Fmc Central Memphis

“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 provide a safe environment by not ensuring supplies were discarded before their expiration date. The findings included: 1. Review of facility policy, “Storage of Supplies” published 11/3/2025 revealed, “...Supplies must be rotated First in - First out (FIFO) to ensure products maintain quality and do not expire. Appropriately dispose of items that have reached the expiration date...” 2. Observations on the treatment floor on 12/15/2025 at 9:45 AM, revealed the following expired supplies in the storage cabinet: One hundred and sixteen (116) 325 mg acetaminophen tablets. Twenty-one (21) Blood collection sets. 3. During an interview on 12/15/2025 at 10:06 AM, the RN verified the above expired supplies. During an interview on 12/16/2025 at 11:02 AM, the CM verified that all supplies should be routinely checked and discarded when expired.”

“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: 46831 Based on review of facility policy, observation, and interview, the facility failed to ensure the cleaning and disinfection of dialysis stations for 2 of 2 (12/15/2025 and 12/16/2025) observation days. The findings included: 1. Review of the facility policy “Prime Bucket Disinfection” published 5/2/2022 revealed, “...Dispose of the saline solution down any marked dirty sink...Clean all surfaces of the prime bucket or approved receptacle, with 1:100 bleach solution...Return clean prime bucket or approved receptacle to the machine...” 2. Observations on 12/15/2025 at 10:45 AM, revealed that PCT#1 failed to wipe wet the internal and external surface of the prime waste container on the floor at Station #3. Observations on 12/16/2025 at 10:18 AM, revealed that PCT#2 failed to wipe wet the internal and external surface of the prime waste container on the floor at Station #7. 3. During an interview on 12/16/2025 at 11:02 AM, the CM verified that the prime bucket should be cleaned and wiped down between every treatment.”

“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 review, observation, and interview, the facility failed to ensure medications were labeled according to facility policy on 1 of 1 (12/15/2025) observation days. The findings included: 1. Review of facility policy, “Medication Preparation and Administration” dated 7/7/2025, revealed, “...When preparing medications, if the vial is not used immediately in its entirety, the nurse or PCT (if allowed by state regulations) must place the date and time the vial was opened on the medication label along with their initials. Note: To ensure all open vials are properly marked, the nurse must never walk away from an opened multi-dose vial without writing the date and time the vial was opened...” 2. Observations on the treatment floor on 12/15/2025 at 9:56 AM, revealed the following medication not properly labeled: One (1) Heparin vial 30 mL opened with no label, time, date, or initials present. 3. During an interview on 12/15/2025 at 10:06 AM, the RN verified the above medication was not labeled per facility policy. During an interview on 12/16/2025 at 11:02 AM, the CM verified that all medications should be dated when first used.”