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
232328 Children's Hospital Of Michigan 3950 Beaubien Blvd Detroit MI 5 (Chicago) 10/28/2020 CIDY21 Standard
Deficiency Tag Deficiency Description Tag Type
K0000 Initial Comments - Not A Deficiency Citation Memo
K0300 Protection - Other Standard
232328 Children's Hospital Of Michigan 3950 Beaubien Blvd Detroit MI 5 (Chicago) 10/27/2021 JY2Z11 Standard
Deficiency Tag Deficiency Description Tag Type
E0000 Initial Comments - Not A Deficiency Citation Memo
E0018 Procedures For Tracking Of Staff And Patients Standard
V0000 Initial Comments - Not A Deficiency Citation Memo
V0401 Pe - Safe, Functional, Comfortable Environment Standard
V0503 Appropriateness Of Dialysis Rx Standard
V0559 Outcome Not Achieved - Adjust Poc Standard
232328 Children's Hospital Of Michigan 3950 Beaubien Blvd Detroit MI 5 (Chicago) 03/12/2025 889N11 Standard
Deficiency Tag Deficiency Description Tag Type
E0000 Initial Comments - Not A Deficiency Citation Memo
V0000 Initial Comments - Not A Deficiency Citation Memo
V0110 Cfc - Infection Control Condition
V0115 Ic - Wear Gowns, Shields/Masks; Staff Not Eat/Drink In Tx Area Standard
V0116 Ic - Items Taken To Station Disposed/Dedicated Or Disinfected Standard
V0122 Ic - Clean, Disinfect Surfaces & Equipment/Written Protocols Standard
V0132 Ic - Training And Education Standard
V0147 Ic - Staff Education Re Catheters/Catheter Care Standard
V0400 Cfc - Physical Environment Condition
V0407 Pe - Hemodialysis Patients In View During Treatments Standard
V0516 Frequency - Initial: 30 Days/13 Tx Standard
V0625 Cfc - Quality Assessment & Performance Improvement Condition
V0627 Ongoing, Uses Indicators - Improved Health Outcomes Standard
V0628 Measure, Analyze And Track Quality Indicators Standard
V0633 Qapi Indicator - Vascular Access Standard
V0636 Qapi Indicator - Pt Satisfaction & Grievances Standard
V0639 Prioritizing Improvement Activities Standard
V0681 Staff Licensed As Req/Qualified/Demonstrate Competencies Standard
V0684 Nurse Manager - 12 Mo Rn + 6 Mo Dialysis Standard
V0710 Cfc - Responsibilities Of The Medical Director Condition
V0712 Md Resp - Qapi Program Standard
V0713 Md Resp - Staff Ed, Training & Performance Standard
V0715 Md Resp - Ensure All Adhere To P&P Standard
V0750 Cfc - Governance Condition
V0756 Adm Resp For Resources For Qapi Standard
V0757 Staff # & Ratio Meet Patient Needs Standard
232328 Children's Hospital Of Michigan 3950 Beaubien Blvd Detroit MI 5 (Chicago) 04/24/2025 889N12 Standard
Deficiency Tag Deficiency Description Tag Type
V0403 Pe - Equipment Maintenance - Manufacturer'S Dfu Standard
232345 Devos Children's Hospital Esrd Unit 35 Michigan St Ne, Ste 3121 Grand Rapids MI 5 (Chicago) 11/06/2020 XF7Q11 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
V0540 Cfc: Patient Plan Of Care Condition
V0556 Poc Completed/Signed By Idt & Patient Standard
V0627 Ongoing, Uses Indicators - Improved Health Outcomes Standard
V0628 Measure, Analyze And Track Quality Indicators Standard
232347 Portage Health Dialysis Center 500 Campus Drive Hancock MI 5 (Chicago) 10/09/2019 9GHG11 Standard
Deficiency Tag Deficiency Description Tag Type
E0000 Initial Comments - Not A Deficiency Citation Memo
V0000 Initial Comments - Not A Deficiency Citation Memo
V0233 Bicarb Mixing Sys - Storage/Use Time Limits/Min Combine Standard
V0403 Pe - Equipment Maintenance - Manufacturer'S Dfu Standard
232347 Portage Health Dialysis Center 500 Campus Drive Hancock MI 5 (Chicago) 12/09/2021 52GB11 Complaint
Deficiency Tag Deficiency Description Tag Type
E0000 Initial Comments - Not A Deficiency Citation Memo
E0003 Establishment Of The Ep Program Dialysis Condition
E0006 Plan Based On All Hazards Risk Assessment Standard
E0028 Dialysis Emergency Equipment Standard
V0000 Initial Comments - Not A Deficiency Citation Memo
V0110 Cfc - Infection Control Condition
V0113 Ic - Wear Gloves/Hand Hygiene Standard
V0115 Ic - Wear Gowns, Shields/Masks; Staff Not Eat/Drink In Tx Area Standard
V0116 Ic - Items Taken To Station Disposed/Dedicated Or Disinfected Standard
V0117 Ic - Clean/Dirty Areas, Med Prep Area, No Common Med Carts Standard
V0122 Ic - Clean, Disinfect Surfaces & Equipment/Written Protocols Standard
V0132 Ic - Training And Education Standard
V0175 Cfc - Water And Dialysate Quality Condition
V0233 Bicarb Mixing Sys - Storage/Use Time Limits/Min Combine Standard
V0260 Personnel - Training Program/Periodic Audits Standard
V0400 Cfc - Physical Environment Condition
V0401 Pe - Safe, Functional, Comfortable Environment Standard
V0625 Cfc - Quality Assessment & Performance Improvement Condition
V0637 Qapi Indicator - Infection Control - Trend/Plan/Act Standard
V0638 Continuously Monitor/Take Action/Track/Sustain Improve Standard
V0725 Cfc - Medical Records Condition
V0727 Mr - Protect Patient Records From Loss/Keep Confidential Standard
V0750 Cfc - Governance Condition
232348 Oaklawn Dialysis Center 310 E Michigan Avenue Marshall MI 5 (Chicago) 06/06/2018 WU5U11 Standard
Deficiency Tag Deficiency Description Tag Type
E0000 Initial Comments - Not A Deficiency Citation Memo
V0000 Initial Comments - Not A Deficiency Citation Memo
V0115 Ic - Wear Gowns, Shields/Masks; Staff Not Eat/Drink In Tx Area Standard
V0637 Qapi Indicator - Infection Control - Trend/Plan/Act Standard
232350 Mymichigan Dialysis Services 509 Osborn Blvd, Ste 200 Sault Sainte Marie MI 5 (Chicago) 01/10/2018 L7DK12 Standard
Deficiency Tag Deficiency Description Tag Type
V0110 Cfc - Infection Control Condition
V0111 Ic - Sanitary Environment Standard
V0122 Ic - Clean, Disinfect Surfaces & Equipment/Written Protocols Standard
V0124 Ic - Hbv - Test All Pts, Review Results/Pt Status Known Preadmit Standard
V0254 Microbial Monitoring - Sample Before Disinfect Standard
V0417 Pe-Fire Safety-Life Safety Code Standard
V0557 Initial Poc Implemented - 30 Days/13 Tx Standard
V0558 Implement Updates Of Poc - 15 Days P Pt Assessment Standard
232350 Mymichigan Dialysis Services 509 Osborn Blvd, Ste 200 Sault Sainte Marie MI 5 (Chicago) 05/26/2021 2T8H11 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
V0543 Manage Volume Status Standard
V0715 Md Resp - Ensure All Adhere To P&P Standard