Atlantis Guaynabo II

“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 unnuanced ESRD Core Survey, observations made on treatment area on unit one (I), during the second shift on 02/04/2025 through 02/06/2025 from 8:30 AM through 12:00PM, it was determined that the facility failed to ensure that the patients wash their hands and vascular access upon entering the unit, the possible risk of infectious agents for 2 out of 23 stations ( Station # 4 and #19). Findings include: During the observations at the entrance of the treatment area on 02/04/2025 at 10:30 AM through 12:00 PM, the following were found: 1. On 02/04/2025 at 11:08 AM, the patient did not wash the access vascular with soap and water then the patient was located at station #4. 2. On 02/04/2025 at 11:08 AM, the patient did not wash the access vascular with soap and water then the patient was located at station #19.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 47632 Based on an unnuanced ESRD Core Survey, observations made on treatment area on unit one, during the first and second shift on 02/04/2025 from 8:30 AM through 3:00PM, it was determined that the facility failed to ensure that patients follow instructions related to the hazards of eating while on dialysis for 2 out of 23 observations at patients stations (#5 and 15). Findings include: During the observations made in the treatment area on 02/04/2025, the following was found: 1. On 02/04/2025 at 1:16 PM, the patient located on station # 5 was eating grapes. 2. On 02/04/2025 at 1:18 PM, the patient located on station #15 was eating potato chips. The facility failed to ensure that patients did not ingest food during the entire dialysis treatment. Allowing patients to ingest food in the treatment area could result in aspiration, choking, cardiac arrest or further complications that could lead to death.”

“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 an unnuanced ESRD Core Survey, observations made on treatment area on unit one, during the first and second shift on 02/04/2025 through 02/06/2025 from 8:30 AM through 12:00PM, it was determined that the facility failed to ensure the nursing staff checked the pH of water used for dialysis, before starting the treatment on a patient. Findings include: The following was observed while the personnel were preparing hemodialysis machines for the first and second shift on 02/04/2025 through 02/06/2025 from 8:30 AM through 12:00 PM: 1. On 02/04/2025 at 11:55 AM, registered nurse (RN) observed, performed pH and conductivity test on the hemodialysis machines located at station #2. RN #4 when performing the pH on the machine inserted the strip to reactivate with dialysate pH, but did not perform the back-and-forth motion for one second and did not wait ten seconds to perform the pH reading. 2. On 02/06/2025 at 10:08 AM, registered nurse (RN) observed, performed pH and conductivity test on the hemodialysis machines located at station #2. RN #5 when performing the pH on the machine inserted the strip to reactivate with dialysate pH, but did not perform the back-and-forth motion for one second and did not wait ten seconds to perform the pH reading. 3. On 02/06/2025 at 10:12 AM, registered nurse (RN) observed, performed pH and conductivity test on the hemodialysis machines located at station #2. RN #6 when performing the pH on the machine inserted the strip to reactivate with dialysate pH, but did not perform the back-and-forth motion for one second and did not wait ten seconds to perform the pH reading. 4. The facility failed to ensure that the registered nurses perform the pH of the dialysate correctly.”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 47384 Based on a ESRD Core recertification survey and observations made of the treatment area on 02/08/2025, it was determined that the facility failed to monitor the building in which dialysis services are furnished and maintained to ensure the safety of the patients, the staff and the public. Findings include: 1. Water damage was observed on the wall of Unit I between station 2 and station 3. 2. Water damage was observed on the wall on the entrance of Unit II (anex) near entrance door.”

“PE-PT CARE ENVIRONMENT-SUFFICIENT SPACE CFR(s): 494.60(c)(1) The space for treating each patient must be sufficient to provide needed care and services, prevent cross-contamination, and to accommodate medical emergency equipment and staff. 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 02/04/2025 from 9:00 AM through 12:00 PM, it was determined that the facility failed to provide sufficient space for treating each patient and to provide needed care and services, prevent cross-contamination, and to accommodate medical emergency equipment and staff. Findings include: Station #9 is located next to the wall, approximately 18 inches from the wall near the nurse station hand wash.”

“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 an unnuanced ESRD Core Survey, observations conducted on unit one in the company of clinical coordinator employee #11, it was determined that the facility failed to ensure that patients receive treatment in a manner that allow staff to have full view of patients access site for the first and second shift during on 02/04/2025 from 8:30AM through 3:00 PM at patients stations #10, #12, #15. This deficient effect 3 out of 23 patients observed receiving treatment. Findings include: During the observations made in the treatment area on 02/04/2025, the following was found: 1. On 02/4/2025 at 9:31 AM, the patient was located on station # 10, it was observed that the vascular access was covered with sheets. 2. On 02/4/2025 at 1:16 PM, the patient was located on station #12, it was observed that the vascular access covered with sheets. 3. On 02/4/2025 at 9:32 AM, the patient was located on station # 15, it was observed that the vascular access covered with sheets. 4. The facility failed to ensurethat vascular access sites are seen by staff members during all dialysis treatment. Allowing patients to cover access provides an opportunity for accidents of needle dislodgement or line disconnection and could result in bleeding or death.”

“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 a ESRD Core recertification survey and observations made of the treatment area and emergency exit routes on 02/05/2025 through 02/06/2025, it was determined that the facility failed to comply with some fire safety requirements. Findings include: 1. Two fire extinguishers were observed bloked by medical equipment not contemplating the 36 inches of clearance established by code NFPA 10 (Standard for Portable Fire Extinguishers), which states that fire extinguishers access can not be blocked by any object. 2. On 02/05/2025 at approximately 2:00 PM, it was observed on the emergency access of Unit I did not have an illuminated exit sign with a directional signal (rumbo) or emergency lights. The fire door of this exit access was observed to be in poor condition, which does not ensure the integrity of the fire barrier. Once outside (exit discharge), a service staircase was observed obstructing the free exit to the outside. 3. On 02/05/2025 at approximately 2:30 PM, it was observed on the emergency access of Unit II (Anex) that the door leading to the exit access does not allow the evacuation of the bariatric chair or wheelchair through the access door to the exit hallway. The hallway towards the exit was observed with obstacles left by occupants of neighboring businesses (cardboard boxes, paint buckets, kitchen utensils, hose). The floor surface prior to the emergency exit door presents an unevenness which may represent a risk of falling and prevent the wheelchair or treatment chair from moving freely. The ramp to the outside (exit discharge) does not comply with the 36-inch wide measurement established by NFPA 101 and NFPA 99. The observations were accepted by the facility engineer (employee #8)”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 47632 Based on policies, procedure reviewed, and 11 records reviewed (RR) on 02/05/2025 through 02/06/2025, it was determined that the facility failed to ensure monitor and document the patients’ blood pressure (B/P) and document nurse action when patient present hypotension and/or hypertension during dialysis treatment for 7 out of 11 records reviewed (R.R #1, #2, # 3, #4, #6, #7 and #9). Findings include: 1. R.R #1 is a 54-year-old male admitted to the facility on 03/29/2024 with a diagnostic End Stage Renal Disease. During the record review performed on 02/05/2025 at 2:23 PM, the hemodialysis treatment three a week for four hours, Dializaer 180 NRE ELEC-BEAM, Blood Flow Rate (BFR) of 400, Dialysis Flow Rate (DFR) of 800 and Patient Dry Weight (EDW) of 104.3 kilograms (kg). a. On 01/27/2025 at 4:40 PM, it was revealed that the Blood Pressure (BP) was 189/89mg/Hg, at 4:45 PM the BP was 180/86mg/Hg, and 5:32 PM the BP was 181/95mg/Hg. b. On 02/03/2025 at 8:10 PM, it was revealed that the BP was 85/54mg/Hg and at 8:11 PM the BP was 82/50 mg/Hg. 2. R.R #3 is a 58-year-old male admitted to the facility on 04/15/2024 with a diagnostic End Stage Renal Disease. During the record review performed on 02/05/2025 at 3:33 PM, the hemodialysis treatment three a week for four hours, Dializaer 160 NRE ELEC-BEAM, Blood Flow Rate (BFR) of 400, Dialysis Flow Rate (DFR) of 800 and Patient Dry Weight (EDW) of 61 kilograms (kg). a. On 01/30/2025 at 5:03 PM, it was revealed that the BP was 87/59mg/Hg. 3. R.R #6 is a 57-year-old male admitted to the facility on 10/01/2024 with a diagnostic End Stage Renal Disease. During the record review performed on 02/06/2025 at 9:40 AM, the hemodialysis treatment three a week for four hours, Dializaer 180 NRE ELEC-BEAM, Blood Flow Rate (BFR) of 350, Dialysis Flow Rate (DFR) of 600 and Patient Dry Weight (EDW) of 105 kilograms (kg). a. On 01/28/2025 at 11:32 AM, it was revealed that the BP was 150/93mg/Hg and at 2:01 PM the BP was 133/91mg/Hg. b. On 01/30/2025 at 10:35 AM, it was revealed that the BP was 147/92mg/Hg. 4. R.R #7 is an 87-year-old male admitted to the facility on 10/01/2024 with a diagnostic End Stage Renal Disease. During the record review performed on 02/06/2025 at 10:39 AM, the hemodialysis treatment three a week for four hours, Dializaer 160 NRE ELEC-BEAM, Blood Flow Rate (BFR) of 350, Dialysis Flow Rate (DFR) of 500 and Patient Dry Weight (EDW) of 80 kilograms (kg). a. On 01/21/2025 at 6:10 AM, it was revealed that the BP was 138/47mg/Hg. b. On 01/25/2025 at 8:03 AM, it was revealed that the BP was 168/78mg/Hg. c. Onn 01/28/2025 at 5:50 AM, it was revealed that the BP was 169/66 mg/Hg. 5. R.R #9 is an 83-year-old male admitted to the facility on 03/28/2023 with a diagnostic End Stage Renal Disease. During the record review performed on 02/06/2025 at 9:08 AM, the hemodialysis treatment three a week for four hours, Dializaer 160 NRE ELEC-BEAM, Blood Flow Rate (BFR) of 350, Dialysis Flow Rate (DFR) of 500 and Patient Dry Weight (EDW) of 105 kilograms (kg). a. On 01/23/2025 at 4:01 PM, it was revealed that the BP was 131/91mg/Hg. b. On 01/25/2025 at 4:01 PM, it was revealed that the BP was 140/97mg/Hg. c. On 01/28/2025 at 3:10 PM, it was revealed that the BP was 147/92mg/Hg. d. On 02/01/2025 at 2:40 PM, it was revealed that the BP was 179/110mg/Hg, at 2:45 PM, the BP was 178/109mg/Hg, at 3:02 PM, the BP was 163/109mg/Hg and at 3:32 PM, the BP was 179/106mg/Hg. No evidence was found of nursing interventions or documentation for hypertension or hypotension. 17959 6. R.R #2 is a 73-year-old female admitted to the facility on 12/02/2024 with a diagnostic End Stage Renal Disease. During the record review performed on 02/05/2025 at 2:15 PM, the hemodialysis treatment three a week for three hours, Dializaer 160 NRE ELEC-BEAM (Filter), Blood Flow Rate (BFR) of 350, Dialysis Flow Rate (DFR) of 500 and Patient Dry Weight (EDW) of 49.50 kilograms (kg). a. On 01/05/2025 at 3:20 PM, it was revealed that the Blood Pressure (BP) was 182/81mg/Hg and at 3:25 PM the BP was 182/85mg/Hg. b. On 01/28/2025 at 8:10 PM, it was revealed that the BP was 189/98mg/Hg, at 5:02 PM the BP was 172/96 mg/Hg. and at 6:32 PM the BP was 93/50. at 4:04 PM, 4:13 PM, 4:52 PM, 5:02 PM, 6:02 PM, 7:26 PM and 7:27 PM provide evidence that the machine reveled “ ALERT: Blood Pressure “ per seven times. c. On 01/30/2025 at 3:10 PM, it was revealed that the BP was 184/87 mg/Hg.and at 3:15 PM the BP was 171/87 mg/Hg. and at 3:10 PM, 3:15 PM, 4:00 PM and 4:30 PM provide evidence that the machine reveled “ ALERT: Blood Pressure “ per four times. d. No evidence was found of nursing interventions or documentation for hypertension or hypotension. 7. R.R #4 is a 67-year-old male admitted to the facility on 04/05/2024 with a diagnostic End Stage Renal Disease. During the record review performed on 02/05/2025 at 3:30 PM, the hemodialysis treatment three a week for four hours, Dializaer 200 NRE ELEC-BEAM, Blood Flow Rate (BFR) of 400, Dialysis Flow Rate (DFR) of 800 and Patient Dry Weight (EDW) of 108.50 kilograms (kg). Access:N Type: Graft Curved Lrft Upper Arm. a. On 01/24/2025 at 18:06 PM, it was revealed that the BP was 98/55 mg/Hg. and at 18:20 PM the BP was 104/55 mg/Hg. No evidence was found of nursing interventions or documentation for hypotension, ended the treatmnt and no evidence if the nurse took the manual B/P. b. On 02/03/2025 at 15:20 PM, the patient iniciated the hemodalysis treatment it was revealed that the BP was 118/51 mg/Hg. and at 15:22 PM the BP was 888/8 mg/Hg., at 15:25 the B/P 110/51, at 15:26 the BP was 88/888 mg/Hg., at 15:27 PM the BP was 888/888 mg/Hg., at 15:28 the B/P 8/80, at 15:29 the B/P 88/8 mg/Hg., at 15:30 PM the BP was 116/69 mg/Hg., at 15:31 the B/P 888/88, at 15:32 the BP was 116/869 mg/Hg., at 15:33 PM, 15:34 and 15:35 the BP was 888/888 mg/Hg., at 15:36 the B/P 888/8, at 15:37 the B/P 88/88, at 15:38 and 1539 the B/P 88/888, at 15:40 the B/P 888/880, at 15:41 the B/P 888/888, at 15:42 the B/P 808/88, at 15:47 and 15:48 the B/P 80/ , at 15:50 the B/P 888/8, at 15:51 the B/P 8/888, at 15:52 the B/P 8/., at 16:02 the B/P 115/80, at 16:31 the B/P 133/78, at 17:03 the B/P 126/71, at 17:32 the B/P 126/70, at 18:08 the B/P 123/72, at 18:34 the B/P 139/74, at 19:03 the B/P 106/63 and at 19:20 the B/P was 137/79. c. According with the patient hemodialysis flowsheet treatment the patient ended the treatment at 19:20, however the hemodyalisis treatment flowsheet provide evidence that until the hour of 15:20 till 19:20 per thyity four times (34) the DFR was maintain in 800. d. The heemodialysis flowsheet provide evidence that the machine reveled “ ALERT: Blood Pressure “ per twenty four times (24). e. The heemodialysis flowsheet provide evidence that the machine reveled “ ERROR “ per twenty three times (23). f. No evidence when the Nurse notified the Biothchnitian to review and change the hemodialysis machine. g. No evidence when the Nurse notified the Physician related to the machine inestability problem. h. No evidence when the Nurse documented this situation related to the machine inestability problem.”

“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: 47632 Based on an unnuanced ESRD Core Survey, procedure reviewed, and 11 records reviewed (RR) on 02/05/2025 through 02/06/2025, it was determined that the facility failed to follow physician’s orders in the Blood Flow Rate (BFR) and Dialysate Flow Rate (DFR) during dialysis treatment and documentation in the management of the patients BFR and DFR 4 out of 11 records reviwed (R.R #1, #3, #4 and #6). Findings include: 1. R.R #1 is a 54-year-old male admitted to the facility on 03/29/2024 with a diagnostic End Stage Renal Disease. During the record review performed on 02/05/2025 at 2:23 PM, the hemodialysis treatment three a week for four hours, Dializaer 180 NRE ELEC-BEAM, Blood Flow Rate (BFR) of 400, Dialysis Flow Rate (DFR) of 800 and Patient Dry Weight (EDW) of 104.3 kilograms (kg). a. On 01/29/2025 at 4:35 PM, 4:40 PM, 5:02 PM, 5:32 PM, 6:02 PM, 6:32 PM, 7:02 PM, 7:03 PM, 7:32 PM, 8:02 PM and 8:35 PM the DFR was decreased to 500. 2. R.R #3 is a 58-year-old male admitted to the facility on 04/15/2024 with a diagnostic End Stage Renal Disease. During the record review performed on 02/05/2025 at 3:33 PM, the hemodialysis treatment three a week for four hours, Dializaer 160 NRE ELEC-BEAM, Blood Flow Rate (BFR) of 400, Dialysis Flow Rate (DFR) of 800 and Patient Dry Weight (EDW) of 61 kilograms (kg). a. On 01/25/2025 at 1:25 PM, 1:33 PM, 2:02 PM, 2:34 PM, 3:34 PM, 4:03 PM, 4:08 PM, 4:32 PM, 5:02 PM, 5:32 PM, 6:02 PM and 6:20 PM the DFR was decreased to 500 and 1:25 PM, 1:33 PM, 2:02 PM, 2:34 PM, 3:34 PM, 4:03 PM, 4:08 PM, 4:32 PM, 5:02 PM, 5:32 PM, 6:02 PM and 6:20 PM the BFR was decreased to 350. b. On 02/03/2025 at 11:30 AM, 12:01 PM, 12:30 PM, 1:00 PM, 1:30 PM, 2:00 PM and 2:30 PM the decrease BFR to 350. 3. R.R #6 is a 57-year-old male admitted to the facility on 10/01/2024 with a diagnostic End Stage Renal Disease. During the record review performed on 02/06/2025 at 9:40 AM, the hemodialysis treatment three a week for four hours, Dializaer 180 NRE ELEC-BEAM, Blood Flow Rate (BFR) of 350, Dialysis Flow Rate (DFR) of 600 and Patient Dry Weight (EDW) of 105 kilograms (kg). a. On 01/25/2025 at 11:05 AM, 11:10 AM, 11:32 AM, 12:02 PM, 12:33 PM, 1:02 PM, 1:32 PM, 2:02 PM, 2:32 PM, 3:02 PM and 3:05 PM the decreased to 500. No evidence was found of the justification on the nurse note or authorized decrease from the physicians. 17959 4. R.R #4 is a 67-year-old male admitted to the facility on 04/05/2024 with a diagnostic End Stage Renal Disease. During the record review performed on 02/05/2025 at 3:30 PM, the hemodialysis treatment three a week for four hours, Dializaer 200 NRE ELEC-BEAM, Blood Flow Rate (BFR) of 400, Dialysis Flow Rate (DFR) of 800 and Patient Dry Weight (EDW) of 108.50 kilograms (kg). Access:N Type: Graft Curved Lrft Upper Arm. a. According with the patient hemodialysis flowsheet treatment the patient ended the treatment at 19:20, however the hemodialysis treatment flowsheet provide evidence that until the hour of 15:20 till 19:20 per thirty-four times (34) the DFR was maintain in 800.”