Fmc St. Joseph’s - Cortland

“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: 48296 Based on document review, observation, and interview, in 5 of 21 observations, facility staff and patients did not perform hand hygiene and/or use gloves as required. These lapses place patients and staff at increased risk for infection. Findings include: -- Per review of the facility’s policy and procedure (P&P) titled “Hand Hygiene,” revised 11/2023, “hand hygiene should be performed before and after direct contact with patients, immediately after removing gloves, and after contact with inanimate objects near the patient. Patients should perform hand hygiene prior to and after each dialysis treatment.” -- Per observation on 9/9/2025 at 10:05 am, at Station #7, Staff A, Clinical Staff, touched the computer keyboard and screen and then disconnected the dialysis tubing from the patient’s access site without performing hand hygiene in between. Staff A acknowledged this finding at the time of observation. -- Per observation on 9/9/2025 at 10:15 am, at Station #6, Staff A touched the computer keyboard and screen and then disconnected the dialysis tubing from the patient’s access site without performing hand hygiene in between. Staff A acknowledged this finding at the time of observation. -- Per observation on 9/9/2025 at 10:30 am, at Station #10, Staff B, Clinical Staff, did not perform hand hygiene prior to leaving the treatment area. Additionally, Staff B did not encourage the patient to perform hand hygiene after treatment. Staff B acknowledged these findings at the time of observation. -- Per observation on 9/9/2025 at 10:40 am, at Station #11, Staff C, Clinical Staff, touched the side table attached to the chair and then disconnected the dialysis tubing from the patient’s access site without performing hand hygiene in between. Staff C acknowledged this finding at the time of observation. -- Per observation on 9/9/2025 at 11:30 am, at Station #2, Staff D, Clinical Staff, touched the computer keyboard and screen and then connected the dialysis tubing to the patient’s access site without performing hand hygiene in between. Staff D 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 facility did not ensure that there was a sufficient number of sinks with warm water and soap available to facilitate handwashing. This lapse could place patients and staff at increased risk for infection. Findings include: -- Per observation, on 9/9/2025 at 9:00 am, in the dialysis patient treatment area, two clean handwashing sinks did not dispense water. -- During interview of Staff E, Clinical Staff, on 9/9/2025 at 10:30 am, 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: 52920 Based on observation and interview, the facility did not ensure that regulated medical waste (RMW) was disposed of in compliance with New York State Codes, Rules, and Regulations Title 10 (10NYCRR) Part 70. Specifically, they did not ensure that RMW was properly stored after removal from patient care areas. This lapse places patients and staff at increased risk of infection. Findings include: -- Per observation, on 9/9/2025 at 9:00 am, the storage room, where RMW is kept, did not have a lock to prevent unauthorized access to the RMW. Staff E, Clinical Staff, and Staff F, Clinical Staff, acknowledged the above findings at the time of observation.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 48296 Based on document review, observation, and interview, facility staff did not ensure that 3 drawers located in the medication administration area, which contained multiple medications, were secured. Having medications unsecured has the potential to negatively affect patient safety. Findings include: -- Per review of the facility’s policy and procedure (P&P) titled “Medication Preparation and Administration,” revised 7/2025, all medications should be kept in a locked cabinet except when in use. -- Per observation on 9/9/2025 at 9:00 am, within the facility’s medication administration area, 3 drawers containing medications were not locked. Medications found in the drawers included multiple boxes of Heparin (medication that prevents blood clots), multiple boxes of Venofer (medication used to treat iron deficiencies), multiple boxes of Ferrlecit (medication used for iron deficiencies), multiple boxes of Vancomycin Hydrochloride (antibiotic), Tazicef (antibiotic), Cefepime (antibiotic), multiple vials of Cefazolin (antibiotic), and 2 prescription bottles of a patient’s Calcitrol (a form of vitamin D). Staff F, Clinical Staff, acknowledged this finding at the time of observation.”

“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: 48296 Based on document review, observation, and interview, facility staff did not ensure expired medications and supplies were removed from the code cart, treatment supply carts, and medication area. Specifically, (1) the facility’s code cart and treatment supply carts contained expired supplies and (2) the medication preparation area contained expired medications. These were available for patient use. These lapses could put patients at risk for untoward outcomes. Findings pertaining to (1) include: -- Per review of facility’s policy and procedure (P&P) titled “Expiration Dates Sterile Supplies,” dated 7/2022, sterile items that have reached the expiration date should be disposed of. -- Per observation on 9/9/2025 at 8:45 am, the following supplies were available for patient use in the code cart: - 2 intravenous administration sets, expired on 7/2025 - 1 cardiopulmonary resuscitation (CPR) adult electrodes/pads, expired on 9/2024 - 6 nasal cannula oxygen tubing, expired on 6/2025 - 5 precision glide 18 gauge needles, expired on 6/2025 --Staff C, Clinical Staff, acknowledged this finding at the time of observation. -- Per observation on 9/9/2025 at 8:45 am, the following supplies were available for patient use in the treatment supply carts: - 1 box of size large nitrite examination gloves, expired on 8/2021 - 1 box of size large lavender nitrite non-powdered examination gloves, expired on 4/2024 - 1 box of size small nitrite examination gloves, expired on 9/2021 - 3 single-use thermometers, expired on 1/6/2023 - 12 single-use thermometers, expired on 11/16/2024 - 41 single-use thermometers, expired on 5/12/2025 --Staff C, Clinical Staff, on 9/9/2025 at 9:20 am, acknowledged the above observations. The expired supplies were disposed of at this time. -- Per observation on 9/9/2025 at 9:10 am, in the medication preparation area 1 - 60 milliliter (ml) Luer lock syringe, that expired on 6/30/2024, was available for patient use. Staff F, Clinical Staff, acknowledged this finding at the time of observation. Findings pertaining to (2) include: -- Per review of the facility’s P&P titled “Medication Preparation and Administration,” dated 7/7/2025, expired medications are to be discarded. -- Per observation on 9/9/2025 at 9:05 am, in the medication preparation area, 1 tube of Glutose 15 (oral glucose gel), that expired on 6/30/2025, was available for patient use. Staff F acknowledged this finding at the time of observation.”