Davita Central New York Dialysis Center

“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: 46619 Based on document review, observation, and interview, in 12 of 21 observations, dialysis unit staff and patients did not perform hand hygiene and use gloves as required. This places patients and staff at risk for potential infection. Findings include: -- Review of the dialysis unit’s policy and procedure (P&P) titled “Infection Control For Dialysis Facilities,” revised 4/2023, indicated hand hygiene should be performed prior to gloving and immediately after removal of gloves. Also, patients should be encouraged to perform hand hygiene before leaving the treatment area upon completion of treatment. -- Per observation on 7/14/2025 at 9:15 am, at Station #1, Staff A, Clinical Staff, removed gloves after performing care to an ateriovenous fistula (AVF) site. Staff A did not perform hand hygiene prior to donning new gloves. Staff A acknowledged this finding at the time of observation. -- Per observation on 7/14/2025 at 9:17 am, at Station #1, Staff A, removed gloves after moving a sharps container into the patient treatment area. Staff A did not perform hand hygiene prior to putting on new gloves. Staff A acknowledged this finding at the time of observation. -- Per observation on 7/14/2025 at 9:20 am, at Station #23, a patient donned a glove to hold gauze over needle sites post treatment. The patient then removed the glove and did not perform hand hygiene before leaving the treatment area. Staff B, Clinical Staff, did not encourage the patient to perform hand hygiene. Staff B acknowledged this finding at the time of observation. -- Per observation on 7/14/2025 at 9:25 am, at Station #22, Staff C, Clinical Staff, typed on the portable computer at chairside, applied gloves and touched the patient’s lines without performing hand hygiene prior to applying gloves. Staff C acknowledged this finding at the time of observation. -- Per observation on 7/14/2025 from 9:25 am, at Station #1, Staff A, removed gloves after touching the dialysis machine. Staff A did not perform hand hygiene prior to donning new gloves. Staff A acknowledged this finding at the time of observation. -- Per observation on 7/14/2025 at 9:40 am, at Station #7, a patient did not perform hand hygiene prior to leaving the treatment area. Staff D, Clinical Staff, did not encourage the patient to perform hand hygiene. Staff D acknowledged this finding at the time of observation. -- Per observation on 7/14/2025 at 10:10 am, Staff E, Clinical Staff, removed gloves and did not perform hand hygiene before reaching into a drawer containing clean supplies. Staff E acknowledged this finding at the time of observation. -- Per observation on 7/14/2025 at 10:15 am, after leaving Station #16, Staff E, removed gloves and did not perform hand hygiene before going to Station #18 to address a machine alarm. Staff E acknowledged this finding at the time of observation. -- Per observation on 7/14/2025 at 10:20 am, at Station #18, Staff E, removed gloves after touching a dialysis machine and did not perform hand hygiene before picking up the paper treatment schedule. Staff E acknowledged this finding at the time of observation. -- Per observation on 7/15/2025 at 10:03 am, at Station #28, Staff C, touched the patient’s Central Venous Catheter (CVC) and then typed on the portable computer at chairside without performing hand hygiene or changing gloves. Staff C acknowledged this finding at the time of observation. -- Per observation on 7/15/2025 at 10:35 am, at Station #19, a patient did not perform hand hygiene prior to leaving the treatment area. Staff F, Clinical Staff, did not encourage the patient to perform hand hygiene. Staff F, acknowledged this finding at the time of observation. -- Per observation on 7/15/2025 at 10:40 am, at Station #18, a patient did not perform hand hygiene prior to leaving the treatment area. Staff F did not encourage the patient to perform hand hygiene. Staff F, acknowledged this finding at the time of observation.”

“IC-SINKS AVAILABLE CFR(s): 494.30(a)(1)(i) A sufficient number of sinks with warm water and soap should be available to facilitate hand washing. This Standard is not met as evidenced by: 46869 Based on observation and interview, the dialysis unit did not ensure that there was a sufficient number of sinks with warm water and soap available to facilitate handwashing. Findings include: -- Per observation, on 7/14/2025 at 10:20 am, of the dialysis unit’s Pod 3 and Pod 4 isolation rooms, the handwashing sinks in both isolation rooms did not dispense water. -- During interview of Staff G, Clinical Staff, on 7/14/2025 at 10:25 am, they acknowledged the above findings.”

“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: 48296 Based on document review, observation, and interview, in 2 of 21 observations, dialysis unit staff did not don proper personal protective equipment (PPE) prior to entering the dialysis station. This places patients and staff at risk for potential infection. Findings include: -- Review of the dialysis unit’s policy and procedure (P&P) titled “Infection Control for Dialysis Facilities,” dated 4/2023, indicated “appropriate personal protective equipment (PPE) will be worn whenever there is the potential for contact with body fluids.” -- Per observation on 7/14/2025 at 9:30 am, at Station #1, Staff H, Clinical Staff, began changing an arteriovenous fistula (AVF) dressing without putting on eye protection or a face shield. Staff H acknowledged this finding at the time of observation. -- Per observation on 7/15/2025 at 10:15 am, at Station #18, Staff A, Clinical Staff, entered the station to terminate treatment and begin the rinseback of the patient. Staff A lacked eye protection or a face shield. Staff A acknowledged this finding at the time of observation.”

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 49512 Based on document review, observation, and interview, dialysis unit staff stored clean supplies and equipment in the patient hemodialysis treatment area. This could place patients and staff at increased risk of infection. Findings include: -- Review of the dialysis unit’s policy and procedure (P&P) titled “Methods of Compliance,” last revised 10/2023, indicated to prevent contact with blood or other potentially infectious materials and to reduce the risk of occupational exposures, facility staff should ensure equipment is cleaned, disinfected, and stored properly in the appropriate area. -- Per observation on 7/14/2025 at 9:25 am, during the Flash tour, blood pressure cuffs, not in use for patient care, were stored on the ledges in the dialysis stations #16, #19, #20, #22, #27. Staff C, Clinical Staff, acknowledged this finding at the time of observation. -- Per observation on 7/14/2025 at 9:25 am, during the Flash tour, DiaSafe filter plastic covers, not in use, were stored on the ledges in the dialysis stations #23 and #28. Staff B, Clinical Staff, indicated they didn’t know what the plastic covers were used for. Staff B acknowledged this finding at the time of observation. -- Per observation on 7/14/2025 at 9:50 am, Station #16, an intravenous (IV) pole with an attached pump and an oxygen concentrator were stored in the station while a patient was receiving hemodialysis treatment. The IV pole, pump and oxygen concentrator were not being used for patient care at the time of observation. Staff C, Clinical Staff, acknowledged the findings at the time of observation.”

“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: 46869 Based on observation and interview, dialysis unit staff did not ensure that uncleanable containers (cardboard boxes) from outside of the unit were stored separately from clean supply areas and patient care areas. Findings include: -- Per observation of the dialysis unit’s main clean supply room, on 7/14/2025 at 9:15 am, uncleanable containers from outside of the unit were used to store clean supplies. -- Per observation of the dialysis unit’s Pod 2 and Pod 3, on 7/14/2025 at 10:00 am, uncleanable containers from outside of the unit were used to store clean supplies for immediate patient use. -- Per observation of the dialysis unit’s home hemodialysis clean supply rooms, on 7/14/2025 at 2:30 pm, uncleanable containers were used to store clean supplies. -- During interview of Staff G, Clinical Staff, on 7/15/2025 at 4:00 pm, they acknowledged the above findings.”

“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: 49512 Based on document review, observation, and interview, in 4 of 21 observations, dialysis unit staff did not properly dispose of potentially infectious waste. Specifically, (1) used needleless syringes were discarded into non-red bag waste receptacles. (2) A sharps container was overfilled. (3) Chux pads (absorbent, disposable pads used to protect surfaces from leaks and spills) contaminated with blood were not properly disposed. This places staff and patients at risk for exposure to infection. Findings related to (1) include: -- Review of the dialysis unit’s policy and procedure (P&P) titled “Methods of Compliance,” last revised 10/2023, indicated that disposable sharps must be discarded as soon as possible into sharps containers that can be closed and are puncture resistant and leak-proof on the sides and bottom. -- Per observation on 7/14/2025 at 9:25 am, Staff I, Clinical Staff, discarded 2 -10 milliliter (ml) needleless syringes into a small zip lock bag that was taped to the arm of the patient’s chair. The syringes had been used to flush central venous catheter lines and verify blood return. -- Per observation on 7/15/2025 at 9:45 am, Staff H, Clinical Staff, discarded 2 - 10 ml needleless syringes into a small zip lock bag that was taped to the arm of the patient’s chair. The syringes had been used to flush central venous catheter lines, verify blood return, and withdrawal of approximately 10 ml of blood per syringe. This bag was carried by Staff H from the chairside area to a large medical waste receptacle in the center of the unit, where it was discarded. -- Per interview of Staff J, Non-Clinical Staff, on 7/15/2025 at 12:50 pm, the above findings were acknowledged. Findings related to (2) include: -- Review of the dialysis unit’s P&P titled “Methods of Compliance,” last revised 10/2023, indicated sharps containers should be replaced when 3/4 full. -- Per observation, on 7/14/2025 at 9:10 am, a sharps container, in the main medication room, was filled past the top lip. -- During interview of Staff G, Clinical Staff, on 7/14/2025 at 9:10 am, they acknowledged the above finding. Findings related to (3) include: -- Per observation on 7/14/2025 at 9:20 am, in Station #23, Staff B, Clinical Staff, discarded 2 Chux pads containing blood (from a patient’s access sites post treatment) into a regular (non-biohazard) waste receptacle. Staff B acknowledged this finding at the time of observation.”

“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: 49512 Based on document review, observation, and interview, (1) in 4 of 6 observations, dialysis unit staff did not clean and disinfect the patient scale between uses. Additionally, the facility’s policy and procedure (P&P) lacked instruction to staff to clean and disinfect the scale between patients. (2) In 1 of 2 observations, dialysis unit staff did not clean and disinfect the dialysis machine post treatment per the dialysis unit’s P&P. Specifically, the dialysis machine was cleaned and disinfected while a patient was in the treatment area. These lapses place patients and staff at risk for potential exposure to infections. Findings related to (1) include: -- Per review of the facility’s P&P titled “Infection Control for Dialysis Facilities,” dated 4/2023, it indicated measures will be taken to prevent cross contamination between patients. The facility’s P&P lacked instruction to clean the scale between each patient use. -- Per observation on 7/14/2025 at 9:05 am, a patient left Station #7 and independently weighed themselves after treatment. The patient touched the handles and keyboard of the scale. The scale and keyboard were not wiped down (cleaned and disinfected) by staff after patient use. -- Per interview of Staff D, Clinical Staff, on 7/14/2025 at 9:15 am, the scale is not cleaned between patients; it is cleaned at the end of the day. Staff D acknowledged the finding at the time of observation. -- Per observation on 7/14/2025 at 9:30 am, a patient was transported in their wheelchair to the scale to be weighed post treatment. Staff B, Clinical Staff, was wearing gloves from the patient’s station and touched the keyboard of the scale. The scale and keyboard were not wiped down after use. Staff B acknowledged the finding at the time of observation. -- Per observation on 7/14/2025 at 9:45 am, a patient leaving Station #1 independently weighed themselves after treatment. The patient touched the handles and keyboard of the scale. The scale and keyboard were not wiped down by Staff A, Clinical Staff, after patient use. Staff A acknowledged the finding at the time of observation. -- Per observation on 7/15/2025 at 10:35 am, a patient leaving Station #19 independently weighed themselves after treatment. The patient touched the handles and keyboard of the scale. The scale and keyboard were not wiped down by Staff F, Clinical Staff, after patient use. Staff F acknowledged the finding at the time of observation. Findings related to (2) include: -- Per review of the dialysis unit’s P&P titled “Infection Control for Dialysis Facilities,” dated 4/2023, it indicated the dialysis station must be completely vacated by the previous patient before teammates can begin to bring disinfection supplies to the station, clean or disinfect the station, and set up for the next patient. -- Per observation on 7/15/2025 at 10:30 am, in Station #18, Staff K, Clinical Staff, was cleaning and disinfecting the dialysis machine while the patient was still in the treatment area following dialysis treatment. Staff K acknowledged this finding at the time of observation.”

“RO-MEETS AAMI/MONITORED, RECORDED ON LOG CFR(s): 494.40(a) 5.2.7 Reverse osmosis: meets AAMI/monitored/recorded on log Refer to RD62:2001, 4.3.7 Reverse osmosis: When used to prepare water for hemodialysis applications, either alone or as the last stage in a purification cascade, reverse osmosis systems shall be shown to be capable, at installation, of meeting the requirements of Table 1, when tested with the typical feed water of the user, in accordance with the methods of [AAMI] 5.2.2. 5.2.7 Reverse osmosis Users should carefully follow the manufacturer’s instructions for feed water treatment and monitoring to ensure that the RO is operated within its design parameters. 6.2.7 Reverse osmosis All results of measurements of RO performance should be recorded daily in an operating log that permits trending and historical review. This Standard is not met as evidenced by: 46869 Based on document review and interview, the dialysis unit did not ensure that all daily logs of reverse osmosis (RO) system performance and chlorine tests were accurate and complete. Findings include: -- Review of the dialysis unit’s daily RO monitoring/chlorine test logs, from 5/1/2025 to 6/28/2025, revealed that there were multiple inaccuracies and/or incomplete fields: - Dates fields were left blank 22 times. - The field “Is the CM 130 (Chlorine Monitoring System) out of idle mode? (Y/N)” was inaccurate 1 time. - The field “Are both the CM 130 results and manual Chlorine test strips/kits results less than 0.1 mg/L? (Y/N)” was left blank 2 times. - The field “Multimedia filter pressure (Pre-Post)” was left blank 1 time. - The field “At end of day, have you placed the CM 130 in idle mode? (Y/N)” was left blank 2 times. - The field “Time & Initials of Teammate performing End of Day Hardness Test” was either left blank, missing initials, or missing the time of day 10 times. - The field “Start of Hot Water Circulation” was left blank 2 times. - The field “Low Disinfection Temperature Alarm” was left blank 4 times. - The field “Chemical Disinfection Initiated” was left blank 6 times. - The field “Test for Chemical Residual After Disinfection” was left blank 7 times. - The field for “Check for Chemical Consumption” was left blank 7 times. -- Review of the dialysis unit’s policy and procedure (P&P) titled, “Daily Water Treatment System Monitoring,” last revised 4/2025, revealed that a licensed nurse reviews the daily RO monitoring/chlorine test logs for completeness and verifies that all parameters are within specified limits. -- During interview of Staff L, Nonclinical Staff, on 7/15/2025 at 9:45 am, they acknowledged the above findings.”

“MIX SYS-DFU/MONITOR/PM/LOG/SANITIZE CFR(s): 494.40(a) 5.4.4.1 Mixing systems: follow DFU/monitor/PM/log/sanitization If a concentrate mixing system is used, the preparer should follow the manufacturer’s instructions for mixing the powder with the correct amount of water. If a concentrate mixing system is used, the number of bags or the weight of powder added should be determined and recorded. Manufacturer’s recommendations should be followed regarding any preventive maintenance and sanitization procedures. Records should be maintained indicating the date, time, person performing the procedure, and results (if applicable). 6.4.1 Mixing systems: Systems for preparing either bicarbonate or acid concentrate from powder should be monitored according to the manufacturer’s instructions. This Standard is not met as evidenced by: 46869 Based on document review and interview, the dialysis unit did not ensure that all acid concentrate mixing logs were accurate and complete. Findings include: -- Review of the dialysis unit’s acid concentrate mixing logs from, 5/1/2025 to 6/10/2025, revealed that there were missing times and/or incomplete sections on three of the forms: - 6/10/2025 Granuflo (132 Gallon) Batch Production Record - Missing time mixed. - 5/6/2025 Granuflo (132 Gallon) Batch Production Record - Missing time mixed. - 5/3/2025 Granuflo (132 Gallon) Batch Production Record - Missing time mixed and second half of mixing log. -- Review of the dialysis unit’s policy and procedure (P&P) titled, “Granuflo Concentrate Dissolution Unit (132 Gallon) Mixing Procedure,” last revised 10/2024, revealed that the Granuflo (132 Gallon) Batch Production Record must be completed, in its entirety, for each acid concentrate batch produced. -- During interview of Staff L, Nonclinical Staff, on 7/15/2025 at 9:45 am, they acknowledged the above findings.”

“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: 46869 Based on observation, interview, and document review, the dialysis unit did not ensure that the facility was maintained for the safety of patients and staff. Specifically, (1) there were 7 fire-rated doors propped open throughout the facility, (2) there were 3 doors that were in disrepair and/or did not ensure secure access to restricted areas of the facility, (3) there was a significant amount of dust coating the exhaust ventilation grille of the regulated medical waste (RMW) storage room, (4) there were 5 broken corner guards throughout the facility, and (5) there was a significant amount of water pooled underneath the staff breakroom’s vinyl floor tiles. Findings related to (1) include: -- Per observation of the dialysis unit’s staff support areas on 7/14/2025, between 9:15 am - 9:45 am, the following conditions were observed: - The fire-rated door to the dialysis unit’s water treatment room was propped open. - The fire-rated door to the dialysis unit’s acid concentrate mixing room was propped open. - Both fire-rated doors to the dialysis unit’s clean storage room were propped open. - The fire-rated door between the loading dock and the water treatment room corridor was propped open. - Both fire-rated doors separating the dialysis unit’s staff support areas from the dialysis unit’s patient care areas were propped open. -- During interview of Staff G, Clinical Staff, they acknowledged the above findings at the times of observation. Findings related to (2) include: -- Per observation of the dialysis unit’s acid concentrate mixing room door, on 7/14/2025 at 9:25 am, both the active and passive doors were in severe disrepair and did not positively latch, which could allow for unsecured access to the mixing room. -- Per observation of the dialysis unit’s clean storage supply room door, on 7/14/2025 at 9:30 am, the door did not positively latch. -- Per observation of the dialysis unit’s RMW room door, on 7/14/2025 at 9:35 am, the door did not positively latch and was not secured against unauthorized access. -- Review of the dialysis unit’s fire door inspection, dated 6/18/2025, revealed that all the doors above had failed their inspection. -- During interview of Staff L, Nonclinical Staff, on 7/15/2025 at 9:45 am, they acknowledged the above findings. Findings related to (3) include: -- Per observation of the dialysis unit’s RMW room, on 7/14/2025 at 9:35 am, the room’s exhaust ventilation grille was coated in dust. -- During interview of Staff L, Nonclinical Staff, on 7/14/2025 at 11: 30 am, they acknowledged the above finding. Findings related to (4) include: -- Per observation of the dialysis unit’s staff support areas and patient care areas on 7/15/2025, between 10:30 am and 10:40 am, there were 5 broken corner guards that exposed the inside of the wall. -- During interview of Staff L, Nonclinical Staff, on 7/15/2025, at 4:00 pm, they acknowledged the above findings. Findings related to (5): -- Per observation of the dialysis unit’s staff lounge, on 7/15/2025 at 10:25 am, there was a significant amount of water pooled underneath the vinyl floor tiles. -- During interview of Staff L, Nonclinical Staff, on 7/15/2025, at 4:00 pm, they acknowledged the above findings.”

“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: 52920 Based on document review, interview, and observation, the dialysis unit did not ensure that all equipment was maintained and operated in accordance with the manufacturer’s recommendations. Specifically, (1) the dialysis unit’s main medication refrigerator and home hemodialysis (HHD) medication refrigerator were not checked for temperature compliance on days that the the dialysis unit was closed (Sundays), (2) there were 2 fire extinguishers that were not annually serviced and 8 fire extinguishers that were not inspected monthly, per National Fire Protection Association (NFPA) 10 requirements, (3) the dialysis unit’s hot water heater’s mixing valve was leaking, and (4) 3 E-sized oxygen tanks were stored without restraints and the quantity of oxygen tanks stored within the dialysis unit’s patient care area exceeded NFPA 99 requirements. Findings related to (1) include: -- Review of the the dialysis unit’s medication refrigerator temperature logs, for the main medication refrigerator and HHD medication refrigerator, from 5/15/2025 - 7/15/2025, revealed that staff did not record the temperatures of the refrigerators on days that the facility was closed (Sunday), -- Review of the dialysis unit’s policy and procedure (P&P) titled, “Medications Requiring Refrigeration,” last revised 4/2025, revealed that the medication refrigerators should be maintained between 36 degrees Fahrenheit (F) and 46 degrees F, and that temperatures must be checked twice daily. The P&P lacked a procedure to validate medication refrigerator temperatures for days that the clinic is closed. -- During interview of Staff G, Clinical Staff, on 7/15/2025 at 4:00 pm, they acknowledged the above findings. Findings related to (2) include: -- Per observation of the dialysis unit on 7/14/2025 and 7/15/2025, 2 fire extinguishers located in the mixing room corridor and in the water treatment room, did not have annual maintenance completed within the last year. Additionally, 8 fire extinguishers did not have monthly inspections completed. -- Review of the dialysis unit’s P&P titled, “Facility Emergency Management Plan (ICHD, Home),” last revised 4/2023, revealed that fire extinguishers must be checked monthly and tested as required by state or local regulations. -- During interview of Staff L, Nonclinical Staff, on 7/14/2025 at 11:20 am, they acknowledged the above findings. Findings related to (3) include: -- Per observation of the dialysis unit’s water treatment room, on 7/14/2025 at 11:30 am and on 7/15/2025 at 10:30 am, there was water leaking from the mixing valve of the hot water heater system. -- During interview of Staff L, Nonclinical Staff, on 7/14/2025 at 11:30 am, they acknowledged the above findings. Findings related to (4) include: -- Per observation of the dialysis unit’s nurse station in Pod 1, on 7/14/2025 at 10:00 am, 3 E-sized oxygen tanks were stored without restraints to prevent tipping. -- Per observation of the dialysis unit’s unenclosed storage alcove in Pod 3 and nurse station in Pod 1, on 7/14/2025 at 10:05 am, there were 22 E-sized oxygen tanks stored within the same smoke compartment. (Oxygen tank storage exceeding 12 E-sized oxygen within the same smoke compartment requires a noncombustible, enclosed storage, as required by NFPA 99.) -- Review of the dialysis unit’s P&P titled, “Facility Emergency Management Plan (ICHD, Home),” last revised 4/2023, revealed that emergency oxygen must be contained in a tip-proof stand and checked routinely with the dialysis unit’s emergency cart. -- During interview with Staff G, Clinical Staff, they acknowledged the above findings at the times of their observation.”

“PR-PRIVACY & CONFIDENTIALITY-RECORDS CFR(s): 494.70(a)(4) The patient has the right to- (4) Privacy and confidentiality in personal medical records; This Standard is not met as evidenced by: 52920 Based on observation, document review, and interview, dialysis unit staff did not ensure the privacy and confidentiality of their patient’s personal information. Findings include: -- Per observation of the dialysis unit’s laboratory room, on 7/14/2025 at 10:30 am, there was a filing cabinet drawer containing patient information that was not secured from unauthorized access. -- Review of the dialysis unit’s policy and procedure (P&P) titled, “Medical Records Custodian and Maintenance,” last revised 4/2025, revealed that the dialysis unit must ensure that all medical records are stored in a safe manner to protect against loss, destruction or unauthorized use. -- During interview of Staff G, Clinical Staff, on 7/14/2025 at 10:30 am, they acknowledged the above findings.”

“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: 48296 Based on document review, medical record (MR) review, and interview, dialysis unit nursing staff did not assess and monitor patients in accordance with generally accepted standards of chronic dialysis care. Specifically, in 2 of 10 MRs reviewed (Patient #1 and Patient #2), dialysis treatment sheets indicated the patient had abnormal vital signs. There was no documentation in the MR regarding these abnormal findings. This lack of appropriate monitoring poses a potential risk for adverse patient outcomes. Findings include: -- Review of the dialysis unit’s policy and procedure (P&P) titled “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment,” dated 4/2024, indicated abnormal findings should be reported to the licensed nurse and documented in the patient’s MR. If an abnormal finding or concern is identified post treatment, this needs to be reported to the licensed nurse. The licensed nurse will assess the patient prior to discharge. Abnormal findings should be documented in the patient’s MR. The following include abnormal findings: Blood pressure (BP)-intradialytic: systolic less than 90 mm/Hg, BP post treatment: sitting systolic BP greater than 140 mm/Hg or less than 90 mm/Hg, and heart or pulse rate pre/intra/post: less than 60 beats per minute. Additionally, members of the patient care team should report any changes in patient conditions or concerns of patient well-being immediately to the licensed nurse at any time. -- Review of Patient #1’s “Treatment Details Report (a part of the MR),” dated 6/30/2025, indicated at 3:33 pm, Patient #1 had a BP of 86/49 mm/Hg. A patient care technician (PCT) wrote a note that stated “Patient awake; alert; and states no complaints at this time.” There was no documentation in the MR that a licensed nurse was notified of the abnormal finding. At 3:37 pm, Patient #1 had a BP of 87/50 mm/Hg. A PCT wrote a note that stated “Treatment terminated.” There was no documentation in the MR that a licensed nurse was notified of the abnormal finding. -- Review of Patient #1’s “Treatment Details Report,” dated 7/1/2025, indicated at 3:31 pm, Patient #1 had a BP of 163/84 mm/Hg. A PCT wrote a note that stated “post”. There was no documentation in the MR that a licensed nurse was notified of the abnormal finding. -- Review of Patient #1’s “Treatment Details Report,” dated 7/2/2025, indicated at 3:51 pm, patient #1 had a BP of 171/89 mm/Hg. A PCT wrote a note that stated “post vitals.” There was no documentation in the MR that a licensed nurse was notified of the abnormal finding. -- Review of Patient #1’s “Treatment Details Report,” dated 7/4/2025, indicated at 3:38 pm, Patient #1 had a BP of 170/80. A PCT wrote a note that stated “treatment terminated.” There was no documentation in the MR that a licensed nurse was notified of the abnormal finding. -- Review of Patient #2’s “Treatment Details Report,” dated 7/1/2025, indicated at 12:32 pm, Patient #2 had a heart rate (HR) of 49. There was no documentation of any interventions in the MR. At 1:02 pm, Patient #2 had a BP of 66/48 mm/Hg. A PCT wrote a note that stated “Patient appears to be tolerating treatment well at this time.” There was no documentation in the MR that a licensed nurse was notified of the abnormal finding. At 1:23 pm, Patient #2 had a BP of 88/54 mm/Hg. A note was written by a registered nurse (RN) that stated “treatment terminated.” There was no documentation regarding the abnormal finding (Patient #2’s abnormal BP) in the MR. -- Review of Patient #2’s “Treatment Details Report,” dated 7/3/2025, indicated at 2:31 pm, Patient #2 had a BP of 82/50 mm/Hg. A RN wrote a note that stated “Patient appears to be tolerating treatment well at this time.” There was no documentation regarding the abnormal finding of Patient #2’s BP in the MR. -- Review of Patient #2’s “Treatment Details Report,” dated 7/5/2025, indicated at 1:02 pm, Patient #2 had a BP of 87/57 mm/Hg. A PCT wrote a note that stated “Patient awake; alert; and states no complaints at this time; low bp nurse notified.” There was no documentation by an RN regarding the abnormal finding of Patient #2’s BP in the MR. At 1:32 pm, Patient #2 had a BP of 73/52 mm/Hg. A PCT wrote a note that stated “low bp nurse notified; patient awake states (the patient) feels fine; uf (ultrafiltration) goal turn off.” There was no documentation by an RN regarding the abnormal finding of Patient #2’s low BP. -- Review of Patient #2’s “Treatment Details Report,” dated 7/8/2025, indicated at 1:35 pm, Patient #2 had a BP of 88/53 mm/Hg. A PCT wrote a note that stated “Patient awake; alert; and states no complaints at this time.” There was no documentation in the MR that a licensed nurse was notified of the abnormal finding. At 2:02 pm, Patient #2 had a BP of 88/54 mm/Hg. A PCT wrote a note that stated “Patient awake; alert; and states no complaints at this time; uf goal remains off.” There was no documentation in the MR that a licensed nurse was notified of the abnormal finding. -- Per interview of Staff G, Clinical Staff on 7/15/2025 at 2:15 pm, they confirmed the above findings.”