Davita Riverlakes at Home Training

“COMPLIANCE WITH FED/STATE/LOCAL LAWS CFR(s): 494.20 The facility and its staff must operate and furnish services in compliance with applicable Federal, State, and local laws and regulations pertaining to licensure and any other relevant health and safety requirements. This Standard is not met as evidenced by: 34510 Based on observation and interview, the facility failed to ensure an antibiotic cream (use to treat or prevent skin infection) was not expired, labeled with patient’s name, and not used for multiple patients. This failure had the potential for antibiotic cream losing its effectivity and spread of infection to patients. Findings: During a concurrent observation and interview on 8/11/25 at 8:46 a.m. in Room 3, with Registered Nurse (RN) 1, in the cabinet, there was a used and opened tube of Gentamicin Sulfate (antibiotic cream) cream with a date opened of 5/30/25 without patient’s name. RN 1 stated the antibiotic cream is multi-dose (use for more than one dose) to be used for multiple patients when changing dressing of a peritoneal catheter (soft, flexible tube surgically placed into the abdomen to facilitate the removal of waste and excess fluid from the body when the kidneys fail). RN 1 stated it (used and opened antibiotic cream) should be thrown away. RN 1 stated the facility does not have a policy on medication labeling, storage, expiration, and use of antibiotic creams for specific patient. During a review of the online reference from Center for Disease Control and Prevention (www.cdc.gov) undated, the online reference indicated, “In a healthcare setting, the CDC and FDA (Food and Drug Administration) generally recommend that antibiotic ointment tubes are considered single-patient use items to prevent the risk of infection transmission. This applies to any topical antiseptic or medication packaged for a single application to one patient.” During a review of the online reference from Drugs.com undated, the online reference indicated, “Antibiotic creams have a shelf life of one month after opening.””

“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: 47734 Based on observation, interview and record review, the facility failed to ensure Registered Nurse (RN) 1 performed hand hygiene after removing gloves when performing dressing change for one of one sampled patient (Patient 4). This failure had the potential to result in Patient 4 developing infection. Findings: During an observation on 8/11/25 at 12:21 p.m. in Peritoneal Dialysis (PD) training room, RN 1 removed the dressing on Patient 4’s catheter exit site (where the PD catheter exits the body and enters the skin) on her abdomen and removed her gloves. RN 1 did not perform hand hygiene after removing her gloves, put on a new pair of gloves, and continued to work on the exit site. During an interview on 8/11/25 at 12:29 p.m. with RN 1, RN 1 stated she should have performed hand hygiene after removing her gloves. During a review of the facility’s policy and procedure (P&P) titled, “Routine Care of the Healed Peritoneal Dialysis Catheter Exit Site in the Facility,” dated April 2024, the P&P indicated, “4. If present, remove old dressing. Remove non-sterile gloves and perform hand hygiene. Put on non-sterile gloves.””

“H-FAC RECEIVE/REVIEW PT RECORDS Q 2 MONTHS CFR(s): 494.100(b)(2),(3) The dialysis facility must - (2) Retrieve and review complete self-monitoring data and other information from self-care patients or their designated caregiver(s) at least every 2 months; and (3) Maintain this information in the patient ’ s medical record. This Standard is not met as evidenced by: 47734 Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) 1 reviewed home treatment records for one of five sampled patients (Patient 6). This failure had the potential for Patient 6’s treatment data not to be assessed timely for any required interventions for treatments and potential for Patient 6 experiencing adverse health outcomes. Findings: During a concurrent interview and record review on 8/12/25 at 1:43 p.m. with RN 1, Patient 6’s “[brand of PD machine] Prescribed Versus Actual Report (PVAR-PD machine report),” dated 5/12/25 to 8/12/25 was reviewed. The PVAR dated 5/12/25 to 8/11/25 indicated the Night UF (ultrafiltration-the pressure-driven removal of excess fluid from the blood during hemodialysis or other forms of dialysis)/Total UF (ml-milliliter) column was incomplete when there were no Total UF documented. RN 1 stated the Total UF should be documented by Patient 6 in his treatment record. RN 1 stated she stated she did not review the Total UF in the PVAR. During a review of the facility’s policy and procedure (P&P) titled, “Daily Home Treatment Record (Flowsheet),” dated April 2025, the P&P indicated, “1. Each peritoneal dialysis [PD] patient has agreed and been trained to complete documentation of each treatment procedure on the Daily Home Treatment Record. . .Patients. . .will be provided paper flowsheets. . .to manually record treatment data in the event CAPD [Continuous Ambulatory Peritoneal Dialysis] exchanges are performed or the connected cycler [machine used for PD treatment] data capture is unavailable for any reason, including. . .known missed data entry. . .This post treatment data review will be verified by the Peritoneal Dialysis registered nurse documenting review in the medical record per guidance below: a. The licensed nurse (RN/LPN/LVN) will review the patient’s data via the submitted Daily Home Treatment Records.””

“H-MONITOR H20 /DIALYSATE INC ON SITE EVAL CFR(s): 494.100(c)(1)(v) Services include, but are not limited to, the following: (v) Monitoring of the quality of water and dialysate used by home hemodialysis patients including conducting an onsite evaluation This Standard is not met as evidenced by: 47734 Based on interview and record review, the facility failed to ensure Registered Nurse (RN) 2 completed the blood leak detector (a sensor that detect blood leak) check for one of two sampled equipment (Equipment 1). This failure had the potential to result in Equipment 1 not detecting blood leaks during patient treatments and potential for patients losing blood without timely intervention and prevention. Findings: During a concurrent interview and record review on 8/12/25 at 2:50 p.m. with RN 2, the facility’s “[brand of HHD machine] Maintenance Schedule Log (MSL),” undated was reviewed. The MSL indicated there were no check marks for the blood leak detector for the months of May, June, and July. RN 2 stated the blood leak detector should be checked monthly and it was not done. During a review of the facility’s policy and procedure (P&P) titled, “[brand of HHD machine] Maintenance Log and Directions,” dated October 2020, the P&P indicated, “3. Blood Leak Detector: The teammate (TM)/Patient performing the cleaning of the blood leak detector will input initials under the month the task was performed. The task is performed monthly.””

“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: 34510 Based on interview and record review, the facility failed to ensure Registered Nurse (RN) 2 performed and completed the HHD pre-training (before training) home site evaluation for one of one sampled patients (Patient 2). This failure had the potential to result in Patient 2’s unidentified home environmental issues, and had the potential to result in the spread and development of infection during their HHD treatment. Findings: During a review of Patient 2’s “HHD Pre-Training Home Site Evaluation (HHDPHSE),” dated 5/27/25, the HHDPHSE indicated a Licensed Vocational Nurse (LVN) completed the checklist. During a review of Patient 2’s “Patient Summary of Information Sheet (PSIS),” dated 8/12/25, the PSIS indicated, “First Treatment Date at Current Facility: 8/11/25, Modality [method or techniques use to perform dialysis]: Home Hemo-Self [a dialysis treatment for end-stage kidney disease where a patient performs hemodialysis at home independently].” During a concurrent interview and record review on 8/12/25, at 2:43 p.m. with RN 2, RN 2 reviewed Patient 2’s HHDPHSE. RN 2 stated the LVN did the initial home visit. RN 2 stated she is the only HHD RN of the facility and she stated she did not perform the HHDPHSE for Patient 2. RN 2 stated a registered nurse (RN) should be completing the HHDPHSE. During a review of the facility’s policy and procedure (P&P) titled, “Home Hemodialysis (HHD) Home Visit Policy” dated 12/1/07, the P&P indicated, “An HHD RN will perform a new patient pre-treatment evaluation prior to the patient’s initiation of HHD training. The HHD RN will document the pre-treatment evaluation on the [facility] new HHD Patient Pre-Treatment Initial Nurse Assessment. During the initial home visit, the HHD RN will complete the Initial Home Site Evaluation form and will include in the patient’s medical record.””