Davita Dialysis Allouez

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 22198 Based on observation, interviews, review of the Emergency Crash Cart log, and policy review, the facility failed to ensure that for one of one uniquely numbered tag used to verify that the emergency crash cart remained intact with emergency supplies and ready to be used in an emergency was accurate. The failure to ensure that the tag was accurate had the potential for crash cart supplies to be missing and unavailable during an emergency situation. Findings include: During an observation on 07/22/25 at 8:03 AM Facility Administrator 1 and Group Facility Administrator (GFA) 6 confirmed the Emergency Crash Cart’s unique numbered tag and identified the tag #6073120. Review of the Emergency Crash Cart log last completed 07/14/25 revealed the unique numbered tag as “6974408” based on audits conducted weekly since 05/14/25. During an interview on 07/22/25 at 8:03 AM Facility Administrator 1 and GFA 6 confirmed the tags do not match and they should. Facility Administrator 1 stated that the Administrative Assistant (14) had gone into the Emergency Crash Cart on 07/21/25 and forgot to notify the RN so the Emergency Crash Cart could be evaluated, and the log could be updated. Facility Administrator 1 confirmed that the Emergency Crash Cart is audited once a week to ensure the contents are accurate and that nothing has expired. Review of the facility’s policy titled “Emergency Equipment Checks” dated 10/24 revealed, “Verify that emergency equipment is maintained in a ready-to-use condition. ... Daily: Break away lock is intact. ...Weekly: Emergency cart (crash cart) is clean, operational and supplies/medications have not expired.””

“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: 22198 Based on observation, interviews, and policy review, the facility failed to ensure one of three staff (Certified Clinical Hemodialysis Technicians (CCHT) 11) 1. changed gloves and performed hand hygiene between gloves changes and tasks and 2. wore gloves while handling dialysis garbage and waste. The failure to change gloves and perform hand hygiene has a high probability of cross contamination, and the transfer of bacteria or other microorganisms unintentionally. Findings include: 1. During an observation on 07/21/25 at 9:33 AM of Central Venous Catheter Care (CVC-thin, flexible tube inserted into a large vein in the chest to provide access to the bloodstream for dialysis treatment), CCHT11 was observed removing the old CVC dressing for patient (P) 8. After the old dressing was removed CCHT11 failed to remove the gloves or perform hand hygiene and continued care by touching clean supplies and performed the antiseptic cleaning of the CVC insertion site. After performing the antiseptic cleaning, CCHT11 removed the gloves and failed to perform hand hygiene and donned new gloves to continue with hooking up the blood lines to initiate the dialysis treatment for P8. During an interview on 07/21/25 at 9:33 AM CCHT 11 stated “I never change my gloves after removing the old dressing.” CCHT11 confirmed she did not perform hand hygiene between glove changes and stated hand hygiene should be performed between each glove change. During an interview on 07/22/25 at 12:00 PM during the Quality Assessment and Performance Improvement (QAPI) review and interview Facility Administrator 1 confirmed that during their infection control (IC) audits the facility had identified failures in hand hygiene and wearing and/or changing gloves between tasks. Facility Administrator 1 confirmed this is something the facility is continuously working on. Also present during the review and interview were Manager of Clinical Services (MCS) 4 and Group Facility Administrator (GFA) 6 Review of the facility’s policy titled “Central Venous Catheter (CVC) with Clearguard HD [hemodialysis] antimicrobial End Caps Procedure” dated 04/25 revealed, “Remove old dressing and discard. ... Remove gloves and discard. Perform hand hygiene per procedure and re-glove. Holding catheter with the nondominant hand and using aseptic technique, clean exit site with 2% Chlorhexidine Gluconate 70% Isopropyl Alcohol swab for a minimum of 30 seconds, apply to the CVC exit site in a “back and forth” pattern, using gentle friction progressing from the insertion site ... Remove gloves and discard, perform hand hygiene per procedure and re-glove.” 2. During an observation on 07/21/25 at 10:22 AM the garbage bag in the large waste receptacle not in the dialysis station area had fallen down into the receptacle, CCHT11 was observed grabbing down into the large common garbage receptacle with potentially hazardous waste using his/her bare hands to pick out the displaces partially filled garbage bags and readjusting the tied knot to stay up on the lip of the garbage receptacle. Without performing hand hygiene, CCHT11 walked over between station Stations 9 and 10 and took a box of gloves of the computer station and then walked into the nurses’ station and placed that box of gloves on a clean supply counter, before performing hand hygiene. During an interview on 07/21/25 at 10:22 AM CCHT11 confirmed he/she should have worn gloves while handling the common dialysis garbage bin bag with potentially hazardous waste. During an interview on 07/22/25 at 8:16 AM a review of the findings of 07/21/25 were discussed with Facility Administrator 1, who stated the facility does conduct monthly IC audits and had identified opportunities where staff were not wearing the appropriate PPE (personal protective equipment) during dialysis initiation/discontinuation and during station cleaning, but was not aware of staff not wearing gloves while handling potentially infectious waste. The Facility Administrator stated we are continuously working on hand hygiene and PPE. Review of the facility’s policy titled “Infection Control For Dialysis Facilities” dated 04/23 revealed, “PURPOSE: To minimize the spread of infections or bloodborne pathogens in the dialysis facility environment. ... All teammates, Physicians and Non-physician (NPP) will perform hand hygiene a. upon entering and exiting the patient treatment area, b. prior to gloving and immediately after removal of gloves, c. after contamination with blood or other infectious material, ... g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse. ... Appropriate PPE will be worn whenever there is the potential for contact with body fluids, hazardous chemicals, contaminated equipment and environmental surfaces, for example, patient care areas.””

“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: 22198 Based on observations, interviews, and policy review, the facility failed to ensure that dialysis supplies that could not be disposed of or disinfected were dedicated to patients for three of three survey days for two of three Certified Hemodialysis Technician (Certified Hemodialysis Technician (CCHT) 11 and 13). The failure to dedicate supplies that cannot be disinfected or disposed of has the potential for spreading bacteria and other microorganisms during cross contamination. Findings include: 1. During an observation of CCHT11 on 07/21/25 at 9:33 AM, after completing the dialysis initiation at Station 5, picked up a box of “small” gloves with paper taped to the side and moved it to Station 3. After checking on the patient at Station 3 CCHT11 picked up the same box of gloves and moved it to Station 5. After finishing at Station 5, picked up that same box of gloves and walked down to Station 10 and placed the box of gloves into Station 10. During an observation on 07/21/25 at 10:22 AM, CCHT11 was observed walking to station Stations 9 and 10 and took a box of gloves of the dialysis computer on wheels and then walked into the nurse’s station and placed that box of gloves on a clean supply counter, before performing hand hygiene. During an interview on 07/21/25 at 10:22 AM, CCHT 11 confirmed he/she was not aware he/she could not take his/her personal box of “small” gloves from Station to Station. CCHT 11 stated “I tape my daily assignment sheet to that box of gloves, so I take it from Station to Station, so I know my daily assignments. CCHT11 stated no one told him/her that he/she could not tape the assignment sheet to the box or that he/she could not move the box of gloves from Station to Station. During an interview on 07/21/25 at 10:30 AM the Group Facility Administrator (GFA) 6 confirmed any item in taken into the dialysis station needs to be dedicated, disposed of, or disinfected but the box of gloves should not be moved from Station to Station. 2. During an observation 07/21/25 at 11:04 AM, 13 brought a can of “CryoDOSE TA” (Topical Anesthetic Spray) sitting on the clean supply countertop shelf into dialysis Station 6 and used the CryoDOSE TA spray on the skin prior to inserting needles into Patient (P) 9. After the task was completed, CCHT13 placed the “CryoDOSE TA” on the back of the dialysis machine. Then placed the CryoDOSE TA back on the clean supply shelf without disinfecting the CryoDose label/can. During an interview on 07/22/25 at 8:16 AM with Facility Administrator 1 and the Group Facility Administrator (GFA) 6, when asked about supplies taken into a dialysis station, stated they should be disinfected, disposed of, or dedicated. Facility Administrator 1 and GFA 6 were asked specifically about the CryoDOSE TA spray cans and confirmed that the spray cans can not be disinfected without damaging the MFR label and should be dedicated to the patient. The Facility Administrator 1 stated the staff should be putting a patient label on it and sending it with the patient and having them bring the spray back for each treatment. Observation on the dialysis treatment floor 07/22/25 at 8:15 AM three cans of CryoDOSE TA were found on the shelves of the clean supply area had dated with the date opened verifying the spray cans had been used. During an interview on 07/22/25 at 8:15 AM, the Facility Administrator 1 and GFA 6 confirmed the cans of CryoDOSE TA found on the clean supply counters had been opened, stating staff know to date products when they are opened. During an observation on 07/23/25 at 8:55 AM Station 4 was set up and ready for a patient. There was a can of CryoDOSE TA observed on the countertop behind the dialysis chair, without a date or a patient label, and appeared to have a red smear on the manufacturer’s label. During an interview on 07/23/25 at 8:55 AM Registered Nurse Manager (RNM) 9 picked up the can to exam it and confirmed that there was no patient label on the can. RNM 9 rotated the can of CryoDOSE TA and stated, “there is blood on the label.” RNM 9 confirmed the cans of CryoDOSE TA” Topical Anesthetic Spray should have a patient label and be dedicated to the patient. Review of the facility’s policy titled, “Infection Control For Dialysis Facilities” dated 04/23 revealed, “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.””

“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: 22198 Based on observations, interviews, and policy review and the manufacturers (MFR) directions for use (DFU), the facility failed to ensure that 1. multi-dose vials of medication were labeled after opening according to the facility’s policy to ensure the multi-dose vials were discarded prior to an antimicrobial preservative no longer effect on viruses and would not protect against contamination, and 2. Failed to remove expired medication, vaccinations and supplements from immediate use for two of two dialysis services areas (In-center hemodialysis and Home Training Peritoneal Dialysis (PD). Failure to remove unlabeled and expired medications, vaccinations and supplements from their immediate used refrigerators puts all 63 current dialysis patients at risk of receiving expired and non-effective medications (Twenty-nine (29) incenter and 34 Home program Peritoneal Dialysis. Findings include: 1. During an observation on 07/22/25 at 8:43 AM in the incenter dialysis unit a bag of “IDPN” (Intradialytic Parenteral Nutrition) was found in the medication refrigerator 1 with an expiration date of 07/11/25. In medication refrigerator 2 an opened and partially used vial of “Epogen” (EPO) 2000 units/2milliliters (mL) During an interview on 07/22/25 at 8:43 AM Facility Administrator 1 confirmed the IDPN had expired and was still available in the immediate use medication refrigerator #1. Facility Administrator 1 confirmed that the EPO top was removed, and the vial of EPO was partially used but not labeled with the date it was opened. During an observation on 07/22/25 at 8:53 AM in the Home Training medication refrigerator one opened and partially used vial of “Epogen” 2000 units/2milliliters (mL) was identified as not labeled with the date it was opened. 2. During an observation on 07/22/25 at 8:53 AM in the Home Training medication refrigerator One vial of opened and partially used “Tuberculin Purified Protein Derivative (Mantoux)” was found in the refrigerator. Written on the box was “opened 05/14/25. Expired 06/11/25.” Two boxes that contained one syringe each of the “Pneumococcal 13 Valent Conjugate Vaccine” had an expiration date of 12/24. During an interview on 07/22/25 at 8:53 AM the Home Training Registered Nurse (HT RN) 10 confirmed that the EPO was not labeled per MFR DFU or the facility’s policy to identify the date it was opened, the partially used “Tuberculin Purified Protein Derivative (Mantoux)” had expired 06/11/25 based on the date opened and the two boxes of Pneumococcal 13 Valent Conjugate Vaccine had an expiration date of 12/24 and these items should not have been in the refrigerator available for immediate use. Review of the facility’s policy titled, “Medication Policy,” dated 10/23 revealed, “The Facility Administrator/designee is responsible for supervising the handling, storing, disposing, administering, and controlling of medications und performs a monthly audit and inventory. ... Medications containing a preservative must be discarded 28 days after opening or accessed (e.g., needle punctured), unless the manufacturer specifies a different (shorter or longer) date or as directed by the manufacturer as in the case of vaccines or state specific pharmacy regulations. Each vial is labeled with the initials of the person opening the vial and the expiration date. Medications are stored in the original vial and are not drawn up and stored overnight in a syringe or any other container. Examples of manufacturers differing time lengths are, but are not limited to: Epogen multidose vials must be discarded 2l days after opening or accessed (e.g., needle punctured)””

“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: 22198 Based on observations, interviews, reviews of policies and manufacture (MFR) directions for use (DFU), the facility failed to ensure that for three of three observation days staff failed to follow the facility’s policies and the MFR DFU when they failed remove expired products from immediate use and failed to label opened products per MFR/DFU to verify the product would be effective. This had the potential to affect all 29 incenter dialysis patients and 34 Home training patients. Total universe 63. Findings include: 1. During an observation on 07/22/25 at 8:03 AM in the incenter dialysis unit a suction canister attached to the mobile suction unit expired on 06/01/24. During an interview on 07/22/25 at 8:03 AM Facility Administrator 1 confirmed that the suction canister’s expiration date was 06/01/24 and was available for immediate use. Review of the facility’s policy titled “Infection Control For Dialysis Facilities” dated 04/23 revealed, “Supplies will be stored in a manner that maintains their integrity. . .Expiration date and package integrity will be verified prior to use. . .Anytime the integrity of a package with or without an expiration date is in question, i.e., torn, ripped, wet or contaminated, the package and its contents must be disposed of and not used.” 2. During an observation on 07/22/25 at 8:16 AM on the incenter dialysis unit the glucose testing strips that had been opened were not dated or labeled to verify the test strip were effective and provide an accurate blood sugar reading. The hi/low quality control (QC) solution used to validate the glucometer was calibrated within the MFR DFR was opened but not dated or labeled with the date opened to verify the solution was viable and effective for performing the QC checks on the glucometer to ensure it was reading blood sugars accurately. During an interview on 07/22/25 at 8:16 AM with Facility Administrator 1 regarding the opened test strip and hi/low QC solution, Facility Administrator 1 confirmed they were not dated to ensure it was discarded after the MFR DFU new expiration date after these products were opened. Facility Administrator 1 confirmed without an open date on the QC hi/low QC solution and the glucometer test strips he/she could not validate these items had not expired and were available for immediate use. During an interview on 07/22/25 at 8:53 AM the Home Training Registered Nurse (HTRN) 10 confirmed that the Home Training department does not have their own Glucometer if they need to perform a blood sugar check they use the Incenter glucometer. HTRN 10 stated, “I heard the glucometer products had not been dated when they opened.” Review of the MFR DFU for the glucometer testing strips “Embrace PRO 50 Test Strips” dated 03/23 revealed, “Use all the strips within 4 months after the first opening.” Review of the MFR DFU for the QC test solution “Embrace PRO Control Solution” dated 08/22 revealed “The control solution can be used for three months after opening the vial. Write the open date on the control solution vial when you first open it.” Review of the facility’s policy titled, “Blood Glucose Testing,” date 04/25, revealed, “Procedures for testing blood glucose levels are performed according to meter manufacturer instructions and approved DaVita policies and procedures. The monitor and strips are stored and used according to monitor manufacturer instructions and approved DaVita policies and procedures. . .Expired control solutions and test strips are not used to perform QC procedures. . .The monitor, strips and control solutions are stored and used according to the manufacturer instructions.” 3. During an observation on 07/23/25 at 11:50 AM Certified Clinical Hemodialysis Technician (CCHT) 11 was observed drawing up Heparin. CCHT11 took an alcohol pad from the package and used it to clean the septum of the Heparin vial. CCHT11 dropped the alcohol pad onto the medication prep countertop and with the first syringe drew up the Heparin. CCHT11 opened a new Heparin vial, inverted the vial, and rotated the vial back and forth on the used alcohol pad, and withdrew the Heparin required to fill the first syringe. A second syringe was obtained, and the vial of Heparin was inverted again put on the same used alcohol pad, rotated the vial back and forth then drew up the Heparin required for the second syringe. During an interview on 07/23/25 at 11:50 AM CCHT 11 stated, “. . .yes, that is the way I do it, that is the way I was taught.” Review of the “Alcohol Prep Pads” MFR DFU revealed, “Do Not Reuse” and “Directions: Wipe Vigorously To Clean The Area.” During an interview on 07/23/25 at 12:05 PM the Manager of Clinical Services (MCS) 4 confirmed that inverting the vial and rubbing it in on an alcohol pad was not acceptable. MCS4 stated with the metal lip of the vial you can’t be sure that the septum was cleaned.”

“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: 22198 Based on observation, interview, record review and policy review, the facility failed to ensure that blood pressures (BP) were documented per policy for one of three in-center hemodialysis patients (Patient P)1) records reviewed. The failure to ensure blood pressures were taken and recorded in the time frame set by the facility had the potential to cause a delay in the treatment of hypertension or hypotension for all 29 in center dialysis patients. Findings include: Review P1’s dialysis treatment sheets titled, “Treatment Details Report” between 07/07/25 and 07/18/25 in the MR, for one of six treatment P1’s BP was not documented for monitoring and assessment every 30 to 45 minutes as follows: a. On 07/16/25-P1’s BP was not taken for one hour between 2:29 PM and 3:29 PM when P1’s BP was 160/101 millimeters of mercury (mm/Hg). P1’s diastolic BP (DBP) [lower number] remained high for the remainder of the dialysis treatment. The staff failed to document for one hour between 4:29 PM when BP was 163/105 mm/Hg and 5:29 PM when the BP was recorded as 162/104. The Registered Nurse (RN) was notified of the elevated DBPs. During an interview on 07/22/25 at 11:26 AM Facility Administrator 1 confirmed that the BPs for P1 on 07/16/25 were not documented every 30 minutes per policy. Facility Administrator 1 stated they identified a problem with the B-Braun machines, if the machines are alarming during the time the BPs are supposed to be taken, the dialysis machine does not capture the BP. Facility Administrator 1 stated the company is working on replacing the machines. Review of the facility’s policy titled “Pre-Intra-Post Monitoring Data Collection, Monitoring and Nursing Assessment” dated 04/24 revealed, “Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse. a. Data collection includes but is not necessarily limited to: ... ii. Measurement of Blood Pressure (BP). ... Non-nocturnal treatments are completed at least every thirty (30) minutes. ...Unless other abnormal parameters are established by the facility Governing Body and documented in the Governing Body Meeting minutes, the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record. Within each category, definitions may be adjusted by a patient specific physician order. In addition, the teammate who is observing or collecting information should report to the licensed nurse whenever there is concern for the patient’s condition or the potential safety of initiating dialysis, even in the absence of specific abnormal findings ... Diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg””

“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: 22198 Based on interview, record reviews, and policy review, the facility failed to follow the individualized dialysis prescription as determined by the medical provider for three of three sampled in-center patients (Patient (P) 1, P2, and P3). Failure to verify and follow the medical providers’ dialysis prescription had the potential to negatively impact the effectiveness of the prescribed dialysis treatments for the 29 patients receiving in-center dialysis treatments at this facility. Findings include: 1. Review of P1’s medical record (MR) revealed a prescribed blood flow rate (BFR) of 400 milliliters per minute (mL/min) and dialysate flow rate (DFR) of 800 mL/min. Review of four of six “Treatment Details Report” between 07/07/25 and 07/18/25 in the MR, indicated the following: a. On 07/11/25 the dialysis treatment started at 1:37 PM and ended at 5:05 PM. The BFR was run at 350 mL/min for the entire dialysis treatment. On 07/11/25 at 1:39 PM the Registered Nurse (RN) document “I verify that the patient’s prescription matches what is currently being delivered during the dialysis treatment.” At 5:21 PM the “Treatment Nurse Assessment” for “Post” dialysis treatment did not include documentation of the change to the physician’s prescribed dialysis treatment BFR flow rate. There was no rationale documentation for the change to the prescribed BFR. b. On 07/14/25 the dialysis treatment started at 1:35 PM and ended at 4:35 PM. The BFR was run at 350 mL/min for the entire dialysis treatment. On 07/14/25 at 2:20 PM the RN document, “I verify that the patient’s prescription matches what is currently being delivered during the dialysis treatment.” At 4:48 PM the “Treatment Nurse Assessment” for “Post” dialysis treatment did not include documentation of the change to the physician’s prescribed dialysis treatment BFR flow rate. There was no rationale documentation for the change to the prescribed BFR. c. On 07/16/25 the dialysis treatment started at 1:58 PM and ended at 5:29 PM. The BFR was run at 250 mL/min for the entire dialysis treatment. On 07/16/25 at 3:01 PM the RN document “I verify that the patient’s prescription matches what is currently being delivered during the dialysis treatment.” At 5:35 PM the “Treatment Nurse Assessment” for “Post” dialysis treatment did not include documentation of the change to the physician’s prescribed dialysis treatment BFR flow rate. There was no rationale documentation for the change to the prescribed BFR. d. On 07/18/25 the dialysis treatment started at 2:05 PM and ended at 5:14 PM. The BFR was run at 250 mL/min for the entire dialysis treatment. On 07/18/25 at 2:34 PM the RN document “I verify that the patient’s prescription matches what is currently being delivered during the dialysis treatment.” At 5:36 PM the “Treatment Nurse Assessment” for “Post” dialysis treatment did not include documentation of the change to the physician’s prescribed dialysis treatment BFR flow rate. There was no rationale documentation for the change to the prescribed BFR. 2. Review of P2’s MR revealed a prescribed BFR of 350 mL/min and DFR of 700 mL/min. Review of one of six “Treatment Details Report” between 07/07/25 and 07/18/25 in the MR indicated the following: a. On 07/16/25 the dialysis treatment started at 11:57 AM and ended at 3:59 PM. The BFR started at 320 mL/min. Then at 12:31 PM to 2:31 PM the BFR was set at 340 mL/min. At 2:31 PM the BFR was changed to 300 mL/min. From 3:01 PM until the end of the treatment 3:59 PM the BFR was running at 330 mL/min. On 07/16/25 at 1:08 PM the RN document “I verify that the patient’s prescription matches what is currently being delivered during the dialysis treatment.” At 4:10 PM the “Treatment Nurse Assessment” for “Post” dialysis treatment did not include documentation of the change to the physician’s prescribed dialysis treatment BFR flow rate. There was no rationale documentation for the change to the prescribed BFR. 3. Review of P3’s MR revealed a prescribed BFR of 400 mL/min and DFR of 500 mL/min. Review of one of six “Treatment Details Report” between 07/07/25 and 07/18/25 in the MR, indicated the following: a. On 07/17/25 the dialysis treatment started at 8:27 AM and ended at 12:08 PM. At 8:27 AM the BFR started at 400 mL/min and from 9:02 AM until the end of dialysis treatment (12:08 PM) the BFR was running at 350 mL/min for the entire dialysis treatment. On 07/17/25 at 8:58 AM the Registered Nurse (RN) document “I verify that the patient’s prescription matches what is currently being delivered during the dialysis treatment.” At 1:18 PM the “Treatment Nurse Assessment” for “Post” dialysis treatment did not include documentation of the change to the physician’s prescribed dialysis treatment BFR flow rate. There was no rationale documentation for the change to the prescribed BFR. During an interview on 07/22/25 at 11:26 AM Facility Administrator 1 confirmed that the BFRs for P1, P2 and P3 were not run per prescription and the RN failed to document the rational or any interventions that were done on behalf of P1. P2, or P3. Review of the facility’s policy titled “Pre-Intra-Post Monitoring Data Collection, Monitoring and Nursing Assessment” dated 04/24 revealed, “ The Nursing assessment will be performed and documented by a licensed nurse; specifically, a Registered Nurse (RN) or if performance of a nursing assessment is permitted by state law, a Licensed Practical Nurse (LPN) / Licensed Vocational Nurse (LVN). ... iii. Verification of prescription including machine parameters. ... v. Review of documentation for accuracy, completion (sic) and patient data. ... The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment or as allowable by state law. ... 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. ... Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately (refer to “Abnormal Findings” section in this policy). The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary.””

“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: 22198 Based on observation, interview and policy review, the facility failed to ensure that for one of two Arteriovenous Fistula (AVF) initiation observations staff did not palpate the access site after the skin was cleaned and before the needles were inserted to ensure skin asepsis was assured. Palpating the skin after it is cleaned with antiseptic prior to needled insertion has the potential to introduce microorganisms into the insertion site. Findings include: During an observation on 07/21/25 at 11:04 AM during dialysis initiation of an AVF at Station 6 for Patient (P) 9, Certified Clinical Hemodialysis Technician (CCHT) 13 was observed cleaning the P9’s skin over the AVF with an antiseptic. After cleaning was completed and the antiseptic dried, CCHT13 was observed palpating the skin over the AVH and applied a topical skin anesthetic. CCHT13 did not re-clean the skin prior to inserting the needles. During an interview of 07/23/25 at 9:07 AM CCHT13 stated “I am not sure why I did that.” CCHT 13 confirmed he/she was aware that the skin needed to be re-cleaned if it was palpated or touched after it was aseptically cleaned. Review of the facility’s policy titled “AV Fistula Or Graft Cannulation with JMS Sysloc ® Mini Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose” dated 04/25 revealed, “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.””