Westhampton Dialysis Center LLC

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 36946 Based on staff (EMP) interview, observations, and document review, it was determined the facility failed to ensure it maintained its treatment floor in a safe manner. Findings: Observations were conducted on the facility’s treatment floor beginning at 10:35 AM on September 22, 2025. Several large areas of the tile flooring were damaged. One (1) approximately seven (7) by three (3) foot area adjacent to the nurse’s working station contained tiles that were visibly stained, worn, and stripped of the surface layer creating an uneven surface not able to be fully cleaned and disinfected. Another approximately four (4) by four (4) foot area adjacent to a storage cabinet on the treatment floor was comprised of tile flooring in which the tile was damaged and in poor repair creating a surface that could not be fully cleaned and disinfected. Tiles were also noted damaged or missing completely behind treatment chairs and in corners of the treatment floor. An interview was conducted with EMP1 at approximately 12:30 PM on September 22, 2025. EMP1 indicated they had been working in the facility since April of this year and the tile treatment floor was damaged when they started in April. EMP1 indicated that facility staff had noticed the floor and talked about repairing or replacing it, but nothing was documented regarding the discussions. The facility provided the surveyor with a contract, “Professional Cleaning Service Contract” with a start date of November 17, 2023. The contracted cleaning service was to “sweep and mop all areas that are tiled or laminated/wood including stairways” six nights per week. The contract further indicated that the floors would be stripped and waxed at an extra cost and this service was recommended quarterly. During the interview with EMP1 at 12:30 PM on September 22, 2025, EMP1 indicated that the contracted cleaning company cleaned the dialysis floor six nights per week. The surveyor requested a log of facility cleaning by the contracted cleaning service. EMP1 stated the facility did not maintain any such cleaning log and/or require the contracted company to maintain a log of when services were performed. EMP1 indicated that the floors had not been stripped or waxed since they began employment in April 2025. EMP1 was unsure if the tile floor had ever been stripped or waxed as recommended by the cleaning company. The facility’s policy, “Physical Environment” last revised July 18, 2025 was reviewed and reads in part, “...Each IRC care center will take steps to endure that all equipment...are maintained and operated in accordance with manufacture’s recommendations...””

“PQ-NURSE MANAGER-12 MO RN+6 MO DIALYSIS CFR(s): 494.140(b)(1) (1) Nurse manager. The facility must have a nurse manager responsible for nursing services in the facility who must- (i) Be a full time employee of the facility; (ii) Be a registered nurse; and (iii) Have at least 12 months of experience in clinical nursing, and an additional 6 months of experience in providing nursing care to patients on maintenance dialysis. This Standard is not met as evidenced by: 36946 Based on staff (EMP) interview and document review, it was determined the facility failed to ensure it had a nurse manager responsible for nursing services in the facility who was a full time employee of the facility. Findings: EMP1 stated to the surveyor during an interview on September 22, 2025 at 11:30 AM that they were the nurse manager. EMP1 indicaterd that they split their time between two (2) seprately certified dialysis facilities and confirmed they were not a full-time employee of only this facility. EMP1 confirmed there was no other full time employee acting in the capacity of a nurse manager at this facility. EMP1’s job description, “Clinic Manager” last revised July 2024 was reviewed and reads in part: “...This is a full-time position in a healthcare facility...” EMP1 again confirmed on September 22, 2025 at approximatey 1:00 PM that the facility did not employ a full time nurse manager.”

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 19883 Based on observation, staff interview, and facility document review, and during the course of a complaint survey, the facility staff failed to follow their infection control plan which could have negatively impacted the health and safety of the facility’s patients. The facility was actively utilizing two dialysis chairs that had what appeared to be areas of dried blood, failed to ensure expired medications were removed and not available for use and failed to ensure appropriate PPE (Personal Protective Equipment) was utilized during a dialysis treatment involving a central catheter line. Please refer to V122, V143 and V146, for further information.”

“CFC-PHYSICAL ENVIRONMENT CFR(s): 494.60 This Condition is not met as evidenced by: 19883 Based on observation, staff interview, and facility document review, and during the course of a complaint survey, the facility staff failed to address torn, corroded, and malfunctioning dialysis chairs, which could have significantly impacted the health and safety of the facility’s patients. The facility used multiple dialysis chairs that had areas of torn vinyl on the arm rests, broken latches on the side doors, malfunctioning latches on the side trays, and corrosion on the metal portions of the underside of the chair. Multiple chairs could not be reclined into the Trendelenburg position. (is a body position where the patient lies flat on the back typically on a 15-30 degree angle with the head in a downward position. By elevating the lower body, this position facilitates the return of blood to the heart, which can be particularly beneficial in cases of hypovolemia or shock where blood pressure needs to be stabilized quickly. Source: www.nurse.com). Please refer to V403 for further information.”

“CFC-QAPI CFR(s): 494.110 This Condition is not met as evidenced by: 19883 Based on staff interview and facility document review, and during the course of a complaint survey, the facility staff failed to ensure the Quality program prioritized major problems that threaten the health and safety of patients. The facility has multiple dialysis chairs that need repairs or replacement, including one chair that caught fire. The facility staff, although aware of the issues, didn’t discuss these safety concerns with the interdisciplinary team, didn’t address any of the circumstances in the Quality Meetings, nor developed a plan of action to correct the problem and prevent a reoccurrence. Please refer to V640 for further information.”

“CFC-RESPONSIBILITIES OF THE MEDICAL DIRECTOR CFR(s): 494.150 This Condition is not met as evidenced by: 19883 During the complaint survey pervasive concerns were identified with malfunctioning dialysis chairs, which included, corrosion on the metal portions of the chairs, tears in the arms of chairs, and torn material attached to the foot rests of the chairs. The electric heating element of one of the chairs had caught fire approximately 12 months prior. There was a lack of evidence that the facility’s Medical Director provided oversight in ensuring that new chairs were obtained, or that the incident related to the chair fire was addressed in the facility’s monthly quality program meetings. Please refer to V711”

“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: 19883 Based on observation, staff interview and facility document review, and during the course of this complaint survey, the facility staff failed to ensure cleaning and disinfection of patient treatment stations per facility policy which resulted in failure to remove dried blood from two (2) of 15 dialysis chairs. The findings included: On 08/11/2025 at 11:30 AM, during a tour of the dialysis treatment floor, the surveyor observed two (2) of 15 dialysis chairs to have a reddish-brown substance which appeared to be dried blood. One dialysis chair had streaks of a reddish-brown substance on a vinyl flap underneath the chair and the second chair had the same type of substance on the top surface of the left arm. Staff Member #1 used a gloved finger and scraped off a portion of the substance. Staff Member #1 concluded during an interview on 08/11/2025 that the substance “looked like dried blood.” Review of the facility’s policy titled: “Cleaning & Disinfection of Equipment, Supplies, and Treatment Area” with a revision date of 6/20/2024 reads in part: “...Spills or splashes of blood must be cleaned up immediately.” And: “...When contaminated with blood, surfaces are first cleaned with a disposable cloth soaked in the bleach/water solution to remove all visible blood, which is discarded after use.””

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 19883 Based on observation, staff interview, and facility document review, and during the course of a complaint survey, the facility failed to: A, Remove three (3) expired vials of medication, and B, Ensure medications were ordered and and replaced before the existing medications expired. The findings included: On 08/11/2025, during an inspection of the facility’s emergency medical cart the surveyor found three vials of the medication, Solu-Medrol (a steroid that prevents the release of substances in the body that cuase inflammation, retrieved from drugs.com 8/14/25) with an expiration date of 07/25. Staff Member #1 confirmed, during an interview on 08/11/2025, that the medications were expired. Review of the facility’s policy titled: “G15 Emergency Equipment & Medication Checks” with a revision date of 11/15/2023, reads in part: “...Medication soon to expire must be reordered and replaced prior to expiring.” And, “...Weekly checks will be documented on the Emergency Medication and Equipment Log.” Review of the Emergency Cart Checklist form evidenced a most recent log check dated 07/22/2025. Solu-Medrol was documented on the log as expiring 07/25. There was no evidence that the emergency medical cart had undergone weekly checks in the past two weeks. Staff Member # 5 confirmed, during an interview on 08/12/2025 that the medication should have been replaced prior to the expiration date of the medication, and a new medication ordered as soon as they had been made aware of the expired medication.”

“IC-CATHETERS:GENERAL CFR(s): 494.30(c)(2) (2) The “Guidelines for the Prevention of Intravascular Catheter-Related Infections” entitled “Recommendations for Placement of Intravascular Catheters in Adults and Children” parts I - IV; and “Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients,” Morbidity and Mortality Weekly Report, volume 51 number RR-10, pages 16 through 18, August 9, 2002. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR Part 51. This publication is available for inspection as the CMS Information Resource Center, 7500 Security Boulevard, Central Building, Baltimore, MD or at the National Archives and Records Administration (NARA). Copies may be obtained at the CMS Information Resource Center. For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_regulations/ibr_locations.html This Standard is not met as evidenced by: 19883 Based on observation, staff interview, and facility document review, and during the course of a complaint survey, the facility failed to ensure that PPE was provided for a patient during Central Venous Catheter (CVC) care. The findings included: On 08/12/2025 at 12:30 PM Staff Member #1 was performing CVC care of a dialysis patient as part of the preparation for the initiation of dialysis. Staff Member #1 didn’t at any time offer a mask to the patient. After the dialysis treatment has been started, the surveyor asked Staff Member #1 what was the reason for the patient not wearing a mask. Staff Member #1 replied, “they should have worn a mask.” Staff Member #1 gave no other explanation as to why they did not offer a mask to the patient. Review of the facility’s policy titled: “ICO5 CVC: Assessment & Site Care” with a revision date of 10/22/2024 reads in part: “...when any CVC procedure is being performed, the patient, caregiver, and anyone assisting/observing must wear required personal protective equipment (PPE), including a full-face shield and mask, or safety goggles and a mask. The patient must also wear a mask during the procedure.””

“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: 19883 Based on observation, staff interview, and document review, and during the course of a complaint survey, the facility staff failed to properly maintain 15 of 15 dialysis chairs and ensure full functionality of all dialysis chairs. The facility staff failed to repair, and/or, replace dialysis chairs with tears on the chair’s arm rests, broken latches on the side doors of the chairs, broken latches on the side trays, malfunctioning of Trendelenburg mechanisms, and corrosion on the metal portions of the underside of the chairs. The condition of the chairs posed a potential patient safety concern. The findings included: On 08/11/2025 at approximately 11:50 AM, the surveyor tour the dialysis treatment area where 10 patients were receiving dialysis treatments. The treatment area contained 15 dialysis chairs. Observation of the dialysis chairs revealed: five (5) of 15 dialysis chairs had multiple tears on the armrests of the chairs, 15 out of 15 dialysis chairs had rust and corrosion on the metal portions of the underside of the chairs four (4) of 15 chairs had vinyl flaps that were torn away from the back of the footrests, one (1) of the side trays, of a chair that was occupied by a dialysis patient was propped up by a rolling tray table. Staff Member #2 reported during an interview on 08/11/2025 that three (3) of the 15 dialysis chairs have side doors that won’t stay closed and latched, and at times will open spontaneously. According to to Staff Member #2, there are at “at least” three chairs that won’t go into the Trendelenburg position, multiple chairs in which the wheels won’t lock and several chair side trays won’t stay in the locked and upright position. Staff Member #2 explained that whenever they have an issue with a malfunctioning chair or other damaged or malfunctioning equipment, they report it to the facility’s charge nurse who then reports it to the facility’s clinic manager. Staff Member #2 assured the surveyor hat they reported issues concerning malfunctioning chairs or other issues to their charge nurse as required. Staff Member #1 reported during an interview on 08/11/25 that the heating element of one (1) of the 15 dialysis chairs caught on fire “last year” and at the time of the fire a patient wasn’t in the chair . Staff Member #1 could not recall the exact date of the incident. According to Staff Member #2 and Staff Member #1, at that time, the facility’s Clinic Manager, cut the electrical cord off the chair, and the chair remained in operation without the use of the heating element. Review of the facility’s policy titled: “Technical Operations Manual” with a current revision date of 02/05/24, reads in part: “...Treatment Floor Furnishings: All dialysis chairs will be inspected monthly for the following: Blood residue, torn upholstery, including small pin holes and small tears, rust/corrosion, stains/dirt, and damage. All dialysis chairs will be repaired or replaced, as needed based upon the monthly inspection. Facility Staff Members reporting an issue will do the following: Record issue found on the Facility Environmental Issues Form...the FTM (Facility Technical Manager) will do the following: Check the form weekly, verify that the issue still exists, develop a plan for repair or replacement, bring the Facility Environmental Issue Form to the Monthly QAPI (Quality Assurance Performance Improvement) meeting and discuss issues listed, the plan of correction and the POC (plan of correction) completion due date.” Staff Member #5 reported during an interview on 08/12/2025 that the facility does not have a plan of correction for the damaged chairs, nor do they have a Facility Environmental Issues form, therefore no documentation related to the damaged chairs or the chair that caught fire, exists. Review of the facility’s QAPI meeting minutes for the past 12 months didn’t reveal any evidence that the damaged chairs were discussed in any of the monthly QAPI meetings and/or a plan of action was developed to prevent reoccurrence of the issues.”

“QAPI-QAPI-IMMEDIATELY CORRECT ANY IJ ISSUES CFR(s): 494.110(c) The facility must immediately correct any identified problems that threaten the health and safety of patients. This Standard is not met as evidenced by: 19883 Based on staff interview and facility document review, and during the course of a complaint survey, the facility staff failed to set priorities for performance improvement when potential patient safety issues were identified. The facility failed to address in their Interdisciplinary Team (IDT) meetings and/or in their Quality Program/Meetings issues concerning equipment maintenance. The findings included: Staff Member #8 , member of IDT, reported during an interview on 08/11/2025 that they were aware of the condition of the dialysis chairs which has “been an ongoing issue.” Staff Member #5 reported during an interview on 08/12/2025 that when a dialysis chair caught fire, there should have been an incident report completed by the facility’s clinical manager but they failed to do so and didn’t discuss the incident in any of the facility’s past 12 monthly QAPI meetings. Review of the facility’s QAPI (Quality Assurance Performance Improvement) minutes for the past 12 months did not evidence that malfunctioning chairs, torn arm rests or the corrosion on the chairs were discussed in any of the monthly meetings.”

“MD RESP-MED DIR QUAL/ACCOUNTABLE TO GOV BODY CFR(s): 494.150 The dialysis facility must have a medical director who meets the qualifications of §494.140(a) to be responsible for the delivery of patient care and outcomes in the facility. The medical director is accountable to the governing body for the quality of medical care provided to patients. This Standard is not met as evidenced by: 19883 Based on observation, staff interview, and facility document review, and during the course of a complaint survey, the facility failed to address the need for repair or replacement of faulty dialysis chairs and a fire incident involving a dialysis chair during facility’s QAPI (Quality Assurance Performance Improvement) monthly meetings. The findings included: On 08/11/2025 at approximately 11:50 AM, during a tour of the facility, surveyor observed on the treatment floor dialysis chairs with torn areas on the arm rests, broken latches on the side doors of the chairs, broken latches on the side trays, malfunctioning of Trendelenburg mechanisms, and corrosion on the metal portions of the underside of the chairs. The condition of the chairs posed a potential patient safety concern. Staff Member #1 reported during an interview on 08/11/25 that the heating element of one of the 15 dialysis chairs caught on fire “last year.” Staff Member #1 could not recall the exact date of the incident, but stated it was “around this time last year, it was in the summer months.” Staff Member #8 , member of IDT, reported during an interview on 08/11/2025 that they were aware of the condition of the dialysis chairs which has “been an ongoing issue” but had no knowledge how the clinic was addressing the problem. Review of the facility’s policy titled: “Technical Operations Manual” with a current revision date of 02/05/24, reads in part: “...Treatment Floor Furnishings: All dialysis chairs will be inspected monthly for the following: Blood residue, torn upholstery, including small pin holes and small tears, rust/corrosion, stains/dirt, and damage. All dialysis chairs will be repaired or replaced, as needed based upon the monthly inspection. Facility Staff Members reporting an issue will do the following: Record issue found on the Facility Environmental Issues Form...the FTM (Facility Technical Manager) will do the following: Check the form weekly, verify that the issue still exists, develop a plan for repair or replacement, bring the Facility Environmental Issue Form to the Monthly QAPI Meeting and discuss issues listed, the plan of correction and the POC (plan of correction) completion due date.” Staff Member #5 reported during an interview on 08/12/2025 that the facility does not have a plan of correction for the damaged chairs, nor do they have a Facility Environmental Issues form, therefore no documentation related to the damaged chairs, or the chair that caught fire exists. Review of the facility’s QAPI meeting minutes for the past 12 months contained no evidence that the damaged chairs were discussed in any of the monthly meetings. There was no plan of action developed to prevent reoccurrence of the issues.”

“GOV-ADM RESP FOR RESOURCES FOR QAPI CFR(s): 494.180(a)(4) The governing body or designated person responsible must appoint an individual who serves as the dialysis facility’s chief executive officer or administrator who exercises responsibility for the management of the facility and the provision of all dialysis services, including, but not limited to- (4) Allocation of necessary staff and other resources for the facility’s quality assessment and performance improvement program as described in §494.110. This Standard is not met as evidenced by: 19883 Based on observation, staff interview and facility document review and during the course of a complaint survey, the facility’s governing body and IDT (interdisciplinary team) failed to address the malfunctioning and deteriorating condition of 15 out of 15 facility’s dialysis chairs over a 12 month period. The findings included: On 08/11/2025 at approximately 11:50 AM during a tour of the dialysis treatment area, the surveyor observed 15 out of 15 dialysis chairs had rust and corrosion on the metal portions of the chairs, four (4) out of 15 dialysis chairs had tears in the arms of the chairs. Multiple chairs had malfunctioning trays and chair doors. Staff Member #5 reported during an interview on 08/11/2025 that they had begun employment with the facility in May, 2025 and ordering new chairs was a priority for them. Staff #5 submitted a request to the facility’s financial officer for order of new chairs and received approval for purchase of eight new chairs, although 15 chairs in the facility needed replacing. At the time of exit, no new dialysis chairs were present and/or in use at the dialysis clinic. Review of the facility’s QAPI (Quality Assurance Performance Improvement) monthly meeting notes for the past 12 months revealed no evidence that the condition of the current dialysis chair, or the need to purchase new chairs, had been addressed by the Medical Director, the Clinic Manager or by the IDT (Interdisciplinary Team). An action plan for replacing the torn and malfunctioning chairs was never developed. There was no evidence that the facility’s governing body monitored indicators that would address plans for improvement, or evaluate for sustained improvement. There was no evidence that the facility set priorities for performance improvement, considered the prevalence and severity of identified problems and gave priority to improvement activities that can effect patient safety.”