United Dialysis Center, Inc.

“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: 36734 Based on observation and interview, the facility failed to encourage hand hygiene post treatment for 2 sampled patient observations (Patient #5 and #6). The findings included: 1. Patient #5 was observed for disconnection of treatment on 08/27/25 at 9:45 AM. Patient #5 was observed holding pressure to her access site post disconnection. Patient #5 was then observed being weighed post treatment and escorted out of the treatment area. There was no encouragement of hand hygiene observed post treatment for Patient #5 prior to the patient exiting the facility. 2. Patient #6 was observed for disconnection of treatment on 08/27/25 at 10:00 AM. Patient #6 was observed being weighed post treatment and then escorted out of the treatment area. There was no encouragement of hand hygiene observed post treatment for Patient #6 prior to the patient exiting the facility. An interview was conducted with the Director of Nursing (DON) on 08/27/25 at 10:30 AM. The DON acknowledged the above.”

“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: 40153 Based on observation, interview, and record review, the facility failed to thoroughly clean a dialysis area and chair after a dialysis treatment for 1 of 1 observations conducted in the main dialysis treatment room. The findings included: A review of the facility policy titled “Infection Control” dated 01/01/2015 showed the following: to minimize the risk for infections, apply cleaning solution on a washcloth and clean the chair. Wiping throughout and getting between the cushions and the arms of the chair. In an observation conducted on 08/27/25 at 10:45 AM, Staff I Patient Care Technician (PCT) was cleaning machine #16, station #3 after a dialysis treatment. Closer observation showed that she cleaned the crevice of the right side of the dialysis chair but did not clean the left side of the chair. In an interview conducted on 08/28/25 at 3:00 PM with the facility ’ s Administrator, she was made aware 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: 40153 Based on observations and interviews, the facility failed to ensure that dialysis equipment was safe and that biohazard containers were sealed during one of two tours of the main dialysis treatment room. The findings included: In an observation conducted on 08/27/25 at 10:30 AM in the main dialysis treatment room, the following was noted: Three out of four biohazard bins were observed to be open and not sealed. Continued observation at 10:55 AM showed that the three biohazard bins were still not sealed. One hand-washing sink had a gallon of vinegar underneath the sink. One hand washing sink had two packs of napkins and one box of Sani-hand wipes underneath the sink. In an interview conducted on 08/28/25 at 3:00 PM with the facility ’ s Administrator, she was told of the findings.”

“PR-RIGHTS POSTED,STATE/NW ONTACT INFO CFR(s): 494.70(c) The dialysis facility must prominently display a copy of the patient’s rights in the facility, including the current State agency and ESRD network mailing addresses and telephone complaint numbers, where it can be easily seen and read by patients. This Standard is not met as evidenced by: 36734 Based on observation and interview, the facility failed to have on display Network 7 information and Performance Certification Score. The findings included: An observation of the waiting room was conducted on 08/27/25 at 9:00 AM. The observation revealed there was no Network 7 information or a Performance Certification score on display in the waiting room. An interview was conducted with the Facility Administrator (FA) on 08/28/25 at 3:00 PM. The FA acknowledged the above.”

“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: 36734 Based on record review and interview, the facility failed to have a dialysis prescription for the access site for treatment for 1 of 4 sampled patients (Patient #2). The findings included: Record review revealed Patient #2 was admitted to the facility on 2/10/24 for treatment. A review of Patient #2’s Dialysis Prescription Order dated 08/15/25 did not reveal the type of access Patient #2 had for treatment. A review of a progress note dated 07/25/25 physician rounding note revealed a note that documented Patient #2 will start using a fistula for treatment. A review of Patient #2’s treatment administration records dated 08/15/25 and 08/25/25 documented the treatments were started using Patient #2’s catheter. An interview was conducted with the Director of Nursing (DON) on 08/28/25 at 12:00 PM. The DON stated although Patient #2 still has a catheter access, the patient’s fistula was the primary use for treatment. The DON further stated a patient’s access should be indicated on the patient’s Dialysis Prescription Order.”

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 36734 Based on record review and interview, the facility failed to conduct a comprehensive assessment for a patient who should have been deemed unstable for 1 of 4 sampled patients (Patient #4). The findings included: Patient #4 was admitted to the facility for treatment on 07/12/23. A review of Patient #4’s most recent care plan dated 11/13/24 documented the patient as stable. A review of Patient #4’s last 6 months of labs revealed the patient had persistent severe nutrition deficit, (albumin < 2.5, > 4 is normal), was anemic (low blood count), had low adequacy (KT/V <1.2), elevated phosphorous, and low calcium levels. Further record review revealed social worker documentation that Patient #4 displayed symptoms of depression and anxiety, and dietician documentation that Patient #4`was non-compliant with diet and medications. An interview was conducted with Facility Administrator (FA) on 08/28/25 at 12:00 PM. The FA acknowledged the above, and confirmed Patient #4 met the criteria for unstable and should have been deemed as so.”

“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: 36734 Based on record review and interview, the facility failed to follow prescription ordered blood flow rate (BFR) for 1 of 4 sampled patients (Patient #4). The findings included: Record review revealed Patient #4 was admitted to the facility on 07/12/23 for treatment. A review of Patient #4’s current dialysis treatment orders revealed an order for treatment for 3 hours with BFR 350-400. for A review of Patient #4’s treatment flow sheets dated 08/22/25 and 08/25/25 revealed the patient received treatment with a BFR from 200-300 for the entire 3 hours of treatment. Further review of the treatment flowsheets revealed there was no explanation of why the prescribed BFR of 350-400 was not achieved. An interview was conducted with the Director of Nursing (DON) on 08/28/25 at 12:00 PM. The DON acknowledged the above.”

“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: 40153 Based on record review and interview, the facility failed to have monthly physician progress notes for 1 of 4 patients reviewed (Patient #1). The findings included: A review of the facility’s policy titled “Patient Plan of Care Policy” dated 01/01/2015 showed the following: the dialysis center must attempt to ensure that all patients are seen at least on a monthly basis by the physician. A chart review revealed that Patient #1 was admitted to the facility on 07/07/2025 for in-center hemodialysis and was deemed unstable for multiple hospitalization in the month of July 2025. A further review did not show any monthly Physician’s notes written for Patient #1. In an interview conducted on 08/27/25 at 1:00 PM with the facility’s Director of Nursing stated that Patient #1 was hospitalized multiple times and that the Nephrologist was seeing him later today for a full assessment.”