Aspirus Langlade Hospital Kidney Care

“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: 47413 Based on observation, record review and interview the facility staff failed to perform glove changes and/or hand hygiene when moving from “dirty” to “clean” tasks while providing CVC (central venous catheter) cares for 1 of 4 patients (Patient #3) with a CVC in a total of 15 observations of care. Findings include: A review of the facility’s policy #19369418 titled, “Hemodialysis Catheter- Initiation/Discontinuation/Assessment/Site Care/Dressing Change Policy” last revised 11/2025 revealed, “... 2. Initiation of Dialysis Treatment... I. Remove gauze dressing from catheter lines if applicable; J. Remove gloves, perform hand hygiene and don new clean gloves...” During an observation on 02/11/2026 at 11:31 AM Patient Care Technician B was observed performing CVC exit site care on Patient #3. Patient Care Technician B removed Patient #3’s gauze dressing from his catheter lines, did not remove her gloves or perform hand hygiene, and began to cleanse the CVC site. During an interview on 02/12/2026 at 10:09 AM with Clinic Supervisor A, she stated that hand hygiene and glove changes should performed anytime going from a “dirty” to a “clean” task.”

“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: 47413 Based on observation, interview and record review, the facility staff failed to complete disinfection of all equipment in the dialysis station for 2 of 2 dialysis stations (Stations #10, 11) observed being cleaned in a total of 15 observations of patient care. Findings Include: A review of the facility’s policy #14895453 titled, “Kidney Care Infection Prevention (System)” last revised 05/2024 revealed, “... VI. Cleaning and Disinfection... B. After each patient treatment, clean environmental surfaces at the dialysis station, including the dialysis chair... treatment tables... and other surfaces that are frequently touched and potentially contaminated with patient’s blood...” During an observation on 02/11/2026 at 9:07 AM, Registered Nurse F was observed cleaning Station #11 and did not clean the following: -Outsides of chair under tray table -Bilateral undersides of tray table -Back of chair -Back of dialysis machine -Under chair footrest -Lower front of dialysis machine and including lower tray During an observation on 02/11/2026 at 9:41 AM, Patient Care Technician C was observed cleaning Station #10 and did not clean the following: -Outsides of chair under tray table -Bilateral undersides of tray table -Back of chair -Back of dialysis machine -Under chair footrest During an interview on 02/12/2026 at 10:10 AM, Quality Manager J stated that staff should be cleaning and disinfecting the sides of the chair, under the tray, the footrest, and the lower part of the dialysis machine between patients. 51016”

“ENVIRONMENT-SECURE & RESTRICTED CFR(s): 494.40(a) 8 Environment: secure & restricted The water purification and storage system should be located in a secure area that is readily accessible to authorized users. The location should be chosen with a view to minimizing the length and complexity of the distribution system. Access to the purification system should be restricted to those individuals responsible for monitoring and maintenance of the system. This Standard is not met as evidenced by: 47413 Based on observation, interview and record review, the facility staff failed to restrict water room access to only the individuals responsible for monitoring and maintaining the system in 1 of 1 water rooms in a total sample of 1 water room observed. Findings Include: A review of the facility’s policy #18650379 titled, “Preparation of Dri-Sate Dry Acid (System) ALH Dri-Sate Acid Concentration Mixing Procedure” last revised 11/2025 revealed, “... 1. Prop water room door open for good ventilation...” During an observation of the water room of the dialysis facility on 02/11/2026 from 8:30 AM-11:20 AM, the door to enter the water room was propped open with a door stop. During an interview on 02/12/2026 at 10:31 AM with Clinic Supervisor A, she stated that normally the water room door should be open for “an hour tops” when staff are mixing acid for ventilation.”

“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: 47413 Based on observation, interview and record review the facility staff failed to ensure that all patient’s faces and accesses are visible during dialysis treatment in 4 of 13 patients observed (Patients #6, 7, 9, 13), in a total sample of 13 patients observed. Findings Include: A review of the facility’s policy #19369328 titled, “Access Needles: Placement and Removal From Fistula/Graft Policy & Procedure” last revised 12/2025 revealed, “... M. Access and arm should be visible to staff at all times during dialysis treatment...” During an observation on 02/11/2026 from 8:45 AM-9:25 AM, Patient #6 had a blanket covering her face, vascular access site and blood line connections while receiving dialysis treatment. During an observation on 02/11/2026 from 8:45 AM-9:25 AM, Patient #9 had a pillow covering his face and a blanket covering his vascular access site and blood line connections while receiving dialysis treatment. During an observation on 02/11/2026 from 8:31 AM through 9:18 AM, Patient #13 had a blanket covering his vascular access site and blood line connections while receiving dialysis treatment. During an observation on 02/11/2026 from 11:08 AM-11:39 AM, Patient #7 had a blanket covering her vascular access site and blood line connections while receiving dialysis treatment. During an interview on 02/12/2026 at 10:31 AM with Clinic Supervisor A, she stated that not having patients’ faces and accesses visualized is a safety issue. 51016”

“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: 47413 Based on interview and record review, the facility staff failed to ensure intradialytic monitoring was completed per facility policy in 5 of 5 in-center medical records reviewed (Patients #1, 2, 3, 4, 5) in a total universe of 5 medical records reviewed. Findings Include: A review of the facility’s policy #19369310 titled, “Dialysis Unit Patient Orientation: Pre, Intra, And Post Assessment Policy” last revised 11/2025 revealed, “... Patient will be assessed during treatment for the following every 30 minutes and as needed: ... Access visibility...” A review of Patient #1’s medical record revealed on the treatment sheet dated 01/26/2026 an intradialytic monitoring “access visible” was documented at 6:51 AM and then again at 8:51 AM (120 minutes later). A review of Patient #2’s medical record revealed on the treatment sheet dated 02/06/2026 an intradialytic monitoring “access visible” was documented at 11:39 AM and then again at 2:08 PM (149 minutes later). A review of Patient #3’s medical record revealed on the treatment sheet dated 02/02/2026 an intradialytic monitoring “access visible” was documented at 12:44 PM and then again at 2:45 PM (121 minutes later). A review of Patient #4’s medical record revealed on the treatment sheet dated 02/06/2026 an intradialytic monitoring “access visible” was documented at 7:22 AM and then again at 9:22 AM (120 minutes later). A review of Patient #5’s medical record revealed on the treatment sheet dated 01/30/2026 an intradialytic monitoring “access visible” was documented at 6:45 AM and then again at 8:13 AM (88 minutes later). During an interview on 02/12/2026 at 10:03 AM with Clinic Supervisor A, she stated that staff should be documenting access visualized every 30 minutes 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: 47413 Based on record review, observation and interview, the facility staff failed to perform skin antisepsis prior to cannulation per policy for 1 of 2 patients (Patient #7) observed for initiation of dialysis with an AV Fistula/Graft in a total of 15 observations of patient care. Findings Include: A review of the facility’s policy #14895453 titled, “Kidney Care Infection Prevention (System)” last revised 05/2024 revealed, “... XII. Maintenance of Aseptic Technique... A. Aseptic technique will be utilized to prepare the access site prior to needle insertion...” During an observation on 02/11/2026 at 9:30 AM, Patient Care Technician B cleansed Patient #7’s arm access site and then palpated on the insertion site prior to cannulation. During an interview on 02/12/2026 at 10:18 AM with Clinic Supervisor A, she stated that the arm access site should not be touched once it is cleaned.”

“QAPI-INDICATOR-MEDICAL INJURIES/ERRORS CFR(s): 494.110(a)(2)(vi) The program must include, but not be limited to, the following: (vi) Medical injuries and medical errors identification. This Standard is not met as evidenced by: 47413 Based on record review and interview the facility staff failed to document the follow-up completed for 1 of 1 adverse events (involving Patient #14) recorded in a total universe of 1 adverse event reviewed. Findings Include: A review of the facility’s policy #14778211 titled, “Quality Assurance Performance Improvement- Aspirus Kidney Care (System)” last revised 03/2024 revealed, “... VIII. ... Data to be reviewed should include... C. Safety and Risk Management (i.e. Occurrence reports)...” A review of the facility’s adverse events log for the past 6 months revealed missing follow-up for 1 patient event: A review of the adverse event involving Patient #14 revealed that Patient #14’s catheter was not running well, alarmed arterial pressure high, and that her lines were beginning to clot during treatment. There was no follow-up documented regarding an investigation into the root cause of the event or what interventions were put into place in attempt to prevent the incident from re-occurring. During an interview on 02/12/2026 at 9:50 AM, the findings were discussed with Clinic Supervisor A and Quality Manager J who stated that staff should document that they notified the doctor about the patient event and there should be follow-up documented to prevent the incident from re-occurring.”