Renal Care Group-Southeast Tyler

“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 ensure a clean and sanitary environment was maintained to reduce the transmission of infectious disease in 1 (in-center treatment area) of 1 clinical area. The facility staff failed to follow the “General Cleanliness and Infection Control Guidelines” policy. During a tour of the facility’s in-center treatment area on 05/05/2025 at 10:30 AM, the surveyor observed the following infection control issues, There was a mix of sterile patient supplies and dirty items stored together on top of the counters in the in-center treatment area in front of dialysis treatment stations #17-22. There was a staff members personal lotion bottled stored on the counter directly next to sterile patient supplies. There was a large blood spill on the floor in front of station # 3. The blood was on the dialysis machine and splattered on the floor around the dialysis machine. There was a patient at the station and the station next the spill at the time of the observation. There was a build-up of dust and dirt particles on the counter tops located in front of station # 2. There was a stethoscope laying on the sink labeled “clean”. It is unknown if the stethoscope had been cleaned and disinfected. There was a large pile of blue and white dialysis clamps laying on the counter. It was unknown if the dialysis clamps were clean or dirty because they were not labeled and stored appropriately. There was a build-up of dust and dirt on top of the emergency code cart. The cart had a large plastic covering the top of the cart but the plastic had been removed and not placed back on the cart appropriately which allowed dust to collect on the cart where patient supplies are stored. There was a pair of black scissors laying in the area labeled “clean sink”. The scissors had a build-up of orange and brown substance on them. The counters had a build-up of supplies and equipment which caused unnecessary clutter. The counters could not be adequately cleaned and disinfected due to the clutter. A review of the facilities policy, “General Cleanliness and Infection Control Guidelines” with a date of 05/05/2025 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, offices, and restrooms. 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. Eating, drinking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is a reasonable likelihood of occupational exposure ...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 ....” An interview was conducted with Staff # 5 on 05/05/2025 at 11:30 AM. Staff # 5 confirmed the infection control findings inside the in-center treatment area. Staff # 5 confirmed that the facility staff failed to follow the “General Cleanliness and Infection Control Guidelines” policy.”

“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 that medications maintained in the facility were properly safeguarded and not accessible to unauthorized persons. The facility staff failed to follow the “Medication Policy”. During a tour of the facility’s in-center treatment area on 05/05/2025, the surveyor observed the emergency code cart unlocked with the second drawer open. The second drawer contained emergency medications that were not secured. The medications were accessible to unauthorized persons. The surveyor observed a patient # 2’s prescription for Velphoro 500 mg (milligram) chewable tablets on the nurses’ station. There were no staff members in the vicinity of the medication, and the medication was accessible to unauthorized persons. A review of the facility policy titled “MEDICATION POLICY” 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 Administrator/designee is responsible for supervising the handling, storing, disposing, administering, and controlling of medications and performs a monthly audit and inventory ... 11. 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 cabinet(s) and locked at the close of each business day or if not under supervision by the licensed teammate or per state regulations. 23. Medications and needle/syringe storage are done in accordance with state regulations.” An interview was conducted with Staff # 5 on 05/05/2025 at 11:30 AM. Staff # 5 confirmed that the medications in the in-center treatment area should be secure and safeguarded from unauthorized persons.”

“MIXING SYSTEMS-LABELING CFR(s): 494.40(a) 5.4.4.1 Mixing systems: labeling Labeling strategies should permit positive identification by anyone using the contents of mixing tanks, bulk storage/dispensing tanks, and small containers intended for use with a single hemodialysis machine. Mixing tanks: Prior to batch preparation, a label should be affixed to the mixing tank that includes the date of preparation and the chemical composition or formulation of the concentrate being prepared. This labeling should remain on the mixing tank until the tank has been emptied. Bulk storage/dispensing tanks: These tanks should be permanently labeled to identify the chemical composition or formulation of their contents. Concentrate jugs: At a minimum, concentrate jugs should be labeled with sufficient information to differentiate the contents from other concentrate formulations used at the facility. This Standard is not met as evidenced by: 48653 Based on observation, record review, and staff interview, the facility staff failed to ensure 3 of 3 acid concentrate jugs were properly labeled and stored in a secure environment. The facility staff failed to follow the “Acid Concentrate Storage and Handling” policy. During a tour of the facility’s in-center treatment area on 05/05/2025 at 10:30 AM, the surveyor observed three 1-gallon acid concentrate jugs stored in the middle of the in-center treatment area on a blue cart with wheels. The acid concentrates were all opened with the seal broken and stored on the same shelf, despite being different concentrations. Jug # 1 was labeled 3.0 K/2.5 Ca and was dated 04/23/2025. There was no time on the jug as required in the facility’s policy. Jug # 2 was labeled 2.0 K/3.0 Ca and was dated 05/01/2025. There was no time on the jug as required in the facility’s policy. Jug # 3 was labeled 3.0 K/3.0 Ca and was dated 03/13/2025. There was no time on the jug as required in the facility’s policy. A review of the facility’s policy, “Acid Concentrate Storage and Handling” with a date of 09/03/2024 revealed, “Policy: Concentrates must be stored in a secured area accessible only to authorized staff members ... The concentrate containers must be kept in a climate-controlled area within the temperature ranges described on the container’s labeling. Store concentrate formulas by type, formulation, and outer case identifiers, such as formula number. Container labels must be clearly visible, be in good condition, and readable. For incenter facilities ...label shelving with formula type. Label all acid containers as outlined in the Concentrate Labeling Requirements policy. Discontinued or expired concentrate formulas must be removed from inventory. Unused acid concentrate that cannot be transferred or returned must be disposed of in accordance with state and local regulations. Blending of unlike formulas is strictly prohibited .... Labeling will occur when: ... 1-gallon: if unused acid will be stored for further use, record the date and time it was opened and the initials of the staff member that opened the container... Post treatment: If acid concentrate will be stored for future use: Externally disinfect the gallon jug with wand still in place using 1:100 bleach cloth or hospital-approved disinfectant. Keep the wand in place until the wand can be removed and replaced with a clean cap. Return the container to the designated storage area. Open, labeled concentrates must be stored separately on a properly labeled location. Do not return the opened acid to the same shelf as the unopened concentrate. Remove the wand assembly, replace the clean cap on the container, rinse wand with RO water, hang vertically, and allow to dry. Once the wand is dry, store in a covered container labeled “clean wands”. If not able to meet requirements, acid concentrate must be discarded after treatment ...” An interview was conducted with Staff # 5 on 05/05/2025 at 11:30 AM, which confirmed the facility staff members were not properly labeling and storing the acid concentrates according to the facility’s policy.”

“MIXING SYSTEMS-CLEANING CFR(s): 494.40(a) 6.4.1 Mixing systems: cleaning Concentrate mixing equipment should be either: (1) completely emptied, cleaned, and disinfected according to the manufacturer’s instructions; or (2) cleaned and disinfected using a procedure demonstrated by the facility to be effective in routinely producing concentrate meeting [these regulations related to allowable bacterial and endotoxin levels]. The disinfection data should be recorded for each ...disinfection cycle using a dedicated log. This Standard is not met as evidenced by: 48653 Based on observation, record review, and staff interview, the facility staff failed to ensure the acid pick-up wands were properly disinfected and stored. The facility staff failed to follow the “Acid Concentrate Storage and Handling” policy. During a tour of the facility’s in-center treatment area on 05/05/2025 at 10:30 AM, the surveyor observed there were several acid pick-up wands lying out on the counter and next to the sink labeled “dirty sink”. It was unknown if the acid pick-up wands had been properly cleaned and disinfected because they were not labeled and were not stored vertically for proper drying. A review of the facility’s policy, “Acid Concentrate Storage and Handling” with a date of 09/03/2024 revealed, “Policy: Concentrates must be stored in a secured area accessible only to authorized staff members ... Post Treatment: If concentrate will be stored for future use: ... Remove the wand assembly, replace the clean cap on the container, rinse wand with RO water, hang vertically and allow to dry. Once wand is dry, store in a covered container labeled, “Clean Wands” .... An interview was conducted with Staff # 5 on 05/05/2025 at 11:30 AM which confirmed the facility staff were not handling the acid pick up wands according to the facility’s policy.”

“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, record review, and staff interview, the facility staff failed to follow the manufacturer’s instructions for use (IFU) for the conductivity testing meter. During a tour of the facility’s in-center treatment area on 05/05/2025 at 10:30 AM, the surveyor observed 4 plastic spray bottles labeled as “RO water”. The bottles did not have the current date written on them to indicate that the RO (reverse osmosis) water had been changed. RO water expires after 24 hours and needs to be changed daily. The bottles had the following dates, Bottle # 1 “04/12/2025” Bottle # 2 “04/29/2025” Bottle # 3 “04/29/2025” Bottle # 4 “03/14/2025” A review of the sticker located on the side of the spray bottles revealed, “Frequent rinsing is the most effective means of preventing hard deposits and bacteria from collecting on conductivity cell electrodes and altering the readings. Rinse the instrument after use. Empty this bottle DAILY and refill it with fresh RO water.” A review of the facility’s policy, “Myron L D6 Measuring Procedures” with a revision date of 11/04/2024 revealed, “Measuring Dialysate Conductivity and pH: ...3. Rinse sample cell according to dialysate meter IFU ...” A review of the “Digital Dialysate Meter Operations Manual” revealed, “Care and maintenance: Dialysate meters should be rinsed with clean water after use ...” An interview was conducted with Staff # 2 on 05/05/2025 at 11:45 AM. Staff # 5 was asked if the conductivity meters are rinsed with the RO water in the spray bottles that were outdated. Staff # 2 stated, “We no longer have to rinse the conductivity meters”. Staff # 2 confirmed that the facility staff were not following the facility’s policy or the manufacturer’s instructions for use.”

“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 ensure a clean and sanitary environment was monitored and maintained in 1 (in-center treatment area) of 1 clinical area. Also, the facility staff failed to follow the facility policy, “General Cleanliness and Infection Control Guidelines”. This deficient practice had the likelihood to result in the transmission of infectious agents within the facility and between patients, staff members, and members of the public. The CDC defines a “sanitary environment” as an environment that meets the “Standard Precautions” for an inpatient hospital setting plus the more stringent precautions that are recommended for hemodialysis units because of the increased potential for contamination with blood and pathogenic microorganisms. During a tour of the facility’s In-Center Treatment Area on 01/13/2025 at 09:45 AM with Staff # 5, the surveyor observed the following infection control issues: * The patient chair located at Station # 8 had a large rip in the seat. There was no way to ensure the chair was adequately cleaned and disinfected due to the damage to the chair’s material. * A patient’s neck pillow was sitting on the counter of the nurse’s station directly next to the “clean” dialysis clamps. * There was an opened AV (arteriovenous) fistula needle sitting on the counter. It was unclear if the needle had been used on a patient or when the needle was opened. *The counters located next to the nurse’s station were cluttered with patient equipment and supplies. There was dust built up on the counter. *There were multiple blood pressure cuffs with unknown substances on the Velcro portion of the cuff. A review of the facility’s policy, “General Cleanliness and Infection Control Guidelines” with a published 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 ... *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. *Supplies or patient belongings should not be kept or stored behind the machine at the patient station ....” An interview with Staff # 5 on 01/13/2025 at 10:30 AM confirmed the infection control issues found in the facility’s in-center treatment area.”

“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 # 24) of 2 direct care staff members failed to change gloves and perform hand hygiene between patient encounters and before touching dialysis equipment and sterile supplies. Also, the facility’s direct care staff failed to follow the facility’s “Cleaning and Disinfecting the Dialysis Station” policy. Findings include: During a tour of the facility’s in-center treatment area on 01/13/2025 at 10:00 AM with Staff # 5, the surveyor observed Staff # 24 (CCHT) providing care to the patient at dialysis station #27. Staff # 24 was observed touching the dialysis machine and keyboard with the same gloves that were used to touch the patient and the patient’s dialysis chair. Staff # 24 did not perform hand hygiene or change gloves between patient contact and contact with the dialysis machine and chair. Also, Staff # 24 used the same gloves to provide care to the patient at dialysis station # 28. Staff # 24 never performed hand hygiene or changed gloves between the two patient interactions. A review of the facility’s policy, “Cleaning and Disinfecting the Dialysis Station” with a published date of 09/05/2023 revealed, “PURPOSE: The purpose of this policy is to provide guidelines to prevent the spread of infectious disease in accordance with appropriate regulations, and to maintain a clean, safe, and aesthetically pleasant environment for patients, staff, and visitors. BACKGROUND: “The Centers for Medicare and Medicaid Services (CMS) has regulations that in order to prevent cross-contamination, a dialysis station must be cleaned and disinfected between dialysis patients. The chair and dialysis equipment are used by multiple patients during a treatment day and it is critical that these items be thoroughly cleaned and disinfected between uses. Also, the nature of dialysis treatments with frequent exposure to blood and body fluids, close proximity of patients and staff, and the immunocompromised status of dialysis patients make dialysis a high-risk area for spreading infectious disease ... Hand hygiene must be performed after contact with the electronic devices and before contact with the patient ...” An interview with Staff # 5 on 01/13/2025 at 10:45 AM confirmed Staff # 24 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-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 that 4 of 4 medications maintained in the facility were properly safeguarded and not accessible to unauthorized persons. The facility staff failed to follow the “Medication Preparation and Administration” policy. Findings include: During a tour of the facility’s in-center treatment area on 01/13/2025 at 09:45 AM with Staff # 5, the surveyor observed four pre-made treatment initiation packs (packs of supplies used to initiate dialysis treatment) sitting on the counter next to the main nurse’s station. The pre-made packs contained syringes of pre-drawn Heparin (a medication used to thin blood). The medication was not labeled with the date and time it was prepared. There was no way to determine how long the Heparin had been sitting on the counter or when it was prepared. The Heparin was not secured and was available for unauthorized persons to access. A review of the facility’s policy, “Medication Preparation and Administration” with a published date of 02/06/2023 revealed, “PURPOSE: To administer medications with the goals of staff and patient safety, optimal therapeutic response, and infection control ... PRE-DRAWING MEDICATIONS: Medications may be pre-drawn up to 4 hours prior to administration. These pre-drawn medications shall be labeled and must be kept under the preparer’s control or in a locked designated medication storage area or refrigerated, if necessary, until delivery to the appropriate patient for administration ... Expiration dates for all stored medications are to be monitored on a monthly basis. Expired medications are to be discarded via Fresenius Kidney Care off-site return program or in accordance with local and/or state laws ...” An interview with Staff # 5 on 01/13/2025 at 09:55 AM confirmed that the facility staff failed to ensure medications were locked up and not accessible to unauthorized persons. Also, Staff # 5 confirmed the syringes were not properly labeled with the date and time of preparation.”

“IC-TRANSDUCER PROTECTORS-NOT WETTED/CHANGED CFR(s): 494.30(a)(1)(i) Use external venous and arterial pressure transducer filters/protectors for each patient treatment to prevent blood contamination of the dialysis machines’ pressure monitors. If the external transducer protector becomes wet, replace immediately and inspect the protector. If fluid is visible on the side of the transducer protector that faces the machine, have qualified personnel open the machine after the treatment is completed and check for contamination. This includes inspection for possible blood contamination of the internal pressure tubing set and pressure sensing port. If contamination has occurred, the machine must be taken out of service and disinfected using either 1:100 dilution of bleach (300-600 mg/L free chlorine) or a commercially available, EPA-registered tuberculocidal germicide before reuse. Change filters/protectors between each patient treatment, and do not reuse them. Internal transducer filters do not need to be changed routinely between patients. This Standard is not met as evidenced by: 48653 Based on observation, policy review, and staff interviews, the facility staff failed to identify 2 (Station # 5 and # 12) of 2 wet (wet with patient blood or other fluid) external transducers (pressure monitors) located on the dialysis machines and failed to follow the facility policy, “Maintenance of Transducer Protectors Procedure.” This deficient practice could cause harm to all patients receiving dialysis at the facility by introducing patient blood into the dialysis machine. This could cause contamination of the dialysis machine and allow other patients to become exposed to blood contamination. Findings include: During a tour of the facility’s In-Center Treatment Area on 01/13/2025 at 10:00 AM, the surveyor observed the dialysis machines at stations # 5 and # 12 have a wet external transducer. The external transducer was wet with the patient’s blood due to high venous pressures during treatment. The surveyor alerted Staff # 5 to the wet transducers. A review of the facility’s policy, “Maintenance of Transducer Protectors Procedures” with a published date of 11/07/2022 revealed, “PURPOSE: The purpose of this policy is to ensure accurate measurement of arterial and venous pressures and prevent cross-contamination during hemodialysis by maintaining clean, dry transducer protectors. BACKGROUND: The transducer protectors must be dry to provide accurate venous and arterial pressures. Cross-contamination can occur if the internal transducer becomes contaminated with blood and is not disinfected or changed before the machine is used on another patient. POLICY: The transducer protector must be changed immediately when contaminated with saline or blood. If the back of the transducer protector is contaminated with blood, the internal transducer must be checked by biomedical staff prior to use of the machine for another patient for contamination and changed or disinfected as necessary. The internal transducer will be examined on at least an annual basis in the home, semiannual basis, or 2000 hours, whichever comes first in the clinic, and any times maintenance is performed by the biomedical staff as part of routine maintenance ...” An interview with Staff # 5 on 01/13/2025 at 10:00 AM confirmed the transducers at stations # 5 and # 12 were wet with the patient’s blood.”

“MIXING SYSTEMS-LABELING CFR(s): 494.40(a) 5.4.4.1 Mixing systems: labeling Labeling strategies should permit positive identification by anyone using the contents of mixing tanks, bulk storage/dispensing tanks, and small containers intended for use with a single hemodialysis machine. Mixing tanks: Prior to batch preparation, a label should be affixed to the mixing tank that includes the date of preparation and the chemical composition or formulation of the concentrate being prepared. This labeling should remain on the mixing tank until the tank has been emptied. Bulk storage/dispensing tanks: These tanks should be permanently labeled to identify the chemical composition or formulation of their contents. Concentrate jugs: At a minimum, concentrate jugs should be labeled with sufficient information to differentiate the contents from other concentrate formulations used at the facility. This Standard is not met as evidenced by: 48653 Based on observation, record review, and staff interview, the facility staff failed to ensure 4 of 4 open acid concentrate jugs were labeled with the date of opening. The facility staff failed to follow the policy, “Acid Concentrate Storage and Handling”. Findings include: During a tour of the facility’s in-center treatment area on 01/13/2025 at 09:45 AM with Staff # 5, the surveyor observed 4 acid-contrate jugs on a black cart. The seal on the jugs had been broken. The surveyor was unable to determine when the jugs had been opened or what the solution in the jug was because there was no label, date, or time. A review of the facility’s policy titled, “Acid Concentrate Storage and Handling” revealed the following: “The purpose of this policy is to provide direction for concentrate storage and handling. Store concentrate formulas by type, formulas and outer case identifiers, such as formula number. Outer box or container labels must be clearly visible, shall be in good condition and readable. Storage areas must use appropriate GHS labeling as stated in OSHA Hazard Communication Program. Label all acid containers as outlined in the Concentrate Labeling Requirements policy. Discontinued or expired concentrate formulas must be removed from inventory. Unused acid concentrate that cannot be transferred or returned, must be disposed of in accordance with state and local regulations. Concentrates must be stored in a secured area accessible only to authorized staff members or, if in the home setting, patient and/or care partner. Every 30 days, the reusable concentrate container must be cleaned: Discard any remaining concentrate. Thoroughly rinse inside and outside of container with reverse osmosis (RO) or deionized (DI) water. Inspect for foreign materials. Place on a shelf inverted to allow to dry Each container will be assigned and labeled with a permanent identification number to facilitate the tracking of containers. Containers will be stored capped to prevent accumulation of dust, dirt or other contaminants. Containers, wands and caps that are stored will be rinsed, allowed to air dry and stored in a manner that will prevent accumulation of dust, dirt or other contaminants.” An interview with Staff # 5 on 01/13/2025 at 10:30 AM confirmed the acid jugs were opened without the appropriate labeling.”

“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 2 (Patient # 3 and Patient # 6) of 2 patient’s arteriovenous (AV) access was visible throughout the entire dialysis treatment. Ensuring proper visualization of the arteriovenous fistula access is important for the early recognition and prevention of bleeding from the patient’s access site. Findings include: During a tour of the facility’s in-center treatment area on 01/13/2025 at 9:30 AM with Staff # 5, the surveyor observed the following: Patient # 3 receiving dialysis treatment at Station # 1. The patient’s arteriovenous access was covered with a personal blanket. There was no documentation in the patient’s medical record to support the patient’s education on the importance of always keeping the access visible. The surveyor observed the patient’s access covered for more than 5 minutes. Patient # 6 was receiving dialysis treatment at Station # 20. The patient’s arteriovenous access was covered with a personal blanket. A review of the facility’s policy, “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 ... Access: Observe and document at the initiation of dialysis and at every safety check that all connections are secure and visible ...Ensure access remains uncovered throughout the treatment ...” An interview with Staff # 5 on 01/23/2025 at 10:00 AM confirmed that the facility staff failed to ensure that all patient’s access was visible throughout the entire dialysis treatment.”

“GOV-RN, MSW, & RD AVAIL TO MEET PT NEEDS CFR(s): 494.180(b)(1) The governing body or designated person responsible must ensure that- The registered nurse, social worker and dietitian members of the interdisciplinary team are available to meet patient clinical needs; This Standard is not met as evidenced by: 48653 Based on staff interviews, the facility’s leadership failed to ensure the social worker had a maximum patient load of 125 patients and available clerical support to meet every patient’s psychological and social needs. Findings include: The facility treated patients Monday through Saturday and had a total patient census of 89. During an interview with Staff # 4 (Licensed Social Worker) on 09/23/2024 at 11:00 AM, Staff # 4 reported, in addition to his full-time commitment at the facility, he was also providing crisis staffing support to 2 other dialysis facilities, located 50 miles away. Staff # 4 reported the combined patient load he was supporting at the other 2 facilities was 70 patients. Staff # 4 acknowledged he was over the maximum patient load of 125 patients. Staff # 4 stated, “We are short 4 social workers in our region”. Staff # 4 (Licensed Social Worker) had a total patient load of 159 patients which exceeds the State maximum of 125 patients. Staff # 4 was unavailable for an in-person interview at the facility because he was working at one of the other dialysis facilities. Staff # 4 does not work at the facility on Mondays and is not present to provide support to patients on Mondays. During an interview with Staff # 1 (Clinical Manager) on 09/23/2024 at 11:15 AM, Staff # 1 acknowledged the Social Worker was above the maximum patient load.”