Davita Poplar Avenue Dialysis

“MD RESP-STAFF ED, TRAINING & PERFORM CFR(s): 494.150(b) Medical director responsibilities include, but are not limited to, the following: (b) Staff education, training, and performance. This Standard is not met as evidenced by: 49570 Based on review of the facilities supporting documentation for the POC and interview, the facility’s Medical Director failed to ensure staff received appropriate education and training to perform their job responsibilities. Failure of the medical director to ensure that facility staff received education, training, and performance follow-up resulted in the inability to verify staff competency and compliance with facility policies and infection control requirements. The findings included: 1. Review of the facilities supporting documentation for the POC revealed six (6) of ten (10) in-service training records conducted between 09/17/2025 and 10/14/2025 revealed the documentation included staff names and dates of attendance; however, the content of the education provided was not thoroughly documented. Several in-service forms referenced “see attached policies,” yet no policies or materials had been attached. Therefore, the facility could not verify the subject matter or adequacy of the training provided to staff. Continued review revealed audit records used to evaluate staff performance contained no evidence of follow-up or re-education when deficiencies had been observed (e.g., improper disinfection of patient care equipment). The forms had not identified whether re-education occurred, if staff members had been re-trained, or whether corrective actions had been taken. Additionally, the documentation had not allowed for tracking or trending of repeat performance issues, making it impossible to determine whether the same employees had been responsible for recurring deficiencies. The facility also reported that patient education had been provided regarding proper disposal of trash during treatment and the need to maintain uncovered access sites; however, no documentation had been available to verify the content of the education. During an interview on 10/14/2025 at 2:30 PM, the Clinical Specialist stated that the facility’s in-services had included review of all facility policies contained in the binder. She explained that a packet of policies had been included with one of the earlier in-services and that packet had been used over and over. When asked about the notation “see attached policies” on several in-service sheets with no attachments, she stated, “Those are the polices that were in there [the binder] - we covered all of them at each in-service.” When asked if that included policies such as governing body and medical director responsibilities, she confirmed, “Yes, we went over all of them.” 2. Review of the inservice documentation reflected that CCHT #1 had attended numerous in-services that discussed the policies. During an interview on 10/15/2025 at 9:05 AM, CCHT #1 stated that she had attended multiple in-services at the facility and could not recall being educated on the governing body or the medical director responsibilities.”

“GOV-ID GOV BODY W/FULL AUTHORITY/RESPONS CFR(s): 494.180 The ESRD facility is under the control of an identifiable governing body, or designated person(s) with full legal authority and responsibility for the governance and operation of the facility. The governing body adopts and enforces rules and regulations relative to its own governance and to the health care and safety of patients, to the protection of the patients ’ personal and property rights, and to the general operation of the facility. This Standard is not met as evidenced by: 49570 Based on review of facility policy, the facility’s Allegation of Compliance (AOC), and Governing Body Minutes, the facility failed to ensure the Governing Body fulfilled its responsibility for overseeing the provision of safe and effective care. The Governing Body failed to ensure that decisions made during Governing Body meetings were effectively implemented and sustained within the facility. The findings included: 1. Review of facility policy, “Governing Body Meeting Requirements,” revised 01/2020, “To ensure all necessary information is discussed and documented ...Requirements... Evidence that the governing body adopts and enforces rules and regulations relative to its own governance and to the health care and safety of patients, to the protection of the patient’s personal and property rights, and to the general operation of the facility ...” 2. Review of the facility’s AOC stated the Governing Body would ensure ongoing re-education and monitoring as needed, including sustained compliance, with tracking in QAPI and Governing Body meetings. Governing Body minutes dated 07/08/2025 documented a decision to restart the gnat treatment regimen and to re-inservice staff on 07/09/2025 and 07/10/2025. At the time of the revisit on 08/11/2025, there was no documentation provided to demonstrate that the staff in-services occurred. Governing Body minutes dated 07/08/2025 also reflected that [Named Pest Control Company] would provide bi-weekly treatments until gnats were eradicated. Documentation reflected a service on 07/08/2025 and the next service on 08/07/2025, which did not meet the bi-weekly frequency stated by the Governing Body. The AOC submitted by the facility during the survey from 06/23/2025-06/26/2025 included a commitment to disinfect all patient chairs on a monthly basis. The patient chairs were disinfected in June 2025 during the onsite recertification visit. There was no documentation the facility performed a monthly chair disinfection for July 2025. Facility leadership reported during a Governing Body meeting on 07/16/2025 that manufacturer guidelines advised against power-washing chairs due to risk of damage. They further reported outreach to an outside vendor for alternative disinfection methods. However, there was no documentation of disinfection in July 2025 as required by the facility’s AOC. On 07/09/2025, Governing Body minutes reflected a decision to restart the EZ Gel treatment regimen from the beginning due to gnats being observed in the facility. The Governing Body minutes further indicated that staff were to be re-inserviced on 07/09/2025 and 07/10/2025; however, there was no documentation of inservice on 7/9/2025 and 7/10/2025 provided to the survey team. On 07/09/2025, Governing Body minutes also reflected that [Named Pest Control Company] would begin providing bi-weekly treatment until gnats were eradicated. Invoices reviewed on 08/11/2025 from [Named Pest Control Company] showed a pest control service visit on 07/08/2025, but there was no further service visits documented until 08/07/2025, failing to meet the bi-weekly treatment frequency stated in the Governing Body minutes. The Governing Body failed to ensure required staff re-education occurred; failed to ensure that bi-weekly pest control services were implemented; failed to ensure back-up chairs were procured as replacement options for facility; and failed to ensure chairs were disinfected monthly as represented in the AOC.”

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 49570 Based on review of facility policy, observation, and interview, the facility failed to implement an effective infection control program to prevent the transmission of infectious diseases and to provide a safe and sanitary environment for patients, staff, and visitors. The findings included: 1. The facility failed to ensure sterile supplies were properly handled and not stored after opening; contaminated materials were discarded immediately; supplies were not stored beneath sinks; surfaces such as sinks, counters, and flooring were clean and intact; staff wore appropriate footwear during patient care; and expired supplies were not available for use. Refer to V-111 2. The facility failed to ensure infection control measures were taken by staff members during initiation and discontinuation of hemodialysis with an AVG/AVF. Refer to V-113 3. The facility failed to disinfect reusable equipment between patient use and failed to prevent the potential for cross-contamination by storing reusable patient care supplies at the dialysis station. Refer to V-116 4. The facility failed to ensure proper cleaning and disinfection of dialysis stations was performed by 2 staff members observed, resulting in the use of a contaminated prime waste container during setup for hemodialysis and failed to ensure patient treatment chairs were maintained in a sanitary condition between patients, resulting in the risk for cross-contamination and transmission of infectious agents. Refer to V-122 5. The facility failed to ensure medications were discarded prior to expiration, creating a potential risk for patient harm. Refer to V-143 6. The facility failed to ensure proper disinfection of CVC connections during initiation and discontinuation of hemodialysis treatment and failed to utilize an appropriate antiseptic agent during CVC exit site care. Refer to V-147”

“CFC-PHYSICAL ENVIRONMENT CFR(s): 494.60 This Condition is not met as evidenced by: 49570 Based on review of facility policy, manufacturer’s guidelines for use, observation, and interviews, the facility failed to ensure the dialysis environment was maintained in a clean, safe, functional, and comfortable manner for patients, staff, and the public. The findings included: The facility failed to prevent conditions that contributed to ongoing pest infestation, failed to properly clean and maintain physical surfaces, failed to ensure medications were properly labeled in accordance with facility policy and failed to ensure medications were secured in a locked cabinet to protect patient safety. Refer to V 401”

“CFC-QAPI CFR(s): 494.110 This Condition is not met as evidenced by: 49570 Based on review of facility policy, document review, meeting minutes, and interview, the facility failed to recognize and prioritize ongoing environmental conditions that posed a risk to the health and safety of dialysis patients. The facility failed to develop, implement, or monitor effective corrective actions through its QAPI program to address pest infestation and sanitation issues identified within the dialysis treatment environment. These failures demonstrated the facility’s inability to operate an ongoing, comprehensive, data-driven QAPI program capable of identifying and addressing problems that affect patient outcomes and care. The findings included: The facility failed to identify and prioritize the presence of live and dead gnats and bed bugs observed in patient treatment areas as a serious patient safety issue; failed to document or discuss environmental sanitation problems in QAPI meeting minutes dated 02/2025, 03/2025, 04/24/2025, and 05/22/2025; failed to Initiate any performance improvement projects or corrective actions related to the pest infestation through the QAPI process; and evaluate or monitor the effectiveness of pest control protocols intended to reduce or eliminate environmental hazards. These failures represent a breakdown in the facility’s ability to maintain an effective, data-driven performance improvement program capable of identifying and mitigating serious risks to patient safety. Refer to V 640”

“CFC-GOVERNANCE CFR(s): 494.180 This Condition is not met as evidenced by: 49570 Based on review of facility policy, review of Governing Body Minutes, and interview, the facility failed to ensure the Governing Body fulfilled its responsibility for overseeing the provision of safe and effective care, including ensuring communication of known environmental hazards to patients and medical staff. The Governing Body failed to recognize and address infestation risks that could impact the health and safety of dialysis patients and staff. The findings included: 1. Review of facility policy, “Governing Body Meeting Requirements,” revised 01/2020, “To ensure all necessary information is discussed and documented ...B. Requirements: 1. Evidence that the governing body adopts and enforces rules and regulations relative to its own governance and to the health care and safety of patients, to the protection of the patient’s personal and property rights, and to the general operation of the facility. Evidence that the QAPI program, outcomes, and projects were reviewed and that recommendations were made ...” The facility failed to notify patients and medical staff regarding a confirmed bed bug infestation involving two separate patients - one in 02/2025 and another in 04/2025 Review of Governing Body Minutes dated 01/09/2025, 02/27/2025, 05/05/2025, and 05/12/2025 failed to reflect documentation or discussion of two confirmed bed bug infestations involving patients - one in 02/2025 and another in 04/2025. The minutes did not include documentation or discussion regarding formal notification of dialysis patients and medical staff concerning the bed bug infestations. The minutes also failed to reflect any documentation or discussion regarding the ongoing gnat infestation throughout the dialysis facility and treatment area, nor did they reflect how the infestation would be appropriately treated. The facility failed to identify or address a concurrent gnat infestation on the treatment floor, which was also not reflected in any Governing Body meeting minutes as of 06/25/2025 These failures represent a breakdown in the Governing Body’s responsibility to ensure patient safety and environmental oversight. The lack of engagement and action contributed to ongoing conditions that placed patients and staff at potential risk. During an interview on 06/25/2025 around 12:55 PM, the FA confirmed that the Governing Body had not discussed either the bed bug or gnat issues, and medical staff and patients had not been formally notified. Refer to V-640”

“Information on Occupancy/Needs CFR(s): §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (7) [(5) or (6)] A means of providing information about the [facility’s] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice’s inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This Standard is not met as evidenced by: 49570 Based on review of facility policy, Governing Body meeting minutes, Patient demographics, and interview, the facility failed to ensure the emergency preparedness plan included the required patient information for safe and effective patient transfer during an emergency. The findings revealed: 1. Review of facility policy, “Emergency Preparedness Plan” revised 07/2023 revealed, “ ...To ensure the dialysis facility complies with all applicable federal, state and local emergency preparedness requirements ...” Review of Governing Body meeting minutes dated 06/24/2025 at 6:00 PM revealed, “New Business: Regarding blood type for the EP patient summary: We will seek guidance from our Office of Chief Medical Officer to determine the best course of action for the following. This wording may be a recommendation and not a mandate ...If there is an emergency regarding blood loss, we would notify emergency services for transport to a facility that has the capability to treat the patient ...” Review of Patient demographics sheet revealed no blood type listed for patients. 2. During an interview on 06/25/2025 at 2:00 PM, the Director of Clinical Services stated that the facility’s current emergency preparedness plan does not include patient blood type on the patient information [demographics] form. She acknowledged that this information is in the EP regulations but confirmed that it was not being documented by the dialysis facility. When asked how the facility would respond if a patient required an emergent blood transfusion during a disaster or transfer, she stated, “We would send the patient to a hospital that is better equipped to determine that information.” When informed that the regulation likely exists to ensure critical information - such as blood type - is readily available in emergencies to prevent delays in care, she had no further response.”

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 49570 Based on review of facility policy, review of the Emergency Preparedness Program, and interview, the facility failed the ensure the governing body evaluated the Emergency Preparedness Program at least annually to assess the program’s effectiveness, as required by facility policy. The findings included: 1. Review of facility policy, “Governing Body Meeting Requirements,” revised 01/2020, “To ensure all necessary information is discussed and documented ...B. Requirements ...16. Evaluates at least annually the effectiveness of emergency and disaster plans and update them as necessary ...” Review of the Emergency Preparedness Program documentation revealed no evidence the governing body had conducted an annual evaluation of the program. 2. During an interview on 06/26/2025 at 5:41 PM, the FA confirmed the Emergency Preparedness Program had not been evaluated by the governing body in the past year.”

“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 review of facility policy, observation, and interview, the facility failed to maintain a sanitary environment on 1 of 2 (06/23/2025) observation days, to minimize the risk of transmission of infectious and communicable diseases. Specifically, the facility failed to ensure sterile supplies were properly handled and not stored after opening; contaminated materials were discarded immediately; supplies were not stored beneath sinks; surfaces such as sinks, counters, and flooring were clean and intact; staff wore appropriate footwear during patient care; and expired supplies were not available for use. The findings revealed: 1. Review of facility policy, “Infection Control and Precautions for All Patients,” revised 07/2023, revealed, “To educate staff on general guidelines in the prevention of infection within the dialysis facility ...” Review of facility policy, “Guidelines for the Handling and Disposal of Infectious Medical Waste,” revised 04/2023, “To properly handle and discard ...infectious waste to prevent the transmission of disease through exposure to bloodborne and airborne pathogens ...3. The following are to be considered and treated as infectious and/or special waste materials: a. Human blood and blood products ...” Review of facility policy, “Facility Space/Design and Safety Requirements” revised 04/2023 revealed, “...Ensure all supplies, medications and testing strips are checked at least monthly for expiration...” Review of facility policy “Personal Appearance” revised 01/01/2025, revealed, “...Open-toed and/or backless footwear should not be worn in areas outside of an office setting...This includes any position that performs duties in a technical and/or patient care area ...” 2. Observations on the treatment floor on 06/23/2025 at 9:15 AM revealed fifty-five (55) 10 mL syringes with needles attached, pre-labeled and opened outside their sterile packaging, stored for use 24 hours later. These were intended for heparin draws on 06/24/2025. During an interview on 06/23/2025 at 9:30 AM, RN #1 verified that she had opened the 10 mL syringes, attached the needles, and pre-labeled each syringe with a patient tag for 06/24/2025. RN #1 stated, “Oh the office printed off the wrong labels. I just didn’t notice.” 3. Observations at the nurses’ desk on 06/23/2025 at 9:45 AM revealed a box labeled with PCT #2’s name containing opened AVG and AVF connection lines outside of sterile packaging. During an interview on 06/23/2025 at 9:49 AM, PCT #2 stated she kept extra supplies on hand and confirmed she would use the opened supplies for patient care, even if they had been sterile before opening. During an interview on 06/26/2025 at 5:41 PM, the FA confirmed that if any sterile supplies were opened and not used, they should be immediately discarded. 4. Observations on the treatment floor on 06/23/2025 at 9:15 AM revealed a rolled up blue chux pad inside a medication/supply drawer with a visible drop of blood. Two pre-filled syringes of heparin were found rolled up inside the chux pad, intended for patient use later that same day. Also rolled up inside the chux pad were gauze pads still inside sterile packaging. During an interview on 06/23/2025 at 9:30 AM, RN #1 verified that she had placed the two heparin syringes and gauze pads inside the chux pad, and when asked how the spot of blood got on the chux pad, RN #1 stated, “I have no idea how that got there.” 5. Observations on the treatment floor on 06/23/2025 at 9:11 AM revealed 2 of 5 facility sinks (Clean Area Sink #1 and Clean Area Sink #2) had items stored underneath: multiple boxes, a purse, gauze sponges, and wipes were observed stored under Clean Area Sink #1. At 9:30 AM, multiple boxes were also found stored underneath Clean Area Sink #2. The storage undernealth the sinks breached infection control protocols by creating a risk for contamination of patient care supplies due to potential water leaks or splash exposure. Observations on the treatment floor on 06/23/2025 and 06/24/2025 revealed the facility sink in the isolation room had glove boxes adhered to the counter surface due to moisture. The facility sink labeled “Clean Sink” across from Station #6 had a visibly broken drain. Observations throughout the treatment floor on 06/23/2025 showed extensive damage to laminate surfaces on chaise walls behind multiple dialysis stations, damaged laminate at the nurses’ stations and at several supply preparation areas, multiple square cuts in the laminate flooring, and damaged countertops at multiple sinks with large areas of staining, peeling, and pitting. The damage prevented proper cleaning and sanitization of those areas. During an interview on 06/24/2025 at 10:00 AM, the BioMed Technician stated that the facility was undergoing renovation and acknowledged that the damaged infrastructure - including the stained and pitted countertops, broken sink drain, delaminated chase wall, nurses’ station, and supply preparation surfaces, and cutouts in the floor - were on a facility’s list for future repair. Some areas of delamination at the nurses’ station had recently been repaired; however, the repair was not seamless and created crevices that posed continued risk for contamination and ineffective surface disinfection. When Surveyor asked BioMed Technician for a contract, invoice, etc. that showed the approval of those areas to be fixed, the BioMed Technician provided an invoice that reflected only a few of the issues had been approved for updates. During an interview on 06/26/2025 at 5:41 PM, the FA stated that renovations were currently happening on the new “home clinic” that was being added at the dialysis facility, and that some of the renovations for the current dialysis treatment floor were still pending formal approval. 6. Observations on the treatment floor on 06/23/2025 at 10:00 AM revealed PCT #2 wearing a pair of lime green plastic clog-style shoes with holes on the tops/sides and an open back, while actively performing duties in the patient treatment area. During an interview on 06/26/2025 at 5:41 PM, the FA stated facility policy should be followed for rotating supplies and monthly checks should be done to ensure all expired supplies were discarded on or before their expiration date. The FA stated that policy and procedure should be followed when pertaining to dress code. 7. Observations on 06/23/2025, revealed the following expired supplies in a supply storage drawer on the treatment floor: One (1) 1mL safety syringe with an expiration date of 8/2024. One (1) Alcohol Prep Pad with an expiration date of 11/2011. Observations on 06/23/2025 revealed the following expired supplies in the back storage room:. One hundred (100) Prevantics Antiseptic Chlorhexidine Gluconate Swabs (expiration date 11/2024. One hundred (100) Prevantics Swabs (expiration date 07/2024) One (1) Naturalyte liquid Acid jug (expiration date 10/02/2024) During an interview on 06/23/2025 at 9:42 AM, the FA verified the above expired supplies and stated staff were expected to follow policy and procedure regarding expired supplies.”

“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: 49570 Based on review of facility policy, observation, and interview, the facility failed to ensure infection control measures were taken by 2 of 2 (PCT #1 and PCT #2) staff members during initiation and discontinuation of hemodialysis with an AVG/AVF on 1 of 1 (06/23/2025) observation days. The findings included: 1. Review of facility policy “Termination of Dialysis Treatment” revised 04/2024, revealed, “...Cover the site with gauze and apply just enough pressure to occlude bleeding from site...After hemostasis is achieved, cover puncture sites with clean Band-aid style bandage or gauze and tape. If patient refuses, document in EMR ...” Review of facility policy “Hand Hygiene” revised 08/2020, revealed, “...HAND HYGIENE will be performed...After gloves are removed ...” 2. Observations on the treatment floor at Station #2 on 06/23/2025 at 10:35 AM, revealed PCT #2 performed post dialysis exit care on RP #7. PCT #2 failed to wash hands after reinfusing the extracorporeal circuit and removing gloves, and failed to replace the blood-soiled gauze on the needle sites once hemostasis was achieved. Observations on the treatment floor at Station #11 on 06/23/2025 at 11:50 AM, revealed PCT #1 performing cleaning and disinfection of a dialysis station, PCT #1 failed to perform hand hygiene after emptying prime waste bucket and removing gloves. 3. During an interview on 06/26/2025 at 5:41 PM, the FA verified that policy and procedure should be followed in regards of hand hygiene and discontinuation of hemodialysis with an AVG/AVF.”

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 49570 Based on review of facility policy, observation, and interview, the facility failed to ensure infection control measures were maintained during direct patient care activities on 2 of 2 (06/23/2025 and 06/24/2025) observation days. Specifically, the facility failed to disinfect reusable equipment between patient use and failed to prevent the potential for cross-contamination by storing reusable patient care supplies at the dialysis station. The findings revealed: 1. Review of facility policy, “Infection Control and Precautions for All Patients”, revised 07/2023, revealed, “ ...Supplies: Items taken into the dialysis station will either be disposed of, dedicated for use only on a single patient or cleaned and disinfected before being taken to a common clean area or used on another patient. A. Non-disposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) will be dedicated for use only on a single patient. B. Preparation of tape will be as follows: DO NOT place directly on the chair or chair side table ...At no time will tape hang directly from the chair or chair side table ...” 2. Observation on the treatment floor at Station #10 on 06/23/2025 at 10:41 AM revealed PCT #1 obtaining a temperature on RP #4 using a handheld digital thermometer. After use, PCT #1 returned the thermometer to a shared area without disinfecting the device. 3. Observation on the treatment floor at Station #11 on 06/24/2025 at 4:45 PM revealed a roll of paper tape stored on the side of the dialysis machine, The tape was not dedicated to a specific patient and was not discarded after use. During an interview on 06/26/2025 at 5:41 PM, the FA confirmed that thermometers must be disinfected between patient’s use and that rolls of tape or other reusable supplies must not be brought to dialysis stations unless dedicated to a single patient and discarded after use, in accordance with facility policy.”

“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: 49570 Based on review of facility policy, observation, and interview, the facility failed to ensure proper cleaning and disinfection of dialysis stations was performed by 2 of 2 (PCT #1 and PCT #2) staff members observed, resulting in the use of a contaminated prime waste container during setup for hemodialysis and failed to ensure patient treatment chairs were maintained in a sanitary condition between patients, resulting in the risk for cross-contamination and transmission of infectious agents. The findings revealed: 1. Review of facility policy, “Cleaning and Disinfection of Dialysis Machine Equipment,” revised 07/2023, revealed, “...To provide guidance on proper disinfection of the dialysis station, machine, equipment and surrounding surfaces with the appropriate method prevents the transmission of disease/infection to the dialysis population...Disinfection procedure ... 4. Empty the prime container into a designated dirty sink ...8. Disinfect all surfaces of the prime waste container, inside and out, with a moistened 1:100 bleach cloth ...11. Clean chair by placing in the reclining position and swing arms out ...to clean seat, footrest, backrest and sides, armrest, inside of chair arms and chair frame and side tray tables ...12. Visible blood: Utilize a two-step process to clean and disinfect. A. First use a moistened 1:100 bleach cloth to remove the blood; b. Then use a second moistened 1:100 bleach cloth to disinfect the surface ...” Review of facility policy, “Infection Control and Precautions for All Patients,” revised 07/2023, revealed, “ ...Cleaning and Disinfection: a. Clean and disinfect the dialysis station (e.g., chairs ...) i. Give special attention to cleaning ...surfaces that are frequently touched and potentially contaminated with patients’ blood ...iii. Discard all fluid and clean and disinfect all surfaces and containers associated with the prime waste (including buckets attached to the machines)...” 2. Observations on the treatment floor at Station #1 on 06/23/2025 at 9:51 AM revealed PCT #2 failed to disinfect the inside and outside surfaces of the prime waste container. PCT #2 placed a moistened bleach cloth in the bucket and did not remove it before setting up the bloodlines for the next hemodialysis treatment. During set up, lines were hung over into the prime bucket to drain with the moistened bleach cloth still present in the bottom. Observations on the treatment floor on 06/24/2025 at 3:00 PM revealed 17 of 21 treatment chairs were visibly soiled and not maintained in a sanitary condition between patients. The remaining 4 chairs were occupied and could not be inspected. The following were observed across multiple chairs: White bicarbonate residue on chair surfaces (primarily on both sides and backs) Accumulated dust and food crumbs on chair rails Tape adhered to chair surfaces and associated patient side trays Dried blood stains on chair armrests, rails, side tables, and inner upholstery Presence of dead gnats on and around several chairs Upholstery with visible cracks and holes These conditions were evident prior to patient use, during active treatment, and following patient discharge, indicating a systemic failure to clean and disinfect patient care equipment between uses. 3. During an interview on 06/26/2025 at 5:41 PM, the FA verified that policy and procedure should be followed when cleaning the prime waste container and that dialysis station chairs should be thoroughly cleaned and disinfected after each patient use.”

“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, observation, and interview, the facility failed to ensure medications were discarded prior to expiration, creating a potential risk for patient harm. The findings included: 1. Review of facility policy, “Guidelines for Administration of Medication” revised 02/2025 revealed, “...An inventory of medications with expiration dates will be kept for timely replacement...” 2. Observations on 06/23/2025 revealed the following expired medications: Eight (8) Ceftriaxone 1g vials (expiration 02/2025) - Medication cabinet Six (6) Hep Lock 10unit 5mL syringes (expiration 02/08/2025) - ‘CCHT #1’s Box’ Twenty-three (23) Prevantics Swabs (expiration 07/2024) - ‘CCHT #1’s Box’ Fifteen (15) Influenza vaccines (expiration 06/11/2024) - Medication refrigerator Fifteen (15) Influenza vaccines (expiration 05/13/2025) - Medication refrigerator 3. During interviews on 06/23/2025 at 9:42 AM, 9:50 AM, and 10:06 AM, the FA, CCHT #1, and RN #1 verified the above expired medications. During an interview on 06/26/2025 at 5:41 PM, the FA stated facility policy should be followed for rotating medications and monthly checks should be done to ensure all expired medications were discarded.”

“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: 49570 Based on review of facility policy, CDC tool kit, observation, and interview, the facility failed to ensure proper disinfection of CVC connections during initiation and discontinuation of hemodialysis treatment and failed to utilize an appropriate antiseptic agent during CVC exit site care. The findings included: 1. Review of facility policy, “Accessing and De-Accessing the Dialysis Catheter” revised 06/2024, revealed, “...Any time the catheter is disconnected from the bloodlines or caps are removed/applied (e.g. initiation/termination of treatment; transposing the lines), clean the sides (threads) and end of hub thoroughly with friction...” Review of facility policy, “Dialysis Catheter Dressing Change Procedure” revised 02/2023 revealed, “...Using aseptic technique, cleanse the skin surrounding the exit site with the appropriate skin antiseptic... Acceptable cleansing agents include ... ChloraPrep ... Povidone iodine ... ExSept ...” Review of the CDC’s “Scrub the Hub!” pdf, (part of the CDC tool kit) dated 11/20/2013 revealed, “ ...Rub for 10 to 15 seconds (unless directed otherwise by the manufacturer’s instructions), generating friction by scrubbing in a twisting motion as if you were juicing an orange. Make sure you scrub the top of the hub well, not just the sides ...” 2. Observation on the treatment floor at Station #13 on 6/23/2025 at 10:06 AM revealed RN #1 performing discontinuation of hemodialysis for RP #3 with a CVC. RN #1 removed the bloodline from the blue (venous) port and scrubbed the hub for approximately 5 seconds, followed by removal of the bloodline from the red (arterial) port and scrubbing of that hub for approximately 5 seconds. RN #1 connected a syringe to each port, flushed the lines, removed the syringe from the blue (venous) port and scrubbed the hub for approximately 2 seconds before applying a port cap. RN #1 then removed the syringe from the red (arterial) port, scrubbed the hub for approximately 2 seconds, and applied a port cap. Observation on the treatment floor at Station #19 on 6/23/2025 at 11:18 AM revealed RN #1 initiated hemodialysis using a CVC for RP #1. RN #1 removed the cap from the blue (venous) port and scrubbed the hub for approximately 6 seconds. RN #1 then removed the cap from the red (arterial) port and scrubbed the hub for approximately 6 seconds. RN #1 connected a syringe to each port, aspirated blood from each connection, flushed the lines, connected the tubing to each port, and initiated hemodialysis. Observation of CVC exit site care on 6/23/2025 at 11:23 AM for RP #1 revealed RN #1 using alcohol as the skin antiseptic instead of the approved agents listed in facility policy (ChloraPrep, Povidone iodine, or ExSept). Observation of CVC exit site care on 6/23/2025 at 12:05 PM for RP #2 revealed the FA using alcohol as the skin antiseptic instead of the approved agents listed in facility policy (ChloraPrep, Povidone iodine, or ExSept). 3. During an interview, on 6/26/2025 at 5:41 PM, the FA stated that staff are expected to follow facility policy and procedures when scrubbing CVC hubs and performing CVC exit site care.”

“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: 49570 Based on review of facility policy, manufacturer’s guidelines for use, observations, and interviews, the facility failed to maintain a safe and sanitary physical environment on 3 of 3 (06/23/2025, 06/24/2025, and 06/25/2025) observation days to minimize the risk of cross-contamination and ensure patient safety. The facility failed to prevent conditions that contributed to ongoing pest infestation, failed to properly clean and maintain physical surfaces, failed to ensure medications were properly labeled in accordance with facility policy and failed to ensure medications were secured in a locked cabinet to protect patient safety. The findings revealed: 1. Review of facility policy, “Facility Space/Design and Safety Requirements,” revised 04/2023, revealed, “Facilities will provide a physical environment that protects the health and safety of patients, staff and the public ...8. Patient treatment area will be designed and equipped to provide proper and safe treatments as well as ...comfort for patients ...14. Floors will be kept free of liquids and debris ...18. Facility premises will be kept free of combustibles not necessary for facility operation ...” Review of facility policy, “Guidelines for the Handling and Disposal of Infectious Medical Waste,” revised 04/2023, “To ensure an environment that is free from potential fire hazards and breeding areas for insects and/or rodents ...” Review of facility policy, “Guidelines for Administration of Medication,” revised 02/2025, revealed, “ ...To maintain the safety and comfort of the patient ...10.a ...Medication(s) will be secured in a locked cabinet ...14. Medications will only be administered by the person preparing the medication to avoid error in administration ...16 ...i. Any medications that are not immediately administered, will be labeled with the patient’s name, medication name, dose, date, time, and preparer’s initials ...17. Medication Storage: a. Medications will be locked in a cabinet ...” 2. Review of manufacturer’s guidelines for use on the label of United 247 (Drain Membrane) revealed, “This product is designed to be used in conjunction with United 248 ... (Devour) ... to treat drains utilized in dialysis treatment. Treat each drain affected at the end of each working day. After the final disinfecting and cleaning routine performed on dialysis equipment feeding into the drain, allow 15 minutes before treating the drain with United 248 and United 247. After 15 minutes has passed, flush drain with clean water. Then pour in 4 ounces of United 248 to keep drains running freely. Once United 248 has been fed into drains, pour 4 ounces of United 247 ...into the drain. The product will float on the top, creating a membrane like cap to control odors, while also working to eliminate any drain flies [gnats] that feed in the drain ...” 3. Observations on the treatment floor on 06/23/2025, 06/24/2025, and 06/25/2025 revealed the following pest infestation and sanitation failures: Numerous live gnats observed flying around various areas of the facility, including patient treatment areas. Gnats observed landing on dialysis machines, station chairs, patients, countertops, sinks, chaise walls, and other equipment Multiple dead gnats observed on countertops, both in and on sinks, along chaise walls, and on dialysis machines and station chairs Liquid ant bait traps were found on the chaise wall behind Station #13 Two electronic bug zappers were observed in use on the treatment floor sitting on the chaise wall - one was between Station #5 and Station #6, and one was behind Station #18 Several spray cans of bug spray were found sitting on the nurses’ station and around the dirty sink area Hallway behind Stations #10 and #11 contained numerous dead bugs on the floor Unknown liquid in spray bottle sitting on chaise wall behind Station #12 and one more spray bottle on the nurses’ station beside clean supplies -neither bottle was labeled Observations on the treatment floor on 06/23/2025, 06/24/2025, and 06/25/2025 revealed the following sanitation & cleanliness issues: Dust and visible dirt piles were present throughout patient care areas; Hallway behind Stations #10 and #11 contained two plastic syringe caps, two sucker (lollipop) sticks, piles of dirt and debris; Area under all sinks on the treatment floor contained dirt, dead bugs, rust remnants, and other debris; Large square cut area under crash cart and under Clean Sink across from Station #6; Drain broken off on Clean Sink across from Station #6; Area on sodium bicarbonate cabinet had no door, exposing supplies to contamination, and Buildup of bicarbonate residue was observed under the chaise wall at Station #5. Observations on the treatment floor on 06/23/2025, 06/24/2025 and 06/25/2025 revealed the following standing water & floor contamination: Several areas around Stations #10, #11 and #12 had standing water on the floor from an unknown source; Two pills were observed on the floor behind Station #7: one large, wide oblong pill and one oval, light green pill. 4. Observations in the conference room on 06/25/2025 at 10:00 AM with BioMed revealed two (2) one-gallon containers [United 247 and United 248] that the facility had been using for the drain flies [gnats] cleaning regimen. The manufacturer’s label on United 247 revealed that the two products worked concurrently to assist with proper pest control and prevention of drain flies (gnats) infestations. During an interview on 06/25/2025 at 10:00 AM, the BioMed Technician stated that United 247 (Drain Membrane) was being poured into each drain monthly rather than daily, which was inconsistent with the manufacturer’s recommendations. The BioMed Technician explained that United 248 (Devour) was administered through an automatic pump that dispensed two ounces per night into each main drain; however, it was not dispensed into the wall box drains. The BioMed Technician further stated he was unaware of the instructions printed on the product containers and relied on the service technician from the vendor company to provide guidance on proper use. During an interview on 06/26/2025 at 5:41 PM, the FA stated that the environmental conditions observed were not acceptable and did not reflect the facility’s expectations for cleanliness and infection prevention. The FA further explained that the environmental services team is responsible for cleaning patient care areas nightly and acknowledged that areas with visible dust, standing water, insect traps, and chemical sprays should have been addressed promptly. The FA confirmed that bug sprays, zappers, and other pest control chemicals are not permitted to be stored or used within patient care areas due to safety and infection control risks. 5. Observations on the treatment floor at the medication preparation area on 06/23/2025 at 9:00 AM revealed: a. Six (6) 3 mL syringes with needles attached prefilled with heparin (medication that slows down or prevents the formation of blood clots) were found stored in a medication preparation area. Each syringe was labeled with the medication name, dosage, and patient name; however, none of the syringes were labeled with the initials of the person who prepared them, nor did they contain the time of preparation. b. Eleven (11) 10 mL syringes with needles attached prefilled with heparin were found stored in a medication preparation area. Each syringe was labeled with the medication name, dosage, and patient name; however, none of the syringes were labeled with the initials of the person who prepared them, nor did they contain the time of preparation. c. Two (2) syringes containing Gentamicin (antibiotic used to treat various bacterial infections) were also observed in the same area. These syringes were similarly incomplete in labeling and were not labeled with the initials of the person who prepared them, nor did they contain the time of preparation. During an interview on 06/23/2025 at 9:15 AM, the FA verified the meds were not labeled with initials or time prepared. 6. Observations on the treatment floor at the medication preparation area on 06/23/2025 at 9:10 AM revealed a cabinet door was unlocked with an area for a lock on the front; however, the lock had been removed. Medications were stored inside this area and was accessible to unauthorized individuals. During an interview on 06/26/2025 at 5:41 PM, the FA verified that policy and procedure should be followed when labeling medications and that medications should be locked and not accessible to unauthorized individuals.”

“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: 49570 Based on review of facility policy, observation, and interview, the facility failed to ensure that patients’ vascular access sites were visible and not covered during treatment on 1 of 2 (06/23/2025) observation days. The practice of leaving the access sites is essential for prompt identification of complications such as infiltration, bleeding, or dislodgement. The findings revealed: 1. Review of facility policy, “Intradialytic Monitoring of Patient” revised 07/2024, revealed, “ ...Ensure Patient’s Access, Blood lines, and Face are visible at all times ...” 2. Observations on the treatment floor at Station #16 on 06/23/2025 at 10:20 AM, 10:43 AM, 11:02 AM, and again at 11:28 AM. revealed the patient’s vascular access site was observed to be covered with a blanket at multiple intervals during treatment. Specifically, the site remained covered during observations. Observations on the treatment floor at Station #5 at 12:28 PM revealed RP #5’s vascular access site was covered. Observations on the treatment floor at Stations #18 and #20 on 06/24/2025 at 9:39 AM revealed both patients were observed with a covered vascular access at 9:39 AM During an interview on 06/26/2025 at 5:41 PM, the FA stated that staff are expected to always maintain visual access of the patient’s access site during hemodialysis treatment.”

“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: 49570 Based on review of facility policy, observation, and interview, the facility failed to ensure appropriate infection control measures were implemented by 3 of 3 (PCT #1, CCHT #1, and CCHT #2) staff members for the effective evaluation and preparation of the vascular access site prior to cannulation of an AVF/AVG on 1 of 1 (06/23/2025) observation days. The facility failed to ensure staff performed and/or verified cleansing of the vascular access site with soap and water prior to antiseptic application per facility policy; failed to ensure the access site was disinfected with alcohol for the minimum of 30 seconds per facility policy; and failed to ensure the site was appropriately re-cleaned following recontamination by direct patient care staff. The findings included: 1. Review of facility policy, “Assessment and Cannulation for AV Fistula/Graft and Patient Self Cannulation” revised 10/2023, revealed, “Procedure: Established AVF ...a. Patient must wash access with soap and water prior to disinfection and cannulation. b. If unable, staff will wash patient’s access with soap and water (rinsing and drying afterwards), with other approved skin cleansing agent or cleansing wipe ...3. Access Preparation ...c. Disinfect each access site separately with one of the below options: Alcohol Prep Pad ...utilize a rubbing motion for at least 30 seconds ...NOTE: Repeat access preparation if cannulation area has been touched/re-contaminated ...” 2. Observations on the treatment floor at Station #10 on 06/23/2025 at 10:30 AM revealed PCT #1 initiated hemodialysis via an AVG/AVF on RP #4. PCT #1 failed to verify or perform washing of the access sites with soap and water prior to antisepsis and failed to perform the required 30-second scrub time on each access site per facility policy. PCT #1 proceeded with antisepsis using an alcohol pad for approximately 21 seconds on one access site and approximately 23 seconds on the second site. Immediately following antisepsis, PCT #1 palpated both access sites with gloved fingers, resulting in recontamination, and initiated cannulation without repeating skin antisepsis. Observations on the treatment floor at Station #14 on 06/23/2025 at 10:54 AM revealed CCHT #2 initiated hemodialysis via an AVG/AVF on RP #6. CCHT #2 failed to verify or perform washing of the access sites with soap and water prior to antisepsis and failed to perform the required 30-second scrub time on each access site per facility policy. CCHT #2 proceeded with antisepsis using an alcohol pad for approximately 3 seconds on one access site and 7 seconds on the second site. Observations on the treatment floor at Station #5 on 06/23/2025 at 11:05 AM revealed CCHT #1 initiated hemodialysis via an AVG/AVF on RP #4. CCHT #1 failed to verify or perform washing of the access sites with soap and water prior to antisepsis and failed to perform the required 30-second scrub time on each access site per facility policy. CCHT #1 proceeded with antisepsis using an alcohol pad for approximately 6 seconds on one access site and approximately 4 seconds on the second site. Immediately following antisepsis, CCHT #1 palpated both access sites with gloved fingers, resulting in recontamination, and initiated cannulation without repeating skin antisepsis. 3. During an interview on 06/26/2025 at 5:41 PM, the FA verified that policy and procedure should be followed when initiating hemodialysis with an AVG/AVF.”

“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: 49570 Based on review of facility policy, QAPI meeting minutes, and interviews, the facility failed to ensure the QAPI program included a comprehensive, data-driven approach to identify, monitor, and address systemic issues impacting patient health and safety. The findings revealed: 1. Review of facility policy, “Introduction to Quality Assessment and Performance Improvement (QAPI),” revised 01/2020, revealed, “A quality assessment and performance improvement program (QAPI) is a well-defined organized program which monitors standards of patient care. The process includes systematically examining patient care, identifying deficiencies, establishing priorities, searching for a probable cause generating and choosing a solution, implementing the solution and then re-examining the case. The purpose of the program is to establish effective problem-focused review and evaluation of the quality, safety, and appropriateness of patient care ...” Review of the facility policy, “Infestation of Bed Bugs” revised 11/2024, revealed, “... Purpose: To provide guidance on identifying suspected or actual bed bug infestation, treating and preventing further spread within the facility... Bed bugs are a growing national problem. Pest control specialists are required to eradicate bed bugs as ordinary household insecticides are ineffective. Periodic inspection and prompt notification of any suspected infestation are key to identifying and controlling infestations. Waiting rooms, visitor lounges, common areas and equipment such as wheelchairs and dialysis chairs should be regularly inspected for bed bugs...Policy... If there are any signs or symptoms of possible infestation on a patient... or within the facility, notify Facility Administrator (FA) Immediately... If actual bed bugs are visualized, save one, if possible... for pest identification purposes... If an active/actual case of bed bugs found, complete an occurrence/incident report...The FA or facility designee will complete the approval request for facility treatment... Notify physician/Advanced Practice Provider and Senior Management... Hold a Governing Body meeting and complete root cause analysis...” 2. Review of a Pest Control work order dated 4/4/2024 revealed, “...Commercial Bed Bug... Technician Comments: Inspected and treated patient area chairs, nurses station, office areas, lab, waiting room, chairs in waiting room, rest rooms, storage areas for bed bugs. Dead bed bug found on floor next to 4th chair in treatment room...” Review of a Pest Control work order dated 4/11/2024 revealed, “... Commercial Bed Bug... Technician Comments: Inspected and treated patient area, chairs, nurses stations, office areas, lab, water room, waiting room, chairs, rest rooms and storage areas for bed bugs. No live bed bugs found...” Review of a Pest Control work order dated 4/18/2024 revealed, “... Commercial Bed Bug... Technician Comments: Inspected and treated patient area chairs, nurses stations, office areas, lab, water room, waiting room, chairs in waiting room, rest rooms and storage areas for bed bugs no live bed bugs found...” Review of a Pest Control work order dated 5/9/2024 revealed, “... Commercial Bed Bug... Technician Comments: Inspected and treated patient area chairs, nurses stations, office areas, lab, water room, waiting room chairs, rest rooms and storage areas...” Review of a Pest Control work order dated 5/30/2024 revealed, “... Commercial Bed Bug... Technician Comments: Inspected and treated entire patient area, waiting room, water room, lab, office areas and all chairs throughout the building for bed bugs. Live bed bugs found on chairs 1, 3, and 17...” Review of a Pest Control work order dated 6/6/2024 revealed, “... Commercial Bed Bug... Technician Comments: Inspected and treated entire patient area, waiting room, water room, lab, office areas and all chairs throughout entire building for bed bugs live bed bugs found in seat 20...” Review of a Pest Control work order dated 6/14/2024 revealed, “... Commercial Bed Bug... Technician Comments: Inspected and treated entire patient area, waiting room, water room, lab, office areas and all chairs throughout entire building for bed bugs no live bed bugs found...” Review of a Pest Control work order dated 6/20/2024 revealed, “... Commercial Bed Bug... Technician Comments: Inspected and treated entire patient area, waiting room, water room, lab, office areas, all chairs throughout and entire building for bed bugs...” Review of a Pest Control work order dated 6/17/2025 revealed “... Commercial Bed Bug... Technician Comments: Inspected and treated entire clinic for bed bugs. All office areas, patient care areas, restroom, water room and all chairs throughout the entire clinic. Bed bugs found on 2 chairs in patient care area...” 3. Review of Social Work note dated 2/26/2025 at 3:11 PM revealed, “... Staff alerted SW to patient (RP #9) having pests on clothing. Patients belongings were placed in a bag and not permitted on the treatment floor. Due to patients intellectual disability, SW contacted patients mother to inform her of staff observations. Patients mother stated she was unaware and that she recently had an exterminator in the home and that she would have him return. SW offered educational materials and resources which she declined stating she is familiar with the pests [bed bugs]...” Review of Social Work note dated 3/7/2025 at 4:42 PM, revealed, “... Staff contacted patients (RP #9) mother. SW communicated with patients mother as well... Requested she not permit patient to come with additional items such as her blanket until we have a letter from pest control stating the home has been treated and there are no signs of infestation....” Review of a Social Work note dated 5/6/2025 at 9:51 AM revealed, “... RN informed SW that they observed bed bugs on the patient (RP #10). They did place patients belongings in a red bag...” Review of a Social Work note dated 5/6/2025 at 9:53 AM revealed, “... SW met with patient (RP #10) who stated they... will purchase items to spray...” Review of a Social Work note dated 5/6/2025 at 9:54 AM revealed, “Patient (RP #10) requested a list of exterminators. SW created list of 5 companies to choose from and gave to patient...” Review of a Social Work note dated 5/13/2025 at 4:16 PM revealed, “... Spoke with patient (RP #10) who stated they have had multiple pest control contractors come in and present their cost. Lowest they have received at this time is $700... They have not reached out to family for any assistance and prefer not to stating’ they can’t help us’...” 4. Review of QAPI meeting minutes dated 02/2025, 03/2025, 04/24/2025, and 05/22/2025 failed to reflect any documented discussion of pest control issues within the dialysis treatment area, despite evidence of an ongoing bed bug infestation. The minutes lacked evidence of problem identification, development of a corrective action plan, or follow-up to monitor effectiveness. During an interview conducted on 06/25/2025 around 12:45 PM, the FA confirmed that pest control issues had not been formally addressed during QAPI meetings, and no specific performance improvement projects were initiated to resolve the concerns or evaluate the facility’s pest control regimen.”