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Based on observation, interview and record review, the facility failed to ensure there was an active infection control program which included surveillance and prevention in 3 of 3 areas (lab/blood room,dialysis treatment room, dialysis supply room). The facility failed to:

A. Ensure expired supplies were discarded and sterile lab supplies were not stored in a soiled lab caddy in the lab/blood room.


B. Ensure floors, cabinets, and dialysis equipment were kept sanitary and in a manner to prevent contamination in the dialysis treatment room /supply room. The facility failed to ensure expired dialysis supplies were discarded.

Refer to tag A0750 for additional information.

Based on observation and interview, the facility failed to ensure sterile lab supplies and equipment were stored in a room that was temperature regulated in 1 of 1 lab/blood room.

This deficient practice had the likelihood to cause harm to all patients requiring lab services.

Findings include:


During an observation on 11/03/2025 after 1:16 p.m. the lab/blood room was noted to not have any temperature gauges in it. The temperature in the room was warm and stuffy. The following was stored in the room:

A box containing vials of Bact/Alert which had storage temperatures of 15-30 degrees Celsius on them (meaning 59-86 degrees Fahrenheit) written on the labels.

Sterile injection needles with Luer-Lok syringes were stored in the room.

Eight packages of sterile blood vacutainer blood collection tubes were stored on shelves in the room. The storage temperature written on the labels was 4-25 degrees Celsius (which is 39.2-77.0 degrees Fahrenheit).

Two blood coolers were within their outer boxes and stored on the floor in the room.

A PowerSpin HXV Centrifuge (lab equipment) which was being used was stored in the room.

Staff #2 confirmed the observations and said that the room was not temperature regulated. Staff #2 confirmed that the room was where they stored blood when it came in.

During an interview on 11/03/2025 at 2:29 p.m., Staff #3 said there was no centralized temperature regulation for the room. They were buying a thermometer now to place in the room.


According to AIA(American Institute of Architects) ASHRAE (The American Society of Heating, Refrigerating and Air Conditioning Engineers) standard 170 gave the following hospital requirements for temperature and humidity:

Lab (General Pathology) 70-75 degrees Fahrenheit and humidity of less than 60 percent.

Based on observation, interview and record review, the facility failed to ensure their infection control program included surveillance and prevention in 3 of 3 areas (lab/blood room,dialysis treatment room, dialysis supply room). The facility failed to:

A. Ensure expired supplies were discarded and sterile lab supplies were not stored in a soiled lab caddy in the lab/blood room.


B. Ensure floors, cabinets, and dialysis equipment were kept sanitary and in a manner to prevent contamination in the dialysis treatment room /supply room. The facility failed to ensure expired dialysis supplies were discarded.

This deficient practice had the likelihood to cause harm to all patients requiring lab services and dialysis treatments.

Findings include:

Lab

During an observation on 11/03/2025 after 1:16 p.m. the lab/blood room was noted with the following:

Four packets of sterile injection needles with Luer-Lok syringes were found which expired 08/31/2025 (over 2 months ago).

A lab caddy in the room that had sterile needles and lab supplies stored in it. The caddy was soiled with spills and dust.

Staff #2 confirmed the observations.


Dialysis room

During an observation on 11/03/2025 after 3:00 p.m.the following was found:

The tile flooring in the dialysis room had a buildup of wax. The original color of the tile was a light gray, but it had brown and black stains throughout the room. Some of the seams between the tile had a buildup of brown substance. Tubing and lines from the dialyzers and reverse osmosis water filtration systems were draped across the soiled tile floor.

The walls in the room had white dried acid spills on them.

The baseboards in the room had a buildup of white acid spill and debris.

Two dialyzing wands were stored in a sink. They were not stored vertically or contained within anything to prevent contamination.

One of the sinks in the room used as an area for water supply had a cabinet door missing. Inside the cabinet a hole had been cut in the drywall and the piping inside the wall was exposed. The floor inside the cabinet was soiled with a buildup of white and black particles. The one cabinet door that was still in place was covered in white dried spills and there was a brown rusted screw holding the cabinet closed.

A nursing supply cart in the room was opened and the following was found:
One drawer was soiled with dust and brown dry stains. Inside the drawer was a bottle of sterile water, oxygen trees which were not contained in a bag, and a bag which had lab vacutainer tubes in it.
Another drawer was soiled with black particles had loose sterile needles stored in it.
Another drawer had 4- 100 milliliter bags of Sodium chloride stored in it. Two of the bags expired 09/2025 and the other two expired 10/2025.

Dialysis supply room
The room where containers of dialysate solution was stored had floor tile which had a buildup of wax. The baseboards in the room were soiled with a buildup of brown, black and white debris.

Staff #'s 10 and 11 confirmed the observations.

Staff #10 said they had reported the broken cabinet door to the facility a while ago, but nothing had been done. No specific time could be given. Staff #10 said that they clean their room daily when in use and the facility staff mop their floor for them.

Dialysis treatment room
On 11/04/2025 after 8:50 a.m. the following was found in the dialysis room:

Dialyzer (PRO 552) was found sitting on a base which was soiled with debris and the bottom of the equipment had a black and brown buildup caked on it.

RO (reverse osmosis)548 water filtration system had dry white spills on the gauges, the base it was sitting in and on the wheels. The base had areas of brown rust on it. Inside the base was a buildup of black debris in the inside corners.

RO (reverse osmosis)708 water filtration system had a build of dried spills on it and the the base it was sitting in had a buildup of black and brown debris in the inside corners. The frame the equipment was housed in was covered in white dried spills and brown rust.

Staff #1 and 10 confirmed the observations.

During an interview on 11/04/2025 after 9:03 a.m., Staff #3 (chief nursing officer) said that dialysis staff had to verbally report issues to them. She had spoken to Staff #1(chief executive officer) and they do quarterly meetings with dialysis and there had been no issues reported. Maintenance had no reports of issues.

During an interview on 11/04/2025 after 9:03 a.m. Staff #1(chief executive officer) confirmed there had been no reports of issues from dialysis.

During an interview on 11/04/2025 after 9:05 a.m., Staff #2 said she was over infection control and the dialysis area was not apart of her rounding.

The facility provided a Core Dialysis policy named "Section 07:Infection Control Policy 736 Cleaning and Disinfecting-Delivery System which was revised 02/17/2020 which read:

"PURPOSE:
To provide an environment that prevents the transmission of infectious agents."
.The exterior surface cleaning had a frequency of being "After Every Treatment. The exterior surface of the machine and any laminated information hanging on the machine should be wiped down using a cloth and a disinfecting cleaner or bleach wipes ..."