Davita Boston Dialysis

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full instant use in case of emergency, unless modified by 20/21.2.2 through 20/21.2.11. 20.2.1, 21.2.1, 7.1.10.1 This Standard is not met as evidenced by: 12268 Based on observation, the facility failed to maintain the stairwells in conformance with NFPA 101, Section 7.2. NFPA 101 section 7.2.2.5.3.1 states open space within the exit enclosure shall not be used for any purpose that has the potential to interfere with egress. ( An example of a use with the potential to interfere with egress is storage.) Findings Include:: On 11/21/24, it was noted that the facility is utilizing the bottom stair landing, of the East and West Stairs, as storage areas. Chairs, boxes and other items were noted on each landing. This was confirmed by the Administrator As a result, the open space within the exit enclosure was not maintained in accordance with Section 7.2.2.5.3.1. These findings were reviewed with the Administrator and Regional Nurse Supervisor at the exit conference.”

“Emergency Lighting CFR(s): NFPA 101 Emergency Lighting Emergency lighting of at least 1-1/2 hour duration is provided automatically in accordance with 7.9. 20.2.9.1, 21.2.9.1, 7.9 This Standard is not met as evidenced by: 12268 Based on surveyor record review, observation and confirmed by the Director of Maintenance (DOM) staff, the facility failed to ensure compliance with section 7. Section 7.8.1.2 requires all illumination in the means of egress be continuous during the time that the conditions of occupancy require that the means of egress be available for use. Section 7.9.2.4 states emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, other than battery systems for emergency luminaires in accordance with 7.9.2.5, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems. NFPA 110 section 7.3.1 states the Level 1 or Level 2 EPS equipment location(s) shall be provided with battery-powered emergency lighting. This requirement shall not apply to units located outdoors in enclosures that do not include walk-in access. Section 7.9.3.1.1, states that testing of required emergency lighting systems shall be permitted to be conducted as follows: (1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2). (2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction. (3) Functional testing shall be conducted annually for a minimum of 1- 1/2 hours if the emergency lighting system is battery powered. (4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3). (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. Findings Include: On 11/21/24, while conducting the surveyor record review, it was noted: 1. There are no written records to substantiate that the emergency lighting battery packs (located in the Main Lobby) were tested monthly and annually as required As a result, the facility failed to comply with section 7.9.3.1.1. 2. Observations revealed that the electrical rooms housing the facility’s automatic transfer switches (ATSs) and Normal Electrical power, and the walk-in generator enclosure are not equipped with battery-powered emergency lighting. As a result, the facility failed to ensure compliance with NFPA 101 and NFPA 110 and the sections referenced above. These findings were reviewed with the Administrator and Regional Nurse Supervisor at the exit conference.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm Systems - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 12268 Based on staff interview and documentation review, the facility failed to ensure that the back-up batteries of the facility’s fire alarm system are tested in accordance with NFPA regulations. NFPA 101, Life Safety Code (2012 edition), Chapter 21.3.4.4 (Fire Safety Functions.) states that the operation of any activating device in the required fire alarm system shall be arranged to accomplish automatically, without delay, any control functions required to be performed by that device. (See 9.6.5.) NFPA 101, Life Safety Code, Section 9.6.1.3, states that a fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. Section 9.6.1.4 states that all systems and components shall be approved for the purpose for which they are installed. Section 9.6.1.5, states that to ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. NFPA 72 (2010 edition), Table 14.4.2.2 requires an annual charger test, a 30 minute annual discharge test, and a semi-annual load test to be conducted of the sealed lead acid batteries. Findings Include: On 11/21/24, documentation review of the semi-annual fire alarm inspection reports, dated 09/03/24, 05/20/24 and 12/27/23 indicated that the facility’s fire alarm control panel’s sealed lead acid back-up batteries have not been subjected to an annual thirty minute discharge test or semi annual load testing, since the batteries were installed or to the previously installed and replaced FACP back up batteries. Vendor records only document a “visual,” inspection conducted on the the FACP batteries and the booster batteries on 09.03/24. There is no documentation to confirm that an annual 30-minute discharge test and/or the semi-annual load voltage test of the FACP batteries was conducted as required. As a result of failing to conduct an annual 30-minute discharge test and semi-annual load tests of the FACP back-up batteries the facility failed to comply with NFPA 101, section 21.3.4.4, section 9.6, and NFPA 72, table 14.4.2.2. These findings were reviewed with the Administrator and Regional Nurse Supervisor at the exit conference.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 12268 Based on observations and records provided, the facility failed to properly maintain the sprinkler system in accordance with NFPA 25. Section 4.1.1 states the property owner or designated representative shall be responsible for properly maintaining a water based fire protection system. Section 4.1.1.1.1 states inspection, testing, maintenance, and impairment shall be implemented in accordance with procedures meeting those established in this document and in accordance with the manufacturer’ s instructions. Section 4.1.1.2 states inspection, testing, and maintenance shall be performed by personnel who have developed competence through training and experience. Section 5.2.4.1 states gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained. Section 5.3.2.1 states gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Section 5.3.2.2 states gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced. 13.3.3 Testing. Section 13.3.3.1 states each control valve shall be operated annually through its full range and returned to its normal position. Section 13.3.3.2 states post indicator valves shall be opened until spring or torsion is felt in the rod, indicating that the rod has not become detached from the valve. 13.3.4 Maintenance. Section 13.3.4.1 states the operating stems of outside screw and yoke valves (OS&Y) shall be lubricated annually. Section 13.3.4.2 states the valve then shall be completely closed and reopened to test its operation and distribute the lubricant. Findings Include: A review of the wet type automatic sprinkler inspection documentation conducted during the survey on 11/21/24 indicated the following. 1. The wet system pressure gages were not being inspected monthly as required by Sections 5.2.4.1. 2. The city side pressure gage was dated 2010, the house side pressure gages were dated 2015 and documentation was not available to substantiate that any of these gages had been calibrated in accordance with Section 5.3.2.1. 3. Documentation was not available to substantiate the annual operation of the OS&Y control valves on the sprinkler system, nor was it evident that the stems had been lubricated annually in accordance with Section 13.3.3.1 and Section 13.3.4.1. These findings were reviewed with the Administrator and Regional Nurse Supervisor at the exit conference.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 21.7.1.4 through 21.7.1.7 This Standard is not met as evidenced by: 12268 Based on documentation review, the facility failed to hold fire drills in accordance with NFPA 101, Section 20.7.1.4 and 20.7.1.6. Section 20.7.1.4 states fire drills in ambulatory health care facilities shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Section 20.7.1.6 states drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. Findings Include: Based on documentation provided during the survey on 5/9/18 survey, it was determined that fire drills were held as follows: - 11/07/24, at 8:00 A.M., at 12:15 P.M., 4:00 P.M., - 11/06/24, at 9:30 A.M., 11:30 A.M., 4:00 P.M., - 09/28/24, at 9:30 A.M., 11:45 A.M., 5: 00 P.M., - 09/27/24, at 9:30 A.M., 11:45 A.M., 5:00 P.M., - 06/21/ 24, at 9:20 A.M., 11:00 A.M., - 06/20/24, at 9:45 A.M., 11:45 A.M., - 06/18/24, at 5:00 P.M., -06/14/24, at 11:45 A.M., 5:35 P.M. As a result of this review and interview with the Administrator, the fire drills were determined as not being in compliance because: 1. The time(s) and date(s) failed to vary. 2. Transmission of a fire alarm signal had not been utilized to conduct the fire drills As a result, the facility’s fire drills were not held in accordance with NFPA 101, Section 21.7.1.6. These findings were reviewed with the Administrator and Regional Nurse Supervisor at the exit conference.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for four continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked and readily identifiable. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 12268 This Standard is not met as evidenced by: Based on observations and confirmed by staff, the facility failed to ensure that the alternate power source is inspected, tested, and maintained as required. Section 21.5.1.1 states utilities shall comply with the provisions of Section 9.1. Section 9.1.3.1 states emergency generators and standby power systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110 section 8.3.1 states the Emergency Power Supply System (EPSS) shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class. Section 8.3.2.1 states the operational test shall be initiated at an ATS and shall include testing of each EPSS component on which maintenance or repair has been performed, including the transfer of each automatic and manual transfer switch to the alternate power source, for a period of not less than 30 minutes under operating temperature. Section 8.3.3 states a written schedule for routine maintenance and operational testing of the EPSS shall be established. Section 8.3.4 states a permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available. 8.3.7 states that storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer’s specifications. Section 8.3.7.1 states that Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted. Section 8.3.7.2 states that Defective batteries shall be replaced immediately upon discovery of defects. Section 8.3.8 (Fuel quality tests) states that a fuel quality test shall be performed at least annually using tests approved by ASTM standards. Section 8.4.1 states EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. Section Section 8.4.6 states transfer switches shall be operated monthly. Section 8.4.6.1 states the monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position. Section 8.4.9.3 states the test shall be initiated by operating at least one transfer switch test function and then by operating the test function of all remaining ATSs, or initiated by opening all switches or breakers supplying normal power to all ATSs that are part of the EPSS being tested. Findings include: On 11/21/24 the following was noted, 1. Weekley inspections of the emergency generator were not provided as required by NFPA 110. section 8.3.7. . 2. Monthly inspections failed to include testing of the emergency generator’s batteries as required by NFPA 110, Section 8.3.7.1 . 3. Annual inspections failed to include a fuel quality test as required by NFPA 110, Section 8.3.88.3.8. These findings were reviewed with the Administrator and Regional Nurse Supervisor at the exit conference.”

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 10249 Based on observations, record review, staff interviews, and policy reviews, the facility failed to ensure that the condition of infection control was met. Five (5) of 11 facility staff observed, (Registered Nurse [RN] #4, Certified Clinical Hemodialysis Technician [CCHT] #7, and Patient Care Technician [PCT] #4, PCT #5, and PCT #6) failed to perform adequate infection control measures to ensure the health and safety of all patients. Findings include: 1. The facility failed to ensure that 2 staff members (PCT #5 and PCT #6) 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 4 staff members (RN #4, CCHT #7, and PCT #6 and PCT #4) wore appropriate personal protective equipment (PPE) when there was a potential for contact with body fluids. Refer to V115. 3. The facility failed to 1.) ensure that proper infection control practices were followed when personal protective equipment (PPE) came in contact with both “clean” and “dirty” areas; and 2.) ensure that potentially dirty equipment was not stored in clean areas. Refer to V117. 4. The facility failed to ensure that 1 of 2 staff members observed (PCT #5), adequately cleaned and disinfected contaminated surfaces, medical devices, and equipment within the dialysis station, on the treatment floor and in the isolation room, therefore increasing the risk for cross contamination of blood borne pathogens. Refer to V122. 5. The facility failed to 1.) ensure that 1 of 1 staff (PCT #5) observed, adhered to proper infection control practices by not closing the Isolation Room door when spurting or spattering of blood was possible for 1 of 1 Patient observed (#9) known to have Hepatitis B; and 2.) ensure that dedicated isolation room equipment was labeled. Refer to V130. 6. The facility failed to ensure that 1 of 2 staff members observed (PCT #6) implemented adequate infection control practices during initiation of dialysis treatment for 1 of 2 patients (#17) with an arteriovenous fistula or graft (AVF/G), out of a total sample of 18 patients. Refer to V142. 7. The facility failed to ensure that 1 of 3 staff members (PCT #4) observed, failed to provide adequate infection control practices to minimize the risk of infection for 1 of 3 Patients (#16) during termination of treatment with a Central Venous Catheter (CVC), out of total sample of 18 patients. Refer to V147.”

“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: 37349 Based on observation, interview, and policy review, the facility failed to ensure that 2 staff members (Personal Care Technician [PCT] #5 and PCT #6) 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’s policy titled, “Hepatitis B Surveillance, Vaccination, Infection Control Measures and Isolation Guidance”, revised in April 2024, included the following: *Gloves are to be worn when touching the chair side cart, monitor and keyboard. Review of the facility’s policy titled, Infection Control for Dialysis Facilities, revised April 2023, included the following: *Hand Hygiene: All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene prior to gloving and immediately after removal of gloves. *Disposable gloves will be worn when caring for the patient or touching the patient’s equipment at the dialysis station, this will include patients and visitors assisting with procedures such as self-cannulation or holding access sites. a. Gloves should be changed when: i. When soiled with blood, dialysate or other bodily fluids. ii. When going from a “dirty” area or task to a “clean” area or task. iii. When moving from a contaminated body site to a clean body site of the same patient; and iiii. After touching one patient or their dialysis delivery system and before arriving to care for another patient or touch another patient’s dialysis delivery system. 1. The facility failed to ensure that 1 staff member (PCT #5) wore gloves while touching surfaces in the isolation room while caring for Patient #9, known to have Hepatitis B. On 10/29/24 at 10:45 A.M., the surveyor observed PCT #5 discontinuing dialysis treatment and conducting a post dialysis assessment. PCT #5 was observed removing her dirty gloves, sanitizing her hands, then with ungloved hands she picked up the digital thermometer and checked Patient #9’s temperature. PCT #5 then touched the computer keyboard to document Patient #9’s vital signs. During an interview on 10/29/24 at 1:05 P.M., PCT #5 said she should not touch anything in the isolation room with bare hands. 2. The facility failed to ensure that PCT #6 performed hand hygiene, when changing gloves, while caring for a patient. On 10/29/24 at 11:20 A.M., the surveyor observed PCT #6 initiate treatment for Patient #17 via an arteriovenous fistula (AVF). During the initiation PCT #6 reached over with his left hand and moved the biohazard container into the station, contaminating his left glove. While holding the open dialysis lines in his right hand he used his right thumb to remove the glove off of his left hand, contaminating the right hand glove holding the open dialysis lines. Without performing hand hygiene he used his right hand to don a new glove on the left hand and proceeded to initiate dialysis treatment for Patient #17. During an interview on 10/29/24 at 11:30 A.M., PCT #6 said he should have performed hand hygiene when changing his gloves. 38141”

“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: 37349 Based on observation, interview, and policy review, the facility failed to ensure that 4 staff members (Registered Nurse [RN] #4, Certified Clinical Hemodialysis Technician [CCHT] #7, and Personal Care Technician [PCT] #6 and PCT #4) wore appropriate personal protective equipment (PPE) when there was a potential for contact with body fluids. Findings include: Review of the facility’s policy titled, Infection Control for Dialysis Facilities, revised April 2023, included the following: *Appropriate PPE will be worn whenever there is the potential for contact with body fluids, hazardous chemicals, contaminated equipment, and environmental surfaces. 1. On 10/29/24 at 9:55 A.M., the surveyor observed RN #4 discontinue treatment for a patient with an arteriovenous fistula or graft (AVF/G). During the discontinuation process, when there was a potential for contact with body fluids, the sleeves of her gown were pushed up, exposing her wrists. 2. On 10/29/24 at 10:35 A.M., the surveyor observed CCHT #7 discontinuing dialysis treatment for a patient. During the discontinuation process, when there was a potential for contact with body fluids, the sleeves of her gown were pushed up exposing her wrists. 3. On 10/29/24 at 11:20 A.M., the surveyor observed PCT #6 initiate treatment for a patient with an AVF. During the initiation process, when there was a potential for contact with body fluids, the sleeves of his gown were pushed up exposing his wrists. 10249 4. On 10/29/24 at 10:10 A.M., the surveyor observed PCT #4 discontinue dialysis treatment for Patient #16 with a Central Venous Catheter (CVC). During the discontinuation process, when there was a potential for contact with body fluids, the sleeves of her gown were pushed up exposing her wrists. During an interview on 10/29/24 at 12:30 P.M., PCT #4 said she was not aware that her wrists were showing, but they should be covered. During an interview on 10/29/24 at 2:30 P.M., the Manager of Clinical Services said that teammates should not have exposed wrists during initiation or termination of dialysis treatment.”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 10249 Based on observation, interview, and policy review, the facility failed to 1.) ensure that proper infection control practices were followed when personal protective equipment (PPE) came in contact with both “clean” and “dirty” areas; and 2.) ensure that potentially dirty equipment was not stored in clean areas. Findings Include: Review of the facility’s policy titled, Infection Control for Dialysis Facilities, last revised April 2023, indicated the following: *Clean areas should be clearly designated for the preparation, handling, and storage of medication and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. 1. The facility failed to ensure that proper infection control practices were followed when personal protective equipment (PPE) came in contact with both “clean” and “dirty” areas. a. On 10/29/24 at 9:00 A.M. during the flash tour on side B, the surveyor observed 1 gown hanging from a hook, located by the exit door to the lobby. The gown was touching the top of a stack of 3 large plastic medication boxes. During an interview on 10/30/24 at 10:55 A.M., Registered Nurse #6 said those boxes were empty medication containers that would be picked up that day, and the gown should not be touching them. b. On 10/29/24 at 9:00 A.M., during the flash tour on side A, the surveyor observed Certified Clinical Hemodialysis Technician (CCHT) #7 remove her gown and place it on a hook at the entrance to the medication preparation area. There was a trash barrel below the hook and the bottom of the gown was within the rim of the barrel. During an interview on 10/30/24 at 7:30 A.M., the Manager of Clinical Services and the Assistant Facility Administrator both said there should be a separation of clean and dirty items. 37349 2. The facility failed to ensure that potentially dirty equipment was not stored in a clean area. On 10/29/24 at 9:00 A.M., during the flash tour on side A, the surveyor observed the following: *A dust pan and broom resting on the eye wash station, in the clean sink area, across from station 36. *A box of gloves on a clean computer station touching the prime waste bucket in station 32, where a patient was currently receiving his/her dialysis treatment. *A dust pan and broom resting in the clean sink area across from station 32. During an interview on 10/30/24 at 7:30 A.M., the Manager of Clinical Services and the Assistant Facility Administrator both said there should be a separation of clean and dirty items.”

“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: 38141 Based on observation, staff interview, and policy review, the facility failed to ensure that 1 of 2 staff members observed, (Patient Care Technician [PCT] #5), adequately cleaned and disinfected contaminated surfaces, medical devices, and equipment within the dialysis station, on the treatment floor and in the isolation room, therefore increasing the risk for cross contamination of blood borne pathogens. Findings include: Review of the facility’s policy titled, “Infection Control for Dialysis Facilities”, revised in April 2023, included the following: *Disinfection. *At the end of each treatment, the dialysis station will be cleaned and disinfected. Surfaces to disinfect include but not necessarily limited to: all surfaces in contact with the patient or their belongings (e.g., dialysis chair, tray tables, blood pressure cuffs) and frequently contacted by healthcare personnel (e.g., control panel, top, front and sides of dialysis machine, touchscreens, countertops). Review of the facility’s policy titled, “Hepatitis B Surveillance, Vaccination, Infection Control Measures and Isolation Guidance”, revised in April 2024, included the following: *Such supplies will be labeled “isolation” will remain in the isolation room/area or station and be disinfected after every patient use with a 1:100 bleach solution. 1. During an observation on 10/29/24 at 10:55 A.M., the surveyor observed PCT #5 clean and disinfect the station in the isolation room following the dialysis treatment for a Hepatitis B patient. PCT #5 failed to: *Clean and disinfect 2 stethoscopes *Clean and disinfect 2 Intravenous (IV) pumps *Clean and disinfect the patient call light *Clean and disinfect 1 digital thermometer *Clean and disinfect 1 guest chair and 1 adjustable stool chair During an interview on 10/29/24 at 1:05 P.M., PCT #5 said she only cleans and disinfects the items that were used during the treatment, and the rest of the equipment that was not used in the isolation room during the treatment will be disinfected by the end of the day. During an interview on 10/30/24 at 8:00 A.M., the Manager of Clinical Services said that all items/areas in the isolation room should be clean and disinfected after treatment is completed. 2. During an observation on 10/29/24 at 9:00 A.M., the surveyor observed PCT #5 cleaning the dialysis machine/treatment area at station 16, for the next patient. She was observed to clean and disinfect the treatment area with 1:100 bleach-soaked pads. PCT #5 disinfected the IV pole and infusion hooks, but failed to disinfect the stethoscope that was hanging on the infusion hook. She also failed to clean and disinfect the basket and spare blood pressure cuff, which was located on the right side of the dialysis machine. During an interview on 10/29/24 at 1:05 P.M., PCT #5 said that she thought she cleaned those areas, but must have forgotten it.”

“IC-HBV-ISOLATION-MACHINES/EQUIP/SUPPLIES CFR(s): 494.30(a)(1)(i) Isolation of HBV+ Patients To isolate HBsAg positive patients, ... dedicate machines, equipment, instruments, supplies, and medications that will not be used by HBV susceptible patients. This Standard is not met as evidenced by: 38141 Based on observation, interview, and policy review, the facility failed to 1.) ensure that 1 of 1 staff (Patient Care Technician [PCT] #5) observed, adhered to proper infection control practices by not closing the Isolation Room door when spurting or spattering of blood was possible for 1 of 1 patients observed (#9) known to have Hepatitis B; and 2.) ensure that dedicated isolation room equipment was labeled. Findings include: Review of the facility’s policy titled, “Hepatitis B Surveillance, Vaccination, Infection Control Measures and Isolation Guidance”, revised in April 2024, included the following: *Dialyzing confirmed or suspected/unknown status: *A door is required to the isolation room, and it must be closed during times when blood or spattering is possible, for example at initiation and termination of treatment. *Equipment/supplies: *Dedicated ancillary supplies such as blood pressure cuffs, clamps, tourniquets, stethoscope, blood glucose meter, bicarb/dialysate jugs, bleach buckets, sharps container, thermometer, pens, centrifuge, and non-disposable items will be used. *Such supplies will be labeled “isolation” and will remain in isolation room/area or station and be disinfected after every patient use with a 1:100 bleach solution. 1. The facility failed to ensure that the door to the isolation room was closed when spurting or spattering of blood was possible. On 10/29/24 at 9:40 A.M., the surveyor observed PCT #5 donning her PPE (gown, face mask, face shield, and gloves) and entered the isolation room to address the dialysis machine alarm. PCT #5 requested for another staff member to bring her an empty syringe. PCT #5 disconnected both blood lines to check for patency. The door to the isolation room remained open during this time. On 10/29/24 at 10:25 A.M., the surveyor observed PCT #5 donning her PPE (gown, face mask, face shield, and gloves) and entered the isolation room. PCT #5 began the discontinuation process of the dialysis treatment including removing catheters from the patient’s arm. The door of the isolation room remained open during this time. During an interview on 10/29/24 at 1:05 P.M., PCT #5 said she should have shut the isolation room door when she disconnected the lines to check for patency, and when she terminated the treatment. 2. The facility failed to ensure equipment used in the isolation room was labeled for isolation use only. On 10/30/24 at 10:35 A.M., the surveyor observed the following items that failed to be labeled for isolation room use only: *2 stethoscopes *1 Intravenous (IV) pump *Dialysis chair *Guest chair *1 oxygen concentrator *Bucket and mop set During an interview on 10/30/25 at 11:15 A.M., Certified Clinical Hemodialysis Technician (CCHT) #4 said that everything should be labeled “isolation” in the isolation room.”

“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: 37349 Based on observation, record review, interview, and policy review, the facility failed to ensure that 1 of 2 staff members observed (Personal Care Technician [PCT] #6) implemented adequate infection control practices during initiation of dialysis treatment for 1 of 2 patients (#17) with an arteriovenous fistula or graft (AVF/G), out of a total sample of 18 patients. Findings include: Review of the facility’s policy titled, AV Fistula or Graft Cannulation with Nipro or Medisystems Safety Fistula Needles and Administration of Heparin Loading Dose, revised October 2022, included the following: *While maintaining aseptic technique, prep each planned needle site by applying a 70% alcohol prep pad to each site using a circular rubbing motion, center out. *While maintaining aseptic technique, cleanse the site by applying skin antiseptic using a circular rubbing motion, moving from the center out and allow to dry. Teammate will need to use a minimum of 4 prep pads per site for at least 60 seconds total contact time to adequately prep cannulation site. *Do not palpate insertion site once areas has been prepped. Once the access site has been prepped, touching it will contaminate the site and possibly allow for the introduction of bacteria during cannulation. Patient #17 was admitted to the facility in January 2018 with a diagnosis of End Stage Renal Disease, requiring dialysis three times per week, and received dialysis via an arteriovenous fistula (AVF). On 10/29/24 at 11:20 A.M., the surveyor observed PCT #6 initiate dialysate treatment for Patient #17 via an AVF. While cleansing the site, PCT #6 used 2 prep pads each for 30 seconds rubbing back and forth from the upper and lower needle sites. He failed to use 4 prep pads per site in a circular motion from center out. After the sites were prepped, Patient #17 moved their access arm behind themselves, potentially recontaminating the sites. Without disinfecting the sites again, PCT #6 cannulated the sites and initiated dialysis treatment. During an interview on 10/29/24 at 11:50 A.M., PCT #6 said he did not see the patient move their arm behind themselves, but if they did he should have disinfected the site again. He also said that each site should be disinfected separately, not in a back and forth motion.”

“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: 10249 Based on observation, interview, and policy review, the facility failed to ensure that 1 of 3 staff members (Patient Care Attendant [PCT] #4) observed, failed to provide adequate infection control practices to minimize the risk of infection for 1 of 3 Patients (#16) during termination of treatment with a Central Venous Catheter (CVC), out of total sample of 18 patients. Findings include: Review of the facility’s policy titled, Central Venous Catheter with Clear guard HD Antimicrobial End Caps Procedure, revised October 2024, included the following: *Discard used barrier that was used during treatment and place a new, clean moisture proof barrier under the catheter to prevent contamination. Instruct patient to turn head to opposite side of CVC exit. *Remove syringe and disinfect the CVC hub with a new alcohol prep pad for each CVC hub. Scrub the hub thoroughly with friction for 15 seconds. Remove any residue, for example blood. Hold the catheter until the antiseptic has dried. On 10/29/24 at 10:10 A.M., the surveyor observed PCT #4 as she entered the station dressed in full PPE (gown, face mask, face shield and gloves). All supplies were resting on the tray attached to the patient’s chair. PCT #4 proceeded with the termination process. PCT #4 disconnected the line from the venous lumen, scrubbed the hub for 13 seconds, then attached a normal saline filled syringe to the hub. PCT #4 then disconnected the arterial line, scrubbed the hub for 13 seconds then attached a normal saline filled syringe to the hub. After infusing the normal saline, into both lumens, PCT #4 disconnect the normal saline syringes and scrubbed the hub for 13 seconds to the arterial line and placed a clean cap on the tip of the line. PCT #4 then repeated the process for the venous line and scrubbed for 10 seconds, then placed the clean cap. PCT #4 failed to scrub the hubs for 15 seconds each, per facility policy. During an interview on 10/29/24 at 12:30 P.M., PCT #4 said she thought it was 10 seconds each.”

“MIXING SYSTEMS-PERM RECORD/VERIF TEST CFR(s): 494.40(a) 5.4.4.1 Mixing systems: perm record/verification testing In addition to container labeling, there should be permanent records of batches produced. These records should include the concentrate formula produced, the volume of the batch, the lot numbers of powdered concentrate packages, the manufacturer of the powdered concentrate, the date and time of mixing, any test results, the person performing the mixing, the person verifying mixing and test results, and the expiration date (if applicable). 6.4.1 Mixing systems Acid and bicarbonate concentrates may be tested by using conductivity or by using a hydrometer. Concentrates should not be used or transferred to holding tanks or distribution systems until all tests are completed. The test results and verification that they meet all applicable criteria should be recorded and signed by the individuals performing the tests. This Standard is not met as evidenced by: 37349 Based on observation, record review, interview, and policy review, the facility failed to ensure that acid concentrate batches received and transferred into storage tanks were verified to ensure the concentrate was properly proportioned, and transferred to the appropriate storage tank. Findings include: Review of the facility’s policy titled, Acid Concentrate System, Incoming Acid Concentrate and Use of Acid Concentrate Containers, revised October 2024, included the following: * A trained teammate will verify with the delivery person the type of acid concentrate, the number of concentrate drum(s), appropriate storage tank prior to filling tank and document the verification on the Acid Concentrate Incoming Supply Log. This procedure is to be performed with each acid concentrate delivery. During the tour of the water room on 10/29/24 at 8:35 A.M., the surveyor observed 2 acid storage tanks in the water room. One acid storage tank was labeled as containing 2 K (potassium) and 2.5 Ca (calcium), and the other acid storage tank was labeled as containing 3 K 2.5 Ca. Review of the Acid Concentrate Incoming Supply Log indicated the following: *8/10/24 - 2 K-2.5 Ca acid received. There was an initial from one teammate indicating the acid was transferred, but failed to indicate a date or verification from a second person. *8/19/24 to 9/30/24 the log failed to have any entries of receipt or transfer of acid for this 6 week period. *9/30/24 - 2 K-2.5 Ca acid received. The log failed to indicate the lot number (#) of the acid or # of drums received. The log also failed to indicate when or by whom the acid was transferred. *10/9/24 - 2 K-2.5 Ca acid was received. The log failed to indicate when or by whom the acid was transferred. *10/22/24 - 2 K-2.5 Ca acid was received. The log failed to indicate when or by whom the acid was transferred. During an interview on 10/30/24 at 11:45 A.M., the Biomed Technician said acid should be logged when received and 2 teammates should document when acid is transferred. During an interview on 11/5/24 at 9:20 A.M., the Assistant Facility Administrator said acid is typically delivered and transferred on a weekly basis.”

“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: 10249 Based on observation, interview, and policy review, the facility failed to ensure the vascular access of every patient was in view of staff during hemodialysis treatments, to ensure patient safety, for 1 sampled patient (#18), out of a total sample of 18 patients. Findings include: Review of the facility’s policy titled, Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment, last revised April 2024, indicated the following: *Vital signs and treatment monitoring-Non-nocturnal treatments are completed at least every thirty (30) minutes. *At a minimum, obtain and document the following: Vascular access visible and line connections intact. On 10/29/24 at 9:10 A.M. through 9:40 A.M., the surveyor observed Patient #18 resting during treatment. Patient #18’s access, on his/her left arm, was covered with a blanket and not visible. During an interview on 10/30/24 at 10:55 A.M., Registered Nurse #6 said she reminds the patients, but said we have an issue with patients covering their access. During an interview on 10/31/24 at 9:00 A.M., the Manager of Clinical Services said that all patients’ access must be visible during treatment.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 10249 Based on record review, and interview, the facility failed to ensure the dialysis treatment order was delivered as prescribed, relative to Blood Flow Rate (BFR-speed (measured in milliliters per minute [ml/min]) in which the patient’s blood is pushed through the dialyzer and back into the body) and Dialysate Flow Rate (DFR-the measurement of how fast the dialysate solution flows in ml/min to draw toxins from the patient’s blood) during the process of dialysis, for 1 of 10 applicable patients (Patient #1) reviewed, out of total sample of 18 patients. Findings include: Patient #1 was admitted to the facility in December 2018 with a diagnosis of End Stage Renal Disease (ESRD), requiring hemodialysis treatments 3 times a week. Review of the physician orders, dated 10/5/24, indicated the dialysis order included a BFR to be delivered at a rate of 400 ml/min, and a DFR to be delivered at a rate of 800 ml/min. Review of the 9 Hemodialysis Flowsheets, dated 10/5/24 through 10/26/24, indicated the BFR and/or DFR had not been delivered as prescribed for 6 of 9 treatments, including the following: *10/5/24 - the BFR was delivered at a rate of 260 ml/min, not 400 ml/min as ordered, and there was no documentation to indicate why the physician’s order was not followed. * 10/8/24 - the BFR was delivered at a rate of 300 ml/min, not 400 ml/min as ordered, and the DFR was delivered at a rate of 500 ml/min and not 800 ml/min as ordered, and there was no documentation to indicate why the physician’s order was not followed. *10/10/24 - the BFR was delivered at a rate of 300 ml/min, not 400 ml/min as ordered, and the DFR was delivered at a rate of 600 ml/min and not 800 ml/min as ordered, and there was no documentation to indicate why the physician’s order was not followed. *10/17/24 - the BFR was delivered at a rate of 300 ml/min, not 400 ml/min as ordered, and there was no documentation to indicate why the physician’s order was not followed. *10/22/24 - the BFR was delivered at a rate of 350 ml/min, not 400 ml/min as ordered, and there was no documentation to indicate why the physician’s order was not followed. *10/24/24 - the BFR was delivered at a rate of 300 ml/min for 1.5 hours, not 400 ml/min as ordered, and there was no documentation to indicate why the physician’s order was not followed. During an interview on 10/31/24 at 9:10 A.M., the Manager of Clinical Services said that if there is a change to the BFR and/or the DFR during treatment, it should be documented in the “stat” line on the treatment sheet. She also said that if there is a change made by a tech, they are to inform the nurse. The Manager of Clinical Services said she could not find any documentation as to why the BFR and/or DFR were changed after she reviewed Patient #1’s treatment sheets.”

“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: 37349 Based on observation, record review, interview, and policy review, the facility failed to ensure that 1 of 2 staff members observed (Personal Care Technician [PCT] #6), 1.) assessed the vascular access for symptoms of stenosis prior to cannulation for 1 of 2 patients (#17) with an arteriovenous fistula (AVF); and 2.) used a tourniquet during initiation of dialysis treatment for 1 of 2 patients (#17) with an AVF, out of a total sample of 18 patients. Findings include: Review of the facility’s policy titled, Arteriovenous Fistula (AVF) and Arteriovenous Graft (AVG) Vascular Access Care, revised October 2024, included the following: *Fistula requires a tourniquet for cannulation. Review of the facility’s policy titled, AV Fistula or Graft Cannulation with NIPRO or Medisystems Safety Fistula Needles and Administration of Heparin Loading Dose, revised October 2022, included the following: *Perform inspection, auscultation and palpation on entire length of access. Determine presence of bruit and thrill. The presence of a bruit and thrill indicates flow through the access. *Apply a new tourniquet for cannulating AVF fistula. A tourniquet should be used to distend the fistula even when vessel does not appear to require it. Patient #17 was admitted to the facility in January 2018 with a diagnosis of End Stage Renal Disease, requiring dialysis three times per week, and received dialysis treatment via an AVF. On 10/29/24 at 11:20 A.M., the surveyor observed PCT #6 initiate dialysis treatment for Patient #17. He palpated the access site to determine if a thrill was present, but did not auscultate the site to listen for a bruit. In addition, he did not use a tourniquet to distend the fistula prior to cannulation. During an interview on 10/30/24 at 7:30 A.M., the Assistant Facility Administrator and Manager of Clinical Services both said that staff should palpate, auscultate, and use a tourniquet when initiating treatment for a patient with an AVF.”

“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: 10249 Based on observation, record review, staff interview, and policy review, the Medical Director failed to 1.) ensure staff administered a heparin (blood thinning medication) intravenous (IV) infusion as ordered by the physician for 3 of 6 applicable patients (#1, #6, and #7); and 2.) ensure staff adhered to the facility administration policy relative to heparin bolus/IV push administration for 2 of 6 applicable patients (#8 and #6), out of a total sample of 18 patients. Findings include: Review of the facility’s policy titled, Anticoagulation, last revised September 2024, indicated the following: *To anticoagulate the patient, the initial loading dose of heparin is administered through the venous fistula needle or venous port of the central venous catheter (CVC) at least 3-5 minutes prior to the initiation of the hemodialysis treatment. *It is recommended that the heparin hourly infusion be discontinued 60 minutes prior to the end of treatment for patients with arterio-venous (AV) fistulas and/or AV grafts per physician’s order/NPP order. It is recommended that the heparin hourly infusion be continued for the entire treatment for patients with CVC. 1. For Patient #6, #1, and #7, the facility failed to ensure staff administered a heparin (blood thinning medication) intravenous (IV) infusion, as ordered by the physician. a. Patient #6 was admitted to the facility in April 2023 with a diagnosis of End Stage Renal Disease (ESRD), requiring dialysis three times per week. Review of the physician orders, dated 4/20/23, indicated to administer heparin, 1000 units per hour via infusion pump. On 10/29/24 at 10:45 A.M., the surveyor observed Registered Nurse (RN) #3 initiate dialysis treatment for Patient #6. RN #3 failed to attach heparin to the dialysis system for administration. The surveyor was unable to interview RN #3. During an interview on 10/30/24 at 3:45 P.M., the Manager of Clinical Services said staff should not document anything that is not done. b. Patient #1 was admitted to the facility in December 2018 with a diagnosis of ESRD, requiring dialysis three time a week. Review of the physician’s orders, dated 9/18/22, indicated to administer heparin, 500 units per hour, and stop 60 minutes before the end of treatment. Review of 9 treatment sheets, dated 10/5/24 through 10/26/24, indicated for 4 of 9 treatments the heparin IV infusion was not stopped 60 minutes before the end of the treatment. *On 10/8/24, Patient #1’s dialysis treatment ended at 10:35 A.M. The staff documented that Patient #1’s heparin infusion was completed at 11:53 A.M., and not the one hour prior to completion of dialysis treatment, as ordered. *On 10/15/24, Patient #1’s dialysis treatment ended at 10:19 A.M. The staff documented that Patient #1’s heparin infusion was completed at 10:34 A.M., and not the one hour prior to completion of dialysis treatment, as ordered. *On 10/17/24, Patient #1’s dialysis treatment ended at 10:12 A.M. The staff documented that Patient #1’s heparin infusion was completed at 12:05 P.M., and not the one hour prior to completion of dialysis treatment, as ordered. *On 10/26/24, Patient #1’s dialysis treatment ended at 12:40 P.M. The staff documented that Patient #1’s heparin infusion was completed at 12:16 P.M., and not the one hour prior to completion of dialysis treatment, as ordered. On 10/31/24 at 9:10 A.M., the Manager of Clinical Services said if the patient has a fistula, staff should stop the heparin infusion 1 hours before the end of treatment per the policy and physician’s order. 38141 c. Patient #7 was admitted to the facility in August 2017 with a diagnosis of ESRD, requiring dialysis three times a week. Review of the physician orders, dated 9/19/24, indicated to administer heparin, 1:1000 units per hour, turn pump off 60 minutes before the end of treatment. Review of 9 treatment sheets, dated 10/28/24 through 10/9/24, indicated for 3 of 9 treatments the heparin IV infusion was not stopped 60 minutes before the end of the treatment. *On 10/11/24, Patient #7’s dialysis treatment ended at 9:23 A.M. The staff documented Patient #7’s heparin infusion was completed at 9:25 A.M., and not the one hour prior to completion of dialysis, as ordered. *On 10/14/24, Patient #7’s dialysis treatment ended at 9:32 A.M. The staff documented Patient #7’s heparin infusion was completed at 9:35 A.M., and not one hour prior to completion of dialysis, as ordered. *On 10/18/24, Patient #7’s dialysis treatment ended at 9:33 A.M. The staff documented Patient #7’s heparin infusion was completed at 11:06 A.M., and not one hour prior to completion of dialysis, as ordered. On 10/31/24 at 9:10 A.M., the Manager of Clinical Services said if the patient has a fistula, staff should stop the heparin infusion 1 hours before the end of treatment per the policy and physician’s order. 2. For Patient #8 and Patient #6, the Medical Director failed to ensure the staff adhered to the facility policy relative to heparin administration. a. Patient #8 was admitted to the facility in August 2023 with a diagnosis of ESRD, requiring dialysis three times a week. Review of the clinical record indicated Patient #8 had a physician’s order to administer heparin IV push 1000 units intravenously (IV) every dialysis treatment. Review of 9 treatment sheets, dated 10/28/24-10/9/24, indicated 4 of 9 treatments staff failed to wait 3-5 minutes after administration of heparin to initiate treatment, including the following: *On 10/16/24 treatment started at 4:06 P.M., heparin was documented as administered at 4:05 P.M., 1 minute after the initiation of treatment, not the 3-5 minutes prior to initiation of dialysis per the facility policy. *On 10/18/24 treatment started at 4:15 P.M., heparin was documented as administered at 4:36 P.M., 21 minutes after the initiation of treatment, not the 3-5 minutes prior to initiation of dialysis per the facility policy. *On 10/25/24 treatment started at 4:08 P.M., heparin was documented as administered at 4:14 A.M., 6 minutes after the initiation of treatment, not the 3-5 minutes prior to initiation of dialysis per the facility policy. *On 10/28/24 treatment started at 4:36 P.M., heparin was documented as administered at 4:38 P.M., 2 minutes after the initiation of treatment, not the 3-5 minutes prior to initiation of dialysis per the facility policy. During an interview on 10/30/24 at 12:30 P.M., the Manager of Clinical Services said the policy says to wait the 3-5 minutes before starting the treatment. 37349 b. Patient #6 was admitted to the facility in April 2023 with a diagnosis of ESRD, requiring dialysis three times per week. Review of the physician orders, dated 4/20/23, indicated to administer heparin, 1000 units (IV) push every dialysis treatment. On 10/29/24 at 10:45 A.M., the surveyor observed Registered Nurse (RN) #3 initiate the dialysis treatment for Patient #6. RN #3 failed to administer heparin 1000 units via IV push which prompted the dialysis machine to alarm, which indicated there was no heparin bolus (IV push) administered. RN #3 cleared the alarm. The dialysis machine then alarmed for a blood leak. RN #3 cleared the blood leak alarm and removed Patient #6 from the dialysis machine. RN #3 flushed the blood leak and reattached the patient to the same dialysis machine and started the dialysis treatment. RN #3 did not administer the heparin 1000 unit IV push per the physcian’s order. The surveyor was unable to interview RN #3.”

“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: 37349 Based on observation, interview, and policy review, the facility failed to ensure 2 staff members (Registered Nurse [RN] #3 and Personal Care Technician [PCT] #6) maintained accurate medical records for 2 patients (#6 and #17), out of a sample of 15 records reviewed, out of a total sample of 18 patients. Findings include: Review of the facility policy titled, Medical Records Documentation Guidance, revised October 2023, included the following: *Teammates are not authorized to sign, date or time a medical record entry on behalf of another teammate, physician, NPP, or any other person. *All entries must be accurate. Inaccurate records can adversely affect patient care and false statements in a medical record can subject the facility and the individual making the false statement to serious administrative, civil and criminal sanctions. 1. Patient #6 was admitted to the facility in April 2023 with a diagnosis of ESRD, requiring dialysis three times per week. Review of the physician order, dated 4/20/23, indicated to administer heparin, 1000 units intravenous (IV) push every dialysis treatment. Review of the physician order, dated 4/20/23, indicated to administer heparin, 1000 units per hour via infusion. On 10/29/24 at 10:45 A.M., the surveyor observed Registered Nurse (RN) #3 initiate the dialysis treatment for Patient #6. RN #3 failed to administer heparin 1000 units via IV push which prompted the dialysis machine to alarm for no heparin bolus (IV push). RN #3 cleared the alarm. The dialysis machine then alarmed for a blood leak. RN #3 cleared the blood leak alarm and removed Patient #6 from the dialysis machine. RN #3 flushed the blood leak and reattached the patient to the same dialysis machine and started the dialysis treatment. RN #3 did not administer the heparin 1000 unit IV push or attach the heparin syringe to the dialysis machine to administer further heparin 1000 units every hour per the physcian’s order. Review of the treatment details report for 10/29/24, indicated that RN #3 documented that heparin 1000 units was administered at 11:11 A.M. despite the surveyor observing the initiation and noting no heparin was administered. Review of the treatment details report for 10/29/24, indicated that RN #3 started the heparin infusion at 11:16 A.M. when treatment started, despite the surveyor observing the initiation and noting no heparin was attached to the dialysis system. The surveyor was unable to interview RN #3. During an interview on 10/30/24 at 3:45 P.M., the Manager of Clinical Services said staff should not document anything that is not done. 2. Patient #17 was admitted to the facility in January 2018 with a diagnosis of end stage renal disease requiring dialysis three times per week. On 10/29/24 at 11:20 A.M., the surveyor observed PCT #6 initiate dialysis treatment for Patient #17. Review of the treatment details report indicated that Registered Nurse (RN) #4 initiated treatment, despite the surveyors observations. During an interview on 10/29/24 at 3:00 P.M., the acting Facility Administrator said that he had called PCT #6 off of the treatment floor before he was able to complete the documentation and RN #4 needed to document the initiation so she could continue with the documentation of the rest of the treatment. During an interview on 10/30/24 at 3:45 P.M., the Manager of Clinical Services said staff should not document anything that is not done.”