Fresenius Kidney Care - Batavia

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 40430 Based on policy review, observation, and interview, the facility does not ensure emergency supplies are immediately available and not expired. Findings include: Review of the policy “Emergency Medications, Equipment, and Supplies,” published 07/07/25, revealed the emergency evacuation box (contains supplies to be used in an emergency/evacuation) must be checked monthly or after use for contents, expiration dates and cleanliness. An itemized log must be kept indicating contents and expiration date of those contents. Items approaching expiration must be reordered and replaced prior to the actual expiration date. Observation on 12/15/25 at 10:15 AM in the evacuation kit revealed 14 central venous catheter (CVC- tube inserted into a large vein to provide access for dialysis) port end caps (used to seal/close the port) expired 10/05/25; one box of medium medical gloves expired March 2022, one box of large gloves expired 06/01/23 and one box of extra-large gloves expired 09/28/25; two bottles of heparin (used to prevent blood clotting) 30,000 units per 30 milliliters expired 06/2025; two D batteries expired March 2025; and one liter bag of normal saline (NS-solution used during dialysis) expired April 2025, 14 NS bags expired October 2025, and one NS bag expired November 2025. Interview on 12/15/25 at 10:30 AM, Staff (K), Registered Nurse, verified these findings. Interview 12/17/25 at 12:30 PM with Staff (F), Facility Administrator verified these findings. A review of “The Maintenance System-TMS,” quality assurance electronic dashboard indicated the evacuation box log was signed off as completed by the nursing staff on 09/29/25, 10/29/25, and 12/03/25.”

“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: 34528 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 12/15/25 at 02:00 PM at Station #16 and Station #15 revealed Staff (J), Patient Care Technician (PCT), touched the hemodialysis machines being set up for the next patient, to reset alarms without wearing gloves. Staff (J) did not perform hand hygiene before or after touching the hemodialysis machines. At 02:45 PM Staff (J) exited Station #14 where Patient # 6 was being treated without removing their gloves. At the nursing station/supply cart, Staff (J) removed their gloves and applied a new pair without performing hand hygiene. Staff (J) entered Station #13 where Patient # 17 was being treated and touched the hemodialysis machine. Interview on 12/17/25 at 12:00 PM with Staff (B), Facility Administrator, verified these 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: 34528 Based on policy review, observation, and interview, staff do not immediately dispose of potentially infectious waste, specifically, used needles removed from the patient after the hemodialysis treatment. Findings include: Review of the policy “Post Treatment Fistula Needle Removal,” published 07/07/25, revealed staff are to carefully remove the needle from the patient and discard the needle in the sharps container (puncture/leak resistant container for disposal of contaminated needles and sharps). Observation on 12/15/25 at 11:00 AM at Station #4 for Patient #7 revealed Staff (H), Licensed Practical Nurse, removed the second needle from Patient #7 and set it on the chairside tray while placing gauze and tape over the needle insertion site. Once Patient #7 was holding gauze on the needle site, Staff (H) disposed of the needle in sharps container. At 11:40 AM at Station #15 for Patient #8, Staff (J), Patient Care Technician removed the second needle from Patient #8 and set it on the chairside tray while placing gauze and tape over the needle insertion site. Once Patient # 8 was holding gauze on the needle site, Staff (J) disposed of the needle in sharps container. Interview on 12/17/25 at 12:00 PM with Staff (B), Facility Administrator, verified these findings.”

“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: 34528 Based on policy review, observation, and interview, the facility does not ensure expired medications are not available for use. Findings include: Review of the policy “Storage of Supplies,” published 11/03/25, revealed staff will appropriately dispose of items that have reached the expiration date. Observation on 12/15/25 at 10:30 AM in the nursing station/laboratory supplies area revealed 11 bottles of Cefazolin (antibiotic) with expiration date of November 2025. At 10:40 AM in the medication preparation area, there was one vial of Doxercalciferol (medication used to regulate calcium and phosphorus levels) with an “open date” of 12/10/25. The medication packaging box, containing the medication, indicated to discard the vial three days after opening. Interview on 12/17/25 at 12:00 PM with Staff (B), Facility Administrator, verified these findings.”