Davita Little Rock Midtown Dialysis

“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: 37145 Based on observation, policy and procedure review and interview, the facility failed to ensure four of four (#9, #13, #14, and #16) patients who held pressure on their access sites to achieve hemostasis, performed hand hygiene prior to exiting the treatment area. The failed practice promoted the spread of infection from cross contamination and had the likelihood to affect all 61 in-center hemodialysis patients on census, all direct care staff and all visitors. Findings follow: A. Review of the facility’s policy titled, “Post Dialysis Vascular Access Care: Fistula/Graft Using Safety Fistula Needles,” with a revised date of April 2023, showed “The patient will be encouraged to hold their sites if their condition permits. When the patient holds their cannulation sites, the patient will be offered gloves and performs hand hygiene when completed. Rationale: Gloves and hand hygiene protects patient and family members from cross contamination.” B. The findings of A were confirmed in an interview with the Facility Administrator on 01/29/25 at 11:25 AM. C. Observation of termination and initiation of dialysis treatments on 01/29/24 from 8:15 AM to 11:00 AM showed Patient # 9, #13, #14 and #16 held their access sites to achieve hemostasis. Patient #9, #13, #14, and #16 did not perform hand hygiene prior to leaving the treatment area.”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 51070 Based on observation, review of policy and interview it was determined the facility failed to maintain a clean, sanitary medication preparation area free from contamination, in that the walls and cabinets used to store medications were covered in an orange sticky residue, personal items (i.e. coats and purses) were hung adjacent to the medication preparation area, and two (#1 and #2) Registered Nurses (RN)s were observed entering the medication preparation area from the treatment room wearing full Personal Protective Equipment (PPE). The failed practice had the likelihood of spreading infectious contaminants to medications during preparation and had the likelihood of affecting all patients receiving medication within the facility. Findings follow: A. Review of policy titled “Medication Policy” revised 10/2023, showed medications should be prepared in “an aseptic environment”. B. Review of policy titled “Infection Control for Dialysis Facilities” revised 4/2023, showed PPE should be removed “prior to leaving the treatment room”. C. During a tour of the Medication Room on 1/27/25 and again on 1/29/25, the following observations showed: 1) Two walls had sticky orange colored residue covering most of the surface area. 2) Two of the four cabinets used to store medications and supplies had sticky orange colored residue on the outside and inside of the cabinets. 3) The medication room was used to store staff members’ personal items adjacent to the medication preparation area (i.e. coats and purses). 4) On 1/29/25 at 9:04 AM, observed RN #1 enter the medication room wearing PPE. 5) On 1/29/25 at 10:40 AM, observed RN #2 enter the medication room wearing PPE. D. During an interview with the Facility Administrator on 1/27/25 at 9:45 AM and again on 1/29/25 at 2:15 PM, she confirmed the findings in A - C.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 51070 Based on observation, policy and procedure review and interview, it was determined that the back of the dialysis machines around the base were not cleaned for four (#1, #7, # 13 and #23) dialysis stations observed and the clean and dirty sinks had a buildup of dirt, dust and grime in the sink basins and white buildup on the faucets. The failed practice had the likelihood of spreading infection and had the likelihood of affecting all 61 in-center hemodialysis patients receiving dialysis within the facility. The findings follow: A. Review of policy titled “Infection Control for Dialysis Facilities” revised 4/2023, showed at “the end of each treatment, the dialysis station will be cleaned and disinfected.” Further surfaces and nondisposable items will be disinfected after patient use. B. During observation of termination and initiation of dialysis on 1/29/25 between 8:15 AM and 11:30 AM, showed that Certified Clinical Hemodialysis Technician (#1 and #2) and Licensed Practical Nurse (#1), failed to wipe the back of the dialysis machine around the base during cleaning. Each machine observed had visible dust, dirt, and grime on the backside around the base of the machine. C. Observation of three “clean” and three “dirty” sinks showed visible dirt, dust, and grime in the sink basins and white build up on the faucets. D. During an interview with the Facility Administrator on 1/29/25 at 2:15 PM, she confirmed the findings in A and C.”

“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: 37145 Based on review of manufacturers insert, observation and interview, it was determined an opened multi-dose vial (MDV) of Tubersol did not have the date opened to determine the 30 day expiration date and the initials of who opened the vial. The failed practice did not assure the MDV had not expired and was not available for use. The failed practice had the likelihood to affect all staff and patients who received the Tubersol injection. The findings were: A. Review of the Tubersol manufacturers insert, showed: “A vial of Tubersol which has been entered and in use for 30 days should be discarded.” B. Observation on 01/27/25 at 9:30 AM with the Administrator showed a Tubersol multiuse vial that had been opened contained approximately half of medication did not have the dated opened or the initials of who opened the vial. C. The findings of A and B were confirmed with the Facility Administrator on 01/28/25 at 3:35 PM.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 51070 Based on observation and interview, it was determined the facility failed to provide a safe environment, in that patient and facility equipment (i.e. wheelchairs, walkers, etc.), were stored in a manner that created obstacles in front of an emergency exit and in a main walk-through area, thereby increasing the risk for falls and/or entrapment during emergencies. The failed practice had the likelihood of affecting all patients and staff entering and exiting the facility. The findings follow: A. During a tour of the facility on 1/27/25 between 8:25 AM and 10:30 AM the following was observed: 1) A treatment chair and broom were found blocking the outside main entrance in front of a metal door marked “emergency exit”. 2) In the treatment room across from the scale, a patient lift, three wheelchairs and two walkers were stored, which extended into the walkway creating obstacles. B. During an interview with the Facility Administrator on 1/27/25 at 8:40 AM, she confirmed the wheelchairs and walkers should be stored outside of the treatment area. C. During an interview with the Facility Group Administrator on 1/27/25 at 11:30 AM, she confirmed the treatment chair, and broom should not be blocking an emergency exit.”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 51070 Based on policy and procedure review, observation and interview, it was determined the physical environment was not maintained to provide a safe environment free from defects and hazards, in that the integrity of baseboards and countertops in the treatment area were in a state of disrepair. The failed practice had the likelihood for the spread of infection. The failed practice had the likelihood of affecting all 61 in-center hemodialysis patients receiving care in the facility. The findings follow: A. Review of policy titled “Infection Control for Dialysis Facilities” revised 4/2023, showed that work surfaces will be cleaned and/or disinfected at the end of each treatment or when there is blood or any exposure to potentially infectious material. B. During a tour of the facility on 1/27/25 between 8:15 AM to 10:30 AM, the following were found in the treatment room: 1) The baseboard on a column next to Station #15 in the treatment room showed peeling/chipped plastic like material and was coming apart from the wall. 2) The laminate behind Station #20, showed buckled laminate coming apart from the countertop. 3) The caulking had peeled off behind Stations #18 and #19 where the countertop and facing met leaving a small gap that could not be cleaned or disinfected. 4) Six small unpatched holes were observed on the wall behind the centrifuge. 5) The countertop next to Station #23 had a one-inch circular hole with exposed wood. 6) A puddle of white liquid was observed on the floor next to a device with a bottle of white liquid behind Station #23. C. During a tour of the facility on 1/27/25 between 8:15 AM to 10:30 AM, the following were found in the supply rooms: 1) Clean supplies were stored on unfinished pressboard shelving units which showed stains, buckling, and flecks of peeling wood. 2) The concrete walls in the back storage area containing boxes of dialysate showed seventeen bolt size holes with powdery concrete residue around each hole. D. During an interview with the Facility Administrator on 1/27/25 at 10:30 AM, she confirmed the findings in A-C.”

“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: 37145 Based on policy and procedure review, observation, and interview, the facility failed to ensure blood pressure (BP) cuffs were maintained in that there was a build-up of threads in the hook portion of the Velcro which did not allow for effective cleaning and disinfection. The failed practice promoted the spread of infection from cross contamination. The failed practice had the likelihood to affect all 61 in-center hemodialysis patients on census and staff. The findings were: A. Review of the facility policy titled, “Infection Control for Dialysis Facilities” revised April 2023 showed, “non-disposable items are to be disinfected after each patient use, prior to removal from treatment area/station and if contaminated between use. If item cannot be cleaned and disinfected it will be dedicated for use on a single patient. At the end of each treatment, the dialysis station will be cleaned and disinfected. Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings (e.g. dialysis chair, tray tables, blood pressure cuffs) and frequently contacted by healthcare personnel (e.g., control panel; top, front and sides of dialysis machine; touchscreens; countertops).” B. On 01/29/25, during observation of initiation and termination of dialysis, showed BP (blood pressure) cuffs at Station #1, #4, #15, and #17 had a build-up of threads in the hook portion of the Velcro which did not allow effective cleaning and disinfection between patients. C. During an interview on 01/29/25 at 12:08 PM the Facility Administrator confirmed the findings in A and B.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 37145 Based on clinical record review, policy review, and interview, it was determined the Registered Nurse (RN) failed to assess, treat, and/or notify Physician of the blood pressure (BP) for four (#4, #6, #7, and #10) of seven (#4-#10) in center hemodialysis patients reviewed. The failed practice placed patients at risk for complications related to un-managed blood pressure. The failed practice had the likelihood to affect all 61 in-center hemodialysis patients on census. The findings were: A. Review of the facility ICHD (In-Center Hemodialysis) Fluid Management Protocol, revised 11/15/23, showed, “Purpose: to provide tools and processes to identify and manage patients whose fluid status could benefit from immediate intervention; ultimately, to optimize fluid management status and prevent fluid related hospitalizations and associated morbidities in adult in-center patients scheduled at least three times a week. TW (target weight) adjustment RN will; adjust TW using information collected during TW assessment based on TW adjustment table. The post weight VS (versus) Target weight trend table showed signs and symptoms of fluid overload (any or combination of the below): Shortness of breath, Rales, Edema, Productive cough, jugular vein distention, Hypertension as documented in the electronic health record. Important considerations Consult with the Physician before decreasing TW per this protocol for patients with frequent intradialytic hypotension, defined as: systolic blood pressure (SBP) < (less than) 100 mmHg (millimeters of mercury) (for patients with predialysis SBP < 160 mmHg) in at least 30 % of treatments in the last 30 days. SBP < 90 mmHg (for patients with predialysis SBP >= (greater than or equal to) 160 mmHg in at least 30% of treatments in the last 30 days. Consult with the Physician before increasing TW for patients with frequent pre-dialysis hypertension defined as: SBP > 160 mmHg in at least 30% of treatments in the last 30 days. A Physician Preference guide for CCHT (Certified Clinical Hemodialysis Technician) guide for notifying Registered Nurse showed, “Pretreatment- Notify RN for assessment before tx (treatment) start SBP > 180 or < 100 or DBP (Diastolic blood pressure) > 90 or < 50. Intradialytic monitoring notify RN if 20 mmHg increase or decrease in BP, signs and symptoms of hypotension. Post monitoring notify RN for SBP > 140 or < 100 or DBP > 90 or < 50.” B. Review of MAT (Measures Assessment Tool) showed the Euvolemic, and pre-treatment BP was to be < 140/90 and post-treatment was to be BP < 130/80. C. During an interview on 01/29/25 at 3:50 PM, RN #1 and RN #2 confirmed findings in A and B. D. Patient #4 1) Review of six TFS (treatment flow sheets), five of six treatments, 01/13/25 - 01/22/25, showed no evidence the RN assessed the patient’s pretreatment and/or post treatment BP, provided treatment, and/or notified Physician of findings. BP Examples: a) 01/13/25 - Pretreatment 181/84, Intradialytic 153/84, 158/86, Postdialytic 115/59 b) 01/15/25 - Pretreatment 162/75, Intradialytic 202/169, 211/80, 169/105, 167/103, 195/96, Postdialytic 211/80 c) 01/17/25 - Pretreatment 156/82, Intradialytic 156/105, 207/189, 185/164, 126/20, 79/51, Postdialytic 150/97 d) 01/20/25 - Pretreatment 152/52, Intradialytic 160/60, 87/60, 161/69, Postdialytic 160/97 e) 01/22/25 - Pretreatment 153/89, Intradialytic 151/86, 151/59, 100,80, 127/33, 124/104, Postdialytic 164/65 2) There was no evidence of an RN assessment for hypertension and no evidence of notification of the Physician for the trend of hypertension. 3) During the interview on 01/29/25 at 3:35 PM, the Facility Administrator confirmed the findings in D. E. Patient #6 1) Review of six TFS, five of six treatments, 01/13/25 - 01/22/25, showed no evidence the RN assessed the patient’s pretreatment, intradialytic, and/or post treatment BP, provided treatment, and/or notified Physician of findings. BP Examples: a) 01/13/25 - Pretreatment 156/75, Intradialytic 170/65, 88/27, Postdialytic 141/60 b) 01/15/25 - Pretreatment 172/93, Intradialytic 170/90, 182/82, 169/91, Postdialytic 164/85 c) 01/17/25 - Pretreatment 193/92, Intradialytic 164/53, 146/48, 82/61, 141/96, Postdialytic 171/73 d) 01/20/25 - Pretreatment 198/98, Intradialytic 172/92, 165/84, Postdialytic 157/80 e) 01/22/25 - Pretreatment 190/93, Intradialytic 182/91, 177/93, 150/64 2) There was no evidence of an RN assessment for blood pressures out of range, provided treatment, and/or notified Physician of findings. 3) During the interview on 01/29/25 at 3:30 PM, the Facility Administrator confirmed the findings in E. F. Patient # 7 1) Review of six TFS, six of six treatments, 01/13/25 - 01/24/25, showed no evidence the RN assessed the patient’s pretreatment, Intradialytic, and/or Post treatment BP. BP Examples: a) 01/13/25 - Pretreatment 165/93, Intradialytic 171/85, Post treatment 171/85. b) 01/15/25 - Pretreatment 177/74, Intradialytic 174/47, 93/50, 93/48, Post treatment 157/71 c) 01/17/25 - Pretreatment 188/87, Intradialytic 86/39, 88/44 d) 01/20/25 - Pretreatment 172/74, Intradialytic 214/96, 201/92 e) 01/22/25 - Pretreatment 164/79, Post treatment 156/77 f) 01/24/25 - Pretreatment 193/85, Intradialytic 156/74, 98/52 2) There was no evidence of an RN assessment for HTN, provided treatment, and/or notified Physician of findings. 3) During the interview on 01/29/25 at 3:30 PM, the Facility Administrator confirmed the findings in F. G. Patient #10 1) Review of six TFS, five of six treatments, 01/07/25 - 01/22/25, showed no evidence the RN assessed the patient’s pretreatment, Intradialytic, and/or Post treatment BP. BP Examples: a) 01/07/25 - Pretreatment 116/58, Intradialytic 86/46, 85/33,71/46, Post treatment 124/61. b) 01/13/25 - Pretreatment 148/76, Intradialytic 79/46, 85/41, 85/42, 78/50, 81/49, Post treatment 101/62 c) 01/17/25 - Pretreatment 170/90, Intradialytic 178/79, Post treatment 141/96 d) 01/20/25 - Pretreatment 172/90, Intradialytic 70/40, 87/51, Post treatment 104/61. e) 01/22/25 - Pretreatment 155/81, Intradialytic 83/45, 85/50, 88/47 2) There was no evidence of an RN assessment for HTN or Hypotension, provided treatment, and/or notified Physician of findings. 3) During the interview on 01/29/25 at 3:30 PM, the Facility Administrator confirmed the findings in G.”

“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: 37145 Based on clinical record review, policy review, and interview, it was determined the Interdisciplinary Team (IDT) failed to modify the patient’s plan of care (POC) for four (#4, #6, #7, and #10) of seven (#4-#10) in center hemodialysis patients when the patients’ blood pressure was outside established parameters. The failed practice placed patients at risk for complications related to un-managed blood pressure and fluid volume. The failed practice had the likelihood to affect all 61 in center hemodialysis. The findings were: A. Review of the facility ICHD (In Center Hemodialysis Fluid Management Protocol, revised 11/15/23, showed, “Purpose: to provide tools and processes to identify and manage patients whose fluid status could benefit from immediate intervention; ultimately, to optimize fluid management status and prevent fluid related hospitalizations and associated morbidities in adult in-center patients scheduled at least three times a week. TW (target weight) adjustment RN will; adjust TW using information collected during TW assessment based on TW adjustment table. The post weight VS (versus) Target weight trend table showed signs and symptoms of fluid overload (any or combination of the below): Shortness of breath, Rales, Edema, Productive cough, jugular vein distention, Hypertension as documented in the electronic health record. Important considerations Consult with the Physician before decreasing TW per this protocol for patients with frequent intradialytic hypotension, defined as: systolic blood pressure (SBP) < (less than) 100 mmHg (millimeters of mercury) (for patients with predialysis SBP < 160 mmHg) in at least 30 % of treatments in the last 30 days. SBP < 90 mmHg (for patients with predialysis SBP >= (greater than or equal to) 160 mmHg in at least 30% of treatments in the last 30 days. Consult with the Physician before increasing TW for patients with frequent pre-dialysis hypertension defined as: SBP > 160 mmHg in at least 30% of treatments in the last 30 days. A Physician Preference guide for CCHT (Certified Clinical Hemodialysis Technician) guide for notifying Registered Nurse showed, “Pretreatment- Notify RN for assessment before tx (treatment start SBP > 180 or < 100 or DBP (Diastolic blood pressure) > 90 or < 50. . Intradialytic monitoring notify RN if 20 mmHg increase or decrease in BP, signs and symptoms of hypotension. Post monitoring notify RN for SBP > 140 or < 100 or DBP > 90 or < 50.” B. Review of MAT (Measures Assessment Tool) showed the Euvolemic, and pre-treatment BP was to be < 140/90 and post-treatment was to be BP < 130/80. C. During an interview on 01/29/25 at 3:50 PM, RN #1 and RN #2 confirmed findings in A and B. D. Patient # 4 1) Review of six TFS (treatment flow sheets), five of six treatments,01/13/25 - 01/22/25, showed the following BP Examples: a) 01/13/25 - Pretreatment 181/84, Intradialytic 153/84, 158/86, Postdialytic 115/59 b) 01/15/25 - Pretreatment 162/75, Intradialytic 202/169, 211/80, 169/105, 167/103, 195/96, Postdialytic 211/80 c) 01/17/25 - Pretreatment 156/82, Intradialytic 156/105, 207/189, 185/164, 126/20, 79/51, Postdialytic 150/97 d) 01/20/25 - Pretreatment 152/52, Intradialytic 160/60, 87/60, 161/69, Postdialytic 160/97 e) 01/22/25 - Pretreatment 153/89, Intradialytic 151/86, 151/59, 100/80, 127/33, 124/104, Postdialytic 164/65 2) There was no evidence the IDT modified the POC related to the patient’s BPs outside of established parameters. 3) During the interview on 01/29/25 at 3:35 PM, the Facility Administrator confirmed the findings in D. E. Patient #6 1) Review of six TFS, five of six treatments, 01/13/25 - 01/22/25, showed the following BP Examples: a) 01/13/25 - Pretreatment 156/75, Intradialytic 170/65, 88/27, Postdialytic 141/60 b) 01/15/25 - Pretreatment 172/93, Intradialytic 170/90, 182/82, 169/91, Postdialytic 164/85 c) 01/17/25 - Pretreatment 193/92, Intradialytic 164/53, 146/48, 82/61, 141/96, Postdialytic 171/73 d) 01/20/25 - Pretreatment 198/98, Intradialytic 172/92, 165/84, Postdialytic 157/80 e) 01/22/25 - Pretreatment 190/93, Intradialytic 182/91, 177/93, 150/64 2) There was no evidence the IDT modified the POC related to the patient’s BPs outside of established parameters. 3) During the interview on 01/29/25 at 3:30 PM, the Facility Administrator confirmed the findings in E. F. Patient #7 1) Review of six TFS, six of six treatments, 01/13/25 - 01/24/25, showed the following BP Examples: a) 01/13/25 - Pretreatment 165/93, Intradialytic 171/85, Post treatment 171/85. b) 01/15/25 - Pretreatment 177/74, Intradialytic 174/47, 93/50, 93/48, Post treatment 157/71 c) 01/17/25 - Pretreatment 188/87, Intradialytic 86/39, 88/44 d) 01/20/25 - Pretreatment 172/74, Intradialytic 214/96, 201/92 e) 01/22/25 - Pretreatment 164/79, Post treatment 156/77 f) 01/24/25 - Pretreatment 193/85, Intradialytic 156/74, 98/52, 2) There was no evidence the IDT modified the POC related to the patient’s BPs outside of established parameters. 3) During the interview on 01/29/25 at 3:30 PM, the Facility Administrator confirmed the findings in F. G. Patient #10 1) Review of six TFS, five of six treatments, 01/07/25 - 01/22/25, showed the following BP Examples: a) 01/07/25 - Pretreatment 116/58, Intradialytic 86/46, 85/33, 71/46, Post treatment 124/61. b) 01/13/25 - Pretreatment 148/76, Intradialytic 79/46, 85/41, 85/42, 78/50, 81/49, Post treatment 101/62 c) 01/17/25 - Pretreatment 170/90, Intradialytic 178/79, Post treatment 141/96 d) 01/20/25 - Pretreatment 172/90, Intradialytic 70/40, 87/51, Post treatment 104/61. e) 01/22/25 - Pretreatment 155/81, Intradialytic 83/45, 85/50, 88/47 2) There was no evidence the IDT modified the POC related to the patient’s BPs outside of established parameters. 3) During the interview on 01/29/25 at 3:30 PM, the Facility Administrator confirmed the findings in G.”

“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: 37145 Based on observation and policy and procedure review, three of three (#8, #15, and #17) patients failed to cleanse their access with soap and water upon entering the treatment area. The failed practice did not ensure the patients’ access sites were cleaned prior to treatment and did not protect against the loss of access due to the likelihood of infection. The failed practice had the likelihood to affect all 61 in-center hemodialysis patients on census. The findings were: A. Review of the facility policy and procedure Infection Control For Dialysis Facilities revised April 2023, showed: “Patients and caregivers will be encouraged to wash their hands and access extremity upon entering the treatment area prior to the initiation of dialysis.” B. During observation of termination and initiation of dialysis on 01/28/25 from 8:30 AM through 11:00 AM Patients #8, #15, and # 17 entered the treatment area and proceeded to assigned stations without washing their hands or access sites. C. On 01/29/25 at 11:06 AM, the Administrator confirmed findings in A-B.”