Usrc Masonic Care Community Dialysis

“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: 36617 Based on document review, observation, and interview, in 2 of 18 observations, dialysis unit staff 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 facility’s policy and procedure (P&P) titled “Personal Protective Equipment (PPE),” revised 7/2023, indicated hand hygiene is performed before donning and after doffing PPE. -- Per observation on 6/30/2025 at 9:55 am, Staff A, Clinical Staff, removed their gloves and gown to get another staff member for patient assistance and did not perform hand hygiene after removing gloves. Staff A acknowledged the finding at the time of observation. -- Per observation on 6/30/2025 at 10:02 am, Staff B, Clinical Staff, did not remove gloves or perform hand hygeine upon completion of a patient assessment and before walking across the room to clean their stethoscope. -- During interview of Staff C, Clinical Staff, on 7/1/2025 at 12:30 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: 36617 Based on document review, observation, and interview, dialysis unit staff did not handle potentially infectious waste appropriately. Specifically, a regulated medical waste container was not available in close proximity for staff to discard used bloodlines. This could lead to patients and staff being exposed to infectious waste. Findings include: -- Review of the facility’s policy and procedure (P&P) titled “Guidelines for the Handling and Disposal of Infectious Medical Waste,” revised 4/2023, indicated the biohazard container should be brought to the point of use (e.g., near chairside) to dispose of biohazardous waste. -- Per observation on 6/30/2025 at 9:40 am, Staff D, Clinical Staff, disconnected used blood lines from the dialysis machine at Station #4 after treatment. Staff D then carried the used bloodlines for approximately 20 feet to dispose of them in a regulated medical waste container located outside Station #2. -- Per observation on 7/1/2025 at 8:30 am, Staff E, Clinical Staff, completed intravenous medication administration at Station #17. Staff E then carried the syringe approximately 20 feet to dispose of the it in a regulated medical waste container by the sink instead of using the regulated medical waste container at the patient’s chairside at Station #17. -- During interview of Staff C Clinical Staff, on 7/1/2025 at 12:30 pm, they acknowledged the above 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: 36617 Based on document review, observation, and interview, dialysis unit staff did not ensure pre-drawn medications were appropriately labeled and administered per the dialysis unit’s policy and procedure (P&P). This could compromise patient/staff safety. Findings include: -- Review of the dialysis unit’s P&P titled “Guidelines for Administration of Medications,” revised 2/2025, indicated medications should only be administered by the person preparing the medication to avoid error in administration. Any medications that are not immediately administered, should be labeled with the patient’s name, medication name, dose, date, time, and preparer’s initials and will not be stored more than four hours prior to the anticipated administration time. -- Per observation on 6/30/2025 at 8:40 am, the medication cabinet contained multiple pre-drawn heparin syringes for patients scheduled for dialysis for the next shift at approximately 10:00 am (1 hour and 20 minutes later). The syringes lacked the time they were prepared and the initials of the person who had prepared the medication. -- Per interview of Staff F, Clinical Staff, on 6/30/2025 at 8:55 am, they prepared all intravenous heparin syringes earlier for the patients scheduled that afternoon. Staff F stated they did not document the time or their initials on the syringe labels when the medication was drawn up. -- Per observation of Staff G, Clinical Staff, on 6/30/2025 at 9:35 am, they obtained a syringe of heparin from the medication cabinet for a patient and administered it to a patient. The medication had been drawn up earlier in the day by another clinical staff member. -- During interview of Staff F, Clinical Staff, on 6/30/2025 at 12:45 pm, they acknowledged the above finding.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 36617 Based on document review, observation, and interview, in 1 of 2 observations, dialysis unit staff did not clean the cannulation site of an arterial venous (AV) fistula in accordance with the dialysis unit’s policy and procedure (P&P). This places patients at risk for potential exposure to infections. Findings include: -- Review of the dialysis unit’s P&P titled “Assessment and Cannulation of Arterial Venous (AV) Fistula/Graft and Patient Self Cannulation,” revised 10/2023, stated, “patient must wash access site with soap and water prior to disinfection and cannulation. If unable staff will wash the patient’s access site with soap and water (rinsing and drying afterwards), or with other approved skin cleansing agent or cleaning wipe...” -- Per observation on 6/30/2025 at 11:20 am, Staff D, Clinical Staff, removed the clear dressing from the patient’s AV fistula cannulation site and wiped off the ointment covering the AV fistula with a gauze pad. Staff D did not cleanse the access site with soap and water or other approved agent, prior to disinfection and cannulation. -- During interview of Staff D on 6/30/2025 at 11:30 am, they acknowledged the above finding.”

“ENVIRONMENT-SECURE & RESTRICTED CFR(s): 494.40(a) 8 Environment: secure & restricted The water purification and storage system should be located in a secure area that is readily accessible to authorized users. The location should be chosen with a view to minimizing the length and complexity of the distribution system. Access to the purification system should be restricted to those individuals responsible for monitoring and maintenance of the system. This Standard is not met as evidenced by: 46869 Based on observation and interview, the dialysis unit did not ensure that the water purification and storage area was restricted to only those individuals responsible for monitoring and maintenance of the system. Specifically, the door to the room did not fully self-latch and was at risk of being left open. Findings include: -- Per observation on 6/30/2025 at 11:00 am, the door between the basement corridor and the facility’s water purification and storage area did not fully self-close and latch to prevent unauthorized entry into the area. -- During interview of Staff H, Biomedical Technician, on 6/30/2025 at 11:00 am, they acknowledged the above findings.”

“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: 46869 Based on observation and interview, the dialysis unit did not ensure that the facility was maintained to provide a safe and functional environment. Specifically, (1) the back door to the dialysis unit treatment area did not fully self-close and latch, which could allow unauthorized access into the unit and (2) the dialysis unit’s soiled workroom was not maintained and clean. Findings related to (1) include: -- Per observation on 6/30/2025 at 9:30 am, the door between the adjacent nursing home common corridor and the dialysis unit treatment area did not fully self-close and latch to prevent unauthorized entry into the treatment area. -- During interview of Staff H, Biomedical Technician, on 6/30/2025 at 10:45 am, they acknowledged the above findings. Findings related to (2) include: -- Per observation on 6/30/2025 at 9:40 am, the dialysis unit’s soiled workroom had built-up hard water stains and corrosion on the walls and floors in 5 different areas of the room, including the area around the flush-rim sink. -- During interview of Staff H, on 6/30/2025 at 10:45 am, 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: 36617 Based on document review, observation, and interview, the dialysis unit did not ensure that all equipment was maintained and operated in accordance with manufacturer’s instructions for use. Specifically, the test strips and control solutions (one to test high levels and one to test low levels) for the blood glucose meter (EvenCare G2 Blood Glucose Monitor) lacked the date they were opened. This could lead to adverse outcomes for patients. Findings include: -- Review of the dialysis unit’s policy and procedure (P&P) titled “Blood Glucose Testing,” revised 2/2023, indicated staff should “follow the manufacture’s guidance for proper storage, expiration and after use by dates of the control solutions and test strips. Document the date new control solution bottles and test strips are opened on each bottle or test strip container. Do not use control solution or test strips past manufacturer expiration date or after use by date.” -- Review of the EvenCare G2 Blood Glucose Monitor manufacturer’s instruction ( information obtained via the internet) indicated, to record the date opened on the test strip bottle label. Discard the bottle and any remaining test strip after 6 months from date of opening. Write down the date when the control solution is first opened. Discard any unused control solution 90 days after first opening or after expiration date. -- Per observation on 7/1/2025 at 9:00 am, Staff I, Clinical Staff, was performing the controls test (test to ensure accuracy of your blood glucose readings) of the EvenCare G2 Blood Glucose Monitor. The test strips and both vials of control solution lacked the date they were opened. There were no manufacturer’s instructions located with the control test kit. Staff I confirmed this finding at the time of observation. -- During interview of Staff J, Clinical Services Director, on 7/1/2025 at 12:30 pm, they acknowledged the above findings and indicated staff should follow the manufacturer’s instructions.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 36617 Based on document review, observation and interview, in 1 of 20 observations, dialysis unit staff did not ensure patients access sites were visible during hemodialysis treatment. This could lead to undetected needle dislodgement or line disconnection. Findings include: -- Review of the facilty’s policy and procedure (P&P) titled “Initiation of Dialysis Treatment,” revised 7/2024, indicated prior to walking away from the patient’s dialysis machine, “verify all prescribed orders are followed. Prescription orders and safety measures include, but are not limited to verifying the following: ... Access, bloodline connections, and face are visible ... “ -- Per observation on 6/30/2025 at 8:45 am, the patient receiving dialysis at Station #17, had their central venous catheter access site covered by their shirt. Staff F, Clinical Staff, acknowledged the finding at the time of observation.”