Rai Care Center - Ames Ave

“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: 47269 Based on review of facility policies and procedures, observations, and staff interviews, Registered Nurse (RN)-E failed to clean and disinfect the isolation room (a room dedicated to the care and treatment of positive hepatitis B patients) hemodialysis machine, treatment chair and surfaces after 2 of 2 patients had completed hemodialysis treatment in the isolation room on 12/1/25. This failed practice had the potential to expose staff and 72 patients on census to blood borne pathogens. Findings are: A. Review of the facility policy titled Cleaning the Dialysis Treatment Area and Isolation Area Procedure, dated 9/2/25, revealed cleaning of the isolation room is imperative to maintain a clean and safe environment for staff and patients. B. Review of the facility policy titled Dialyzing Patients with Positive Hepatitis B Antigen (HBsAg+), dated 6/4/25, revealed the primary staff assigned to the isolation room shall pay special attention to cleaning the hemodialysis machine and all surfaces in the isolation room to prevent hepatitis B (contained in blood and body fluids) from spreading to patients who are not hepatitis B positive, as the hepatitis B virus can live on surfaces for at least seven days. C. Observation of positive hepatitis B patients (2 of 2) receiving treatment in the isolation room on 12/1/25 between 10:40 AM and 3:30 PM, revealed RN-E as the primary and sole staff assigned to the isolation room. D. Observation of the empty isolation room on 12/2/25 at 9:30 AM, a day when no patients were scheduled to dialyze in the isolation room, revealed the following: 1. Dried blood smear present on the right arm of the dialysis chair. 2. Dried blood splatters on the sharps container attached to the hemodialysis machine. 3. Dried blood splatters on the floor of the isolation room. 4. Dried blood splatters on the two walls adjacent to the dialysis chair. E. During observation of the isolation room and staff interview on 12/2/25 at 9:45 AM, RN-E confirmed they were the primary and sole staff assigned to the isolation room. RN-E further confirmed the areas identified, during surveyor observation on 12/2/25 at 9:30 AM, as dried blood that RN-E failed to clean up as required by facility policies and procedures. F. During observation of the isolation room and staff interview on 12/2/25 at 10:00 AM, Advanced Practice Registered Nurse (APRN)-P confirmed the areas identified, during surveyor observation on 12/2/25 at 9:30 AM, as dried blood that RN-E failed to clean up as required by facility policies and procedures.”

“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: 47269 Based on review of facility policies and procedures, observations and staff interviews, Registered Nurse (RN)-E failed to label an opened multidose vial (a vial of liquid medication containing multiple doses) of heparin (a blood thinning medication) located in the isolation room. Failure to label the multidose vial of heparin had the potential to allow the medication, which was unable to be verified as being viable, to be administered to 2 of 2 hemodialysis (HD) patients receiving dialysis treatment in the isolation room. Findings are: A. Review of the facility policy titled Medication Preparation and Administration, dated 7/7/25, revealed the nurse must never walk away from a multi-dose vial without writing the date and time the vial was opened. B. Observation of positive hepatitis B patients (2 of 2) receiving treatment in the isolation room on 12/1/25 between 10:40 AM and 3:30 PM, revealed RN-E as the primary and sole staff assigned to the isolation room. C. Observation of the empty isolation room on 12/2/25 at 9:30 am, a day when no patients were scheduled to dialyze in the isolation room, revealed an opened, unlabeled multidose vial of heparin. D. During observation and staff interview on 12/2/25 at 9:45 AM, RN-E revealed they had opened the multi-dose vial of heparin, located in the isolation room, on 12/1/25. RN-E confirmed they were aware of the facility policy to label multidose vials of medication and also confirmed they had failed to follow the facility policy for labeling the opened multidose vial of heparin. E. During observation and staff interview on 12/2/25 at 10:00 AM, Advanced Practice Registered Nurse (APRN)-P confirmed the opened multi-dose vial of heparin, located in the isolation room, was unlabeled and that RN-E had failed to follow the facility policy for labeling the multidose vial of heparin after opening the multidose vial.”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 47269 Based on review of facility policies, procedures, and monthly facility meeting minutes, observations, and staff interviews, the facility failed to maintain the building where hemodialysis treatments were provided. This failed practice had the potential to increase the risk for growth of infectious organisms with the potential for affecting the health and safety of staff and 72 patients on census. Findings are: A. Review of the facility policy titled Equipment Installation - Operation - Maintenance - Repair - and Disposal, dated 7/30/25, revealed the building in which dialysis services are furnished will be maintained for the safety of patients and staff. B. Environmental tour of the facility on 11/25/25 at 9:40 AM with the facility Charge Registered Nurse (CRN-B), revealed the following areas in need of repair and/or replacement: Isolation Room: 1. The designated dirty sink presented with chipped porcelain exposing untreated metal around the drain. 2. The isolation room windowsills presented with chipped paint throughout. Patient Treatment Area: 1. The hallway wall adjacent to the patient restroom, presented with gouges and missing paint throughout. 2. The vinyl covering of the stadium chairs next to the patient scale appeared ripped with foam padding exposed. 3. The two nurse workstation desk walls, located in the center of the patient treatment area, presented with a stained, presented with a porous cork board. 4. Two stained, clothed chairs were located at the two nurses’ workstations. 5. The vinyl covering of one staff stool was missing stitching, with foam padding exposed. 6. The television stands (16 of 16), located at hemodialysis treatment stations 1-16, presented with scratches and missing paint. C. Review of the facility Quality Assurance and Performance Improvement (QAPI, a data driven comprehensive approach for maintaining and improving areas identified for patient safety) meeting minutes for August, September and October of 2025 failed to include the areas of the dialysis building, identified during the environmental tour of the facility on 11/25/25 at 9:40 AM, as needing repair and/or replacement. D. During environmental tour and staff interview on 12/1/25, the facility’s BioMed Technician: 1. Revealed it is the responsibility of all staff to report areas needing repair and/or replacement to either the BioMed Technician (BT) or the Facility Administrator (FA). 2. Confirmed the areas of the dialysis building, identified during the environmental tour of the facility on 11/25/25 at 9:40 AM, as needing repair and/or replacement and also confirmed these areas had not been reported by staff to either the BT or to the FA.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 47269 Based on review of facility policies and procedures, observations, and staff interview, the facility failed to identify and remove expired Residual Chlorine test strips (testing strips used to assess for chlorine breakthrough at the hemodialysis machine prior to initiating patient treatments) stored in the isolation room. This failed practice had the potential to expose the blood stream of 2 of 2 hemodialysis (HD) patients to chlorine while receiving dialysis treatment in the isolation room. Findings are: A. Review of the facility policy titled Testing for Residual Bleach using WaterCheck RC Residual Chlorine Reagent Test Strips, dated 5/2/24, revealed staff are not to use the test strips after the manufacturer’s expiration date. B. Observation of positive hepatitis B patients (2 of 2) receiving treatment in the isolation room on 12/1/25 between 10:40 AM and 3:30 PM, revealed Registered Nurse (RN)-E as the primary and sole staff assigned to the isolation room. C. Observation of the isolation room on 12/2/25 at 9:30 AM, a day when no patients were scheduled to dialyze in the isolation room, revealed a bottle containing four WaterCheck RC Residual Chlorine Reagent test strips dated 2/2025. D. During observation of the isolation room and staff interview on 12/2/25 at 9:45 AM, RN-E: 1. Confirmed they were the primary and sole staff assigned to the isolation room on 12/1/25. 2. Revealed they had utilized the expired bottle of WaterCheck RC Residual Chlorine Reagent test strips dated 2/2025. 3. Confirmed they were aware of the facility policy not to use the chlorine reagent test strips past their expiration date. 4. Confirmed they failed to identify the chlorine reagent test strips were expired prior to using them. E. During observation of the isolation room and staff interview on 12/2/25 at 10:00 AM, the facility Advanced Practice Registered Nurse (APRN)-P confirmed RN-E had failed to follow the facility policy and had utilized the expired chlorine reagent test strips.”

“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: 47269 Based on review of facility policies and procedures, observations, and staff interview, 2 of 7 staff members (Registered Nurse (RN)-C and Patient Care Technician (PCT)-J) failed to follow facility policy and procedure for wearing gloves while accessing the touch screens on the hemodialysis (HD) machines for 3 of 4 sampled patients (Patient 1, 2, and 7). This failed practice provided the opportunity for transmission of infectious diseases among patients receiving HD treatments during the survey observation. The facility census was 83. Findings are: A. Review of the facility policy titled Exposure Categories and Determination, dated 7/1/24, revealed gloves must be worn when touching any part of the dialysis machine or equipment. B. On 8/12/24, observation of the provision of patient care revealed: 1. At 9:40 AM and 11:45 AM, RN-C touched the treatment monitor of the HD machine being used for Patient #1, with a glove wrapped around their index finger. 2. At 11:25 AM, PCT-J touched the treatment monitor of the HD machine being used for Patient #2, with a glove wrapped around their index finger. 3. At 12:30 PM, PCT-J touched the treatment monitor of the HD machine being used for Patient #7, with a glove wrapped around their index finger. C. During staff interview on 8/12/24 at 1:30 PM, the Facility Administrator (FA) confirmed it is the expectation that staff will follow facility policies and procedures for wearing gloves when touching any part of the dialysis machine or equipment.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 47269 Based on review of facility policies and procedures, record review, and staff interview, facility Patient Care Technicians (PCTs) failed to follow facility policies and procedures for notification of a Registered Nurse (RN), when Blood Pressure (BP) readings were not within the facility’s policy parameters, during hemodialysis (HD) treatment for 3 of 4 sampled patients (Patient 9, 10, and 12). The facility census was 83. Findings are: A. Review of the facility policy titled Patient Assessment and Monitoring, dated 5/1/2023, revealed the PCT must notify the RN of any patient BP readings of systolic BP parameters greater than 180 mm (millimeters)/Mercury (Hg) or equal to or less than 100 mm/Hg and/or diastolic BP parameter greater than 100 mm/Hg during HD treatment. B. Review of Patient 9’s clinical record revealed PCTs failed to notify an RN for BP readings outside of policy parameters for the following treatments: 1. 7/30/24 at 11:41 AM, PCT-O failed to notify an RN for a BP of 162/133 C. Review of Patient 10’s clinical record revealed PCTs failed to notify an RN for BP readings outside of policy parameters for the following treatments: 1. 7/23/24 at 1:03 PM, PCT-K failed to notify an RN for a BP of 98/44 2. 7/23/24 at 1:34 PM, PCT-N failed to notify an RN for a BP of 85/38 3. 7/30/24 at 11:30 AM, PCT-L failed to notify an RN for a BP of 193/87 4. 7/30/24 at 12:09 PM, PCT-L failed to notify an RN for a BP of 189/78 5. 8/10/24 at 3:03 PM, PCT-L failed to notify an RN for a BP of 191/78 6. 8/10/24 at 3:34 PM, PCT-I failed to notify an RN for a BP of 187/80 7. 8/10/24 at 3:52 PM, PCT-L failed to notify an RN for a BP of 191/80 D. Review of Patient 12’s clinical record revealed PCTs failed to notify an RN for BP readings outside of policy parameters for the following treatments: 1. 7/29/24 at 7:57 AM, PCT-J failed to notify an RN for a BP of 196/101 2. 7/29/24 at 8:01 AM, PCT-J failed to notify an RN for a BP of 202/95 3. 7/29/24 at 10:32 AM, PCT-J failed to notify an RN for a BP of 90/58 4. 8/5/24 at 12:02 PM, PCT-J failed to notify an RN for a BP of 94/52 5. 8/9/24 at 12:21 PM, PCT-H failed to notify an RN for a BP of 169/138 6. 8/12/24 at 8:14 AM, PCT-J failed to notify an RN for a BP of 224/114 7. 8/12/24 at 8:30 AM, PCT-J failed to notify an RN for a BP of 215/97 E. During staff interview on 8/12/24 at 2:45 PM, the Facility Administrator (FA) confirmed facility PCTs had failed to document an RN was notified when BP readings were outside of policy parameters during HD treatments for Patient 9, 10, and 12.”