Fmc Westwood Dialysis Center (Bma Westwood)

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 44223 Based on observations, staff interviews, and policy review, the facility failed to meet the condition of infection control directly related to the care and services provided by the dialysis facility staff whom were working within the contracted dialysis den (an area where nursing homes provide home dialysis treatments to multiple residents in a common area within the nursing home, more commonly referred to as a den setting). The dialysis den staff consist of one Registered Nurse (RN) and one Certified Clinical Hemodialysis Technician [CCHT]. Observations found that 2 of 2 staff (CCHT #7 and RN #10) failed to implement adequate infection control measures to ensure the health and safety of all patients. Findings Include: 1. The facility failed to ensure that 2 of 2 dialysis den staff members (CCHT #7 and RN #10) observed, implemented adequate infection control practices related to glove use and hand hygiene, to reduce the risk of spread of infection while caring for patients. Refer to V113. 2. The facility failed to ensure that 1 of 2 dialysis staff members (CCHT #7) working within the dialysis den wore appropriate PPE during care of a patient and/or disinfection of a dialysis station and wore PPE appropriately during the initiation and termination of treatment to prevent the risk of cross contamination. Refer to V115. 3.) The facility failed to ensure that 2 of 2 dialysis den staff members (CCHT #7 and RN #10) utilized appropriate biohazard containers which contained contaminated hemodialysis equipment to decrease the potential spread of infection. Refer to V121. 4.) The facility failed to ensure one of one dialysis den staff members (CCHT #7 ) observed, adequately disinfected contaminated surfaces, medical devices and equipment within the dialysis station, increasing the risk of cross contamination with blood borne pathogens. Refer to V122. 5.) The facility failed to follow the algorithm recommended for evaluation and immunization against Hepatitis B infection for 1 of 6 dialysis den patients out of 10 applicable patients (#11) in a total sample of 12. . Refer to V126. 6.) The facility failed to ensure that 1 of 1 dialysis den staff members (CCHT #7) observed, followed proper infection control practices during the initiation of dialysis for 1 patient (Patient #9) with an Arteriovenous Fistula/Graft (AVF/G). Refer to V142.”

“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: 44223 Based on observation, interview, and policy review, the facility failed to ensure that 2 of 2 dialysis den staff members (Certified Clinical Hemodialysis Technician [CCHT] #7 and Registered Nurse [RN] #10) observed, implemented adequate infection control practices, related to glove use and hand hygiene, to reduce the risk of spread of infection while caring for patients. Findings Include: Review of the facility policy titled, Personal Protective Equipment, published 11/6/23, indicated the following: *Staff must remove gloves and wash hands after: patient care, exposure to blood and body fluids, touching any surfaces within the patient station. *If hands are not visibly soiled, an alcohol-based hand sanitizer may be used. *Always perform hand hygiene after glove removal. *Avoid touching surfaces with gloved hands that will be touched with ungloved hands(for ex. patient charts and computers). 1. During observation of the Dialysis Den on 6/30/25 at 10:55 A.M., the surveyor observed RN #10 initiate treatment for a patient in station 5. After RN #10 completed the initiation of treatment, she proceeded to remove her gloves and failed to perform hand hygiene. RN #10 then adjusted the dialysis machine with ungloved hands. RN #10 failed to perform hand hygiene after touching the machine, causing concern for potential cross contamination. 2. During observation of the Dialysis Den on 6/30/25 at 11:15 A.M., the surveyor observed CCHT #7 remove a blanket and a blood pressure cuff from a patient with ungloved hands. She then proceeded to pull over a stool to the patient’s station and without performing hand hygiene, she donned clean gloves and started the termination of treatment, causing concern for potential cross contamination. 3. During an observation of the Dialysis Den on 6/30/25 at 11:30 A.M., the surveyor observed CCHT #7 disconnect a patient from dialysis treatment. During discontinuation, CCHT #7 removed her gloves and donned new gloves one time without performing hand hygiene. Specifically, after she disconnected the blood lines. 4. During an observation of the treatment floor at the Dialysis Den on 6/30/25 at 11:40 A.M., the surveyor observed CCHT #7 initiate dialysis treatment for Patient #12. CCHT #7 donned a pair of gloves and removed two gauze dressings that were stained with dried blood. CCHT #7 then washed the access sites with soap and water, cannulated both the lower and upper sites and initiate dialysis treatment. CCHT #7 did not remove her gloves and perform hand hygiene and did not don a new pair of gloves after the removal of the gauze that was stained with dried blood. During an interview on 6/30/25 at 2:15 P.M., RN #10 said that she doesn’t wear gloves when adjusting the machine because it is a touch screen and the gloves make it difficult to change the numbers. She said she should have performed hand hygiene after touching the machine. During an interview on 6/30/25 at 2:15 P.M., CCHT #7 said that she did not realize that she had to change her gloves and perform hand hygiene after disconnecting the lines but she would make sure she starts doing that. 27189”

“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: 27189 Based on observation, interview and policy review, the facility failed to ensure that 1 of 2 dialysis staff members (Certified Clinical Hemodialysis Technician (CCHT) #7) working within the dialysis den wore appropriate PPE during care of a patient and/or disinfection of a dialysis station and wore PPE appropriately during the initiation and termination of treatment to prevent the risk of cross contamination. Findings include: Purpose: The purpose of this policy is to identify Personal Protective Equipment (PPE) and potential areas for use. Responsibility: Employees with potential exposure to hazardous chemicals, blood, or other potential infectious materials *Per OSHA’s bloodborne pathogen Standard, the employee must evaluate the task and the type of exposure expected and, based on the determination, select the “appropriate” personal protective equipment needed, based on the task and risk exposure to blood and other potentially infectious materials (OPIM). *Personal protective equipment including face shield or mask and protective eyewear with full side shield, fluid resistant gowns and gloves, must be worn to protect employees from blood or other potentially infectious materials (OPIM). PPE is used to protect employees who are occupationally exposed to blood or OPIM when performing procedures during which spurting or splattering of blood might occur (e.g. during initiation and termination of dialysis, cleaning of Dialyzer and centrifugation of blood). *Eyewear: Protective eyewear is provided by the facility and must be eye protection designed under normal conditions of use to prevent blood and OPIM from reaching the eyes. 1. The facility failed to ensure that one staff member (CCHT #7) wore a face shield during termination of dialysis treatment for a patient with a Central Venous Catheter (CVC) and during the disinfection of a dialysis station (disinfection is performed with a 1:100 bleach solution). During an observation on 6/30/25 at 10:26 A.M., CCHT #7 completed the termination of dialysis on Patient #12 who had a CVC in place. CCHT #7 failed to wear a face shield during the termination process, causing concern for potential risk of blood splatter and increasing the risk for potential cross contamination. During an observation on 6/30/25 at 10:45 A.M., CCHT #7 was observed disinfecting station #6. CCHT #7 disinfected the dialysis station without wearing a face shield, causing concern for potential risk of blood splatter and increasing the risk for potential cross contamination. During an interview on 6/30/25 at 2:50 P.M. CCHT #7 said she thought she had donned a face shield for the above procedures but had not. 44223 2. The facility failed to ensure that CCHT #7 wore PPE properly during the initiation and termination of dialysis procedures. During observations of the dialysis den treatment floor from 10:20 A.M. through 3:00 P.M., the surveyor observed CCHT #7 initiate and terminate treatment for patients. During these times CCHT #7’s pant legs were pulled up, exposing her ankles and part of her calves, which fails to protect her from blood spurting or splatter, increasing the risk for cross contamination. During an interview on 6/30/25 at 2:50 P.M. CCHT #7 said that she knows her pant legs are up but they are a jogger style scrub and they rise up and there is not much she can do about it. During an interview on 7/1/25 at 8:45 A.M., the Home Program Manager said that staff should be making sure that their skin is not exposed to potential blood splatter.”

“IC-HANDLING INFECTIOUS WASTE CFR(s): 494.30(a)(4)(i) [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- (i) Handling, storage and disposal of potentially infectious waste; This Standard is not met as evidenced by: 44223 Based on observation, interview, and policy review, the facility failed to ensure that 2 of 2 dialysis den staff members (CCHT #7 and RN #10) utilized appropriate biohazard containers which contained contaminated hemodialysis equipment to decrease the potential spread of infection. Findings include: Review of the facility policy, titled General Cleanliness and Infection Control Guidelines, published on 5/5/25, indicated the following: *Regulated medical waste shall be placed in a container that is in accordance with OSHA bloodborne standard 1910.1030 and is closeable, leak proof and labeled and/or color-coded. * Regulated waste shall be placed in containers which are: * Closable * Constructed to contain all contents and prevent leakage of fluids during handling, storage, transport, or shipping * Labeled or color-coded * Closed prior to removal to prevent spillage or protrusion of contents during handling, storage, transport, or shipping During observation of the treatment floor at the dialysis den on 6/30/25 from 10:20 A.M. through 3:00 P.M., the surveyor observed a cardboard biohazard container against the wall. It was a labeled cardboard box without a lid. Throughout the entire observation there was a red bag inside the cardboard container and there was no lid available to cover the top. Staff disposed of used dialysis supplies in the open biohazard container. During an interview on 6/30/25 at 2:50 P.M., Certified Clinical Hemodialysis Technician (CCHT) # 7 said that this was a temporary container until more plastic ones with lids could be purchased. During an interview on 7/1/25 at 8:45 A.M., the Home Program Director said the patient census has increased at the den and has required more biohazard containers. She said maintenance gave this box until new plastic containers could be brought to the den. She said the biohazard container should have had a cover on it.”

“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: 27189 Based on observation, interview, and policy review, the facility failed to ensure one of one dialysis den staff members (Certified Clinical Hemodialysis Technician [CCHT] #7 ) observed, adequately disinfected contaminated surfaces, medical devices, and equipment within the dialysis station, increasing the risk of cross contamination with blood borne pathogens. Findings Include: Review of the facility policy titled Cleaning and Disinfecting the Dialysis Station (dated 9/5/23), indicated, but was not limited to the following: Definition: Dialysis Station *Area including the dialysis machine, chair/bed and other reusable equipment or supplies utilized during dialysis treatment, patient training, and/or patient clinic visits. Equipment in the dialysis station may include (but is not limited to) the following: -Dialysis machine/cycler and attachments such as IV pole, BP cuff and hand sanitizer/holder, organizer. -Chair/bed. -Pureflow SL. -Individual television and remote. *All work surfaces shall be cleaned and disinfected with 1:100 bleach solution after completion of procedures. Make the surface glistening wet and let air dry unless otherwise specified by the manufacturer. During an observation of the dialysis den on 6/30/25 at 10:40 A.M., the surveyor observed CCHT #7 disinfecting station 6 to prepare the treatment area and dialysis machine for the next patient. She disinfected the dialysis station using disposable wipes that were soaked with a 1:100 bleach solution. CCHT #7 failed to disinfect the back of the dialysis machine, the back of the dialysis chair and behind the dialysis station. She also failed to disinfect the television and the stethoscope hanging from the top of the Intravenous (IV) pole. During an interview on 6/30/25 at 2:24 P.M., CCHT#7 said that she didn’t realize that all of the above areas should be disinfected but will disinfect the above areas moving forward.”

“IC-HBV-VACCINATE PTS/STAFF CFR(s): 494.30(a)(1)(i) Hepatitis B Vaccination Vaccinate all susceptible patients and staff members against hepatitis B. This Standard is not met as evidenced by: 27189 Based on record review, interview, document review, and policy review the facility failed to follow the algorithm recommended for evaluation and immunization against Hepatitis B infection for 1 of 6 dialysis den patients out of 10 applicable patients (#11) in a total sample of 12. Findings include: Review of the CMAB recommended Evaluation and Immunization against Hepatitis B infections 1.0 (dated 5/16/25) indicated but was not limited to the following: GENERAL ORDERS: *This algorithm should be initiated on patient admissions to the clinic. *In patients with anti-HBs level less than 10 mlU/ml and previously vaccinated. *This algorithm is intended for patients with End Stage Renal Disease (ESRD). *Document vaccine order and administration in the electronic medical record. *Maintain the signed consent of declination in the patients medical record. ESTABLISH PATIENT HEPATITIS B VACCINATION STATUS: -Obtain history of Hepatitis B Vaccinations: *Check medical records. *Speak with patient and/or family. *Review patient discharge summaries from the hospital. *Review correspondence from the Primary Care Physicians (PCP) office. -Patient has no history of Hepatitis B Vaccination or vaccination status is unknown, begin vaccination process. *Educate patient using the Vaccine Information Statement (VIS) for Hepatitis B Vaccine. *Discuss with patient consent for Hepatitis B Vaccine. *If patient does not consent, obtain sighed declination on Heplisav B vaccination consent form and file in Medical record, *Inform Physician. *Offer vaccination annually. *If patient does consent, obtain signed consent on Heplisav-B Vaccination Patient consent form and fine in Medical Record *Begin vaccination based on history. For Patient #11, who recieves his/her dialysis in the dialysis den, the facility failed to initiate the above process for hepatitis B when the anti-HBs level was less than 10 mlU/ml on 5/12/25. Patient # 11 was admitted to the facility in April 2025 with diagnosis of ESRD requiring hemodialysis four times a week. Review of the facilities Hepatitis B Summary report (creation date 6/30/25 at 11:07 A.M.) indicated that patient’s hepatitis status was as follows: *Most recent Hep B Surface Ab result (anti-HBc) drawn on 5/12/25 was <10. *Most recent Hep-B surface Ag (HBsAg) result drawn on 5/12/25 was negative. *Most Recent Hepatitis Status-Unknown. Review of the medical record indicated no information regarding any of the above required information/documentation for Patient # 11’s Hepatitis B vaccination status. During an interview on 7/2/25 at 1:15 P.M., Registered Nurse (RN) # 8 said that the above information should have been obtained when Patient #11 was admitted to the facility but was not.”

“IC-O-SIGHT-MONITOR ACTIVITY/IMPLEMENT P&P CFR(s): 494.30(b)(1) The facility must- (1) Monitor and implement biohazard and infection control policies and activities within the dialysis unit; This Standard is not met as evidenced by: 27189 Based on observation, interview and policy review, the facility failed to ensure that 1 of 1 dialysis den staff members (Certified Clinical Hemodialysis [CCHT] #7) observed, followed proper infection control practices during the initiation of dialysis for 1 patient (Patient #9) with an Arteriovenous Fistula/Graft (AVF/G). Findings include: Review of the facility policy titled, Assessment and Cannulation, dated 5/5/25 indicated but was not limited to the following: *Disinfect cannulation site as follows using any of the disinfectants: *70% Isopropyl alcohol pad: Using gentle friction clean the access site beginning in the center and continuing outward 2 inches in concentric circle for 30 seconds and allow to dry before cannulation. *Perform skin antisepsis on one site at a time, allow to dry and then cannulate. Do not touch cannulation sites after skin disinfection. For Patient #9, CCHT #7 failed to disinfect the AVG sites prior to cannulation. Patient #9 has a diagnosis of End Stage Renal Disease (ESRD) and was receiving hemodialysis four times a week at the Dialysis Den. During an observation on the treatment floor at the dialysis den on 6/30/25 at 9:40 A.M., the surveyor observed CCHT #7 initiate dialysis treatment for Patient #9, via an AVG. CCHT #7 obtained soap and water and washed and dried the area. Without disinfecting the lower access site, CCHT #7 cannulated the lower access site. She failed to disinfect the lower access site prior to cannulating. CCHT #7 then disinfected the upper access site for a total of 7 seconds using an alcohol prep pad and then cannulated the upper access site. CCHT #7 failed to disinfect the upper access site for 30 seconds, as per the facility policy prior to cannulation. During an interview on 6/30/25 at 2:15 P.M., CCHT #7 said she didn’t realize that she had not disinfected the access sites prior to cannulation according to facility policy, but thought she had.”

“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: 27189 Based on observation and interview, the facility failed to ensure equipment solutions were labeled appropriately by indicating what type of solution the bottles contained. Findings include: During an observation of the incenter treatment floor on 7/1/25 at 1:55 P.M., the Lab Prep Area was observed. This is where the Myron meter and testing solutions for the meter are kept. The Myron meter provides fast, accurate, on-the-spot measurements of Total Dissolved Solids(TDS) or conductivity. The area had one 32 ounce bottle that contained a clear solution. The bottle had been dated and initialed by a staff member, however the bottle did not indicate what the clear solution in the bottle was. There was another smaller bottle (blue cap with a long spout) that had been dated and initialed by a staff member, but this bottle did not indicate what the clear solution in the bottle was. During an interview on 7/1/25 at 1:55 P.M., the Clinical Manager said that although the solutions were dated and initialed by the staff, the bottles should have indicated the type of solution that was in the bottles and did not.”

“PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This Standard is not met as evidenced by: 44223 Based on record review, interview, and policy review, the Interdisciplinary Team (IDT) of the facility failed to complete an initial comprehensive assessment for 3 of 10 applicable patients (#8,#11,#7), out of a total sample of 12 patients, within 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. Findings Include: Review of the facility policy, titled Comprehensive Interdisciplinary Assessment and Plan of Care, published 7/3/23, indicated the following: *The comprehensive Interdisciplinary Assessment and Plan of Care must be developed and implemented by an interdisciplinary team (IDT) consisting of at a minimum, the patient or patient’s designee, a registered nurse, the patient’s attending physician (or physician extender where allowed by State regulations), qualified master’s degree level social worker and qualified registered dietitian. *An Initial Comprehensive Interdisciplinary Assessment (CIA) and Plan of care (POC) must be conducted on all patients new to dialysis within the later of 30 calendar days or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session. Patients changing modality are classified as new patients and must have comprehensive interdisciplinary assessments and plans of care completed with the same frequency as patients new to dialysis. *A follow up CIA must occur within 90 days. The POC should be adjusted as appropriate and implemented within 15 days of reassessment. 1. For Patient #8, the facility failed to ensure that a comprehensive assessment was completed by a Registered Nurse (RN) prior to developing the plan of care for an experienced dialysis patient returning from one dialysis facility to another, within 30 days of the patient’s admission to the new facility. Patient #8 was admitted to the facility in May 2025 with a diagnosis of End Stage Renal Disease requiring dialysis three times a week. Review of the clinical record indicated Patient #8 was transferring back into the facility after being out of the country for greater than one month. Review indicated the patient was being admitted to the facility as a new patient. Further review indicated Patient #8 was assessed by the Interdisciplinary Team with the exception of the RN as follows: *Registered Dietitian completed a comprehensive assessment on 5/6/25. *Social Worker completed a comprehensive assessment on 5/7/25. *Physician completed a comprehensive assessment on 5/12/25. The care plan was developed based on the assessments and reviewed on 5/12/25 as an initial 30 day care plan. During an interview on 7/1/25 at 4:30 P.M., the Clinic Manager (CM) said that the RN assessment was missed. 27189 2. For Patient #11, the facility failed to ensure that a comprehensive assessment was completed by the physician prior to developing the plan of care (initial admission 9/2024) with the patient returning to the dialysis den April 2025 after repeated admissions from one dialysis facility to another (going home and being hospitalized in between the admissions) within 30 days of the patient’s admission to the current facility. Patient #11 was currently admitted to the facility in April 2025 with a diagnosis of End Stage Renal Disease requiring dialysis four times a week at the dialysis den. Record review indicated Patient #11 was assessed by the Interdisciplinary Team with the exception of the physician as follows: *Registered Dietitian completed a comprehensive assessment on 4/4/25. *Social Worker completed a comprehensive assessment on 4/4/25. *Registered Nurse completed a comprehensive assessment on 4/4/25. The care plan was developed based on the assessments and reviewed on 4/14/25 as an initial 30 day care plan. During an interview on 7/2/25 at 2:30 P.M., RN #8 said that a physician assessment should have been done, but was not completed as required. 10249 3. For Patient #7, the facility failed to ensure that a comprehensive reassessment was completed by a Registered Nurse [RN] prior to developing the plan of care for an experienced dialysis patient transferring from one dialysis facility to another, within three months of the patient’s admission to the new facility. Patient #7 was admitted to the facility in February 2025 with diagnoses that included end stage renal disease and type 1 diabetes, requiring dialysis treatments three times a week. Review of the clinical record indicated that Patient #7 was transferred from another facility to be closer to home. Further review indicated that Patient #7 was reassessed by the Interdisciplinary team with the exception of the RN as follows: *Registered Dietitian completed comprehensive reassessment on 3/3/25. *Social Worker completed a comprehensive reassessment on 3/10/25. *Physician completed a comprehensive reassessment on 3/3/25. The care plan was developed based on the assessments and reviewed on 3/17/25 as a 90 day care plan. During an interview on 7/2/25 at 2:00 P.M., RN #3 said she had not completed a nursing comprehensive reassessment, but rather used the comprehensive assessment, dated 1/22/25, that was completed at the previous facility.”

“POC-VA MONITOR/PREVENT FAILURE/STENOSIS CFR(s): 494.90(a)(5) The patient’s vascular access must be monitored to prevent access failure, including monitoring of arteriovenous grafts and fistulae for symptoms of stenosis. This Standard is not met as evidenced by: 27189 Based on observation, interview, and policy review, the facility failed to ensure that 1 staff members (Certified Clinical Hemodialysis Technician [CCHT] #7) observed at the dialysis den, evaluated a vascular access to ensure functionality by the way of listening for a bruit the length of the access (swooshing sound heard with a stethoscope placed over the access) and palpating for a thrill (palpable vibration/buzzing sensation on the skin over the area of turbulent blood flow) for 1 dialysis den patient (#9) with arteriovenous fistula/graft (AVF/AVG) access site. Findings include: Review of the facility’s policy titled Access Assessment and Cannulation, dated 5/5/25, indicated but was not limited to the following: LISTEN: *Bruit High pitch/whistle. *Bruit not present throughout access. *Document in treatment record. *Staff are trained to auscultate the vascular access with a stethoscope the entire length of the access for changes in the sound of the bruit. FEEL: *Pulse not soft/not easily compressible. *Thrill not strong at anatomists. *Thrill not present throughout access. *Document in treatment record. *Thrill should have of two sensations-a purring like a cat, or a vibration like a cell phone. It should not pulsate. Strong pulsation suggests there is a flow issue due to stenosis. For Patient #9, CCHT #7 failed to listen (auscultate) and feel (palpate) the AVG prior to cannulation. Patient #9 has a diagnosis of End Stage Renal Disease (ESRD) and was receiving hemodialysis four times a week at the dialysis den. Patient #9 had an AVG for access. During an observation on the treatment floor at the dialysis den on 6/30/25 at 11:40 A.M., the surveyor observed CCHT #7 initiate dialysis treatment for Patient #9, via an AVG. CCHT #7 obtained soap and water and washed and dried the area. CCHT #7 informed the surveyor that Patient #9 had an AVG and that she would not be using a tourniquet. Without listening for the presence of a bruit or palpating for the presence of a thrill, she inserted the needles into the lower access, and then upper access. CCHT #7 failed to assess for the presence of a bruit with the use of a stethoscope and palpate for the presence of a thrill prior to cannulation. During an interview on 6/30/25 at 2:15 P.M., CCHT #7 said she didn’t listen for the bruit or palpate for a thrill prior to cannulation, but should have.”

“QAPI-INDICATOR-INF CONT-TREND/PLAN/ACT CFR(s): 494.110(a)(2)(ix) The program must include, but not be limited to, the following: (ix) Infection control; with respect to this component the facility must- (A) Analyze and document the incidence of infection to identify trends and establish baseline information on infection incidence; (B) Develop recommendations and action plans to minimize infection transmission, promote immunization; and (C) Take actions to reduce future incidents. This Standard is not met as evidenced by: 44223 Based on review of the Quality Assessment Performance Improvement (QAPI) Program, staff interviews, and policy review, the facility failed to ensure monthly infection control audits were conducted at the dialysis den to be consistently measured, analyzed, and that a plan was developed based on results of these monthly reports. Findings Include: Review of the facility policy titled, Quality Assessment and Performance Improvement Program, published 11/4/24, indicated the following: *Quality Assessment and Performance Improvement is a shared continuous process to provide safe patient care and improve patient outcomes. The Quality Assessment and Performance Improvement (QAPI) Program encompasses all aspects of patient care, including in-center, home hemodialysis, home peritoneal dialysis and self-care, as well as support services to provide the care. *The QAPI Program is designed and implemented to objectively, systematically, and comprehensively monitor, evaluate, and improve the quality and safety of patient care and services by identifying opportunities and resolving identified problems through the use of continuous quality improvement (CQI) methodology to achieve measurable improvement of health outcomes, optimize the number of patients who achieve individual patient targets, and prevent and reduce medical errors. *The QAPI program is a collaboration among the interdisciplinary team that must develop, implement, maintain, and evaluate an effective, data driven, quality assessment and performance improvement program. QAPI requires the use of aggregate patient data to evaluate the facility patient outcomes. Review of the QAPI Meeting Minutes Report Summary from December 2024 through May 2025 indicated that monthly infection control visual audits were not completed for 6 of 6 months at the Dialysis Den, therefore staff were unable to track, trend, or analyze within the QAPI committee. During the survey conducted at the dialysis den on 6/30/25, the surveyors observed infection control breaches which included: * Staff failed to consistently perform hand hygiene. * Staff failed to don/doff appropriate personal protective equipment (PPE). * Staff failed to adequately clean and disinfect contaminated surfaces, medical devices, and equipment within the hemodialysis station, increasing the risk of cross contamination with blood borne pathogens. * Staff failed to implement adequate infection control practices during the termination of a central venous catheter. *Staff failed to implement adequate infection control practices during the initiation and termination of a Arterio-fistula or graft. *Staff failed to implement adequate infection control practices around biohazard equipment (leaving biohazard container open with no lid) During an interview on 7/1/25 at 8:45 A.M., the Home Program Director said there are no monthly infection control audits completed at the dialysis den. She said it has been challenging because they have not had consistent nursing staff there to delegate it or to be accountable for it being done. She further said that she is not able to get there all the time so it makes it difficult to complete them but said they need to work on a better process so that the audits can get done. During an interview on 7/3/25 at 1:00 P.M., the Clinic Manager said that there are no infection control audits completed for the Dialysis Den.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 44223 Based on record review, policy review, and staff interview, the Medical Director failed to ensure staff followed the policy related to reversal of Central Venous Catheter (CVC) lines for 1 of 10 applicable patients (#5) reviewed, out of a total sample of 12 patients. Findings include: Review of the facility policy, entitled, Reversal of Central Venous Catheter Lines, dated 2/5/24, indicated the following: *Reversal of CVC lines requires the following documentation in the patient’s medical record: -Provider order with frequency (each treatment x 1, etc.) entered in the patient record. -Reason for line reversal. -Action of line in the treatment record. -Evaluation of catheter and future need for vascular referral. Patient #5 was admitted to the facility in January 2025 with a diagnosis of End Stage Renal Disease requiring hemodialysis three times a week. Review of treatment flowsheets, dated 6/10/25 through 6/28/25, indicated for 1 of 9 treatments, the CVC lines were reversed, including 6/26/25. There was no documentation indicating that nursing had notified the physician and obtained an order to reverse the lines. During an interview on 7/2/25 at 10:35 A.M., the Clinic Manager (CM) said that staff should notify the physician if the CVC lines are reversed and that there was no order from the physician. She said it got missed.”