Davita Henderson Dialysis Center

“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: 29191 Based on observation, record review, and staff interview, the facility failed to monitor and provide a sanitary environment to minimize the transmission of infectious agents within the facility’s in-center treatment area. The facility staff failed to follow the “Infection Control for Dialysis Facilities” 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 facility with Staff #15 on 03/10/2025 at 10:30 AM the surveyor observed the following: Laboratory Area * The laboratory refrigerator had dirt and dust build-up on the bottom shelf. In-Center Treatment Area * Observed 1 brown colored ceiling tile which appeared to be water-stained. * There were 12 blood pressure cuffs with a large amount of unknown debris affixed to the Velcro portion of the cuff. * The Intradialytic parenteral nutrition refrigerator (IDPN) had white crystallized substance flakes on the bottom shelf. * Underneath the clean sink on the treatment floor by the patient’s scales was a large amount of white substance on the floor. The drawers were cluttered with computer parts, sink drain, plastic containers, papers, and a TV remote. The cabinet under the drawers had dust particles and dead bugs. There was a plastic lid on the shelf of the cabinet with the dead bugs. * The computer stands were covered in dust with several rust spots on the legs of the computer stand that were located between each dialysis chair on the treatment floor. * Observed a black cart with 3 shelves that the bleach bottles are stored on. The cart was covered in a white splash substance with dust particles. There was a fly swatter on the bottom of the cart. * There was a piece of laminate chipped off the chase wall located at station #1. * Staff personal items (2 bottles of lotion) were observed in the drawers with the patient’s sterile supplies. * In the patient clean supply room, an E cylinder metal rusted cart that had 18 E cylinders full of oxygen. Also, 2 Baxter infusion pumps had not had preventive maintenance since August of 2024. The pumps were available to the staff for patient use. A review of facility policy, “Infection Control for Dialysis Facilities,” dated April 2023, revealed the following: “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 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.” An interview with Staff #15 was conducted on 03/10/2025 at 11:00 AM. Staff #15 acknowledged the infection control findings in the facility’s in-center treatment area.”

“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 staff interviews, the facility staff failed to follow the correct procedure for cleaning and disinfecting contaminated dialysis equipment and surfaces in the in-center treatment area. The facility staff failed to follow the “Infection Control for Dialysis Facilities” policy. These findings had the likelihood to cause harm by increasing the risk of infection to all patients receiving care at the facility by allowing supplies and equipment that had been exposed to microbial contamination and unclean surfaces. Findings include: During a tour of the facility’s in-center treatment area on 03/10/2025 at 10:30 AM, the surveyor observed the following infection control issues: Staff #7 was observed cleaning dialysis station #5 after the completion of patient treatment. The surveyor observed Staff #7 open the wings of the dialysis chair, clean them, and promptly close them. The staff member did not allow for adequate drying time of the disinfectant before closing the wings on the chair. During the tour of the in-center treatment area, the surveyor observed blue and white clamps in two separate plastic containers sitting on the wall chase. There was no label to determine if the clamps were clean or dirty. The plastic containers were dull with white splash marks. The containers had an unclean appearance. Also, there were 12 of 12 blood cuffs that were covered with lint on the Velcro of the cuff, the blood pressure cuffs had a well used appearance. A review of the facility’s policy titled “Infection Control For Dialysis Facilities,” with a revision date of April 2023, revealed the following: “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 and are included in the policy: Infection Control and Isolation Measures for Known or Suspected Hepatitis B Antigen Positive Patients... 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. 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.” In an interview with on 03/10/2025 at 10:35 AM, Staff #7 confirmed the wings of the dialysis chair had been closed wet, not allowing the appropriate drying time of disinfectant solution on the dialysis chairs. Staff #15 acknowledged that there was no label to determine if the clamps were clean or dirty.”

“IC-HBV-VACCINATE PTS/STAFF CFR(s): 494.30(a)(1)(i) Hepatitis B Vaccination Vaccinate all susceptible patients and staff members against hepatitis B. This Standard is not met as evidenced by: 48653 Based on record review and staff interview, the facility staff failed to: A. ensure the Hepatitis B vaccine was made available to 4 (Patient # 9, # 10, # 11, # 12) of 4 susceptible patients at the facility. B. ensure the Hepatitis vaccination was administered in accordance with the manufacturer’s guidelines and the facility’s Hepatitis B policy in 2 (Patient # 13 and # 14) of 2 patient medical records reviewed. C. follow the “HEPATITIS B SURVEILLANCE, VACCINATION, INFECTION CONTROL MEASURES AND ISOLATION GUIDANCE” policy. Hepatitis B Virus is an infection that causes both short-term and long-term liver disease. It is a virus spread through contact with body fluids such as blood. Hemodialysis patients are at an increased risk of contracting the virus due to compromised immune systems and the frequent exposure to blood. A review of the facility’s “Vaccinations and Surveillance Report” dated 03/10/2025 revealed, The facility had an in-center hemodialysis patient census of 60. There were 23 of 60 patients considered susceptible to the Hepatitis B virus. Patient # 9 Patient # 9 was admitted to the facility on 02/07/2025 with a diagnosis of “Acute Kidney Injury” requiring in-center hemodialysis. Patient # 9 had a Hepatitis B Surface Antibody (HBsAb) result of “6” on 02/10/2025 indicating the patient was susceptible to the Hepatitis B virus. Patient # 9 signed a “Consent- Hepatitis B Vaccine” form on 02/07/2025 and selected, “Upon this offering, I have chosen to receive the vaccine”. As of 03/10/2025 the patient had not received the first dose of the vaccine series and remained susceptible to the Hepatitis B virus while receiving in-center hemodialysis treatment. Patient # 10 Patient # 10 was admitted to the facility on 02/21/2025 with a diagnosis of “End Stage Renal Disease” requiring in-center hemodialysis. Patient # 10 had a Hepatitis B Surface Antibody (HBsAb) result of “<3” on 02/21/2025 indicating the patient was susceptible to the Hepatits B virus. Patient # 10 signed a “Consent-Hepatitis B Vaccine” form on 02/21/2025 and selected, “Upon this offering, I have chosen to receive the vaccine”. As of 03/10/2025 the patient had not received the first dose of the vaccine series and remained susceptible to the Hepatitis B virus while receiving in-center hemodialysis treatment. Patient # 11 Patient # 11 was admitted to the facility on 03/04/2025 with a diagnosis of “End Stage Renal Disease” requiring in-center hemodialysis. Patient # 11 had a Hepatitis B Surface Antibody (HBsAb) result of “3” on 03/04/2025 indicating the patient was susceptible to the Hepatits B virus. Patient # 11 signed a “Consent-Hepatitis B Vaccine” form on 03/04/2025 and selected, “Upon this offering, I have chosen to receive the vaccine”. As of 03/10/2025 the patient had not received the first dose of the vaccine series and remained susceptible to the Hepatitis B virus while receiving in-center hemodialysis treatment. Patient # 12 Patient # 12 was admitted to the facility on 02/18/2025 with a diagnosis of “End Stage Renal Disease” requiring in-center hemodialysis. Patient # 12 had a Hepatitis B Surface Antibody (HBsAb) result of “7” on 02/18/2025 indicating the patient was susceptible to the Hepatits B virus. Patient # 12 signed a “Consent-Hepatitis B Vaccine” form on 02/18/2025 and selected, “Upon this offering, I have chosen to receive the vaccine”. As of 03/10/2025 the patient had not received the first dose of the vaccine series and remained susceptible to the Hepatitis B virus while receiving in-center hemodialysis treatment. Patient # 13 Patient # 13 had a Hepatitis B Surface Antibody (HBsAb) result of “<3” on 01/15/2025. The patient received dose # 1 of the Engerix vaccine on 12/13/2024 and dose # 2 on 03/01/2025. The patient did not have any hospitalizations or missed treatments between dose # 1 and dose # 2. The facility staff failed to give the Engerix vaccine according to the manufacturer’s recommended vaccine schedule of the initial dose with a second dose 1 month later, a third dose 2 months later, and a fourth dose 6 months after the initial. Patient # 14 Patient # 14 had a Hepatitis B Surface Antibody (HBsAb) result of “<3” on 02/01/2024, indicating the patient was susceptible to the Hepatitis B virus. The patient did not have a Hepatitis B Surface Antigen result on April 2024, September 2024, and November 2024, as required by the facility’s “HEPATITIS B SURVEILLANCE, VACCINATION, INFECTION CONTROL MEASURES AND ISOLATION GUIDANCE” policy. A review of the facility’s “HEPATITIS B SURVEILLANCE, VACCINATION, INFECTION CONTROL MEASURES AND ISOLATION GUIDANCE” policy with a date of April 2024 revealed, Purpose: To prevent the spread of Hepatitis B infections in the dialysis setting ... Policy: 1. HBV serological status (i.e., the results of Hepatitis B Surface antigen [HBsAg], Total Hepatitis B Core Antibody [total anti-HBc or HBcAb], and Hepatitis B Surface Antibody [anti-HBs or HBsAb]) of all patients should be known before admission to the hemodialysis facility. 2. If the hepatitis B surface antigen (HBsAg) status is unknown, the facility Medical Director will be notified and the patient treated as a suspect patient for hepatitis B infection. For further guidance refer to DIALYZING CONFIRMED POSITIVE OR SUSPECTED/UNKNOWN STATUS section below. 3. The facility Medical Director will be made aware of pending admissions for all hepatitis B surface antigen (HBsAg) positive patients. 4. All patients will be routinely tested [as required by the schedule for routine surveillance testing for Hepatitis B Virus (refer to Routine Surveillance Testing table)]. 5. Results will be reviewed promptly to verify that patients are managed appropriately based on their testing results. 6. Documentation of the following will remain in the patient’s current active medical record: a. HBV serology results such as Hepatitis B surface antibodies (HBsAb or anti-HBs); Hepatitis B total core antibody (total anti-HBc or HBcAb) and Hepatitis B Surface antigen (HBsAg) b. If a patient has received the hepatitis vaccination series, a copy of the vaccination record 7. Results from Hepatitis B surface antigen drawn within 30 days is required prior to first treatment date. 8. All permanent patients including AKI patients will have HBV serologic testing drawn immediately upon admission to the facility and results known within seven (7) days of admission (i.e., Hepatitis B Surface antigen [HBsAg], Total Hepatitis B Core Antibody [total anti-HBc or HBcAb], and Hepatitis B Surface Antibody [anti-HBs or HBsAb]) a. Review results and determine status and next steps (refer to Admission Screening table) b. Obtain orders for routine surveillance testing (refer to Routine Surveillance Testing table) 10. An order will be obtained for hepatitis B vaccination. The patient is provided the Vaccination Information Sheet (VIS) and a consent form (included in Patient Registration Packet found in Reggie). The patient will consent to the vaccination or will decline. The completed form will be kept in the patient’s health record. 11. Patients who start hemodialysis may have a history of vaccination against hepatitis B. These persons should have responded to the vaccine when their immune status was normal, but if their hepatitis B surface antibody (HBsAb or anti-HBs) levels are less than (<) 10 mIU/mL when they begin dialysis, they should be revaccinated with a complete primary series. 12. Vaccinate per manufacturers guidelines. (Note: Hepatitis B vaccine is to be administered by the intramuscular route in the deltoid muscle for adult patients). 13. Test all vaccinated patients for HBsAb one (1) to two (2) months after the last dose of the full vaccine series (adequate response is defined as greater than or equal (?) 10 mIU/mL). a. If hepatitis B surface antibody (HBsAb) is less than (<) 10 mIU/mL, consider the patient susceptible, revaccinate with an additional full series, and retest for HBsAb one (1) to two (2) months after the last dose of the second series. i. No additional doses of vaccine are warranted for those patients who do not respond to a full second series. ii. Such patients are considered vaccine non-responders. They remain susceptible to hepatitis B infection and monthly hepatitis B surface antigen (HBsAg) testing is required. b. If the hepatitis B surface antibody (HBsAb) is greater than or equal to (>) 10 mIU/mL, consider patient immune, and retest annually for HBsAb. c. On annual retesting of immune patients due to vaccination, HBsAb less than (<) 10 mIU/mL, with nephrologist order, administer a booster dose of vaccine. i. Retest for HBsAb one (1) to two (2) months after the booster dose 1. If HBsAb is greater than or equal (?) 10 mIU/mL continue to retest annually for HBsAb. 2. If the HBsAb is less than (<) 10 mIU/mL following the booster dose, no subsequent/future doses of vaccine will be provided. Patient will be considered a non-responder and managed as a susceptible patient. ii. There is no limit to the number of annual boosters although future doses should be discontinued if at any time, the patient fails to respond with HBsAb greater than or equal (?) 10 mIU/mL ....” A review of the manufacturer’s guidelines for administration of Engerix revealed, “Primary immunization consists of a series of 4 doses (2-mL each) given as a single 2-mL dose or two 1-mL doses on a 0-, 1-, 2-, and 6-month schedule. In hemodialysis patients, antibody response is lower than in healthy persons and protection may persist only as long as antibody levels remain above 10 mIU/mL ....” An interview was conducted with Staff # 16 on 03/10/2025 at 3:30 PM. Staff # 16 confirmed the facility staff were not following the manufacturer’s guidelines or the facility’s policy for the administration of Engerix or the testing of patients who are susceptible to the Hepatitis B virus.”

“MIX SYS-DFU/MONITOR/PM/LOG/SANITIZE CFR(s): 494.40(a) 5.4.4.1 Mixing systems: follow DFU/monitor/PM/log/sanitization If a concentrate mixing system is used, the preparer should follow the manufacturer’s instructions for mixing the powder with the correct amount of water. If a concentrate mixing system is used, the number of bags or the weight of powder added should be determined and recorded. Manufacturer’s recommendations should be followed regarding any preventive maintenance and sanitization procedures. Records should be maintained indicating the date, time, person performing the procedure, and results (if applicable). 6.4.1 Mixing systems: Systems for preparing either bicarbonate or acid concentrate from powder should be monitored according to the manufacturer’s instructions. This Standard is not met as evidenced by: 48653 Based on record review and staff interviews, the facility’s staff failed to ensure accurate documentation of the rinsing and disinfection of the bicarbonate tanks located inside the facility’s water room. Also, the facility staff failed to follow the policy, “BETTER WATER-CENTRAL BICARB SYSTEM WITH DUAL INLET VALVE AND SPRAYERS -DISINFECTION WITH BLEACH”. During a review of the facility’s “Bicarb System Daily Rinse Log and Bicarb System Bleach Disinfect Log” for January and February of 2025, the surveyor observed the following, January 2025 01/02/2025 at 3:55 PM: Bicarb system bleached. 01/02/2025 at 3:55 PM: Bicarb system rinsed. 01/16/2025 at 3:55 PM: Bicarb system bleached. 01/16/2025 at 3:55 PM: Bicarb system rinsed. 01/23/2025 at 3:15 PM: Bicarb system bleached. 01/23/2024 at 3:15 PM: Bicarb system rinsed. 01/30/2025 at 4:15 PM: Bicarb system bleached. 01/30/2025 at 4:15 PM: Bicarb system rinsed. February 2025 02/06/2025 at 4:00 PM: Bicarb system bleached. 02/06/2025 at 4:00 PM: Bicarb system rinsed. 02/20/2025 at 4:00 PM: Bicarb system bleached. 02/20/2025 at 7:00 PM: Bicarb system rinsed. 02/27/2025 at 4:00 PM: Bicarb system bleached. 02/27/2025 at 4:00 PM: Bicarb system rinsed. The bicarbonate tank must be rinsed and cleared of bicarbonate prior to disinfecting the tank. A review of the facility’s policy, “BETTER WATER-CENTRAL BICARB SYSTEM WITH DUAL INLET VALVE AND SPRAYERS -DISINFECTION WITH BLEACH” with a revision date of 04/2024 revealed, “WARNING: Do not attempt to disinfect or clean the Bicarb System while patients areconnected to the central bicarb loop. Verify that ALL patient are off central loop and have left the treatment floor prior to beginning cleaning and/or disinfection procedures. NOTE: The Bicarb System should be rinsed free of bicarbonate solution at the end of each treatment day and bleach disinfected at least weekly. Disinfection procedure should only be completed once bicarb system has been rinsed free of residual Bicarb. Perform Better Water Dual Tank Bicarb Mixing and Delivery System Nightly Rinsing prior to beginning this disinfection procedure....” An interview was conducted with Staff # 11 on 03/10/2025 at 3:30 PM. Staff # 11 confirmed the facility staff were not writing an accurate time for the rinsing and bleaching of the bicarbonate tank but instead were putting the same time for both procedures.”

“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: 48653 Based on observation, record review, and staff interviews, the facility’s biomedical staff failed to ensure the acid mixer was labeled to identify the liquid contents inside the mixer and failed to ensure there were no acid leaks present in the chase wall at 6 (Stations # 1, # 2, # 3, # 5, # 6, # 10) of 13 stations. Also, the facility’s staff failed to follow the policy, “PREPARATION OF ROCKWELL CITRAPURE® UTILIZING DAMX45 DRY ACID CONCENTRATE MIXER”. During a tour of the facility’s water room and in-center treatment area on 03/10/2025 at 1:00 PM with Staff # 11, the surveyor observed the following, The acid mixer was filled with liquid contents and there was no label on the acid mixer to identify the contents inside the mixer. Staff # 11 was unable to identify the liquid inside the mixer when asked. The chase wall was opened by the surveyor at Stations # 1, #2, # 3, # 5, # 6, and # 10. There was a large build-up of acid crystals on the back of the wall boxes and the acid crystals covered the surrounding plumbing and tubing. A review of the facility’s policy, “PREPARATION OF ROCKWELL CITRAPURE® UTILIZING DAMX45 DRY ACID CONCENTRATE MIXER” with a date of October 2024 revealed, “ ....15. Label mixer with Date and Time, Catalog number and formula. Identifies solution being mixed in tank ...” An interview was conducted with Staff # 11 on 03/10/2025 at 1:30 PM. Staff # 11 confirmed the acid mixer had not been labeled, and the back of the wall boxes were not being checked monthly for acid leaks.”

“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 facility staff failed to ensure the Reverse Osmosis (RO) bottle in the treatment area by the hydrometers was labeled with a current date. This deficient practice had the likelihood to cause harm and risk of infection to all in-center patients. An RO bottle would allow contaminants and microorganisms to enter the water when using (RO) solution that was over 24 hours. Findings include: A tour of the treatment floor on 03/10/2025 at 10:30 AM revealed the following: A bottle of RO water in the treatment area by the hydrometers was labeled with a date of 03/05/2025. A bottle of (RO) solution per the policy was to be changed daily. A review of the facility policy titled “OPERATION OF PORTABLE MYRON L CONDUCTIVITY METER (D-1)” revealed the following: Materials required: “* Myron L dialysate meter * D1 meter plunger/clean sample collection container or disposable collection cup * Dialysis delivery system in conductivity and without conductivity alarms * PPE-personal protective equipment (face protection, gloves, fluid resistant/fluid impervious barrier garment) * Dialysis quality water obtained fresh daily NOTES: * Manual pH testing must be performed prior to each patient treatment. Requirement for independent conductivity testing is determined by manufacturer’s guidelines. Refer to specific hemodialysis machine priming policies and procedures to determine the requirement of performing independent conductivity testing in the facility. * Fresh dialysis quality water should be used for rinsing the D1 meter cell. Do not use pressurized or spray devices for cleaning the D1 meter. * If a separate container is used for dialysis quality water the container should be labeled with date and initials of teammate filling the container. * The exterior of D1 meter should be cleaned with 1:100 bleach solution after collecting a sample from another dialysis delivery system to prevention cross-contamination. * Dialysis quality water should be used to rinse the plunger and cell cup of the D1 meter. * The D-1 meter and calibration solutions should be located in a clean area. * The outside of the D-1 meter must be disinfected after use prior to returning the meter to the storage location. * The dipper end of the cell plunger will deliver the right amount of sample to be tested. *The plunger enclosed with the dialysate meter has been calibrated specifically for this instrument. If a different plunger is used, the dialysate meter must be recalibrated.” An interview with Staff #15 on 03/10/2025 at 10:30 AM acknowledged that the RO bottle located in the treatment area was labeled 03/05/2025 and did not have a current date to know if the RO solution was effective and not contaminated.”

“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 failed to ensure the emergency pull cord was accessible for a patient in the event they fell in the lobby bathroom or the in-center treatment floor patient bathroom. The emergency pull cord should be within 6 inches of the floor. This deficient practice has the likelihood of causing harm to patients in an emergency. Findings include: Upon entering the facility’s lobby on 03/10/2025 at 9:15 AM, the emergency pull cord was wrapped around the safety handrail in the lobby bathroom and was not accessible for a patient to call for help in the event the patient fell on the floor. The call cord remained wrapped around the handrail for two days until the surveyor notified the facility staff. Upon entering the facility’s in-center treatment floor at on 03/10/2025 at 10:26 AM, the emergency pull cord was wrapped around the safety handrail in the patient’s bathroom and was not accessible for a patient to call for help in the event the patient fell on the floor. The call cord remained wrapped around the handrail for two days until the surveyor notified the facility staff. An interview with Staff #16 on 03/11/2025 at 3:00 PM confirmed the pull cord was wrapped around the safety handrail in the lobby bathroom and the in-center patient bathroom and was not accessible for a patient to call for help in the event the patient fell on the floor.”