Carl T Curtis Health Ed Center Dialysis

“CFC-PHYSICAL ENVIRONMENT CFR(s): 494.60 This Condition is not met as evidenced by: 47269 V402 Based on the review of facility policies and procedures, observations, and staff interviews, the facility failed to clean and maintain the floor of the water room to ensure safe and sanitary conditions for patients and staff. This failed practice increased the risk of microbial growth with the potential for negatively affecting the health and safety of all 22 patients on census. PKs copy V403 Based on the review of facility policies and procedures, observations, and staff interviews, the facility failed to maintain the dialysis wall boxes (frames recessed into the wall at each hemodialysis station containing connections for acid, treated water and a drain to dispose of waste products). Additionally, the facility failed to have a policy and procedure that utilized the manufacturer’s directions for use (DFU) for cleaning and maintaining the safe and functional operations of the dialysis wall boxes. These failed practices increased the risk of microbial growth with the potential for negatively affecting the health and safety of all 22 patients on census.”

“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 the review of facility policies and procedures, observations, and staff interviews, the facility failed to clean and maintain the floor of the water room to ensure safe and sanitary conditions for patients and staff. This failed practice increased the risk of microbial growth with the potential for negatively affecting the health and safety of all 22 patients on census. Findings are: A. Review of the undated facility policy titled Safety Management Plan, revealed the building in which dialysis services are furnished will be constructed and maintained for the safety of the patients. B. During observation of the facility water room on 4/14/25 at 10:15 AM with the Registered Nurse (RN) Unit Manager (UM) the following areas of the water room were identified and confirmed: 1. A thin layer of dust was present on the water room floor. 2. Seven residual chlorine test strips had been discarded on the water room floor after the chlorine tests had been performed. 3. The painted floor of the water room was chipped and bare cement was exposed. C. During staff interview on 4/22/25 at 8:30 AM, the RNUM revealed they are responsible for performing weekly facility audits. The RNUM confirmed they had failed to identify the areas in the water room needing cleaning and repair.”

“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 V403 Based on the review of facility policies and procedures, observations, and staff interviews, the facility failed to maintain the dialysis wall boxes (frames recessed into the wall at each hemodialysis station containing connections for acid, treated water and a drain to dispose of waste products). Additionally, the facility failed to have a policy and procedure that utilized the manufacturer’s directions for use (DFU) for cleaning and maintaining the safe and functional operations of the dialysis wall boxes. These failed practices increased the risk of microbial growth with the potential for negatively affecting the health and safety of all 22 patients on census. Findings are: A. Review of the undated facility policy titled Safety Management Plan, revealed all building systems in which dialysis services are provided will be maintained and free from defects and/or hazards to ensure safety and functionality for patients. B. During observation of the dialysis wall boxes on 4/14/25 at 11:15 AM with the Registered Nurse (RN) Unit Manager (UM), the following were identified and confirmed by the RNUM: 1. Dialysis wall boxes 13 of 13 had brown staining throughout. 2. Dialysis wall boxes 6 and 11 had a layer of white crystallization surrounding the acid connections. 3. Dialysis wall boxes 2, 3, 5, 6, 7, 8, 9, 10, 12 and 13 had nonfunctioning acid connections. C. During staff interview on 4/22/25 at 8:00 AM, the RNUM confirmed a policy and procedure did not exist that utilized the dialysis wall box manufacturer DFU for cleaning and maintaining the safe and functional operations of the dialysis wall boxes. The RNUM was unable to provide a copy of the dialysis wall box manufacturer DFU, stating the dialysis wall boxes were original to the dialysis facilities construction twenty years prior. Additionally, the RNUM revealed they are responsible for performing weekly facility audits. The RNUM confirmed they had failed to identify maintenance was needed on the 13 of 13 dialysis wall boxes.”