Davita Longmont Dialysis Center

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 45020 Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition for Coverage §494.30 Infection Control, was out of compliance. V113 - 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. Based on observations, interviews, and document review, the facility failed to ensure three of five patients, who were observed after their dialysis treatment ended, performed hand hygiene prior to exiting the facility according to facility policy. V122 - [Standard: Procedures for infection control. The facility must demonstrate that it follows standard infection control precautions by implementing-] [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. Based on observations, interviews, and document review, the facility failed to ensure the dialysis station bleach cleaning solution containers were labeled with expiration dates according to facility policy to ensure its efficacy in two of two bleach bin containers observed.”

“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: 45020 Based on observations, interviews, and document review, the facility failed to ensure three of five patients, who were observed after their dialysis treatment ended, performed hand hygiene prior to exiting the facility according to facility policy. Findings include: Facility policy: The Infection Control for Dialysis Facilities policy read, the purpose of this policy is to minimize the spread of infections or bloodborne pathogens in the dialysis facility environment. Patients and caregivers will be encouraged to perform hand hygiene after treatment before leaving the treatment area. Reference: According to the Infection Control Commandments for staff posted on the wall of the patient treatment floor, staff will help patients protect themselves by asking them to wash their hands after treatment. 1. The facility failed to ensure patients were asked to perform hand hygiene after treatment, and before leaving the treatment floor, according to facility policy. A. Observations i. On 8/25/25 at 9:44 a.m., an observation was conducted at station #5. The patient was observed with clamps on their right arm to hold pressure to their access sites following the removal of needles used for treatment. The patient was observed touching the clamps and the gauze dressing under the clamps with an ungloved hand. A staff member removed the clamps, changed the gauze dressing to the access sites and applied tape. The patient gathered their belongings, got themselves into their wheelchair, went to the scale, touched the buttons on the scale and obtained their weight. Staff did not educate or request the patient to perform hand hygiene before the patient left the facility at 9:53 a.m. At 9:54 a.m., another patient entered the facility, went to the scale, touched the scale buttons, and obtained their weight. ii. On 8/25/25 at 10:56 a.m., an observation was conducted at station #14. The patient was observed with clamps on their left arm to hold pressure to their access sites following the removal of needles used for treatment. At 11:04 a.m., a staff member removed the clamps, changed the gauze dressing to the access sites and applied tape. The patient gathered their belongings, walked to the scale, touched the buttons on the scale and obtained their weight. Staff did not educate or request the patient to perform hand hygiene before the patient left the facility. iii. On 8/25/25 at 11:19 a.m., an observation was conducted at station #13. The patient was observed with clamps on their left arm to hold pressure to their access sites following the removal of needles used for treatment. The patient was observed touching the clamps and the gauze dressing under the clamps with an ungloved hand. At 11:34 a.m. and 11:55 a.m., a staff member changed the bloody gauze from one of the access sites and replaced the clamp. At 12:03 p.m., a staff member removed the clamps, changed the gauze dressings and applied tape. The patient gathered their belongings, walked to the scale, touched the buttons on the scale and obtained their weight. Staff did not educate or request the patient to perform hand hygiene before the patient left the facility. This was in contrast to the Infection Control for Dialysis Facilities policy which stated, patients would be encouraged to perform hand hygiene after treatment, before leaving the treatment area, to minimize the spread of infections or blood borne pathogens in the dialysis facility environment. This was also in contrast to the Infection Control Commandments for staff posted on the wall of the treatment floor, which instructed staff to help patients protect themselves by asking them to wash their hands after treatment. B. Interviews i. On 8/27/25 at 9:45 a.m., an interview was conducted with patient care technician (PCT) #1. PCT #1 stated if a patient held their access sites with a gloved hand, hand hygiene was to be performed after glove removal. PCT #1 stated there was a risk the clamps could be contaminated, and hand sanitizer was to be offered to the patient before leaving the facility. PCT #1 stated if hand hygiene was not performed by the patient, there was a risk of cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred with harmful effect), which could increase the risk of infection. ii. On 8/27/25 at 10:09 a.m., an interview was conducted with registered nurse (RN) #2. RN #2 stated patients were to perform hand hygiene before leaving the facility. RN #2 stated after a patient’s access site was stabilized, the expectation was for patients to perform hand hygiene and for staff to remind them to do so. RN #2 stated if a patient did not perform hand hygiene after treatment, there was a risk of infection, which could lead to hospitalization.”

“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: 45020 Based on observations, interviews, and document review, the facility failed to ensure the dialysis station bleach cleaning solution containers were labeled with expiration dates according to facility policy to ensure its efficacy in two of two bleach bin containers observed. Findings include: Facility policies: The Preparation of One to One Hundred (1:100) Bleach Solution policy read, with indelible marking pen and label, label container with expiration date, time and initials. The solution is good for 24 hours only. The Preparation of One to One Hundred (1:10) Bleach Solution policy read, with indelible marking pen and label, label container with expiration date, time and initials. The solution is good for 24 hours only. 1. The facility failed to ensure patient care staff prepared bleach solution used to clean patient chairs, dialysis machines and supplies used in patient care according to facility policy. Specifically, the bleach containers were not labeled with the expiration dates, times and staffs’ initials. A. Observation i. On 8/25/25 at 9:30 a.m., the patient care area was observed. Two containers filled with a solution were observed on a storage cart. The containers had labels on them, indicating they were filled with a bleach solution, however, there was no documentation of the date and time of when the bleach solutions expired, the strength of the bleach solutions, or initials to indicate which staff member had mixed the solutions. During the observation, a staff member stated the bleach solutions had been prepared that morning, but could not provide evidence. This was in contrast to the Preparation of 1:100 and 1:10 Bleach Solution policies which read, containers should have been labeled with the expiration date, time and initials. B. Interviews i. On 8/27/25 at 9:45 a.m., an interview was conducted with patient care technician (PCT) #1. PCT #1 stated bleach solutions were used to clean patient chairs and dialysis machines after each use, as well as occasional blood spills. PCT #1 stated it was important for a label to be placed on the containers with the date and time it was prepared, and the expiration date, because the bleach solutions were not as effective after 24 hours. PCT #1 also stated expired bleach solutions might not have cleaned surfaces effectively, which increased the risk of cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred with harmful effect), which could increase the risk of infections, including C-diff (Clostridium difficile is a contagious bacterial infection causing diarrhea and inflammation of the colon). ii. On 8/27/25 at 10:09 a.m., an interview was conducted with registered nurse (RN) #2. RN #2 stated bleach solution containers were to be labeled with the expiration date, time and staff initials at the time they were prepared. RN #2 stated bleach containers were labeled because bleach could lose effectiveness over time. RN #2 also stated patients were at risk for infections such as HIV (human immunodeficiency virus, a virus that attacks the body’s immune system) if expired bleach solutions were used to clean equipment and supplies.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 45020 Based on observations, document review, and interviews, the facility failed to ensure clinical staff demonstrated compliance when dispensing and administering intravenous (IV) medication from vials. Specifically, the facility failed to label an open multi-dose vial (MDV) with the expiration date according to facility policy in one of two observations conducted in a medication preparation area. Findings include: Facility policy: The Medication policy read, the purpose of this policy is to provide guidance for the safe and aseptic preparation of all medications. Medications containing a preservative must be discarded 28 days after opening or accessed (needle punctured) unless the manufacturer specifies a different (shorter or longer) date or as directed by the manufacturer. Each vial is labeled with the initials of the person opening the vial and the expiration date. Reference: According to the manufacturer’s instructions for use for heparin, heparin sodium injection is an anticoagulant (a blood thinner). Preserved with Benzyl Alcohol, multiple-dose vials. 1. Facility staff failed to label an open multi-dose vial of medication with the expiration date according to facility policy. A. Observation i. On 8/25/25 at 9:26 a.m., an observation of the facility’s medications revealed an open MDV of heparin (a blood thinner) on a countertop in a medication preparation area. There was no date on the vial to indicate when the medication expired. Patient care technician (PCT) #3 stated the vial should have been labeled with the time and date when it was first opened. This observation and the statement made by PCT #3 were in contrast to the Medication policy, which stated medication must be labeled with the initials of the person opening the vial and the expiration date. B. Interviews i. On 8/27/25 at 9:45 a.m., an interview was conducted with PCT #1. PCT #1 stated when a MDV was opened, the staff member was expected to label the vial with the expiration date and their initials. PCT #1 stated if the vial was not dated when it was opened there was a risk the medication could be contaminated, lose effectiveness, and not perform as intended. PCT #1 stated if heparin did not work as intended, the patient’s blood could clot and interrupt their dialysis treatment. ii. On 8/27/25 at 10:09 a.m., an interview was conducted with registered nurse (RN) #2. RN #2 stated it was important to label MDVs to ensure the medication was still safe to be administered to the patient. RN #2 stated heparin was only good for 28 days after opened. RN #2 stated heparin was to be labeled with the date it was opened, the expiration date, and the initials of the staff member who opened the vial. RN #2 stated if the medication was not labeled appropriately, expired, and was then administered to the patient, there was a risk the medication could not perform as intended, which could cause blood clots or increased bleeding during dialysis treatments.”