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“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: 48020 Based on observation, interview and record review, the facility’s direct care staff failed to: wash/sanitize hands after removal of contaminated gloves: 1 of 6 staff observed: Charge Nurse (H) Findings: Review of the facility’s current policy and procedure: Hand Hygiene: published 11/06/2023, reference number 47664, version 8 directs the staff as follows: “”Hands Will Be ... Decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water “ Immediately after removing gloves ...” Charge Nurse (H) Observation on 08/28/2024 at 8:47 a.m., revealed Charge Nurse (H) at nursing home facility #3 performing a Central Venous Catheter (CVC) dressing change on Patient #8. After initiating the patient’s hemodialysis treatment, Charge Nurse (H) removed her contaminated gloves, grabbed clean gloves out of a box on the side of the clean supply cart, and donned the clean gloves without washing/sanitizing her hands. Charge Nurse (H) then picked up the pen and clipboard from the top of the NxStage machine table of Random Patient #8 and began to documenting. The Surveyor immediately notified her of break in infection control technique by not washing or sanitizing her hands after removing the contaminated gloves. Charge Nurse (H) said, “Okay.””

“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: 48020 Based on observation and interview, the facility’s direct care staff failed to prevent cross contamination by storing patient records on top of the clean supplies in the clean supply cart. Findings: Nursing Home Facility #3 Observation of the nursing home facility #3 clean supply cart on 08/28/2024 at 7:40 a.m. revealed two folders with patient records on top of the clean supplies in drawer #2. The staff failed to prevent cross contamination of the clean supplies by storing patient records on the clean supplies. The Surveyor notified Charge Nurse (H) of the cross contamination by storing patient records on the clean supplies in the clean supply cart. Charge Nurse (H) said, “Okay.””

“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: 48020 Based on observation, interview and record review, the facility’s direct care staff failed to clean and disinfect the wall boxes in 1 of 2 training rooms with wall boxes. Findings: Review of facility’s current policy and procedure on cleaning and disinfecting the dialysis station published 09/05/2023, reference number 47806 version 14 directs staff as follows: “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.” Review of the Center for Disease Control (CDC) Dialysis Safety: Dialysis Wall Boxes and Drains states: “wall boxes need to be cleaned, disinfected, and properly maintained to decrease risk of patient infections. Wall boxes are part of the immediate patient care environment and are considered contaminated or dirty.” Training Room #0, Wall box #3 Observation of Training Room #0 on 08/26/2024 at 9:56 a.m. revealed NxStage #6520 with the drain line going into wall box #3. Wall box #3 had greenish brown build up and dust. Wall box #3 had not been disinfected. The Surveyor immediately notified the Home Therapies Manager of the dirty wall box. She confirmed wall box #3 in Room #0 had not been disinfected.”

“H-HOME PT PLAN OF CARE DEV/UPDATED CFR(s): 494.100(b)(1)(iii) Services include, but are not limited to, the following: (iii) Development and periodic review of the patient’s individualized comprehensive plan of care that specifies the services necessary to address the patient’s needs and meets the measurable and expected outcomes as specified in §494.90 of this part. This Standard is not met as evidenced by: 48020 Based on observation, interview and record review, facility failed to ensure all members of the facility’s interdisciplinary team complete patients’ comprehensive interdisciplinary assessments plan of care on staff assisted home hemodialysis patients receiving hemodialysis treatment in nursing home facilities in 1 of 8 sampled patients. Patient #2 Findings Review of the facility’s current policy and procedure: Hand Hygiene: published 11/06/2023, reference number 47664, version 8 directs the staff as follows: “The Comprehensive Interdisciplinary Assessment and Plan of Care must be developed and implemented by an interdisciplinary team (IDT) consisting of at a minimum, the patient or patient’s designee, a registered nurse, the patient’s attending physician (or physician extender where allowed by State regulations), qualified master’s degree level social worker and qualified registered dietitian.” Patient #2 Review of Patient #2’s clinical record revealed on 08/27/2024 revealed the patient was admitted to the nursing home hemodialysis facility #2 on 05/24/2024 with diagnosis of diabetes mellitus, and end stage renal disease. Review of the physician’s progress note dated 08/09/2024 revealed the following physical exam comments: “trach/vent + peg - tube feeds.” Review of the patient’s clinical record (initial comprehensive interdisciplinary assessment plan of care) dated 07/01/2024 revealed there was no documented assessment plan of care by the facility’s staff assisted home hemodialysis registered nurse in the signed POC meeting document. The record revealed documented assessments by other members of the interdisciplinary team on 06/05/2024. Interview on 08/27/2024 at 3:10 p.m., with Registered Nurse (D) confirmed that her assessment plan of care for Patient #2 was not included in the signed POC meeting document. Registered Nurse (D) stated, “I don’t know why it is missing.””

“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: 48020 Based on observation, interview and record review, the Facility’s Medical Director failed to ensure nurses are performing central venous catheter dressing changes per policy in 3 of 8 sampled patients: Registered Nurse (G), Charge Nurse (H) and Patient #’s 6, 7, 8 Findings: Review of the facility’s current policy and procedure on Changing the Catheter Dressing Procedure; published 02/05/2024, reference number 45664, version 8 directs staff as follows: “Policy “ Complete catheter exit-site care and dressing replacement before initiation of treatment ... “ The exit site will have disinfectant applied and a new dressing applied as follows: o Replace gauze dressing each treatment o Replace transparent dressings every 7 days or more often if wet, soiled, or loose. Note: Transparent dressings are recommended for home hemodialysis patients...” Registered Nurse (G) Patient #6 On 08/28/2024 at 8:34 a.m., Patient #6 was observed in the dialysis room at nursing home facility #3 receiving central venous catheter (CVC) care before the hemodialysis treatment. The patient had a gauze dressing covering the CVC exit site. Registered Nurse (G) was observed to remove the dressing covering the CVC lumens, clean the CVC lumen and hubs with alcohol and then connect the patient to the hemodialysis machine and initiated the hemodialysis treatment. Registered Nurse (G) did not complete the catheter exit-site care and replace the gauze dressing. Registered Nurse (G) Patient #7 On 08/28/2024 at 9:40 a.m., Patient #7 was observed in the dialysis room at nursing home facility #3 receiving central venous catheter (CVC) care before the hemodialysis treatment. The patient had a gauze dressing covering the CVC exit site. Registered Nurse (G) was observed to remove the dressing covering the CVC lumens, clean the CVC lumen and hubs with alcohol and then connect the patient to the hemodialysis machine and initiated the hemodialysis treatment. Registered Nurse (G) did not complete the catheter exit-site care and replace the gauze dressing. Charge Nurse (H) Patient #8 On 08/28/2024 at 8:47 a.m., Patient #8 was observed in the dialysis room at nursing home facility #3 receiving central venous catheter (CVC) care before the hemodialysis treatment. The patient had a gauze dressing covering the CVC exit site. Charge Nurse (H) was observed to remove the dressing covering the CVC lumens, clean the CVC lumen and hubs with alcohol and then connect the patient to the hemodialysis machine and initiated the hemodialysis treatment. Charge Nurse (H) did not complete the catheter exit-site care and replace the gauze dressing. Interview with Charge Nurse (H) at 10:30 a.m. confirmed that the gauze dressings on Patients #’s 6, 7, and 8 were not changed before initiating the treatment. The Surveyor notified Charge Nurse (H) that according to their policy, the gauze dressings should be changed each treatment. Charge Nurse (H) she stated, “I thought the dressing change was every 7 days.””