532503 Wind River Dialysis Center

“CFC-PATIENT PLAN OF CARE CFR(s): 494.90 This Condition is not met as evidenced by: 37220 Based on medical record review, staff interview, and policy and procedure review, the facility’s interdisciplinary team failed to develop a plan of care in a timely manner for 5 of 5 sample patients (#1, #2, #3, #4, #5) reviewed (V542). In addition, the facility failed to ensure the plan of care was signed by the interdisciplinary team members and the patient or the patient’s designee for 4 of 5 sample patients (#2, #3, #4, #5) reviewed (V556).”

“Develop EP Plan, Review and Update Annually CFR(s): §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: 37220 Based on review of the emergency response and communication plan documentation and staff interview, the facility failed to evaluate and update the emergency preparedness plan every two years. The census was 46. The findings were: 1. Review of the “Emergency Response and Communication Plan” showed the plan was last reviewed on 11/12/17. 2. Interview with the nurse manager on 8/8/25 at 9:30 AM confirmed the emergency preparedness plan had not been reviewed as required.”

“Names and Contact Information CFR(s): §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: 37220 Based on review of the emergency response and communication plan documentation and staff interview, the facility failed to evaluate and update the communication plan’s internal contact information to include all of the required information (staff, entities providing services under arrangement, patients’ physicians) every two years. The census was 46. The findings were: 1. Review of the “Emergency Response and Communication Plan” showed the plan was last reviewed on 11/12/17. Further review showed the plan failed to include the current contact information of the staff, patients’ physicians, and entities providing services under arrangement. 2. Interview with the nurse manager on 8/8/25 at 9:30 AM confirmed the emergency preparedness plan had not been reviewed and updated as required.”

“Emergency Officials Contact Information CFR(s): §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This Standard is not met as evidenced by: 37220 Based on review of the emergency response and communication plan documentation and staff interview, the facility failed to include the contact information for the State Licensing and Certification Agency. The census was 46. The findings were: 1. Review of the “Emergency Response and Communication Plan” showed the plan was last reviewed on 11/12/17. Further review showed the plan failed to include the contact information for the State Licensing and Certification Agency. 2. Interview with the nurse manager on 8/8/25 at 9:30 AM confirmed the emergency preparedness plan was incomplete.”

“Methods for Sharing Information CFR(s): §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility’s] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility’s] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI’s care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4). This Standard is not met as evidenced by: 37220 Based on review of the emergency response and communication plan documentation, review of the “Communication of patient information” method, and staff interview, the facility failed to maintain a current medical record of each patient to ensure continuity of care during an emergency. The census was 46. The findings were: 1. Review of the facility’s emergency preparedness documentation failed to show patient information had been updated to reflect the current needs of the patients. 2. Interview with the nurse manager on 8/8/25 at 9:30 AM confirmed the emergency preparedness plan was incomplete; however, she and the social worker had updated the information during the evening hours of 8/7/25. 3. Review of the “Communication of patient information” method showed “The patient information we communicate externally includes: patient demographics, phone numbers, physical addresses, treatment Kardex/regiment (sic), labs and Medication Administration Record (sic).””

“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: 37220 Based on review of the emergency response and communication plan documentation, staff interview, review of quality assurance performance improvement (QAPI) documentation, and review of policy and procedures, the facility failed to provide training to staff on the emergency preparedness plan every two years. The census was 46. The findings were: 1. Review of the emergency response and communication plan documentation showed no evidence the facility had trained staff on the emergency preparedness plan. 2. Interview with the nurse manager on 8/8/25 at 9:30 AM confirmed the training of staff on the emergency preparedness plan had not been completed. 3. Review of the January 2025, February 2025, March 2025, and April 2025 QAPI documentation showed “Emergency Preparedness: Nothing for community since before COVID 19... 2020/2021 no meeting with County Emergency Prep r/t [related to] COVID Determining dates. ‘Table Top’ Fremont County Emergency Preparedness cancelled (sic) rt [related to] COVID Community Based Emergency attended last time Oct 10, 2019. Nothing was held 2020/2021 r/t COVID No community activity related to COVID.” There was no QAPI documentation for May and June 2025. 4. Review of the policy “Staff Training and Testing on Emergency Preparedness”, dated 10/ 2017, showed “Policy: Wind River Dialysis Center will provide an annual staff training and testing of the Emergency Plan and execute our plans by putting them in action through simulated events. We will also analyze our facility’s response, any gaps or areas of improvement and correct action process and will maintain documentation of all staff straining (sic) and exercises... All existing and new WRDC staff will be tested initially and annually on their knowledge of the emergency plan and preparedness, and mock exercise.””

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 37220 Based on review of the emergency response and communication plan documentation, staff interview, review of quality assurance performance improvement (QAPI) documentation, and review of policy and procedure, the facility failed to test the emergency preparedness plan related to the risks identified in the facility’s risk assessment. The census was 46. The findings were: 1. Review of the emergency response and communication plan documentation showed no evidence the facility had tested the emergency preparedness plan as required. 2. Interview with the nurse manager on 8/8/25 at 9:30 AM confirmed the required testing of the emergency preparedness plan had not been completed. 3. Review of the January 2025, February 2025, March 2025, and April 2025 QAPI documentation showed “Emergency Preparedness: Nothing for community since before COVID 19... 2020/2021 no meeting with County Emergency Prep r/t [related to] COVID Determining dates. ‘Table Top’ Fremont County Emergency Preparedness cancelled (sic) rt [related to] COVID Community Based Emergency attended last time Oct 10, 2019. Nothing was held 2020/2021 r/t COVID No community activity related to COVID.” There was no QAPI documentation for May and June 2025. 4. Review of the policy “Staff Training and Testing on Emergency Preparedness”, dated 10/ 2017, showed “Policy: Wind River Dialysis Center will provide an annual staff training and testing of the Emergency Plan and execute our plans by putting them in action through simulated events. We will also analyze our facility’s response, any gaps or areas of improvement and correct action process and will maintain documentation of all staff straining (sic) and exercises... All existing and new WRDC staff will be tested initially and annually on their knowledge of the emergency plan and preparedness, and mock exercise.””

“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: 37220 Based on observation and staff interview, the facility failed to ensure the non-disposable thermometer and oximeter (used to assess a patient’s oxygen saturation level) was cleaned and disinfected before and after patient use during 2 random observations. The findings were: 1. Observation on 8/6/25 at 1:16 PM showed RN #1 brought an oximeter to station #9 to obtain an oxygen saturation level. The RN returned to the nursing desk and without cleaning and disinfecting the oximeter used her own finger to demonstrate to the surveyor how the oximeter was linked to an application on her phone. The oximeter was then placed on the nurse’s desk. 2. Observation on 8/6/25 at 2:07 PM showed RN #1 obtained an oxygen saturation level on patient #6 and then placed the oximeter into her pocket. Interview with the RN at that time confirmed the oximeter was in her pocket as well as a thermometer. Further the RN revealed she cleaned the oximeter with alcohol after use; however, an observation of the activity did not occur. 3. Interview with the nurse manager on 8/7/25 at 3:16 PM confirmed non-disposable equipment should be cleaned and disinfected before and after patient use.”

“IC-SUPPLY CART DISTANT/NO SUPPLIES IN POCKETS CFR(s): 494.30(a)(1)(i) If a common supply cart is used to store clean supplies in the patient treatment area, this cart should remain in a designated area at a sufficient distance from patient stations to avoid contamination with blood. Such carts should not be moved between stations to distribute supplies. Do not carry medication vials, syringes, alcohol swabs or supplies in pockets. This Standard is not met as evidenced by: 37220 Based on observation and staff interview the facility failed to ensure dialysis supplies were not kept in staff pockets for 1 random observation. The findings were: 1. Observation on 8/6/25 at 2:07 PM showed RN #1 obtained an oxygen saturation level on patient #6 and then placed the oximeter into her pocket. Interview with the RN at that time confirmed the oximeter was in her pocket as well as a thermometer. 2. Interview with the nurse manager on 8/7/25 at 3:16 PM revealed she was unaware of the requirement and showed the surveyor a thermometer that was in her pocket.”

“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: 37220 Based on review of personnel files, policy and procedure review, and staff interview, the facility failed to ensure the hepatitis B vaccine was offered and initiated at hire for 2 of 5 sample employees (RN #1, PCT #2) reviewed. The findings were: 1. Review of the personnel file for RN #1 showed she was hired on 10/26/24. The personnel file showed a laboratory report, dated 11/27/21, which indicated the RN was not immune to hepatitis B. There was no evidence the RN had been offered the hepatitis B vaccination upon hire. 2. Review of the personnel file for PCT #2 showed she was hired on 6/10/25. There was no evidence PCT #2’s immune status had been determined and/or offered the hepatitis B vaccination upon hire. 3. Interview with the nurse manager on 8/6/25 at 2:38 PM confirmed no further documentation was available. 4. Review of the policy and procedure “Health Supervision of Employees”, last reviewed July of 2024, showed “POLICY: Employees will have the following tests done during the probationary period. Proof of any prior tests is to be given to the Nurse Manager. Results are documented and filed in personnel file...2. Hepatitis B series (3 doses) if never started before...Employees who are < 10 SRU [indicated patient was not immune] will be required to receive a Hepatitis B booster...””

“IC-TRAINING & EDUCATION CFR(s): 494.30(a)(1)(i) Infection Control Training and Education Infection control practices for hemodialysis units: intensive efforts must be made to educate new staff members and reeducate existing staff members regarding these practices. This Standard is not met as evidenced by: 37220 Based on review of personnel files, staff interview, and policy and procedure review, the facility failed to provide education on infection control for new staff members and reeducate existing staff members for 2 of 5 sample employees (PCT #2, PCT #3) reviewed. The findings were: 1. Review of the personnel file for PCT #2 showed she was hired on 6/10/25. There was no evidence PCT #2 had received infection control training upon hire. 2. Review of the personnel file for PCT #3 showed she was hired on 4/24/24. There was no evidence PCT #3 had received infection control training upon hire or had participated in the annual in-service provided by the facility on 1/12/25. 3. Interview with the nurse manager on 8/6/25 at 2:38 PM confirmed no further documentation was available. 4. Review of the policy “In service Policy”, last reviewed July of 2024, showed “Purpose: To ensure continuity of training and education for the staff of the dialysis center. Also, to assist staff in the decision making process in the event of an emergency...2. Mandatory In-services such as, Emergency Preparedness and Infection Control will be done on an annual basis...Verification of attendance must be kept. All staff must sign in on the Sign In sheet. This will be kept in an In service log located in the Nurse Manager’s office.””

“PERSONNEL-TRAINING PROGRAM/PERIODIC AUDITS CFR(s): 494.40(a) 9 Personnel: training program/periodic audits A training program that includes quality testing, the risks and hazards of improperly prepared concentrate, and bacterial issues is mandatory. Operators should be trained in the use of the equipment by the manufacturer or should be trained using materials provided by the manufacturer. The training should be specific to the functions performed (i.e., mixing, disinfection, maintenance, and repairs). Periodic audits of the operators’ compliance with procedures should be performed. The user should establish an ongoing training program designed to maintain the operator’s knowledge and skills. This Standard is not met as evidenced by: 37220 Based on record review and staff interview, the facility failed to ensure periodic audits of the operator’s compliance with the water testing procedure, the preparation of bicarbonate solution, and dialysate pH and conductivity testing at the point of use, were completed as required. The census was 46. The findings were: Review of the facility’s records showed no evidence periodic audits had been completed to ensure operators’ compliance with procedures which included water testing, dialysate testing, and preparation of the bicarbonate solution. Interview with the nurse manager on 8/7/25 at 2:45 PM confirmed the audits had not been completed.”

“POC-IDT DEVELOPS PLAN OF CARE CFR(s): 494.90(a) The interdisciplinary team must develop a plan of care for each patient. This Standard is not met as evidenced by: 37220 Based on medical record review, staff interview, and policy and procedure review, the interdisciplinary team failed to develop a plan of care in a timely manner for 5 of 5 sample patients (#1, #2, #3, #4, #5) reviewed. The findings were: 1. Review of the most recent care plan, provided by the facility, for patient #1 showed the annual plan of care was dated January of 2024. The plan showed individualized notes from the social worker and the dietitian; however, the note section from the physician and nurse were left blank. There was no evidence the patient’s plan of care had been reviewed and updated since January 2024. 2. Review of the most recent care plan, provided by the facility, for patient #2 showed the annual plan of care was dated January of 2025. Further review of the plan of care showed the cardiovascular assessment, lipids, education assessment, transplant status, advance directive, and psychosocial assessment sections were left blank. 3. Review of the most recent care plan, provided by the facility, for patient #3 showed the annual plan of care was dated January of 2025. Further review of the plan of care showed the lipids, psychosocial, education, transplant status, and advance directive sections were left blank. 4. Review of the most recent care plan, provided by the facility, for patient #4 showed the annual plan of care was dated 9/7/23. The facility was unable to locate any additional documentation. 5. Review of the most recent care plan, provided by the facility, for patient #5 showed the annual plan of care was dated 10/9/24. Further review of the plan of care showed the current status of the patient was not determined, and the lipid, cardiovascular, blood pressure/fluid management, bone health and nutrition, psychosocial, and advance directive sections were not included. 6. Interview with the nurse manager on 8/8/25 at 10:47 AM revealed she was unable to locate any further documentation. 7. Review of the policy and procedure “Patient Care Plan”, last reviewed July 2024, showed “Policy: Each dialysis patient has an individualized, printed care plan based on their medical problems, treatment provided, and functional status. Print the care plan from the Spectra lab company (it will contain the current and past three months lab results with the care plan) ...1. Each dialysis patient will have a printed plan of care...3. The patient care plan may be in a standardized format, but must be personalized for each patient, reflecting the medical, psychological, social and functional needs of the patient. The plan is completed after assessments are completed by each discipline...The Patient Care Plans are developed by a professional team. The team includes the nephrologist, primary nurse, Head Nurse, social worker and the dietitian.””

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 37220 Based on medical record review and staff interview, the facility failed to ensure the plan of care was signed by the interdisciplinary team members and the patient or the patient’s designee for 4 of 5 sample patients (#2, #3, #4, #5) reviewed. The findings were: 1. Review of the plan of care for patient #2, dated January 2025, failed to include the signature of the physician, the social worker, and the patient or the patient’s designee. 2. Review of the plan of care for patient #3, dated January 2025, failed to include the signature of the physician, the social worker, and the patient or the patient’s designee. 3. Review of the plan of care for patient #4, dated 9/7/23, failed to include the signature of the patient or the patient’s designee. 4. Review of the plan of care for patient #5, dated 10/9/24, failed to include the signature of the patient or the patient’s designee. 5. Interview with the nurse manager on 8/8/25 at 10:47 AM confirmed no further documentation was available.”

“QAPI-ONGOING;USES INDICATORS=IMPROVEMENT CFR(s): 494.110(a)(1) The program must include, but not be limited to, an ongoing program that achieves measurable improvement in health outcomes and reduction of medical errors by using indicators or performance measures associated with improved health outcomes and with the identification and reduction of medical errors. This Standard is not met as evidenced by: 37220 Based on review of the quality assurance performance improvement (QAPI) documentation and staff interview, the facility failed to have an ongoing QAPI program for 6 of 6 months reviewed from January through June 2025. The findings were: 1. Review of the January 2025 QAPI documentation failed to include the signatures of the dietitian, the social worker, and the bio-med/water quality technician. 2. Review of the February 2025 QAPI documentation failed to include the signature of the bio-med/water quality technician. 3. Review of the March 2025 QAPI documentation failed to include the signature of the social worker and the bio-med/water quality technician. 4. Review of the April 2025 QAPI documentation failed to include the signature of the social worker and the bio-med/water quality technician. 5. There was no QAPI documentation for the months of May and June. 6. Interview with the social worker on 8/7/25 at 9:57 AM revealed the QAPI committee met monthly; however, the meetings had been more sporadic in the last few months after the facility switched to an electronic medical record (EMR) system. 7. Interview with the nurse manager on 8/8/25 at 10:52 AM confirmed there was no QAPI documentation for May and June. In addition, the nurse manager stated the change to the EMR system had been challenging and she was still learning how to use the software system.”

“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: 37220 Based on review of the quality assurance performance improvement (QAPI) documentation and staff interview, the facility failed to ensure all required quality indicators were addressed for 6 of 6 months reviewed from January 2025 through June 2025. The findings were: 1. Review of the January, February, March, and April 2025 QAPI documentation showed no evidence the facility had a system in place to monitor the quality indicators of fluid and blood pressure management, physical plant safety, and patient morbidity. No quality assurance documentation was available for May and June 2025. 2. Interview with the nurse manager on 8/8/25 at 10:52 AM confirmed the quality assurance program failed to include all of the required elements.”

“LAB-CLIA LABS/MEET NEEDS OF PTS CFR(s): 494.130 The dialysis facility must provide or make available, laboratory services (other than tissue pathology and histocompatibility) to meet the needs of the ESRD patient. Any laboratory services, including tissue pathology and histocompatibility must be furnished by or obtained from, a facility that meets the requirements for laboratory services specified in part 493 of this chapter. This Standard is not met as evidenced by: 37220 Based on observation, medical record review, and staff interview, the facility failed to obtain a CLIA (clinical laboratory improvement amendment) certificate of waiver to perform testing on human specimens for the purpose of providing information for diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of the health of, human beings. The census was 46. The findings were: 1. Observation on 8/5/25 at 2:45 PM showed a glucometer (instrument used for obtaining blood sugar levels) was located in the clean area of the facility. Further observation showed no evidence the facility had obtained and posted the CLIA certificate. 2. Review of the physician orders for patient #1 showed the facility was to monitor blood sugar levels during the dialysis treatment. 3. Interview with the nurse manager on 8/8/25 at 11:12 AM revealed she was unaware the facility required a CLIA certificate.”

“PQ-PCT CERTIFIED CFR(s): 494.140(e)(4) Patient care dialysis technicians must- (4) Be certified under a State certification program or a national commercially available certification program, as follows- (i) For newly employed patient care technicians, within 18 months of being hired as a dialysis patient care technician; or (ii) For patient care technicians employed on October 14, 2008, within 18 months after such date. This Standard is not met as evidenced by: 37220 Based on review of the personnel technical information data sheet and the staff schedule, staff interview, and policy and procedure review, the facility failed to ensure staff performing the duties of the PCT were certified within 18 months of their date of hire for 2 of 7 PCTs (PCT #4, PCT #5) reviewed. The findings were: 1. Review of the personnel technical information data sheet, provided by the nurse manager, showed PCT #4 was hired on 3/16/23. Review of the August 2025 staff schedule showed PCT #4 was scheduled to work 19 out of 26 days. There was no evidence the PCT had successfully passed a standardized certification examination within 18 months of her date of hire. 2. Review of the personnel technical information data sheet, provided by the nurse manager showed PCT #5 was hired on 5/20/20. Review of the August 2025 staff schedule showed PCT #5 was scheduled to work 18 out of 26 days. There was no evidence the PCT had successfully passed a standardized certification examination within 18 months of her date of hire. 3. Interview with the nurse manager on 8/8/25 at 11:37 AM confirmed the PCTs had been employed longer than 18 months and had not passed a certification examination. 4. Review of the “Hemodialysis Technician Training” policy, last reviewed July 2024, showed “Policy: To ensure proper and progressing new hemodialysis technician training, all new dialysis technicians will work through a slow process of educational materials, testing, check off lists, and 1:1 with CCHT (Certified Clinical Hemodialysis Technicians), and Registered Nurses. Average Hemodialysis Technician training takes 4-6 months...8. Plan to take national certification exam prior to 18 months of employment. Every Patient Care Technician must pass the certification to continue employment after 18 months of service. If you do not pass we will allow a re-take exam. After 3 attempts and you continue to fail the certification you will be relieved of your position per CMS guidelines.””

“MD RESP-DEVELOP, REVIEW & APPROVE P&P CFR(s): 494.150(c)(1) The medical director must- (1) Participate in the development, periodic review and approval of a “patient care policies and procedures manual” for the facility; This Standard is not met as evidenced by: 37220 Based on the review of policies and procedures and staff interview, the medical director failed to sign and approve the patient care policy and procedure manual. The findings were: Review of the facility’s policies and procedures showed the current medical director had not signed and approved the policies. Interview with medical director on 8/7/25 at 11:59 AM revealed he had taken over the duties of the medical director in December of 2024 and updating the policies and procedures was “a work in progress”.”