Premier Dialysis Company

“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: 44232 Based on observation, record review, and interview, the agency failed to ensure hand hygiene and glove changes were performed by direct care staff completing CVC (a flexible tube placed in the large vein above the heart that delivers medications and blood products) exit site care in 1 of 2 observations (Employees: PCT 1), and failed to ensure staff instructed the patients on proper use of hand hygiene after holding their access with a gloved hand during 3 of 3 post dialysis access care for arteriovenous fistula or graft (AVF). (Patients: #1, 11, and 15) Findings Include: 1. A review of a facility policy reviewed dated 01-02-2025, titled “Hand Washing Technique, Hand Hygiene, and Glove use” indicated but was not limited to, “ ... developed handwashing policies to reduce pathogens on the hands and wrists, thereby decreasing direct and indirect transmission of infectious microorganisms ... “Hand Hygiene” includes either washing hands with soap and water, or using a waterless alcohol-based antiseptic had rub ... hand hygiene is necessary after glove removal ... c. Decontaminate hands before having direct contact with patients ... e. Decontaminate hands after contact with body fluids or excretions, mucus membranes, nonintact skin, and wound dressings ...g. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. h. Decontaminate hands after removing gloves ...” 2. A review of a facility policy reviewed dated 01-02-2025, titled “Routine Exit Site and Catheter Care” indicated but was not limited to, “ ... Procedure: ... 1. Gather necessary supplies. 2. Remove old dressing from exit site. 3. Wash hands ... “ 3. On 07/15/2025 at 10:15 AM, PCT 3 was observed applying a clean dressing to Patient #1’s left upper access after the patient held pressure with their right gloved hand. Patient #1 removed their glove and discarded it in the trash receptacle. Patient #1 was not instructed or offered hand hygiene prior to leaving the treatment floor. 4. On 07/15/2025 at 10:30 AM, PCT 1 was observed applying a clean dressing to Patient #11’s left upper access after the patient held pressure with their right gloved hand. Patient #11 removed their glove and discarded it in the trash receptacle. Patient #2 was not instructed or offered hand hygiene prior to leaving the treatment floor. 5. During an observation of CVC exit site care on 07/15/2025 at 11:05 AM, PCT 1 removed the old dressing from Patient #11’s CVC access site and discarded the dressing in the trash receptacle. PCT 1 removed their gloves, donned new gloves without performing hand hygiene. During an interview on 07/15/2025 at 2:09 PM, when asked when hand hygiene is to be performed during a CVC dressing change, PCT 1 verbalized hand hygiene is to be done prior to donning gloves, remove the old dressing, throw gloves and dressing in the trash, don new gloves, clean the site and apply a new dressing. When asked why they had not performed hand hygiene prior to donning gloves began verbalizing this is how they were taught. PCT 1 indicated patients were to do hand hygiene coming into treatment room and when they leave. 6. On 07/15/2025 at 11:00 AM, RN 1 was observed applying a clean dressing to Patient #15’s left upper access after the patient held pressure with their right gloved hand. Patient #15 removed their glove and discarded it in the trash receptacle. Patient #15 was not instructed or offered hand hygiene prior to leaving the treatment floor. During an interview on 07/15/2025 at 11:14 AM, RN 1 confirmed hand hygiene is to be performed by staff and patients anytime gloves are removed or prior to donning new gloves.”

“GOV-INTERNAL GRIEVANCE SYS ID/IMPLEMENTED CFR(s): 494.180(e) The facility’s internal grievance process must be implemented so that the patient may file an oral or written grievance with the facility without reprisal or denial of services. The grievance process must include- (1) A clearly explained procedure for the submission of grievances. (2) Timeframes for reviewing the grievance. (3) A description of how the patient or the patient’s designated representative will be informed of steps taken to resolve the grievance. This Standard is not met as evidenced by: 44232 Based on record review and interview, the facility failed to ensure grievances were documented when made by patients for 1 of 1 patient complaints. (Patients: #5) Findings Include: 1. A review of a revised policy dated 09/19/2024, titled “Patient Grievance Policy” indicated but was not limited to, “ ... Grievance: Any complaint or concern, expressed verbally or in writing, by a patient ... Documentation: The Grievance Officer will document the grievance using the “Patient Grievance Form,” noting details of the complaints ... Staff are required to assist patients in understanding ... to report any grievances promptly ... “ 2. During the entrance conference on 07/15/2025 at 9:15 AM, when queried about the patient complaint process, the FA indicated the facility had had huddles to reassure staff reported complaints, and reviewed the process of reporting, documentation provided to the FA and MD, investigation, and follow up after the complaint had been closed. 3. On 07/15/2025 at 8:45 AM, Patient #5, communicated they had voiced a complaint regarding PCT 1’s treatment towards them. Patient #5 further indicated PCT 1 told the patient they couldn’t talk on their phone and arguing about how the PCT loved the patients when the patient asked PCT 1 to leave their station. Patient #5 verbalized they were aware of the grievance process and had asked to file a grievance and had not received any further communication with anyone. 4. On 07/15/2025 at 9:05 AM, PCT 3 verbalized Patient #5 had reported to them regarding their concerns with PCT 1. PCT 3 indicated they had reported Patient #5’s concerns to the MSW. 5. On 07/15/2025 at 11:14 AM, RN 1, communicated patient complaints are to be reported to the FA and MSW for investigation. When asked regarding any complaints from patients regarding staff, RN 1 indicated Patient #5 and PCT 1 had conflicts and did not get along, to assist with the issue of the personality conflicts PCT 1 had not been assigned to Patient #5. RN 1 failed to report Patient #5’s grievance to the FA for investigation and resolution. 6. On 07/15/2025at 1:15 PM, the MSW communicated Patient #1 had been upset regarding shift times and indicated Patient #5 reported to them PCT 1 broke their purse. The MSW failed to provide evidence a grievance report had been completed, with investigation, and resolution. 7. On 07/15/2025 at 2:00 PM, when asked PCT 1 if they had heard any complaints from patients, indicated they had heard Patient #5 complaint about them. PCT 1 stated, “[Patient #5] has no regards. Sits on her phone, arrives late always. I can’t speak to her.” PCT 1 further communicated they reported Patient #5 had been on their phone and asked them to keep it down. PCT 1 further stated, “No fixing some people. I stay away from her.” 8. On 07/16/2025 at 7:30 AM, when asked regarding any staff concerns, Patient #9 verbalized the place is running so much better, and the staff they had issues with were gone. Patient #9 further indicated PCT 4 is great, and tried to train PCT 1, but they would not listen. PCT 1 had to be moved to Tuesday, Thursday, and Saturdays. 9. On 07/16/2025 at 8:00 AM, when asked regarding any staff complaints, RN 1 verbalized they reported a complaint to the FA and MD regarding PCT 1 having been told to put a gown on while disconnecting a patient’s dialysis treatment, argued with staff and became loud and refused to leave. 10. On 07/16/2025 at 8:15 AM, PCT 4 indicated they had voiced concerns regarding PCT 1 leaving patients, having words with Patient #5, and PCT 1 cursing at them trying to assist Patient #5.”

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 44232 Based on observation, record review, and interview, the agency failed to ensure the oxygen tank located next to the emergency crash cart were full and safe to use in case of an emergency, and failed to ensure supplies were checked for expiration dates for 1 of 1 emergency crash carts. Findings Include: 1. A review of a facility policy revision dated 01/02/2025, tiled “Routine Maintenance on Dialysis Equipment” indicated but was not limited to, “Scheduled dialysis equipment and maintenance and documentation will be performed ... “ 2. A review of a facility documents tiled “ Emergency Crash Cart Checklist” dated June 2, 2025 through June 30, 2025, noted the emergency crash cart had been checked and verified with staff initials. 3. During a flash tour on 06/30/2025 at 9:25 AM, observed an oxygen cylinder tank by the crash cart. The oxygen cylinder had no hiss when turned on and the pressure gauge read zero. During an interview on 06/30/2025 at 9:50 AM, RN 2 tested the oxygen cylinder tank by the crash cart. RN 2 confirmed the oxygen cylinder used for emergencies had been empty. 44354 4. During a flash tour on 06/30/2025 at 9:28 PM observed in drawer of the crash cart a safety lock packet with an expiration date of 02/28/2025. 5. The findings were reviewed with the Medical Director and FA on 07/02/2025 at 12:45 PM and the FA acknowledged the crash cart was to be checked for supplies and expired items were to be replaced and removed and the FA acknowledged the 4 oxygen cylinder tanks were empty.”

“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: 44354 Based on observation and interviews, the agency failed to ensure hand hygiene and glove changes were performed by direct care staff completing CVC (a flexible tube placed in the large vein above the heart that delivers medications and blood products) exit site care in 2 of 2 observations (Employees: PCT 2, and PCT 4 ), and 1 of 2 observations of initiation of a CVC dialysis treatment (Employees: PCT 4) , and 1 of 2 discontinuation of a CVC dialysis treatment (Employees: PCT 2 ) to prevent exposure to blood and potentially contaminated items appropriately while on the treatment floor. Findings Include: 1. A review of a facility policy reviewed dated 01-02-2025, titled “Hand Washing Technique, Hand Hygiene, and Glove use” indicated but was not limited to, “ ... developed handwashing policies to reduce pathogens on the hands and wrists, thereby decreasing direct and indirect transmission of infectious microorganisms ... “Hand Hygiene” includes either washing hands with soap and water, or using a waterless alcohol-based antiseptic had rub ... hand hygiene is necessary after glove removal ... c. Decontaminate hands before having direct contact with patients ... e. Decontaminate hands after contact with body fluids or excretions, mucus membranes, nonintact skin, and wound dressings ...g. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. h. Decontaminate hands after removing gloves ...” 2. A review of a facility policy reviewed dated 01-02-2025, titled “Routine Exit Site and Catheter Care” indicated but was not limited to, “ ... Procedure: ... 1. Gather necessary supplies. 2. Remove old dressing from exit site. 3. Wash hands ... “ 3. A review of a facility document dated 06/04/2025, titled “Inservice Attendance Sign-In Form” indicated the course had been titled “Infection Control Overview and Handout.” The information provided during the in service had been an overview of infection control, hand hygiene, PPE, and safe injection and medication practices. The attendance form noted PCT 2’s and PCT 4’s signatures on the sign in form. 4. During an observation of an initiation of a dialysis treatment with a CVC on 06/30/2025 at 3:15 PM, PCT 4 discarded a dressing and other trash in a receptacle. PCT 4 removed their gloves, donned new gloves and failed to perform hygiene. 44232 5. During an observation of a discontinuation of dialysis treatment with a CVC on 06/30/2025 at 2:21 PM, PCT 2 flushed Patient #14’s ports, then obtained tape from the supply island, and applied a dressing to Patient #14’s ports, without discarding their gloves, performing hand hygiene prior to obtaining the dressing. 6. During an observation of CVC exit site care on 06/30/2025 at 3:15 PM, PCT 2 removed the old dressing from Patient #2’s and discarded the dressing in the trash receptacle. PCT 2 removed their gloves, donned new gloves without performing hand hygiene. During an interview on 06/30/2025 at 2:45 PM, when questioned when to perform hand hygiene and CVC care, PCT 2 verbalized hand hygiene and glove changes were to be completed after removing the patient’s old dressing, after touching the machines, and after obtaining heparin for administration. The findings were reviewed with the Medical Director and FA, on 07/02/2025 at 12:45 PM, which the Medical Director stated, “I walked around and told the staff about watching infection control.””

“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: 44232 Based on record review and interview the facility failed to ensure masks and gowns were worn appropriately by PCT 1 in 3 of 3 observations. (Employee: PCT 1) Findings include: 1. A review of a facility policy revision dated 01-02-2025, titled “Infection Control Practices and Procedures for Dialysis Facilities and Treatments Performed in the Home” indicated but was not limited to, “ ... Personnel will wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures ... “ 2. A review of a facility document dated 06/04/2025, titled “Inservice Attendance Sign-In Form” indicated the course had been titled “Infection Control Overview and Handout.” The information provided during the in service had been an overview of infection control, hand hygiene, PPE, and safe injection and medication practices. The attendance form noted PCT 1’s signature on the sign in form. 3. During an observation on 07/01/2025 at 6:05 AM, PCT 1 was observed initiating the dialysis treatment of a CVC for Patient #32, while wearing a blue gown open not fastened, and without a face shield. 44354 4. During an observation on 07/01/2025 at 6:10 AM PCT 1 was observed inserting a dialysis needle into Patient #22’s access site while wearing a face mask positioned below their nose and no goggles or face shield protecting the eyes. 5. During an observation on 07/01/2025 at 6:22 AM PCT #1 was observed inserting a dialysis needle into Patient #24’s access site while wearing a face mask positioned below their nose and no goggles or face shield protecting the eyes. During an interview with PCT 1 on 07/01/2025 at 2:20 PM, PCT 1 reported “catching” themselves with their mask off and not sure when to wear a faceguard since they have on regular glasses. PCT 1 also reported they were not sure if they received any training in infection control from this facility. The findings were reviewed with the Medical Director and FA, on 07/02/2025 at 12:45 PM, which the FA communicated they had told PCT 1 several times to fasten their gown and wear a mask, and the MSW as well had told PCT 1 to fasten their gown.”

“CARBON ADSORPTION-10 MINUTES EBCT CFR(s): 494.40(a) 5.2.5 Carbon adsorption: 10 min EBCT Refer to RD62:2001, 4.3.9 Carbon adsorption media: When granulated activated carbon is used as the adsorption medium ... each adsorption bed shall have an [empty bed contact time] EBCT of at least 5 minutes at the maximum product water flow rate (a total EBCT of at least 10 minutes). This Standard is not met as evidenced by: 44232 The facility failed to have posted the empty bed contact time (EBCT) on the 2 carbon tank filters for 1 of 1 facility. Findings include: 1. A review of a facility policy revision date 01/02/2025, titled “Water System Monitoring” indicated but was not limited to , “ ... The EBCT calculation must be completed prior to the start of the new water system by the water vender and monthly thereafter by the biomed Technician. Documentation for this calculation will be maintained in the water audit forms as well as posted on the carbon tank ... “ 2. During a water room observation 0n 06/30/2025 at 12:30 PM, observed the 2 carbon tanks without the EBCT of the 2 carbon tanks posted. During an interview on 06/30/2025 at 12:35 PM, when requested the EBCT of the carbon systems, the Biomed Technician communicated he was unaware, one of the tanks had been replace and the sign was gone.”

“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: 44232 Based on observation, record review, and interview, the facility failed to provide a safe and comfortable environment for 1 of 1 stand alone in-center dialysis facilities. Findings Include: 1. A review of a facility policy, titled “Building Requirements and General Safety,” indicated but was not limited to, “ ... The facility shall provide a physical environment that protects the health, safety, and welfare of patients, the personnel, and the public ... The physical premises and the physical environment of the facility and those areas of the facility’s surrounding ... 7. Personnel must operate and maintain equipment in accordance with manufacturer’s instructions ... “ 2. A review of a facility policy revision date 01/02/2025, titled “Water System Monitoring” indicated but was not limited to , “ ... I) Daily Testing ... b) Hardness Testing ... i)At or near the end of the operating day, samples shall be drawn from a point immediately after the water softener and tested for Hardiness. 3. On 06/30/2025 at 8:35 AM, upon arrival observed behind the facility a broken wooden fence half around the dumpster. Noted boxes, debris, and trash in front and on the side of the opened dumpster. 4. On 06/30/2025 at 9:15 AM during a flash tour observation of the water room, observed 4 broken down boxes propped against the wall, a bag of 0.9% Sodium Chloride on the floor upon entering the water room. Observed upon entering the acid mixing room, noted a white crystal substance coating the floor from the yellow metal storage container on the right side of the room to the two acid storage tanks. Observed 3 feet of the floor covered in a rust colored substance in front of the yellow metal storage container. Observed a piece of carboard under the connection pipes saturated and covered in a white crystal substance. Observed a container of RBC Water Hardness Test Strips expired 03/2025 on the brine tank. 5. On 06/30/2025 at 12:30 PM during an observation and interview of the water room with the Biomed Technician, observed a container of RBC Water Hardness Test Strips expired 03/2025 on the brine tank. When asked about the container of expired testing strips, the Biomed Technician confirmed they had expired and the strips re used to test the water for hardiness at the end of the day. 6. A review of agency documents dated 03/03/2025 through 0620/2025, titled “Daily Water Log” noted daily water checks including end of the day checks for water hardiness daily recorded and signed by staff initials. During an interview on 07/01/2025 at 1:15 PM, when asked about the testing strips in the water room and checking for expirations, PCT 4 indicated they should check the container of testing strips prior to use to ensure they are not expired. The findings were reviewed with the Medical Director and FA, on 07/02/2025 at 12:45 PM, which the Medical Director communicated the dumpster is under contact, but if the fence is broken, we need to fix it.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 44232 Based on observation, record review, and interview, the facility failed to ensure the visualization of a patient’s access during dialysis treatment in 2 of 6 observations of the treatment area. (Patients: #23, 24, and 25 ) Findings Include: 1. A review of a facility policy revision date 01/02/2025, titled “Building Requirements and General Safety” indicated but was not limited to, “ ... The facility shall provide a physical environment that protects the health, safety, and welfare of patients ... 13. Patients will have their access site in full view at all times to ensure patient safety. Dislodgement and disconnection could result in exsanguinations and death in minutes ... “ 2. During an observation on 07/01/2025 at 8:40 observed Patient #25 fully covered with a grey blanket. At 8:54 AM, observed RN 1 answer Patient #25’s dialysis machine alarm and failed to remove the blanket from Patient #25’s access. 3. During an observation on 07/01/2025 at 8:40 observed Patient #24 fully covered with a white and black blanket. At 8:53 AM, observed RN 1 providing medication to Patient #24 and failed to remove the blanket from Patient #24’s access. Patient #24’s access remained covered at 9:30 AM. 44354 4. During an observation on 07/01/2025 at 12:45 PM Patient # 24 was covered from head to toes with a blanket covering their access site and face. PCT 4 spoke to patient , the patient pulled their blanket down to answer and covered back up. PCT 4 failed to instruct patient to uncover access site. During an interview on 07/01/2025 at 12:55 PM PCT 4 reported not knowing what kind of access site Patient had and turned and looked at fully covered patient and said “oh that’s not right I can ’ t see [gender of Patient].””

“PR-RESPECT & DIGNITY CFR(s): 494.70(a)(1) The patient has the right to- (1) Respect, dignity, and recognition of his or her individuality and personal needs, and sensitivity to his or her psychological needs and ability to cope with ESRD This Standard is not met as evidenced by: 44232 Based on observation, record review, and interview, the facility failed to ensure staff provided an environment in which the needs and rights of every patient were considered and respected for 1 of 1 facility. Findings Include: 1. A review of a facility policy revision date 01/02/2025, indicated but was not limited to, “This faciity endeavors to provide an environment in which the needs and rights of every patient are considered and respected ... The personal relationship between the patient and medical team preserves that the patient’s dignity as a human being is inherent ... 19. Patients have the right to be treated with consideration, dignity, respect, and recognition ... “ 2. A review of a facility document revision date 01/01/2017, titled “ Job Description-Hemodialysis Registered Professional Nurse” indicated but was not limited to, “ ... Provides safe, effective delivery of age specific patient care ... Demonstrates ability to work with any patient or staff ... Maintains a safe environment for self, patient and family ... Ability to foster an environment of cooperation, collaboration and teamwork ... Ability to remain calm ... “ 3. On 07/01/2025 at 5:13 AM RN 1 entered the conference room and reported only one PCT was there with them and RN 1 was not was not caring for 14 patients by themselves and said “I’m quitting.” 4. On 07/01/2025 5:28 AM observed RN returning to the lobby and noted patients knocking on the outside door, unlocked the door allowing patients to enter the lobby. Patients’ #19, #22, #24, #25, #28, and #32 entered the lobby. RN 1 told them they were quitting. 5. On 07/01/2025 at 6:00 AM Patient #33 had entered the lobby and reported “I’m leaving” and was observed to phone someone to pick her up. RN 1 was observed talking with Patient #33 and Patient #33 showed RN 1 her ankles and said “ ...no swelling” and reported they would come back tomorrow because they knew it would be behind and take too long and stated “ I can’t wait that long it’s a mess . . .” 6. At 6:06 AM RN 1 opened the treatment room doors and began admitting patients to the treatment floor. 7. On 07/01/2025 at 9:35 AM the FA communicated RN1 lacked coping skills and the facility had been actively interviewing for RNs. The FA further communicated the RN had been upset as one of the PCTs quit without notice that day and the RN usually had a Licensed Practical Nurse (LPN) working their days and the LPN had not been available. The findings were reviewed with the Medical Director and FA, on 07/02/2025 at 12:45 PM, which the Medical Director indicated they had been made aware of events on 07/01/2025 by the RN and that behavior was unacceptable.””

“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: 51279 Based on observation, record review, and interview the facility failed to ensure a PCT used appropriate personal protective equipment (PPE) during 2 of 2 initiations of treatments with an AV fistula (PCT 4). Findings Include: 1. A review of a policy revised on 05/01/2024 titled, “Infection Control Practices and Procedure for Dialysis Facilities and Treatments Performed in the Home,” indicated but was not limited to, “POLICY ... These practices should be carried out routinely for all patients in the chronic dialysis setting ... because of the increased potential for blood contamination during dialysis ... Gloves, gowns, masks, and goggles or face shields must be worn when there is a potential for contamination with blood or other potentially infectious material ...” 2. During an observation on 02/05/2025 at 10:21 AM, PCT 4 was observed accessing Patient #20’s right upper arm arteriovenous fistula (AV fistula, connection between an artery and vein, used for dialysis) at Station 8. PCT 4 was observed wearing a blue gown, gloves, and goggles. During an observation on 02/05/2025 at 11:05 AM, PCT 4 was observed accessing Patient #13’s left lower arm AV fistula in the isolation room. PCT 4 was observed wearing a blue gown, gloves, and goggles. PCT 4 failed to wear a mask while accessing Patient #20’s AV fistula and Patient #13’s AV fistula. During an interview on 02/05/2025 at 11:22 AM, PCT 4 indicated appropriate PPE when accessing an AV fistula is gown, gloves, and goggles. When queried if a mask was necessary when accessing an AV fistula, PCT 4 indicated a mask was only indicated when providing care for a CVC (Central Venous Catheter, a thin flexible tube that’s inserted into a vein to deliver fluids, blood, medicine, or nutrients) and it was not the facility’s policy to wear a mask when accessing an AV fistula. During an interview on 02/05/2025 at 11:30 AM, the FA indicated the facility had scaled back the usage of masks. When queried when a mask is to be used, the FA indicated a mask is used when accessing a CVC or if the staff member is feeling ill. During an interview on 02/05/2024 at 1:04 PM, the FA indicated the facility has been following the guidance of Entity 1. When shown the facility’s current policy regarding masks as PPE, the FA indicated they understood the policy indicates masks should be worn if there is a potential for blood contamination.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 44232 Based on observation and interview, the facility failed to properly manage the handling of expired supplies for 1 of 1 stand alone dialysis in-center facility. Findings Include: 1. During a observation on 02/03/2025 at 11:50 AM, in the cabinet observed the following; a plastic container with 58, 3 milliliter (ml) lavender top vacutainer blood collection tubes expiration dated 11/30/2024, one package of 50, 3 ml gold top vacutainer blood collection tubes expiration dated 10/30/2024, one package of 50, 3 ml gold top vacutainer blood collection tubes expiration dated 12/05/2024, and one 40 ml Anaerobic culture vial expiration dated 12/10/2024. During an interview on 02/03/2025 at 12:25 PM, RN 1 confirmed the supplies had expired and should have been disposed of. RN 1 further indicated RN 3, had been responsible for ensuring supplies were ordered and expired items were destroyed. 2. During an interview on 02/05/2025 at 8:00 AM, RN 3 confirmed they were aware of the findings of expired lab supplies. RN 3 further indicated they set up the lab supplies and should have monitored the supplies more closely for expired items.”

“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: 51279 Based on observations, record review, and interview the facility failed to maintain a safe, functional, and comfortable environment for dialysis patients for 1 of 1 In-Center dialysis treatment centers. Findings Include: 1. A review of a policy effective on 05/01/2024 titled, “Building Requirements and General Safety,” indicated but was not limited to, “ ... The facility shall provide a physical environment that protects the health, safety, and welfare of patients, personnel, and the public ...” 2. On 02/03/2025 at 10:20 AM, the following observations were made: An observation of clear plastic wrap tangled in a bush located in the front of the building, a rectangle foam packing material leaning against the exterior of the building, a green cap in the mulch located in the front of the building, a blue exam glove in the mulch located in the front of the building, cigarette butts in the sidewalk crevices located in the front of the building, the handicap button located on the exterior of the facility malfunctioned, and the hand sanitizer machine failed to administer hand sanitizer. During an interview on 02/03/2025 at 10:51 AM, the FA indicated they were not aware the handicap button on the exterior of the building was not working. When queried about the automatic hand sanitizer machine not working, the FA indicated they were not aware the automatic hand sanitizer machine was not working. During an interview on 02/03/2025 at 11:11 AM, the BioMed indicated they did not know the handicap door was not working. 3. On 02/04/2025 at 8:30 AM, the following observations were made: An observation of clear plastic wrap tangled in a bush located in the front of the building, a rectangle foam packing material leaning against the exterior of the building, a green cap in the mulch located in the front of the building, a blue exam glove in the mulch located in the front of the building, cigarette butts in the sidewalk crevices located in the front of the building, the handicap button located on the exterior of the facility malfunctioned, and the hand sanitizer machine failed to administer hand sanitizer. During an interview on 02/04/2025 at 1:30 PM, when queried about the cleanliness of the facility inside and outside, the FA indicated the cleaning company is horrible and does not always clean the center. 4. On 02/05/2025 at 07:45 AM, the following observations were made: An observation of clear plastic wrap tangled in a bush located in the front of the building, a rectangle foam packing material leaning against the exterior of the building, a green cap in the mulch located in the front of the building, a blue exam glove in the mulch located in the front of the building, cigarette butts in the sidewalk crevices located in the front of the building, the handicap button located on the exterior of the facility malfunctioned, and the hand sanitizer machine failed to administer hand sanitizer. 5. During an observation of the water room on 02/03/2025 at 11:15 AM, observed three dialysis machines half blocking the entry door, and observed 7 dialysis machines blocking the walkway and acid tanks. Observed water on the floor in front of the Multifilter Carbon tank and water leaking out of the bottom of the tank. During an interview on -2/03/2025 at 11:15 AM, the Biomed Technician confirmed the old dialysis machines were no longer used and blocked pathways of the water room. The Biomed Technician further confirmed the Multifilter Carbon tank had a leak and needed repair. 6. On 02/03/2025 at 3:55 PM, observed the cabinet door under the island in front of the clean sink broken preventing closure. During an interview on 02/03/2025 at 3:55 AM, PCT 2 confirmed the cabinet door had a broken hinge and prevented closure. 7. During an observation on 02/04/2025 at 10:33 AM, observed 3 dialysis machines partially blocking the inside entrance of the water room. Observed water on the floor from the back wall to front of the Multimedia Absorption filter tank and saturated a piece of cardboard box in front of the tank. Observed 7 dialysis machines blocking the walkway and acid tanks. 8. During an observation on 02/05/2025 at 10:50 AM, observed 3 dialysis machines partially blocking the inside entrance of the water room. Observed water on the floor from the back wall to front of the Multimedia Absorption filter tank and saturated a piece of cardboard box laying on the floor in front of the tank. Observed 7 dialysis machines blocking the walkway and acid tanks. During an interview on 02/05/2025 at 1:11 PM, the FA confirmed the old dialysis machines in the water room should have been gone per their last survey. The FA further indicated they were aware of the Carbon Filter tank leak and needed repairs.”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 51279 Based on record review and interview the facility failed to maintain a complete and accurate medical record by not obtaining and retaining a completed Against Medical Advice (AMA) Form for 3 of 3 active clinical records reviewed (Patient # 5, 9, and 12) with patients ending treatment early and 1 of 1 inactive clinical records reviewed (Patient #1). Findings Include: 1. A review of a policy effective on 01/01/2017 titled, “Consent to Treatment,” indicated but was not limited to, “POLICY ... It is the policy of the facility to obtain patients’ signatures on consent forms for the following procedures: ... 4. Early termination of treatment against medical advice ... If a patient is unable to sign a consent form, the reason should be stated on the form by the staff obtaining the signature and signed by two witnesses ...” 2. A review of the inactive clinical record for Patient #1 revealed an order titled, “Dialysis (treatment that removes excess fluid in the body when the kidneys are unable to function appropriately) Order Report,” dated 10/28/2024. The order included but was not limited to, “Duration: 4:00”. A review of the inactive clinical record Patient #1’s treatment sheet dated 11/13/2024, indicated treatment was initiated at 6:05 AM and ended at 9:13 AM. Patient #1’s actual treatment duration was 3 hours and 5 minutes. The treatment record evidenced the patient signed off early and was refusing recommendations. A review of the facility document titled, “Early Termination of Treatment (AMA),” dated 11/13/2024 and signed by a witness and PCT 1. The treatment record failed to evidence documentation of Patient #1 refusing to sign the AMA form. A review of the inactive clinical record Patient #1’s treatment sheet dated 11/22/2024, indicated treatment was initiated at 5:32 AM and ended at 9:00 AM. Patient #1’s actual treatment duration was 3 hours and 28 minutes. The treatment record evidenced the patient was taken off early due to transportation. A review of the facility document titled, “Early Termination of Treatment (AMA),” dated 11/22/2024 and signed by RN 2 and PCT 1. The treatment record failed to evidence documentation of Patient #1 refusing to sign the AMA form. A review of the inactive clinical record Patient #1’s treatment sheet dated 11/26/2024, indicated treatment was initiated at 5:52 AM and ended at 9:06 AM. Patient #1’s actual treatment duration was 3 hours and 10 minutes. The treatment record evidenced the patient was taken off early due to other. A review of the facility document titled, “Early Termination of Treatment (AMA),” dated 11/26/2024 and signed by RN 1 and PCT 1. The treatment record failed to evidence documentation of Patient #1 refusing to sign the AMA form. A review of the inactive clinical record Patient #1’s treatment sheet dated 12/09/2024, indicated treatment was initiated at 6:10 AM and ended at 9:06 AM. Patient #1’s actual treatment duration was 2 hours and 52 minutes. The treatment record evidenced the patient was taken off early signed off early and was refusing recommendations. A review of the facility document titled, “Early Termination of Treatment (AMA),” dated 12/09/2024 and signed by RN 1 and PCT 1. The treatment record failed to evidence documentation of Patient #1 refusing to sign the AMA form. 3. A review of the clinical record for Patient #12 revealed a document titled, “Dialysis Order Report,” dated 01/29/2025. The order included but was not limited to, “Duration: 3:30”. A review of the clinical record Patient #12’s treatment sheet dated 01/24/2025, indicated treatment was initiated at 1:43 PM and ended at 4:14 PM. Patient #12’s actual treatment duration was 2 hours and 27 minutes. The treatment record evidenced the patient signed off early and was refusing recommendations. A review of the facility document titled, “Early Termination of Treatment (AMA),” dated 01/24/2025 and signed by RN 1. The treatment record failed to evidence documentation of Patient #12 refusing to sign the AMA form and a witness signature. A review of the clinical record Patient #12’s treatment sheet dated 01/29/2025, indicated treatment was initiated at 1:40 PM and ended at 4:35 PM. Patient #12’s actual treatment duration was 2 hours and 53 minutes. The treatment record evidenced the patient signed off early and was refusing recommendations. A review of the facility document titled, “Early Termination of Treatment (AMA),” dated 01/29/2025 and signed by RN 1. The treatment record failed to evidence documentation of Patient #12 refusing to sign the AMA form and a witness signature. During an interview on 02/04/2025 at 12:30 PM, when requested copies of the AMA forms the FA stated, “I saw the patients did not sign the AMAs provided and should have.” 44232 4. A review of the clinical record for Patient #5 contained a physician signed dialysis order dated 01/29/2025, for a prescribed treatment duration time of 4 hours. A review of 11 treatment flowsheets dated 01/11/2025 through 02/01/2025, evidenced prescribed treatment time of 4 hours. A review of the treatment flowsheet dated 01/21/2025, indicated actual duration of dialysis treatment for 2 hours and 58 minutes. Patient #2 had been taken off treatment 1 hour and 2 minutes early. The treatment flowsheet indicated Patient #2 requested early termination of treatment due to family issues. A review of a facility document titled “Early Termination of Treatment Against Medical Advice (AMA)” dated 01/21/2025 evidenced a RN 2’s signature. The AMA form failed to evidence Patient #2’s signature or documentation Patient #2 refused to sign. During an interview on 02/04/2025 at 8:09 AM, when queried the process when a patient requested off treatment early, RN 2 indicated an AMA form must be obtained and signed by the patient or if the patient refused a witness and nurse signed the AMA form. 5. A review of the clinical record for Patient #9 contained a physician signed dialysis order dated 01/29/2025, for a prescribed treatment duration time of 4 hours and 15 minutes. A review of 9 treatment flowsheets dated 01/08/2025 through 01/31/2025 evidenced the following: A review of treatment flowsheet dated 01/08/2025 indicated a prescribed duration time of 4 hours and 15minutes. The actual duration of dialysis treatment for Patient #9 for 3 hours and 4 minutes. Patient #9 had been taken off treatment 1 hour and 11 minutes early. The treatment flowsheet indicated Patient #9 refused recommendations and AMA per request. A review of the AMA form dated 01/08/2025 evidenced a RN 1’s signature. The AMA form failed to evidence Patient #9’s signature or documentation Patient #9 refused to sign. A review of treatment flowsheet dated 01/13/2025 indicated a prescribed duration time of 4 hours and 15minutes. The actual duration of dialysis treatment for Patient #9 for 3 hours and 2 minutes. Patient #9 had been taken off treatment 1 hour and 13 minutes early. The treatment flowsheet indicated Patient #9 refused recommendations and AMA per request. A review of the AMA form dated 01/13/2025 evidenced a RN 1’s signature. The AMA form failed to evidence Patient #9’s signature or documentation Patient #9 refused to sign. A review of treatment flowsheet dated 01/24/2025 indicated a prescribed duration time of 4 hours and 15minutes. The actual duration of dialysis treatment for Patient #9 for 2 hours and 45 minutes. Patient #9 had been taken off treatment 1 hour and 30 minutes early. The treatment flowsheet indicated patient had been taken off early due to area left blank AMA per patient request. A review of the AMA form dated 01/24/2025 evidenced a RN 1’s signature. The AMA form failed to evidence Patient #9’s signature or documentation Patient #9 refused to sign. A review of treatment flowsheet dated 01/27/2025 indicated a prescribed duration time of 4 hours and 15minutes. The actual duration of dialysis treatment for Patient #9 for 3 hours and 1 minutes. Patient #9 had been taken off treatment 1 hour and 14 minutes early. The treatment flowsheet indicated Patient #9 refused recommendations and AMA per request. A review of the AMA form dated 01/27/2025 evidenced a RN 1’s signature. The AMA form failed to evidence Patient #9’s signature or documentation Patient #9 refused to sign. A review of treatment flowsheet dated 01/29/2025 indicated a prescribed duration time of 4 hours and 15minutes. The actual duration of dialysis treatment for Patient #9 for 3 hours and 7 minutes. Patient #9 had been taken off treatment 1 hour and 8 minutes early. The treatment flowsheet indicated Patient #9 refused recommendations and AMA per request. A review of the AMA form dated 01/29/2025 evidenced a RN 1’s signature. The AMA form failed to evidence Patient #9’s signature or documentation Patient #9 refused to sign. A review of treatment flowsheet dated 01/31/2025 indicated a prescribed duration time of 4 hours and 15minutes. The actual duration of dialysis treatment for Patient #9 for 2 hours and 38 minutes. Patient #9 had been taken off treatment 1 hour and 37 minutes early. The treatment flowsheet indicated Patient #9 refused recommendations and AMA per request. A review of the AMA form dated 01/31/2025 evidenced a RN 1’s signature. The AMA form failed to evidence Patient #9’s signature or documentation Patient #9 refused to sign. During an interview on 02/05/2025 at 8:09 AM, RN 3 indicated when a patient requested off their dialysis treatment early the following must be completed; an AMA form had to be printed off, the nurse addressed health consequences for the patient not receiving their dialysis treatment, and then had patient sign the AMA form. RN 3 further indicated if the patient had refused to sign the AMA form the nurse obtained a PCT or witness signature and marked patient refused to sign AMA form.”

“GOV-INTERNAL GRIEVANCE SYS ID/IMPLEMENTED CFR(s): 494.180(e) The facility’s internal grievance process must be implemented so that the patient may file an oral or written grievance with the facility without reprisal or denial of services. The grievance process must include- (1) A clearly explained procedure for the submission of grievances. (2) Timeframes for reviewing the grievance. (3) A description of how the patient or the patient’s designated representative will be informed of steps taken to resolve the grievance. This Standard is not met as evidenced by: 44232 Based on record review and interview, the facility failed to ensure grievances were documented when made by patients for 5 of 5 patient complaints. (Patients: #8, 9, 21, 24 and 26) Findings Include: 1. A review of a revised policy dated 09/19/2024, titled “Patient Grievance Policy” indicated but was not limited to, “ ... Grievance: Any complaint or concern, expressed verbally or in writing, by a patient ... Documentation: The Grievance Officer will document the grievance using the “Patient Grievance Form,” noting details of the complaints ... Staff are required to assist patients in understanding ... to report any grievances promptly ... “ 2. During the entrance conference on 02/03/2025 at 10:44 AM, when queried about patient complaints, the FA indicated they had spoken to the patients regarding their complaints about staff not getting along. 3. A review of the grievance logs dated 10/24/2024 through 01/07/2025, contained complaints regarding the MSW not applying for a patient ’ s grant, IPRO, the ESRD Network called in a complaint regarding patient complaint regarding care not provided during treatment, and a patient complaint of staff lack of concern. The complaint logs failed to evidence complaints from patients reported by staff and patients of staff ’ s behaviors. 4. During an interview on 02/03/2025 at 1:15 PM, when quired regarding the environment cleanliness and staffing issues, indicated trash is normally out in the front entrance and the front handicapped accessible door does not work. Patient #8 further indicated they had complained to the MSW and nursing staff regarding PCT 1 ’ s rudeness and not trusting them. 5. During an interview on 02/03/2025 at 1:42 PM, the MSW indicated the most recent complaint they were aware of was a complaint against themselves. When queried if there had been any complaints regarding shortened treatment times, the MSW indicated Patient # 26 had complained about shortened treatment times due to transportation arriving to pick the patient up early. When queried about the complaint process, the MSW indicated they write the complaint up, talk to the staff involved, determine a resolution, the FA signs off, and document the resolution. 6. During an interview on 02/03/2025 at 4:15 PM, RN 1 confirmed Patient #8, 9, and 24 regarding behavior of PCT 1. When queried if reported the complaints RN 1 indicated they report all complaints to the FA. 7. During an interview on 02/05/2025 at 1:27 PM, indicated Patient #21 complained to them regarding the staff inappropriate behaviors. The FA failed to provide a grievance document regarding Patient #21 ’ s complaint about inappropriate staff behavior. The FA further indicated if a patient reports a complaint to the MSW or staff they are to file a grievance.”

“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: 44232 Based on observation and interviews, the agency failed to ensure staff used hand hygiene appropriately while on the treatment floor by 2 of 3 Patient Care Technicians (PCT) (Employees: PCT 3 (4 times), PCT 1 (3 times)), and failed to ensure staff instructed the patients on proper use of hand hygiene after holding their access with a gloved hand during 2 of 3 decannulations of an arteriovenous fistula or graft (AVF). (Patients: #1, and 7) Findings Include: 1. A review of an Indiana Dialysis Company, Limited Liability Company (LL) policy revision dated 01-26-2022, titled “Hand Washing Technique, Hand Hygiene, and Glove use” indicated but was not limited to, “ ... developed handwashing policies to reduce pathogens on the hands and wrists, thereby decreasing direct and indirect transmission of infectious microorganisms ... “Hand Hygiene” includes either washing hands with soap and water, or using a waterless alcohol-based antiseptic had rub ... hand hygiene is necessary after glove removal ... c. Decontaminate hands before having direct contact with patients ... g. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. ...” 2. On 09-11-2024, PCT 3 was observed applying a clean dressing to Patient #1’s left upper access after the patient held pressure with their right gloved hand. Patient #1 removed their glove and discarded it in the trash receptacle. Patient #1 was not instructed or offered hand hygiene prior to leaving the treatment floor. 3. On 09-11-2024, PCT 3 was observed applying a clean dressing to Patient #7’s right upper access after the patient held pressure with their left gloved hand. Patient #7 removed their glove and discarded it in the trash receptacle. PCT 3 assisted Patient #7 to the scale and held the patient’s belongings. Patient #7 was not instructed or offered hand hygiene prior to leaving the treatment floor. 4. On 09-11-2024, observed PCT 1 completing Central Venous Catheter (CVC) (a long flexible tube inserted into a large vein) exit site care for Patient #15. PCT 1 removed the old dressing from Patient #15’s exit site and discarded it in the trash receptacle. PCT 1 disinfected the area around the CVC exit site with antiseptic without completing hand hygiene and donning new gloves. 5. On 09-11-2024, observed PCT 1 verify dialysis orders and current delivered treatment parameters for Patient #15. PCT 1 touched the machine to confirm orders at Station #1, removed their gloves, donned new gloves, and adjusted the machine alarm at Station #13 without completing hand hygiene. 6. On 09-11-2024, observed PCT 1 verify dialysis orders and current delivered treatment parameters for Patient #20. PCT 1 touched the machine to confirm orders at Station #13, removed their gloves, donned new gloves, and adjusted the machine alarm at Station #1 without completing hand hygiene. During an interview on 09-13-2024, PCT 1 confirmed hand hygiene and donning new gloves were necessary after touching a machine, patient, or dirty dressing. PCT 1 further indicated the patients were to be offered hand hygiene after they handled their access with a gloved hand. PCT 1 stated, “I knew I was forgetting something.” 7. On 09-13-2024, PCT 3 was observed applying a clean dressing to Patient #2’s left upper access after the patient held pressure with their right gloved hand. Patient #2 removed their glove and discarded it in the trash receptacle. Patient #2 was not instructed or offered hand hygiene prior to leaving the treatment floor. 8. On 09-13-2024, observed PCT 3 completing CVC exit site care for Patient #21. PCT 3 removed the old dressing from Patient #21’s exit site and discarded it in the trash receptacle. PCT 3 disinfected the area around the CVC exit site with antiseptic without completing hand hygiene and donning new gloves. During an interview on 09-13-2024, PCT 3 confirmed they had been instructed on infection control and were in orientation. Confirmed hand hygiene was to be completed after gloves are removed.”

“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: 44232 Based on observation, record review, and interview, the facility failed to ensure Personal Protective Equipment (PPE) was worn appropriately to mitigate exposure risk in 1 of 1 stand alone dialysis treatment centers. (Employees: Registered Nurse (RN) 1, and 2) Findings Include: 1. A review of an Indiana Dialysis Company, Limited Liability Company (LLC) policy revision dated 01-26-2022, titled “Infection Control Practices and Procedures for Dialysis Facilities and Treatments Performed in the Home” indicated but was not limited to, “ ... Personnel will wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures ... “ 2. On 09-11-202, RN 1 was observed wearing a gown and mask while they assisted the surveyor into the Conference room. RN 1 failed to remove their PPE prior to leaving the treatment floor. 3. On 09-13-2024, RN 2 was observed in the front lobby wearing their gown and masks, talking with the patients. RN 2 failed to remove their PPE prior to leaving the treatment area. During an interview on 09-13-2024, RN 2 confirmed PPE from the treatment room was not to be worn in the front lobby.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 44232 Based on observation, record review, and interview, the facility failed to ensure the safe handling of medications and liquid supplements for 1 of 1 medication observations. Findings Include: 1. A review of an Indiana Dialysis Company, Limited Liability Company (LLC) policy dated 01-02-2017, titled “Control and Storage of Medications on the Dialysis Unit,” indicated but was not limited to” ... Discard medication if: ... b. Opened without completed date and/or initials ... “ 2. A review of the Liquacel (a liquid protein supplement) container’s label for directions indicated to use the product within 3 months of opening. 3. On 09-11-2024 at 11:01 AM, observed the following at the medication station: an open 32-ounce container of Watermelon Liquacel (a liquid protein supplement), in the cabinet above the countertop, an open bottle ¼ full of Calcitriol Capsules 0.5 micrograms (mcg) expiration date 07/2025, ¼ bottle of Calcitriol Capsules 0.25 mcg expiration date 07/2025, 1/8 bottle of Clonidine 0.1 milligram (mg) expiration date 01/2026, ½ full bottle of Benadryl HCI 25 mg, and a ¾ full bottle of Acetaminophen 325mg. The medications were not labeled with staff initials or date opened. During an interview on 09-11-2024 at 11:05 AM, Registered Nurse (RN) 2 confirmed they knew the date and initials should be placed on the medications and Liquacel after they were opened. RN 2 further indicated they did not put the date opened on the Liquacel and medications.”

“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: 44232 Based on observation, record review, and interview, the facility failed to provide a safe and comfortable environment for 1 of 1 stand alone in-center dialysis facilities. Findings Include: 1. A review of an Indiana Dialysis Company, Limited Liability Company (LLC) policy dated 01-01-2017, titled “Building Requirements and General Safety,” indicated but was not limited to, “ ... The facility shall provide a physical environment that protects the health, safety, and welfare of patients, the personnel, and the public ... “ 2. On 09-11-2024, during a flash tour of the facility, observed the baseboard in the hallway between the offices of the staff bathroom and the hallway leading to the home storage area broken and off. On 09-11-2024, when asked about the baseboard in the hallway of the home exam rooms and staff bathroom, the home therapies RN 4 confirmed they had been broken and loose for a while. 3. On 09-11-2024, during a flash tour of the water room, observed an empty plastic bottle and trash labels on the floor in front of the carbon tanks, and discarded packages and used testing strips of RPC chlorine packages on the floor surrounding the brine tank and in the floor drain in front of the white trash receptacle. Observed 6 dialysis machines in the storage area connected to the water room, obstructing the pathway to the acid tanks, and observed 3 machines in the water room covered in plastic. During an interview on 09-11-2024, RN 2 confirmed trash was on the floors of the water room and the Biomed technician was responsible for cleaning the area. 4. On 09-12-2024, the Biomed technician confirmed there were discarded packages and used testing strips of RPC chlorine packages on the floor surrounding the brine tank and in the floor drain in front of the white trash receptacle. When queried regarding the dialysis machines in the water room and adjoining storage acid room providing limited space, the Biomed technician indicated they were the old machines being stored until they could get rid of them. 5. On 09-11-2024, observed the back of the dialysis chair at Station #1 leaning against the wall unit. During an interview on 09-11-2024, Patient #1 at Station #1 confirmed their dialysis chair was broken. Patient #1 indicated the staff propped the back against the wall. 6. On 09-13-2024, observed the dialysis chairs at Stations #1, 4, and 14 to have broken backs and were unable to sit straight up. During an interview on 09-13-2024, PCT 1 confirmed the dialysis chairs were broken. 7. On 09-13- 2024, observed the wall floor base under the wall unit wood splintered and insulation showing across the baseboards for Station #7. During an interview on 09-13-2024, PCT 1 confirmed the missing baseboard, wood, and insulation across Station #7’s back wall unit baseboard. PCT 1 indicated it appeared to be damaged from a leak.”

“PR-RESPECT & DIGNITY CFR(s): 494.70(a)(1) The patient has the right to- (1) Respect, dignity, and recognition of his or her individuality and personal needs, and sensitivity to his or her psychological needs and ability to cope with ESRD This Standard is not met as evidenced by: 44232 Based on record review and interview, the facility failed to ensure the staff treated the patients with respect and dignity for 1 of 1 in-center dialysis facilities. Findings Include: 1. A review of an undated Indiana Dialysis Company, Limited Liability Company (LLC), policy titled “Patient & Team Members Relations,” was provided by the Administrator on 09-13-2024 at 1:12 PM. The policy indicated but was not limited to, “ Consider the individual’s need or condition as important ... Be compassionate and understanding...not judgmental. Provide quality patient care ... Professional conduct is always expected of all team members while at work ... Verbal or physical abuse of patients, family members, team members, physicians or managers will never be tolerated and may lead to immediate termination ... “ 2. A review of a facility document titled “Grievance Log” was provided by the Administrator on 09-11-2024. The grievance logs dated 01-05-2024 through 09-19-2024 revealed 5 patient grievances related to the Registered Nurse’s attitude, rudeness, lack of empathy, unhappiness with interactions, and leaving the building before the patient’s treatment. 3. A review of a Confidential Patient Grievance dated 06-12-24, signed by the Administrator, indicated Patient #4’s caregiver, Person 3, on behalf of Patient #4, complained to the Administrator about Registered Nurse (RN) 5’s lack of empathy and rudeness towards Patient #4. Person 3 indicated they could overhear RN 5’s conversations with Patient #4 over the speakerphone and noted RN 5 was inconsiderate by interrupting the conversation. The resolution documented was “the Administrator apologized and gave contact information for further needs.” During an interview on 09-13-2024, Patient #4, indicated RN 5 had no bedside manner. Patient #4 indicated when they spoke with RN 5 about their concerns of a new diagnosis, RN 5 gave no empathy or help and just indicated it would hurt really bad. 4. During an interview on 09-11-2024, the Registered Dietician (RD) confirmed they were aware of patient concerns with RN 5. The RD indicated patients had concerns about speaking rudely to people over the phone and didn’t know what kind of mood RN 5 would be in, so they did not like her answering the phone. 5. During an interview on 09-11-2024, Patient #2 indicated RN 5 had a no-care attitude toward the patients. Patient #2 further confirmed RN 5 was at the facility on Monday, 09-09-2024. They saw the RN leave the agency when the facility doors were scheduled to open to initiate patient treatments. 6. During an interview on 09-11-2024, Patient #8 indicated RN 5 would argue with other patients and staff who are no longer here. Patient #8 indicated the patients had complained to the staff about RN 5. 7. During an interview on 09-12-2024, Patient #13 indicated they changed to a Tuesday, Thursday, and Saturday schedule due to RN 5 speaking disrespectfully to the patients and them. Patient #13 stated, “She is no good, rude, and disrespectful, and needs to go.” 8. During an interview on 09-13-2024, PCT 2 confirmed RN 5 was rude to the patients and the patients complained about RN 5. 9. During an interview on 09-13-2024, Patient #23 indicated RN 5 was mean to all of the patients and he was too sick this winter to do anything about it. Patient #23 indicated they were fearful of RN 5 and it was going to be better without RN 5 around this week. 10. A review of the personnel record for Registered Nurse (RN) 5, hire date 07-10-2023, was completed on 09-13-2024. RN 5’s record contained a signed facility document dated 07-10-2024 titled “Indiana Dialysis Company LLC,” which indicated RN 5 had read and understood they were responsible for following the employee handbook and the facility policies and procedures. 11. During an interview on 09-13-2024 at 1:10 PM, the Administrator confirmed RN 5 was on a leave of absence not instituted by the agency as of 09-09-2024. The Administrator indicated they had to intervene once when the Medical Director questioned RN 5 about lab results; RN 5 had her finger in the Medical Director’s face and was yelling.”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 44232 Based on record review and interview, the facility failed to ensure maintained a complete and accurate clinical record by obtaining Against Medical Advice (AMA) from 4 of 6 clinical records reviewed (Patients: #5, 8, and 11) and focused reviewed. (Patient: #1, 2, 7, and 23) Findings Include: 1. A review of an undated facility document titled “Treatment Documentation Guidelines” provided by the Administrator on 09-13-2024. The treatment guidelines indicated but was not limited to, “ ... The machine set up should be checked against the prescription F ... Against Medical Advice (AMA) must be filled out, and documents for cutting treatment ... “ 2. A review of the clinical record for Patient #5 contained a dialysis order dated 08-12-2024 for a treatment duration of 4:00 hours. A review of Patient 5’s treatment sheet dated 08-16-2024, indicated treatment was initiated at 7:48 AM and ended at 10:31 AM. Patient 5’s treatment ran for 2:43 hours. The treatment record failed to evidence documentation of an AMA, physician notification, or why treatment was terminated early. A review of Patient 5’s treatment sheet dated 08-16-2024, indicated treatment was initiated at 7:48 AM and ended at 10:31 AM. Patient 5’s treatment ran for 2:43 hours. The treatment record failed to evidence documentation of an AMA, physician notification, or why treatment was terminated early. 3. A review of the clinical record for Patient #8 contained a dialysis order dated 07-27-2024 for a treatment duration of 4:00 hours. A review of Patient 8’s treatment sheet dated 08-26-2024, indicated treatment was initiated at 7:50 AM and ended at 10:07 AM. Patient 8’s treatment ran for 2:17 hours. The treatment record failed to evidence documentation of an AMA, physician notification, or why treatment was terminated early A review of Patient 8’s treatment sheet dated 08-26-2024, indicated treatment was initiated at 8:39 AM and ended at 11:34 AM. Patient 8’s treatment ran for 2:55 hours. The treatment record failed to evidence documentation of an AMA, physician notification, or why treatment was terminated early. 4. A review of the clinical record for Patient #11 contained a dialysis order dated 07-26-2024 for a treatment duration of 4:00 hours. A review of Patient #11’s treatment sheet dated 08-26-2024, indicated treatment was initiated at 8:01 AM through 12:06 PM. Patient #11 ran for 3:01 hours. The treatment record failed to evidence documentation of an AMA, physician notification, or why treatment was terminated early. A review of Patient 11’s treatment sheet dated 08-30-2024, indicated treatment was initiated at 8:13 AM and ended at 11:27 AM. Patient 11’s treatment ran for 3:14 hours. The treatment record failed to evidence documentation of an AMA, physician notification, or why treatment was terminated early. A review of Patient 11’s treatment sheet dated 09-02-2024, indicated treatment was initiated at 7:32 AM and ended at 10:48 AM. Patient 11’s treatment ran for 3:16 hours. The treatment record failed to evidence documentation of an AMA, physician notification, or why treatment was terminated early. A review of Patient 11’s treatment sheet dated 09-09-2024, indicated treatment was initiated at 8:45 AM and ended at 11:31 AM. Patient 11’s treatment ran for 2:46 hours. The treatment record failed to evidence documentation of an AMA, physician notification, or why treatment was terminated early. A review of Patient 11’s treatment sheet dated 09-11-2024, indicated treatment was initiated at 7:19 AM and ended at 11:06 AM. Patient 11’s treatment ran for 3:41 hours. The treatment record failed to evidence documentation of an AMA, physician notification, or why treatment was terminated early. 5. A focused review of Patient #1’s treatment sheet dated 09-09-2024, indicated Patient #1 had a dialysis prescription duration time of 3:45 hours. Patient #1’s treatment was initiated at 8:19 AM and ended at 10:39 AM. Patient #1 ran for 2:16 hours. The treatment record failed to evidence documentation of an AMA, physician notification, or why treatment was terminated early. 6. A focused review of Patient #2’s treatment sheet dated 09-09-2024, indicated Patient #2 had a dialysis prescription duration time of 4:00 hours. Patient #2’s treatment was initiated at 8:28 AM and ended at 10:42 AM. Patient #1 ran for 2:10 hours. The treatment record failed to evidence documentation of an AMA, physician notification, or why treatment was terminated early. 7. A focused review of Patient #7’s treatment sheet dated 09-09-2024, indicated Patient #7 had a dialysis prescription duration time of 4:00 hours. Patient #1’s treatment was initiated at 8:39 AM and ended at 11:21 AM. Patient #7 ran for 2:16 hours. The treatment record failed to evidence documentation of an AMA, physician notification, or why treatment was terminated early. 8. A focused review of Patient #23’s treatment sheet dated 09-09-2024, indicated Patient #23 had a dialysis prescription duration time of 3:30 hours. Patient #23’s treatment was initiated at 8:34 AM and ended at 9:34 AM. Patient #23 ran for 1:00 hour. The treatment record failed to evidence documentation of an AMA, physician notification, or why treatment was terminated early. During an interview on 09-13-2024 at 10:33 AM, RN 2 confirmed they printed out the AMA forms on 09-12-2024 and indicated they did not complete them with the patients on 09-09-2024. RN 2 stated, “No. We did not offer the patients the opportunity to stay as they had 2nd and 3rd shift patients. Indicated they did not notify the physician of patient treatment times being shortened.” 9. During an interview on 09-13-2024, when queried regarding when the RN is to inform the physician, the Medical Director indicated per the protocol, they should be informed when treatment times were not met. The Medical Director indicated they were informed of the delay in treatments on 09-09-2024 for the 1st shift but were not informed patients on the 1st shift were told they could not complete their treatment due to the start times of the patients on the 2nd shift.”

“PQ-STAFF NURSE-MEET STATE REQUIREMENTS CFR(s): 494.140(b)(4) Each nurse who provides care and treatment to patients must be either a registered nurse or a practical nurse who meets the practice requirements in the State in which he or she is employed. This Standard is not met as evidenced by: 47343 Based on record review and interview, the agency failed to ensure Registered Nurses (RN) providing patient care had a current Cardiopulmonary Resuscitation (CPR, an emergency procedure to continue the flow of oxygen and blood throughout the body) certification for 1 of 1 RN personnel record reviewed. (RN 1) Findings Include: 1. A policy titled “Mandatory In-Service Education-Personnel”, Policy Number: 03.103, with a revised date of 01-26-2022 indicated but was not limited to, “ ... I. The personnel folder for each employee will contain documentation for compliance to the following: a. CPR ...” 2. A review of RN 1’s personnel file evidenced a date of hire of 05-14-2024 and a CPR license which expired on 07-13-2024. The agency failed to ensure RN 1 had a current CPR license. During an interview with the Administrator, Admin 3, on 08-06-2024 at 1:40 PM, they indicated RN 1’s CPR license was expired. 3. During an interview with the Home Training Nurse, Admin 2, on 08-06-2024 at 2:25 PM, they indicated CPR licenses were supposed to be verified annually and the clinicians had to be recertified every 2 years.”

“PQ-PCT-STATE REQUIREMENTS & HS DIPLOMA CFR(s): 494.140(e)(1),(2) Patient care dialysis technicians must- (1) Meet all applicable State requirements for education, training, credentialing, competency, standards of practice, certification, and licensure in the State in which he or she is employed as a dialysis technician; and (2) Have a high school diploma or equivalency; This Standard is not met as evidenced by: 47343 Based on record review and interview, the agency failed to ensure Patient Care Technicians (PCT) had a current Cardiopulmonary Resuscitation (CPR, an emergency procedure to continue oxygen and blood flow throughout the body) certification for 3 of 4 PCT personnel records reviewed. (PCT 2, 3, and 4) Findings Include: 1. A policy titled “Mandatory In-Service Education-Personnel”, Policy Number: 03.103, with a revised date of 01-26-2022 indicated but was not limited to, “ ... I. The personnel folder for each employee will contain documentation for compliance to the following: a. CPR ...” 2. A review of PCT 2’s personnel file evidenced a hire date of 09-03-2022 and a CPR license which expired on 03-27-2024. A review of PCT 3’s personnel file evidenced a hire date of 11-14-2023 and a CPR license which expired on 06-21-2024. A review of PCT 4’s personnel file evidenced a hire date of 01-08-2024 and failed to evidence a CPR license. The agency failed to ensure the PCTs had current CPR licenses. 3. During an interview with the Administrator, Admin 3, on 08-06-2024 at 1:40 PM, they indicated PCT 3 and 4’s CPR licenses were expired. The agency failed to provide a current CPR license for PCT 2. 4. During an interview with the Home Training Nurse, Admin 2, on 08-06-2024 at 2:25 PM, they indicated CPR licenses were supposed to be verified annually and the clinicians had to be recertified every 2 years.”

“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: 47343 Based on observation and interviews, the agency failed to ensure staff used hand hygiene appropriately while on the treatment floor by 2 of 6 Patient Care Technicians (PCT). (Employees: PCT 1, and 6.) Findings Include: 1. A review of an agency policy dated 01-26-2022 and titled “Hand Washing Technique, Hand Hygiene, and Glove use”, indicated but was not limited to, “ ... developed handwashing policies to reduce pathogens on the hands and wrists, thereby decreasing direct and indirect transmission of infectious microorganisms ... “Hand Hygiene” includes either washing hands with soap and water, or using a waterless alcohol-based antiseptic had rub ... hand hygiene is necessary after glove removal ... 1. Indications for handwashing and hand antisepsis. a. When hands are visibly dirty or contaminated ... c. Decontaminate hands before having direct contact with patients. d. Decontaminate hands after contact with a patient’s intact skin ... e. Decontaminate hands after contact with body fluids ... f. Decontaminate hands if moving from a contaminated body site to a clean body site during patient care. g. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. ...” 2. On 04-01-2024 at 2:30 PM, PCT 1 was observed disconnecting Patient #1 from dialysis. PCT 1 donned gloves, without performing hand hygiene, and assisted Patient #1 with putting their coat on. PCT 1 doffed gloves after obtaining Patient #1’s weight before the patient left the treatment area, and donned new gloves, without performing hand hygiene to start prepping Station 1 for the next patient. 3. On 04-02-2024 at 11:53 AM, PCT 6 was observed initiating treatment and performing Central Venous Catheter (CVC) (a flexible tube placed into a large vein above the heart and delivering medications and blood products) exit site care for Patient #16 using their CVC. PCT 6 failed to perform hand hygiene before donning gloves, after retrieving supplies for the patient’s exit site care. PCT 6 used the same gloves, removed Patient #16’s old exit site dressing, and discarded the old exit site dressing. PCT 6 removed the gloves, failed to perform hand hygiene after doffing the gloves, and retrieved a new dressing for Patient #16’s exit site. PCT 6 failed to perform hand hygiene before donning gloves to place the new, clean dressing on Patient #16’s exit site. PCT 6 failed to perform hand hygiene after doffing the gloves they used to complete the exit site dressing change. PCT 6 failed to perform hand hygiene before donning gloves to attach the dialysis lines to the patient’s CVC. PCT 6 failed to perform hand hygiene after doffing gloves when they finished initiating Patient #16’s treatment. PCT 6 was observed moving from the isolation room, where Patient #16 received treatment, to Patient #17’s station at Station 10, and failed to perform hand hygiene before donning new gloves to provide care for Patient #17. 4. During an interview with PCT 1 on 04-01-2024 at 2:05 PM, they confirmed hand hygiene should be performed when changing their gloves. 5. During an interview with PCT 3 on 04-01-2024 at 3:05 PM, when queried regarding times they performed hand hygiene, they indicated hand hygiene should be performed before and after gloving, in between patients, when going from the machine to the patient. They indicated hand hygiene should be offered to the patients upon entry into the treatment area and upon exit from the treatment area. 6. During an interview with PCT 6 on 04-02-2024 at 12:10 PM, they confirmed hand hygiene should be performed after any care or interaction with the patients, when changing gloves, and between patients.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 47343 Based on record review and interview, the agency failed to ensure the nurse was notified of patient’s low blood pressure for 1 of 4 active records reviewed. (Patient #3) Findings Include: 1. A review of an agency policy dated 01-26-2022 and titled “Hypotension” (low blood pressure), indicated but was not limited to, “ ... Take blood pressure, and pulse every 30 minutes and as needed ... 1. If the patient’s systolic blood pressure is less than 90 mmHg ... Procedure ... 1. Determine severity of hypotension. Notify Charge Nurse/Director of Nursing/Physician. ...” 2. During a review of Patient #3’s clinical record, it evidenced documents titled “HD Treatment Flowsheet”. A total of 10 treatment records were reviewed from 03-11-2024 to 04-01-2024. The treatment record dated 03-11-2024 evidenced Patient #3’s blood pressure was 88/47 at 10:05 AM, 70/43 at 10:30 AM, and 83/49 at 10:31 AM during Patient #3’s dialysis treatment. The patient’s post treatment blood pressure while standing was 85/50 at 10:42 AM. PCT 3 failed to notify the nurse of Patient #3’s systolic (the pressure of circulating blood against the walls of the blood vessels) blood pressure below 90mmHg. The treatment record dated 03-15-2024 evidenced Patient #3’s blood pressure was 89/52 at 9:15 AM, 79/44 at 9:46 AM, 77/41 at 9:49 AM, 76/46 at 10:00 AM, and 84/52 at 10:15 AM during the patient’s dialysis treatment. PCT 3 failed to notify the nurse of Patient #3’s systolic blood pressure being below 90mmHg. The treatment record dated 03-20-2024 evidenced Patient #3’s blood pressure was 84/56 at 7:30 AM, 82/54 at 7:31 AM, 88/44 at 8:30 AM, 85/52 at 8:35 AM, 84/45 at 8:45 AM, and 86/44 at 9:30 AM during the patient’s dialysis treatment. The patient’s blood pressure at the end of the treatment was 85/46 at 10:24 AM. PCT 3 failed to notify the nurse of Patient #3’s systolic blood pressure being below 90mmHg. The treatment record dated 03-25-2024 evidenced Patient #3’s blood pressure was 82/75 at 8:30 AM, 84/54 at 8:34 AM, 79/49 at 9:00 AM, 85/49 at 9:01 AM, 74/49 at 9:30 AM, 70/42 at 9:31 AM, 40/21 at 9:42 AM, 49/28 at 10:00 AM, and 79/30 at 10:03 AM during the patient’s dialysis treatment. PCT 3 failed to notify the nurse of Patient #3’s systolic blood pressure being below 90mmHg. The treatment record dated 03-27-2024 evidenced Patient #3’s blood pressure was 86/55 at 9:30 AM, 75/48 at 9:31 AM, 89/34 at 9:32 AM, 68/37 at 10:00 AM, and 83/44 at 10:01 AM during the patient’s dialysis treatment. PCT 3 failed to notify the nurse of Patient #3’s systolic blood pressure being below 90mmHg. The treatment record dated 04-01-2024 evidenced Patient #3’s blood pressure was 83/54 at 9:02 AM, 88/54 at 9:03 AM, and 80/44 at 9:15 AM during the patient’s dialysis treatment. The patient’s blood pressure at the end of treatment was 74/47 at 10:15 AM, 86/53 at 10:21 AM, and 78/43 at 10:25 AM. PCT 3 failed to notify the nurse of Patient #3’s systolic blood pressure being below 90mmHg. 3. During an interview with Patient Care Technician (PCT) 2 on 04-01-2024 at 9:10 AM, they indicated they checked the patients’ blood pressures every 30 minutes, ensured patients’ accesses were uncovered and no blood was leaking from the sites. They indicated they should notify the nurse of any concerns with the patients during dialysis. 4. During an interview with PCT 1 on 04-01-2024 at 2:05 PM, they indicated they would monitor the patient’s fluid and blood pressure and report any issues to the nurse. 5. During an interview with Admin 2 on 04-02-2024 at 3:20 PM, they indicated the nurse was to be notified of a low blood pressure with a systolic less than 90mmHg.”

“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: 44232 Based on observation, record review, and interview, the facility failed to ensure staff used and hand hygiene appropriately while on the treatment floor by 3 of 4 Patient Care Technicians (PCT). (Patients: #6, 8, 9, 15, 17, 18, and 27) (Employees: PCT 4 (3 times), 6 (2 times), and 8 (2 times)) Findings Include: 1. A review of a revised 01-26-2022, Indiana Dialysis Company, LLC policy titled, “Hand Washing Technique, Hand Hygiene, and Glove use,” indicated but was not limited to, “ ... the facility has developed handwashing policies to reduce pathogens on the hands and wrists, thereby decreasing direct and indirect transmission of infectious microorganisms ... 1. Indications for handwashing and hand antisepsis ... g. Decontaminate hands after contact with inanimate objects ... h. Decontaminate hands after removing gloves ... For prevention of Intravascular Catheter-related infections staff will wear clean or sterile gloves when changing the dress on intravascular catheters, Staff will observe hand hygiene before or after palpating catheter insertion sites, as well as before and after accessing or dressing an intravenous catheter ... “ 2. On 01-17-2024 at 9:20 AM, a sign posted on the wall above the sink at the entrance to the treatment area was reviewed, The sign titled, “Hand Hygiene How To” provided pictures and written instructions on how to complete a hand wash and hand rub with hand sanitizer which indicated the best practice to prevent infection. 3. On 01-18-2024 at 4:30 PM, a facility document dated November 2023 through January 202, titled, “Staff Infection Control Audit Tool, Section PPE. And Hand Hygiene” was provided by the Clinical Manager. The documents indicated a review of the monthly infection prevention audits completed. 4. On 01-17-2024 at 11:55 AM, PCT 4 was observed completing Central Venous Catheter (CVC) (a flexible tube placed in the large vein above the heart that delivers medications and blood products) exit site care for Patient #6. PCT 4 obtained dressing supplies from the top of the dialysate machine. PCT 4 used the same gloves, removed Patient #6’s old exit site dressing, and discarded the dressing in the trash receptacle. After discarding the old dressing without removing their gloves, completing hand hygiene, and donning new gloves, cleansed around the area of the CVC exit site. PCT 4 applied a sterile dressing around the exit site. 5. During an observation on 01-17-2024 at 3:00 PM, PCT 4, discontinued the treatment for Patient #15, at Station #12. Patient #15 held pressure on their left vascular access site with a gloved right hand. Patient #15 discarded their glove in the trash receptacle beside their chair. PCT 4 obtained Patient #15’s weight prior to the patient leaving the treatment area. Patient #15 was not offered hand sanitizer or instructed to perform hand hygiene before leaving the treatment floor. 6. During an observation on 01-17-2024 at 3:20 PM, PCT 8, discontinued the treatment for Patient #27, at Station #9. Patient #27 held pressure on their left upper vascular access site with a gloved right hand. Patient #27 discarded their glove in the trash receptacle beside their chair. PCT 8 obtained Patient #27’s weight prior to the patient leaving the treatment area. Patient #27 was not offered hand sanitizer or instructed to perform hand hygiene before leaving the treatment floor. 7. During an observation on 01-17-2024 at 3:25 PM, PCT 4, discontinued the treatment for Patient #8, at Station #10. Patient #8 held pressure on their left lower vascular access site with a gloved right hand. Patient #8 discarded their glove in the trash receptacle beside their chair. PCT 4 obtained Patient #8’s weight prior to the patient leaving the treatment area. Patient #8 was not offered hand sanitizer or instructed to perform hand hygiene before leaving the treatment floor. During an interview on 01-17-2024 at 12:25 PM, Patient #8 indicated they were instructed to wash their hands and access prior to coming into the treatment area. 8. During an observation on 01-17-2024 at 4:00 PM, PCT 8, discontinued the treatment for Patient #18, at Station #7. Patient #18 held pressure on their left upper vascular access site with a gloved right hand. PCT 8 removed Patient #18’s glove and discarded it in the trash receptacle beside the treatment chair. PCT 8 obtained Patient #18’s weight prior to the patient leaving the treatment area. Patient #18 was not offered hand sanitizer or instructed to perform hand hygiene before leaving the treatment floor. 9. During an interview on 01-18-2024 at 11:15 AM, PCT 4 confirmed hand hygiene should be performed after gloves are removed. 47343 During an observation on 01-17-2024 at 4:05 PM, Patient Care Technician (PCT) 6 failed to perform hand hygiene prior to donning gloves. During an observation on 01-17-2024 at 3:04 PM, PCT 6 discontinued Patient #9 from their dialysis treatment at Station #4. Patient #9 held pressure on their left lower vascular access site with a gloved right hand. Patient #9 discarded their glove in the trash beside their chair. Patient #9 was not offered hand sanitizer or instructed to perform hand hygiene before leaving the treatment floor.”

“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: 47343 Based on observation, record review and interview, the agency failed to ensure all supplies were disinfected or discarded after use by 1 of 6 Patient Care Technicians (PCT). (PCT 6) Findings Include: 1. A policy titled “Infection Control Practices and Procedures for Dialysis Facilities and Treatments Performed in the Home” revised 01-26-2022 indicated but was not limited to, “ ... 1. Infection Control ... b. ... items taken to a patient’s dialysis station includeing those placed on top of dialysis machines, will be either disposeed of, dedicated for use only on a single patient, or cleaned and disinfected before being returned to a common clean area or used for other patients. ...” 2. During an observation on 01-17-2024 at 3:34 PM, PCT 6 placed a blue clamp used on Patient #9 on the machine’s pole at Station 4. PCT 6 failed to disinfect 4 blue clamps on the machine’s pole before prepping the machine for the next patient. During an interview with PCT 6 on 01-17-2024 at 3:05 PM, they indicated when they cleaned the machines and chairs after a patient’s treatment they were to remove the clamps used for the previous patient and brought to the cleaning solution and new clamps brought to the station when cleaned.”

“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: 47343 Based on observation and interview, the agency failed to ensure the machine, chairs, and supplies were appropriately disinfected by 3 of 6 Patient Care Technicians (PCT) observed. (PCT: 2, 4, and 6(twice)) Findings Include: 1. A policy titled “Infection Control Practices and Procedures for Dialysis Facilities and Treatments Performed in the Home” revised 01-26-2022 indicated but was not limited to, “ ... e. Machine Disinfection ... 2. Patients equipment will be bleached disinfected at the end of each treatment. 3. Empty contents of prime bucket into dirty sink ... Disinfecct both inside and outside of prime bucket ...” 2. During an observation on 01-17-2024 at 3:34 PM, PCT 6 failed to clean all of the machine’s surface at Station 4. PCT 6 failed to clean the lower half, below the blood pump, of the machine. PCT 6 failed to clean the outside of the sides of the chair. PCT 6 failed to open the sides of the chair and disinfect the inside on the chair. PCT 6 failed to disinfect the blood pressure cuff and the television screen. 3. During an observation on 01-18-2024 at 10:30 AM, PCT 2 cleaned station 7’s machine and chair. PCT 2 failed to empty the prime container and clean the inside and outside of the prime container. 4. During an interview with PCT 6 on 01-17-2024 at 3:05 PM, they indicated they were to clean the top of the machine, inside the pump, the filter, dialyzer, the sides of the machine, and the entire front of the machine. PCT 6 indicated if the chair was soiled they would open up the chair and clean the inside of the side of the chair, but would not open up the chair otherwise. They indicated they were to wipe the television down. They indicated they needed to work on cleaning the blood pressure cuff. They indicated with the patient schedules being back to back, they had not had time to clean the blood pressure cuff, but should clean it more often than they did. 44232 5. On 01-17-2024 at 3:35 PM, PCT 4, was observed cleaning the dialysis station at Station #13. PCT 4 did not clean the interior and exterior of the prime container after emptying the waste in the wall unit box drain. Afterwards PCT 4 placed the uncleaned prime container on the cleaned dialysate machine.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 47343 Based on observation and interview, the agency failed to ensure expired items were discarded for 1 of 1 in center treatment floors. Findings Include: 1. A policy titled “Control and Storage of Medications on the Dialysis Unit” revised 01-26-2022 indicated but was not limited to, “ ... Assess for ... b. Expired (outdated) ...” 2. On 01-17-2024 at 12:37 PM, 8 luer adaptors with an expiration date of 06-25-2023 were in the treatment room drawer labeled “Bandaids, Alcohol Pads, and Tape”. The agency failed to ensure expired items were discarded. 3. During an interview with the Clinical Coordinator on 01-17-2024 at 12:43 PM, they indicated expired items were to be discarded and were not to be on the treatment floor.”

“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: 44232 Based on observation, record review, and interview, the facility failed to maintain the proper care and treatment of the Central Venous Catheter (CVC) for patients observed in 2 of 2 initiation of dialysis and 2 of 4 discontinuation of dialysis treatments. (Patients: #6, 23, 24, and 29) (Employees: Patient Care Technician (PCT) 1 (twice), 2, and 4 ) Findings Include: 1. A review of a revised 01-26-2022, Indiana Dialysis Company, LLC policy titled, “In-Center Hemodialysis Catheter Care,” indicated but was not limited to, “ ... steps are taken to minimize the risk of infection to the hemodialysis catheter and other accesses ... E. To cleanse the connection between any CVC catheter hub and cap use four pads: 1. Hold up the catheter at the connection site with one pad. 2. Use the second pad to clean from catheter connection up catheter limb for 10 centimeters (cm), use one pad each limb. 3. Cleanse first hub connection site and cap vigorously with the first pad and discard then using a new pad cleanse the second hub connection ... “ 2. During an observation on 01-17-2024 at 11:50 AM, PCT 4 was observed initiating dialysis treatment for Patient #6. Patient #6 had a CVC (a flexible tube placed in the large vein above the heart to give medicine, nutrients, or blood products). PCT 4 scrubbed the hub 7 swipes with the alcohol pad. The PCT failed to scrub the hubs vigorously prior to initiating treatment. During an interview on 01-17-2024 at 1:00 PM, PCT 6 indicated infection control in services covered CVC care scrubbing the hubs for around 20 seconds and using hand hygiene and gloving techniques. 4. During an interview on 01-18-2024 at 11:00 AM, PCT 4 indicated they had received infection control in service that morning. The PCT further indicated they had been checked off on CVC dressing changes, CVC initiation, discontinuation, hand hygiene, gloving, and the machines. 5. During an observation on 01-18-2024 at 11:15 AM, PCT 1 was observed discontinuing dialysis treatment for Patient #23. Patient #23 had a CVC. PCT 1 scrubbed the hub for 5 seconds. The PCT failed to scrub the hubs vigorously prior to initiating treatment. 6. During an observation on 01-18-2024 at 11:55 AM, PCT 1 was observed initiating dialysis treatment for Patient #24. Patient #24 had a CVC. PCT 1 scrubbed the hub 5 swipes with the alcohol pad. The PCT failed to scrub the hubs vigorously prior to initiating treatment. During an interview on 01-18-2024 at 12:25 PM, PCT 1 confirmed they had infection control training, regarding CVC care. 7. During an interview on 01-18-2024 at 4:45 PM, these findings were reviewed with the Clinical Manager. The Clinical Manager confirmed 5 wipes or 7 seconds is not long enough to equate to scrubbing the CVC hub vigorously per their company policy. 47343 8. During an observation of a discontinuation of a central venous catheter on 01-18-2024 at 11:25 AM, PCT 2 cleaned Patient #29’s catheter hubs for 5 seconds each. PCT 2 failed to appropriately disinfect the patient’s catheter according to the agency policy.”

“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: 44232 Based on observation, record review, and interview, the facility failed to provide a safe and comfortable environment for 1 of 1 stand alone in-center dialysis facilities. Findings Include: 1. A review of a revised 01-26-2022, Indiana Dialysis Company, LLC policy titled, “Infection Control Practices and Procedure for Dialysis Facilities and Treatment Performed in the Home,” indicated but was not limited to, “ ... The infection control practices recommended for dialysis facilities ... will reduce opportunities for patient-to-patient transmission of infectious agents, directly or indirectly via contaminated devices, equipment and supplies, environmental surfaces ... Environmental cleaning of the dialysis facility ... will be accomplished ... “ 2. During a flash tour of the treatment floor on 01-17-2024 at 9:30 AM, observed a puddle of water from the dialysate machine #05 covering the floor between the areas of Station #1 and Station #2 to the wall unit. During an interview on 01-17-2024 at 9:40 AM, the Patient Care Technician (PCT) 6, was queried about the water on the floor. PCT 6 indicated there are lots of water leaks on the treatment floor. 3. During the flash tour of the treatment floor on 01-17-2024 at 9:50 AM, observed water on the floor between Station #12 and Station #13. 4. During a flash tour of the water room on 01-17-2024 at 10:00 AM, observed 21 discarded packages and used testing strips of RPC chlorine test packages surrounding the white trash can and floor drain. During an interview on 01-18-2024 at 8:15 AM, the Biomed Technician indicated the PCTs throw the package wrappers of the chlorine test strips on the floor. The Biomed further indicated they should throw the packages from the chlorine test strips in the white trash can, the used packages on the floor could clog the floor drain. 5. During an observation on 01-18-2024 at 12:00 PM, observed a blue glove on the floor in front of the trash can in front of the nurse’s station, a roll of tape under the patient treatment chair at Station #9, 2 blue gloves on the floor at Station #13 by the trash can, a roll of tape under the patient’s treatment chair and a white mask on the floor at the left side of Station #8. During an interview on 01-18-2024 at 4:50 PM, during a review of these findings, the Medical Director confirmed they noticed the trash on the treatment floor and tried to be an example and picked some trash at Station #8 today.”

“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: 44232 Based on observation, record review, and interview, the facility failed to ensure systems were in place to maintain the integrity of the facility structure of the floors, walls, and treatment chairs to allow for effective cleaning for 1 of 1 stand alone in-center dialysis facilities. Findings Include: 1. A review of a revised 01-26-2022, Indiana Dialysis Company, LLC policy titled, “Infection Control Practices and Procedure for Dialysis Facilities and Treatment Performed in the Home,” indicated but was not limited to, “ ... The infection control practices recommended for dialysis facilities ... will reduce opportunities for patient-to-patient transmission of infectious agents, directly or indirectly via ... environmental surfaces ... Environmental cleaning of the dialysis facility ... will be accomplished ... “ 2. During a flash tour of the treatment floor on 01-17-2024, at 9:20 AM, observed the baseboard along the wall unit’s floor off and the base of walls and flooring discolored black and brown with debris. During an interview on 01-17-2024 at 9:21 AM, Patient #13, was queried about the cleanliness of the facility. Patient #13 indicated the patients had talked to the Medical Director regarding the clinic floors being dirty, and the chairs being awful and needing to be replaced. 3. On 01-17-2024 at 9:50 AM observed under the clean sink at the nurse’s station the baseboard broken and missing sections with dirt and debris at the base of the wall and flooring. 4. On a flash tour of the water room on 01-17-2024 at 10:00 AM, observed the wall plaster peeling and chipped on the left side of the entry door. Observed the baseboard coming off the back wall behind the bicarb station and the wall plaster peeling and cracked. 5. During an observation on 01-17-2024 at 12:20 PM, at Station #5, observed torn upholstery of the seat, back, and right arm cushion of the patient’s treatment chair. Further noted reddish-brown stains on the seat cushion of the patient’s treatment chair. 6. During an observation on 01-17-2024 at 11:36 AM, observed water on the floor between Stations #12 and #13 from the machine to the wall unit baseboard along with black and brown debris covering the wall. During an interview on 01-17-2024 at 11:37 AM, Patient #15 at Station #12, was queried about the facility’s cleanliness and environment. Patient #15 indicated the facility was not clean. The floors needed to be cleaned, and behind their chair against the wall’s baseboard was mold and debris. Patient #15 further stated, “ This is my life sitting here.” 7. On 01-17-2024 at 12:20 PM, observed between Stations #7 and #8, the floor tiles were discolored gray and black. Further observed the wall unit baseboard coated with black and brown debris. 8. On 01-17-2024 at 1:00 PM, observed a white substance at Station #2 under and behind the patient’s treatment chair. During an interview on 01-17-2024 at 1:00 PM, the Patient Care Technician (PCT) 6, was queried about the floors and patient’s treatment chairs. PCT 6 indicated it was bicarb under the chair from the wall unit. PCT 6 further indicated the patient’s treatment chairs are old and ripped up and they do not recline back fully. 9. During an observation on 01-17-2024 at 1:15 PM, at Station #3, observed torn upholstery of the seat and right arm cushion of the patient’s treatment chair. Further noted reddish-brown stains on the right arm tray of the patient’s treatment chair. 10. During an observation on 01-17-2024 at 1:20 PM, at Station #5, observed torn upholstery in the seat and stain on the right arm tray of the patient’s treatment chair. 11. During an observation on 01-17-2024 at 3:00 PM, at Station #1, observed torn upholstery in the seat, back, and both arms of the patient’s treatment chair. 12. During an observation on 01-17-2024 at 3:45 PM, Station #10, observed torn upholstery on the seat and bilateral armrests of the patient’s treatment chair. 13. On 01-17-2024 at 3:46 PM, Station #9, observed torn upholstery on the seat and bilateral armrests of the patient’s treatment chair. 14. On 01-17-2024 at 3:47 PM, at Station #1, observed torn upholstery on the seat and bilateral armrests of the patient’s treatment chair. 15. On 01-17-2024 at 3:48 PM, observed at Station #3, torn upholstery on the seat with the yellow foam insert showing, and tears in the bilateral armrests of the patient’s treatment chair. 16. On 01-17-2024 at 3:50 PM, observed at Station #12, torn upholstery on the seat and back of the patient’s treatment chair. 17. On 01-17-2024 at 3:48 PM, observed at Station #13, torn upholstery on the headrest, seat, and bilateral armrests of the patient’s treatment chair. During an interview on 01-18-2024 at 8:23 AM the Biomed Technician, was queried about the wall and baseboard deterioration and damage. The Biomed Technician indicated the machines were not leaking. The leaks were from the PCT’s use of the wall unit back flows not being fully turned off or not being turned on correctly which caused the vent tube to leak. The baseboards were called coeband and were worn off the wall base from the spills not being cleaned. The Biomed further indicated the back floor and wall bases were covered in dirt and grime not mold from years of not cleaning well. The Biomed Technician confirmed the wall deterioration at the entry of the water room door, the damage to the back walls at the bicarb station was from the damage caused by bicarb, from overfill, and the runoff of bicarb solution during PCT use. 18. During an interview on 01-18-2024 at 8:21 AM with the Biomed Technician, PCT 4 indicated they dumped the prime containers in the wall unit boxes drain. The Biomed Technician confirmed the PCT gave another reason for the problem with water on the floors and the condition of the walls. 19. During an interview on 01-18-2024 at 11:30 AM, PCT 1 was queried about the wall units leaking. PCT 1 indicated the wall units do not have safety valve stops on the valves to prevent the solution from leaking at times during connections, disconnections, and shutting-off processes. PCT 1 demonstrated how the solution can leak out during the connection. 20. On 01-2024 at 11:45 AM, the Medcial Director, provided documents titled “Agreements” from Entity 4, a cleaning company. The documents evidenced the signature of the Medcial Director, with the date section blank. The doucment further evidenced Entity 4’s sales representation name, title, and date 10-18-2023. The facility failed to evidence cleaning had been completed.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 44232 Based on observation, record review, and interview, the facility failed to ensure the visualization of a patient’s access was observed in 4 of 6 observations of the treatment area. (Patients: #5, 11, 23, 24, and 26) Findings Include: 1. On 01-17-2024 at 12:05 PM, Patient #11 was observed at Station #2. Patient #11’s right upper access was fully covered with a purple and gray blanket. At 12:50 PM, the Patient Care Technician (PCT) 6, reviewed Patient #11’s dialysis prescription when Patient #11’s access was then made visible. 2. On 01-18-2024 at 2:50 PM, Patient #5 was observed fully covered to their neck with a blue blanket in the isolation room. At 3:30 PM, PCT 5 was observed speaking to Patient #5. Patient #5’s access remained fully covered. Patient #5’s access remained covered until 3:45 PM when Patient #5 used their cell phone. 3. On 01-18-2024 at 10:15 AM, Patient #23 was observed at Station #14. Patient #23’s Central Venous Catheter (CVC) (a flexible tube placed in the large vein above the heart to give medicine, nutrients, or blood products) access was covered with their gray shirt. At 10:45 AM, Patient 23’s access was covered by a gray shirt and a blue blanket. At 11:15 AM, the Registered Nurse (RN) 3, uncovered Patient #23’s access, placed a blue drape under the patient’s access, and secured the drape with tape. 4. On 01-18-2024 at 11:25 AM, Patient #26 was observed at Station #8. Patient #26’s CVC was fully covered with a red, gray, and cream plaid blanket. At 11:30 AM, the Medical Director was observed picking up trash at Station #8 and spoke to Patient #26. Patient #26’s access remained covered at 12:10 PM. 5. On 01-18-2024 at 12:10 PM, Patient #24 was observed at Station #5. Patient #24’s CVC was fully covered with a gray blanket. Patient #24’s access remained covered at 12:23 PM. During an interview on 01-18-2024 at 12:25 PM, PCT 1, was queried about the visibility of a patient’s access site. PCT 1 indicated a patient’s access site should be uncovered at all times.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 47343 Based on observation, record review and interview, the agency failed to ensure vascular access sites were washed with soap and water before treatment by 2 of 8 Patient Care Technicians (PCT 2 and 6) observed. Findings Include: 1. A policy titled “Cannulation of the AV (sic Arteriovenous, the connection of an artery and vein) Fistula and AV Graft” revised 01-26-2022 indicated but was not limited to, “ ... IV. Procedure ... 1. Patient or staff need to wash access with soap and water or another skin cleanser and pat dry prior to treatment ...” 2. During an observation on 01-17-2024 at 4:05 PM, PCT 6 brought Patient #17 into the treatment area and obtained the patient’s weight. They led Patient #17 to Station #1 and failed to ensure Patient #17 washed their access site. PCT 6 failed to wash or cleanse the patient’s access site prior to initiating treatment. 3. During an observation on 01-18-2024 at 10:55 AM, PCT 2 brought Patient #31 into the treatment area and obtained the patient’s weight. They brought Patient #31 to Station #6 and failed to ensure Patient #31 washed their access site. PCT 2 failed to wash or cleanse the patient’s access site prior to initiating treatment. 4. During an interview with Patient #29 on 01-18-2024 at 11:34 AM, they indicated washing their hands was not something they normally did. Patient #29 indicated they had never been asked to wash their hands by the staff before. 5. During an interview with Registered Nurse (RN) 3 on 01-18-2024 at 11:34 AM, they indicated patients were to wash their hands before and after treatment. They indicated access sites were to be washed before treatment.”