Usrc Royston

“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: 33921 Based on observation, staff and patient interviews, a review of facility records and a review of the pictures related to this complaint, it was determined that the facility failed to provide a safe environment, as evidenced by an unsecured dumpster for general waste storage and disposal. Failure to provide a secured storage and disposal of trash, garbage, and waste in a manner that will not permit the transmission of disease, create a nuisance, or provide a breeding place for insects or rodents, had the potential risk to negatively affect the health and safety of all 52 patients who were receiving hemodialysis services at this facility and others in the neighborhood. Findings include: The facility was located in a business strip with other small, one-story commercial buildings. During a tour of the facility with the Facility Administrator on 11/18/25 at approximately 10:00 a.m., it was revealed that there was a dumpster at the back of the facility. The dumpster had a cover but was not secured and there were boxes that was above the top level of the dumpster so that the cover remained open with approximately a six-to-seven-inch gap. There was no fencing around the dumpster. On the ground at the left side of the dumpster was a soiled glove. There were no other trash outside of the dumpster and there were no trash hanging on the sides of the dumspter. Behind the dumpster was a fenced-in children’s playground. There was no trash around the playround close to the dumpster. During an interview with the Facility Administrator at approximately 10:10 a.m., she stated that a lady from the other commercial buildings in the strip complained to the facility’s Administrative Assistant (which she relayed to the Facility Administrator), that this past Sunday (11/16/25), the dumpster was overflowing with trash, and there were soiled pads, gloves, syringes with needles, etcetera (etc.). The Facility Administrator also stated that the facility’s Janitorial Service personnel reported last Sunday (11/16/25), that the dumpster was overflowing with trash which was very unusual, because it had never happened before. She also stated that the facility’s Janitorial Service personnel were the ones responsible for taking out the regular trash (general, non-biohazard trash in large bags), and disposing them into the dumpster when they came to clean the facility, on a daily basis except on Saturday. The Facility Administrator also stated that the same dumpster was used by the other occupants of the other commercial buildings in this business strip (which included another doctor’s office), and the city’s garbage removal service picked up the garbage from the dumpster on Mondays or Tuesdays and Thursdays. During the above interview with the Facility Administrator (while outside, next to the dumpster), a personnel from one of the other commercial buildings approached us also and he confirmed that he also noticed this past Sunday (11/16/25), that the dumspter was overflowing with trash, which had never happened before and he stated that he had been working at this business strip for approximately five years. During individual interviews with five patients (Ps), P#1, P#2, P#3, P#4, and P#5, on 11/18/25 between 10:30 a.m. and 10:45 a.m., all of the five patients were satisfied with the care they received at this facility. They did not see the dumpster (whether full of trash or not). During individual interviews with the facility’s Direct Patient Care (DPC) Staff such as: Patient Care Technicians (PCTs - PCT AA, PCT BB, and PCT CC) and Registered Nurse (RN AA), on 11/18/25 between 11:45 a.m. and 11:55 a.m., all DPC Staff stated that the regular trash were stored in large gray bags that lined the trash bins, and the Janitorial Service personnel dispose of the large gray trash bags into the dumpster and they had not observed if the dumpster was full or not. All DPC Staff also added that biohazard waste were stored in large red bags that lined the Biohazard boxes and were stored in a locked Biohazard Room and were picked up by Stericycle (a global company that provides highly specialized services such as collection, treatment, and disposal of medical waste, sharps and pharmaceutical waste, as well as secure information destruction...), as well as sharps containers. A review of the facility’s Complaint and Grievance Logs between January 2025 and November 18, 2025, there were no complaints related to an overflowing dumspter. A review of the pictures that the complainant sent in relation to this complaint showed a dumpster with an overflowing trash that were scattered around the dumpster. A review of the facility’s Agreements Manual confirmed the facility’s Janitorial Service, Stericycle, Pest Control, etc. The Facility Administrator confirmed on 11/18/25 at approximately 11:05 a.m., that Stericycle collected the biohazard boxes and sharps containers weekly. She also confirmed that the dumpster use and pickup service was billed to this facility. But the whole business strip occupants were also using the same dumpster. There were no other dumpsters for others to use in this business strip.”