Baldwin Dialysis Center

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 49321 Based on observations, staff interviews, a review of the facility Policies and Procedures, and a review of Center for Disease Control and Prevention (CDC) Recommendations, it was determined that the Infection Control Committee failed to ensure that two of two Patient Care Technicians, (PCT AA and PCT BB), one of one Licensed Practical Nurse, (LPN AA), and one of one Registered Nurse (RN AA), practiced appropriate infection control techniques. This deficient practice had the potential to negatively affect the health and safety of all 31 hemodialysis patients who were receiving treatment at this facility and four of four Direct Patient Care (DPC) Staff (Nurses and PCTs). Findings include: Cross references: V 113 - Failure of the Infection Control Committee to ensure that two of two PCTs (AA and BB), and one of one Licensed Practical Nurse (LPN AA) performed hand hygiene between glove changes and between touching dirty and clean areas. V 115 - Failure of the Infection Control Committee to ensure that two of two PCTs (AA and BB), one of one LPN (LPN AA) and one of one Registered Nurse (RN AA) wore appropriate Personal Protective Equipment (PPE), such as (faceshield, or mask and protective goggles) while initiating and terminating hemodialysis treatments. V 122 - Failure of the Infection Control Committee to ensure that two of two PCTs (AA and BB), one of one LPN (LPN AA) and one of one RN (RN AA), wiped down and cleaned dried blood off of sharps containers before each patient use. V 147 - Failure of LPN AA to practice infection control techniques during initiation and termination of hemodialysis treatment of patients (P), (P#9 and P#10), who used Central Venous Catheters (CVCs) as their hemodialysis access.”

“CFC-WATER & DIALYSATE QUALITY CFR(s): 494.40 This Condition is not met as evidenced by: 49321 Based on observation, a review of facility records, and staff interviews, it was determined that the facility failed to ensure that there was a safe enviroment for 31 in-center hemodialysis patients as evidenced by failure of one of one Patient Care Technician (PCT AA), and one of one Licensed Practical Nurse (LPN AA) observed, independently verified the hemodialysis machine’s dialysate pH (acidity) and Conductivity (ability of the dialysate to conduct electricity), according to the manufacturer’s Directions for Use (DFU), using a Phoenix Meter (a device used to measure pH and Conductivity), prior to initiating patients’ (P), (P#8’s and P#9’s) hemodialysis treatment; and failure of two of two PCTs (AA and BB) to calibrate three of three Phoenix Meters (#1, #2, and #3) before daily use to verify accurate function of the Phoenix Meters before taking measurements or whenever inaccurate readings were suspected. This deficient practice had the potential to cause harm to P#8 and P#9, and the other 11 in-center hemodialysis patients, (P#7, P#10, P#11, P#12, P#13, P#14, P#15, P#16, P#17, P#18 and P#19), who were undergoing hemodialysis treatment at the time of this observation. The facility census was 31. Findings include: Cross Reference: V 250 - Failure of the facility to ensure that PCTs AA and BB calibrated the three Phoenix Meters daily before use and to ensure that LPN AA and PCT AA independently verified the machines’ dialysate pH and Conductivity according to the manufacturer’s DFU, prior to the initiation of each hemodialysis treatment.”

“CFC-GOVERNANCE CFR(s): 494.180 This Condition is not met as evidenced by: 49321 Based on observation, staff interviews, and a review of facility records, it was determined that the Governing Body failed to demostrate responsibility and accountability for the operations of the facility. This failure had the potential to negatively affect the health and safety of 31 in-center hemodialysis patients who were receiving hemodialysis treatment at this facility. Findings include: Cross References: V 113 - Failure of the Infection Control Committee to ensure that two of two Patient Care Technicians (PCTs AA and BB), and one of one Licensed Practical Nurse (LPN AA) performed hand hygiene between glove changes and between touching dirty and clean areas. V 115 - Failure of the Infection Control Committee to ensure that two of two PCTs (AA and BB), one of one LPN (LPN AA) and one of one Registered Nurse (RN AA) wore appropriate Personal Protective Equipment (PPE), such as (faceshield, or mask and protective goggles) while initiating and terminating hemodialysis treatments. V 122 - Failure of the Infection Control Committee to ensure that two of two PCTs (AA and BB), one of one LPN (LPN AA) and one of one Registered Nurse (RN AA), wiped down and cleaned dried blood off of sharps containers before each patient use. V 147 - Failure of LPN AA to practice infection control techniques during initiation and termination of hemodialysis treatment of patients (P), (P#9 and P#10), who used Central Venous Catheters (CVCs) as their hemodialysis access. V 250. - Failure of the facility to ensure that PCTs AA and BB calibrated the three Phoenix Meters daily before use and to ensure that LPN AA and PCT AA independently verified the machines’ dialysate pH and Conductivity according to the manufacturer’s DFU, prior to the initiation of each hemodialysis treatment.”

“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: 49321 1. Based on observation, staff interviews, and a review of facility Policies and Procedures, it was determined that the Infection Control Committee failed to ensure that two of two Patient Care Technicians, (PCT AA and PCT BB), and two of two Patients, (P), (P#7 and P#9) observed, performed hand hygiene (washed hands with soap and water or used an alcohol-based hand sanitizer), after the removal of contaminated gloves or between glove changes. Failure to perform infection control techniques such as hand hygiene, increased the risk of cross contamination with the potential to expose patients and staff to blood-borne pathogens in the dialysis enviroment. This deficient pratice had the potential to affect the other 11 patients, (P#8, P#10, P#11, P#12, P#13, P#14, P#15, P#16, P#17, P#18 and P#19), who were undergoing hemodialysis at the time of this observation and all four Direct Patient Care (DPC) Staff (PCTs AA and BB, Licensed Practical Nurse - LPN AA and Registered Nurse - RN AA). The facility census was 31. Findings include: During observation in the Patient Treatment Room on 7/31/24 between 9:10 a.m. and 11:30 a.m., the following was revealed: - P#7 at Station (S), (S16), was observed at 9:10 a.m., taking his right hand glove off after holding his access site for hemostasis (cessation of bleeding). Without performing hand hygiene, P#7 then went to the weighing scale and touched the bar in front of the weighing scale, as well as the on/off button (to get his weight). P#7 exited the Patient Treatment Room without performing hand hygiene and without a reminder from the Direct Patient Care (DPC) Staff, (Nurses and PCTs). - PCT AA was observed at 9:16 a.m., during initiation of hemodialysis treatment on P#8, with an Arterio-Venous-Fistula (AVF), at S15. PCT AA touched P#8’s access site again after disinfecting it with alcohol pads, thereby re-contaminating the access site. In addition, PCT AA did not change gloves and did not perform hand hygiene between touching the dialysis machine (dirty) and the computer keyboard (clean). - PCT BB was observed at 9:27 a.m., going from S19 to S20 without performing hand hygiene between glove changes. - PCT BB was observed at 9:28 a.m., securing P#9’s access site dressing at S18. PCT BB did not perform hand hygiene after removing her gloves. P#9 exited the Patient Treatment Room without performing hand hygiene after glove removal and without a reminder by DPC staff for P#9 to perform hand hygiene. - PCT AA was observed at 9:39 a.m., terminating P#12’s hemodialysis treatment at S14. PCT AA did not remove gloves after touching the hemodialysis machine (dirty) and did not perform hand hygiene before touching the computer keyboard (clean). Wearing the same contaminated gloves, PCT AA pulled the sharps container to S14 then proceeded to remove P#12’s fistula needles without changing contaminated gloves and without performing hand hygiene. - During an interview with PCT AA on 8/2/24 at 11:00 a.m., she stated she had problems with cannulating sometimes and she was never told she had to use a hand sanitizer between glove changes. She also added that she was aware that she must wash her hands. - During an interview with PCT BB on 8/2/24 at 11:30 a. m., she confirmed that she did not perform hand hygiene between glove changes but washed her hands with soap and water before leaving the Patient Treatment Room. A review of facility policy# G40, titled, “General Infection Control Measures”, with last revision date of 11/29/2022, stated: 8. Hands are always washed after gloves are removed and between patient contact, as well as after touching blood, body fluids, secretions, excretions and contaminated items. 9. Antiseptic hand sanitizers must be alcohol based and may be used in place of soap and water: -if hands are not soiled -during emergencies in the absence of sink/water (such as during an evacuation or loss of water services) - before gloving and after glove removal if the gloves and/or PPE have had no exposure to or contact with blood or other potentially infectious materials. 17. Patients will be educated and encouraged to: -wear gloves when holding their access sites after needle removal. -wash their hands before entering and leaving the patient treatment area. - A review of facility Infection Control Audit Tool, specifically, Initiation with AVF/AVG, with last revision date of 9/1/23, stated: - Apply antiseptic to skin over cannulation sites and allow to dry; sites not touched again after skin antisepsis, without repeating skin antisepsis...”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 49321 Based on observation, staff interviews, and a review of the facility Policies and Procedures, it was determined that the Infection Control Committee failed to ensure that two of two Patient Care Technicians, (PCT AA and PCT BB), one of one Licensed Practical Nurse, (LPN AA), and one of one Registered Nurse, (RN AA) observed, wore a face shield, (Personal Protective Equipment-PPE) during the initiation and discontinuation of hemodialysis treatments on patients at Stations (S), (S2, S10, S15, and S18). This deficient practice had the potential to expose PCT AA’s, PCT BB’s, LPN AA’s, and RN AA’s face and eyes to spattered blood. Findings include: During observation on the treatment floor on 7/31/24 between 9:10 a.m. and 10:10 a.m., the following was revealed: - PCT AA was observed at 9:16 a.m., inserting the patient’s (P), (P#8’s) fistula needles at S15, without wearing a face shield or mask and eye goggles. When PCT AA was asked on 7/31/24 at 9:20 a.m., if she was aware that she didn’t put on her PPE (faceshield or mask and eye goggles) during the insertion of the P#8’s fistula needles, PCT AA stated, “I know, I left my goggles in the car. I don’t wear face PPE all the time”. - LPN AA was observed during initiation of hemodialysis treatment on P#9 with a Central Venous Catheter (CVC) at S2. LPN AA did not wear a face shield over her prescription eyeglasses. - PCT BB was observed at 9:23 a.m., inserting P#13’s fistula needles at S10 with no face shield over her prescription eyeglasses. PCT BB stated on 7/31/24 at 9:38 a.m., that they were provided with faceshields or eye goggles, she just didn’t use them. - RN AA was observed disconnecting P#9’s bloodlines at end of treatment from the CVC without wearing a face shield over her prescription eyeglasses. - The Facility Administrator was notified of this observation on 7/31/24 at 10:10 a. m., and she stated that the staff knew to wear the proper PPE. A review of the facility’s Policy# A410, titled, “Treatment Initiation - Catheter”, with the latest revision date of 11/15/2023, stated: Required PPE: Gloves, Gown, Full face shield or mask and approved safety glasses. A review of the facility’s Policy# IC04, titled, “Cannulation & Treatment Initiation with AVF/AVG”, with the latest revision date of 4/2023, stated: Standard precautions, Aseptic Non-Touch Technique (ANTT), use of appropriate personal protective equipment (PPE) and all other applicable Innovative Renal Care (IRC) infection control policies and procedures will be used when fistula needles are placed, repositioned, and removed. -A review of Policy #G40 Infection Control, last revised 11/29/2022 and listed under, “General Infection Control Measures”, stated: - #34 When any CVC procedure is being performed (such as treatment initiation or discontinuation or CVC site care) the caregiver must wear a full face shield and mask or safety googles and a mask.”

“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: 49321 Based on observation, staff interviews, a review of the Centers for Disease Control and Prevention (CDC) guidelines, and a review of the facility’s Policies and Procedures and Infection Control Audit Tool, it was determined that the Infection Control Committee failed to ensure that two of two Patient Care Technicians, (PCT AA and PCT BB), one of one Licensed Practical Nurse, (LPN AA) , and one of one Registered Nurse, (RN AA), who were present during this observation, immediately and thoroughly cleaned and disinfected blood-contaminated surfaces on the covers of four of four large sharps containers placed around the Patient Treatment Room. This failure could lead to the transmission of dangerous pathogens through cross contamination; and had the potential to negatively affect the health and safety of 13 of 13 in-center hemodialysis Patients (P), (P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14, P#15, P#16, P#17, P#18 and P#19), who were undergoing hemodialysis treatment at the time of this observation. The facility census was 31. Findings include: During observation in the Patient Treament Room on 7/31/24 between 8:50 a.m. and 10:00 a.m., the following was revealed: - Beside the clean sink facing Stations (S), S10 and S11, there was a large sharps container (#1) that had four dime-size drops of dried blood on the top cover. - Beside another clean sink facing S14 and S15, there was another large sharps container (#2) that had dried splattered blood on the top cover. - Beside the clean sink facing S20, the lab supply entrance, and S1, there was a large sharps container (#3) that had six small drops of dried blood on the top cover. - By the clean sink facing S4, the exit off the treatment floor and S5, there was a large sharps container (#4), that had three thick lines of clotted blood on the top cover. - The Facility Administrator and RN AA were notified of this observation on 7/31/24 at 10:00 a.m. - This surveyor went back to the Patient Treatment Room on 7/31/24 and 5:00 p.m. to see if the dried blood on top of the sharps containers had been cleaned between patients. It was revealed that only sharps container #2 next to the clean sink facing S14 and S15, was cleaned. The other three sharps containers (#1, #3, and #4), still had the same dried blood observed observed earlier. During staff interviews on 8/2/24, between 11:00 a.m. and 12:30 p.m., the following was revealed : - PCTs AA and BB stated that the staff, wipe down their sharps containers at the end of the day. - LPN AA stated that the PCTs make sure the sharps containers were wiped down at the end of the day and biohazard boxes were changed out. According to the CDC guidlines, failure in environmental cleaning and disinfection have lead to transmission of bloodborne pathogens (e. g., Hepatitis B virus) and other infections from one patient to another in hemodialysis units. Correct cleaning and disinfection of enviromental surfaces (including sharps containers, floors, patients’ chairs, dialysis equiptment surfaces, especially with blood splatter) must be performed between patient uses to prevent transmission of dangerous pathogens. - A review of the facility’s Policy# G40, titled, “Infection Control”, with last revision date of 11/29/22, did not mention disinfecting the sharps containers with blood or blood splatters between patient treatment. - A review of the facility’s Infection Control Audit Tool, with last revision date of 9/1/23, stated: Blood spills immediately cleaned with a 1:100 bleach solution x2... no visible wet or dry blood (cleaned twice).”

“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: 49321 Based on observation, a review of the Centers for Disease Control and Prevention (CDC) guidelines and recommendations, a review of facility Policies and Procedures (P&P) and facility Infection Control Audit tool, and staff interview, it was determined that the Infection Control Committee failed to ensure that one of one Licensed Practical Nurse, (LPN AA) observed, during initiation and discontinuation of hemodialysis (HD) treatment on Patients, (P), (P#9 and P#10), who had Central Venous Catheters (CVCs), utilized appropriate infection control techniques to prevent cross contamination. This breach in infection control techniques could negatively affect the health and safety of P#9 and P#10 and the other 13 patients who used CVCs, as their dialysis access. Findings include: During observation in the Patient Treatment Room on 7/31/24 between 9:10 a.m. and 11:30 a.m., the following was revealed: - LPN AA was observed at 9:23 a.m., during initiation of hemodialysis treatment on P#9, who had a CVC, at S2. LPN AA did not remove contaminated gloves (dirty) after removing P#9’s old CVC dressing (dirty) and before cleaning the CVC exit site. After cleaning the CVC exit site, LPN AA removed dirty/contaminated gloves and placed them on the clean blue liner with other sterile and clean supplies. LPN AA did not perform hand hygiene before donning a new pair of gloves, then with the new pair of gloves (clean), LPN AA removed the old pair of gloves (dirty) off the blue liner with the clean supplies and placed them in a clear bag on the side of the treatment chair. - LPN AA was observed at 10:12 a.m., performing P#10’s CVC exit site care, post treatment at S11. LPN AA removed the used (contaminated) band-aid from the CVC exit site. Then without removing gloves and without performing hand hygiene, LPN AA applied a new sterile dressing over the exit site. LPN AA did not cover the CVC exit site with a sterile dressing after cleaning the CVC exit site prior to initiating P#10’s hemodialysis treatment, but only applied a band-aid to the site during treatment. According to the CDC, cross contaminating (going from dirty to clean equipment/tasks/area), could cause the spread of bacteria/infections. - A review of facility Policy# G40, titled, “Infection Control”, with last revision date of 11/29/22, stated: 8. Hands are always washed after gloves are removed and between patient contacts, as well as after touching blood, body fluids, secretions, excretions and contaminated items. 9. Antiseptic hand cleaners must be alcohol-based and may be used in place of soap and water: * if hands are not soiled... * before gloving and after glove removal... 11. Associates will wash hands and any other skin with soap and running water... following contact with blood or other potentially infectious materials. 30. Aseptic Technique will be used to ... clean the CVC exit site. - A review of facility Procedure# A410, titled, “Treatment Initiation - Catheter’’, with last revision date of 11/15/23, did not specify procedural steps for removal of old CVC dressing and cleaning CVC exit site before initiation of treatment. - A review of facility Infection Control Audit Tool, with last revision date of 9/1/23, specifically, “CVC Exit Site Care”, stated: - Remove old dressing and discard without contaminating clean supplies. - Remove gloves, hand hygiene, don clean gloves. - Cleanse area around CVC exit site with antiseptic, allow to dry before applying dressing. Sterile dressing applied to CVC exit site... Remove gloves, hand hygiene. - During an interview with LPN AA on 8/2/24 at 12:21 p.m., she stated that the hand sanitizer was sticky. LPN AA also stated, when she completes catheter care she cleans the site and places a band-aid over the catheter exit site. At the termination of hemodialysis treatment, she places a sterile dressing over the band-aid.”

“DIALYS PROPORT-MONITOR PH/CONDUCTIVITY CFR(s): 494.40(a) 5.6 Dialysate proportioning: monitor pH/conductivity It is necessary for the operator to follow the manufacturer’s instructions regarding dialysate conductivity and to measure approximate pH with an independent method before starting the treatment of the next patient. This Standard is not met as evidenced by: 49321 Based on observation, staff interviews, and a review of facility records, it was determined that the facility failed to ensure that there was a safe enviroment for 31 in-center hemodialysis patients as evidenced by failure of one of one Patient Care Technician (PCT AA), and one of one Licensed Practical Nurse (LPN AA) observed, independently verified the hemodialysis machine’s dialysate pH (acidity) and Conductivity (ability of the dialysate to conduct electricity), according to the manufacturer’s Directions for Use (DFU), using a Phoenix Meter (a device used to measure pH and Conductivity), prior to initiating patients’ (P), (P#8’s and P#9’s) hemodialysis treatment; and failure of two of two PCTs (AA and BB) to calibrate three of three Phoenix Meters (#1, #2, and #3) before daily use to verify accurate function of the Phoenix Meters before taking measurements or whenever inaccurate readings were suspected. This deficient practice had the potential to cause harm to P#8 and P#9, and the other 11 in-center hemodialysis patients, (P#7, P#10, P#11, P#12, P#13, P#14, P#15, P#16, P#17, P#18 and P#19), who were undergoing hemodialysis treatment at the time of this observation. The facility census was 31. Findings include: During observation in the Patient Treatment Room on 7/31/24 between 9:10 a.m. and 11:30 a.m., the following was revealed: - PCT AA was observed at 9:16 a.m., initiating P#8’s hemodialysis treatment at Station (S), S15. PCT AA did not independently verify the machine dialysate’s pH and Conductivity before initiating P#8’s hemodialysis treatment. - LPN AA was observed at 9:23 a.m., initiating P#9’s hemodialysis treatment at S2. LPN AA did not independently verify the machine dialysate’s pH and Conductivity before initiating P#9’s hemodialysis treatment. - During an interview with PCT AA on 8/2/2024 at 11:17 a.m., PCT AA was asked if there was a reason she did not independently verify the machine dialysate’s pH and Conductivity before initiating P#8’s hemodialysis treatment. PCT AA stated that she didn’t have a reason for not independently verifying the pH and Conductivity. - During an interview with LPN AA on 8/2/24 at 12:21 p.m., LPN AA stated that she didn’t know why she did not independently check the machine dialysate’s pH and Conductivity before initiating P#9’s hemodialysis treatment and she added that they had a very heavy load of catheters and the nurses were always assigned a bay or section of patients per shift. A review of the 2008K Hemodialysis Machine (which this facility was using) Operation manual, page 52 stated: Warning! Always verify the conductivity and approximate pH of the dialysate solution through independent means (e.g. using a conductivity meter or pH paper or meter as applicable) before initiating each dialysis treatment. Verify that the conductivity is reasonably close to the Theoretical Conductivity Value (TCD) and the pH is between 6.9 and 7.6. If they are not, do NOT initiate dialysis. A review of the facility’s Phoenix Meter Daily Calibration documentation for the months of June, 2024 and July, 2024 revealed: - Three of three Phoenix Meters (#1, #2, and #3), in the month of June had no documentation of daily calibration on the following dates: June 7 (Friday), June 10 (Monday), June 12 (Wednesday), June 14 (Friday), June 26 (Wednesday), and June 28 (Friday). - Three of three Phoenix Meters (#1, #2, and #3), in the month July, had no documentation of daily calibration on the following dates: July 12 (Friday), and July 15 (Monday). - During a tour of the facility with the Facility Administrator on July 31, 2024 at 11:30 a.m., it was revealed that the rinse bottle with R.O. (Reverse Osmosis) water that was used to rinse the Phoenix Meters was dated 7/22/24 and the bleach bottle with 1:100 solution that was used to clean the Phoenix Meter was dated 7/22/24 at 5:10 a.m. A review of the Phoenix Meter Calibration Guide Stated: Perform the following steps daily before instrument use: 1. Rinse 2.Disinfect 3. Rinse 4. Verify 5. Rinse Daily - Rinse and refill the rinse bottle with fresh R.O. water. Rinse and refill the bleach bottle with fresh bleach solution daily.”

“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: 49321 Based on observation and staff interviews, it was determined that the facility failed to ensure that the building in which dialysis services were provided, was maintained free from damage and defects to ensure the safety of the patients and staff. This failure to maintain the integrity of all surfaces could hinder effective cleaning and disinfection of the surfaces, thus providing a potential for microbial growth. This deficient practice was observed in one of one Patient Treatment Room, in one of one Supply Room, and in one of one Dialysate Preparation Room. Findings include: During a tour of the facility with the Facility Administrator on 7/31/24 at 11:00 a.m., the following was observed: In the Patient Treatment Room: - The wall trim under the glass separating the treatment room and the laboratory (Lab) area, on the left side of Station (S), (S20), was rusted. - The floor and the dry wall, which was approximately six steps to the Lab entrance, was wet and the paint had bubbled up. - The drain box at S2, had a thick layer of dried, white, crystallized sediment. In the Supply Room: - The floor was scratched up and dirty with dust and small pieces of paper and plastic littered the floor’s surface. The floor next to the back door had a sticky substance that was covered with dust. - The floor drain #1 was cracked and had a wooden pallet jammed on the corner of the drain. On top of this wooden pallet were cases of supplies. - The floor under the shelf, was covered with thick dust, dirt and scattered old RPC strips (used for testing Chlorine/Chloramine). - A steel ladder was leaning against the electrical junction box (an electrical enclosure that houses one or more wiring connections) and on the floor, under the ladder was a water pump. There was no clear path to get to the electrical junction box in case of an emergency. In the Dialysate Preparation Room: - There was standing water around the floor drain (drain #2). - The floor around the first Bicarbonate Mixing Tank had deep scratches and there were four rusted bolts behind the left corner of the second Bicarbonate Mixing Tank. - The area under the DI (deionization) Connection Box, where staff performed testing of Chlorine/Chloramine and water hardness, were littered with old RPC strips and hardness test strips and was covered with dirt and dust. - The drain for the backflow preventer was covered with a thick, rust-colored substance. The Facility Administrator, who was present during the tour on 7/31/24 at 11:00 a.m., confirmed these findings and referred this surveyor to the facility’s Biomedical Technician (BMT). - A second tour of the Dialysate Preparation Room with the BMT was conducted on 7/31/24 at 12:00 p.m. The BMT acknowledged the above findings and stated that this was a small space.”