Fkc Nazareth

“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: 45377 Based on observations (OBS) of the in-center treatment (ICTX) area and interviews with the director of operations and clinical manager, the facility failed to maintain a sanitary environment, and failed to remove expired supplies from the ICTX area for two (2) of three (3) observations (OBS): OBS#1 and OBS#3. Findings include: Facility Policy Storage of Supplies and Supply Expiration Dates for Inpatient Services, Reference Number: 47588, Version 4 reviewed on August 11, 2025 at approximately 3:00 PM reads in part, “Supplies will be rotated First-in-First-out (FIFO) to ensure products maintain quality and to monitor expiration dates. Any item that is expired, damaged ....will be removed from stock and disposed of appropriately.” Facility Policy Infection Control Overview, Reference Number 47661, Version 4 reviewed on August 12, 2025 at approximately 3:00 PM reads in part, “ Mandatory Components of Program: surveillance program of specific measures for prevention, early detection, control ... “ Facility Policy General Cleanliness and Infection Control Guidelines, Reference Number 47685, Version 8 reviewed on August 12, 2025 at approximately 3:15 PM reads in part, “ All areas must be kept clean and organized, including but not limited to treatment areas ...Facility staff are accountable for cleaning rooms/areas not assigned to contracted staff. Such cleaning should be done regularly using a scheduled developed by the facility. “ The findings of the facility ’ s Infection Control Audit conducted 06/13/2025, reviewed on August 12, 2025 at approximately 3:30 PM, found that the audit question: Are ceiling tiles free of stains, cracks or missing tiles had a 100% “ yes “ response. Facility Policy Personal Protective Equipment, Reference Number 47663, version 6, reviewed on August 13, 2025 at 10:00 states in part, “ All personal protective equipment (PPE) shall be removed prior to leaving the treatment area. “ OBS #1 of the in-center treatment area conducted August 11, 2025 from 8:50 AM to 12:15 PM revealed the following: Four (approximate 32 gallon) non infectious trash receptacles were found without lids: Trach receptacle #1, across from treatment station #9, was full to the top with trash and without a lid. Trach receptacle #2, across from treatment station #10, was three-quarters filled with trash and without a lid. Trash receptacle #3, between treatment stations #3 and #4, was one-half full of trash and without a lid. Trash receptacle #4, across from treatment station #7, was one-half full of trash and without a lid. One trash lid was observed to be standing on the floor, against the wall, across from treatment stations #8 and #9. A two-tier black cart, across from treatment station #9 was noted to have 3 empty boxes sitting on top of clean supplies on the top shelf. The bottom shelf, which was empty, was noted to be covered in white and brown debris. A two-tier black cart, across from treatment station #10, was noted to have blue absorbent pads covering the top shelf. On top of the blue pads were approximately 6 white fistula pressure clamps and several (at least 10) blue A clamps. It was unclear if the clamps were clean or dirty. When a patient care technician was asked (8/11/2025 at 10:45 AM) if the clamps were clean or dirty, s/he responded that the clamps were clean. There was no signage or bins to distinguish clean from dirty clamps. An uncovered small bucket of bleach was also sitting on the top shelf. There were no clamps in the bucket. The blue pads did not look clean. The cart also contained a clear, rectangular bin which appeared to house some connections for the hemodialysis machine. The sides of the bin were cloudy and contained quite a bit of white debris around all sides. Two trash lids were sitting on the bottom of the cart. There were four (4) missing ceiling tiles, leaving one 2 x 2 open ceiling space near treatment stations #11 and #12, two 4 x 2 open ceiling spaces near treatment stations #11 and #12, and one 2 x 2 open ceiling space near the nurses ’ station, all exposing the plenum space. There were seven (7) ceiling tiles with large water stains near/above treatment stations #11 and #12, and one ceiling tile with a small water stain near/above treatment station #10. In an interview with the clinical manager on 8/12/2025 at approximately 9:00 AM, the clinical manager stated that the ceiling tiles had been removed due to water leakage from the condenser/HVAC system above the dropped ceiling. It was unknown as to the length of time that the ceiling tiles had been removed. A blue supply cart across was treatment stations #9 and #10 in drawer #4 contained thirteen (13) male to male luer adapters, lot #30092, expired 06/23/2024. The surveyor accompanied PF#4 and PF#5 for a total chlorine water check. The surveyor observed that PF#4 and PF#5 left the treatment area without removing PPE gowns, proceeded down the hallway outside of the dialysis unit to the water treatment room, conducted the test, and returned to the dialysis treatment area without removing and replacing PPE gowns which is not in accordance with facility policy. OBS #3 of the in-center treatment area conducted August 13, 2025 from 7:15 AM to 7:45 AM PM revealed the following: One, 32-gallon trash receptacle across from treatment station 8 was found without a lid, and one trash receptacle near the nurses ’ station was found without a lid. One trash receptacle lid was observed underneath the black cart across from station #10. The top of the small lab specimen refrigerator, across from treatment stations #11 and #12, contained loose white debris. All expired supplies were given to the charge nurse on duty. An interview conducted with the director of operations and clinical manager on August 13, 2025 starting at 2:30 PM confirmed the above findings.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 45377 Based on review of facility policies and procedures, medical records (MR), dialysis treatment documentation, and an interview with the director of operations and clinical manager, the facility did not follow its policy for adhering to the dialysis prescription for three (3) of seven (7) MR’s reviewed: MR#4, MR#5, and MR#6 and documenting values meant to assist with evaluating adequacy for five (5) of seven (7) MR’s reviewed: MR#1, MR#3, MR#4, MR#6, and MR#7. Findings include: Facility Policy 5008X Patient Assessment and Monitoring, Reference Number 64462, Version 3 reviewed on August 12, 2025 at approximately 8:00 AM reads in part, “Monitoring During Treatment: Document machine parameters and safety checks every 30 or more often as needed but not to exceed 45 minutes or per state regulations .....Check machine settings and measurements. Check prescribed blood flow is being achieved or reason is documented in the medical record if unable to meet prescribed blood flow. Record KECN value with 30-minute safety checks.” A review of medical records and hemodialysis treatment (HDTX) records was conducted on August 6, 2025 starting at approximately 7:45 AM, and again on August 7, 2025 starting at approximately 8:00 AM. The admission date (AD) is below. MR#1 AD 06/13/2025: HD Treatment (HDTX) Record Review: 07/23/2025: HDTX was initiated a10:31 AM and ended 2:05 PM. Documentation of KECN values (a measure used to determine the adequacy of the dialysis treatment) occurred at 12:24 PM and 1:03 PM only, which was not in accordance with facility policy. 07/30/2025: HDTX was initiated 10:30 AM and ended 2:07 PM . Documentation of KECN values occurred at 11:24 AM, 11:51 AM, and 12:53 AM which was not in accordance with facility policy. 08/01/2025: HDTX was initiated at 10:30 AM and ended at 2:09 PM. Documentation of KECN values occurred at 12:01 PM only, which was not in accordance with facility policy. MR# 3 AD 11/29/2023: HD Treatment (HDTX) Record Review: 08/04/2025: HDTX was initiated 5:40 AM and ended 9:31 PM. Documentation of KECN values occurred at 6:33 AM and 8:32 AM which was not in accordance with facility policy. 08/06/2025: HDTX was initiated at 5:40 AM and ended 9:28 AM. Documentation of KECN values occurred at 7:03 AM and 8:26 AM which was not in accordance with facility policy. MR#4 AD 02/02/2020. HD Treatment (HDTX) Record Review: 07/29/2025: HDTX was initiated 4:55 AM and ended 9:00 AM. Documentation of KECN values occurred at 6:37 AM and 7:04 AM which was not in accordance with facility policy. 08/05/2025: The HD prescription contained an order for a blood flow rate (BFR) of 400 mL/min. Treatment was initiated 5:00 AM. BFR was 350 mL/min from initiation of treatment until 6:50 AM at which time the BFR was increased to 400 mL/min. There was no documentation as to the reason for the change in BFR. MR#5 AD 08/09/2024. 08/04/2025: The HD prescription contained an order for a dialysis flow rate (DFR) 800 mL/min. HD Treatment was initiated at 1:55 PM. At 4:50 PM, the DFR was decreased to 500 mL/min until the end of treatment at 5:45 PM. There was no documentation as to the reason for the change in DFR. MR#6 AD 04/28/2022. HD Treatment (HDTX) Record Review: 07/15/2025: The HD prescription contained an order for a BFR 350 mL/min. Treatment was initiated at 3:47 PM. BFR was decreased to 300 mL/min at 5:29 PM and remained at that rate until the end of treatment at 7:23 PM. There was no documentation as to the reason for the change in BFR. Documentation of KECN values occurred at 4:30 PM and 6:00 PM which was not in accordance with facility policy. 07/19/2025: HDTX was initiated 3:45 PM AM and ended 7:18 PM. Documentation of KECN values occurred at 5:02 PM and 5:32 PM which was not in accordance with facility policy. 08/02/2025: The HD prescription contained an order for a BFR 350 mL/min. Treatment was initiated at 3:50 PM. BFR was decreased to 280 mL/min at 4:29 PM, increased to 300 mL/min at 4:59 PM, then decreased to 240 mL/min until the end of treatment at 7:21 PM. There was no documentation as to the reason for the changes in BFR. Documentation of KECN values occurred at 4:59 PM, 5:32 PM, and 6:02 PM which was not in accordance with facility policy. MR#7 AD 10/24/2020. HD Treatment (HDTX) Record Review: 07/31/2025: HDTX was initiated 5:10 AM and ended 9:45 AM. There was no documentation of KECN values. 08/02/2025: HDTX was initiated at 5:10 A and ended 10:02 AM. Documentation of KECN values occurred at 7:03 AM only which was not in accordance with facility policy. 08/07/2025: HDTX was initiated at 5:13 AM and ended 9:48 AM. Documentation of KECN values occurred at 6:05 AM, 6:06 AM, and 6:37 AM which was not in accordance with facility policy. An interview conducted with the director of operations and clinical manager on August 13, 2025 starting at 2:30 PM confirmed the above findings.”