Davita St. Louis Dialysis Center

“CFC-PATIENTS- RIGHTS CFR(s): 494.70 This Condition is not met as evidenced by: 36473 Based on interview, record review and policy review the facility failed to: - Protect one (#1) of one patient on the dialysis treatment unit from verbal abuse that resulted in psychological distress with the potential for physical harm. (refer to V452) - Protect all patients on the dialysis treatment unit from the potential for further assaults by allowing the alleged perpetrator [Staff B, Patient Care Technician (PCT)] to return to work prior to a complete investigation. (refer to V452) - Provide internal policies and procedures (P/P) on abuse and neglect (A/N) and reporting of high-risk incidents or events. (refer to V452) These deficient practices resulted in the facility’s non-compliance with specific requirements found under the Condition of Participation (CoP): Patient Rights. The facility census was 78 in-center patients. The severity and cumulative effect of these systemic practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ). On 12/11/25, after the surveyor informed the facility of the IJ, the facility staff created educational tools and began educating all staff and put into place an action plan to protect patients. On 12/11/25, at the time of survey exit, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following: The Facility Administrator (FA) or Manager of Clinical Services (MCS) will conduct mandatory in-services for all teammates starting 12/11/2025. Education included a review of: · Teammate Policies 5.19 Anti Violence with emphasis on providing a safe workplace for all teammates and has zero tolerance for violence in the workplace. The facility takes all threats of workplace violence very seriously. Acts or threats of physical violence whether expressed or implied-including intimidation, harassment and/or coercion-that involve or affect the facility or occur on the property and sponsored events will not be tolerated. INVESTIGATING A THREAT OR VIOLENT ACT Management will take a complete report of the incident and conduct a thorough investigation to determine whether a violation of this policy has occurred. When the investigation is complete, a decision will be made concerning the appropriate level of corrective action, if any. The facility’ goal is to handle all situations with utmost sensitivity while meeting the goals of workplace safety and security. VIOLATIONS Failure to abide by all terms and conditions of the policies described above may result in discipline, up to and including termination. · Teammate Policy PS 5.9 Teammate Investigations Policy with emphasis on but not limited to determine it is necessary and appropriate to investigate complaints and allegations when a violation of law or policy has potentially occurred or for any other concerning circumstances. In such cases, the facility is committed to a prompt and thorough investigation, which is ultimately beneficial to the teammate(s). Efficient and effective investigation processes help ensure that all involved teammates are treated fairly, and that concerns are addressed appropriately. The facility, in its discretion, may take appropriate corrective action, up to and including termination of employment, against any teammate not meeting these expectations. · Policy 3-01-07A Patient’s Rights Policy with emphasis on but not limited to: To be treated with (i) respect, dignity, and recognition of my individuality, choices, strengths, abilities, cultural values, religious beliefs and personal needs, to the extent possible during treatment; and (ii) sensitivity to my psychological needs and ability to cope with ESRD. · Policy 3-01-06A Addressing Patient Grievances: Teammates emphazing: 1. Patient grievances may be verbal or written. They may be submitted directly to a facility teammate or submitted to the Guest Services department. 2. All complaints/grievances should be documented on the facility Patient Grievance Log. 3. All details of patient grievances and discussions will be documented. This documentation will be maintained in a separate file and kept in a secure and locked location. The Grievance Investigation Document may be used for this purpose. This form is not for patient use. Grievance documentation is not part of the patient medical record and should not be provided to the patient. 4. The teammate receiving the grievance should report the grievance to the charge nurse, Facility Administrator (FA), or Social Worker. 5. Based on the nature of the complaint, the appropriate member of the interdisciplinary team (IDT) will discuss the grievance with the patient and take appropriate action towards a solution, if possible. 6. If the patient grievance cannot be resolved, the FA will be notified. The FA will meet with the patient to discuss the grievance and take appropriate action towards a solution, if possible. If the grievance is not resolved, the patient should be invited to a grievance conference. The grievance conference should be coordinated to occur within 10 days of receipt of the complaint. Verification of attendance at in-services are evidenced by teammates signature on clinical in-service form. Any teammate not present for today’s in-service will get the in-service on their next scheduled workday before starting any patient care. The Facility Administrator or designee will conduct observational audits on patient and teammate interactions daily x 2 weeks, weekly x 4 weeks to verify that all patients are being treated with respect, dignity and sensitivity. The Facility Administrator or designee will continue to follow grievance policy and process and review any grievance at the time of the event and ensure resolution is obtained. The Facility Administrator will review all completed grievances, as well as any threats or acts of violence, are followed up on timely and discussed in Facility Health Meeting also known as QAPI. Members of the Governing Body including Medical Director, FA and Regional Operations Director have agreed to meet daily until otherwise determined by Governing Body to monitor the facilities ongoing progress towards compliance of this plan. This plan of removal will also be reviewed during Facility Health Meetings and the FA will report progress, as well as any barriers to maintaining compliance, with supporting documentation included in the meeting minutes. The FA will review results of all audits with Medical Director weekly x 4. The FA and Medical Director are responsible for compliance with this plan of removal.”

“PR-RESPECT & DIGNITY CFR(s): 494.70(a)(1) The patient has the right to- (1) Respect, dignity, and recognition of his or her individuality and personal needs, and sensitivity to his or her psychological needs and ability to cope with ESRD This Standard is not met as evidenced by: 36473 Based on observations, interviews, record reviews and policy reviews, the facility failed to: - Provide a safe environment for one (#1) of one patient on the dialysis treatment unit from alleged verbal threat from staff that resulted in psychological distress with the potential for physical harm; - Provide a safe environment for all patients on the dialysis treatment unit from the potential for further assaults by allowing Staff B, Patient Care Technician (PCT), alleged perpetrator (AP) to return to work prior to a complete investigation; and - Provide internal policies and procedures (P/P) on abuse and neglect (A/N) and reporting of high-risk incidents or events. These failures placed all patients that receive treatment at the facility at risk for mental harassment, emotional distress, fear of reprisal and physical harm. The facility census was 78 in-center patients. Findings included: 1. Observation made on 12/10/25, showed Staff B, AP, was working. 2. During an interview on 12/11/25 at 11:05 AM, Patient #1 stated Staff B, AP: - Threatened him and he has had to watch his back. - Stated they would have someone kill him. - Stated they would have the building blown up. 3. During an interview on 12/10/25 at 2:32 PM, Staff B, AP, stated they brought the patient into the treatment unit and Patient #1 did not want to sit in a stained chair. The patient thought it had blood on it. The patient then stated they did not want him/her to stick them, and then Staff E, Registered Nurse (RN), intervened. Staf B felt Patient #1 had a grudge against him/her. 4. During an interview on 12/10/25 at 2:50 PM, Staff E, RN, stated Staff B, AP, covered for her/him while she/he was on break. When he/she came back on the treatment floor Staff B and Patient #1 were yelling. Staff E deescalated the situation, and sent Staff B home with no other problems. 5. During an interview on 12/11/25 at 11:19 AM, Staff D, Certified Clinical Hemodialysis Technician (CCHT), stated they worked on the day of the incident and heard Staff B, AP, and Patient #1 loud and not friendly. They heard Staff B state they would have the place blown up. 6. During an interview on 12/10/25 at 3:05 PM, Staff F, CCHT, stated they worked on the day of the incident on the other side of the unit. They overheard Staff B, AP, and Patient #1 in loud conversation and failed to hear the exact words said. 7. During an interview on 12/11/25 at 12:10 PM, Patient #2, stated: - They sat right across from Patient #1 on the day of the incident. - Staff B, AP, started their treatment that day and could tell Staff B was not happy to be there. - Patient #1 stated, “they did not want Staff B to start their treatment.” - Staff B stated, “they didn’t want to put them on anyway. “ - Staff B stated, “I got somebody that will blow this motherfucking place up.” - They then saw Staff B remove their jacket, cussing and stated, “She got people that will get you.” 8. Review of Patient #1’s interview taken on 12/08/25 by Staff G, Social Worker, showed: - Staff B, AP, brought them into the treatment unit. - They asked Staff B for a shake and Staff B stated, “No, I can’t get you shit.” - Patient #1 saw red spots on their chair ,assumed it was blood, and asked Staff B for something to clean it up. - Staff B stated, “Be for real and quit playing stupid.” - Patient #1 told Staff B, “I didn’t do anything to you, I just got here.” - Staff B stated, “Boy, fuck you.” - Patient #1 told Staff B, “Fuck you too.” - Staff B stated, “I don’t fuck with your kind.” - Patient #1 told Staff B, “I don’t fuck with you bitch.” - Another staff member came and asked Staff B to just go put another patient on and Staff B stated, “Fuck no.” - Patient #1 told Staff B, “You are being very unprofessional and you know you are being recorded.” - Staff B stated, “I will call my people and blow this motherfucker up” and “I have a nephew that will come up here and muck (kill) you in the parking lot” and “you’re a crackhead, broke ass nigga and that’s why they were homeless.” - Patient #1 questioned the other teammates about letting Staff B talk to them like that and Staff E, RN, told he/she to calm down. 9. Review of Patient #2’s interview taken on 12/09/25 at 12:20 PM, by Staff G, Social Worker, showed: - Staff B, AP, and Patient #1 went back and forth cussing at each other. - Patient #1 stated, “I am going to call corporate on you.” - Staff B stated, “I don’t care and I have somebody that will come blow this place up.” 10. Review of Patient #1’s medical record showed the patient had a diagnosis of End Stage Renal Disease (ESRD, kidney failure) and was also in contact isolation for Candida Auris (a fungal infection resistant to medication). 11. Review of the facility’s documentation titled, “St. Louis Dialysis Teammate Investigation,” undated and signed by Staff A, Facility Administrator (FA), showed: - On 12/06/25 at 9:00 AM, Staff B, AP, called Staff A, FA, and reported: - Patient #1 called her a “fat bitch”. At that time, Staff A, FA told Staff B, AP, to go home and they would have a talk with Patient #1. - On 12/06/25 at 4:53 PM, Staff C, Charge Nurse, called Staff A, FA, and stated, “Staff B and Patient #1, had an altercation on the unit, the incident was bad and would be constituted as abuse”. - On 12/09/25, Staff D, Social Worker, MSW, received a statement from Patient #2 regarding the incident that occurred on 12/06/25 between Staff B and Patient #1. Patient #2 stated that Staff B, AP, threatened to blow the place up. There were initial failures by the facility to include, the incident happened on 12/06/25 at approximately 9:00 AM and Staff C, Charge Nurse, failed to contact Staff A, FA, until 4:53 PM regarding a bad abusive situation. In addition, when Staff A, FA, was notified of the incident, Staff A failed to place Staff B, AP, on non patient/staff contact and/or administrative leave until the investigation was completed. Staff B, AP, was allowed to work 12/08/25, 12/09/25 and 12/10/25 until the surveyor’s investigation. 12. Review of the facility’s policy titled, “Anti-Violence Policy,” last reviewed on 11/2025, stated that examples of prohibited violent conduct was using threatening or abusive language, suggestion or intimidation that violence will occur, harassment and engaging in any behavior that imperils the safety of patients. 13. Review of the facility’s policy titled, “Patient Rights,” last reviewed on 04/2025, showed the direction for staff to: - Treat patients with respect, dignity and recognition of individuality, choices, strengths, abilities, cultural values, religious beliefs and person needs, to the extent possible during treatment and sensitivity to the patient’s psychological needs and ability to cope with ESRD. - Treat patients free from abuse, neglect, exploitation, coercion, manipulation, sexual abuse, sexual assault, seclusion, or restraint or misappropriation of the patient’s personal property. - Treat patients with adequate, safe, sanitary, and efficient dialysis treatment and respectful care by competent personnel in a comfortable environment. 14. Although requested the facility failed to provide an abuse/neglect policy. 15. Although requested, the facility failed to provide the video of the front lobby for 12/06/25, the day of the incident. 16. Although requested, the facility failed to file a police report for the alleged threat of violence related to Staff B, AP’s, comment that she would have somebody come “blow up” this place. 17. Although requested, the facility failed to provide Staff B’s personnel file for review. 18. Although requested, the facility failed to provide Staff B’s detailed education log showing their education related to abuse/neglect and patient rights. 19. Review of the timesheet for Staff B, AP, showed Staff B worked: - 12/06/25 from 5:18 AM - 9:02 AM (date of the alleged incident); - 12/08/25 from 5:17 AM - 2:29 PM; - 12/09/25 from 7:08 AM - 12:59 PM; and - 12/10/25 from 5:15 AM - 2:45 PM. 20. Education to Nursing Supervisors regarding the expectation of removal of staff after an accusation of abuse or neglect until the completion of the investigation failed to occur until 12/10/25 (At time of survey conducted by the State Agency). The delayed removal of Staff B, AP, had the potential to expose all patients and staff at the facility to the risk of continued abuse by Staff B.”

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 17026 Based on record review and staff interview, the facility staff failed to maintain documentation of the full scale and table top exercises for emergency preparedness. This had the potential to effect all patients on dialysis and cause an increase in complications in the event of an emergency. The facility census was 73. Findings included: 1. Review of the facility’s emergency preparedness information showed it did not contain documentation of the full scale or table top exercises for emergency preparedness. 2. During an interview on 4/1/25 at 1:27 PM, the facility administrator said she did not have documentation of the full scale or table top exercises for emergency preparedness, but staff need to maintain that documentation.”

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 17026 Based on observations and staff interview, the facility staff failed to maintain a sanitary environment by not ensuring a clean refrigerator that stored the protein shakes, not maintaining a clean acid mixer, and not keeping the area below the sink in the laboratory area free of rust. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 73. Findings included: 1. Observation on 3/31/25 at 11:08 AM of the refrigerator with the protein shakes in the storage room adjacent to the treatment area showed the refrigerator had brown and yellow spills throughout the bottom on the inside of the refrigerator. 2. Observation on 3/31/25 at 11:09 AM of the area under the sink in the laboratory area showed rusted areas on the inside of the cabinet. 3. Observation on 3/31/25 at 11:13 AM of the acid mixer showed spills, splatters, and stains on the top and sides of the acid mixer. 4. During an interview on 4/1/25 at 1:01 PM, the facility administrator said staff need to ensure the facility environment remains clean.”

“IC-TRAINING & EDUCATION CFR(s): 494.30(a)(1)(i) Infection Control Training and Education Infection control practices for hemodialysis units: intensive efforts must be made to educate new staff members and reeducate existing staff members regarding these practices. This Standard is not met as evidenced by: 17026 Based on record review and staff interview, the facility staff failed to maintain documentaion of the tuberculosis (contagious disease of the lungs) screening for five out of 14 employees. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 73. Findings included: 1. Review of the employee information showed it did not contain documentaion of the tuberculosis screening for five out of 14 staff. 2. During an interview on 4/1/25 at 1:01 PM, the facility administrator said she could not find the documentation that showed the five employees were screened for tuberculosis.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 17026 Based on observations and staff interview, the facility staff failed to ensure medications were not expired and failed to initial and date two medication vials when opened. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 73. Findings included: 1. Observation of the medication area on 3/31/25 at 11:04 AM showed 0.4 milligram nitroglycerin (medication used to prevent and treat chest pain) that expired 1/31/25. 2. Observation of the medication area on 3/31/25 at 11:02 AM showed an approximately half full 30 milliliter vial of heparin (medication used to prevent blood clots) not initialed or dated when staff opened it. 3. Observation of the medication area on 3/31/25 at 11:03 AM showed a partially used vial of doxercalciferol (medication that is the synthetic form of vitamin D) not initialed or dated when staff opened it. 4. During an interview on 4/1/25 at 1:27 PM, the facility administrator said staff need to ensure the medications were not expired and staff need to initial and date when they open medication vials.”

“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: 17026 Based on observations and staff interview, the facility staff failed to ensure the dialysis access remained visible to staff at 12 (station # 2, # 3, # 4, # 6, # 7, # 9, # 11, # 12, # 13, # 14, # 18, and # 19) out of 25 dialysis stations. This had the potential to effect all patients on dialysis and cause an increase in complications related to bleeding or needle dislodgement. The facility census was 73. Findings included: 1. Observation on 3/31/25 at 12:17 PM showed the patient had their dialysis access covered with a blanket and not visible to staff at dialysis stations # 3, # 4, # 9, # 13, and # 18. Further observation on 3/31/25 at 1:08 PM showed the patient had their dialysis access covered with a blanket at stations # 3, # 4, # 9, # 13, #18, and # 19. 2. Observation on 4/1/25 at 8:26 AM showed the patient had their dialysis access covered with a blanket and not visible to staff at dialysis stations # 2, # 4, and # 7. Observation on 4/1/25 at 10:30 AM showed the patient at dialysis station # 7 still had his dialysis access covered with a blanket. 3. Observation on 4/1/25 at 12:01 PM showed the patient had their dialysis access covered with a blanket and not visible to staff at dialysis stations # 6, # 12, and # 14. Further observation on 4/1/25 at 12:38 PM showed the patient had their dialysis access covered with a blanket at stations # 11, # 12, and # 14. 4. During an interview on 4/1/25 at 1:27 PM, the facility administrator said they educated the patients regarding keeping the dialysis access uncovered and visible, but they need to remind the patients to keep the dialysis access visible and document if the patient refuses to keep the dialysis access visible.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 17026 Based on record review and staff interview, the facility staff failed to follow the physician order for heparin (medication that prevents blood clots) administration during dialysis treatment for three patients (Patient # 8, # 9, and # 43) out of seven clinical records reviewed. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 73. Findings included: 1. Review of the treatment flow sheet dated 3/31/25 for Patient # 8 showed the physician directed staff to stop the heparin administration 60 minutes before the end of dialysis treatment, but staff continued the heparin administration until the end of the dialysis treatment. 2. Review of the treatment flow sheet dated 3/26/25 for Patient # 9 showed the physician directed staff to stop the heparin administration 60 minutes before the end of dialysis treatment, but staff continued the heparin administration until the end of the dialysis treatment. 3. Review of the treatment flow sheet dated 3/27/25 for Patient # 43 showed the physician directed staff to stop the heparin administration 60 minutes before the end of dialysis treatment, but staff continued the heparin administration until the end of the dialysis treatment. 4. During an in interview on 4/1/25 at 1:01 PM, the facility administrator said staff should follow the physician order for heparin administration during dialysis treatments.”