Davita Golden Triangle Dialysis

“CFC-PHYSICAL ENVIRONMENT CFR(s): 494.60 This Condition is not met as evidenced by: 48653 Based on observation, record review, and staff interview, the facility staff failed to: A. maintain and provide dialysis staff a functional and comfortable treatment environment in 2 (Storage Room and Bio-Hazard Waste Room) of 2 areas observed in the facility. (Cross Refer to Tag: V0401) B. ensure that 1 (Patient # 8) of 1 isolation patients had access to the emergency nurse call cord during hemodialysis treatment. (Cross Refer to Tag: V0402) C. ensure that 2 (Intravenous Pump # 1 and Hoyer Lift # 1) of 2 patient equipment in the facility was labeled with a current preventative maintenance (PM) date after the equipment had preventative maintenance performed. (Cross Refer to Tag: V0403) D. ensure that 1 (Patient # 8) of 1 isolation patients’ hemodialysis access was visible throughout the entire treatment. Additionally, the facility staff failed to follow the “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment” policy. (Cross Refer to Tag: V0407)”

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 48653 Based on observation, record review, and staff interview, the facility staff failed to ensure that: A. one of 1 emergency crash cart and associated emergency equipment (suction regulator) was checked for operational status weekly, as required by the facility’s policy, “Emergency Equipment Checks”. B. ten of 10 oxygen E-Cylinders were stored in a secure oxygen tank rack. Findings include: A. This deficient practice had the likelihood of resulting in a delay in care and treatment to patients requiring suction during a respiratory arrest event. During a tour of the facility’s in-center treatment area on 09/22/2025 at 1:34 PM with Staff # 20 (Charge Nurse), the surveyor observed that the emergency crash cart was covered with a thick plastic covering. Upon uncovering the emergency crash cart, the surveyor noted the suction regulator was not plugged into an electrical outlet and could not be checked for operational status. The surveyor instructed Staff # 20 to plug the suction regulator into an electrical outlet to verify that the suction regulator was operational. Staff # 20 stated, “I checked the code cart this morning because we always check the code cart on Monday mornings. I did not plug the suction in this morning to make sure it was working.” When Staff # 20 turned the suction regulator on, the surveyor discovered the regulator was not providing suction. Staff # 20 and Staff # 9 observed that the suction regulator was not providing suction, and the staff members had to call the biomedical technician to check the equipment. Staff # 20 (Charge Nurse) failed to ensure the emergency equipment was operational and ready for use in the case of a patient emergency. A review of the facility’s “Emergency Equipment Checklist” with a date of 09/22/2025 revealed, Staff # 20 (Charge Nurse) had documented the suction machine was operational. A review of the facility’s policy, “Emergency Equipment Checks,” with a date of October 2024, revealed, “Purpose: Verify that emergency equipment is maintained in a ready-to-use condition. Policy: 1. Emergency equipment, including, but not limited to, oxygen, airways, suction, automated external defibrillator (AED), and artificial resuscitator (Ambu bag), and emergency drugs will be on the premises at all times. 2. Recommended emergency medications to stock in the facility are medications to treat allergic reactions, anaphylactic reactions, hypoglycemia, and chest pain. Medications that treat cardiac arrest or other emergencies are provided by and administered by Emergency Medical Services (EMS). 3. The following equipment checks will be performed by a licensed nurse teammate to verify the designated equipment is available and functional: ...Weekly: Oxygen supply is adequate (at least 1 tank either on or next to the emergency cart. Airways are available. Suction is operational. AED is operational and pads are compatible with the AED device ...The artificial resuscitator (Ambu bag) is operational. Emergency crash cart is clean, operational, and supplies/medications have not expired ...” An interview was conducted with Staff # 9, # 11, and # 20 on 09/22/2025 at 1:40 PM in the in-center treatment area. The staff members confirmed the suction regulator was not operational, and the staff members had to change the associated suction cannister to ensure suction was present. 48749 B. This deficient practice had the likelihood to cause harm to the facility’s dialysis patients and staff if the oxygen E-Cylinders fell over. If an oxygen E-Cylinder falls over, it can pose a serious safety threat due to the potential of it becoming a projectile and fire hazard from the pressurized oxygen rapidly escaping the cylinder. During a tour of the facility on 09/22/2025 at 3:40 PM, the surveyor observed that ten (10) oxygen E-Cylinders were stacked loosely on their sides on a shelf in the storage room. The E-Cylinders were not secured in a designated oxygen tank rack in the storage room. An interview was conducted with Staff #9 on 09/22/2025 at 5:30 PM. Staff #9 acknowledged the surveyor’s findings that the oxygen E-Cylinders were not secured in an oxygen tank rack in the storage room.”

“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: 48653 Based on observation, record review, and staff interview, the facility staff failed to provide and monitor a sanitary environment to minimize the transmission of infectious agents in 1 (In-Center Treatment Area) of 1 areas of the facility. The facility staff failed to follow the “Infection Control for Dialysis Facilities” policy. Findings include: During a tour of the facility’s in-center treatment area on 09/22/2025 at 1:00 PM with Staff # 9, the surveyor observed the following infection control issues: A central supply cart was located on the in-center treatment floor and was found to contain an expired solution of ExSept Antimicrobial Cleanser with an expiration date of “09-03-2025”. There was a white clamp lying on the counter next to a bleach bucket. The surveyor was unable to determine if the clamp was clean or dirty. There were 2 blue dialysis clamps lying on the windowsill next to the emergency exit door. Four large, white, decorative wall moldings were covered in a thick layer of dust. The wall moldings were made of a material that did not allow for easy and appropriate disinfection and cleaning. There were areas of orange and brown splatter on the wall moldings. The floors of the in-center treatment area were very dirty with discoloration. The floors located between the hemodialysis machines and the wall boxes had black residue and dirt built up. The surveyor was able to remove the black residue with a bleach wipe. There were 3 intravenous pump (IV) poles that had a build-up of dust and dirt on the bottom portion of the poles. Two medication refrigerators were in the medication preparation area. The refrigerators had a build-up of dirt, dust, and other unidentifiable debris on the bottom shelf of the refrigerators. The drawers located at the medication preparation area contained sterile patient supplies. The inside of the drawers was dirty and contained dirt, dust, hair, and other unidentifiable debris. There was a silver metal lamp sitting on the counter of the mediation preparation area. The lamp was covered in rust and had large pieces of dried and sticky residue that were left on the lamp where tape or stickers had previously been. The rust from the lamp was flaking off onto the medication preparation counter. The laboratory refrigerator was dirty. The inside of the refrigerator had unidentifiable black splatter on the walls and bottom shelf of the refrigerator. There was a gray pillow and white blanket stored on the oxygen E-cylinder racks. The pillow and blanket were not in a bag and were stored with oxygen cylinders and the patient Hoyer lift. Staff # 9 was unable to verbalize where the pillows and blanket came from or who they belonged to. There was an empty corrugated cardboard box sitting on the floor located outside the patient isolation room. “External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material, serve as generators of and reservoirs for dust.” (AAM1 ST46-Section 5.2 Receiving items). A review of the facility’s “Infection Control for Dialysis Facilities” policy with a date of April 2023 revealed, “Purpose: To minimize the spread of infections or bloodborne pathogens in the dialysis facility environment. Policy: The Centers for Disease Control (CDC) Recommendations for preventing Transmission of Infections among Chronic Hemodialysis Patients (Dialysis Precautions) will be followed when caring for all patients. Additional precautions recommended by the CDC are to be observed for patients with infectious hepatitis B ...” An interview was conducted with Staff # 9 on 09/22/2025 at 1:45 PM. Staff # 9 confirmed the infection control findings.”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 48653 Based on observation, record review, and staff interview, the facility staff failed to ensure all medications maintained in the facility were properly safeguarded and not accessible to unauthorized persons. The facility staff failed to follow the “Medication Policy”. Findings include: During a tour of the facility’s in-center treatment area on 09/22/2025 at 1:30 PM with Staff # 9, the surveyor observed the following: There were 2 medication refrigerators located in the medication preparation area. The medication refrigerators were unlocked and accessible to unauthorized persons. There were 2 pre-filled medication syringes sitting on the chairside of Station # 10. The medications were unsecured and accessible to unauthorized persons. There was no patient present at Station # 10. There were 2 pre-filled medication syringes sitting on the chairside of Station # 15. The medications were unsecured and accessible to unauthorized persons. There was no patient present at Station # 15. A review of the facility’s “Medication Policy” with a date of October 2023 revealed, “Purpose: To provide guidance for medication management in the facility and to provide guidance for the safe and aseptic preparation of all medications. Policy: 1. The Facility Administrator/designee is responsible for supervising the handling, storing, disposing, administering, and controlling of medications and performs a monthly audit and inventory ....All refrigerated medications, for example, erythropoietin-stimulating agents (ESA) and vaccines, are to be locked at the close of each business day or if not under supervision by the licensed teammate or per state regulations. Non-refrigerated medications are to be stored in cabinets and locked at the close of each business day or if not under supervision by the licensed teammate or per state regulations ...” An interview was conducted with Staff # 9 on 09/22/2025 at 1:45 PM, which confirmed there were unsecured medications in the 2 medication refrigerators and at hemodialysis Station # 10 and Station # 15.”

“H20 TANK-SHAPE/VENT/DISINFECT/FILTER P CFR(s): 494.40(a) 5.3.2 Water storage tank: shape/vent/disinfected/filter post When used, storage tanks should have a conical or bowl-shaped base and should drain from the lowest point of the base. Storage tanks should have a tight-fitting lid and be vented through a hydrophobic 0.2 µm air filter. The filter should be changed on a regular schedule according to the manufacturer’s instructions. A means shall be provided to effectively disinfect any storage tank installed in a water distribution system. 7.1 General strategies for bacterial control [in storage tanks]: An ultrafilter, distal to the storage tank, or some other form of bacterial control device is recommended. Storage tanks are therefore not recommended for use in dialysis systems unless they are frequently drained and adequately disinfected. This Standard is not met as evidenced by: 48749 Based on observation and interview, the facility’s biomedical staff failed to ensure that the reservoir vent filter was changed on the facility’s water storage holding tank, primary concentrate tank, and secondary concentrate tank. The facility failed to follow its “Central Water Treatment Systems Minimum Components and Requirements” policy. Findings include: During an observation tour of the facility’s water treatment room, on 09/22/2025 at 3:30 PM, the water holding tank was observed attached to the water treatment system. The tank had a vented filter with a sticker on the exterior that read “date installed 12/21/21, replacement due date 06/22.” Additionally, the primary concentrate tank and the secondary concentrate tank were observed to have vented filters with a sticker on the exterior that read “date installed 12/21/21, replacement due date 06/22.” An interview was conducted with Staff #17 on 09/22/2025 at 4:30 PM. The surveyor asked Staff #17 how often the filters were to be replaced. Staff #17 stated, “I don’t know.” A review of the facility’s “Central Water Treatment Systems Minimum Components and Requirements” policy revealed the following; “25. Indirect water systems with storage tank(s) in place will have *Conical or bowl-shaped base, and will drain from the lowest point of the base. *Tight-fitting, sealed lid vented through a hydrophobic 0.2 ?m air filter. The filter bowl will be non-opaque *The filter will be changed according to the manufacturer’s specifications and will be documented.” A review of the facility’s “Filter Change” guidelines revealed: “RESERVOIR VENT FILTER Normally changed every 90 days.”. The facility was unable to provide documentation to support that the vent filters were changed every 90 days. An interview was conducted with Staff #19 on 09/22/2025 at 4:40 PM. Staff #19 stated, “vent filters are supposed to be replaced quarterly.””

“ACID BULK STORAGE TANKS-SAFETY CONTROLS CFR(s): 494.40(a) 5.4 Concentrate preparation 5.4.3 Bulk storage tanks (acid concentrate): safety controls Procedures should be in place to control the transfer of the acid concentrate from the delivery container to the storage tank to prevent the inadvertent mixing of different concentrate formulations. If possible, the tank and associated plumbing should form an integral system to prevent contamination of the acid concentrate. The storage tanks and inlet and outlet connections, if remote from the tank, should be secure and labeled clearly. This Standard is not met as evidenced by: 48749 Based on observation and interviews, the facility’s Biomedical staff failed to ensure that the acid storage tank did not contain contaminated acid solution resulting from a leak at the acid concentrate delivery pump. This deficient practice had the potential to cause harm to all patients receiving contaminated acid through the loop at the chairside, via the dialysis machine at the facility. Findings include: During a tour of the facility’s water room on 09/22/2025 at 3:30 PM, the surveyor observed that there was a white crystal substance (Acid) build-up around the connection of the concentrate delivery pump between the primary and secondary concentrate tanks. Also, observed a white crystal substance (Acid) build-up on the outlet check valve at the top of the secondary tank. An interview was conducted with Staff #9 and Staff #11 on the afternoon of 09/22/2025. Staff #9 and Staff #11 confirmed the surveyor’s findings of a white crystal substance built up around the connection of the concentrate delivery pump and the outlet check valve at the top of the secondary tank.”

“BICARB MIX SYS-STOR/USE TIME/MIN COMBINE CFR(s): 494.40(a) 5.4.4.3 Bicarbonate concentrate mixing systems: storage/use time limits/min combine Once mixed, bicarbonate concentrate should be used within the time specified by the manufacturer of the concentrate. 7 Strategies for bacterial control 7.1 General Storage times for bicarbonate concentrate should be minimized, as well as the mixing of fresh bicarbonate concentrate with unused portions of concentrate from a previous batch. The manufacturer’s instructions should be followed if they are available. This Standard is not met as evidenced by: 48749 Based on observation and interview, the facility staff failed to properly store the NaturaLyte Bicarbonate Concentrate Powder as recommended by the manufacturer’s guidelines. This deficient practice had the likelihood to cause harm to the facility’s in-center patients by potential cross-contamination through exposure. Findings include: During a tour of the facility’s storage room on 09/22/2025 at 5:40 PM, the surveyor observed two pallets with bags of Naturalyte Bicarbonate Concentrate Powder. There was bicarbonate powder spilling from two of the bags on one of the pallets. Also, there was bicarbonate powder spilled on the other Bicarbonate bags on the pallet and the floor. There was a buildup of dust, dirt, and debris on the storage room floor and around the pallets containing the bicarbonate powder that had the likelihood to contaminate the open bags of bicarbonate. The surveyor had to point out the spilled bicarbonate powder bags to the leadership staff. Leadership staff removed the bicarbonate from the pallet so that the ripped bicarbonate bags would not be available to the facility staff who mix bicarbonate solution. A review of the manufacturer’s guidelines for “Naturalyte Bicarbonate Concentrate Powder” revealed the following: “ Store in a dry location, protect the product from physical damage and extreme temperatures, including freezing and excessive heat.” An interview was conducted with Staff #9 on 09/22/2025 at 5:40 PM. Staff #9 confirmed the surveyor’s findings of spilled bicarbonate powder, open bags of bicarbonate powder, and debris on the storage room floor.”

“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: 48749 Based on observation and interview, the facility staff failed to maintain and provide staff a functional and comfortable treatment environment 2 (Storage Room and Bio-Hazard Waste Room) of 2 areas observed in the facility. During a tour of the facility on 09/22/2025, the surveyor observed the following safety issues: STORAGE ROOM - (RECEIVING AREA) *The floor was covered in dust, dirt, brown colored stains, and debris throughout the supply room. *The back door did not have a complete seal around the bottom of the door. The was a noticeable gap at the bottom that would allow insects, dust, and dirt to come into the area where patient supplies were being stored. Observed multiple dead bugs on the floor. BIO-HAZARD WASTE AREA * The doorway was blocked by cardboard boxes stacked up on the floor. The entrance into the biohazard room was covered in dust, dirt, brown colored stains, and debris. * The floor was discolored and dirty. There was brown and black buildup around the corners of the room. *There were cardboard boxes, red bags, and debris on the floor. An interview was conducted with Staff #9 and Staff #11 on the afternoon of 09/22/2025. Staff #9 and Staff #11 confirmed the the facility staff had failed to maintain the facility’s storage room.”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 48653 Based on observation and staff interview, the facility staff failed to ensure that 1 (Patient # 8) of 1 isolation patients had access to the emergency nurse call cord during hemodialysis treatment. Findings include: During a tour of the facility’s in-center treatment area with Staff # 9 on 09/22/2025 at 1:30 PM, the surveyor observed Patient # 8 receiving hemodialysis treatment in the facility’s isolation room. The patient did not have access to the emergency nurse call cord because the cord was found hanging behind the patient’s dialysis chair. The patient could not call for help in the event of an emergency. An interview with Staff # 9 was conducted on 09/22/2025 at 1:30 PM. Staff # 9 confirmed the patient did not have access to the emergency nurse call cord to summon help in the event of an emergency.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 48653 Based on observation and staff interview, the facility’s biomedical staff failed to ensure that 2 (Intravenous Pump # 1 and Hoyer Lift # 1) of 2 patient equipment in the facility was labeled with a current preventative maintenance (PM) date after the equipment had preventative maintenance performed. Findings include: During a tour of the facility’s in-center treatment area on 09/22/2025 at 1:00 PM with Staff # 9, the surveyor observed a Baxter Flogard Intravenous Pump (IV) with a preventative maintenance sticker affixed to the pump that read, “Date of PM: 07/2024, Next Due: 07/2025”. The intravenous pump had not been updated to reflect the current PM date, which was completed on 07/25/2025 by Staff # 17, according to maintenance records. Further observation revealed the facility’s patient Hoyer Lift had preventative maintenance performed on 07/23/2025 by Staff # 17. However, the patient Hoyer Lift had not been updated with a current PM sticker. An interview was conducted with Staff # 9 on 09/22/2025 at 1:40 PM. Staff # 9 confirmed the preventative maintenance had been completed and that the stickers on the equipment needed to be updated to reflect the current PM date.”

“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: 48653 Based on observation, record review, and staff interview, the facility’s direct care staff failed to ensure that 1 (Patient # 8) of 1 isolation patients’ hemodialysis access was visible throughout the entire treatment. Additionally, the facility staff failed to follow the “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment” policy. Findings include: During a tour of the facility’s in-center treatment area with Staff # 9 on 09/22/2025 at 1:30 PM, the surveyor observed Patient # 8 receiving hemodialysis treatment in the facility’s isolation room. The patient’s hemodialysis access was covered with a blanket and was not visible to the facility’s direct care staff. Failure to ensure the patient’s hemodialysis access was visible throughout treatment had the likelihood of resulting in the patient’s needle becoming dislodged. A dislodged needle could result in the patient losing blood at an accelerated rate. A review of the facility’s “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment” policy, with a date of April 2024, revealed, “Purpose: To obtain and document baseline and ongoing information about the patient before, during, and after the dialysis treatment through data collection and nursing assessment. This information will be used in planning and documenting the patient’s dialysis treatment, monitoring during treatment and for reviewing the patient’s response to the treatment and status prior to discharge. Policy: Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse ....2. The nursing assessment will be performed and documented by a licensed nurse; specifically a Registered Nurse or if performance of a nursing assessment is permitted by state law, a Licensed Practical Nurse (LPN)/Licensed Vocational Nurse (LVN). The assessment includes the following components: i. Review of patient reports, data collection, complaints and response to treatment. ii. Verification that machine safety checks have been completed and documented. iii. Verification of prescription including machine parameters. iv. Verification that the patient’s access is visible and face is not covered ....” An interview was conducted with Staff # 9 on 09/22/2025 at 1:35 PM, which confirmed that the patient receiving hemodialysis treatment in the isolation room had the hemodialysis access covered with a blanket.”

“PQ-STAFF NURSE-MEET STATE REQUIREMENTS CFR(s): 494.140(b)(4) Each nurse who provides care and treatment to patients must be either a registered nurse or a practical nurse who meets the practice requirements in the State in which he or she is employed. This Standard is not met as evidenced by: 48653 Based on observation, record review, and staff interview, per Texas Occupations Code §301.351(c)(1)-(5), the facility staff failed to ensure that 3 (Staff # 18, # 22, # 23) of 3 licensed nurses were wearing an identification badge while providing patient care as required by the Texas Board of Nursing. Findings include: During a tour of the facility’s in-center treatment area with Staff # 9 on 09/22/2025 at 1:15 PM, the surveyor observed 3 licensed nurses providing care to hemodialysis patients. The staff were not wearing a name badge with identification and title while providing patient care. A review of the Texas Occupations Code [TOC] §301.351(c)(1)-(5) revealed, “ ...While interacting with the public in a nursing role, each nurse shall wear a clearly legible insignia identifying the nurse as a registered or vocational nurse. The insignia may not contain information other than: (1) the registered or vocational nurse designation; (2) the nurse’s name, certifications, academic degrees, or practice position; (3) the name of the employing facility or agency, or other employer; (4) a picture of the nurse; or (5) any other information authorized by the board ...” A review of Patient # 1’s “Patient Rights” signed on 11/25/2024 revealed, “Purpose: This form outlines the rights you have as a patient treating at a DaVita facility. Please read the following statements carefully. As a DaVita patient, I understand I am entitled to the following: ...14. To know the names, professional status, and experience of the staff who are providing and coordinating my care and treatment ...” A review of “Section 5: Work Environment of Employee Handbook” (no date provided) revealed, “ ...When wearing a gown in the patient treatment area, any item such as name badge, lanyard, pin, and/or button must remain under the teammate’s gown ...” An interview was conducted with Staff # 22 (Licensed Vocational Nurse) on 09/22/2025 at 5:55 PM. Staff # 22 was asked if they had an identification badge on. Staff # 22 stated, “No, our company policy states we do not have to”. An interview was conducted with Staff # 9 on 09/22/2025 at 6:00 PM. Staff # 9 confirmed that the Employee Handbook and the Patient Rights Policy conflicted with the Texas Occupations Code.”

“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: 48653 Based on observation, record review, and interview, the facility failed to monitor and provide a sanitary environment to minimize the transmission of infectious agents within the dialysis center. The facility staff failed to follow the facility policy, “Infection Control for Dialysis Facilities”. This deficient practice had the likelihood to cause harm to patients, staff members, and the public by increasing the risk of transmission of infectious agents within the facility. Findings Include: During a tour of the facility on 04/15/2024 at 1:04 PM with Staff # 11, the surveyor observed the following infection control issues: Water Treatment Room * A dried white substance was found splashed on the floor and around the outside of the acid-holding tank. * A brown and black substance was found on the floor around the residual acid waste sink. The floor was dirty and had a build-up of debris and dust on it. In-Center Treatment Area * 1 IV (intravenous) pump was found in the area designated as “clean”. The IV pump had a thick build-up of dust and dirt on the back portion of the pump. The power cord had an unidentifiable brown substance splashed on it. * 2 oxygen concentrators and 1 IV pump were found stored next to a large gray trashcan. The trashcan was full and had trash inside of it. * The cabinet door located under the sink designated as “clean” had a build-up of rust on the door hinge. The rust was coming off the metal hinge and was found built up on a packaged dialyzer. * Machine # 26 was designated as “clean”. The back of the machine had a thick build-up of dust on the back, bottom ledge of the machine. The dialysis filter on the back of the machine was dirty. It had a thick build-up of dust and dirt inside it. There was also rust noted in the blood pump module. * An expired ExSept bottle with an expiration date of “04/08/2024” was found on the black supplies cart. A review of facility policy, “Infection Control for Dialysis Facilities” dated, April 2023 revealed, “PURPOSE: To minimize the spread of infections or bloodborne pathogens in the dialysis facility environment. POLICY: The Centers for Disease Control (CDC) Recommendations for preventing the transmission of infections among chronic hemodialysis patients (Dialysis Precautions) will be followed when caring for all patients. Additional precautions recommended by the CDC are to be observed for patients with infectious hepatitis B ... DISINFECTION 12. Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infectious materials (i.e. used or brought into the station) and prior to returning to clean/designated area or removal from treatment area. a. Prior to routine disinfection, remove all visible blood i. For visible blood or gross blood spills, a 1: 10 (one to ten) bleach solution must be utilized. ii. After all visible blood is cleaned with the 1: 10 (one to ten) bleach solution, teammates are to use a new disposable towel soaked with 1: 10 (one to ten) bleach solution and clean area a second time. iii. Cleaning of visible blood should be performed when first observed b. Use an appropriate disinfectant such as 1: 100 (one to one hundred) bleach solution for routine disinfection of environmental surfaces. i. Disinfection should be completed by using a wiping motion with friction. ii. Sufficient disinfectant should be applied so that surfaces are visibly wet. iii. Surfaces should be allowed to air dry in order to provide sufficient disinfectant contact time iv. Items disinfected via submersion will be fully submerged 13. At the end of each treatment, the dialysis stations will be cleaned and disinfected. a. Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings (i.e., dialysis chair, tray tables, blood pressure cuffs) and frequently contacted by healthcare personnel (i.e., control panel, top, front, and sides of a dialysis machine; touchscreens; countertops). i. The wall box, drain and water supply lines are considered part of the dialysis delivery system ... FACILITY HYGIENE 16. Clean areas should be designated for the preparation, handling, and storage of medications and unused supplies and equipment. Clean areas should be separated from contaminated areas where used supplies and equipment are handled.” During an interview with Staff # 11 on 04/15/2024 at 2:00 PM, Staff # 11 confirmed the facility had infection control issues.”

“ACID BULK STORAGE TANKS-SAFETY CONTROLS CFR(s): 494.40(a) 5.4 Concentrate preparation 5.4.3 Bulk storage tanks (acid concentrate): safety controls Procedures should be in place to control the transfer of the acid concentrate from the delivery container to the storage tank to prevent the inadvertent mixing of different concentrate formulations. If possible, the tank and associated plumbing should form an integral system to prevent contamination of the acid concentrate. The storage tanks and inlet and outlet connections, if remote from the tank, should be secure and labeled clearly. This Standard is not met as evidenced by: 48653 Based on observation, record review, and staff interviews, the facility’s biomedical staff failed to identify and promptly correct an acid leak present in the facility’s water treatment room. Also, the facility staff failed to follow the policy, “Responsibilities of the Biomed Department”. During a tour of the facility’s water treatment room on 04/15/2024 at 12:54 PM, the surveyor observed a large build-up of dried white crystals on the piping located under the acid mixer. A review of the facility policy titled, “Responsibilities of the Biomed Department” with a revision date of October 2021 revealed, “PURPOSE: To provide guidance for the responsibilities of the DaVita Biomed department. POLICY: 1. The responsibilities of the Biomed Department include: Repair and maintain, with support documentation, all dialysis delivery machines, RO water treatment systems, ancillary equipment, and related equipment used in the provision of care to patients as recommended by the equipment manufacturer’s specifications and DaVita policies and procedures ....” During an interview with Staff # 17 on 04/15/2024 at 1:00 PM, Staff # 17 acknowledged the acid leak coming from under the acid mixer.”

“CONC OUTLETS-SEPARATE/LABELED/CONNECT SAFETY CFR(s): 494.40(a) 5.5.5 Concentrate outlets: separate/labeled/connection safety To prevent mix-ups with delivery of two or more types of acid concentrate, each concentrate should have its own outlet. Concentrate outlets should be compatible with the dialysis machine and have a means of minimizing the risk that the wrong concentrate will be connected to an outlet. The dispensing outlets should be labeled with the appropriate symbol (see AAMI Table 3) indicating the proportioning ratio for the dialysis machine and should be color-coded blue for bicarbonate, red for acid. 6.5 Concentrate distribution A daily check to ensure that the appropriate acid and bicarbonate concentrate is connected to the corresponding concentrate delivery line is recommended if the storage tank is not permanently connected to its distribution piping. This Standard is not met as evidenced by: 48653 Based on observation and staff interviews, the facility’s staff failed to ensure the wall box outlets were clearly labeled with the acid and bicarbonate concentrations. During a tour of the facility’s in-center treatment area on 04/15/2024 at 1:00 PM with Staff # 11, the surveyor observed the acid and bicarbonate labels on all 30 wall boxes were not legible and identifiable. During an interview with Staff # 11 on 04/15/2024 at 1:30 PM, Staff # 11 acknowledged the wall boxes needed to be re-labeled so that staff could identify the acid and bicarbonate concentration coming from the wall box outlets.”

“PR-PTS INFORMED OF RIGHTS WHEN BEGIN TX CFR(s): 494.70 The dialysis facility must inform patients (or their representatives) of their rights (including their privacy rights) and responsibilities when they begin their treatment and must protect and provide for the exercise of those rights. This Standard is not met as evidenced by: 48653 Based on record review and staff interview, the facility failed to ensure a properly executed informed consent for hemodialysis treatment was completed for Patient # 1. Also, the facility staff failed to follow the policy, “INFORMED CONSENT FOR DIALYSIS TREATMENT”. Findings: During a review of Patient # 1’s medical record, the surveyor observed the patient signed “CONSENT-HEMODIALYSIS TREATMENT” on 03/07/2024. The Registered Nurse witnessed the informed consent. The Registered Nurse’s signature is illegible and there was no date or time. There was no signature from the physician who ordered the hemodialysis treatment. There was no physician’s signature on the informed consent. There was no documentation in the medical record by the physician confirming risks and benefits had been explained to the patient before the initiation of hemodialysis treatment as required by the facility’s informed consent policy. During an interview with Staff # 18 (Administrative Assistant) on 04/15/2024 at 1:30 PM, Staff # 18 stated, “I obtain the consent forms for all of the patients. I read the consent for hemodialysis form to the patient and the patient signs the form. If the patient has any questions, I send the patient to the Registered Nurse for questions related to the informed consent.” Staff # 18 was asked if she has any training or licenses that qualify her to assess the patient’s competence and cognitive function. Staff # 18 stated, “No, I do not and I do not assess the patient’s competence or cognitive function before reading the consent forms to the patient but my job description states I am to obtain all consents on new admissions.” A review of the Job Description for “Administrative Assistant- Clinical III Job Code: O329” with an effective date of March 2014 revealed, “The Administrative Assistant- Clinical III provides clerical, communication, and administrative support to a dialysis facility. This position reports to the Facility Administrator. Essential Duties and Responsibilities ... Prepares patient charts and obtains consents on all new admissions ... Minimum Qualifications: a. High School diploma or equivalent required, medical secretary experience a plus. b. Demonstrated abilities in basic clerical skills, filling, and all office machines. c. Intermediate to advanced computer skills (Microsoft Office products and Outlook). d. Knowledge of purchasing and inventory control methodologies preferred.” A review of the facility policy, “INFORMED CONSENT FOR DIALYSIS TREATMENT” with a revision date of April 2023 revealed, “PURPOSE: To provide guidance for the informed consent for dialysis treatment. POLICY: 1. This policy applies to all patients receiving dialysis treatment within a DaVita Inc. facility (including visiting patients). This does not pertain to any home training programs or other procedures that require separate consent. 2. A statement signed by the patient will be placed in the patient’s chart. 3. To guarantee that every patient is fully informed regarding dialysis treatment, prior to the first dialysis treatment in the facility he/she must have the following: a. Explanation of ESRD diagnosis, risks, benefits, complications, and alternatives to treatment explained to them by the patient’s physician. b. An opportunity to ask questions of the dialysis facility teammates relating to the facility operation. c. An informed consent (Authorization for the Verification of Consent to Hemodialysis Procedure or Authorization for and Verification of Consent to Peritoneal Dialysis Procedure) signed by the patient or personal representative and witnessed by the Registered Nurse. 4. If a patient or the patient’s personal representative is unable to sign the informed consent in person, the registered nurse will send an encrypted email with the informed consent to the patient or the Davita approved video platform for web conferencing to fully inform the patient or the patient’s representative of the patient’s dialysis treatment including 3(a)-(b) above. a. Using the DaVita-approved platform for web conferencing, the Registered Nurse must then verbally obtain the patient or the patient’s personal representative’s informed consent. The RN must then document that verbal consent was obtained from the patient or the patient’s personal representative via a DaVita-approved platform for web conferencing and provide the reason for obtaining verbal consent (e.g., out of town, unavailable, etc). 5. The consent, original signed consent form must be filed in the patient’s current medical record at all times. 6. A new consent form must be signed: a. When a patient transfers to another Davita facility. b. When the patient is readmitted to DaVita after discharge/transfer c. When the patient changes modalities. 7. If a patient is officially discharged or transferred to another facility, the patient must review and sign a new consent form prior to returning for treatment in the original DaVita facility.” During an interview with Staff # 11 (Facility Administrator) on 04/15/2024 at 1:40 PM, Staff # 11 acknowledged there was no documentation from the physician stating risks and benefits had been explained to the patient prior to obtaining consent. Also, Staff # 11 confirmed the Administrative Assistant’s job description included the duty of obtaining consent from the patients and the facility failed to follow the informed consent policy.”

“IC-SINKS AVAILABLE CFR(s): 494.30(a)(1)(i) A sufficient number of sinks with warm water and soap should be available to facilitate hand washing. This Standard is not met as evidenced by: 29191 Based on observation and interview, the facility failed to ensure that the sinks in the in-center treatment area had warm water for staff to wash their hands. On 01/18/2024 the sink located at the nurse’s station area was turned on and allowed to run for 40 seconds and the water remained cold. The facility had a natural gas leak on Monday January 15, 2024. The natural gas has been off 3 days. There are 2 hot water heaters in the facility. Both hot water heaters run off natural gas. One of the hot water heaters has been alarming since 12/31/2023. An interview with Staff #1 confirmed the water at all the in-center treatment sinks was cold water. Staff #1 confirmed the natural gas has been off for 3 days.”

“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: 29191 Based on observation and interview, the facility staff failed to ensure that dirty clamps were submerged in the bleach water. The bleach containers were used for cleaning and disinfecting non-disposable equipment. Also, the facility failed to follow its policy on “INFECTION CONTROL FOR DIALYSIS FACILITIES.” This deficient practice had the likelihood of causing harm to the patients by exposing patients to clamps that had not been disinfected. Findings include: During a tour of the in-center treatment floor observed a bleach container that held blue and white clamps. The clamps were not completely submerged in the 1:100 bleach solution. There was no way to determine if the clamps were being disinfected per the policy procedure. There was large container of blue clamps sitting on the counter by the nurse’s station that had no lid and it was not labeled, so there was no way to determine if the clamps were clean or dirty. A review of the policy titled, “ INFECTION CONTROL FOR DIALYSIS FACILITIES” dated April 2023 revealed the following: “14. Non-disposable items are to be disinfected after each patient use, prior to removal from treatment area/station, and if contaminated between uses. If item cannot be cleaned and disinfected it will be dedicated for use on a single patient. a. Stethoscopes will be disinfected with alcohol prep pad and/or 1:100 (one to one hundred) bleach solution and if they are visibly contaminated with blood or body fluids should be disinfected with a 1:10 (one to ten) bleach solution. b. Hemostats (blood line clamps) should be in the open position and fully submerged in an appropriate disinfectant solution. For disinfection of vascular access clamps, please refer to policy: Utilizing Vascular Access Clamps c. Containers used to soak clamps, or other non-disposable equipment will be cleaned and disinfected at the conclusion of the day, or immediately after visible contamination.” An interview with Staff #1 on 01/18/2024 at 1:30 PM confirmed the blue and white clamps were not submerged in the bleach solution to obtain disinfection and that the container of blue clamps was not labeled to know if the clamps were clean.”

“ACID BULK STORAGE TANKS-SAFETY CONTROLS CFR(s): 494.40(a) 5.4 Concentrate preparation 5.4.3 Bulk storage tanks (acid concentrate): safety controls Procedures should be in place to control the transfer of the acid concentrate from the delivery container to the storage tank to prevent the inadvertent mixing of different concentrate formulations. If possible, the tank and associated plumbing should form an integral system to prevent contamination of the acid concentrate. The storage tanks and inlet and outlet connections, if remote from the tank, should be secure and labeled clearly. This Standard is not met as evidenced by: 29191 Based on observation and interview, the facility failed to ensure that the bulk storage acid tank did not contain a contaminated acid solution. This deficient practice had the likelihood to cause harm to all patients receiving in-center hemodialysis at the facility. Findings include: On a tour of the water room on 01/18/2024 at 1:30 PM, observed there was a white substance build-up around the outlet valve at the bottom of the acid storage tank. Also, there was white substance build-up around the pump going to the 2K acid storage tank. The transfer tubing had an acid build-up of a clear white substance running down the tubing and around the connecter. Also, the white substance was splashed on the wall of the acid tank and floor. An interview with Staff #1 and #13 on 01/18/2024 at 1:30 PM confirmed there was a large amount of acid (white substance) build-up and splash on the acid tank, outlet valve, acid pump, transfer tubing, and floor.”

“BICARB MIX SYS-EMPTY/DISINFECT/PREV CORROSION CFR(s): 494.40(a) 5.4.4.3 Bicarbonate concentrate mixing systems: empty/ disinfect/prevent corrosion Bicarbonate concentrate mixing tanks should be designed to drain completely. Mixing tanks should have a tight-fitting lid and should be designed to allow all internal surfaces to be disinfected and rinsed. Because concentrate solutions are highly corrosive, mixing systems should be designed and maintained to prevent corrosion. This Standard is not met as evidenced by: 29191 Based on observation and interview, the facility failed to ensure that the bicarbonate mixing system did not contain contaminated bicarbonate solution. This deficient practice had the likelihood to cause harm to all patients receiving in-center hemodialysis at the facility. Leaking of the bicarbonate solution can cause corrosion in the bicarbonate mixing system. Findings include: On a tour of the water room on 01/18/2024 at 1:30 PM, observed there was a large amount of white substance build-up around the bicarbonate pump and connectors. Also, the white substance was splashed on the bottom of the mixing system and onto the floor. An interview with Staff #1 and #13 on 01/18/2024 at 1:30 PM confirmed there was a large amount of bicarbonate (white substance) build-up on the bicarbonate pump, connectors, and splash on the bottom of the mixing system and onto the floor.”

“ACID CONC DIST-CONC LABELED & COLOR-CODED RED CFR(s): 494.40(a) 5.5.3 Acid concentrate distribution systems: labeled & color-coded red Acid concentrate delivery piping should be labeled and color-coded red at the point of use (at the jug filling station or the dialysis machine connection). All joints should be sealed to prevent leakage of concentrate. If the acid system remains intact, no rinsing or disinfection is necessary. More than one type of acid concentrate may be delivered, and each line should clearly indicate the type of acid concentrate it contains. This Standard is not met as evidenced by: 29191 Based on observation and interview, the facility’s staff failed to ensure that the dialysis stations’ wall boxes (acid dispensing outlets) had no leaks and were properly cleaned. Also, the facility’s staff did not follow the policy “Infection Control for the Dialysis Facilities” for cleaning the wall boxes. This deficient practice has the likelihood to cause nonbacterial contamination and evaporation in the wall boxes and infect the patients receiving in-center hemodialysis at the facility. Findings include: A tour of the in-center treatment area on 01/18/2024 at 1:30 PM observed that wall boxes had dried crusted white sediment in the outlet boxes and around the acid outlets. Staff #1 and #13 were on the tour and observed the acid outlets and wall boxes had dried crusted white sediment. The surveyor asked who was responsible for cleaning the wall boxes. Staff #1 stated, “The staff is responsible for cleaning the wall boxes”. A review of the CDC guidelines related to dialysis wall boxes revealed the following: “Dialysis wall boxes are frames recessed into the wall at each hemodialysis station that contain connections for the dialysis machine to receive acid and base concentrates and treated water, and dispose of waste products. There are several infection prevention and control issues unique to wall boxes. They can become easily contaminated with microorganisms, which can subsequently be transferred to dialysis patients, a vulnerable group at high risk of infection. Thus, wall boxes need to be cleaned, disinfected, and properly maintained to decrease risk of patient infections.” A review of the facility policy titled; “Infection Control for the Dialysis Facilities” revealed the following: “WALL BOX AND DRAIN/WATER LINE CARE AND MAINTENANCE: 58. The Wall box, Drain, and Water supply lines are considered part of the dialysis delivery system and should be cleaned with 1:100 (one to one hundred) bleach as part of routine station disinfection between each patient treatment. This process will also be completed for the wall boxes in the biomedical repair area once daily. This process of cleaning the drain and water supply lines will also be completed prior to bringing a machine to the treatment floor. NOTE: Do not wipe wall boxes during any active disinfection process in order to avoid chemical reactions (i.e. bleach and citric acid).” An interview with Staff #1 on 01/18/2022 at 1:30 PM confirmed the acid outlets and wall boxes had dried crusted white sediment in all the in-center stations’ wall boxes.”

“BICARB CONC DIST-COLOR CODED BLUE & SEALED CFR(s): 494.40(a) 5.5.4 Bicarbonate concentrate distribution systems: color coded blue & sealed Bicarbonate concentrate delivery piping should be color-coded blue at the point of use (at the jug filling station or dialysis machine connection). All joints should be sealed to prevent leakage of concentrate. This Standard is not met as evidenced by: 29191 Based on observation and interview, the facility’s staff failed to ensure that the dialysis stations’ wall boxes (Bicarbonate dispensing outlets) had no leaks and were properly cleaned. Also, the facility’s staff did not follow the policy “Infection Control for the Dialysis Facilities” for cleaning the wall boxes. This deficient practice has the likelihood to cause bacterial growth and provide another source of initial bioburden in the wall boxes and infect the patients receiving in-center hemodialysis at the facility. Bicarbonate systems should be clean and free of spills of concentrate to prevent corrosion. Findings include: A tour of the in-center treatment area on 01/18/2023 at 1:30 PM observed that wall boxes had dried crusted white sediment in the outlet boxes and around the bicarbonate outlets. Staff #1 and #13 were on the tour and observed the bicarbonate outlets and wall boxes had dried crusted white sediment. The surveyor asked who was responsible for cleaning the wall boxes. Staff #1 stated, “The staff is responsible for cleaning the wall boxes”. A review of the CDC guidelines related to dialysis wall boxes revealed the following: “Dialysis wall boxes are frames recessed into the wall at each hemodialysis station that contain connections for the dialysis machine to receive acid and base concentrates and treated water, and dispose of waste products. There are several infection prevention and control issues unique to wall boxes. They can become easily contaminated with microorganisms, which can subsequently be transferred to dialysis patients, a vulnerable group at high risk of infection. Thus, wall boxes need to be cleaned, disinfected, and properly maintained to decrease risk of patient infections.” A review of the facility policy titled; “Infection Control for the Dialysis Facilities” revealed the following: “WALL BOX AND DRAIN/WATER LINE CARE AND MAINTENANCE: 58. The Wall box, Drain, and Water supply lines are considered part of the dialysis delivery system and should be cleaned with 1:100 (one to one hundred) bleach as part of routine station disinfection between each patient treatment. This process will also be completed for the wall boxes in the biomedical repair area once daily. This process of cleaning the drain and water supply lines will also be completed prior to bringing a machine to the treatment floor. NOTE: Do not wipe wall boxes during any active disinfection process in order to avoid chemical reactions (i.e. bleach and citric acid).” An interview with Staff #1 on 01/18/2024 at 1:30 PM confirmed the bicarbonate outlets and wall boxes had dried crusted white sediment in all the in-center station’s wall boxes.”

“DIALYS PROPORT-MONITOR PH/CONDUCTIVITY CFR(s): 494.40(a) 5.6 Dialysate proportioning: monitor pH/conductivity It is necessary for the operator to follow the manufacturer’s instructions regarding dialysate conductivity and to measure approximate pH with an independent method before starting the treatment of the next patient. This Standard is not met as evidenced by: 29191 Based on observation and interview, the Bio-Medical staff failed to ensure the conductivity and pH solution bottles at 1 of 1 Tri-station was functioning to assist the staff in performing conductivity and checking pH ranges at the dialysis machines. These findings had the likelihood to cause harm to all patients if the conductivity solution to verify the conductivity of the dialysis machines was not functioning within a closed circuit. A broken closed circuit would allow contaminants to enter the R/O and conductivity solution bottles. Findings include: The manufacturer’s instructions for the dialysis machines stated the conductivity should be checked with an independent device. The Phoenix meter’s instruction requires the use of various conductivity solutions. During a tour of the treatment floor on 01/18/2024, observed that the R/O solution bottle and bleach bottle solution in the Tri-station at the in-center treatment area had no secure lids and the labels on the solution bottles were not readable. The normal setup for a tri-station would be a closed circuit. Connected to the closed circuit would be a syringe that allows the staff to draw solutions from the R/O solution and conductivity solutions. The system would be completely closed. A broken closed circuit would allow contaminants to enter the bottle of R/O solution, bleach solution, and conductivity solution. An interview with Staff #1 on 01/18/2024 at 1:30 PM acknowledged that the tri-station closed circuit was broken and the label on the R/O solution and bleach solution bottles were not readable.”

“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: 29191 Based on observation and interview, the facility failed to monitor and provide a sanitary environment to minimize the transmission of infectious agents within the dialysis center. These findings have the likelihood to cause harm by increasing the risk of infection to all patients receiving care at the facility. Findings Include: Observed the following infection control and safety issues during a tour of the facility on January 18, 2024, at 1:30 PM with staff members #1 and #13: IN-CENTER TREATMENT AREA: * The hand washing sinks dirty and clean for the nursing staff on the in-center treatment floor had infection control issues and safety issues. Surveyor looked under 7 of 8 sinks in the treatment area and observed rusted drains, rusted hinges, holes in the plaster underneath the drains, dirt, and plaster particles. Under one of the sinks was a large dead roach. Some of the hinges were so rusted the cabinet door fell on the hinge. There was green and black discolored plaster under the sinks and the plaster was wet and crumbled when touched. *Observed several of the nursing chairs and stools on the treatment floor that had rips in the cushion and the cushion was showing through the vinyl. The metal rims on the chairs were rusted. Cushion and rust cannot be cleaned or disinfected. *Observed floor with multiple areas of black splotches throughout the in-center treatment area. Staff #1 stated, “The floors are due for stripping and wax.” During an interview on 01/18/2024 at 1:30 PM Staff #1 confirmed the above infection control and safety issues within the in-center treatment facility.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 29191 Based on observation and interview, the facility’s Biomedical technician failed to monitor and maintain the dialysis machines were operating according to the manufacturer’s recommendations within the dialysis center. These findings have the likelihood to cause harm by increasing the risk to all patients receiving care at the facility for dialysis machines not operating per the manufacturer’s guideline. Findings Include: During a tour of the in-center treatment floor observed that the clear plastic facing on dialysis machine #2 was cracked. This defective issue would allow moisture and contamination in the circulation area of the dialysis tubing. During an interview on 01/18/2024 at 1:30 PM Staff #1 confirmed the above infection control and safety issues with dialysis machine #2.”