Fresenius Medical Care Midwest Glendale

“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: 29972 Based on observations and record review the facility staff failed to ensure the emergency crash cart was immediately available for use in case of an emergency in 1 of 1 emergency crash carts observed (treatment floor), in a total sample of 1 crash cart observed. Findings Include: Review of policy and procedure #46865 Version 8 titled, “Emergency Medications, Equipment and Supplies” published 07/07/2025 revealed, “The emergency cart should be located where it is readily accessible during medical emergency situations and shall NOT be blocked by wheelchairs, equipment, or other facility supplies.” On 10/01/2025 at 10:30 AM, observed the emergency crash cart on the treatment floor in the corner next to Station 1. Per observation the dialysis chair was blocking the emergency crash cart, not allowing the cart to be easily accessed in case of an emergency. During interview with Registered Nurse (RN) G on 10/01/2025 beginning at 1:45 PM, RN G confirmed the location of the emergency crash cart and stated that the chair was blocking the crash cart especially if a patient were reclined with their feet up in the chair. During interview with Nursing Manager A and Nurse Manager B on 10/01/2025 beginning at 1:30 PM, while discussing observations, Nurse Manager A stated that the emergency crash cart should not be blocked.”

“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: 29972 Based on observations, record review and interview the facility staff failed to ensure that staff perform hand hygiene after removing gloves in 2 of 10 patient observations (Patient (Pt) #6, #8), in a total sample of 10 patients observed; and failed to wear gloves appropriately when touching “dirty” equipment in 1 of 6 staff observed (Patient Care Technician (PCT) C), in a total of 6 staff observations. Findings Include: Review of policy and procedure #47663 Version 6 titled, “Personal Protective Equipment” published 11/06/2023 revealed: - “Personal protective equipment including...gloves, must be worn to protect employees from blood or other potentially infectious materials...” - “Staff must remove gloves and wash hands after: Patient Care, Exposure to blood and body fluids, Touching any surfaces within the patient station...” - “If hands are not visibly soiled, an alcohol based hand sanitizer may be used...Always perform hand hygiene after glove removal.” Review of policy and procedure #47664 Version 8 titled, “Hand Hygiene” published 11/06/2023 revealed: - “Hands will be decontaminated using alcohol based hand rub...immediately after removing gloves...After contact with inanimate objects near the patient...” On 10/01/2025 beginning at 10:30 AM, observed PCT F initiating Pt #6’s dialysis treatment using a Central Venous Catheter (CVC). PCT F dropped a bottle of sanitizer on the floor, picked it up, and then proceeded to don gloves before performing Pt #6’s CVC care; PCT F did not perform hand hygiene before donning gloves allowing for potential cross contamination. On 10/01/2025 beginning at 11:00 AM, observed PCT F initiating Pt #8’s dialysis treatment using an Arteriovenous Fistula/Graft (AVF/G). PCT F did not apply hand sanitizer to the back of his hands after removing gloves in 2 opportunities for hand hygiene observed during treatment initiation. On 10/01/2025 beginning at 2:35 PM, observed PCT C wrap a glove around her index finger to silence the machine alarms at Station 1 and Station 2. PCT C did not wear the glove appropriately, protecting all fingers and hands from potential cross contamination. PCT C did not perform hand hygiene after removing the gloves from her finger. During interview with Nursing Manager A and Nurse Manager B on 10/02/2025 beginning at 1:30 PM, while discussing observations, Nurse Manager A stated that staff should perform hand hygiene before and after donning and removing gloves. Manager A stated that staff should not have glove wrapped around one finger when touching the equipment.”

“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: 29972 Based on observation, interview, and record review the staff failed to wear personal protective equipment (PPE) appropriately when initiating dialysis treatment in 3 of 10 patient care observations (Patient (Pt) #6, #7, #8), in a total sample of 10 patient observations of care. Findings Include: Review of policy and procedure #47663 titled, “Personal Protective Equipment” version 6 Published 11/06/2023 revealed; - “Personal protective equipment including a full face-shield or mask and protective eyewear with full side shield, fluid-resistant gowns and gloves, must be worn to protect employees from blood or other potentially infectious materials.” On 10/01/2025 beginning at 10:30 AM, observed Patient Care Technician (PCT) F initiate dialysis treatment for Pt #6, Pt #7, and Pt #8. PCT F’s wrist and wrist watch was uncovered and exposed during dialysis treatment initiation, allowing for potential cross contamination and blood exposure. During interview with Nursing Manager A and Nurse Manager B on 10/02/2025 beginning at 1:30 PM, while discussing observations, Manager A stated that the wrist should be covered with the lab coat sleeve while initiating dialysis treatment.”

“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: 29972 Based on observation, interview, and record review staff failed to clean and disinfect all the equipment at the dialysis station between patients to prevent cross contamination in 1 of 2 observations of dialysis station cleaning (Station (St) #6), in a total sample of 2 observations of station cleaning; and failed to clean and disinfect the Hoyer lift after use in 1 of 1 observations of the Hoyer lift used for a patient (Patient (Pt) #12), in a total sample of 1 observation of the staff using the Hoyer lift. Findings Include: Review of policy and procedure #47806 Version 15 titled, “Cleaning and Disinfecting the Dialysis Station” published 09/02/2025 revealed: - “A dialysis station must be cleaned and disinfected between dialysis patients.” - Dialysis Stations: “Area including the dialysis machine, chair, and other reusable equipment or supplies utilized during dialysis treatment...Equipment in the dialysis station may include (but is not limited to) the following: Dialysis machine and attachments such...hand sanitizer/holder...” On 10/02/2025 beginning at 10:00 AM, observed Patient Care Technician (PCT) I cleaning and disinfecting St #6; PCT I did not clean the following: - Hansen Connectors and lines attached to the dialysis machine - Bottle of hand sanitizer/basket attached to the dialysis machine - Down sides of dialysis chair seat cushions On 10/01/2025 beginning at 1:50 PM, Observed PCT D and PCT F using a Hoyer lift to transfer Pt #12 to the treatment chair. PCT D returned the Hoyer lift to the clean supply room without cleaning and disinfecting the Hoyer lift after use. During interview with Nursing Manager A and Nurse Manager B on 10/02/2025 beginning at 1:30 PM, while discussing observations, Manager A stated that the above areas should be cleaned during the station disinfection. Manager A stated that the Hoyer lift should be cleaned before returning to the supply room.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 29972 Based on observation, interview, and record review staff failed to ensure Central Venous Catheters (CVCs) are accessed in a manner to prevent potential cross contamination in 2 of 2 patients observed with a CVC (Patient (Pt) #6, #7) in a total sample of 2 patients observed with a CVC. Findings include: Review of policy and procedure #45664 titled, “Changing the Catheter Dressing Procedure” Published 02/05/2024 Version 8, revealed: -If using 2% Chlorhexidine and 70% alcohol (Chloraprep): “Using gentle back and forth friction, clean the exit site beginning in the center and continuing outward 2 inches in a concentric circle for 30 seconds...” Review of policy and procedure # 45651 titled, “Initiation of Treatment Using a Central Venous Catheter...” Published 05/05/2025 Version 9 revealed: - “Threads and end of the luer lock (hub) must be scrubbed with 70% sterile alcohol pad for 10-15 seconds and any time caps are removed, or blood lines are disconnected (i.e. end of treatment...) to reduce risk of contamination.” On 10/01/2025 beginning at 10:30 AM, observed Patient Care Technician (PCT) F performing Pt #6’s CVC exit site care. PCT F cleansed the skin surrounding the CVC exit site with Chloraprep for 20 seconds and not 30 seconds as per policy. On 10/01/2025 beginning at 2:25 PM, observed PCT C discontinuing Pt #6’s dialysis treatment using a CVC. PCT C disconnected the blood lines from the CVC hubs and used alcohol pads to scrub the arterial hub for 4 seconds and the venous hub for 5 seconds. PCT C did not scrub the hubs for 10-15 seconds as per policy. On 10/01/2025 beginning at 2:50 PM, observed PCT F discontinuing Pt #7’s dialysis treatment using a CVC. PCT F disconnected the blood lines from the CVC hubs and used alcohol pads to scrub the arterial hub for 6 seconds and the venous hub for 9 seconds. PCT F did not scrub the hubs for 10-15 seconds as per policy. During interview with Nursing Manager A and Nurse Manager B on 10/02/2025 beginning at 1:30 PM, while discussing observations, Nurse Manager A stated that staff should follow the policy when performing CVC care.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 29972 Based on record review and interview, staff failed to ensure that the nursing evaluations address patient’s fluid management needs post dialysis treatment in 2 of 7 records reviewed (Patients (Pt) #2, 4); failed to ensure nursing assessments are completed when the blood pressure is out of parameters as per policy in 3 of 7 medical records reviewed (Pt #1, 4, 5); and failed to ensure blood pressure and heart rate is monitored as per policy in 2 of 7 records reviewed (Pt #2, 4), in a total sample of 7 medical records reviewed. Findings include: Review of policy and procedure #45265 titled, “Nursing Supervision and Delegation” Version 6 Published 11/06/2023 revealed: - “Prior to discharge the Registered Nurse (RN) must review the treatment record to confirm...Whether the patient is achieving dry weight and identify reason for patient not achieving dry...” - “The Team Leader/Charge Nurse will use their clinical judgement based on individual patient needs to determine if any clinical interventions are necessary.” - “RN should address “Any post treatment weight with a variance from the estimated dry weight of 1.0 kg.” - “Prior to discharge the Registered Nurse (RN) must review the treatment record for whether the patient is achieving dry weight and identify reason for patient not achieving dry weight; and blood pressures <100 systolic or greater than 180 systolic (normal 120).” - “Any observed changes or abnormal findings in the patient’s condition...must be reported to the qualified RN...who will assess the patient.” - “Document all findings in the patient’s medical record.” Review of policy and procedure #45284 titled, “Patient Assessment and Monitoring” Published 05/01/2023 Version 4 revealed: - “Record blood pressure (BP); recheck blood pressures after a drop...Report to the nurse any Systolic blood pressures greater than 180...Diastolic blood pressures greater than 100...Diastolic blood pressure less than or equal to 100...” - “Document findings and interventions in the medical record.” - “Weight: Obtain the patient’s post weight. Ensure the post weight is consistent with the goal set of the machine.” - Lung sounds, Edema, Heart sounds: “The RN will assess/re-assess post treatment as indicated.” - “Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes.” Fluid Assessments: Review of Pt #2’s treatment sheets revealed the following: - On 10/01/2025: Pt #2’s Estimated Dry Weight (EDW) was 96.0 kg (kilograms) and the post-treatment weight was 97.3 kg (1.3 kg above the EDW). There was no documentation of nursing evaluation/assessment to address Pt #2’s post weight being >1 kg above the EDW. Review of Pt #4’s treatment sheets revealed the following: -On 09/30/2025: Pt #4’s Estimated Dry Weight (EDW) was 135.1 kg and the post-treatment weight was 137.0 kg (1.9 kg above the EDW). There was no documentation of nursing evaluation/assessment to address Pt #4’s post weight being >1 kg above the EDW. Blood Pressure Assessments and Monitoring: Review of Pt #1’s Treatment Sheets revealed: -On 09/25/2025 Pt #1’s Systolic BP (SBP) was 93 (parameters between 100-180) at 10:02 AM, 191 at 10:39 AM, and 187 at 12:06 PM. There was no documented evidence of a Registered Nurse (RN) assessment addressing the SBP being out of parameters as per policy. -On 09/27/2025 Pt #1’s SBP was 185 at 11:04 AM and 181 at 11:31 AM. There was no documented evidence of a Registered Nurse (RN) assessment addressing the SBP being out of parameters as per policy. Review of Pt #2’s Treatment Sheets revealed: -On 10/01/2025 Pt #2’s BP and Heart Rate (HR) was checked at 4:01 PM and then not again until 5:07 PM (1 hour and 6 minutes later); there was no documented evidence that Pt #2’s BP and HR were monitored every 30 to 45 minutes as per policy. Review of Pt #4’s Treatment Sheets revealed: -On 09/29/2025 Pt #4’s BP and heart rate was checked at 11:35 AM and then not again until 12:40 PM (1 hour and 5 minutes later); there was no documented evidence that Pt #4’s BP and HR were monitored every 30 to 45 minutes as per policy. - On 09/30/2025 Pt #4’s SBP was 188 at 10:30 AM and 193 at 12:04 PM; there was no documented evidence of a Registered Nurse (RN) assessment addressing the SBP being out of parameters as per policy. Review of Pt #5’s Treatment Sheets revealed: -On 09/26/2025 Pt #5’s SBP was 188 at 7:32 AM and 201 at 8:02 AM. There was no documented evidence of a Registered Nurse (RN) assessment addressing the SBP being out of parameters as per policy. During interview with Nursing Manager A and Nurse Manager B on 10/02/2025 beginning at 1:30 PM, while discussing medical record findings, Nurse Manager A stated that nursing assessments and monitoring for blood pressure and fluid management should be completed and documented as per policy.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 29972 Based on record review and interview, staff failed to follow prescribed blood flow rates for 3 of 7 medical records reviewed (Patients #1, 4, 5), in a total sample of 7 medical records reviewed. Findings include: Review of policy and procedure #47334 titled, “Unable to Achieve Prescribed Blood Flow Rate” version 3 published 11/01/2021 revealed: - “Achieving prescribed BFR (Blood Flow Rate) is a critical parameter in achieving adequate treatment Kt/V (adequacy).” - “Notify physician/extender if unable to achieve prescribed blood flow rate.” - “Document in patient’s treatment record what action taken to address the inadequate blood flow and if unable to resolve. The nurse shall document any physician orders.” A review of Pt #1’s medical record revealed a physician order for BFR of 500. Review of Pt #1’s dialysis treatment sheets revealed the following: -On 09/25/2025 the BFR was set at 450 during the entire dialysis treatment . There was no documentation in the medical record addressing the BFR not being set at the ordered rate and notification to the provider. -On 09/27/2025 the BFR was set at 400 and 450 during the entire dialysis treatment . There was no documentation in the medical record addressing the BFR not being set at the ordered rate and notification to the provider. A review of Pt #4’s medical record revealed a physician order for BFR of 450. Review of Pt #4’s dialysis treatment sheets revealed the following: -On 09/29/2025 the BFR was set at 300 during the entire dialysis treatment . There was no documentation in the medical record addressing the BFR not being set at the ordered rate and notification to the provider. A review of Pt #5’s medical record revealed a physician order for BFR of 450. Review of Pt #5’s dialysis treatment sheets revealed the following: -On 09/29/2025 the BFR was set at 400 during the entire dialysis treatment . There was no documentation in the medical record addressing the BFR not being set at the ordered rate and notification to the provider. During interview with Nursing Manager A and Nurse Manager B on 10/02/2025 beginning at 1:30 PM, while discussing medical record findings, Nurse Manager A stated that staff should set the BFR at the ordered rate and if the rate is unable to be maintained they document the reasons why and the interventions completed as per policy.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 29972 Based on record review, observation, and interview staff failed to perform skin antisepsis as per policy when when using a Arteriovenous Fistula/Graft (AVF/G) in 1 of 2 observations of staff initiating treatment using an AVF/G (Patient (Pt) #10), in a total sample of 3 observations of patients using a AVF/G. Findings Include: Review of policy and procedure #45178 titled, “Access Assessment and Cannulation” Version 5 published 05-05-2025, revealed the following: - “70 % isopropyl alcohol pad: Using gentle friction, clean the access site beginning in the center and continuing outward 2 inches in a concentric circle for 30 seconds...” - “Perform skin antisepsis on one site at a time, allow to dry and then cannulate. Do not touch cannulation sites after skin disinfection...” On 10/01/2025 beginning at 11:00 AM, observed Patient Care Technician (PCT) E initiating Pt 10’s dialysis treatment using an AVF/G. PCT E cleansed vascular access site #1 with an alcohol wipe for 9 seconds and cleansed site #2 for 15 seconds; PCT H did not perform skin antisepsis for 30 seconds each site as per policy. During interview with Nursing Manager A and Nurse Manager B on 10/02/2025 beginning at 1:30 PM, while discussing observations, Nurse Manager A stated that staff should apply alcohol antiseptic for 30 seconds each site as per policy.”

“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: 29972 Based on observation, interview, and record review the facility failed to ensure all medications are secured from unauthorized access as per policy in 1 of 1 emergency medications observed (Crash cart), in a total sample of 1 crash cart observed. Findings Include: Review of policy and procedure #47544 titled, “Receiving and Stocking Medications” Version 2 Published 11/07/2022 revealed, “Ensure that all medications are secured in a lockable cabinet or medication refrigerator.” On 10/01/2025 beginning at 2:00 PM, observed the Crash Cart (emergency cart) containing emergency medications including; Sodium Bicarbonate, Narcan, Epinephrine, Solumedrol, Calcium Chloride, Benadryl, and Glucose. The Crash cart was secured with a plastic pull tab. Per interview with RN G on 10/01/2025 beginning at 2:00 PM, RN G stated that housekeeping staff clean the dialysis facility at night after staff leave the building. RN G stated that the Crash cart is not locked up at night and the medications remain in the Crash Cart.”