Atlantis Juncos

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 47632 Based on observations made in the treatment area on 05/28/2025, it was determined that the facility failed to monitor the environment to ensure its sanitation and reduce the potential transmission of infectious agents within and between units, due to the lack of adherence to “standard precautions”. Findings include: 1. During the observations made in the unit area on 05/28/2025, the following were found: a. On 05/28/2025 at 9:01 AM, it was observed that the nurse (employee# 4) used the pedestal sphygmomanometer without disinfecting it between patients. b. On 05/28/202 at 10:07 AM, the nurse (employee# 5) was observed picking up trash from the floor with gloves, throwing it in the trash, and touching the dialysis machine. c. On 05/28/2025 at 10:17 AM, biohazard bins were observed touching dialysis machines at stations #1, 4, 6, 7, 8, 12, 13, 15, and 17. 2. During the observations made in the surgical medical supply cart on 05/29/2025, the following were found: a. On 05/28/2025 at 8:53 AM, eleven hemodialysis fistula needle sets #16 were observed with an expiration date of 03/31/2025. 47384 3. On 05/28/2025 approximately at 8:30 AM, during visual inspection of treatment unit it was observed that regular and biomedical (red) trashcans were in contact with dialysis machines hoses.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [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-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 47632 Based on observations made in the treatment area and review of policies/procedures, it was determined that the facility failed to establish procedures, to ensure that cleaning and disinfection of contaminated surfaces, medical devices, and equipment are performed which can affect all patients receiving treatment. Findings include: Clinical Manager (employee #1) provided the facility policy Document# 15.40 last update on 02/09/2024, External Surface Disinfection of Patient Care Device on 05/28/2025 at 3:08 PM. The policy states on page 2 the blood pressure cuff will be spray cleaned with an EPA: between each patient care. 1. During the observations made in the treatment area on 05/28/2025 at 9:15 AM, the following were found: a. On 05/28/2025 at 9:01 AM, it was observed that the nurse (employee# 4) used the pedestal sphygmomanometer without disinfecting it between patients. The facility failed to ensure cleaning and disinfection of medical devices by staff members during all dialysis treatment.”

“DIALYS PROPORT-MONITOR PH/CONDUCTIVITY CFR(s): 494.40(a) 5.6 Dialysate proportioning: monitor pH/conductivity It is necessary for the operator to follow the manufacturer’s instructions regarding dialysate conductivity and to measure approximate pH with an independent method before starting the treatment of the next patient. This Standard is not met as evidenced by: 47632 Based on observations made in the treatment area and review of policy and procedure on 05/28/2025, it was determined that the facility failed to ensure that nursing staff verified the pH of the test water appropriately used for dialysis prior to starting treatment on a patient. Findings include: Clinical Manager (employee #1) provided the facility policy Document# 15.43 last update on 04/29/2025, Dialysis pH Testing and Conductivity using the Myron-L Meter on 05/29/2025 at 1:43 PM. The policy states on page 3 dip the strip into the solution to be tested and move back and forth for one second. The following was observed while the personnel were preparing hemodialysis machines for the second shift on 05/28/2025 from 12:45 PM: 1. On 05/28/2025 at 12:45 PM, registered nurse (RN) (employee #4) observed performed the pH and conductivity test on the hemodialysis machines located at station #15. RN # 4, upon performing the pH on the machine, inserted the strip to reactivate with the pH of the dialysate, but did not move the strip back and forth for one second. The facility failed to ensure that registered nurses perform dialysate pH in accordance with facility policy.”

“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: 15884 Based on a ESRD Core recertification survey and observations made of the treatment area, during the first shift of 05/28/2025 from 10:50 AM through 1:55 PM , it was determined that the facility failed to implement and maintain a program to ensure that all equipment are maintained and operated in accordance with the manufacturer’s recommendations. Findings include: 1. Broken vinyl was observed on foot rest of treatment chairs on stations #10 and #11. 47632 2. On 05/28/2025 at 9:05 AM, during the assessment of the crash cart, it was observed that the tube connected to the suction bottle of the secretion aspirator was missing. The facility failed to ensure that the crash cart had the emergency equipment in working order in case of an emergency situation. 47384 3. On 05/28/2025 at 8:22 AM, during the assessment of the crash cart, it was observed that the Oxygen tank key (wrench) was not promptly available on cart.”

“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: 47632 Based on observations made in the treatment area on 05/28/2025, it was determined that the facility failed to ensure that patients receive treatment in a manner that allows staff to have full view of patients access site for the first and second shift at patients’ stations #17, and #18. This deficient effect 2 out of 21 stations patients observed receiving treatment. Findings include: During the observations made in the treatment area on 05/28/2025 at 9:15 AM, the following were found: 1. On 05/28/2025 at 9:20 AM, the patient was located on station # 17; it was observed that the vascular access was covered with sheets. 2. On 05/28/2025 at 10:08 AM, the patient was located on station # 18; it was observed that the vascular access was covered with sheets. The facility failed to ensure vascular access sites should be seen by staff members during all dialysis treatment. Allowing patients to cover access provides an opportunity for accidents of needle.”

“PE-FIRE SAFETY-LIFE SAFETY CODE CFR(s): 494.60(e)(1) (1) Except as provided in paragraph (d)(2) of this section, dialysis facilities that do not provide one or more exits to the outside at grade level from the patient treatment area level must comply with provisions of the Life Safety Code (NFPA 101 and its Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4) applicable to Ambulatory Health Care Occupancies, regardless of the number of patients served. This Standard is not met as evidenced by: 47384 Based on observations made of the surroundings and treatment area, document review and interview during the first and second shift on 05/28/2025 from 8:00 AM through 12:00 PM, it was determined that the facility failed to maintain Life Safety measures that complies with NFPA 101 (Life Safety Code) and NFPA 99 (Health Care Facilities Code) provisions which could affect all patients receiving treatment and staff. Findings include: 1. Exit discharge leading to the back of the building has a elevation (2 3/4 inches) which poses a safety risk for evacuation of patients in wheelchairs or treatment chairs. It does not comply with NFPA 101 7.2.5. 2. Loaded sprinkler heads were observed throughout the treatment unit and waiting area. 3. At the moment of the survey no written evidence that fire doors in the facility had been inspected. To assure that fire doors are working properly NFPA 80 (Standard for Fire Doors and Other Opening Protectives) section 5.2.1 mandates that fire doors should be inspected and tested at least once a year.”

“QAPI-QAPI-IMMEDIATELY CORRECT ANY IJ ISSUES CFR(s): 494.110(c) The facility must immediately correct any identified problems that threaten the health and safety of patients. This Standard is not met as evidenced by: 15884 Based on review of the facility’s cardiorespiratory drills and training. manual , documentation and observation made of the on 05/28/2025 at 10:50 AM, and discussion of the event with the facility manager ( employee #1) and QAPI regional director (employee #2) on 05/29/2015 it was determined that the facility failed to ensure that nursing staff are trained and competent related to work together to maximize patient management during cardiorespiratory resuscitation. Findings include: On 05/28/2025 at 10:50 AM after finished and being disconnected from hemodialysis circuits this 48 years old male patient has a cardiorespiratory arrest. Nursing personnel begin to manage the emergency and apply CPR ( cardio-pulmonary resuscitation). While nursing personnel were in the process of perform the CPR it was observed lack of a coupled integrated approach to perform essential actions during the management of the emergency. While the nursing personnel were in the process QAPI regional director (employee #2) begin to participate on the process and began to lead the process, until 11:01 AM when the emergency medical technicians came to participate in the process and apply advanced life support. Patient left the treatment area with emergency medical technicians on 05/28/2025 at 11:10 AM. Facility evidence of CPR training and drills were requested to the clinical manager (employee # 1) on 05/28/2025 at 2:55 PM. This evidence was reviewed, and it was identified that CPR drills were performed on April 10, 2025, on October 15, 2024, and on July 09, 2024. Drills were performed and evaluation of employee performance was documented on an assessment tool. This assessment tool evaluation does not include documentation of details of team performance during the drill , or performance on assigned tasks. The assessment tool only indicates whether or not it met the evaluated criterion.”

“CFC-PHYSICAL ENVIRONMENT CFR(s): 494.60 This Condition is not met as evidenced by: 47632 Based on a Core complaint investigation, observations made of the treatment area, review of policies/procedures and interviews for March 19 through 21, 2024 from 8:00 AM until 3:00 PM, it was determined that the facility failed to ensure safety during weighting the patient inside the unit transfer by ambulance using stretchers’ which makes this condition 42 Cfc §494.60 Physical environment Condition of Participation “Not Met”. This resulted in Immediate Jeopardy (IJ) which can affect 12 out of 12 patients admitted at the facility who require to be transported on a stretcher and weighted. IJ began: 03/20/2024 at 10:30 AM through Facility Notified: 03/20/2024 at 3:00 PM IJ template provided to the facility. Removal Plan Received: 03/20/2024 at 4:14 PM Accepted by surveyor: 03/20/2024 at 4:21 PM Findings include: 1.During the observation on 03/20/2024 at 10:30 AM when patients enter on stretchers to be weighted. The emergency medical technician observed raising the stretcher 10 inches off the ground in order to place a metal additive that levels the wheels of the stretcher and to be able to weigh the patient on stretcher. 2. The Brecknell model MS1000 scale is designed for wheelchairs, not foe stretchers, The scale measures 31 inches from side to side. The stretcher measures 39 inches from wheel to wheel. The facility uses a metal bar that measures 7.5 inches high, therefore there is a potential risk of falls, patients and emergency medical technicians have verbalized fear of falling off the stretcher due to this type of practice. The removal plan is received on: 03/20/2024 at 4:14 PM Atlantis maintain procedures to guarantee patients safety and security. In the event of noncompliance with Tag 401 related to health, safety and or quality regulations model of scale used in the facility, the following corrective actions was established: 1. Communication is established with Vice President of Operations and Corporate Personnel to work together to find and search for alternatives. 2. A new Dorado facility scale (soon to be opened) will be immediately moved to the Juncos facility, today 03/20/2024. 3. Documents related to the new scale was requested and received from Purchase Department. New Scale Model is: Detecto Model 8500 AC (Stretcher Scale). 4. Request for scale certification will be generated today 03/20/2024. 5. Scheduled for 03/21/2024 scale calibration and certification (see P.O. attached) Prepared By: Clinical Operations Manager Date: 03/20/2024 at 4:41 PM IJ lifted on 03/21/2024 at 12:17 PM while survyors were onsite. A new scale was installed for stretchers at the facility.”

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 47632 Based on an unannounced recertification CORE survey and observational tour of the patient treatment area during the first shift, on 03/19/2024 from 9:00 AM through 4:00 PM, it was determined that the facility failed to maintain a work environment that complies with infection control standards and safety protocol. The facility failed to ensure that it is sanitary to reduce possible transmission of infectious agents related to mosquitoes, and nursing staff use of Personal Protective Equipment outside the treatment area which may represent a risk of cross contamination. This can affect 68 out of 68 patients. Findings include: 1. During the round provided in the treatment area with the Supervisor (employee #4) on 03/19/2024 at 10:00 AM to 4:00 PM, the following was observed: a. Dust particles were found on the counter located in the isolation area and the table located on the chair. b. On 03/19/2024 at 10:05 AM, Mosquitoes were observed alive in the paper dispenser. c. On 03/19/2024 at 10:20 AM a hand sanitizer with an expiration date of 12/2022 was found in the emergency cart. 2. During the round in the waiting room on 03/20/2024 at 1:00 PM to 2:00 PM, the following was observed: a. On 03/20/2024 at 1:27 PM a supervisor (employee #5) was observed carrying a patient in a wheelchair outside the facility with Personal Protective Equipment.”

“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: 47632 Based on ESRD Core Recertification survey, an observation tour in the patient treatment area during the second shift, 03/19/2024 from 10:00 AM to 4:00 PM, it was determined that the facility failed to ensure the medical equipment safe, functional, and comfortable for the patient and staff while the patients were receiving treatments. facility failed to ensure it is designed, constructed, equipped, and provide dialysis patients and staff in a safe, functional, and comfortable treatment environment related to pest control. This can affect 68 out of 68 patients. Findings include: 1. During the round provided in the treatment area on 03/19/2024 at 10:00 AM to 4:00 PM, the following was observed: a.On 03/19/2024 at 10:43 AM, a broken screen was observed at station #1. b. On 03/19/2024 at 10:05 AM, during the round at the isolation area in company of the supervisor (employee #4), mosquitoes were observed in the area. The facility failed to maintain equipment in optimal condition. 20423 During the review of the self-reported incident report of the facility on 03/19/2021 at 9:00 AM it was found that the facility investigates a fall: 2. R.R. #2 a 71-year-old female admitted to the facility on 07/15/20222 with a diagnosis of End Stage Renal Disease and Diabetes Mellitus Type II and Hight Blood Pressure. The physician ordered Hemodialysis treatment 3 times per week (Tuesday, Thursday, and Saturday in the second shift). with a Dialyzer NR160 (Elec-Beam Filter), BFR 350, DFR, 500 Dry weight 117 Kg, Heparin 2,000 unit in a Bolus By Catheter Double Lumen cuffed in the left Internal Jugular. This patient was transported by ambulance in a stretcher on 02/06/2024 during the initial of the treatment the patient refers to the nurse that during the transfer from the ambulance the emergency medical technician (EMT) slip and she fall with the stretcher and hit herself in the face and side. The patient was evalauted by the nurse and had no signs of trauma and she finish her treatment. During the facility incident investigation revealed that the Ambulance Company EMT did not notify to the facility nurse about the patient fall, the incident was investigated by the social worker an referred to the physician. However, no mitigation plan was found to prevent a EMT from slipping and a patient fall from occurring again. The area is where ambulance take patients down on stretchers. A mitigation plan was not demonstrated so that another similar incident does not occur.”

“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: 47384 Based on a ESRD Core recertification survey and observations made of the treatment area, during the first shift of 03/20/2024 from 8:30 AM through 4:00 PM , it was determined that the facility failed to implement and maintain a program to ensure that all equipment are maintained and operated in accordance with the manufacturer’s recommendations. Findings include: 1. Broken vinyl was observed on treatment chairs on stations #3, #18. 2. One (1) out of four (4) medical screen was found with broken components. 3. During the evaluation of the preventive maintenance documents, it was observed that on the date of December 14, 2023, dialysis machine #24 had a damaged time measurement clock, which does not allow accurate monitoring of hours.”

“PR-PRIVACY & CONFIDENTIALITY-TREATMENT CFR(s): 494.70(a)(3) The patient has the right to- (3) Privacy and confidentiality in all aspects of treatment; This Standard is not met as evidenced by: 47632 Based on ESRD Core survey, an observation tour in the patient treatment area during the second shift, 03/19/2024 from 10:00 AM to 4:00 PM, it was determined that the facility failed to ensure privacy on expose private body part during the connection from the hemodialysis machine in the dialysis facility. Finding include: 1. During the round provided in the treatment area on 03/19/2024 at 10:00 AM to 4:00 PM, the following was observed: a. On 03/19/2024 at 12:48 PM, registered nurse #6 is observed cleaning the catheter without the screen in place. b. On 03/19/2024 at 12:49 PM, registered nurse #7 is observed cleaning the catheter without the screen in place. c. On 03/19/2024 at 12:52 PM, registered nurse #8 is observed cleaning the catheter without the screen in place. d. On 03/19/2024 at 12:49 PM, registered nurse #6 is observed cleaning the catheter without the screen in place. e. On 03/19/2024 at 1:03 PM, registered nurse #10 a connection was observed in the catheter without the screen in place. f. On 03/19/2024 at 1:10 PM, registered nurse #11 a connection was observed in the catheter without the screen in place. The facility failed to ensure privacy with the screen at the time of connection and cleaning of the patient’s catheter during dialysis treatment.”