Davita Willard Avenue Dialysis

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 47491 Based on observations, facility documentation, facility policy and interviews, the facility failed to provide a clean and sanitary environment. The findings included: 1. Observations conducted in the lobby of the facility on 11/20/24 identified the following: a. Staff Person #7 entered the lobby wearing his/her dialysis gown bringing a patient into the clinic for treatment. Interview Staff Person #7 on 11/20/24 at 9:35 AM identified he/she should have removed his/her dialysis gown prior to entering the lobby. Review of the Infection Control for Dialysis Facilities policy directed staff to remove personal protective equipment (gowns, gloves, eye protection, face shield) prior to leaving the treatment area.”

“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: 44675 Based on observation, interview and review of facility policy the facility failed to ensure staff hand hygiene was performed per facility policy and that patient’s performed hand hygiene after applying pressure to their access sites following treatment. The findings included: Observations conduced on 11/18/24, 11/19/24 and 11/20/24 identified the following: 1a. On 11/18/24 at 10:05 AM Staff Person #1 was observed with gloves on, removing the used hemodialysis setup at Station #7. Staff Person #1 then discarded her gloves and put on new gloves without the benefit of hand hygiene. Staff Person #1 then proceeded to Station #7 to change the gauze from Patient #31’s first needle that was removed from his/her bleeding arteriovenous graft (AVG). She then removed Patient #31’s second needle, removed her gloves, closed the lid to the sharps container and moved the sharps container to the center of the treatment floor without the benefit of hand hygiene. Staff Person #1 then put on new gloves, went to Station #5 where Patient #32 was treating, touched the hemodialysis lines and removed her gloves without the benefit of hand hygiene. Staff Person #1 put on new gloves, grabbed the sharps container and biohazard bin with gloved hands and brought them over to Station #5 and terminated Patient #32’s treatment without the benefit of performing hand hygiene after touching the dirty equipment. b. On 11/18/24 at 10:15 AM Staff Person #1 had gloves on and took the sharps container and biohazard bin with gloved hands and brought it to Station #5. She then removed the used hemodialysis setup, removed her gloves and without the benefit of hand hygiene proceeded to Station #5, removed Patient #32’s blood pressure cuff and removed his/her hemodialysis needles from his/her arteriovenous fistula (AVF). She then took the sharps container and biohazard bin and moved it to the center of the clinic floor. With the same gloves, Staff Person #1 applied sanitizer to her gloved hands and touched the clean machine in testing at Station #4. c. On 11/18/24 at 10:20 AM Staff Person #1 went to Station #5 with gloved hands and taped up Patient #32’s AVF needle sites and without the benefit of removing her gloves and performing hand hygiene, she proceeded to Station #4 to initiation hemodialysis treatment for Patient #33 (including placing needles into Patient #33’s AVF). The Director of Clinical Services was notified at 10:21 AM of the concerns of infection control and improper hand hygiene of Staff Person #1. Subsequently, after the Director of Clinical Services observed improper hand hygiene of Staff Person #1, she provided re-education on hand hygiene, including performing hand hygiene after glove removal and prior and after use of the clean chairside cart to Staff Person #1 immediately. d. On 11/18/24 at 1:30 PM Staff Person #3 applied gloves, reset an alarm at Station #13, removed her gloves without the benefit of hand hygiene and typed on the computer at the clean chairside cart. At 1:34 PM Staff Person #3 applied gloves, reset Station #13’s alarm and removed her gloves without the benefit of hand hygiene. At 1:39 PM Staff Person #3 applied gloves, reset Station #13’s alarm and removed her gloves without the benefit of hand hygiene. At 1:40 PM Staff Person #3 again applied gloves, reset Station #13’s alarm and removed her gloves without the benefit of hand hygiene. e. On 11/18/24 at 2:00 Staff Person #3 put on new gloves, grabbed the sharps container with gloved hands and brought it over to Station #13 and terminated Patient #20 treatment without the benefit of performing hand hygiene after touching the dirty equipment. The Director of Clinical Services was notified at 2:01 PM of the concerns of infection control and improper hand hygiene of Staff Person #3. f. On 11/19/24 at 9:39 AM Staff Person #4 with gloved hands, went to Station #15 and reset Patient #35’s alarm and then removed her gloves without the benefit of hand hygiene. g. On 11/19/24 at 9:42 AM Staff Person #3 with gloved hands, went to Station #13 and reset Patient #7’s alarm and then removed her gloves without the benefit of hand hygiene. h. On 11/19/24 at 9:49 AM Staff Person #3 with gloved hands, went to Station #16 and removed Patient #5’s hemodialysis AVF needles. Staff Person #3 then proceeded Station #17, removed her right glove, kept on her left glove, took out a clean glove from the clean chairside cart, applied the clean glove to her right glove with her left hand and reset the alarm at Station #17 without proper glove removal and hand hygiene between patient stations. i. On 11/19/24 at 9:56 AM Staff Person #5 with gloved hands, went to Station #9 and tapped Patient #38’s hemodialysis AVF needles. Staff Person #5 then took the thermometer off the clean chairside cart and proceeded to take the patient’s temperature and placed the thermometer back on the chairside cart without the benefit of changing gloves and performing hand hygiene. On 11/19/24 the Manager of Clinical Services (MCS)was notified at 2:30 PM of the concerns of infection control and improper hand hygiene of multiple staff members, the MCS identified that the facility would immediately start education on hand hygiene j. On 11/20/24 at 9:29 AM, Staff Person #6 failed to remove his/her gloves after disinfecting Station #4 and before disinfecting Station #5. k. On 11/20/24 at 9:40 AM Staff Person #3 removed her gloves after being in Station #13 and proceeded to reset an alarm at Station #11 without the benefit of hand hygiene. Staff Person #3 proceeded back to Station #13 without the benefit of hand hygiene before applying a new pair of gloves. l. On 11/20/24 at 9:50 AM, Staff Person #5 was observed moving a walker at Station #6 while wearing gloves, had removed his/her gloves, obtained gloves for Patient #28 without first performing hand hygiene and applied new gloves to his/her own hands without performing hand hygiene. Staff Person #5 again removed his/her gloves, retrieved the portable sharps container, and put on a new pair of gloves without performing hand hygiene. Staff Person #5 then removed the arterial and venous needles from Patient #28’s access, brought the used dialysis lines and dialyzer to the hazardous waste bucket, touched the 1:100 bleach solution container with the same gloves worn after removing Patient #28’s needles, removed his/her gloves and started typing on the computer next to Station #6 without performing hand hygiene. After applying new gloves, Staff Person #5 took Patient #28’s temperature and the patient’s temperature at Station #7, removed his/her gloves and performed hand hygiene prior to using the computer. Staff Person #5 then applied new gloves, checked the pH level of the dialysis machine at Station #5, removed his/her gloves without performing hand hygiene, applied new gloves to check Patient #28’s access (touching his/her access area), removed his/her gloves without performing hand hygiene, applied new gloves and attached the Hansen tubing to the dialyzer at Station #4, removed his/her gloves without performing hand hygiene, pressed the auto door opener to let a patient into the clinic, applied new gloves without performing hand hygiene and set-up Station #4’s dialysis supplies (needles, gauze, alcohol wipes, and tape) for use. Staff Person #5 proceeded to clean Patient #29’s arm at Station #4 to prepare for cannulation, changed his/her gloves without performing hand hygiene, cannulated Patient #29’s left arm access, applied gauze, tape, and connected the dialysis lines to the access. Staff Person #5 then removed his/her gloves and touched the mouse and keyboard of the computer next to Station #4 without performing hand hygiene, applied new gloves, touched the dialysis machine (starting Patient #29’s treatment), removed his/her gloves and then performed hand hygiene. 2a. On 11/18/24 at 2:12 PM, Patient #23 was observed holding his/her hemodialysis access site with his/her gloved right hand. Patient #23 removed the glove at 2:17 PM and did not perform hand hygiene, walked to the weigh station, pressed a button at the weight station with his/her right hand, provided the staff member his/her weight printout, and then was provided hand sanitizer before leaving the clinic. b. On 11/20/24 at 10:05 AM, Patient #28 was observed holding his/her hemodialysis access sites with his/her gloved right hand. At 10:09 AM, Patient #28 removed his/her glove and did not perform hand hygiene, walked to the weight station, placed his/her right hand on the railing at the weight station, put on his/her coat and exited the facility without performing hand hygiene. Interview with Staff Person #1 on 11/19/24 at 2:50 PM identified patients should perform hand hygiene after holding his/her access and removing his/her glove as to prevent cross contamination when the patient’s unclean hand encounters surfaces in the clinic (for example, the weigh station). Interview with Staff Person #8 on 11/20/24 identified he/she forgot to provide Patient #28 with hand sanitizer after holding his/her sites following treatment and that facility practice was to have the patient perform hand hygiene after holding his/her access site. Review of the infection control for dialysis facilities policy directed that all teammates and physicians will perform hand hygiene prior to gloving and immediately after removal of gloves, after contamination with blood or other infectious material, after patient and dialysis delivery system contact, between patients even if the contact is casual and before touching clean areas such as supplies, supply cart and chairside keyboard/mouse. The policy further directed gloves should be changed when going from a “dirty” area or task to a “clean” area or task and after touching one patient or their dialysis delivery system and before arriving to care for another patient or touch another patient’s dialysis delivery system. The policy identified the chair side cart terminals mounted on the counter, monitor and keyboard are considered clean areas. Additionally, the policy identified that patients are encouraged to wash their hands upon entering the treatment area and wash their hands before leaving the treatment area.”

“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: 44675 Based on observation, interview and review of facility policy the facility failed to ensure staff disinfected multiuse patient equipment after patient use per facility policy. The finding included: a. Observations conduced on 11/18/24 at 10:20 AM, Staff Member #2 took a stethoscope that was hanging off a wall and listened to the patient at Station #4’s heart and lungs. Staff Member #2 then placed the stethoscope back on the wall (a clean area)without disinfecting the stethoscope after patient use. b. Observations conducted on 11/19/24 t 9:56 AM Staff Person #5 with gloves on, taped up the patient’s hemodialysis access at Station #9. Staff Person #5 then took the thermometer off the clean chairside cart and proceeded to take the patient’s temperature and placed the thermometer back on the chairside cart without the benefit of performing hand hygiene and disinfecting the thermometer after patient use before placing it back to a clean area. c. Observations conducted on 11/19/24 at 1:50 PM identified Staff Person #4 disinfecting Station #11 after a hemodialysis treatment. Staff Person #4 removed the used oxygen concentrator from Station #11 and placed it at the nursing station (a clean area) without disinfecting it. d. Observations conducted on 11/20/24 at 9:45 AM identified Staff Member #3 took her stethoscope from around her neck to auscultate the patients’ lungs and heart rate at Station #12. Staff Member #3 then put the stethoscope back around her neck without disinfecting the stethoscope after patient use. Review of the infection control policy directed that non-disposable items are to be disinfected after each patient use, prior to removal from treatment area/station and if contaminated between uses. The chair side cart terminals mounted on the counter, monitor and keyboard are considered clean areas.”

“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: 47491 Based on observation and review of facility policy, the facility failed to clean and disinfect the hemodialysis station after hemodialysis treatment in accordance with facility policy. The findings included: a. Observation conducted on 11/19/24 at 2:20 PM identified Staff Person #1 placing a bleach rag on top of the dialysis machine at Station #3 prior to the patient vacating the station. Furthermore, upon disinfecting the chair at Station #3 following a patient’s treatment, failed to clean the outer sides of the chair. b. Observation conducted on 11/20/24 at 9:25 AM identified Staff Person #5 cleaning the dialysis machine at Station #4, however he/she failed to disinfect the hoses located in front of the machine, the Hansen hoses on the side of the machine, the IV pole, the left side of the machine, the counter in back of the station, and the television screen and arm following a patient’s treatment. Upon cleaning the chair at Station #4, Staff Person #5 failed to extend the recliner of the chair when disinfecting the chair. c. Observation conducted on 11/20/24 at 9:29 AM identified Staff Person #5 disinfecting the dialysis machine at Station #5, however he/she failed to disinfect the hoses located in front of the dialysis machine, the hoses connected to the Hansen’s, the IV pole, the left side of the machine, the counter in back of the station, the television screen and arm, and the prime bucket. Upon cleaning the chair at Station #5, Staff Person #5 failed to extend the recliner of the chair when disinfecting the chair. Review of the infection control for dialysis facilities policy directed at the end of each treatment, the dialysis station will be cleaned and disinfected. It directed the wall box, drain and watery supply lines are considered part of the dialysis delivery system. It further directed to disinfect all surfaces in touch with the patient or their belongings and surfaces frequently contacted by healthcare personnel.”

“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: 44675 Based on a review of clinical records, interview, and policy review for one (1) of four (4) hemodialysis patients reviewed for hepatitis (Patient #6), the facility failed to ensure the patient was educated and offered the hepatitis B vaccination when the patient became susceptible to the hepatitis B virus in accordance with facility policy. The findings include the following: Patient #6 was admitted with diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis three times (3)weekly for three (3) hours and thirty (30) minutes with a left central venous catheter (CVC). Review of Patient #6’s hepatitis B antibodies dated 2/8/24 identified Patient #6’s antibodies were sixteen (16). On 8/27/24 Patient #6’s antibodies were less than three (3) (3 or less indicates that the patient was susceptible to the Hepatitis B virus). Review of Patient #16’s medical record identified Patient #16 had no Energix vaccinations (Hepatitis B vaccination) on file as administered. Interview with the Clinical Specialist on 11/19/24 at 2:40 PM identified Resident #6 should have been offered the Hepatitis B vaccine when their antibodies drop below ten (10, susceptible of the Hepatitis B vaccine). Review of the hepatitis B surveillance, vaccination, infection control measures and isolation guidance policy directed for an antibody less than ten (10) and core negative, the patient is susceptible to hepatitis B and to offer the vaccination series. It further directed that results will be reviewed promptly to verify that patients are managed appropriately based on their testing results.”

“IC-CATHETERS:GENERAL CFR(s): 494.30(c)(2) (2) The “Guidelines for the Prevention of Intravascular Catheter-Related Infections” entitled “Recommendations for Placement of Intravascular Catheters in Adults and Children” parts I - IV; and “Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients,” Morbidity and Mortality Weekly Report, volume 51 number RR-10, pages 16 through 18, August 9, 2002. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR Part 51. This publication is available for inspection as the CMS Information Resource Center, 7500 Security Boulevard, Central Building, Baltimore, MD or at the National Archives and Records Administration (NARA). Copies may be obtained at the CMS Information Resource Center. For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_regulations/ibr_locations.html This Standard is not met as evidenced by: 44675 Based on observation, interview and review of facility policy for one (2) of three (4) patients (Patient #25 and #30) reviewed for catheter care, the facility failed to ensure staff donned personal protective equipment appropriately per facility policy. The finding included: 1. Patient #25 had diagnoses that included end stage renal disease. Review of the physician’s orders directed hemodialysis three (3) times weekly for three (3) hours utilizing a central venous catheter (CVC). Observations conducted on 11/19/24 at 2:34 PM identified Staff Person #6 disconnecting Patient #25’s CVC from both the arterial and venous blood lines at the end of his/her dialysis treatment, inserting heparin solution into each limb of the CVC, and applying end caps to each limb of the CVC while Patient #25’s mask was only covering his/her mouth. Interview with Staff Person #6 identified Patient #25’s mask should have been covering both his/her nose and mouth during the disconnection/termination of treatment process and indicated it must have slid down while he/she was terminating Patient #25’s treatment. Staff Person #6 further indicated he/she should have adjusted the patient’s mask to cover his/her nose to prevent infection/cross contamination. 2. Patient #30 was admitted to the facility with diagnoses that included end stage renal disease. Patient #30’s physician orders included hemodialysis treatment three (3) times a week for three (3) hours and thirty (30) minutes with a left central venous catheter (CVC). Observations conducted on 11/19/24 at 1:37 PM identified Staff Person #5 discontinuing Patient #30’s hemodialysis treatment. Staff Person #5 had a mask on, however was observed with his mask not covering his nose throughout the duration of the procedure. Review of the central venous catheter procedure directed to put on PPE and provide a mask to the patient. The teammate and patient will wear masks covering the nose and mouth during the procedure. It identified those measures are vital to preventing the exposure of the catheter and exit sit to nasal droplets and infectious bacteria such as MRSA.”

“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: 32738 On 11/19/24 at approx. 9:30 AM and during document review, the facility failed to maintain a building that was constructed and maintained to ensure the safety of the patients, the staff and the public. The findings include the following: a. Documentation was not provided to indicate that the fire drills are being conducted , as required by section # 21.7.1.6 of the “Life Safety Code”; i.e. there is no indication that fire drills were done in the 4th quarter of 2023/2024.”

“PA-IMMUNIZATION/MEDICATION HISTORY CFR(s): 494.80(a)(3) The patient’s comprehensive assessment must include, but is not limited to, the following: Immunization history, and medication history. This Standard is not met as evidenced by: 47491 Based on clinical record review, interviews, and review of facility documentation for one (1) of four (4) patients (Patient #9), reviewed for vaccinations, the facility failed to properly assess a patient for tuberculosis in accordance with facility policy. The findings included: Patient #9 was admitted to the facility on 6/29/24, had diagnoses which included end stage renal disease, a physician’s order for hemodialysis treatments three (3) times weekly for three (3) hours and thirty (30) minutes, using an upper left arm arteriovenous fistula. Review of Patient #9’s Vaccination and Surveillance Report identified a TB RAQ (Tuberculosis Risk Assessment) was completed on 7/30/24, however there were no TST (Tuberculosis Skin Test) administered until 10/17/24 (three (3) months and eighteen (18) days following admission to the facility. Interview with Facility Administrator #2 on 11/20/24 at 1:48 PM identified the facility utilized chest x-ray results dated 6/24/24 to clear the patient for admission to the facility, however follow-up tuberculosis skin tests (TST’s) were not performed in accordance with facility policy. The Facility Administrator #2 further indentified he/she was unable to identify why the TST’s were not administered. Review of the facility’s Tuberculosis Infection Control Policy directed to administer the initial TST following admission and a second TST one to three weeks following admission or draw a QuantiFERON (a blood test used to identify if a person has been exposed to tuberculosis).”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 44675 Based on observation, interview and review of facility policy for six (6) of six (6) Patients (Patient #10, #11, #12, #13, #14 and #15) the facility failed to ensure pre-drawn medications were appropriately labeled in accordance with facility policy, for six (6) of six (6) patients (Patient # 17, 18, 19, 20, 21, and 22) reviewed for medications, the facility failed to ensure that medications were prepared timely in accordance with facility policy, for one (1) of four (4) patients (Patient #1), reviewed for treatment adherence, the facility failed to ensure the patient completed an against medication advice form for early termination of treatment and document in the medical record per facility policy, the facility failed to discard expired supplies and update patient clinical and contact information in the emergency evacuation boxes, and failed to discard/properly label expired peritoneal dialysis solution. The findings included: 1. During the flash tour of the facility treatment floor on 11/18/24 at 9:15 AM identified medication syringes were drawn for second shift patients with no initials of the staff member who drew the medications and the time drawn: a. Patient #10’s Heparin 6,000 units bolus and 400 units/hour maintenance. b. Patient #11’s Heparin 1,000 units bolus, 800 units/hour maintenance 2,000 units arterial intra-catheter and 2,000 units venous intra-catheter. c. Patient #12’s Heparin 1,500 units bolus and 800 units/hour maintenance. d. Patient #13’s Heparin 800 units bolus and 400 units/hour maintenance. e. Patient #14’s Heparin 1,000 units bolus, 800 units/hour maintenance, 2,100 units arterial intra-catheter and 2,200 units venous intra-catheter. f. Patient #15’s Heparin 3,000 units bolus and 600 units/hour maintenance. Review of the medication: handling, administration, storage and disposal policy directed any medication drawn up before the time it is to be administered shall be labeled with the date/time the medication was drawn up and the initials of the nurse who drew up the medication. 2a. Patient #17 had a diagnosis of end stage renal disease and required hemodialysis three (3) times weekly. Physician’s orders dated 11/18/24 directed to administer 2000 units of heparin prior to the initiation of hemodialysis treatment. b. Patient #18 had a diagnosis of end stage renal disease and required hemodialysis three (3) times weekly. Physician’s orders dated 11/18/24 directed to administer 1000 units of heparin prior to the initiation of hemodialysis treatment and 800 units of heparin during dialysis treatment. c. Patient #19 had a diagnosis of end stage renal disease and required hemodialysis three (3) times weekly. Physician’s orders dated 11/18/24 directed to administer 3000 units of heparin prior to the initiation of hemodialysis treatment. d. Patient #20 had a diagnosis of end stage renal disease and required hemodialysis three (3) times weekly. Physician’s orders dated 11/18/24 directed to administer 800 units of heparin prior to the initiation of hemodialysis treatment. e. Patient #21 had a diagnosis of end stage renal disease and required hemodialysis three (3) times weekly. Physician’s orders dated 11/18/24 directed to administer 1400 units of heparin prior to the initiation of hemodialysis treatment and 800 units of heparin during dialysis treatment. Observations on 11/18/24 at 9:25 AM during the flash tour of the medication preparation area on the treatment floor identified Patient #17 through Patient #21’s heparin syringes were prepared, however the medication label on each syringe identified above, with the exception of Patient #21, had a preparation time of 10:00 AM (timed 30 minutes after the observation). Patient #21 had a preparation time of 6:00 AM, however did not start treatment until 10:52 AM (four (4) hour and fifty-two (52) minutes after it was drawn. Interview with Staff Person #3 on 11/18/24 at 9:47 AM identified that heparin should be prepared within two (2) hours of use and that the time stamp on the label should be at the time the medication was poured/prepared. Staff Person #3 further identified he/she was unable to recall the exact time the heparin was drawn, however indicated it was not at 6:00 AM that morning. Review of the Medication Policy directed all syringes prepared from single use vials/ampules or multidose vials should be prepared and administered within a four (4) hour period and for medications not immediately administered or administered by another teammate, the medication must be labeled with the patient name, name of the medication, date, time prepared, dose and initials of the teammate preparing the medication. 3a. Patient #17 had a diagnosis of end stage renal disease and required hemodialysis three (3) times weekly. Physician’s orders dated 11/18/24 directed to administer Cinacalet HCl 30 milligrams during each hemodialysis treatment. b. Patient #18 had a diagnosis of end stage renal disease and required hemodialysis three (3) times weekly. Physician’s orders dated 11/18/24 directed to administer Calcitriol 0.25 micrograms during each hemodialysis treatment. c. Patient #19 had a diagnosis of end stage renal disease and required hemodialysis three (3) times weekly. Physician’s orders dated 11/18/24 directed to administer Calcitriol 0.75 micrograms during each hemodialysis treatment. d. Patient #20 had a diagnosis of end stage renal disease and required hemodialysis three (3) times weekly. Physician’s orders dated 11/18/24 directed to administer Calcitriol 0.25 micrograms during each hemodialysis treatment. e. Patient #21 had a diagnosis of end stage renal disease and required hemodialysis three (3) times weekly. Physician’s orders dated 11/18/24 directed to administer Calcitriol 1.0 micrograms during each hemodialysis treatment. f. Patient #22 had a diagnosis of end stage renal disease and required hemodialysis three (3) times weekly. Physician’s orders dated 11/18/24 directed to administer Cinacalcet 150 milligrams during each hemodialysis treatment. Observations on 11/18/24 at 9:25 AM during the flash tour of the medication preparation area on the treatment floor identified that although Patient #17 through Patient #22’s aforementioned medications were stacked in medication cups with the initials and time filled on the label, the medications poured were for patients on the following shift (before the patients were in the facility), and the time the medications were prepared was 10:00 AM (forty-five (35) minutes after the observation was made). Interview with the Clinical Coordinator on 11/20/24 at 1:23 PM identified staff was to wait for patients to arrive in the facility and brought to their station (physically in their station) before preparing their medication(s). Review of the medication administration policy identified medication preparation should be performed only for the current shift of patients, for example, do not prepare medications for more than one shift of patients. 4. Patient #1 was admitted to the facility with diagnoses that included end stage renal disease. Patient #1’s physician orders included hemodialysis treatment three times a week for three hours and thirty minutes, 2.0 K 2.5 Ca dialysate, estimated dry weight (EDW) of 71 kg and blood flow rate of 400. Review of Patient #1’s hemodialysis flowsheets identified the following: a. On 11/2/24 Patient #1 received 2 hours and 54 minutes of treatment (36 minutes short of the prescribed treatment time) with no documentation as to why Patient #1’s prescribed treatment time was not met and if the physician was notified. Review of Patient #1’s medical record identified no against medical advice (AMA) form was reviewed and completed. b. On 11/16/24 Patient #1 received 3 hours of treatment (30 minutes short of the prescribed treatment time) with no documentation as to why Patient #1’s prescribed treatment time was not met and if the physician was notified. Review of Patient #1’s medical record identified no against medical advice form was reviewed and completed. Review of the prescribed treatment time not met policy directed that the registered nurse will verify that a patient signs the early termination of treatment against medical advice form any time the patient requests to terminate their treatment earlier than the prescribed run time. 4. Survey of the contents of the emergency evacuation boxes on 11/18/24 at 9:50 AM identified the following: a. A package of band-aids with an expiration date of 11/3/24. b. Thirteen (13) packages of Fifteen (15) gauge needles with an expiration date 7/31/24. c. Patient Summary Report (which includes all patient’s dialysis prescriptions, current medications, vaccination history, treatment data, and current lab results) dated 9/18/23 - 4/12/24. d. Patient Contact List (with contact and transportation information) dated 4/8/24. Interview with the Charge Nurse on 11/18/24 at 10:00 AM identified facility practice was to audit the emergency cart contents monthly, discard expired supplies on or prior to the date of expiration, update the Patient Summary Report and Patient Contact Lists on a monthly basis, that it was the Clinical Coordinator’s responsibility to ensure the aforementioned reports were printed on a monthly basis, and was unsure as to why these documents weren’t updated. Review of the emergency equipment checks policy directed the facility administrator or designee to review the contents of the emergency evacuation kit(s) and replace missing or expired supplies at least monthly. Review of the Facility Emergency Management Plan directed the evacuation kit(s) should contain a copy of each patient’s treatment orders and medication list and update or replace them at least monthly. 5. Observations made in the Peritoneal Dialysis storage area on 11/19/24 at 8:45 AM identified two (2) cases of 4.25% dialysate solution, 2,000 milliliter bags, and two (2) cases of 2.5% dialysate solution, 2,000 milliliter bags, with expiration dates of July 2024. Interview with the Peritoneal Dialysis Nurse on 11/19/24 at 8:50 AM identified the solutions listed above were expired and if they were to be kept, should be marked “for training use only” or disposed of. The Peritoneal Dialysis Nurse further identified all four cases were not marked “for training use only”. Review of the Infection Control for Dialysis Facilities policy directed the expiration date and package integrity would be verified prior to use.”