Fresenius Medical Care Henderson County

“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: 29191 Based on observation and interview, the facility’s administrative staff failed to ensure that the patient information was updated in the emergency transport box in case of a disaster, and that one employee could transport the emergency box in the event of a disaster. Also, the facility’s staff failed to check the AED (Automatic defibrillator) during operational hours when dialysis treatments were conducted in the in-center area and the Home therapy department. This deficient practice was likely to harm a dialysis patient in an emergency disaster situation if the patient’s information was not updated. Findings included: During the tour of the facility on 05/20/2025, the surveyor requested to examine the contents of the emergency transport cart. In an interview with the Clinical Manager was asked how often the patient information was updated. Staff #1 stated,” I did not know that a roster had to be on the Emergency transport cart.” A review of the AED-Zoll defibrillator log for the in-center treatment area for April 2025, the following daily checks were missed: April 2, 3, 9, 16, 28, and 30th. The emergency box was a large, red metal crash cart, not a lightweight A review of the facility policy titled “Emergency Medications, Equipment and Supplies” revealed the following: “Emergency * An emergency evacuation box must: Evacuation box to be available for grab in case of fire or the immediate need to evacuate the clinic. * Contain all patient and staff emergency contact information. * Be checked monthly or after use for contents, expiration dates and cleanliness. * All staff must know the location of the evacuation box and who is responsible to grab it during an emergency evacuation. * An itemized log must be kept indicating the contents and expiration dates of the contents. Items approaching expiration must be reordered and replaced prior to the actual expiration date. The box must be light enough in weight to be moved easily by one staff member in the event of facility evacuation. Boxes with carrying handles are recommended. An emergency evacuation box is usually a large tackle box or cooler.” A review of the AED-Zoll defibrillator log for the Home Therapy department area for April 2025, the following daily checks were missed: April 4 and 16th. An interview with Staff #2 and #5 on 05/21/2025 at 9:30 AM confirmed that the daily AED defibrillator checks had not been conducted during operational hours. Additionally, Staff #2 confirmed that the emergency transfer box was the red metal crash cart.”

“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’s staff failed to provide and monitor a sanitary environment to minimize the transmission of infectious agents in 3 (In-Center Hemodialysis Treatment Area, Home Dialysis Treatment Area, Supply Room) of 3 areas of the dialysis facility. The facility staff failed to follow the “General Cleanliness and Infection Control Guidelines” policy. Findings include: During a tour of the facility on 05/20/2025 at 10:00 AM the surveyor observed the following infection control issues: In-Center Hemodialysis Treatment Area There were 3 return vents located on the ceiling in the in-center treatment area. All 3 of the vents had a thick build-up of dust. Vent # 1 was located on the ceiling in front of the laboratory door. Vent # 2 was located on the ceiling in front of hemodialysis treatment station # 15. Vent # 3 was located on the ceiling above the supply room door. There was a large brown stain on one of the ceiling tiles located above the medication preparation area. The medication preparation area should maintain a clean environment due to the preparation of sterile IV (intravenous) medications. The back of the dialysis machines located at Station # 3 and # 4 had a thick lining of dust on the vent and bottom ledge of the machines. Home Dialysis Treatment Area There were 3 bottles of expired Alcavis 50 High Disinfectant. Bottle # 1 expired on 05/02/2025. Bottle # 2 was labeled with an opening date of “08/2024”. Bottle # 3 was labeled with an opening date of “09/2024”. A review of the manufacturer’s guidelines revealed, “Discard 6 months after opening”. There was a dark brown and red splatter on the wall above the sharps container located in training room # 2. The sharps container in room # 2 was overfilled with used needles and biohazard waste. The IV (intravenous) pump in training room # 2 was dirty. There was brown splatter on the top and back of the pump. There were areas of high-level dust throughout the home training area. Including the emergency code cart, the metal rack containing sterile patient supplies, and the counters in the training rooms. The medication room had expired glucometer testing strips with an expiration date of “01/25/2025”. There were corrugated cardboard boxes stored on the floor. The cardboard boxes contained patient supplies. “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).” Supply Room There was a build up of dirt and dust located on the shelves where sterile patient supplies were stored. There was a build-up of dirt and dust located on the floor behind and under the storage shelves. There was no plastic lining on the bottom shelves of the supply racks. The bottom shelves contained clean and sterile patient supplies. There were 2 large cardboard boxes containing sterile 2”x2” non-woven gauze. The boxes had an expiration date of “02-2025”. A review of the facility’s policy titled “General Cleanliness and Infection Control Guidelines” with a date of 11/04/2024 revealed, “Purpose: The purpose of this policy is to provide guidance for FKC staff on preventing the spread of infectious disease and maintaining a clean, safe, and aesthetically pleasant environment for patients, staff, and visitors ... Policy: All areas must be kept clean and organized, including but not limited to treatment areas, water/supply rooms, and offices. Walkways must be kept clear of debris and free of clutter. Facilities must adhere to any state-specific regulations that pertain to facility cleaning and disinfection ... Specimens of blood or other potentially infectious materials shall be placed in a container which prevents leakage during collection, handling, processing, storage, transport, or shipping. Facility staff are accountable for cleaning rooms/areas not assigned to contracted cleaning staff. Such cleaning should be done regularly using a schedule developed by the facility ... Contaminated needles/sharps are not to be recapped, bent, sheared, or broken. During use, sharps containers shall be: easily accessible and located as close as is feasible to the immediate area where sharps are used or can be reasonably anticipated to be found. Maintained upright throughout use; replaced routinely and not be allowed to overfill ... All containers for storage or disposal of needles/sharps shall be replaced on a regularly scheduled basis or when no more than 2/3 to ¾ full. The containers must be closed prior to being full and prior to being disposed ...” An interview was conducted with Staff # 1 and # 2 on 05/20/2025 at 2:00 PM. Staff # 1 and # 2 confirmed the infection control issues found within the facility.”

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 48653 Based on observation, policy review, and staff interview, 1 (Staff # 14) of 1 direct care staff members failed to change gloves and perform hand hygiene between patient encounters and dialysis equipment and supplies. Findings include: During a tour of the facility’s in-center treatment area on 05/20/2025 at 10:00 AM, the surveyor observed Staff # 14 (RN) providing care to the patient at dialysis station # 5. Staff # 14 was observed touching the dialysis machine and keyboard. Staff # 14 proceeded to go into the laboratory room with the same gloves on. Staff # 14 never removed gloves or performed hand hygiene. An interview with Staff # 1 and # 2 on 05/20/2025 at 2:00 PM confirmed Staff # 14 did not change gloves and complete hand hygiene at the appropriate times and intervals as required in the facility policy, “Cleaning and Disinfecting the Dialysis Station”.”

“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 ensure the Hepatitis B vaccine was made available to 1 (Patient # 11) of 1 susceptible patients at the facility and failed to ensure the Hepatitis B vaccination was administered per the facility’s Hepatitis B policy in 1 (Patient # 15) of 1 patient medical records reviewed. 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 05/21/2025 revealed, The facility had an in-center hemodialysis patient census of 97. There were 39 of 97 patients considered susceptible to the Hepatitis B virus. Patient # 11 Patient # 11 was admitted to the facility on 04/03/2025. Patient # 11 had a Hepatitis B Surface Antibody (HBsAb) result of “<10” on 05/06/2025, indicating the patient was susceptible to the Hepatitis B virus. As of 05/21/2025, 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 # 15 Patient # 15 was admitted to the facility on 12/07/2013. The patient had received one series of the Heplisav Hepatitis B vaccine in 2023. The vaccine was not given at the appropriate time intervals per the facility’s Hepatitis B policy, and the patient remained susceptible to the virus. The patient was deemed a “non-responder” by the physician on 06/17/2024. The patient’s vaccine administration dates are as follows: Dose 1: 11/14/2022 Dose 2: 01/03/2023 Dose 3: 04/10/2023 Dose 4: 05/09/2023 Due to the vaccine series being given incorrectly, it is unknown if the patient is a “non-responder” or if the patient did not respond to the vaccine due to the administration errors. A review of the facility’s “Patient Vaccination for Hepatitis B” with a date of 02/07/2022 revealed, “Purpose: Provide guidance for hepatitis B vaccination ... Vaccine Guidelines: The Hepatitis B vaccine shall be offered to all susceptible patients, including peritoneal and home hemodialysis patients ...Patients who do not respond to the primary vaccine series should be revaccinated with one additional vaccine series and retested for response 2 months after the final dose of the vaccine ...Patients with anti-HBs less than 10IU.ml after receiving two complete vaccination series may be deemed a non-responder by the physician ....” A review of the facility’s Heplisav-B Vaccination Patient Consent Form revealed, “ ...The current label states that the safety and effectiveness of HEPLISAV-B have not been established in adults on hemodialysis, but your prescriber feels that available scientific vaccine literature supports the safety and efficacy of the vaccine. The vaccination series consists of four (4) doses. The first dose is given very soon after the decision to be vaccinated is made. The second, third, and fourth doses are administered at one month, two months, and four months, respectively.” An interview was conducted with Staff # 2 on 05/21/2025 at 10:15 AM. Staff # 2 confirmed that the facility staff were not following the facility’s policy for the administration of the hepatitis-B vaccine.”

“SOFTENERS: TESTING HARDNESS/LOG CFR(s): 494.40(a) 6.2.4 Softeners: Testing hardness/log Users should ensure that test accuracy and sensitivity are sufficient to satisfy the total hardness monitoring requirements of the reverse osmosis machine manufacturer. Total hardness of the water exiting the water softener should be measured at the end of each treatment day. Water hardness test results should be recorded in a water softener log. This Standard is not met as evidenced by: 29191 Based on observation, record review, and interview, the facility’s governing body failed to ensure that personnel responsible for checking and/or testing the facility’s water hardness underwent a color blindness test for 1 (#15) of 1 staff member. Findings included: There was no color blindness test found in Staff #15’s file which included hardness testing requiring color differentiation, the person performing the analysis should be able to distinguish between the colors of blue, purple, and red. An interview with Staff #2 on 05/20/2025, at 4:30 PM, revealed that Staff #15 did not have a color blindness test in her file.”

“BACT CONTROL-DISINFECT 1X/MO/DWELL CFR(s): 494.40(a) 7 Strategies for bacterial control 7.1 General: disinfect monthly/disinfection dwell Routine low-level disinfection of the pipes should be performed to control bacterial contamination of the distribution system. The frequency of disinfection will vary with the design of the system and the extent to which biofilm has already formed in existing systems, but disinfection must be performed at least monthly. A mechanism should be incorporated in the distribution system to ensure that disinfectant does not drain from pipes during the disinfection period. This Standard is not met as evidenced by: 29191 Based on observation, record review, and interview, the facility’s staff failed to ensure the Minncare disinfectant solution was not expired before disinfecting the CWP (central water plant) weekly per the recommended manufacturer’s instructions. Also, there were Minncare HD residual test strips in use that were expired and currently being used by the staff. In addition, the staff failed to check that all disinfectant had been removed from the central water system before patient were connected to the dialysis machines. This deficient practice had the likelihood to expose patients to chemical disinfectants and cause harm to all patients receiving dialysis at the facility. Findings include: The staff had been performing the disinfectant tests weekly. A review of the CWP disinfectant Start log revealed that the disinfection was performed on 3/5/2025, but the Minncare disinfectant solution had expired on 03/04/2025, which was documented by Staff #23. In the water room, several containers of used Minncare solution were found, with used solution sitting on the floor of the water room. There was no way to determine if disinfectant containers were currently being used to disinfect the CWP. A review of the CWP water purification system instruction manual 3.2.1 stated, “Disinfection must be performed on a regular basis to ensure consistent microbiological quality of the product water. Required frequency depends on factors such as inlet water quality and operation schedule, and should therefore be determined by regular microbiological testing. Once a week should, however, be the minimum.” An interview with Staff #3 and #7 on 05/21/2025 at 10:00 AM confirmed that the Minncare solution and test strips being used by staff had expired.”

“MIXING SYSTEMS-PERM RECORD/VERIF TEST CFR(s): 494.40(a) 5.4.4.1 Mixing systems: perm record/verification testing In addition to container labeling, there should be permanent records of batches produced. These records should include the concentrate formula produced, the volume of the batch, the lot numbers of powdered concentrate packages, the manufacturer of the powdered concentrate, the date and time of mixing, any test results, the person performing the mixing, the person verifying mixing and test results, and the expiration date (if applicable). 6.4.1 Mixing systems Acid and bicarbonate concentrates may be tested by using conductivity or by using a hydrometer. Concentrates should not be used or transferred to holding tanks or distribution systems until all tests are completed. The test results and verification that they meet all applicable criteria should be recorded and signed by the individuals performing the tests. This Standard is not met as evidenced by: 29191 Based on record review and interview, the facility failed to ensure the staff read the specific gravity on the “Hydrometer out to three decimal points” as required by the manufacturer’s guidelines for 2 of 2 logs reviewed for March and April 2025. Findings include: A review of the acid log for 03/21/2025 revealed the acceptable specific gravity range for the low reading was 1.190 and the high reading was 1.202. The actual specific gravity reading on the hydrometer was 1.20, which may have been out of range if the test was carried to the 3rd digit. An interview with staff #3 on 05/21/2025 at 10:30 AM confirmed the reading was not carried out to the 3rd digit as required before transferring to the acid tank. A review of the acid log for 04/09/2025 revealed the acceptable specific gravity range for the low reading was 1.190 and the high reading was 1.202. The actual specific gravity reading on the hydrometer was 1.20, which may have been out of range if the test was carried to the 3rd digit. An interview with staff #3 on 05/21/2025 at 10:30 AM confirmed the reading was not carried out to the 3rd digit as required before transferring to the acid tank. A review of the manufacturer’s “Granuflo” powder concentrate 45 X indicated the reading should be a 3-digit number for both lower limits and upper limits. An interview with the Bio-Medical technician on 05/21/2025 at 10:030 AM confirmed the readings should be taken to the 3rd digit for “Granuflo” acid powder.”

“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: 48653 Based on observation and staff interview, the facility staff failed to identify and promptly correct expired conductivity solutions on the tri-station located in the facility’s in-center treatment area. Also, the facility staff failed to ensure the RO (reverse osmosis) water was changed daily. During a tour of the facility’s in-center treatment area on 05/20/2025 at 10:30 AM, the surveyor observed an expired bottle of “Mesa Labs Conductivity Standard Solution 50mS/cm” solution on the tri-station located in the facility’s in-center treatment area. The expiration date of the bottle was “05/16/2025”. The bottle of RO water had expired with a date of “05/10” written on the bottle. The sticker on the side of the RO bottle revealed, “Empty this bottle DAILY and refill it with fresh RO water.” An interview was conducted with Staff # 1 on 05/20/2025 at 11:00 AM. Staff # 1 confirmed the facility staff failed to identify and correct expired conductivity solutions and RO water.”

“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, record review and interview: A. the facility staff failed to ensure that the glucometers were within the control range and followed the manufacturer’s instructions for 1 of 2 glucometers used in the In-Center treatment area and the Home Therapy area. B. the facility’s biomedical staff failed to implement and maintain a program to ensure that all equipment and supplies had preventative maintenance performed. A. This deficient practice had the likelihood to provide inaccurate glucose results, which could lead to mismanaged blood glucose levels for all patients receiving care at the facility. Findings include: A review of “Blood Glucose Logs” provided by the Home Therapy Manager, for glucometer 04495-907, for March and April 2025, revealed that the acceptable low blood glucose control range should be 91-120. On 03/19/2025, the recorded low control was 125. There was no documentation that the Glucometer was recalibrated by Staff #19. On 04/3/2025, the recorded low control was 124. There was no documentation that the Glucometer was recalibrated by Staff #19. Review of the facility’s policy titled, “Embrace PRO Blood Glucose Monitoring System Quality Control” revealed, “... 16. If control results fall outside the acceptable range, the test must be repeated.” Review of the “Embrace Pro” blood glucose monitoring system manufacturer’s instruction revision date 09/2020 revealed, “ ...p. eleven, if the “test fall outside the range printed on the test strip vial, repeat the test ...” An interview on 05/21/2025 at 2:00 PM, with the Home Therapy Manager, confirmed that the staff did not repeat calibration of the abnormal low testing level. 48653 B. Findings include: During a tour of the facility’s in-center treatment area on 05/21/2025 at 10:00 AM, the surveyor observed an IV (intravenous) pump with no preventative maintenance (PM) sticker. An interview was conducted with Staff # 3 on 05/20/2025 at 10:45 AM. Staff # 3 confirmed the IV pump did not have a PM sticker. It was unknown when the last preventative maintenance was performed.”

“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 staff failed to ensure 3 (# 11, # 12, # 13) of 3 patients’ hemodialysis access sites were visible throughout the entire treatment. The facility staff failed to follow the “Patient Monitoring During Patient Treatment” policy. Ensuring proper visualization of the arteriovenous fistula access is important for the early recognition and prevention of bleeding from the patient’s access site. During a tour of the facility’s in-center treatment area on 05/20/2025 at 10:30 AM, the surveyor observed Patient # 11, # 12, and # 13 with blankets covering the hemodialysis access sites. An interview was conducted with Staff # 14 (Charge RN) on 05/20/2025 at 10:35 AM. The surveyor walked to the chairside of Patient # 13 with Staff # 14 and asked Staff # 14 to report what was incorrect in the patient’s care. Staff # 14 was unable to verbalize that the patient’s site was not visible and covered with a blanket without prompting from the surveyor. A review of the facility’s policy, “Patient Monitoring During Patient Treatment” revealed, “Purpose: The purpose of this policy is to provide direction for monitoring dialysis patients during treatment ... Policy: Monitor the patient at the initiation of treatment and every 30 minutes, or more frequently as necessary. All patients must be under visual observation by FMS Clinical Staff during treatment. Ensure each patient’s face is visible and uncovered ...Access: Observe and document at the initiation of dialysis and at every safety check that all connections are secure and visible ...Ensure that bloodlines are secured to the patient to allow for minor adjustments in patient’s positioning during treatment. Ensure access remains uncovered throughout the treatment. Observe and ensure: Tape is secure, needles are intact, no bleeding or infiltration is noted ...” An interview was conducted on 05/20/2025 at 2:30 PM with Staff # 1 and # 2. Staff # 1 and # 2 confirmed that the patient’s dialysis access should be visible at all times during hemodialysis treatment.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 48653 Based on medical record review and staff interview, the facility staff failed to obtain a physician’s order for hemodialysis treatment before initiating treatment on 4 (Patient # 1, # 2, # 5, and # 6) of 4 patients. This deficient practice had the likelihood of patients receiving the incorrect hemodialysis prescription and treatment. A review of patient medical records was conducted with Staff # 2 on 05/21/2025 at 9:45 AM. Patient # 1 A review of Patient # 1’s medical record revealed the patient was admitted to the facility on 03/10/2025. The patient’s first hemodialysis treatment was on 03/10/2025 at 1:41 PM. A review of the patient’s order for hemodialysis revealed Staff # 22 (Medical Director) did not sign the hemodialysis treatment orders until 03/20/2025. Patient # 2 A review of Patient # 2’s medical record revealed the patient was admitted to the facility on 01/06/2025. The patient’s first hemodialysis treatment was on 01/06/2025 at 1:18 PM. A review of the patient’s order for hemodialysis revealed Staff # 22 (Medical Director) did not sign the hemodialysis treatment orders until 01/31/2025. Patient # 5 A review of Patient # 5’s medical record revealed the patient was admitted to the facility on 10/29/2021. The patient’s first hemodialysis treatment was on 10/29/2021. A review of the patient’s updated 2025 order for hemodialysis revealed that Staff # 22 (Medical Director) did not sign the hemodialysis treatment orders. As of the survey date, 05/21/2025, Staff # 22 had not signed the annual order for hemodialysis treatment. Patient # 6 A review of Patient # 6’s medical record revealed the patient was admitted to the facility on 04/01/2025. The patient’s first hemodialysis treatment was on 04/01/2025 at 1:16 PM. A review of the patient’s order for hemodialysis revealed Staff # 22 (Medical Director) did not sign the hemodialysis treatment orders until 04/08/2025. An interview was conducted with Staff # 2 on 05/21/2025 at 11:30 AM. Staff # 2 confirmed the physician had not signed the patient’s orders for hemodialysis.”

“GOV-GB RESP FOR STAFF ORIENTATION CFR(s): 494.180(b)(3) The governing body or designated person responsible must ensure that- (3) All staff, including the medical director, have appropriate orientation to the facility and their work responsibilities; This Standard is not met as evidenced by: 29191 Based on record review and interview, the facility governing body failed to ensure that Staff #14 and #15 had a signed job description outlining work responsibilities. This deficiency posed a likelihood of harm to dialysis patients, as staff were unaware of their job responsibilities for caring for facility patients. Findings included: A review of Staff #14’s personnel file revealed that there was no job description included. Staff #14 began working at the facility on February 7, 2022. A review of Staff #15’s personnel file revealed that there was no job description included. Staff #15 began working at the facility on August 7, 2022. In an interview with the Clinical Manager #2 on 05/20/2025 at 4:30 PM, when asked if the staff member was supposed to have a job description, Staff #2 stated, “All staff members should have a signed job description in their personnel file.””

“GOV-STAFF HAVE ACCESS TO CONTINUING ED CFR(s): 494.180(b)(4) The governing body or designated person responsible must ensure that- (4) All employees have an opportunity for continuing education and related development activities This Standard is not met as evidenced by: 29191 Based on record review and interview, the Facility Administrative Staff failed to ensure the Registered Nurse and technical staff had at least 5 CEUs (continuing education credits) annually, which were related to end-stage renal disease, for 2 (#14 and #15) of 3 staff personnel files reviewed. Findings include: A review personnel file for Staff #14 (Registered Nurse) revealed 1 hour of documented continuing education units. Staff #14 (Registered Nurse) did not have at least 5 CEUs relating to end-stage renal disease in the past year. A review of the personnel file for Staff 15 (CCHT), a certified clinical hemodialysis technician, revealed no current hours of documented continuing education units. Staff #15 (CCHT) did not have at least five CEUs related to end-stage renal disease in the past year. An interview with Staff #2 on 05/20/2025 at 4:00 PM confirmed that the clinical and technical staff did not have at least 5 CEUs relating to end-stage renal disease in the past year.”

“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 and staff interview, the facility’s biomedical staff failed to identify an acid leak present within the facility’s water treatment room. During a tour of the facility’s water treatment room on 01/31/2024 at 11:45 AM with Staff # 1 and Staff # 2, the surveyor observed an acid leak present under the large bulk storage tank. There was a large amount of white crystal build-up located on and around the piping under the acid storage tank. During an interview with Staff # 1 on 01/31/2024 at 11:45 AM, Staff # 1 was questioned regarding the acid leak. Staff # 1 stated, “I was not aware there was an acid leak there.” An interview with Staff # 1 and # 2 on 01/31/2024 at 11:50 AM confirmed the facility did not promptly identify and correct an acid leak that was present within the facility’s water treatment room.”