There are  23 surveys for this facility. Please select a date to view the survey results.

V 0113 The Facility Administrator or designee held mandatory in-service(s) for all clinical teammates starting on 8/27/2025. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-05-01 "Infection Control for Dialysis Facilities" with the emphasis on but not limited to: [Hand Hygiene]: 1) All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene... a. upon entering and exiting the patient treatment area, b. prior to gloving and immediately after removal of gloves ... d. after patient and dialysis
delivery system contact... f. between patients even if the contact is casual. [Disposable Gloves]: 1) Disposable gloves will be worn when caring for the patient or touching the patient's equipment at the dialysis station. 2) Gloves should be changed when ... After touching one patient or their dialysis delivery system and before arriving to care for another patient or touch another patient's dialysis delivery system. Verification of attendance at in-service will be evidenced by teammates signature on in-service sheet.
The Facility Administrator or designee will conduct infection control audits to verify teammates performan hand hygiene with glove wearing and glove changing per policy and procedure: daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored with monthly infection control audits. Instances of non-compliance will be addressed immediately.
The Facility Administrator or designee will review audit results with teammates during homeroom meetings, and with the Medical Director during monthly Quality Assurance and Performance Improvement meetings known as Facility Health Meetings. The Facility Administrator will report progress, as well as any barriers to maintaining compliance. Action plans will be evaluated for effectiveness and new plans developed when needed until sustained compliance is achieved. Supporting documentation will be included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.

V 0146 The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 08/27/25. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-06-01 "Medication Policy" with emphasis on but not limited to: 1) Medication preparation should be performed only for the current shift of patients. 2) If medications are prepared and administered immediately, by the same licensed nurse teammate, the medications do not need to be labeled. If the medication is not immediately administered or is to be administered by another teammate, the medication must be labeled with the patient name, name of medication, date, time prepared, dose and initials of the teammate preparing the medication. Verification of attendance at in-service will be evidenced by teammates signature on in-service sheet.
Manager of Clinical Services (MCS) provided support and education to teammates immediately after the finding. Medication labels were reprinted and labeled properly, including teammate's initials and preparation time per policy.
The Facility Administrator or designee will conduct observational audits for medication preparation and administration to verify syringes are properly labeled per policy: daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored with the monthly infection control audits. Instances of non-compliance will be addressed immediately.
The Facility Administrator or designee will review audit results with teammates during homeroom meetings, and with the Medical Director during monthly Quality Assurance and Performance Improvement meetings known as Facility Health Meetings. The Facility Administrator will report progress, as well as any barriers to maintaining compliance. Action plans will be evaluated for effectiveness and new plans developed when needed until sustained compliance is achieved. Supporting documentation will be included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.