Kempsville Dialysis Center

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 34452 Based on observations, document review and interview, it was determined that the facility failed to ensure staff wear face masks correctly during Patient care for two (2) of nine (9) Staff Members (SM), SM # 4 and # 5. The findings include: On August 13, 2025, between 9:45 AM and 12:00 PM, the following was observed during initiation and termination of treatment: A 9:55 AM, SM # 4 was observed wearing the face mask below the chin. SM # 4 was observed pulling the face mask up above nose by touching the front of the mask with gloved hand while providing care at Station # 21. SM # 4 then pulled the mask back below the chin with gloved hand when leaving the treatment station. SM # 4 failed to change gloves and perform hand hygiene after touching the front of the face mask. At 10:00 AM, SM # 5 was observed wearing the face mask below the chin. SM # 5 was observed pulling the face mask up above the nose by touching the front of the mask with gloved hand while providing care at Station # 9. SM # 5 then pulled the mask back below chin with gloved hand when leaving the treatment station. SM # 4 failed to change gloves and perform hand hygiene after touching the front of the face mask. At 10:15 AM, SM # 5 was observed at Station # 8. SM # 5 pulled the face mask up and down with an un-gloved hand by touching the front of the mask. SM # 5 failed to perform hand hygiene after touching the front of the mask and before continuing to Station # 4 to provide care. On August 13, 2025, at 2:00 PM, SM # 1 stated masks are optional in the treatment area unless providing CVC (central venous catheter) care. SM # 1 indicated that the facility follows CDC (Center for Disease Control) guidelines for infection control. CDC guidelines include “face masks should completely cover your nose and mouth and fit snuggly against the sides of your face and without gaps. You should not touch the mask when wearing it.” On August 14, 2025 at approximately 12:00 PM, a review of the facility’s policy titled “Personal Protective Equipment” revealed in part “Face masks are single use only and must be discarded after the task for which they were needed is completed.””

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 34452 Based on document review and interview, it was determined that the facility failed to ensure the Patient’s treatment blood flow rate (BFR) was as prescribed by the Physician for three (3) of ten (10) Patients (P); P # 6, # 7, and # 9. The findings include: On August 13, 2025, the clinical record review revealed the following: P # 6- The flowsheet dated August 9, 2025 revealed the BFR was documented as 350 the entire treatment (11:43 AM to 3:02 PM). The Physician ordered BFR was 400. There was no documentation that the Physician and/or Registered Nurse (RN) was notified of the decreased BFR. The flowsheet dated August 12, 2025 revealed the BFR was documented as 350 the entire treatment (11:43 AM to 3:05 PM). The Physician ordered BFR was 400. There was no documentation that the Physician and/or Registered Nurse (RN) was notified of the decreased BFR. P # 7- The flowsheet dated July 30, 2025 revealed the BFR was documented as 300 the entire treatment (9:40 AM to 1:24 PM). The Physician ordered BFR was 350. There was no documentation that the Physician and/or Registered Nurse (RN) was notified of the decreased BFR. The flowsheet dated August 1, 2025 revealed the BFR was documented as 300 the entire treatment (9:45 AM to 1:24 PM). The Physician ordered BFR was 350. There was no documentation that the Physician and/or Registered Nurse (RN) was notified of the decreased BFR. P # 9- The flowsheet dated August 9, 2025 revealed the BFR was documented as 400 the between 6:46 AM to 8:01 AM. The Physician ordered BFR was 450. There was no documentation that the Physician and/or Registered Nurse (RN) was notified of the decreased BFR. On August 14 , 2025 at approximately 12:00 PM, a review of the facility’s policy titled “Patient Assessment and Monitoring” revealed in part “Check prescribed blood flow is being achieved or reason is documented in the medical record if unable to meet prescribed blood flow.” In an interview on August 14, 2025 at approximately 1:00 PM, Staff Member # 1 indicated staff are expected to document the reason the BFR is not as prescribed.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 34452 Based on document review and interview, it was determined that the facility failed to ensure: the Registered Nurse (RN) performed and documented the nursing assessment within one (1) hour of the treatment initiation per facility policy for two (2) of ten (10) Patients (P), P # 6 and # 9; staff obtained a standing blood pressure (BP) per facility policy on three (3) of ten (10) Patients, P # 7, # 8, and # 10; and staff obtained machine parameters and vital signs to include blood flow rate (BFR) and BP at least every 30 minutes for one (1) of ten (10) Patients, P # 5. The findings include: On August 13, 2025, the clinical record review revealed the following: P # 5- The flowsheet dated August 5, 2025 revealed there was no documented machine parameters and vital signs to include BFR and BP between 11:00 AM and 12:05 PM (greater than 30 minutes). P # 6- The flowsheet dated August 12, 2025 revealed the treatment was initiated at 11:43 AM and ended at 3:02 PM. The RN assessment was documented at 1:19 PM (greater than one (1) hour). P # 7- The flowsheet dated August 4, 2025 revealed there was no standing BP on the pre-treatment assessment. Mobility was documented as “ambulates with assistive device”. The post-treatment BP was documented as 140/91. The flowsheet dated August 6, 2025 revealed there was no standing BP on the pre or post-treatment assessment. Mobility was documented as “ambulates with assistive device”. P # 8- The flowsheet dated August 11, 2025 revealed there was no standing BP on the pre-treatment assessment. Mobility was documented as “ambulates w/o assist”. The post-treatment BP was documented as 143/82. P # 9- The flowsheet dated August 9, 2025 revealed the treatment was initiated at 6:36 AM and ended at 1:38 AM. The RN assessment was documented at 1:35 PM (greater than one (1) hour). P # 10- The flowsheet dated August 8, 2025 revealed the pre-treatment BP was documented as 120/63. There was no standing BP on the post-treatment assessment. Mobility was documented as “ambulates w/o assist”. On August 14, 2025 at 12:00 PM, a review of the facility’s policy titled “Patient Assessment and Monitoring” revealed in part “blood pressure and pulse rate every 30 minutes or more as needed and documented machine parameters and safety checks every 30 minutes or more often as needed. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment. Standing BP and weight are obtained pre and post dialysis by the licensed nurse or PCT (Patient Care Technician).” In an interview on August 14, 2025 at approximately 1:00 PM, Staff Memeber # 1 indicated staff are expected to document if information is not obtained or late.”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 34452 Based on document review and interview, it was determined that the facility failed to ensure the patient’s care plan was signed by the team members including the Patient for five (5) of ten (10) Patients, P # 5, # 6, # 7, # 8 and # 9. The findings include: On August 13, and 14, 2025, the clinical record review revealed the following: P # 5- The annual care plan meeting was documented as November 11, 2024. There was no Patient signature on the care plan to indicate participation in the care plan meeting. P # 6- The annual care plan meeting was documented as April 24, 2025. There was no Patient signature on the care plan to indicate participation in the care plan meeting. P # 7- The annual care plan meeting was documented as January 13, 2025. There was no Patient signature on the care plan to indicate participation in the care plan meeting. P # 8- The annual care plan meeting was documented as June 9, 2025. There was no Patient signature on the care plan to indicate participation in the care plan meeting. P # 9- The annual care plan meeting was documented as March 27, 2025. There was no Patient signature on the care plan to indicate participation in the care plan meeting. On August 14, 2025 at approximately 12:00 PM, review of the facility’s policy titled “Comprehensive Interdisciplinary Assessment and Plan of Care” revealed in part “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, a registered nurse, the patient’s attending Physician, social worker and registered dietitian. The plan of care should be signed at the time of the interdisciplinary team meeting for those attending in person. If unable to sign at the time of the meeting or if attending remotely, the care plan must be signed by the IDP member within 30 days of the interdisciplinary team meeting”. In an interview on August 14, 2025 at 2:10 PM, Staff Member # 1 indicated the Patient does participate in care plans if requested.”

“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: 41450 Based on staff record review, staff interview and facility documentation review, the medical director failed to ensure that facility staff implemented the facility’s health and safety policy for tuberculosis testing for one (1) staff member (SM), SM #4, out of a survey sample of three (3) staff members. The findings include: On 8/13/25 at approximately 11:15 AM, staff record reviews were conducted and revealed the following: SM #4, hired on 3/4/24, received the initial dose of a two-step Mantoux tuberculin skin test (TST) method on 3/6/24 which resulted as “negative” on 3/8/24. There was no documentation for the administration of the required second dose. On 8/13/25 at approximately 1:45 PM, SM #1 confirmed the findings and stated, “I thought that I only needed to give one TB skin test, I didn’t know that there was supposed to be two”. The facility policy for TB testing, monitoring, and surveillance was requested and received. On 8/13/25 at approximately 2:30 PM a review of the facility’s policy titled, “Employee Tuberculosis Testing”, dated 5/5/2025, page 1, read, “TB testing using the two-step tuberculin skin test (TST) method is required upon hire” and page 2 read, “If first step TST result is negative, administer second TST within 1-3 weeks”. Facility staff failed to complete Tuberculosis (TB) testing for SM #4.”