating Pt #4’s dialysis treatment using a AVF/G. PCT I performed skin antisepsis as per policy, then palpated the access sites immediately prior to cannulation allowing for potential contamination. On 09/16/2025 beginning at 11:49 AM, observed PCT M initiating Pt #5’s dialysis treatment using a AVF/G. PCT M performed skin antisepsis as per policy, then palpated the access sites immediately prior to cannulation allowing for potential contamination. During interview on 09/18/2025 beginning at 3:20 PM, while discussing observations with Facility Administrator (FA) B, Group FA C, and Clinical Services Manager (CSM) D, FA C stated that staff should not palpate the vascular access site after performing skin antisepsis as per policy.”

“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 1 medical records reviewed for new admissions less than 90 days (Patient (Pt) #22), 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 #22’s medical record revealed Pt #22’s first dialysis treatment was on 07/17/2025, as of the date of the review on 09/18/2025 (63 days), there was no documentation of staff completing the initial comprehensive POC. Per interview with Group Facility Administrator (FA) C on 09/18/2025 at 1:20 PM, FA C stated that staff has not completed Pt #22’s initial comprehensive POC; FA C stated that this should have been completed.”

“QAPI-MEASURE/ANALYZE/TRACK QUAL INDICATORS CFR(s): 494.110(a)(2) The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves. This Standard is not met as evidenced by: 29972 Based on record review and interview, the facility staff failed to ensure that quality data is tracked and analyzed to address issues with, Modality Choice, Mortality, Hospitalizations, and Hospital Readmissions < 30 days in 1 of 1 Quality Assessment and Performance Improvement (QAPI) programs reviewed (In-Center Hemodialysis), in a total of 1 QAPI programs reviewed. Findings include: Review of policy #5-15-06 titled, “Continuous Quality Improvement Program” last revised April 2024 revealed the following: -Written documentation and plans of action will be documented within the FHM (Facility Health Meeting) application known as Facility Health Record (FHR)...Copies of the QI (Quality Improvement) meeting minutes will be provided upon request to CMS (Centers for Medicare and Medicaid). - “The facility will measure, analyze, and track quality indicators or other aspects of performance. The program must include, but not limited to, the following:...Mortality-review of deaths, Hospitalizations...Other indicators as reflected in the Quality Improvement and Facility Management Meeting minutes form.” - “Continuous monitoring of the above indicators will be reflected in the meeting minutes. Any area identified as underperforming will be reviewed to identify root causes for underperformance, will have an action plan identified that will result in performance improvement...” Modality Choice: Review of the FHR dashboard, revealed in the June 2025, July 2025, and August 2025 FHM, the interdisciplinary team (IDT) did not document QI meeting minutes showing evidence of continuous tracking, monitoring, and analyzing Modality choice education/referrals. Mortality Review: Review of deaths revealed there were 2 deaths in May 2025 (Patient (Pt) #27 and #28) and 1 death in July 2025 (Pt #29). Review of the FHR Mortality dashboard, revealed in the June 2025 and August 2025 FHM, there was no documentation in the QI meeting minutes showing evidence of the interdisciplinary team (IDT) discussing and analyzing these deaths to identify any contributory factors or concerns in the mortality reviews. Hospitalizations and Readmissions < 30 days: Per interview with FA C and CSM D while discussing QAPI on 09/18/2025 beginning at 4:30 PM, CSM D stated that the Hospitalization Rate goal is 1.2 and the Readmission Rate goal is 25%. Review of the Hospitalizations Metrics data in the FHR dashboard revealed that the Hospitalization Rate for May 2025 data was 2.37, June 2025 1.62, and July 2025 2.23 (not meeting goal May, June, and July). The Readmission Rate for May 2025 was 53.3 and June 2025 was 40 (not meeting goal May and June). Review of the FHR Hospitalizations dashboard, revealed in the June 2025, July 2025, and August 2025 FHM, the interdisciplinary team (IDT) did not document QI meeting minutes showing evidence of trending and analyzing Hospitalizations and Readmissions to identify any patterns, commonalities, and root cause and develop an effective action plan based on findings. Per interview with FA C and CSM D while discussing QAPI on 09/18/2025 beginning at 4:30 PM, FA C stated that the staff do not discuss BP management and Modality education/referrals in FHR. FA C stated that there was no documentation of the above deaths in FHR and stated that the IDT should be discussing all death in the FHM. FA C confirmed that the facility did not meet goals for hospitalizations rates and readmissions rates and stated there should be meeting minutes discussing root cause analysis and action plans to address not meeting goals.”

“QAPI-INDICATOR-MEDICAL INJURIES/ERRORS CFR(s): 494.110(a)(2)(vi) The program must include, but not be limited to, the following: (vi) Medical injuries and medical errors identification. This Standard is not met as evidenced by: 29972 Based on record review and interview facility staff failed to recognize and address trends related to adverse events in 1 of 1 Quality Assessment and Performance Improvement (QAPI) programs reviewed (In-Center Hemodialysis), in a total of 1 QAPI programs reviewed. Findings include: Review of policy #5-15-06 titled, “Continuous Quality Improvement Program” last revised April 2024 revealed the following: -Written documentation and plans of action will be documented within the FHM (Facility Health Meeting) application known as Facility Health Record (FHR)...Copies of the QI (Quality Improvement) meeting minutes will be provided upon request to CMS (Centers for Medicare and Medicaid). -The facility will measure, analyze, and track quality indicators or other aspects of performance. The program must include, but not limited to...Review of trends of adverse patient occurrences...Other indicators as reflected in the FHR application. -Continuous monitoring of the above indicators will be reflected in the meeting minutes. Review of the Adverse Event Summary Report revealed: -May 2025: Patient Infection -June 2025: Delay in loop/bicarbonate disinfection, 2 patient falls, and treatment error -July 2025: Cardiac arrest, equipment malfunction, treatment delay due to staff arriving late Review of the FHR dashboard, revealed in the June 2025, July 2025, and August 2025 FHM, the interdisciplinary team (IDT) did not document QI meeting minutes showing evidence of the IDT analyzing and discussing adverse events. Per interview with FA C and CSM D while discussing QAPI on 09/18/2025 beginning at 4:30 PM, FA C stated that there is no documentation showing evidence of the IDT discussing and analyzing adverse events in FHR.”

“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 facility staff failed to develop goals, analyze trends, and develop action plans to address Hepatitis B vaccinations and susceptible patients in 1 of 1 Quality Assessment and Performance Improvement (QAPI) programs reviewed (In-Center Hemodialysis), in a total sample of 1 QAPI programs reviewed; failed to ensure the Infection Log is complete and accurate in 3 of 6 months reviewed (April 2025, May 2025, August 2025), in a total sample of 6 months of Infection Logs reviewed; and failed to track and trend infection control practices of staff in 3 of 6 months of Infection Control staff practice audits reviewed (May 2025, July 2025, August 2025). Findings include: Review of policy #5-15-06 titled, “Continuous Quality Improvement Program” last revised April 2024 revealed the following: - “The facility will measure, analyze, and track quality indicators or other aspects of performance. The program must include, but not limited to, the following:...Infection Control, including...Vaccination rates for Hepatitis B...” - “Continuous monitoring of the above indicators will be reflected in the meeting minutes. Any area identified as underperforming will be reviewed to identify root causes for underperformance, will have an action plan identified that will result in performance improvement...” Hepatitis B Vaccinations: Review of the Metric trends for Infection Prevention & Management in the FHR dashboard revealed the “Hepatitis Vaccinated, Full Series %” was 41% in May 2025, 30% in June 2025, and 40% in July 2025 and “N/A (not applicable) was documented under “Goal.” Review of the FHR Infection Prevention & Management dashboard, revealed in the June 2025, July 2025, and August 2025 FHM, the interdisciplinary team (IDT) did not document QI meeting minutes showing evidence of continuous monitoring, tracking, and analyzing quality indicators for Hepatitis B Vaccinations and susceptible patients. Per interview with FA C and CSM D while discussing QAPI on 09/18/2025 beginning at 4:30 PM, FA C stated that there is no established goal for Hepatitis B Vaccinations. FA C stated that there was no documentation in FHR that the IDT discussed and analyzed Hepatitis B Vaccinations and susceptible patients in FHM. Infection Control Log: Review of hospitalizations log revealed: -Patient (Pt) #19 was admitted to the hospital with a blood stream infection on 04/01/2025 and a wound infection on 05/09/2025. -Pt #16 was admitted to the hospital for a related infection on 08/01/2025. Review of the Infection Control Logs from April 2025, May 2025, and August 2025 revealed Pt #16 and #19 are not listed on the Infection Control logs. Review of the Infection Prevention & Management FHR dashboard revealed the “Infection Tracking Log Reviewed” was not reviewed for April 2025, June 2025, and July 2025. Per interview with CSM E on 09/17/2025 at 3:30 PM, CSM E stated that Pt #19 was admitted to the hospital with a blood stream infection resulting in a leg amputation and a subsequent infection of the leg amputation. Per CSM E Pt #16 was admitted with Shingles. CSM E stated that both patient’s infections should have been documented on the Infection Log but were not. Per interview with FA C and CSM D while discussing QAPI on 09/18/2025 beginning at 4:30 PM, FA C stated that Infection Tracking Logs should be reviewed monthly in FHM. Infection Control Audits: Review of Infection Control staff practice audits from 03/2025 through 08/2025 revealed there were no audits completed in May 2025, July 2025, and August 2025 to track infection control staff issues in FHR. Per interview with CSM D on 09/17/2025 beginning at 3:38 PM, CSM D stated that there were no Infection Control Audits completed for May 2025, July 2025, and August 2025. Per CSM D staff practice audits should be completed monthly.”

“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 observation, record review, and interview the facility failed to ensure emergency medications and supplies are secured from unauthorized access in 1 of 1 emergency crash carts observed (In-center Hemodialysis), in a total of 1 crash cart reviewed; and failed to ensure nursing staff safely administer medications as per policy in 1 of 2 medication administration observations (Patient (Pt) #17), in a total sample of 2 medication administration observations. Findings Include: Review of policy and procedure #1-06-01 titled, “Medication Policy” last revised October 2023 revealed the following: -“Non-refrigerated medications are to be stored in cabinet(s) and locked at the close of each business day or if not under the supervision by the licensed teammate...” Review of policy and procedure #1-02-08 titled, “Emergency Equipment Checks” last revised October 2024 revealed: -The part of the cart containing medications and other supplies will be sealed with a break away lock...” Review of policy and procedure #12-08-12B titled, Administration of Intravenous (IV) Iron Sucrose (Venofer) Through the Dialysis Delivery System” last revised October 2023 revealed: - “IV Iron Sucrose should be administered...via slow IV push...over 2 to 5 minutes...” Crash Cart Security: On 09/16/2025 beginning at 2:15 PM and 09/17/2025 beginning at 8:45 AM observed that the crash cart on the treatment floor was not secured with a break away lock. Per observations, the crash cart contained Epinephrine (Adrenaline). Per interview with Registered Nurse (RN) G on 09/16/2025 beginning at 2:30 PM, RN G stated that housekeeping staff clean the facility and treatment area in the evening after staff leave. Per RN G, the medication in the crash cart is not locked up at the end of the day and the crash cart remains in the treatment area. RN G stated that a break away lock should be on the crash cart at all times. RN G stated that medication should be stored in a locked cabinet at the end of the day. Medication Administration: On 09/16/2025 beginning at 1:00 PM, observed Registered Nurse (RN) G administering intravenous (IV) Venofer to Pt #17 during dialysis treatment via the dialysis lines. RN G administered the Venofer over 28 seconds, not over 2 to 5 minutes as per policy. During interview on 09/18/2025 beginning at 3:20 PM, while discussing observations with Facility Administrator (FA) B, Group FA C, and Clinical Services Manager (CSM) D, CSM D stated that Venofer should be administered slowly over 2 to 5 minutes.”

“MR-COMPLETE RECORDS PROMPTLY CFR(s): 494.170(b)(1) (1) Current medical records and those of discharged patients must be completed promptly. This Standard is not met as evidenced by: 29972 Based on record review and interview the facility staff failed to ensure that nursing assessments and medications administered are documented promptly and reflect the actual time of the assessment and/or medication administration in 6 of 7 medical records reviewed (Patient (Pt) #20, 21, 22, 23, 24, 26); and failed to ensure vital signs are documented at least every 30 minutes as per policy in 3 of 7 medical records reviewed (Pt #21, 22, 24), 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 revised April 2024 revealed: - “Vital signs and treatment monitoring...are completed at least every thirty minutes...At a minimum, obtain and document the following:...Blood pressure...Heart or pulse rate...Blood and dialysate flows, arterial and venous pressures...Fluid removal and/or replacement...Vascular access visible...” - “All findings, interventions, and patient response will be documented in the patient’s medical record.” - “The licensed nurse will round on those patients without reported abnormal findings and complete the nursing assessment within 1 hour of dialysis treatment initiation or sooner (pre treatment)...” Nursing Assessments: Review of Pt #20’s Treatment sheets revealed: -On 09/08/2025 Pt #20’s dialysis treatment started at 6:20 AM and the Pre-Treatment Nurse Assessment was not completed until 9:30 AM, 3 hours and 10 minutes after treatment started (should be within 1 hour as per policy). -On 09/03/2025 Pt #20’s dialysis treatment started at 6:30 AM and the Pre-Treatment Nurse Assessment was not completed until 8:09 AM, 1 hour and 39 minutes after treatment started. -On 09/02/2025 Pt #20’s dialysis treatment ended at 10:03 AM and the Post-Treatment Nurse Assessment was not documented as completed until 5:38 PM, 7 hour and 35 minutes after treatment ended. Review of Pt #21’s Treatment sheets revealed: -On 09/17/2025 Pt #21’s dialysis treatment ended at 10:04 AM and the Post-Treatment Nurse Assessment was not documented as completed until 1:30 PM, 3 hour and 26 minutes after treatment ended. -On 09/12/2025 Pt #21’s dialysis treatment ended at 10:28 AM and the Post-Treatment Nurse Assessment was not documented as completed until 1:38 PM, 3 hour and 10 minutes after treatment ended. Review of Pt #22’s Treatment sheets revealed: -On 09/06/2025 Pt #22’s dialysis treatment started at 12:18 PM and the Pre-Treatment Nurse Assessment was not documented as completed until 4:49 PM, 4 hours and 31 minutes after treatment started (should be within 1 hour as per policy). Pt #22’s dialysis treatment ended at 1:30 PM and the Post-Treatment Nurse Assessment was not documented as completed until 4:50 PM, 3 hours and 20 minutes after treatment ended. -On 09/04/2025 Pt #22’s dialysis treatment started at 12:28 PM and the Pre-Treatment Nurse Assessment was not documented as completed until 2:38 PM, 2 hours and 10 minutes after treatment started. -On 09/02/2025 Pt #22’s dialysis treatment started at 12:25 PM and the Pre-Treatment Nurse Assessment was not documented as completed until 5:15 PM, 4 hours and 45 minutes after treatment started (should be within 1 hour as per policy). Pt #22’s dialysis treatment ended at 3:37 PM and the Post-Treatment Nurse Assessment was not documented as completed until 5:17 PM, 4 hours and 43 minutes after treatment ended. Review of Pt #23’s Treatment sheets revealed: -On 08/29/2025 Pt #23’s dialysis treatment started at 12:04 PM and the Pre-Treatment Nurse Assessment was not documented as completed until 08/30/2025 (the next day) at 7:53 AM, 19 hours and 49 minutes after treatment ended (should be within 1 hour as per policy). Pt #23’s dialysis treatment ended at 2:53 PM and the Post-Treatment Nurse Assessment was not documented as completed until 08/30/2025 (the next day) at 7:55 AM, 17 hours and 2 minutes after treatment ended 4:50 PM. -On 08/27/2025 Pt #23’s dialysis treatment started at 11:57 AM and the Pre-Treatment Nurse Assessment was not documented as completed until 10:57 PM, 11 hours after treatment ended. Review of Pt #24’s Treatment sheets revealed: -On 09/09/2025 Pt #24’s dialysis treatment started at 11:30 AM and the Pre-Treatment Nurse Assessment was not documented as completed until 09/10/2025 (the next day) at 8:11 AM, 20 hours and 41 minutes after treatment ended (should be within 1 hour as per policy). Pt #24’s dialysis treatment ended at 3:30 PM and the Post-Treatment Nurse Assessment was not documented as completed until 09/10/2025 (the next day) at 8:13 AM, 20 hours and 43 minutes after treatment ended. Review of Pt #26’s Treatment Sheets revealed: -On 07/25/2025 Pt #26’s BP was 86/70 at 8:00 AM and 80/45 at 9:03 AM (systolic parameters >90); Pt #26 treatment ended at 9:58 AM. The nurse documented giving Midodrine (increase BP) at 12:54 PM, after Pt #26 was discharged, not reflecting the actual time of medication administration. The nurse documented “patient feels ok,” at 2:20 PM, after the patient was discharged, not reflecting the actual time of the nursing assessment. Vital signs: Review of Pt #21’s Treatment sheets revealed on 09/09/2025 vital signs (including Blood Pressure and Heart Rate) were documented at 9:31 AM, then not again until 10:53 AM, 1 hour and 22 minutes later (should be at least every 30 minutes as per policy). Review of Pt #22’s Treatment sheets revealed on 09/02/2025 vital signs (including Blood Pressure and Heart Rate) were documented at 12:25 PM, then not again until 1:28 PM, 1 hour and 3 minutes later (should be at least every 30 minutes as per policy). Review of Pt #24’s Treatment sheets revealed on 09/13/2025 vital signs (including Blood Pressure and Heart Rate) were documented at 11:31 AM, then not again until 1:45 PM, 2 hours and 14 minutes later (should be at least every 30 minutes as per policy). During interview on 09/18/2025 beginning at 3:20 PM, while discussing medical record findings with Facility Administrator (FA) B, Group FA C, and Clinical Services Manager (CSM) D, FA C and CSM D confirmed the findings and stated that the pre treatment nursing assessments should be completed within the first hour of dialysis treatment and staff should document the actual time of the pre and post nursing assessment. CSM D stated that vital signs should be monitored and documented at least every 30 minutes.”

“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 evaluations address Fluid management needs in 1 of 10 patient records reviewed (Patients (Pt) #1); failed to ensure that the Registered Nurse (RN) performs an assessment when blood pressure (BP) and/or heart rate (HR) are out of range as per policy in 8 of 10 patient records reviewed (Pt #1, 2, 3, 4, 6, 7, 8, 9); and failed to ensure patients are monitored during dialysis treatment as per policy in 1 of 10 patient records reviewed (Pt # 3), in a total sample of 10 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: - “If abnormal finding is reported to the licensed nurse pre-treatment, the nurse will assess the patient prior to the initiation of dialysis.” -Vital signs and treatment monitoring...Non-nocturnal treatments are completed at least every 30 minutes. - “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.” - “If an abnormal finding 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.” - “All findings, interventions and patient response will be documented in the patient’s medical record.” - Abnormal findings include: Fluid Status...Post-treatment: If patient is above or below 1 kilogram from the target weight (TW);” - Abnormal Findings include: Blood Pressure-Intradialytic (during treatment)...”Systolic (blood pressure) greater than 180...or less than 90...Diastolic (blood pressure) greater than or equal to 100 or less than 50...” - Abnormal Findings include: Blood Pressure Post Treatment... “Standing systolic BP greater than 140...Standing diastolic BP greater than 90...If patient is not able to stand, document the reason...” -Abnormal findings include: Heart or pulse rate of “Less than 60 beats per minute or greater that 100 beats per minute...” Fluid Assessment and Evaluations: Review of Pt #1’s treatment sheets revealed the following: -On 12/26/2023: Pt #1’s TW (target weight) was 37 kg (kilograms) and the post-treatment weight was 39.5 kg; 2.5 kg above the TW. There was no documentation of nursing interventions including notifying the physician, to address Pt #1’s post weight being >1 kg above the TW as per policy. BP/HR Nursing Assessments and Monitoring: Review of Pt #1’s treatment sheets revealed the following: -On 01/04/2023: Pt #1’s BP dropped from 125/73 at 3:31 PM to 93/60 at 4:01 PM. At 4:01 PM, Patient Care Technician (PCT) G documented “Turned UF (ultrafiltration--fluid removal) off”, the UF continued to stay off until approximately 6:01 PM (2 hours); there was no documentation of a RN assessment and intervention to address Pt #1’s low BP and the UF being turned off. At 5:31 PM, PCT G documented “C/O (complains of) cramping”; there was no documentation of a nursing assessment recognizing, addressing, and evaluating Pt #1’s complaint of cramping. Review of Pt #2’s treatment sheets revealed the following: -On 04/20/2023 Pt #2’s BP was 185/111 at 12:32 PM, 182/106 at 1:32 PM, 187/100 at 2:03 PM, and 194/111 at 2:32 PM; there was no documentation of RN assessments and interventions to address Pt #2’s high BPs as per policy (abnormal findings--systolic >180, diastolic >100). Review of Pt #2’s treatment sheet revealed there was no documentation of a Post-Treatment standing BP being completed to ensure Pt #2 was safe to ambulate (to move by walking) at discharge. Review of Pt #2’s RN Post-Treatment Data Collection & Assessment documented at 3:15 PM, revealed Pt #2 ambulates with a walker. -On 04/25/2023 Pt #2’s Pre-Treatment Data Collection & Assessment documented at 11:34 AM revealed that Pt #2 ambulates independently with a walker. Review of Pt #2’s treatment sheet revealed there was no documentation of a standing BP being completed in the Pre-Treatment and Post-Treatment vital signs (VS). Review of Pt #3’s treatment sheets revealed the following: -On 04/01/2023 Pt #3’s VS’s including BP and heart rate were taken at 12:04 PM and then again at 1:32 PM (1 hour and 28 minutes later) this was not every 30 minutes as per policy. Pt #3’s VSs were taken at 2:02 PM and then again at 2:58 PM (56 minutes later). Pt #3’s BP was 159/123 (diastolic >100) at 2:58 PM and there was no documentation of a RN assessment and interventions to address Pt #3’s high BP. Pt #3’s Post Treatment nursing assessment documented at 3:29 PM did not address Pt #3’s high BP. Review of Pt #5’s treatment sheets revealed the following: -On 05/27/2023 Pt #5’s Pre-Treatment sitting BP was 177/131; Pt #5’s ordered BP parameters were <180/90 “if out of range notify the RN.” Pt #5’s dialysis treatment started at 6:54 AM, the RN did not complete the Pre-Treatment assessment until 7:22 AM; 28 minutes after treatment started. Per policy the RN should assess prior to treatment initiation when a Pts VS are out of range. -On 05/27/2023 Pt #5’s BP was 191/135 at 7:01 AM, 189/133 at 7:31 AM, 200/130 at 8:00 AM, 184/129 at 8:31 AM, 192/130 at 9:01 AM, 178/127 at 9:31 AM, 153/135 at 10:01 AM, and 186/128 at 10:07 AM. Review of Pt #5’s treatment sheet revealed there was no documentation of RN interventions to address Pt #5’s consistently elevated BP, including notifying the physician. Per review of RN Progress Note at 2:22 PM, “(Pt #5) came into clinic not feeling well and stated that she had a headache and was given Tylenol...” Review of the RN Pre-Treatment assessment documented at 7:22 AM revealed no documentation that Pt #5 complained of a headache. Review of the treatment sheets for the Medications Administered revealed there was no documentation of Tylenol being administered. Review of Pt #5’s treatment sheet revealed there was no documentation of a nurse completing a Post-Treatment RN assessment. During interviews with Facility Administrator (FA) B and Clinical Services Manager (CSM) C on 05/30/2024 beginning at 1:40 PM, while discussing medical record findings, CSM C stated that the nurse should have contacted the physician to discuss Pt #5’s consistently high BP and documented this contact in the medical record. Per FA B, the nurse should have documented Pt #5’s symptoms of a headache in the Pre-Treatment nursing assessment and documented in the Medication Administration record that Tylenol was given. Review of Pt #6’s treatment sheets revealed the following: -On 10/13/2023 Pt #6’s Pre-Treatment nursing assessment at 11:24 AM revealed, “Ambulates-No assistance Needed.” Review of Pt #6’s Pre-Treatment Vitals revealed there was no documentation of Pt #6’s standing BP. Pt #6’s BP was 76/42 at 11:01 AM, 62/49 at 11:03 AM, 82/50 at 11:12 AM, and 78/52 at 11:21 AM (abnormal <90 systolic; < 50 diastolic). Review of the treatment sheet revealed the UFR (ultrafiltration rate--fluid removal) was “0” from 11:03 AM to approximately 11:21 AM; there was no documentation of RN assessments and interventions to address Pt #6’s low BPs. Review of Pt #7’s treatment sheets revealed the following: -On 05/24/2023 Pt #7’s BP was 63/47 at 1:33 PM and 89/71 at 1:44 PM (abnormal <90 systolic; < 50 diastolic); there was no documentation of RN assessment, interventions, and evaluation addressing Pt #7’s low BPs. Review of Pt #8’s treatment sheets revealed the following: -On 07/21/2023 Pt #8’s BP was 86/54 at 12:31 PM and 87/47 at 1:31 PM (abnormal <90 systolic; < 50 diastolic); there was no documentation of RN assessments and interventions to address Pt #8’s low BPs. -On 07/18/2023 Pt #8’s BP was 86/48 at 8:01 AM , 91/46 at 8:02 AM, and 91/45 at 9:00 AM; there was no documentation of RN assessments and interventions to address Pt #8’s low BPs. Review of Pt #9’s treatment sheets revealed the following: -On 05/18/2023 Pt #9’s Pre-Treatment sitting BP was 87/59 and HR 106; Pt #9’s ordered BP parameters were > 90/40 (abnormal HR >100). Pt #9’s dialysis treatment started at 5:47 AM, the RN did not complete the Pre-Treatment assessment until 6:20 AM; 33 minutes after treatment started. Per policy the RN should assess the Pt prior to treatment initiation when VS are out of range. -On 05/18/2023 at 6:01 AM, Pt #9’s BP was 91/73 heart rate (HR) 143, per documentation by the PCT “Pt is okay, feels weak and short of breath nurse alerted.” Pt #9’s BP was 75/48 and HR 116 at 6:31 AM, BP 74/61 and HR 130 at 7:01 AM, and BP 73/34 at 7:39 AM, per documentation by the PCT, “Nurse Aware of Pt symptoms.” At 7:21 AM documentation revealed “Turned UF off due to low BP”; there was no documentation of RN assessments, interventions, and evaluations addressing Pt #9’s low BPs and elevated HR, including notifying the physician. Per review of Pt #9’s treatment sheet, there was no documentation of a RN Post-Treatment assessment. During interviews with Facility Administrator (FA) B and Clinical Services Manager (CSM) C on 05/30/2024 beginning at 1:40 PM, while discussing medical record findings, FA B and CSM C stated that the nurse should be assessing patients prior to the start of dialysis treatment when there are abnormal findings pre-treatment. FA B stated that the nurse should complete an assessment and interventions when VS are out of range as per policy. Per FA B, staff should notify the Provider when the patient is more than 1.0 kg above dry weight post treatment. FA B stated that a standing BP should be taken before and after treatment on all patient unless they are unable to ambulate, staff should document the reasons why a standing BP was not done.”

“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 4 of 10 medical records reviewed (Patients (Pt) #1, 2, 3, 7); and failed to follow prescribed blood flow rates (BFR) and/or dialysate flow rates (DFR) for 2 of 10 medical records reviewed (Pt #2, 8), in a total sample of 10 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.” 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: -“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.” Shortened Treatments: Review of Pt #1’s dialysis treatment sheet dated 12/26/2022 revealed Pt #1’s ordered dialysis treatment time was 3 hours. Per review of the treatment sheet, Pt #1 dialyzed for 1 hour and 49 minutes (1 hour and 11 minutes short). There was no documentation of an Early Termination of Treatment Against Medical Advice form signed and nursing interventions documented as per policy, including notifying the physician. Review of Pt #2’s dialysis treatment sheet dated 04/25/2023 revealed Pt #2’s ordered dialysis treatment time was 3 hours. Per review of the treatment sheet, Pt #2 dialyzed for 2 hour and 51 minutes (39 minutes short). There was no documentation of an Early Termination of Treatment Against Medical Advice form signed and nursing interventions documented as per policy, including notifying the physician. Review of Pt #3’s dialysis treatment sheet dated 01/11/2023 revealed Pt #3’s ordered dialysis treatment time was 3 hours and 15 minutes. Per review of the treatment sheet, Pt #3 dialyzed for 1 hour and 59 minutes (1 hour and 16 minutes short). There was no documentation of an Early Termination of Treatment Against Medical Advice form signed and nursing interventions documented as per policy, including notifying the physician. Review of Pt #7’s dialysis treatment sheet dated 05/24/2023 revealed Pt #7’s ordered dialysis treatment time was 3 hours. Per review of the treatment sheet, Pt #7 dialyzed for 2 hour and 7 minutes (53 minutes short). There was no documentation of an Early Termination of Treatment Against Medical Advice form signed and nursing interventions documented as per policy, including notifying the physician. Dialysis Flow Rates and Blood Flow Rates: A review of Pt #2’s Treatment Sheets revealed orders for a DFR of 800. Review of Pt #2’s Treatment Sheets revealed the following: -On 04/25/2023 the DFR was set at 500 the entire dialysis treatment; there was no documentation addressing why Pt #2 was not dialyzing at the prescribed DFR. A review of Pt #8’s Treatment Sheets revealed orders for a BFR of 450. Review of Pt #8’s Treatment Sheets revealed the following: -On 07/18/2023 the BFR was set at 325 the entire dialysis treatment; there was no documentation addressing why Pt #8 was not dialyzing at the prescribed BFR and nursing interventions. During interviews with Facility Administrator (FA) B and Clinical Services Manager (CSM) C on 05/30/2024 beginning at 1:40 PM, while discussing medical record findings, FA B and CSM C confirmed findings and stated staff should be documenting in the medical record the reason patient’s time was shortened, nursing interventions addressing shortened treatment, and notifying the physician. FA B confirmed there was no documentation of Early Termination of Treatment Against Medical Advice forms signed for the above shortened treatments. FA B stated that patients should be dialyzing at their prescribed BFR and DFR and if this is not possible, staff should be documenting the interventions completed and the reason why the patient is not dialyzing at the prescribed flow rates.”