Dci Jackson

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 33763 Based on facility policy review, observation, and interview, the facility failed to ensure adequate Infection control measures were taken to ensure patient safety and a clean and sanitary environment. The findings included: 1. The facility failed to ensure expired supplies were disposed of and failed to ensure supplies were stored in a sanitary environment. Refer to V111 2. The facility failed to ensure hand hygiene was performed per faciity policy on the treatment floor. Refer to V113 3. The facility failed to ensure dialysis machines and stations were adequately cleaned to prevent cross-contamination. Refer to V122 4. The facility failed to ensure expired medications were disposed of and not readily available for use on the treatment floor. Refer to V143 5. The facility failed to ensure measures to prevent CVC related infections were performed during CVC exit site care, initiation of hemodialysis via a CVC, and discontinuation of hemodialysis via CVC. Refer to V147”

“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: 49570 Based on facility policy review, observation and interview, the facility failed to ensure expired supplies were not available for use in 6 of 7 (medication storage area [1-12 side] and [13-25 side], crash cart, lab, Peritoneal Dialysis supply storage area, and warehouse) supply storage areas observed and failed to ensure infection control measures were taken to provide a sanitary environment in 1 of 7 [supply closet] supply storage areas. The findings included: 1. Review of the facility policy titled “Crash Cart” revised 12/2021 revealed, “...The crash cart checklist will be completed monthly (1st Monday of the month, if applicable) to verify that all medications and supplies are on hand and within date; not expired...” Review of the facility policy titled “Work Day Inventory Policy” revised January 2025 revealed, “...1. When performing inventory counts, expiration dates will be monitored, and appropriate staff notified when approaching expiration date so that stock can be replenished...2. Expired stock should not be available for use and should be discarded...” Review of the facility policy titled “Standard Practices for Hemodialysis Units” last revised January 2025 revealed, “...Staff members should not eat, drink, or apply makeup in the dialysis treatment area or in the lab, warehouse, RO room, bicarb mix room...Personal items of employees (cell phones, purses, drink containers, etc) must be stored in lockers or the breakroom...) 2. Observations on 1/27/2025 at 8:45 AM in the medication storage area (1-12 side) revealed seven (7) 3mL syringes with attached 23Gauge needle with an expiration date of 5/31/2024. Observations on 1/27/2025 at 9:02 AM in the medication storage area (13-25 side) revealed fifteen (15) 3mL syringes with attached 23Gauge needle with an expiration date of 5/31/2024. Observations on 1/27/2025 at 9:03 AM in the crash cart revealed six (6) 3mL syringes with attached 23Gauge needle with an expiration date of 5/31/2024. During an interview on 1/27/2025 at 9:03 AM, RN #3 confirmed the above supplies were expired. 3. Observations on 1/27/2025 at 9:18 AM in the lab revealed fifty (50) S-monovette 92x15mm lab supplies with an expiration date of 3/31/2023. During an interview on 1/27/2025 at 9:18 AM, RN #2 confirmed the lab supplies were expired. 4. Observations on 1/27/2025 at 3:13 PM in the peritoneal dialysis supply storage area revealed sixty-six (66) 4.0 mL yellow top Vacutainers for blood collection with an expiration date of 12/31/2024. Observations on 1/27/2025 at 3:15 PM in the peritoneal dialysis supply storage area revealed two (2) packs of size 7 sterile gloves with an expiration date of 7/2024. Observations on 1/27/2025 at 3:15 PM in the peritoneal dialysis supply storage area revealed three (3) Chlorhexidine Gluconate and Isopropyl Alcohol swabs with an expiration date of 10/2022. Observations on 1/27/2025 at 3:28 PM in the peritoneal dialysis supply storage area revealed one (1) 1 mL syringe with attached 27Gauge needle with an expiration date of 11/30/2023. During an interview on 1/27/2025 at 3:15 PM, the NM and RN #4 confirmed the peritoneal dialysis supplies were expired. 5. Observations on 1/27/2025 at 3:36 PM in the warehouse revealed one (1) bottle of ultrasound gel with an expiration date of 3/2021. Observations on 1/27/2025 at 3:40 PM in the warehouse revealed a box containing two hundred and fifty (250) 16Gauge hemodialysis needle sets with an expiration date of 12/31/2024. During an interview on 1/27/2025 at 3:40 PM the Equipment Technician confirmed the warehouse supplies were expired. 6. Observations on 1/27/2025 at 9:09 AM in the supply closet revealed one opened half eaten protein bar and wrapper laying on the top shelf of storage shelving. During an interview on 1/27/2025 at 9:13 AM RN #2 confirmed that the protein bar was there and confirmed that it was not appropriate for anyone to be eating in the supply closet. During an interview on 1/29/2025 at 11:27 AM, the NM confirmed that no one should be eating on the floor or in stock rooms.”

“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: 33763 Based on facility policy review, observation and interview, the facility failed to ensure hand hygiene was performed according to facility policy to prevent the spread of infectious bacteria by 2 of 8 (LPN#1 and CCHT #2) staff observed on the treatment floor. The findings included: 1. Review of the facility policy titled, “Hand Antisepsis” dated August 2014 revealed, “...Hand Antisepsis will be followed per CDC guidelines...Use of an alcohol based rub may be done in the following instances...After handling of equipment, supplies, or environmental surfaces at the patient station. Before patient contact. Before putting on gloves...After removal of gloves...” 2. Observations on 1/27/2025 at 9:18 AM on the treatment floor at Station #13, revealed LPN #2 discontinuing dialysis on RP #1. LPN #2 performed hand hygiene, donned gloves and placed the supplies on the chairside table. LPN #2 moved the Patient’s walker and belongings away from the treatment station. Without removing the gloves and performing hand hygiene, LPN #2 opened 2 pre-filled syringes, removed the caps and laid them on top of a glove on the chairside table. LPN #2 failed to remove the gloves and perform hand hygiene after touching the Patient’s walker and before opening clean supplies. 3. Observations on 1/27/2025 at 10:00 AM on the treatment floor at Station #10, revealed CCHT #2 cleaning the dialysis station. CCHT #2 emptied the prime waste bucket while wearing gloves, wiped down the outside of the prime waste bucket, and returned to the dialysis machine. CCHT #2 continued cleaning the dialysis machine without performing hand hygiene after emptying the prime waste bucket. 4. During an interview on 1/29/2025 at 11:27 AM, the NM verified staff should perform hand hygiene “All of the time.” The NM verified staff should remove gloves, perform hand hygiene, and don clean gloves after handling dirty items, before handling clean supplies, and after emptying and cleaning the prime waste bucket, and before continuing to clean the dialysis machine.”

“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: 33763 Based on facility policy review, observation, and interview, the facility failed to ensure dialysis stations were fully disinfected between patients by 1 of 2 (CCHT #2) staff members observed and failed to ensure contaminated objects were not put on tops of dialysis machines on 1 of 2 (10/27/2025) observation days. The findings included: 1. Review of the facility policy titled “Standard Practices for Hemodialysis Units” last revised January 2025 revealed, “...Clean and disinfect the dialysis station (e.g., chairs, beds, tables, machines) between patients...Clean the tops of machines and do not place any contaminated objects on top of the dialysis machine. Clean the entire station (chair/machine/ancillary equipment)...Chair will be fully reclined with all external front-facing and side chair surfaces, including seat cushions, and tops of side tables, cleansed with a 1% bleach solution of bleach and water...” 2. Observations on 1/27/2025 at 9:25 AM on the treatment floor at Staion #6, revealed two 3mL syringes with attached needle and half filled with a clear liquid laying on top of the dialysis machine. 3. Observations on 1/27/2025 at 9:50 AM on the treatment floor, revealed CCHT#2 disinfecting Station #9. CCHT #2 failed to clean the internal and external surfaces of the prime waste bucket. 4. Observations on 1/27/2025 at 10:00 AM on the treatment floor, revealed CCHT #2 disinfecting Station #10. CCHT #2 failed to clean the inside of the prime waste bucket and failed to open and clean the chair footrest. 5. During an interview on 1/29/2025 at 11:27 AM, the NM stated the syringes could be left on top of the dialysis machines because they were considered clean.”

“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: 49570 Based on facility policy review, observation and interview, the facility failed to ensure expired medications were not available for use and/or labeled correctly in 4 of 6 (medication storage area [1-12 side] and [13-25 side], medication refrigerator [13-25 side], and Peritoneal Dialysis medication storage area) medication storage areas observed. The findings included: 1. Review of the facility policy titled, “Disposal of Expired or Wasted Non-Narcotic Medications” issued 5/2017 revealed, “PROCEDURE: 2. Expiration dates on all medication will be noted on the inventory worksheet...KEY POINTS: 2. Physically checking and documenting the expiration dates will serve as a monthly reminder to be prepared to dispose of expired meds and have new meds ordered/received before the expiration date...” Review of facility policy titled, “Heparin” issued 7/1998 revealed, “...1. Heparin labels will be printed each day to ensure the correct Heparin dose is given...4. Time/Date/Initial will be noted on each Heparin 1000u/ml multi-dose vials that is opened...” 2. Observations on 1/27/2025 at 8:44 AM in the medication storage area (13-25 side) revealed one unopened Albuterol Sulfate inhaler with an expiration date of 8/2024. During an interview on 1/27/2025 at 9:00 AM, RN #3 confirmed the Albuterol Sulfate inhaler was expired. 3. Observations on 1/27/2025 at 3:30 PM in the Peritoneal Dialysis medication storage area revealed four syringes of darbepoetin alfa 10 mcg/0.4mL with an expiration date of 12/2024. During an interview on 1/27/2025 at 3:30 PM, RN #4 confirmed the darbepoetin alfa vials were expired. 4. Observations on 1/27/2025 at 8:44 AM in the medication storage area (1-12 side) revealed one heparin 30,000 units per 30 mL multi-dose vial opened and unlabeled. During an interview on 1/27/2025 at 8:45 AM, RN #3 confirmed the heparin was not labeled, and stated it should be labeled with the date and time opened, along with the initials of staff member opening the medication. 5. Observations on 1/27/2025 at 8:52 AM in the medication refrigerator (13-25 side) revealed one syringe of Mircera 50 mcg/0.3 mL opened and unlabeled. During an interview on 1/27/2025 at 8:53 AM, the NM confirmed the Mircera did not have a label on it with the date and time opened, and the initials of the staff member who opened it. He verified the medication should have been labeled per facility policy.”

“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: 33763 Based on facility policy review, observation, and interview, the facility failed to ensure measures to prevent CVC related infections were followed for 1 of 5, (Patient #10) sampled patients with a CVC and by 4 of 4 (LPN #2, RN #1, LPN #1, and RN #3) nurses observed on the treatment floor. The findings included: 1. Review of the facility policy titled, “Central Venous Catheter: Exit Site Care” revised 10/2018 revealed, “...To improve patient outcome, strategies must be implemented to reduce the incidence of catheter-related infections. CVC exit site care must be completed prior to initiation of the hemodialysis procedure...” Review of the facility policy titled, “CVC: Accessing with Closed System Connections” revised 10/2018 revealed, “...Closed system connectors are attached to both the arterial and venous hubs of the CVC. These connectors are left in place during hemodialysis and also throughout the next week...Closed system connectors must be changed every seven days...to minimize tracking errors...all closed system connection devices will be changed pre-treatment per patient schedule (Monday or Tuesday)...Whenever the closed system connector is used, a minimum 15 second alcohol pad scrub to the end of the connector is required...Procedure...Place barrier pad underneath CVC lumens 8. Open closed system connector packages and scrub both hubs with alcohol 15 sec each. 9. Aseptically attach Heparin bolus to one and 10 cc NS flush to the other...Remove bridge tape from port connection 9. Scrub port connection (arterial and venous) with alcohol prep pad; cleanse for minimum of 15 seconds...11. Remove exisitng caps...12. The catheter ends are now open and exposed, ensure that the CVC is held so that contamination does not occur. 13. Scrub each exterior hub with new alcohol prep pad for a minimum 15 seconds...Post-treatment...Before detaching blood lines rinseback/treatment termination - remove bridgetape from arterial port, scrub external connection between closed system connector and bloodline...Perform rinse back per policy...Discard gloves; sanitize hands 4. Don clean gloves...Flush both arterial and venous lumens with 10 ml saline...” 2. Medical record review for Patient #10 revealed an admission date of 2/27/2023 with diagnoses which included Type 2 Diabetes Mellitus with End Stage Renal Disease. Review of the physician’s order dated 12/23/2024 revealed Patient #10 was to receive hemodialysis treatments via CVC three times a week. Review of the Hemodialysis Flowsheet dated 1/13/2025 revealed no documentation CVC exit site care was completed, and no documentation the closed system connectors were changed. Review of the Hemodialysis Flowsheet dated 1/20/2025 revealed no documentation CVC exit site care was completed, and no documentation the closed system connectors were changed. During an interview on 1/28/2025 at 1:01 PM, the NM stated CVC exit site care should be performed and closed system connectors should be changed before initiation of treatment every Monday or Tuesday. 3. Observations on 1/27/2025 at 9:18 AM on the treatment floor at Station #13, revealed LPN #2 discontinuing dialysis via CVC on RP #1. LPN #2 performed hand hygiene, donned gloves and placed the supplies on the chairside table. LPN #2 moved the Patient’s walker and belongings away from the treatment station. Without removing the gloves and performing hand hygiene, LPN #2 opened 2 pre-filled syringes, removed the caps and laid them on top of a glove on the chairside table, leaving the syringes open to air. LPN #1 removed the gloves, performed hand hygiene and donned new gloves, disconnected the arterial line and used the opened syringe of saline to flush the arterial line, then began the rinse-back cycle. At the completion of the rinseback cycle, LPN #2 disconnected the venous line and used the remaining opened syringe of saline to flush the venous line. LPN #2 failed to remove the gloves and perform hand hygiene after touching the Patient’s walker, and failed to ensure aseptic technique was used by placing open syringes directly on a glove on the chairside table prior to use. During an interview on 1/28/2025, the NM verified gloves should be changed and hand hygiene performed after touching contaminated objects and before performing patient care. When asked if it was acceptable to open syringes, then lay them on a glove on the chairside table, the NM stated, “We teach them to hold them” until ready for use. 4. Observations on 1/27/2025 at 10:15 AM on the treatment floor at Station #21, revealed RN #1 performing CVC exit site care and initiation of dialysis to Random Patient #16. RN #1 failed to change the CVC exit site dressing prior to initiation of treatment, failed to change the CVC closed system connectors prior to initiation of treatment, and was observed cleaning the CVC closed system connectors with an alcohol prep pad for less than 4 seconds instead of at least 15 seconds per facility policy prior to connecting the sterile syringes to each closed system connector for initiation of treatment. Observations on 1/27/2025 at 2:31 PM on the treatment floor at Station #21 Revealed RN #1 discontinuing dialysis via CVC on RP #16. The CVC dressing appeared to have been changed and was dated 1/27/2025. RN #1 scrubbed the closed system connectors less than 4 seconds instead of at least 15 seconds per facility policy prior to connecting the sterile syringes. During an interview on 1/27/2025 at 2:31 PM, RN #1 stated she changed RP #16’s CVC dressing, performed exit site care, and changed the CVC closed system connectors, “right after lunch.” (Note: The Hemodialysis Flowsheet dated 1/27/2025 revealed RN #1 documented changing the catheter caps (closed system connectors) and performing access dressing change (exit site care) at 12:31 PM. The flowsheet further revealed the treatment was initiated at 10:39 AM and ended at 2:35 PM.) During an interview on 1/28/2025 at 1:01 PM, the NM stated CVC exit site care and closed system connectors should be changed before initiation of treatment every Monday or Tuesday. When asked if the closed system connectors should be changed during the treatment, the NM stated, the only way to change them after the treatment was started, was to stop the treatment and disconnect the lines. 5. Observations on 1/27/2025 at 10:50 AM on the treatment floor at Station #9, revealed LPN #1 initiating dialysis via CVC on Patient #7. After completing CVC exit site care and dressing change, LPN #1 performed hand hygiene and donned gloves. LPN #1 removed the closed system connectors from the arterial and venous limbs, then laid the uncapped catheter hubs directly on the moisture proof barrier leaving them open to air. LPN #1 scrubbed the catheter hubs with alcohol per policy, then placed new closed system connectors on the hubs and completed the procedure per policy. LPN #1 placed uncapped catheter hubs directly on the moisture proof barrier placing Patient #7 at increased risk for CVC related infection. During an interview on 1/28/2025 at 1:01 PM, the NM stated staff are taught to hold the catheter lumens in their hand when changing the closed system connectors. The NM stated the “caps [catheter hubs] should never touch the barrier.” 6. Observations on 1/27/2025 at 11:13 AM on the treatment floor at Station #22, revealed RN #3 performing CVC exit site care and initiation of dialysis to Random Patient #6. RN #3 failed to change the CVC exit site dressing prior to initiation of treatment, failed to change the CVC closed system connectors prior to initiation and at end of treatment, and was observed cleaning the CVC closed system connectors with an alcohol prep pad for 5 seconds instead of at least 15 seconds per facility policy prior to connecting the sterile syringes to each closed system connector for initiation of treatment. During an interview on 1/27/2025 at 2:45 PM, RN #3 revealed the CVC exit site dressing had been changed during the hemodialysis treatment because to RN #3’s knowledge the dressing can be changed “before, during, or after treatment.” 7. During an interview on 1/28/2025 at 1:01 PM, the NM stated CVC exit site care and closed system connectors should be changed before initiation of treatment every Monday or Tuesday. When asked if the closed system connectors should be changed during the treatment, the NM stated, the only way to change them after the treatment was started, was to stop the treatment and disconnect the lines. The NM was asked how closed system connectors should be cleaned. The NM stated they should be scrubbed with alcohol swabs for at least 15 seconds.”

“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: 33763 Based on facility policy review, observation and interview, the facility failed to ensure visibility of hemodialysis access sites during treatment on 1 of 2 (1/27/25) observation days. The findings included: 1. Review of the facility policy titled “INITIATION OF HEMODIALYSIS TREATMENT FOR AVF/AVG AND CVC” revised 11/10/16 revealed, “...Insures Access and bloodline connection is visible...Visualizing access and bloodline connections at all times help decrease the risk of complications and early intervention if needed...” 2. Observations on 1/27/2025 beginning at 8:23 AM on the treatment floor at Station #8 revealed RP #10 receiving hemodialysis. RP#10’s hemodialysis access site remained covered and not visible from 8:23 AM until 9:34 AM. 3. Observations on 1/27/2025 beginning at 8:23 AM on the treatment floor at Station #9 revealed RP #11 receiving hemodialysis. RP#11’s hemodialysis access site remained covered and not visible from 8:23 AM until 9:34 AM. 4. Observations on 1/27/2025 beginning at 8:24 AM on the treatment floor at Station #5 revealed RP #9 receiving hemodialysis. RP#9’s hemodialysis access site remained covered and not visible from 8:24 AM until 9:34 AM. 5.Observations on 1/27/2025 beginning at 8:24 AM on the treatment floor at Station #2 revealed RP #8 receiving hemodialysis. RP#8’s hemodialysis access site remained covered and not visible from 8:23 AM until 9:34 AM. 6. Observations on 1/27/2025 beginning at 8:25 AM on the treatment floor at Station #14 revealed RP #12 receiving hemodialysis. RP#12’s hemodialysis access site remained covered and not visible from 8:23 AM until 9:34 AM. 7.Observations on 1/27/2025 beginning at 8:28 AM on the treatment floor at Station #23 revealed RP#7 receiving hemodialysis. RP#7’s hemodialysis access site remained covered and not visible from 8:28 AM until 9:50 AM. During these observations, RP#7 became nauseated, and RN #1 went to the Patient’s chairside. RN #1, then left the Patient’s chairside, obtained ordered anti-nausea medication, returned to the chairside and administered the medication. RN #1 failed to identify the Patient’s access was covered, failed to remove the Patient’s blanket to visualize the access site, and failed to instruct the Patient to keep the access site visible. 8. Observations on 1/27/2025 beginning at 8:30 AM on the treatment floor at Station #20 revealed RP #13 receiving hemodialysis. RP#13’s hemodialysis access site remained covered and not visible from 8:30 AM until 8:40 AM. 9. Observations on 1/27/2025 beginning at 8:30 AM on the treatment floor at Station #19 revealed RP #14 receiving hemodialysis. RP#14’s hemodialysis access site remained covered and not visible from 8:30 AM until 8:40 AM. 10. Observations on 1/27/2025 beginning at 8:30 AM on the treatment floor at Station #15 revealed RP #15 receiving hemodialysis. RP#15’s hemodialysis access site remained covered and not visible from 8:30 AM until 8:40 AM. 11. During an interview on 1/29/2025 at 11:30 AM, the NM stated hemodialysis access sites should be uncovered and visible at all times. The NM continued and stated if patients refused to keep their access site uncovered, staff should document their refusal.”

“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: 33763 Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure facility policies and physician’s orders for Heparin and/or BFR were followed for 6 of 6 (Patient #5, #6, #7, #8, #9, and #10) sampled in-center hemodialysis patients. The findings included: 1. Review of the facility policy titled, “Heparin” revised 7/1998, revealed, “To provide guidelines on preparing and administering Heparin to hemodialysis patients correctly and safely...SUPPORTIVE DATA...Peak anticoagulant activity is reached in 5-10 minutes after injection..Administer dose per standing orders or by specific patient order per MD...7. Heparin should be allowed to circulate in the patient a minimum of 5 minutes to allow peak effect before treatment initiation...” Review of the facility policy titled, “Initiation of Hemodialysis Treatment for AVF/AVG and CVC” revised 11/10/2016 revealed, “...Administer the prescribed Heparin bolus: allowing 5 minutes to obtain anticoagulation effect prior to initiation of dialysis...Adjust blood flow rate according to access / physician orders...If unable to obtain ordered BFR, trouble shoot causes and involve CN if needed. Document BFR obtained and efforts/resolution...” 2. Medical record review for Patient #5 revealed an admission date of 6/23/1997 with diagnoses which included Focal Glomerulosclerosis and End Stage Renal Disease. Review of a physician’s order dated 5/6/2024, revealed a heparin loading dose of 3000 units. A physician’s order dated 11/25/2024 revealed a BFR of 350. Review of the Hemodialysis Flowsheet dated 1/1/2025 revealed Patient #5 was administered a heparin loading dose of 3000 units at 6:08 AM. The treatment was started 3 minutes later at 6:11 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Review of the Hemodialysis Flowsheet dated 1/3/2025 revealed Patient #5 was administered a heparin loading dose of 3000 units at 6:10 AM. The treatment was started 3 minutes later at 6:13 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Further review revealed, the BFR was 300 from 6:32 AM until 9:12 AM. There was no documentation stating why the BFR was not delivered at the ordered rate of 350. There was no documentation the physician was notified. Review of the Hemodialysis Flowsheet dated 1/6/2025 revealed Patient #5 was administered a heparin loading dose of 3000 units at 6:20 AM. The treatment was started 3 minutes later at 6:23 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Review of the Hemodialysis Flowsheet dated 1/11/2025 revealed no documentation the heparin loading dose was administered. There was no documentation why the heparin wasn’t administered. Review of the Hemodialysis Flowsheet dated 1/13/2025 revealed Patient #5 was administered a heparin loading dose of 3000 units at 6:08 AM. The treatment was started 3 minutes later at 6:11 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Review of the Hemodialysis Flowsheet dated 1/17/2025 revealed Patient #5 was administered a heparin loading dose of 3000 units at 6:12 AM. The treatment was started 3 minutes later at 6:15 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Review of the Hemodialysis Flowsheet dated 1/20/2025 revealed Patient #5 was administered a heparin loading dose of 3000 units at 6:06 AM. The treatment was started 1 minute later at 6:07 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. 3. Medical record review for Patient #6 revealed an admission date of 11/1/2024 with diagnoses which included Chronic Kidney Disease Stage 5. Review of a physician’s orders dated 11/01/2024 revealed a heparin loading dose of 5000 units and a BFR of 400. Review of the Hemodialysis Flowsheet dated 12/31/2025 revealed Patient #6 was administered a heparin loading dose of 5000 units at 6:53 AM. The treatment was started 3 minutes later at 6:56 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Further review revealed, the BFR was 350 from 6:57 AM until 8:02 AM and 300 from 8:32 AM until 9:51 AM. There was no documentation stating why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified. Review of the Hemodialysis Flowsheet dated 1/2/2025 revealed Patient #6 was administered a heparin loading dose of 5000 units at 7:00 AM. The treatment was started 3 minutes later at 7:03 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Review of the 1/4/2025 Hemodialysis Flowsheet revealed the BFR was 300 from 7:02 AM until 7:32 AM and 350 from 8:02 AM until 9:53 AM. There was no documentation stating why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified. Review of the Hemodialysis Flowsheet dated 1/7/2025 revealed Patient #6 was administered a heparin loading dose of 5000 units at 6:43AM. The treatment was started 3 minutes later at 6:46 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Review of the Hemodialysis Flowsheet dated 1/9/2025 revealed Patient #6 was administered a heparin loading dose of 5000 units at 6:42 AM. The treatment was started 3 minutes later at 6:45 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Review of the Hemodialysis Flowsheet dated 1/11/2025 revealed Patient #6 was administered a heparin loading dose of 5000 units at 7:03 AM. The treatment was started 3 minutes later at 7:06 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Review of the Hemodialysis Flowsheet dated 1/14/2025 revealed Patient #6 was administered a heparin loading dose of 5000 units at 6:46 AM. The treatment was started 3 minutes later at 6:49 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Further review revealed, the BFR was 350 from 6:59 AM until 9:46 AM. There was no documentation stating why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified. Review of the Hemodialysis Flowsheet dated 1/16/2025 revealed Patient #6 was administered a heparin loading dose of 5000 units at 6:36 AM. The treatment was started 3 minutes later at 6:39 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Review of the Hemodialysis Flowsheet dated 1/21/2025 revealed Patient #6 was administered a heparin loading dose of 5000 units at 6:42 AM. The treatment was started 3 minutes later at 6:45 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Review of the Hemodialysis Flowsheet dated 1/23/2025 revealed Patient #6 was administered a heparin loading dose of 5000 units at 6:49 AM. The treatment was started 3 minutes later at 6:52 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Review of the Hemodialysis Flowsheet dated 1/25/2025 revealed Patient #6 was administered a heparin loading dose of 5000 units at 6:54 AM. The treatment was started 3 minutes later at 6:57 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Further review revealed, the BFR was 350 from 7:02 AM until 9:31 AM. There was no documentation stating why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified. 4. Medical record review for Patient #7 revealed an admission date of 3/4/2021 with diagnoses which included Hypertensive Chronic Kidney Disease and End Stage Renal Disease. Review of a physician’s orders dated 11/25/2024 revealed a heparin loading dose of 5000 units. A physician’s ordered dated 10/7/2024 revealed a BFR of 350. Review of the Hemodialysis Flowsheet dated 12/2/2025 revealed Patient #7 was administered a heparin loading dose of 8000 units at 10:36 AM. The treatment was started 3 minutes later at 10:39 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Review of the Hemodialysis Flowsheet dated 12/4/2025 revealed Patient #7 was administered a heparin loading dose of 8000 units at 10:58 AM. The treatment was started 3 minutes later at 11:01 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Review of the Hemodialysis Flowsheet dated 12/9/2025 revealed Patient #7 was administered a heparin loading dose of 8000 units at 10:37 AM. The treatment was started 3 minutes later at 10:40 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Review of the Hemodialysis Flowsheet dated 12/11/2025 revealed Patient #7 was administered a heparin loading dose of 8000 units at 10:41 AM. The treatment was started 3 minutes later at 10:44 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Review of the Hemodialysis Flowsheet dated 12/13/2025 revealed Patient #7 was administered a heparin loading dose of 8000 units at 10:14 AM. The treatment was started 3 minutes later at 10:17 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Review of the Hemodialysis Flowsheet dated 12/20/2025 revealed Patient #7 was administered a heparin loading dose of 8000 units at 10:47 AM. The treatment was started 3 minutes later at 10:50 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Review of the Hemodialysis Flowsheet dated 12/27/2025 revealed Patient #7 was administered a heparin loading dose of 8000 units at 10:35 AM. The treatment was started 3 minutes later at 10:38 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Review of the 1/3/2025 Hemodialysis Flowsheet revealed the BFR was 300 from 12:02 PM until 2:01 PM. There was no documentation stating why the BFR was not delivered at the ordered rate of 350. There was no documentation the physician was notified. Review of the Hemodialysis Flowsheet dated 1/15/2025 revealed Patient #7 was administered a heparin loading dose of 8000 units at 10:45 AM. The treatment was started 3 minutes later at 10:48 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Review of the 1/24/2025 Hemodialysis Flowsheet revealed the BFR was 200 from 11:31 AM until 2:18 PM. There was no documentation stating why the BFR was not delivered at the ordered rate of 350. There was no documentation the physician was notified. 5. Medical record review for Patient #8 revealed an admission date of 11/14/2024 with diagnoses which included Chronic Kidney Disease Stage 5. Review of physician’s order dated 11/1/2024 revealed a BFR of 400. A physician’s order dated 11/19/2024 revealed a heparin loading dose of 5000 units. A physician’s order dated 1/7/2025 revealed the heparin loading dose was increased to 6000 units. Review of the 1/2/2025 Hemodialysis Flowsheet revealed the BFR was 300 from 6:30 AM until 9:30 AM. There was no documentation stating why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified. Review of the Hemodialysis Flowsheet dated 1/4/2025 revealed Patient #8 was administered a heparin loading dose of 5000 units at 6:02 AM. The treatment was started 3 minutes later at 6:05 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Further review revealed, the BFR was 300 from 6:31 AM until 10:01 AM. There was no documentation stating why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified. Review of the Hemodialysis Flowsheet dated 1/7/2025 revealed Patient #8’s treatment was started at 6:27 AM, 1 minute before the heparin loading dose of 5000 units was administered. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Further review revealed, the BFR was 350 from 9:01 AM until 10:30 AM. There was no documentation stating why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified. Review of the Hemodialysis Flowsheet dated 1/9/2025 revealed Patient #8 was administered a heparin loading dose of 6000 units at 6:05 AM. The treatment was started 3 minutes later at 6:08 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Further review revealed, the BFR was 350 from 8:01 AM until 10:01 AM. There was no documentation stating why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified. Review of the Hemodialysis Flowsheet dated 1/11/2025 revealed Patient #8 was administered a heparin loading dose of 6000 units at 7:30 AM. The treatment was started 3 minutes later at 7:33 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Further review revealed, the BFR was 375 from 7:33 AM until 11:31 AM. There was no documentation stating why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified. Review of the Hemodialysis Flowsheet dated 1/14/2025 revealed Patient #8 was administered a heparin loading dose of 6000 units at 6:13 AM. The treatment was started 3 minutes later at 6:16 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Further review revealed, the BFR was 250 from 8:01 AM until 8:30 AM. There was no documentation stating why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified. Review of the Hemodialysis Flowsheet dated 1/16/2025 revealed Patient #8 was administered a heparin loading dose of 6000 units at 6:25 AM. The treatment was started 3 minutes later at 6:28 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Review of the Hemodialysis Flowsheet dated 1/18/2025 revealed Patient #8 was administered a heparin loading dose of 6000 units at 6:07 AM. The treatment was started 3 minutes later at 6:10 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Further review revealed, the BFR was 350 from 8:01 AM until 10:01 AM. There was no documentation stating why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified. Review of the Hemodialysis Flowsheet dated 1/21/2025 revealed Patient #8 was administered a heparin loading dose of 6000 units at 6:19 AM. The treatment was started 3 minutes later at 6:22 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Further review revealed, the BFR was 300 from 7:01 AM until 10:01 AM. There was no documentation stating why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified. Review of the Hemodialysis Flowsheet dated 1/23/2025 revealed Patient #8 was administered a heparin loading dose of 6000 units at 6:18 AM. The treatment was started 3 minutes later at 6:21 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Review of the Hemodialysis Flowsheet dated 1/25/2025 revealed Patient #8 was administered a heparin loading dose of 6000 units at 6:02 AM. The treatment was also started at 6:02 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. 6. Medical record review for Patient #9 revealed an admission date of 2/2/2023 with diagnoses which included Type 2 Diabetes Mellitus with End State Renal Disease. Review of a physician’s order dated 12/23/2024 revealed a BFR of 400, a heparin loading dose of 8000 units, and an hourly dose of 2000 units for four hours. NOTE: Heparin infusion should total 16000 units per treatment per physician orders. Review of the Hemodialysis Flowsheet dated 12/31/2024 revealed Patient #9 was administered a heparin loading dose of 8000 units at 10:49 AM. The treatment was started 3 minutes later at 10:52 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Further review revealed Patient #9 received a total of 14000 units of heparin instead of 16000 units as prescribed. There was no documentation why the Patient was not administered the extra 2000 units of heparin. Continued review revealed, the BFR was 200 from 10:53 AM until 11:01 AM; 350 from 11:01 AM to 12:01 PM; and 300 from 12:31 PM to 2:53 PM. There was no documentation stating why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified. Review of the Hemodialysis Flowsheet dated 1/2/2025 revealed Patient #9 was administered a heparin loading dose of 8000 units at 11:12 AM. The treatment was started 3 minutes later at 11:15 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Further review revealed Patient #9 received a total of 10500 units of heparin instead of 16000 units as prescribed. There was no documentation why the Patient was not administered the extra 5500 units of heparin. Review of the Hemodialysis Flowsheet dated 1/4/2025 revealed Patient #9 was administered a heparin loading dose of 8000 units at 10:59 AM. The treatment was started 3 minutes later at 11:02 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Further review revealed Patient #9 received a total of 12000 units of heparin instead of 16000 units as prescribed. There was no documentation why the Patient was not administered the extra 4000 units of heparin. Review of the Hemodialysis Flowsheet dated 1/7/2025 revealed Patient #9 was administered a heparin loading dose of 8000 units at 10:58 AM. The treatment was started 3 minutes later at 11:01 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Further revealed Patient #9 received a total of 11000 units of heparin instead of 16000 units as prescribed. There was no documentation why the Patient was not administered the extra 5000 units of heparin. Review of the Hemodialysis Flowsheet dated 1/9/2025 revealed Patient #9 was administered a heparin loading dose of 8000 units at 11:06 AM. The treatment was started 3 minutes later at 11:09 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Further review of revealed Patient #9 received a total of 15000 units of heparin instead of 16000 units as prescribed. There was no documentation why the Patient was not administered the extra 1000 units of heparin. Review of the Hemodialysis Flowsheet dated 1/11/2025 revealed Patient #9 was administered a heparin loading dose of 8000 units at 11:00 AM. The treatment was started 3 minutes later at 11:03 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Further review of revealed Patient #9 received a total of 14000 units of heparin instead of 16000 units as prescribed. There was no documentation why the Patient was not administered the extra 2000 units of heparin. Review of the Hemodialysis Flowsheet dated 1/14/2025 revealed Patient #9 was administered a heparin loading dose of 8000 units at 11:16 AM. The treatment was started 3 minutes later at 11:19 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Further review revealed Patient #9 received a total of 15000 units of heparin instead of 16000 units as prescribed. There was no documentation why the Patient was not administered the extra 1000 units of heparin. Review of the Hemodialysis Flowsheet dated 1/16/2025 revealed Patient #9 was administered a heparin loading dose of 8000 units at 11:06 AM. The treatment was started 3 minutes later at 11:09 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Further review revealed Patient #9 received a total of 14000 units of heparin instead of 16000 units as prescribed. There was no documentation why the Patient was not administered the extra 2000 units of heparin. Review of the Hemodialysis Flowsheet dated 1/18/2025 revealed Patient #9 was administered a heparin loading dose of 8000 units at 10:43 AM. The treatment was started 3 minutes later at 10:46 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Further review revealed Patient #9 received a total of 15000 units of heparin instead of 16000 units as prescribed. There was no documentation why the Patient was not administered the extra 1000 units of heparin. Review of the Hemodialysis Flowsheet dated 1/21/2025 revealed Patient #9 was administered a heparin loading dose of 8000 units at 11:15 AM. The treatment was started 3 minutes later at 11:18 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Further review revealed Patient #9 received a total of 14000 units of heparin instead of 16000 units as prescribed. There was no documentation why the Patient was not administered the extra 2000 units of heparin. Review of the Hemodialysis Flowsheet dated 1/24/2025 revealed Patient #9 was administered a heparin loading dose of 8000 units at 11:16 AM. The treatment was started 3 minutes later at 11:19 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Further review revealed Patient #9 received a total of 8000 units of heparin instead of 16000 units as prescribed. There was no documentation why the Patient was not administered the extra 8000 units of heparin. Continued review revealed, the BFR was 300 from 11:19 AM until 11:31 AM; 200 from 12:01 PM to 12:30 PM; and 350 from 1:00 PM to 3:12 PM. There was no documentation stating why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified. Review of the Hemodialysis Flowsheet dated 1/25/2025 revealed Patient #9 was administered a heparin loading dose of 8000 units at 6:50 AM. The treatment was started 3 minutes later at 6:53 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Further review revealed Patient #9 received a total of 14000 units of heparin instead of 16000 units as prescribed. There was no documentation why the Patient was not administered the extra 2000 units of heparin. 7. Medical record review for Patient #10 revealed an admission date of 2/27/2023 with diagnoses which included Type 2 Diabetes Mellitus and End State Renal Disease. Review of a physician’s order dated 12/23/204 revealed a Heparin loading dose of 5000 units and a BFR of 400. Review of the Hemodialysis Flowsheet dated 1/4/2025 revealed Patient #10 was administered a heparin loading dose of 5000 units at 5:57 AM. The treatment was started 3 minutes later at 6:00 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Further review revealed, the BFR was 300 from 6:02 AM until 9:32 AM. There was no documentation stating why the BFR was not delivered at the ordered rate of 400. There was no documentation on physician was notified. Review of the Hemodialysis Flowsheet dated 1/6/2025 revealed Patient #10 was administered a heparin loading dose of 5000 units at 5:57 AM. The treatment was started 3 minutes later at 6:00 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Review of the Hemodialysis Flowsheet dated 1/8/2025 revealed no documentation the heparin loading dose was administered. There was no documentation why the heparin wasn’t administered. Further review revealed, the BFR was 300 from 5:58 AM until 9:33 AM. There was no documentation stating why the BFR was not delivered at the ordered rate of 400. There was no documentation on physician was notified. Review of the Hemodialysis Flowsheet dated 1/10/2025 revealed Patient #10 was administered a heparin loading dose of 5000 units at 5:49 AM. The treatment was started 3 minutes later at 5:52 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Further review revealed, the BFR was 200 from 5:53 AM until 9:33 AM. There was no documentation stating why the BFR was not delivered at the ordered rate of 400. There was no documentation on physician was notified. Review of the Hemodialysis Flowsheet dated 1/13/2025 revealed Patient #10 was administered a heparin loading dose of 5000 units at 5:54 AM. The treatment was started 3 minutes later at 5:57 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Review of the Hemodialysis Flowsheet dated 1/15/2025 revealed Patient #10 was administered a heparin loading dose of 5000 units at 5:52 AM. The treatment was started 3 minutes later at 5:55 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Review of the Hemodialysis Flowsheet dated 1/17/2025 revealed no documentation the heparin loading dose was administered. There was no documentation why the heparin wasn’t administered. Further review revealed, the BFR was 300 from 6:03 AM until 10:03 AM. There was no documentation stating why the BFR was not delivered at the ordered rate of 400. There was no documentation on physician was notified. Review of the Hemodialysis Flowsheet dated 1/22/2025 revealed Patient #10 was administered a heparin loading dose of 5000 units at 6:06 AM. The treatment was started 3 minutes later at 6:09 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Review of the Hemodialysis Flowsheet dated 1/24/2025 revealed Patient #10 was administered a heparin loading dose of 5000 units at 5:53 AM. The treatment was started 3 minutes later at 5:56 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. Review of the Hemodialysis Flowsheet dated 1/27/2025 revealed Patient #10 was administered a heparin loading dose of 5000 units at 5:55 AM. The treatment was started 3 minutes later at 5:58 AM. Staff failed to wait 5 minutes after administering the heparin before starting the treatment. 8. During an interview on 1/28/2025 at 1:00 PM, the NM verified staff should wait a minimum of 5 minutes to start the treatment after administering heparin. The NM continued and stated if the heparin is not administered, the prescribed amount of heparin isn’t administered, or if the prescribed BFR is not run, staff should document the reason why.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 33763 Based on facility policy review, observation, and interview, the facility failed to ensure measures to reduce the risk of infection during cannlation of an AVF and/or AVG were followed by 2 of 2 (CCHT #1 and #2) staff members observed initiating hemodialysis via an AVG or AVG. The findings included: 1. Review of the facility policy titled, “AV Fistula and Graft Cannulation” revised 8/2022 revealed, “...Validate that patient has washed access with antibacterial soap and water, nurse assisted if unable...Preps skin in a circular motion and progressing out with alcohol prep pad for 1 minute...If either site is touched after prepping then the area must be cleaned again...” 2. Observations on the treatment floor on 1/27/2025 at 9:52 AM revealed CCHT #1 escorted RP #3 to Station #17. RP #3 was not observed washing the access site with soap and water prior to walking to Station #17. CCHT #1 began the cannulation procedure without washing the Patient’s access site with soap and water. During an interview on 1/27/2024 at 9:57 AM, RP #3 stated she washed the access site prior to arriving at the facility, but not after arriving. During an interview on 1/29/2025 at 11:30 AM, the NM stated patients should wash their access sites prior to entering the treatment floor. The NM continued and stated if the patient is unable to wash their access site, staff should wash it for them. 3. Observations on 1/27/2024 at 10:55 AM on the treatment floor revealed CCHT #2 initiating hemodialysis on RP #5 via an AVF/AVG. CCHT #2 cleaned the access site with antiseptic and allowed the site to air dry. CCHT #2 then recontaminated the access site by feeling the site with a gloved finger and did not re-cleanse the site prior to cannulation. During an interview on 1/29/2025 at 11:27 AM, the NM stated staff should “Look, Listen, Feel” the AVF/AVG access site prior to cleaning with antiseptic. If access site is recontaminated after cleansing, it should be cleansed again with antiseptic prior to cannulation.”