Dialysis Clinics, Inc. - Belton

“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: 18018 Based on observation, policy review, and interview the dialysis facility failed to ensure staff provided and maintained a clean environment when staff failed to: - Maintain clean surfaces of various equipment, pipes, and floor in the Water Treatment Area. - Maintain a barrier between the large red bio-hazardous cart and patients’ supplies for cannulation in the prep station located on the Treatment Floor. - Maintain surfaces that are free from scraped-out areas on the wall/wall column, missing material on the bottom of the chase walls, and dialysis chairs free from splits in the chair’s seats located on the Treatment Floor. These failed practices had the potential for increased risk of cross-contamination and transmission of pathogens to all patients and staff. The In-Center-Hemodialysis (hemodialysis, a machine used to filter wastes, fluids, and salts from blood when the kidneys are no longer able to perform the filtering process) census was 34. Findings included: Water Treatment Room 1. Observations conducted during the Flash Tour on 05/19/25 at 12:25 PM, showed: - The Backflow Preventer pipe contained large amounts of a rust-like substance on the pipe; the floor drain contained a bluish-green colored substance on the surface; the white pipe contained rust-like streaks running down the pipe’s surface; and a large area on the floor under the pipe contained an orange-colored substance. - The black pallets contained a large amount of dust and dirt build-up on the surfaces. - The Housekeeper’s black storage unit contained dust on the shelves. - The Water Treatment Room contained dust and dirt along the edges of the floor. - The 3K (K, potassium) - 2.5 C (C, calcium) tank and 2K - 2.5 C tank contained: - Adhesive residual on the outside surface of the tanks. - The floor behind the tanks contained a dark colored build-up with dust and dirt. - The wall behind the tanks contained dark brown colored streaks running down the wall surface. - The metal on the double door frame contained dirt. - The gray pipes on the Ultra Filter Cartridge contained dirt and the bolts contained a rust-like substance. - The floor drain in front of the Ultra Filter Cartridge contained a dark colored substance on the outside surface. - Both sides of the door contained areas with a rust-like substance. - The hot water tank contained: - A dried white substance on the top surface of the tank. - The pipes contained a rust-like and bluish-green colored substance. - The surface of the hot water’s tank contained a rust-like substance. - The outside surface of the Inlet contained a thick layer of a dried whitish- yellow colored substance. - The floor surface under the hot water tank contained rust-like areas. - The electric box for the hot water tank contained large amounts of black particles on the top surface of the box. - A black portable cart that contained chlorine testing supplies contained dust in the corners and outside surface. - The bolts on the metal brace on the Particulate Filter #2 contained areas with a rust-like substance. - The floor throughout the Water Treatment Room contained dust, dirt, and areas with a blackish-orange colored substance. - The white pipes behind the Reverse Osmosis (RO, used to purify water used in dialysis treatments) system and Carbon Tank #2 contained large amounts of dark colored substance on the pipe’s surface and the bolts on the metal frame contained areas with a rust-like substance. - The floor under the RO system contained dust, dirt, and a rust-like substance on the metal frame. - Three floor drains contained areas with a rust-like substance on the outside rim of the drains. - Dust was on top of the black Brine tank’s lid. - The metal storage units contained various amounts of a rust-like substance on the frames of the units. Treatment Floor 2. Observations conducted on 05/20/25 and 05/22/25, showed: - The large red bio-hazard cart without a lid/cover was located next to the prep station teammates assembled kits with supplies for cannulation of patients’ access sites for dialysis treatment. Above the bio-hazard cart was six blue bins that contained the kits with supplies. The area above the red bio-hazard cart did not have a barrier or splash guard to prevent contamination and/or splashing on the supplies in the blue bins when teammates disposed used bloodlines and dialyzer into the red bio-hazard cart without a lid/cover. - Four oxygen concentrators were parked next to the large red bio-hazard cart. 3. Observations on 05/20/25 at 10:46 AM, and 2:25 PM, showed the dialysis chairs located at patient Stations #1, #10, and #11 had various amounts and lengths of splits in the seat of the dialysis chairs that exposed white material caused by the splits in the material. 4. Observations on 05/20/25 at 2:25 PM, showed: - The wall located at patient Station #1 contained scraped-out areas behind the dialysis chair and the wall to the right side contained scraped-out areas that varied in shape and length exposing white material. - The bottom portion of the chase walls located between patient Stations #1 and #2, between #2 and #3, and #6 contained missing areas that varied in shape, size, and length that exposed the material in the missing areas. - The wall column located next to patient Station #12 contained an area with scraped out material that exposed white material under the scraped-out area. The facility’s failure to: - Remove adhesive from surfaces caused the surface to be non-cleanable and increased the risk to harbor pathogens and bacteria. - Have in place a barrier/splash guard that went to the end of the cabinet, increased the risk for the kits with supplies to become contaminated from splashing when teammates disposed of bio-hazardous items into the large red bio-hazard cart. - Have a lid/cover on the large red bio-hazard cart increased the risk of the oxygen concentrators to become contaminated from splashing when staff disposed used bio-hazardous items into the large red bio-hazard cart. - Maintain the material of the seats of the dialysis chairs free from splits caused the areas with splits to be non-cleanable and increased the risk to harbor pathogens and bacteria. - Maintain the wall, wall column and chase walls free from scraped-out areas and missing areas increased the risk for the opened areas to harbor pathogens and bacteria in the opened/missing areas. 5. Review of the facility’s document titled, “Employee Handbook,” dated 12/06/24, showed staff directive: HOUSEKEEPING - A clean orderly work area indicates an efficient worker, reduces accidents, improves health conditions, reduces fire hazards, adds to the efficiency of your work and improves the quality of your work. We can all help by placing trash in containers provided and by applying a few common-sense simple rules of tidiness. Everyone must take responsibility for keeping the facility’s work areas clean and sanitary. 6. During an interview on 05/22/25 at 1:00 PM, Staff A, Registered Nurse, Clinical Manager stated: - Expectation was for both teammates and Bio-med staff to keep the facility clean in all areas of the facility, for example, Water Treatment Room and Treatment Floor. - Expectation was for both teammates and Bio-med staff to keep all surfaces and equipment throughout the facility clean and it was a team effort by all staff. - Acknowledged the large red bio-hazard cart located next to the oxygen concentrators and prep station that teammates assembled patients’ cannulation supplies increased the risk of the oxygen concentrators and cannulation kits to become contaminated from splashing from the used bloodlines and dialyzer when teammates disposed the used bio-hazardous items into the large red bio-hazard cart because the barrier/splash guard did not extend to the end of the cabinet.”

“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: 18018 Based on observation, policy review, and interview, the facility failed to ensure staff performed hand hygiene, (washing hands with soap and water or use of appropriate hand sanitizer) and wore gloves when indicated and performed hand hygiene before gloving, after glove removal, and before re-gloving when staff provided cares and treatments for patients. These failures to ensure staff practiced appropriate infection control prevention had the potential for cross-contamination and the spread of infections to both patients and staff. The In-Center Hemodialysis (hemodialysis, a machine used to filter wastes, fluids, and salts from blood when the kidneys are no longer able to perform the filtering process) census was 34. Findings included: 1. Observations conducted on 05/19/25, showed: - At 2:51 PM, Staff E, Certified Clinical Hemodialysis Technician (CCHT), turned off the dialysis machine alarm at patient Station #3 without wearing gloves. - At 2:55 PM, Staff E, CCHT, removed gloves and re-gloved without performing hand hygiene after removal of gloves or before re-gloving. - At 3:06 PM, Staff C, Registered Nurse (RN), failed to perform hand hygiene before gloving twice to turn off the dialysis machine alarm at patient Station #10. - At 3:10 PM, Staff C, RN, failed to perform hand hygiene before gloving to program the dialysis machine at patient Station #5. - AT 3:19 PM, Staff E, CCHT, retrieved additional wiping cloths from a stack and placed the wiping cloths into the container with bleach wearing the same gloves worn to disinfect patient Station #9. - At 3:25 PM, Staff C, RN, gloved without performing hand hygiene before gloving. - At 3:45 PM, Staff E, CCHT, removed gloves and re-gloved without performing hand hygiene after removal of gloves or before re-gloving. 2. Observations conducted on 05/20/25, showed: -At 10:06 AM, Staff G, CCHT, touched the dialysis machine screen without wearing gloves. - At 10:58 AM, Staff E, CCHT, touched the dialysis machine without wearing gloves. 3. Observations conducted on 05/21/25, showed: - At 10:57 AM, Staff F, Patient Care Technician (PCT), failed to remove gloves, perform hand hygiene and re-glove after Staff F evaluated, located, and palpated Patient #1’s access sites. Wearing the same gloves Staff F cannulated Patient #1’s access sites. - At 11:22 AM, Staff G, CCHT, removed used bloodlines and dialyzer from patient Station #11 and failed to remove gloves, perform hand hygiene and re-glove before cleansing/disinfecting patient Station #11. Staff G wore the same gloves worn to dispose of bio-hazardous items to cleanse/disinfect the patient Station. - At 2:10 PM, Staff H, CCHT, removed gloves and re-gloved without performing hand hygiene after removal of gloves or before re-gloving. - At 2:22 PM, Staff H, CCHT, removed used bloodlines and dialyzer from patient Station #4 and failed to remove gloves, perform hand hygiene and re-glove before cleansing/disinfecting patient Station #4. Staff H wore the same gloves worn to dispose of bio-hazardous items to cleanse/disinfect the patient Station. - At 2:45 PM, Staff H, CCHT, removed used bloodlines and dialyzer from patient Station #4 and wearing the same gloves, Staff H retrieved additional wiping cloths from a stack. 4. Observations conducted on 05/22/25, showed: - At 7:05 AM, Staff G, CCHT, failed to perform hand hygiene before gloving. - At 10:04 AM, Staff I, CCHT, failed to perform hand hygiene before gloving. - At 10:55 AM, Staff I, CCHT, failed to remove gloves, perform hand hygiene and re-glove after Staff I evaluated, located, and palpated Patient #14’s access sites. Wearing the same gloves Staff I cannulated Patient #14’s access sites. Staffs’ failure to: - Perform hand hygiene after glove removal and before re-gloving increased the risk of staff contaminating the gloves during re-gloving. - Remove gloves, perform hand hygiene, and re-glove before retrieving additional wiping cloths from the stack of wiping cloths increased the risk of contaminating the remaining wiping cloths touched by contaminated gloves worn by staff. - Remove gloves and perform hand hygiene after staff assessed a patient’s access sites increased the risk of staff contaminating the patient’s access sites during the cannulation process. - Remove gloves, perform hand hygiene and re-glove after discarding disposable bloodlines and dialyzer increased the risk of the gloves becoming contaminated with blood and/or body fluids and increased the risk of cross-contamination of all surfaces touched wearing the contaminated gloves during the patient Station cleansing/disinfection process. 5. Review of the facility’s policy titled, “Hand Washing,” dated 10/28/13, showed staff directives: - The most important and most basic technique in preventing and controlling transmission of pathogens is hand washing. - Hand washing will be done: - Prior to and after any aseptic, sterile and/or patient care procedure. - After contact with keyboards or screens whether gloved or ungloved. - Whenever hands become soiled or possibly contaminated. - Before and after each patient contact. - After handling of equipment and supplies. - After removal of gloves or between glove changes. 6. Review of the facility’s policy titled, “Preparation and Cannulation of Internal Access,” dated 05/2019, showed staff directive: - Perform vascular access assessment: - Look at the access; - Listen to the access with a stethoscope; and - Feel the access with your gloved hand. - Select cannulation sites. - Change gloves and hand hygiene. - With clean gloved hands clean cannulation sites. 7. During an interview on 05/22/25 at 1:00 PM, Staff A, RN, Clinical Manager, stated: - The expectation of staff was to perform hand hygiene before gloving, after removal of gloves and before re-gloving. - Staff was expected to wear gloves when touching the dialysis machine. - The expectation of staff was to remove gloves, perform hand hygiene and re-glove before retrieval of additional wiping cloths from the stack of wiping cloths. - Staff was expected to remove gloves, perform hand hygiene and re-glove after staff evaluated, located, and palpated patients’ access sites and before cannulating patients’ access sites.”

“IC-HANDLING INFECTIOUS WASTE CFR(s): 494.30(a)(4)(i) [The facility must demonstrate that it follows standard infection control precautions by implementing-] (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the- (i) Handling, storage and disposal of potentially infectious waste; This Standard is not met as evidenced by: 18018 Based on observation, policy review, and interview, the facility failed to ensure staff appropriately disposed of bio-hazardous waste (blood and/or body fluids) for 12 out of 12 observations conducted of staff disposing bio-hazardous waste materials/items (used bloodlines and dialyzer) after patients’ dialysis treatments. This failed practice had the potential for increased exposure to blood and/or body fluids to both patients and staff. The In-Center Hemodialysis (Hemodialysis - a machine used to filter wastes, fluids, and salts from blood when the kidneys are no longer able to perform the filtering process) census was 34. Findings included: 1. Observations conducted on 05/19/25, 05/20/25, 05/21/25, and 05/22/25, showed staff removed used bloodlines/dialyzer from the dialysis machine at the end of patients’ treatment and carried the used bio-hazardous items without being contained in a fluid resistant red bio-hazardous waste bag to the large red bio-hazardous carts located either next to the cannulation prep station, between patient Stations #4 and #5 or between patient Stations #8 and #9. 2. Observations on 05/19/25, showed: - At 2:33 PM, Staff C, Registered Nurse (RN), carried uncontained used bio-hazardous waste items from patient Station #2 to the large red bio-hazardous cart. Staff C carried the uncontained bio-hazardous waste items in front of Patient #12 and Patient #24 as the patients sat in the dialysis chairs receiving dialysis treatment. - At 3:13 PM, Staff E, Certified Clinical Hemodialysis Technician (CCHT), carried uncontained used bio-hazardous waste items from patient Station #3 to the large red bio-hazardous cart. - At 3:14 PM, Staff E, CCHT, carried uncontained used bio-hazardous waste items from patient Station #1 to the large red bio-hazardous cart. - At 3:41 PM, Staff G, CCHT, carried uncontained used bio-hazardous waste items from patient Station #6 to the large red bio-hazardous cart. Staff G carried the uncontained bio-hazardous waste items in front of Patient #27 as the patient sat in the dialysis chair receiving dialysis treatment. - At 3:53 PM, Staff G, CCHT, carried uncontained used bio-hazardous waste items from patient Station #5 to the large red bio-hazardous cart. - At 4:05 PM, Staff C, RN, carried uncontained used bio-hazardous waste items from patient Station #10 to the large red bio-hazardous cart. Staff C carried the uncontained bio-hazardous waste items in front of Patient #25 as the patient sat in the dialysis chair receiving dialysis treatment. 3. Observation on 05/20/25 at 2:06 PM, showed Staff E, CCHT, carried uncontained used bio-hazardous waste items from patient Station #6 to the large red bio-hazardous cart. Staff E carried the uncontained bio-hazardous waste items in front of Patient #7 and Patient #14 as the patients sat in the dialysis chairs receiving dialysis treatment. 4. Observations on 05/21/25 showed: - At 11:11 AM, Staff A, RN, Clinical Manager (CM), carried uncontained used bio-hazardous waste items from patient Station #10 to the large red bio-hazardous cart. Staff A carried the uncontained bio-hazardous waste items in front of Staff F, Patient Care Technician (PCT), while Staff F was working on the dialysis machine at patient Station #8. - At 11:22 AM, Staff G, CCHT, carried uncontained used bio-hazardous waste items from patient Station #11 to the large red bio-hazardous cart. Staff G carried the uncontained bio-hazardous waste items in front of Patient #1 as the patient sat in the dialysis chair receiving dialysis treatment. - At 2:10 PM, Staff H, CCHT, carried uncontained used bio-hazardous waste items from patient Station #2 to the large red bio-hazardous cart. Staff H carried the uncontained bio-hazardous waste items in front of Patient #18 and Patient #15 as the patients sat in the dialysis chairs receiving dialysis treatment. 5. Observations on 05/22/25, showed: - At 9:53 AM, Staff G, CCHT, carried uncontained used bio-hazardous waste items from patient Station #1 to the large red bio-hazardous cart. - At 10:23 AM, Staff G, CCHT, carried uncontained used bio-hazardous waste items from patient Station #2 to the large red bio-hazard cart. Staffs’ failure to either place the bio-hazard waste materials/items in a red bio-hazard waste bag or move the large red bio-hazard cart to the patient Station to dispose of bloodlines and dialyzer removed from the dialysis machine after a patient’s dialysis treatment increased the risk of exposing patients and staff to infections and cross-contamination when staff carried the bio-hazardous waste materials/items without being contained in a red bio-hazard waste bag. 6. Review of the facility’s policy titled, “Termination of Dialysis using Utilizing Fresenius 2008 K, K2 & T Dialysis Delivery System with Nipro Bloodlines,” dated 2016, showed staff directive: Discard the dialyzer and tubing into the hazardous waste container. 7. During an interview on 05/22/25 at 1:00 PM, Staff A, RN, CM, stated staff should not carry uncontained used bloodlines and dialyzer from the patient Station to the large red bio-hazardous carts located next to the cannulation prep station, between patient Stations #4 and #5 and between patient Stations #8 and #9. Staff A stated the expectation of staff was to bring the large red bio-hazardous cart to the patient Station to dispose of used bloodlines and dialyzer.”

“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: 18018 Based on observation, policy review, and interview, the facility failed to ensure staff consistently, thoroughly, and properly cleansed and disinfected patients’ dialysis Stations at the end of a patient’s dialysis treatment and prior to the initiation of the next patient’s dialysis treatment for eight out of eight observations made of staff performing Station disinfection. The failure to properly clean and disinfect patient Stations increased the potential for cross-contamination that could cause infection risks to all patients and staff. The In-Center Hemodialysis (Hemodialysis, a machine used to filter wastes, fluids, and salts from blood when the kidneys are no longer able to perform the filtering process) census was 34. Findings included: 1. Observation on 05/19/25 at 3:45 PM, showed Staff E, Certified Clinical Hemodialysis Technician (CCHT), failed to cleanse/disinfect the following items at patient Station #2: - The dialysis machine’s base and back; - The intravenous (IV - in a vein) hooks; and - The outside surface of the red sharps container and garbage can. 2. Observation on 05/21/25 at 9:30 AM, showed Staff G, CCHT, failed to cleanse/disinfect the following items at patient Station #1: - The dialysis machine’s supply lines and cords; - The supply/wall box and chase wall; - Drop the dialysis chair side trays and clean/disinfect all surfaces/crevices of the side trays; - The blood pressure cord; - The IV pole and hooks; and - The outside surface of the red sharps container and garbage can. 3. Observation on 05/21/25 at 11:22 AM, showed Staff G, CCHT, failed to cleanse/disinfect the following items at patient Station #11: - The dialysis machine’s supply lines, cords, and base; - The supply/wall box and chase wall; - Drop the dialysis chair side trays and clean/disinfect all surfaces/crevices of the side trays; - The blood pressure cord; - The IV pole and hooks; and - The outside surface of the red sharps container and garbage can. 4. Observation on 05/21/25 at 2:22 PM, showed Staff H, CCHT, failed to cleanse/disinfect the following items at patient Station #4: - The dialysis machine’s supply lines, cords, base and back; - The supply/wall box and chase wall; - The clipboard/documents attached to the dialysis machine’s IV pole; - Place the dialysis chair in the reclined position prior to the cleansing/disinfection process; - The blood pressure cord; and - The IV pole and hooks. 5. Observation on 05/21/25 at 2:36 PM, showed Staff H, CCHT, failed to cleanse/disinfect the following items at patient Station #2: - The dialysis machine’s top, supply lines, cords, and back; - The supply/wall box and chase wall; - The clipboard/documents attached to the dialysis machine’s IV pole; - The blood pressure cord; and - The IV pole and hooks. 6. Observation on 05/21/25 at 2:36 PM, showed Staff F, Patient Care Technician (PCT), failed to cleanse/disinfect the following items at patient Station #8: - The dialysis machine’s top, supply lines, cords, base, and back; - The supply/wall box and chase wall; - The blood pressure cord; and - The IV hooks. 7. Observation on 05/22/25 at 10:30 AM, showed Staff G, CCHT, failed to cleanse/disinfect the following items at patient Station #3: - The dialysis machine’s top, supply lines and cords; - The supply/wall box and chase wall; - The clipboard/documents attached to the dialysis machine’s IV pole; - Drop the dialysis chair side trays and clean/disinfect all surfaces/crevices of the side trays; - The blood pressure cord; - The IV pole and hooks; and - The outside surface of the red sharps container and garbage can. 8. Observation on 05/22/25 at 11:17 AM, showed Staff G, CCHT, failed to cleanse/disinfect the following items at patient Station #1: - The dialysis machine’s supply lines and cords; - The supply/wall box and chase wall; - The clipboard/documents attached to the dialysis machine’s IV pole; - Drop the dialysis chair side trays and clean/disinfect all surfaces/crevices of the side trays; - The blood pressure cord; - The IV pole and hooks; and - The outside surface of the red sharps container and garbage can. 9. Review of the facility’s policy titled, “Cleaning and Disinfecting Equipment,” dated 05/12/21, showed staff directives: - Clean all surfaces of the machine: front, back, and ledges. - Clean the BP (blood pressure) cuff and cord. - Thoroughly clean the dialysis chair. Allow to air dry. Lay the chair flat. Depending on model of chair, open the arms. Clean ALL surfaces. - The chase behind the machine must be cleaned between patients. It is considered part of the patient Station and therefore, “dirty”. 10. During an interview on 05/22/25 at 1:00 PM, Staff A, Registered Nurse, Clinical Manager, stated staff was expected to follow the facility’s policy related to cleaning and disinfecting equipment and surfaces.”

“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: 18018 Based on observation, policy review, and interview, the facility failed to ensure patients’ dialysis vascular (blood vessels) access sites/bloodline connections and face remained uncovered and in view during dialysis treatment for 14 patients (#1, #5, #6, #12, #13, #16, #18, #19, #20, #21, #22, #23, #24, and #25) of 14 patients observed for non-visible access/bloodline connections and/or face. A non-visible access/bloodline connection or patient’s face could result in staffs’ failure to quickly detect needle dislodgement or bloodline disconnection, which could result in significant bleeding episodes and affected the safety of all patients that received dialysis treatment at the facility. The In-Center Hemodialysis (Hemodialysis, a machine used to filter wastes, fluids, and salts from blood when the kidneys are no longer able to perform the filtering process) census was 34. Findings included: 1. Observation on 05/19/25, showed Patient #18’s access sites was covered by a blanket and non-visible to staff from 2:00 PM to 2:40 PM. 2. Observations conducted on 05/20/25, showed: - At 7:20 AM, the access sites was covered by a blanket and non-visible to staff for Patient #6, Patient #13, Patient #16, and Patient #19. - At 9:00 AM, Patient #19’s access sites was covered by a blanket and non-visible to staff. - At 9:05 AM, Patient #6’s access sites was covered by a blanket and non-visible to staff. 3. Observations conducted on 05/21/25, showed: - At 6:50 AM, Patient #20’s access sites was covered by a blanket and non-visible to staff. - At 6:55 AM, Patient #21’s access sites was covered by a blanket and non-visible to staff. - At 8:49 AM, Patient #22’s access sites was covered by a blanket and non-visible to staff and at 10:48 AM, Patient #22’s face and access sites was covered by a blanket and non-visible to staff. - From 9:36 AM to 10:30 AM, Patient #23’s access sites and bloodline connections was covered by a blanket and non-visible to staff and at 10:29 AM, Patient #23’s face, access sites and bloodline connections was covered by a blanket and non-visible to staff. - From 10:14 AM to 11:30 AM, Patient #24’s face and access sites was covered by a blanket and non-visible to staff. - At 12:04 PM, the access sites was covered by a blanket and non-visible to staff for Patient #12, Patient #18, #24, and #25. - At 2:00 PM, the access sites was covered by a blanket and non-visible to staff for Patient #1, Patient #5, and Patient #18. 4. Observation on 05/22/25 at 6:41 AM, showed Patient #16’s face, access sites, and bloodline connections was covered by a blanket and non-visible to staff. 5. Review of the facility’s policy titled, “Intradialytic Monitoring of Patients,” dated 05/2019, showed staff directive: The vascular access must be visible at all times and will be checked for poor flow or infiltration. 6. During an interview on 05/22/25 at 1:00 PM, Staff A, Registered Nurse, Clinical Manager, stated the expectation was for patients’ face, access sites and bloodline connections to remain visible to staff throughout a patient’s dialysis treatment. Staff A stated staff was expected to document if a patient was non-compliant with keeping their face, access sites, and bloodline connections visible during their dialysis treatments and staff was expected to document education related to risk of covering the patient’s face, access sites and bloodline connections.”