Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 012515 (X3) Date Survey Completed 08/06/2025
Name of Provider or Supplier Fresenius Medical Care Opelika Street Address, City, State 2609 Village Professional Drive, Suite 2, Opelika, AL
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
V0111 IC-SANITARY ENVIRONMENT
CFR(s): 494.30

The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas.


This STANDARD is not met as evidenced by:
Based on observations and interviews, it was determined the facility failed to maintain and ensure a safe and sanitary environment for patients, staff, and visitors, which included: 1. The incenter patient treatment floor was free of pests/vermin. 2. The hand washing sink at the incenter medication preparation (med prep) counter was clean. 3. Incenter hemodialysis patient treatment chairs were in good repair without tears in the vinyl. The failure to maintain patient treatment chairs without tears was cited during the recertification survey conducted on 4/20/23. 4. The incenter treatment supply carts were clean. 5. The incenter treatment floors were without dirt/dust, and other brown/black substance build up. The failures increased the potential for contamination with blood and pathogenic microorganisms and had the potential to negatively affect all one hundred thirty-two patients who dialyze and receive home therapy services, facility staff, and visitors. Findings include: Observations were conducted on 8/5/25 from 11:15 AM to 5:20 PM. 1. On 8/5/25 from 4:35 PM to 5:20 PM a tour of the incenter (IC) treatment floor was conducted with Employee Identifier (EI) # 1 Clinical Manager (CM). EI # 1 picked up a piece of dialysis counter strip off the treatment floor at dialysis station twenty-seven. There was a black bug underneath the counter piece. The failure to ensure the facility was free from pests/vermin increases the risk of transmission of infectious disease. 2. The hand washing/clean sink at the med prep counter had pink/red substances surrounding the faucet plate, and rust along the sink bowl edge. This failure had the potential for contamination of intravenous and oral medications preparation and administration to all patients. 3. Thirteen of thirty IC hemodialysis dialysis treatment chairs had tears in the vinyl covering at the armrests, the bottom and middles seat cushions, and middle and lower footrests. Some chairs had multiple tears in different locations of the treatment chair. This failure prevented the patient treatment chairs from being properly disinfected between patient dialysis treatments, and increased the potential for contamination with blood and pathogenic microorganisms, including hepatitis B. 4. The four supply carts on the incenter treatment floor that contained patient treatment supplies had dirt, dust, cardboard pieces, and white substances along the cart sides and on the cart shelves. There was paper tape along inside and outside surfaces of the carts, including the cart handle. There was an open tape roll attached to one cart handle. There was a supply cart that held a box of clean clamps, and a thermometer. The cart shelf had four large, rusted bolts on the top shelf adjacent to the supplies. The treatment supply carts needed cleaning. The failure to maintain clean treatment supply carts increased the potential for contamination of supplies used to provide dialysis treatments. 5. There was dirt, an unidentified black substance, and dust build up along the IC treatment floors, including areas surrounding the hemodialysis machine, the dialysis stations, the emergency cart, and the patient scales. An interview was conducted on 8/5/25 at 5:20 PM with EI # 1, who confirmed the facility was not maintained in a safe and sanitary manner, which increased the potential for transmission of infectious organisms to patients, staff, and visitors.