Johnson Dialysis Center LLC

“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: 40153 Based on observations, interviews, and record review, the facility failed to ensure non-disposable equipment was cleaned between patients for 2 of 6 patients observed during hemodialysis treatments (Patient #6 and Patient #11). The findings included: A chart review revealed Patient #6 was admitted to the facility on 04/03/2025 for in-center hemodialysis. A chart review revealed Patient #11 was admitted to the facility on 10/17/2022 for in-center hemodialysis. In an observation conducted on 07/28/25 at 11:40 AM, the Medical Director was observed wearing a lab coat from outside into the Patient’s dialysis treatment room. He donned a pair of clean gloves without performing hand hygiene and walked over to Patient #6 and touched her feet, took another clean glove with his dirty gloves, placed his stethoscope inside the glove, and continued to touch Patient #6 with his stethoscope. Continued observation showed the Medical Director removing his dirty gloves and putting on another pair of gloves without performing hand hygiene. He walked over to Patient #11 and touched his shoulder with his gloves. He then took another clean glove, placed his stethoscope inside it, and continued to touch the Patient with his stethoscope. In an interview conducted on 07/20/2025 at 8:50 AM with the facility’s Administrator, he was made aware of the findings.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 47207 Based on observation and interview, the facility failed to provide a clean environment for the initiation of dialysis for 1 of 1 patient observed. (Patient #4) PCT (S 8) was observed on July 28th around 11 AM initiating the process of dialysis via CVC (Central Venous Catheter) for Patient (P4). The patient was seated in the chair and her jacket was unzipped and opened to expose the Central Venous Catheter (CVC) dressing. After removing the dressing from the site, the jacket and shirt fell onto the exposed skin and CVC site. PCT (S8) moved the jacket and clothing from the area he applied an antiseptic to the area, however, the jacket had again touched the exposed area. The PCT(8) then applied the clean dressing to the area. An interview with the PCT (8) when asked why he had not moved the jacket and secured it away from the area, PCT (P8) he stated the patient was cold.”

“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: 47207 Based on observation and interviews, the facility failed to provide adequate emergency supplies/equipment in the evacuation cart. The findings included: During observation of the Emergency Evacuation cart on 7/28/2025 around 12:30 PM, the log for the Evacuation cart was also reviewed. The log of the contents indicated “Saline 1000 ML bags “6”. The Staff F (RN) confirmed this cart is for evacuation in the event of an emergency. The surveyor inquired regarding the number of Saline Bags and the RN confirmed they have 6 bags and 16 patients. The emergency evacuation cart does not have one saline bag for each dialysis chair in the facility. The RN stated, “Okay, I will get 10 more bags.””

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 40153 Based on observations, interviews, and record review, the facility failed to ensure that the dialysis access site was visible during hemodialysis treatment for 1 of 6 patients observed (Patient #7). The findings included: A chart review showed Patient #7 was admitted to the facility on 07/25/2025 for in-center hemodialysis. In an observation conducted on 07/28/25 at 11:24 AM in the main dialysis treatment room, Patient #7 was receiving dialysis treatment via Arteriovenous (AV) Fistula. A closer observation revealed her dialysis access site was entirely covered by a heavy blanket. In this observation, Patient #7 said she was never educated by staff to ensure that her access site was visible during the entire dialysis treatment. In an interview conducted on 07/29/2025 at 8:50 AM with the facility’s Administrator, he was made aware of the findings.”

“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: 40153 Based on observations, interviews and record review, the facility failed to obtain immunization history regarding Hepatitis B vaccination for 1 of 4 patients reviewed (Patient #1). The findings included: A review of the facility’s policy titled “Hepatitis Surveillance, Vaccinations, and Infection Control Measures” dated 07/29/2025 revealed the following: Hepatitis B vaccination must be considered for all susceptible dialysis patients who does not have adequate antibody protection for Hepatitis B. A record review revealed Patient #1 was admitted to the facility on 06/20/2025 for in-center hemodialysis. Patient #1 labs revealed the patient was negative for Hepatitis B immunity on 06/04/2025. Further review did not reveal Patient #1 was offered the Hepatitis B vaccine by the facility. In an interview conducted on 07/28/25 at 3:00 PM with the Administrator, he acknowledged the findings.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 40153 Based on interviews and record reviews, the facility failed to follow the dialysis prescription for Blood Flow Rate (BFR) for 2 of 4 patients reviewed for dialysis (Patient #1 and Patient #2). The findings included: A review of the facility’s policy titled “Notations and Execution of Physicians’ Orders” dated May 27, 2008 documents the following: “orders to be carried out during the current patient treatment shall be transcribed to the current dialysis flow sheet of that patient.” 1. A chart review revealed Patient #1 was admitted to the facility on 06/20/2025 for Hemodialysis. A physician order dated 07/25/2025 documents BFR between 350 to 400. A treatment sheet dated 07/28/2025 showed the following BFRs recorded: 244, 343, and 344. The facility did not follow the BFR order for ranges between 350 to 400. There was no documentation/rationale as to the reason for the deviation from the order. 2. A record review revealed Patient #2 was admitted to the facility on 02/26/2025 for in-center Hemodialysis. The Dialysis Order Report dated 07/11/2025 revealed a physician order for BFR between 350 to 400. A review of the Hemodialysis Treatment Flow Sheet dated 07/28/2025 documents the following: the BFR was 300, 300, 300, 300, 315, 250, 250, 250, 250, 250, 250, 250, and 165. There is no documentation/rationale for the deviation from the prescription order of 350 to 400 range. An interview was conducted on 07/29/25 at 9:00 AM with the facility’s Administrator, and he was made aware of the findings.”