S&C QCOR ESRD 2567s
d QCOR:  Quality, Certification and Oversight Reports.
ESRDs 2567s
Selection Criteria

Time Interval

Please select the calendar year or years for which you would like data.

Note: There is currently no ESRD 2567 data available past Feb 19, 2026 due to data system migrations.

Provider Characteristics

Use these filters if you want to limit the report to providers that have certain characteristics. To select more than one option, hold down the Ctrl (individual point-and-click) OR Shift keys (select through a range) while you click on the additional desired option(s).

Survey Type & Deficiency Tags

Use these filters if you want to limit the reports to providers on specific survey types, or to reports that were cited for specific ESRD deficiency tags and tag types. To select more than one option, hold down the Ctrl (individual point-and-click) OR Shift keys (select through a range) while you click on the additional desired option(s).

CCN and Facility Name

Use these filters if you know the name (or partial name) of the facility you are searching for, or the CMS Certification Number (CCN) for the facility you are searching for.

Other Survey Characteristics

Select one of the options below to filter by surveys that cite deficiencies or by surveys that are deficiency-free. By default, only surveys that cite deficiencies are displayed. Selecting "All" displays all surveys.

CMS Certification Number Facility Name Address City State CMS Region Date of CMS Survey Survey Event ID Survey Type Statement of Deficiencies Report
152647 Fort Wayne South Dialysis 302 E Pettit Ave Fort Wayne IN 5 (Chicago) 06/11/2020 E9Z011 Special
Deficiency Tag Deficiency Description Tag Type
E0000 Initial Comments - Not A Deficiency Citation Memo
V0000 Initial Comments - Not A Deficiency Citation Memo
V0112 Ic - Cdc Mmwr 2001 Standard
V0113 Ic - Wear Gloves/Hand Hygiene Standard
V0122 Ic - Clean, Disinfect Surfaces & Equipment/Written Protocols Standard
V0132 Ic - Training And Education Standard
V0143 Ic - Aseptic Techniques For Iv Meds Standard
152647 Fort Wayne South Dialysis 302 E Pettit Ave Fort Wayne IN 5 (Chicago) 01/28/2022 TWR711 Special, Standard
Deficiency Tag Deficiency Description Tag Type
E0000 Initial Comments - Not A Deficiency Citation Memo
V0000 Initial Comments - Not A Deficiency Citation Memo
V0113 Ic - Wear Gloves/Hand Hygiene Standard
V0115 Ic - Wear Gowns, Shields/Masks; Staff Not Eat/Drink In Tx Area Standard
V0117 Ic - Clean/Dirty Areas, Med Prep Area, No Common Med Carts Standard
V0122 Ic - Clean, Disinfect Surfaces & Equipment/Written Protocols Standard
V0175 Cfc - Water And Dialysate Quality Condition
V0196 Carbon Adsorption - Monitoring, Testing Frequency Standard
V0250 Dialysate Proportioning - Monitor Ph/Conductivity Standard
V0401 Pe - Safe, Functional, Comfortable Environment Standard
V0402 Pe - Building - Constructed/Maintained To Ensure Safety Standard
V0403 Pe - Equipment Maintenance - Manufacturer'S Dfu Standard
V0455 Privacy & Confidentiality In Records Standard
V0503 Appropriateness Of Dialysis Rx Standard
V0506 Immunization/Medication History Standard
V0543 Manage Volume Status Standard
V0544 Achieve Adequate Clearance Standard
V0675 Cfc - Laboratory Services Condition
V0715 Md Resp - Ensure All Adhere To P&P Standard
152647 Fort Wayne South Dialysis 302 E Pettit Ave Fort Wayne IN 5 (Chicago) 06/23/2025 USFC11 Standard
Deficiency Tag Deficiency Description Tag Type
E0000 Initial Comments - Not A Deficiency Citation Memo
V0000 Initial Comments - Not A Deficiency Citation Memo
V0111 Ic - Sanitary Environment Standard
V0407 Pe - Hemodialysis Patients In View During Treatments Standard
V0715 Md Resp - Ensure All Adhere To P&P Standard
152648 Fort Wayne West Dialysis 4916 Illinois Rd Ste 118 Fort Wayne IN 5 (Chicago) 01/14/2022 R5FT11 Standard
Deficiency Tag Deficiency Description Tag Type
E0000 Initial Comments - Not A Deficiency Citation Memo
V0000 Initial Comments - Not A Deficiency Citation Memo
V0113 Ic - Wear Gloves/Hand Hygiene Standard
V0116 Ic - Items Taken To Station Disposed/Dedicated Or Disinfected Standard
V0121 Ic - Handling Infectious Waste Standard
V0122 Ic - Clean, Disinfect Surfaces & Equipment/Written Protocols Standard
V0143 Ic - Aseptic Techniques For Iv Meds Standard
V0520 Frequency Reassessment - Unstable - Monthly Standard
V0551 Va Monitor To Prevent Failure/Stenosis Standard
152648 Fort Wayne West Dialysis 4916 Illinois Rd Ste 118 Fort Wayne IN 5 (Chicago) 03/21/2025 Z9HO11 Standard
Deficiency Tag Deficiency Description Tag Type
E0000 Initial Comments - Not A Deficiency Citation Memo
V0000 Initial Comments - Not A Deficiency Citation Memo
V0113 Ic - Wear Gloves/Hand Hygiene Standard
V0470 Rights Posted With State/Nw Contact #S And Addresses Standard
V0504 Assess B/P & Fluid Management Needs Standard
V0511 Dialysis Access Type & Maintenance Standard
V0544 Achieve Adequate Clearance Standard
152649 Appleseed Dialysis 1833 Magnavox Way Fort Wayne IN 5 (Chicago) 03/15/2022 79E511 Standard
Deficiency Tag Deficiency Description Tag Type
E0000 Initial Comments - Not A Deficiency Citation Memo
V0000 Initial Comments - Not A Deficiency Citation Memo
V0196 Carbon Adsorption - Monitoring, Testing Frequency Standard
V0401 Pe - Safe, Functional, Comfortable Environment Standard
V0587 Fac Receive/Review Self Monitoring Data Every 2 Months Standard
152649 Appleseed Dialysis 1833 Magnavox Way Fort Wayne IN 5 (Chicago) 07/02/2025 SM0J11 Standard
Deficiency Tag Deficiency Description Tag Type
E0000 Initial Comments - Not A Deficiency Citation Memo
V0000 Initial Comments - Not A Deficiency Citation Memo
V0587 Fac Receive/Review Self Monitoring Data Every 2 Months Standard
152651 Jeffersonville Dialysis 365 Quartermaster Ct Jeffersonville IN 5 (Chicago) 12/20/2019 EWH711 Standard
Deficiency Tag Deficiency Description Tag Type
E0000 Initial Comments - Not A Deficiency Citation Memo
E0028 Dialysis Emergency Equipment Standard
V0000 Initial Comments - Not A Deficiency Citation Memo
V0101 Compliance With Fed/State/Local Laws Standard
V0113 Ic - Wear Gloves/Hand Hygiene Standard
V0122 Ic - Clean, Disinfect Surfaces & Equipment/Written Protocols Standard
V0147 Ic - Staff Education Re Catheters/Catheter Care Standard
V0402 Pe - Building - Constructed/Maintained To Ensure Safety Standard
V0543 Manage Volume Status Standard
152651 Jeffersonville Dialysis 365 Quartermaster Ct Jeffersonville IN 5 (Chicago) 04/21/2023 JB9911 Standard
Deficiency Tag Deficiency Description Tag Type
E0000 Initial Comments - Not A Deficiency Citation Memo
E0028 Dialysis Emergency Equipment Standard
E0036 Ep Training And Testing Standard
V0000 Initial Comments - Not A Deficiency Citation Memo
V0113 Ic - Wear Gloves/Hand Hygiene Standard
V0143 Ic - Aseptic Techniques For Iv Meds Standard
V0147 Ic - Staff Education Re Catheters/Catheter Care Standard
V0585 Training Content Including Emergency Prep For Home Pts Standard
V0590 Coordination Of Care By Member Of Idt Standard
152652 Paoli Dialysis 555 West Longest Street Paoli IN 5 (Chicago) 11/21/2019 1W0911 Complaint, Standard
Deficiency Tag Deficiency Description Tag Type
E0000 Initial Comments - Not A Deficiency Citation Memo
E0028 Dialysis Emergency Equipment Standard
E0033 Methods For Sharing Information Standard
V0000 Initial Comments - Not A Deficiency Citation Memo
V0101 Compliance With Fed/State/Local Laws Standard
V0110 Cfc - Infection Control Condition
V0113 Ic - Wear Gloves/Hand Hygiene Standard
V0116 Ic - Items Taken To Station Disposed/Dedicated Or Disinfected Standard
V0122 Ic - Clean, Disinfect Surfaces & Equipment/Written Protocols Standard
V0175 Cfc - Water And Dialysate Quality Condition
V0196 Carbon Adsorption - Monitoring, Testing Frequency Standard
V0250 Dialysate Proportioning - Monitor Ph/Conductivity Standard
V0401 Pe - Safe, Functional, Comfortable Environment Standard
V0455 Privacy & Confidentiality In Records Standard
V0503 Appropriateness Of Dialysis Rx Standard
V0543 Manage Volume Status Standard
V0544 Achieve Adequate Clearance Standard
V0559 Outcome Not Achieved - Adjust Poc Standard
V0726 Medical Records - Complete, Accurate, Accessible Standard