Liberty Dialysis - Caldwell

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 39430 Based on observations and staff interviews, the facility failed to maintain a sanitary environment. Specifically, the facility did not ensure cleanliness and maintenance of the treatment floor, cabinets, and other common areas. This had the potential to affect all patients receiving dialysis treatments. Findings include: Observation conducted on 08/18/2025 beginning at 9:30 AM on the treatment floor revealed the following: 1. The treatment floor in multiple areas was visibly dirty and stained. In high-traffic zones, the flooring was cracked, broken, and lifting from the subfloor, rendering it incapable of being properly cleaned and sanitized. 2. Multiple cabinets throughout the unit were observed to be cracked and broken, with laminate surfaces peeling. Additionally, thick layers of dust and debris were noted beneath the sink in the laboratory area and under the sink near the patient weight scale. 3. Squares of tape used to mark dialysis chair placement on the treatment floor were dirty, peeling, and unable to be effectively cleaned or sanitized. An interview was conducted with the Nursing Manager on 08/18/2025 beginning at 2:15 PM. The manager acknowledged the facility had been experiencing challenges with housekeeping services and stated a new service was being initiated. He agreed that the observed conditions required correction. The facilty failed to maintain a sanitary enviroment.”

“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: 39430 Based on staff interview, record review, and policy review, it was determined the facility failed to ensure unstable patients received a comprehensive reassessment on a monthly basis with appropriate changes to their active POCs. This directly impacted 1 of 8 dialysis patients (Patient #1) whose record was reviewed, and had the potential to impact all patients receiving treatment at the facility. This resulted in the patient not being reassessed and the POC not being revised when deteriorating health status occurred. Findings include: A facility document titled, “Comprehensive Interdisciplinary Assessment and Plan of Care,” dated 7/03/23, gave minimum criteria for identifying patients as unstable. The criteria included extended or frequent hospitalizations, “More than 3 admissions in the last 30 days.” These guidelines were not followed. A patient was not marked as unstable who had 3 hospitalizations in 30 days. Patient #1 was a 69 year old male who had been dialyzing in the facility since 11/27/21. In his most recent POC, dated 8/26/24, Patient #1 was marked as stable. Patient #1 had 3 hospitalizations within 30 days. The hospitalizations were on 11/06/24, 11/18/24, and 12/04/24. There was no update to Patient #1’s care plan marking him unstable. The FA was interviewed 8/20/25 beginning at 9:00 AM. He confirmed Patient #1 was marked as stable and should have had an unstable care plan based on his 3 hospitalizations within 30 days. The facility failed to ensure a comprehensive reassessment and updated POC of an unstable patient was completed at least monthly.”