Carthage Dialysis Center

“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: 48749 Based on observation and interview, the facility staff failed to ensure that 2 of 2 sinks in the in-center treatment area had warm water available. The facility staff failed to follow the facility’s “Hand Hygiene” policy. 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 in-center treatment area with Staff #4 on 06/16/2025 at 10:00 AM the surveyor observed the following: The facility had 1 clean sink and 1 dirty sink located on the in-center treatment floor that did not have warm water. The surveyor washed hands for 30 seconds, and the water remained cold for the duration. In addition, the surveyor observed that the countertops around the sinks were worn and chipped, preventing thorough cleaning and disinfecting of the surfaces. According to the CDC (Centers for Disease Control), “Healthcare facilities should ensure that supplies necessary for adherence to hand hygiene are readily accessible in all areas where patient care is being delivered. Hand Hygiene means cleaning your hands by using either handwashing (washing hands with soap and hot water), antiseptic hand wash, antiseptic hand rub (i.e., alcohol-based hand sanitizer including foam or gel), or surgical hand antisepsis.” A review of the facility’s “Hand Hygiene” policy dated 11/06/2023, revealed the following; “Sink Policy: A sufficient number of sinks with soap and plumbed with both hot and cold water shall be available to facilitate hand washing.” An interview was conducted with Staff #16 on the afternoon of 06/16/2025. Staff #16 confirmed that the 2 sinks in the in-center treatment area did not have hot water available for the patients and staff to wash their hands with warm water. Staff #16 reported that there was an issue with the hot water heater and the pilot light.”

“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: 48749 Based on observation, policy review, and staff interviews, the facility staff failed to ensure that patient vaccines were properly stored. Findings include: During a tour of the facility on 06/16/2025 at 10:00 AM, the surveyor observed that the Tuberculin and Hepatitis B vaccines were stored next to the walls of the refrigerator. According to the CDC (Centers for Disease Control) guidelines for the storage of immunizations, https://www.cdc.gov/vaccines/hcp/downloads/storage-handling-toolkit.pdf : “Store between 35 and 46 degrees. Place the vaccine in bins with open airflow or leave the top off. Make sure the door is shut. Remove crisper bins and place water bottles labeled “Do Not Drink” in the bottom. Leave 2-3 inches between all vaccine’s containers and refrigerator walls. Post do not unplug on refrigerator. Don’t use a dormitory-style refrigerator. Don’t store vaccines on the top shelf Don’t put food and beverages in the refrigerator. Don’t put vaccines or diluents in the door or floor of the refrigerator. Don’t drink or remove water bottles. All vaccines have an expiration date determined by the manufacturer that must be observed. Providers should record the vaccine expiration dates and lot numbers on a stock or inventory record for each vaccine vial when a shipment is received. When vaccines are removed from storage, clinicians and other health-care providers should note whether an expiration window exists for vaccines stored at room temperature or at an intermediate temperature.” An interview was conducted with Staff #4 on the morning of 06/17/2025 AM. Staff #4 acknowledged the findings of the patient vaccines stored next to the walls of the refrigerator.”

“IC-HANDLING INFECTIOUS WASTE CFR(s): 494.30(a)(4)(i) [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- (i) Handling, storage and disposal of potentially infectious waste; This Standard is not met as evidenced by: 48749 Based on observation and staff interviews, the facility failed to monitor and provide a secure environment to store outside infectious waste. This deficient practice had the likelihood to cause harm by increasing the risk of infectious waste being made available to the public and pilfering through infectious waste outside of the facility. Findings include; On 06/16/2025 at 9:40 AM, the surveyor observed one unsecured dumpster at the back of the facility. There was an accumulation of garbage bags stacked up on top of the dumpster and on the ground in front of the dumpster. The unsecured dumpster allowed the public and rodents to pilfer through the hazardous trash. An interview was conducted with Staff #4 on 06/16/2025 at 10:00 AM. Staff #4 acknowledged that the dumpster was unsecured and overflowing with infectious waste.”

“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 observations and staff interviews, the facility’s biomedical staff failed to identify and promptly correct an acid leak present in the facility’s water room and in-center treatment area. During a tour of the facility’s water room with Staff #4 and #16 on June 16, 2025, at 11:00 AM, the surveyor observed a significant acid leak under the acid holding tank, along with a large wet area. There was a substantial ring of dried acid crystals around the joints of the piping connected to the storage tank. The acid was dripping from the holding tank onto the floor. During a tour of the facility’s in-center treatment area with Staff #4 on June 16, 2025, at 10:30 AM, the surveyor noticed an acid leak in the chase wall behind Stations #1 through #12. Dried acid crystals were observed along the plumbing and piping inside the chase wall. A black substance was dried around the outlets of the chase wall. The surveyor noted significant built-up corrosion on the backside of the wall boxes inside the chase wall. An interview was conducted with Staff #16 on June 17, 2025, at 1:45 PM, which confirmed the acid leaks present in the facility’s water room and in-center treatment area.”

“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 observations and staff interviews, the facility’s biomedical staff failed to identify and promptly correct a bicarbonate leak present in the facility’s water room and in-center treatment area. During a tour of the facility’s water room with Staff #4 and #16 on June 16, 2025, at 11:00 AM, the surveyor observed a significant bicarbonate leak under the bicarbonate mixing tank, with a substantial ring of dried acid crystals around the joints of the piping connected to the mixing tank. During a tour of the facility’s in-center treatment area with Staff #4 on June 16, 2025, at 10:30 AM, the surveyor noticed a bicarbonate leak in the chase wall behind Stations #1 through #12. Dried acid crystals were observed along the plumbing and piping inside the chase wall, with a black substance dried around the outlets. The surveyor noted significant built-up corrosion on the backside of the wall boxes inside the chase wall. An interview was conducted with Staff #16 on June 17, 2025, at 1:45 PM, which confirmed the presence of bicarbonate leaks in the facility’s water room and in-center treatment area.”

“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 monitor and provide a safe and sanitary environment to minimize the transmission of infectious agents in 3(Lobby, In-Treatment Area, and Storage Room) of 3 areas observed in the facility. These findings had the likelihood to cause harm by increasing the risk of infection to all 38 in-center patients receiving care at the facility. Findings include; During a tour of the facility on 06/16/2025 at 10:00 AM, the surveyor observed the following infection control and safety issues; Lobby Area: * Upon entering the building, there was no covered awning for wheelchair patients to be protected from inclement weather. In-Treatment Area: * There were 4 electrical outlets pulled away from the walls, exposing wires and leaving an opening allowing for insects to enter the in-center treatment area. Storage Room: * There were open cardboard boxes stored on the shelf next to sterile supplies. The sterile supplies were being administered directly out of their cardboard boxes to the treatment floor. “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).” An interview was conducted on the afternoon of 06/16/2025 with Staff #4 and Staff #16. Staff #4 and Staff #16 acknowledged the findings of the missing awning, the electrical outlets, and the cardboard boxes.”

“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: 29191 Based on observation and staff interviews, the facility’s staff failed to construct and maintain the physical building in which dialysis services were furnished in 2 (Water Room and Entrance Walkway to the water room) of 3 areas. Also, facility staff failed to ensure the emergency pull cord (a call light strategically placed throughout the facility to provide a user with a means of summoning help in an emergency) was accessible for the facility’s patients in the event of an emergency. A. During a tour of the facility’s building with Staff # 17 on 06/16/2025 at 11:00 PM, the surveyors observed the following physical environment issues: Water Room * There was a black pallet upon entrance to the water room where the surveyor observed several Millipedes (worms) under the pallet, along with dust and dirt particles. * There was a large amount of dried acid splatter on the floor behind the acid-holding tank and draining down the floor toward the “Mar Cor” R/O water system and the holding tank for the R/O (reverse osmosis) water tank. The water room floor had several areas that were covered in white acid splatter. * The back wall of the water room had a 4-foot by 4-foot area that had water damage. The Sheetrock was exposed and crumbling. When the surveyor went to touch the wall, a portion of it crumbled onto the floor. * There was a piece of ceiling tile missing above the UV lamp, and insulation was showing. * Observed that the water room floor was not sealed, and in the corner by the R/O holding tank, had a cut-out area that contained rocks and pebbles that was ½ inch below the regular unsealed floor. Entrance Walkway to the Water Room * The walkway leading to the entrance of the water room was blocked with pallets of supplies, 2 plastic totes of painting supplies, and a cardboard box full of piping supplies. The staff walked around the objects to get to the water room. The biomedical area was cluttered and in disarray. A review of the meeting minutes from March and April 2025 revealed that there has been physical plant issues reported concerting the maintenance to the water/dialsate loop and the sinks/counter tops in the in-center treatment floor area. An interview with Staff #17 on 06/16/2025 at 11:00 PM confirmed the presence of damage to the wall, unsealed floor, leaky piping, the acid and bicarbonate mixing equipment in the facility’s water room was leaking, and a cluttered pathway to the water room. 48749 B. This deficient practice had the likelihood of causing harm and delay of care to patients in the event of an emergency. Findings include: Upon entering the facility’s lobby on 06/16/2025 at 9:45 AM, the surveyor observed the following; * The emergency pull cord in the lobby was against the wall behind a chair and not easily accessible to patients. * The emergency pull cord in the patient’s unisex bathroom was knotted up above the handrail and not easily accessible for the facility’s patients in the event of an emergency. The emergency pull cord should be within 6 inches of the floor, hanging freely, and accessible to patients. An interview was conducted with Staff #4 on the afternoon of 06/17/2025. Staff #4 acknowledged the surveyor’s findings of the emergency pull cord behind a chair in the lobby and knotted up above the handrail in the facility’s lobby bathroom.”