Fmc Strong Health Dialysis-Clinton Crossings

“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: 40430 Based on policy review, observation, and interview, nursing staff do not follow standard infection control practices regarding the use of gloves and hand hygiene. Findings include: Review of policy “Hand Hygiene,” published 11/06/23, revealed hands will be decontaminated using alcohol-based hand rub or by washing with antimicrobial soap and water before and after direct contact with patients, when entering and leaving the treatment area, immediately after removing gloves, and after contact with any inanimate objects near the patient. Observation on 01/21/26 at 12:05 PM at Station #15 for Patient #9 revealed Staff (H), Registered Nurse, used their gloved hands, touched the sharps container (puncture/leak resistant container for disposal of contaminated needles and sharps) three times to bring it closer within their reach. Then Staff (H) removed Patient #9 needles from their fistula (access to deliver hemodialysis treatment to patient) without removing gloves and performing hand hygiene. Observation on 01/22/26 at 09:45 AM at Station #15 for Patient #22 revealed Staff (M), Registered Nurse, charting on the hemodialysis machine keyboard. Staff (M) removed their gloves but did not perform hand hygiene before applying another pair of clean gloves to take Patient #22’s temperature and terminate the treatment. After terminating the treatment, Staff (M) pushed the footrest down on the dialysis chair. Without changing gloves or performing hand hygiene, Staff (M) proceeded to cleanse the central venous catheter (CVC-tube inserted into a large vein in the body to provide access for dialysis) ports, disconnected the lines from the port, and flushed the catheter ports. At 02:55 PM at Station #13 for Patient #36, Staff (N), Patient Care Technician, terminated Patient #36 treatment, clamped the blood lines, removed their gloves but did not perform hand hygiene. Staff (N) exited the station and walked to the nurses’ station cupboard to retrieve supplies. Staff (N) returned to the station but did not perform hand hygiene before applying another pair of clean gloves. Staff (N) removed needles from Patient #36 fistula. Interview on 01/23/26 at 01:30 PM with Staff (B), Clinic Manager, verified this finding.”

“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: 40430 Based on policy review, observation, and interview, the facility does not ensure personal protective equipment (PPE-equipment worn for protection from workplace hazards such as blood) such as gowns, face shields, eye wear, or masks were worn properly by staff when performing procedures during which spurting or splattering of blood may occur. Findings include: Review of the policy “Personal Protective Equipment (PPE),” published 11/06/23, indicated PPE including, but not limited to, full face shield or mask and protective eye wear with full side shield, must be worn to protect employees from blood or other potentially infectious materials. Observation on 01/21/26 at 12:28 PM at Station #15 for Patient #9 revealed Staff (H), Registered Nurse, removed used blood line tubing from the hemodialysis machine wearing a mask without a full-face shield/protective glasses with a full side shield. At 03:30 PM at Station #22 for Patient #34, Staff (T), Patient Care Technician, terminated/rinsed back (return blood from hemodialysis machine back to patient) Patient #34’s blood wearing a mask without a full-face shield/protective glasses with a full side shield. At 03:35 PM at Station #25 for Patient #35, Staff (U), Licensed Practical Nurse, cannulated (insert needles) Patient #35’s fistula (access to deliver hemodialysis treatment to patient) wearing a mask without a full-face shield/protective glasses with a full side shield Interview on 01/23/26 at 01:30 PM with Staff (B), Clinic Manager, verified this finding.”

“IC-SUPPLY CART DISTANT/NO SUPPLIES IN POCKETS CFR(s): 494.30(a)(1)(i) If a common supply cart is used to store clean supplies in the patient treatment area, this cart should remain in a designated area at a sufficient distance from patient stations to avoid contamination with blood. Such carts should not be moved between stations to distribute supplies. Do not carry medication vials, syringes, alcohol swabs or supplies in pockets. This Standard is not met as evidenced by: 40430 Based on policy review, observation, and interview, in three of three team/patient care areas, the facility does not ensure adequate separation of clean and dirty supplies. Specifically, clean supplies were stored on the same countertop with blood-filled lab specimen tubes. Findings include: Review of the policy “Storage of Supplies,” published on 11/03/25, indicated proper storage conditions are necessary to provide a safe environment and to ensure supplies are not contaminated or damaged. Observations on 01/21/26 from 10:45 AM to 03:40 PM and 01/22/26 from 09:45 AM to 11:00 AM in the patient care areas revealed clean supplies, including personal protective equipment (PPE-gowns, face masks), a box of tissues, a roll of paper towels, and three ring chart/binders, were stored on the same shelf/counter with multiple blood filled patient laboratory specimen tubes held in white blood tube holder/racks located in each patient care “team” areas (Team 1, Team 2, and Team 3). Interview on 01/23/26 at 01:30 PM with Staff (B), Clinic Manager, verified this finding.”

“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: 25545 Based on observation and interview, the facility did not ensure that the building was maintained free of insects and/or maintain the physical environment for one of three patient care treatment areas. Findings Include: Observation on 01/21/26 at 10:45 AM on the treatment floor at Station #14 revealed approximately 30 ants on the floor and half wall of the station. Interview at 11:30 AM with Staff (E), Biomedical Technician, verified these findings. Observation on 01/21/26 at 11:30 AM in patient care treatment areas “Team 3,” revealed the sheet vinyl was pulling away from the counter, and a metal trim had already pulled away from the corner of the counter of the nursing station entrance/exit. The area was taped with medical tape to hold the sheet vinyl and metal trim in place. This area would not be able to be thoroughly disinfected. Interview at 11:40 AM with Staff (E), Biomedical Technician, verified these 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: 40430 Based on policy review, observation, document review, and interview, in three of three team/patient care areas, the facility does not maintain equipment according to the manufacturer instructions. Specifically, the facility does not ensure expired supplies are not available for use. Findings include: Review of the policy “Emergency Medications, Equipment and Supplies,” published on 07/07/25, indicated the emergency cart and evacuation boxes are to be checked monthly for expiration dates. Review of the policy “Storage of Supplies,” published on 11/03/25, indicated proper storage conditions are necessary to provide a safe environment and to ensure supplies are not expired. Supplies must be rotated to ensure products maintain quality and do not expire. Appropriately dispose of items that have reached the expiration date. Observation on 01/21/26 at 10:55 AM at the “Team 2” nursing station revealed one bottle of “Water Check-RC” residual chlorine test strips labeled with an “open date” of 08/17/25 and “use by date” of 11/17/25. Manufacturer printing on the bottle label read “Important: use within three months after opened.” Observation on 01/22/26 from 10:00 AM to 10:30 AM in the “Team 1” emergency evacuation box (contains required patient supplies in the event of emergency facility evacuation) revealed five intravenous (IV-used to administer fluid into a vein) lines expired on 02/29/24 and five IV lines expired on 04/24/25; in the “Team 2” emergency evacuation box there were 10- IV lines expired on 05/20/24; and in the “Team 3” emergency evacuation box there were 10- IV lines expired on 02/29/24. The emergency “crash” cart (contains emergency equipment and medications for medical emergencies) revealed an oxygen face mask that expired on 07/07/25. Review of the emergency code cart, the medication checklist, and emergency box contents log revealed staff signed off a review completed on 01/12/26. Interview on 01/22/26 at 10:30 AM with Staff (K), Registered Nurse and on 01/23/26 at 01:30 PM with Staff (B), Clinic Manager, verified these findings.”

“PQ-STAFF LIC AS REQ/QUAL/DEMO COMPETENCY CFR(s): 494.140 All dialysis facility staff must meet the applicable scope of practice board and licensure requirements in effect in the State in which they are employed. The dialysis facility’s staff (employee or contractor) must meet the personnel qualifications and demonstrated competencies necessary to serve collectively the comprehensive needs of the patients. The dialysis facility’s staff must have the ability to demonstrate and sustain the skills needed to perform the specific duties of their positions. This Standard is not met as evidenced by: 34528 Based on policy review, document review, and interview, one of four licensed practical nurses did not have a current license. Findings include: Review of policy “Credential and Verification Requirements,” (no date) revealed this policy applies to all current employees. License status must be monitored on an ongoing basis. Staff must maintain a valid credential while actively working for the company. Ensure employees have a valid credential in the state in which they are working. When a credential has expired, managers must confirm the employee is no longer performing their job duties. Review of the document “Licensed Practical Nurse Job Title,” dated 12/17/20, revealed required credentials include a current appropriate state licensure. Review of the “University of the State of New York Education Department Office of the Professions Registration Certificate,” revealed Staff (R) was registered to practice as a licensed practical nurse in New York State through 12/31/25. Review of the employee time sheet from 01/01/26 through 01/23/26 revealed Staff (R) worked on 01/02/26 from 05:19 AM to 03:24 PM, on 01/05/26 from 05/05/26 from 05:24 AM to 08:17 PM, on 01/09/26 from 05:26 AM from 01:18 PM, on 01/10 26 from 01:12 PM to 08:42 PM, on 01/12/26 PM from 05:18 AM to 04:10 PM, on 01/16/26 from 05:21 AM to 03:05 PM, on 01/23/26 from 05:20 AM to 12:08 PM. Review of medical record treatment flowsheets from 01/02/26 to 01/16/25 revealed Staff (R) electronically signed their name while providing patient care on 01/02/26, 01/05/26, 01/09/26, 01/12/26 to Patient #32, on 01/10/26 to Patient #33, and on 01/16/26 to Patient #24. Interview on 01/23/26 at 02:45 PM with Staff (B), Nurse Manager, verified these findings.”