Dci Cumberland

“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: 46831 Based on facility policy review, observation, and interview, the facility failed to ensure appropriate infection control measures were taken by allowing 2 of 6 (CCHT #1 and #2) team members providing patient care to wear artificial nails on 1 of 2 observation days. The findings included: 1. Review of the facility policy “Standard Precautions & Infection Control” revised 07/11/2018, revealed “...Staff...As they tend to harbor bacterial growth, fingernail extensions are not permitted...” 2. Observations on the treatment floor on 08/04/2025 at 2:26 PM, revealed CCHT #1 was wearing short, acrylic nails with bright orange nail polish. Observations on the treatment floor on 08/04/2025 at 2:32 PM, revealed CCHT #2 was wearing short, acrylic nails with bright orange nail polish. 3. During an interview on 08/06/2025 at 10:55 AM, the NM stated acrylic nails should not be worn by staff.”

“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: 46831 Based on facility policy, observation, and interview, the facility failed to ensure medications were discarded before their expiration date for 1 of 1 medication stations on 1 of 2 observation days. The findings included: 1. Review of the facility policy “Medication Storage” dated 09/21/2021, revealed “...Medications will not be expired...” 2. Observations at the medication station on 08/04/2025 beginning at 9:05 AM revealed the following expired medications: Twenty-four (24) cartons Nepro Nutritional Shake (a calorically dense source of nutrition with high-quality protein) with expiration date of 05/2025. Twenty-five (25) Gentamicin (powerful antibiotic to treat serious bacterial infections) Injections 80 mg/2 mL with expiration date of 07/2025. 3. During an interview on 08/04/2025 at 10:45 AM, RN #1 verified the above medications were expired and should have been discarded. During an interview on 08/04/2025 at 2:10 PM, the NM stated the expired medications should have been discarded and not available at the medication station.”

“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: 46831 Based on policy review, medical record review, and interview, the facility failed to ensure 1 of 7 (Patient #2) sampled patients received the prescribed dialysis prescription for BFR on 4 of 10 sampled treatment days. The findings included: 1. Review of the facility policy “Documentation of Abnormal Values & Prescription Deviations During Treatment” issued 1/31/2018, revealed “...Any deviation from the treatment prescription must also be documented and explained on the flowsheet...” 2. Medical record review for Patient #2 revealed an admission date of 06/09/2025 with diagnoses that included Hypertensive Chronic Kidney Disease. Review of a 07/01/2025 physician’s order revealed a BFR of 450. Review of the 07/07/2025 Hemodialysis Flowsheet revealed the BFR was 400 from 12:00 PM until 2:30 PM and 250 from 3:01 PM until 3:30 PM and 200 at 3:30 PM. There was no documentation stating why the BFR was not delivered at the ordered rate of 450. There was no documentation of physician being notified. Review of the 07/16/2025 Hemodialysis Flowsheet revealed the BFR was 400 from 12:31 PM until 4:16 PM. There was no documentation stating why the BFR was not delivered at the ordered rate of 450. There was no documentation of physician being notified. Review of the 07/18/2025 Hemodialysis Flowsheet revealed the BFR was 400 from 9:07 AM until 1:07 PM. There was no documentation stating why the BFR was not delivered at the ordered rate of 450. There was no documentation of physician being notified. Review of the 07/23/2025 Hemodialysis Flowsheet revealed the BFR was 400 from 12:31 PM until 4:04 PM. There was no documentation stating why the BFR was not delivered at the ordered rate of 450. There was no documentation of physician being notified. 3. During an interview on 08/06/2025 at 12:41 PM the NM stated, “...Any deviation to prescribed BFR should be noted on the flow sheet...””

“QAPI-MONITOR/ACT/TRACK/SUSTAIN IMPROVE CFR(s): 494.110(b) The dialysis facility must continuously monitor its performance, take actions that result in performance improvements, and track performance to ensure that improvements are sustained over time. This Standard is not met as evidenced by: 46831 Based on the Entrance Conference Materials List and interview, the facility failed to provide staff practice audits for infection prevention for 1 of 3 survey days. The findings include: 1. Review of the facility policy “Standard Precautions & Infection Control” revised 07/11/2019, revealed “...Surveillance for infections and other adverse events is required to monitor the effectiveness of infection control practices, as well as training and education of both staff members and patients to ensure that appropriate infection control behaviors and techniques are carried out...Infection Control Training and review of the Exposure Control Plan should be reviewed with staff on an annual basis and documented...” 2. Review of the Entrance Conference Materials List presented to the facility on 08/04/2025, revealed the facility was unable to provide staff practice audits for infection prevention. 3. During an interview on 08/04/2025 at 2:10 PM, the NM stated, “...I can’t find any of the infection control audits...the employee who took care of these is no longer employed...I have no idea where they would be...””