Lakes Dialysis Center

“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: 40153 Based on observations, interviews and records review, the facility failed to: 1) encourage hand hygiene post treatments for 3 of 18 sampled patients (Patient #11, Patient #12 and Patient #14); 2) practice hand hygiene during observation of Central Venous Catheter (CVC) connection for 2 of 18 sampled patient (Patient #13); 3) change gloves during Arteriovenous (AV) fistula initiation for 1 of 18 sampled patients (Patient #2) 4) change gloves and practice hand hygiene during disconnection of AV fistula for 1 of 18 sampled patient (Patient #2). The findings included: A review of the facility’s policy titled “Infection Control/Hand Washing” dated 11/01/2010 shows the following: hand hygiene must be performed every time gloves are removed. Gloves are not entirely free of leaks or 100% tear-proof, and hands may become contaminated when gloves are removed. It further showed how to instruct patients and family on the importance of hand hygiene, proper technique, and ways to incorporate routines into everyday practice. 1. A record review revealed Patient #11 was admitted to the facility on 09/06/2013 for in-house hemodialysis. In an observation conducted on 09/03/2025 at 12:03 PM, Patient #11 completed his hemodialysis treatment at station #16. Staff T/ Patient Care Technician (PCT) escorted Patient #11 to the exit door and did not remind or encourage Patient #11 to wash their hands. 2. A record review showed Patient #12 was admitted to the facility for in-house hemodialysis on 11/29/2024. On 09/03/2025 at 12:10 PM, Patient #12 completed his hemodialysis treatment at Station #11. Staff U/PCT escorted Patient #12 to the exit door and did not remind or encourage Patient #12 to wash their hands. 3. A record review revealed Patient #14 started in house hemodialysis on 02/26/2025. On 09/04/25 at 12:45 PM, Patient #14 completed her hemodialysis treatment at Station #8. Staff V/ PCT escorted Patient #14 outside and did not remind or encourage Patient #14 to wash their hands. 4. In an observation conducted on 09/03/25 at 12:12 PM, Staff S/PCT was noted at station #7, disconnecting the AV fistula access site on Patient #2. He was observed cleaning his hands and putting on a pair of new gloves. He removed multiple dirty tapes from the access site and taped them on the top of one gloved hand. He removed the tapes from the top of the glove and placed them on the dirty surface. He then proceeded to take a clean piece of tape and put it on top of the one glove that had previously had dirty tape on it. Staff S/ PCT proceeded to take the clean tape and place it around the access site. 5. In an observation conducted on 09/03/2025 at 12:24 PM, Staff U/ PCT, was noted at station #13 performing the connection of a CVC for Patient #13. Staff U/ PCT cleaned her hands, placed a pair of clean gloves, touched Patient #13’s shirt, and proceeded to touch the access site. Staff U/PCT removed her gloves, cleaned her hands, and placed a new pair of gloves. She then touched the metal bar on the dialysis machine with her cleaned hands and proceeded to touch the access site without practicing hand hygiene beforehand. Continued observation showed Staff U/PCT taking her gloves off, and without practicing hand hygiene, grabbed a pair of green clips and placed them on top of the clean surface. She continued to put on a pair of new gloves without practicing hand hygiene, then touched the dialysis machine and the access site. 6. In an observation on 9/03/2025 at approximately 2:12 PM, Staff S/PCT, was observed preparing the CVC access site for dialysis. He pushed back Patient #2’s shirt and jacket with tape from the access site. He then removed the dressing from the arterio and venous access ports and proceeded to clean each and replace the old ports with new sterile ports, as he turned away, the shirt and jacket fell down onto the now sterile access ports. Staff S/PCT then retaped the shirt and jacket to proceed with dialysis treatment Staff P/ PTC observed this and stated they would review the process with Staff S/PCT. In an interview conducted on 09/05/2025 at 4:00 PM with the facility’s Administrator, she was told of the findings.”

“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 observations and Interviews the facility’s emergency equipment did not have an accurate inventory for the medications available and expiration dates for all medications with expiration. The findings included: On September 5, 2025 at approximately 3:00 PM, Staff J (Charge nurse) was going through the inventory of medications she had in the crash cart. The Charge Nurse started to provide the information from memory. She was asked how the facility keeps record of the equipment and medications in the emergency cart. She stated it was in the computer system. She was asked to print out a list which she then did. She opened the crash cart and was asked to show how many Epinephrine were available she pointed and stated “One”. It was then she was shown the inventory which indicated two were available on the cart. Normal Saline 1000 millimeters was found on the cart with the wrong date October 01, 2025 not the date listed in the inventory December 01,2025 Going further through the inventory the Charge Nurse was asked why there was no date listed for 100 cc Syringes (saline) she stated that this was something the facility would have to speak with their computer systems organization about but presently they could not put in a date. The Clinical Manager was then asked to provide an inventory of the items in the evacuation carts. The Clinical Manager stated she did not have a list, when asked why not she stated the facility had not asked to have one from the computer systems organization. When asked how she knew how many of each item was in the cases she stated we count I know I have 10 1000 cc saline bags in this cart and .14 in the other, which she did.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 53121 Based on observations and interviews, the facility failed to have a physician order for 1 out of 18 sampled patients. Patient #7 The findings included: A review of the last 10 treatment sheets revealed missing Doctor’s order for 08/26/2025 for Patient #7. The Dialysis Flow Rate (DFR) was showing a rate of SEQ. During an interview on 09/04/2025 at 4:33 PM, Staff X (RN home program Assistant Director of Nursing) defined the SEQ as a change in the prescription. Staff X (RN home program Assistant Director of Nursing) acknowledged that the nursing notes did not show communication with the physician to change the DFR to SEQ.”

“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 observation and interview, the facility failed to obtain an immunization history regarding pneumonia and Hepatitis B vaccines for 4 of 18 sampled patients (Patient #8, Patient #10, Patient #6, and Patient #5). The findings included: 1) A review of the facility’s policy titled “Immunization and Screenings Policy for Patients,” revised on 02/06/2025, showed the following: all patients will be educated on the benefits of immunizations. Each patient will be offered the above vaccinations and screenings. The patients must sign the consent or refusal for all immunizations and screening tests provided by this facility. It further showed that all facilities should offer the Pneumococcal vaccine to all patients upon admission to the dialysis facility after assessment of the vaccine history. 2) A chart review revealed that Patient #8 was admitted to the facility for in-house hemodialysis on 10/23/2024. A review of the Vaccination/Test Report provided by the facility showed no Pneumonia vaccination history or status for Patient #8. 3) A chart review revealed that Patient #5 was admitted to the facility for new home hemodialysis on 05/19/2025. A review of the vaccination Test report provided by the facility showed no Hep B vaccination was given with no explanation provided for Patient #5. 4) A chart review revealed that Patient #6 was admitted to the facility for in-center hemodialysis on 05/03/2024. A review of the vaccination Test report provided by the facility showed no Hep B vaccination was given with no explanation provided for Patient #6. The HepB result received from the hospital on 07/10/25 was documented has been declined without explanation. Upon admission no HepB vaccine was administered or offered to the patient. On 09/04/2025 at 4:33 PM, an interview was conducted with staff J (charge nurse) who confirmed that the patient will receive the HepB vaccine as soon as possible starting today 09/04/2025. 5) A chart review revealed that Patient #10 was admitted to the facility for new in-center hemodialysis on 07/22/2025. A review of the vaccination Test report provided by the facility showed no Hep B vaccination was given with no explanation provided for Patient #10. Patient’s Hep B result received from the hospital on 07/14/25 was < 4. However, no HepB vaccine was administered or offered to the patient. On 09/04/2025 at 4:33 PM, an interview was conducted with staff J (charge nurse) who confirmed that the patient will receive the HepB vaccine as soon as possible starting today 09/04/2025. Staff J (Charge Nurse) stated that Patient #8 did not have a history of Pneumonia vaccination status and was not sure whether Patient #8 was offered or received the vaccine.”

“POC-MANAGE MINERAL METABOLISM CFR(s): 494.90(a)(3) Provide the necessary care to manage mineral metabolism and prevent or treat renal bone disease. This Standard is not met as evidenced by: 40153 Based on interviews and record review, the facility failed to provide the necessary care and services to manage mineral metabolism for 1 of 18 sampled patients reviewed. (Patient #4) The findings included: A review of the facility’s Doxercalciferol policy dated 07/01/2015 showed the following: initiating Hectorol therapy if the PTH (Parathyroid hormone) level is over 600 picograms per milliliter with an initial dose of 2.0 micrograms. A chart review revealed Patient #4 was admitted for in-house hemodialysis on 07/04/2025. A review of the PTH lab showed that it was 1182 on 07/04/72025 and 941 on 08/06/2025. Further review did not show that Hectorol therapy was started for Patient #4. A review of the Dietitian Evaluation Report dated 09/03/2025 showed the following: Patient #4 is recommended to receive Vitamin D as per protocol given at dialysis center 3 times a week. In an interview on 09/04/2025 at 4:33 PM, Staff J (Charge Nurse) stated that Patient #4 should have started on Hectorol (Vitamin D analogs) at 2.0 micrograms and that she had contacted the doctor to place the order for the following day.”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 40153 Based on record review and interview, the facility needed a comprehensive assessment/care plan signed by all Interdisciplinary Team (IDT) members and the patients for 6 of 18 sampled patients (Patient #8, Patient #9, Patient #5, Patient #6, Patient #7, and Patient #10). The findings included: A review of the facility’s policy titled “Patient Plan of Care” dated 09/14/2018 showed the following: the complete plan of care shall be signed by the team members, including the patient or the patient’s designee. If the patient chooses not to sign the plan of care, this choice shall be documented on the plan of care, along with the reason the signature was not provided. A chart review revealed that Patient #8 was admitted to the facility on 10/23/2024 for in-house hemodialysis. Unstable care plans were completed on 08/29/2025 and on 07/2520/25 for post-hospitalization. Further review did not show Patient #8’s signature in the two unstable care plans. A chart review revealed that Patient #9 was admitted to the facility on 2/07/2025 for in center hemodialysis. An unstable care plan for extended hospitalization was completed on 7/11/2025, the following month on 8/15/2025 a stable care plan was completed on the patient; neither was signed by the patient though there is documentation in patient notes that the patient was in-center on 7/25/2025 and on 8/20?2025. Staff E acknowledged that the patient had not signed the plans of care. A chart review revealed that Patient #6 was admitted to facility on 5/3/2024 for in-center dialysis. A stable care plan was completed on 8/15/2025. Further review showed that Patient #6’s signature is not on the stable care plan. A chart review revealed that Patient #7 was admitted to facility on 3/25/2022 for nursing home dialysis. A stable care plan was completed on 7/10/2025. Further review showed that Patient #7’s signature is not on the stable care plan. A chart review revealed that Patient #5 was admitted to facility on 5/19/2024 for new home dialysis. A stable care plan was completed on 6/13/2025. Further review showed that Patient #5’s signature is not on the stable care plan. A chart review revealed that Patient #10 was admitted to facility on 7/22/2025 for new in-center dialysis. A stable care plan was completed on 8/12/2025. Further review showed that Patient #10’s signature is not on the stable care plan. In an interview conducted on 09/05/2025 at 4:00 PM with the facility’s Administrator, she was told of the findings.”

“POC-PTS SEEN BY MED STAFF 1X/MO CFR(s): 494.90(b)(4) The dialysis facility must ensure that all dialysis patients are seen by a physician, nurse practitioner, clinical nurse specialist or physician’s assistant providing ESRD care at least monthly, as evidenced by a monthly progress note placed in the medical record, and periodically while the hemodialysis patient is receiving in-facility dialysis. This Standard is not met as evidenced by: 53121 Based on observations and interviews, the facility failed to have monthly progress notes for 1 of 18 sampled patients. Patient #7 The findings included: A review of Patient #7’s medical record from March to August 2025 revealed it only contained notes for the months of July and August 2025. During an interview on 09/04/25 at 4:33 PM, Staff X (Home program Assistant Director of Nursing) acknowledged that Patient #7’s medial record didn’t contain notes from March to June 2025, she stated that the notes were not available.”