Davita West Lakewood Dialysis

“Emergency Lighting CFR(s): NFPA 101 Emergency Lighting Emergency lighting of at least 1-1/2 hour duration is provided automatically in accordance with 7.9. 20.2.9.1, 21.2.9.1, 7.9 This Standard is not met as evidenced by: 47557 Based on observation and staff interview during record review, it was determined that the facility failed to maintain emergency lighting in accordance with Life Safety Code NFPA 101 1. Exit/Emergency lights no 30-second reports available for review 2. Exit/Emergency Lights: no annual 90-minute inspection report available for review NFPA 101 7.9.2.1* Emergency illumination shall be provided for a minimum of one and 1/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 ft-candle (10.8 lux) and, at any point, not less than 0.1 ft-candle (1.1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft-candle (6.5 lux) and, at any point, not less than 0.06 ft-candle (0.65 lux) at the end of 1 1/2 hours. A maximum-to-minimum illumination uniformity ratio of 40 to 1 shall not be exceeded. NFPA 101 7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3. 7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows: (1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2). (2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction. (3)Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered. (4)The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3). (5)Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and facility maintenance department at the exit conference.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 47557 Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 101 1. Sprinkler | Annual report revealed that the facility needs to complete a 5-year internal inspection. The facility was red-tagged for the jockey pump being impaired. 2. Sprinkler | 3-Year Dry system full-trip report was not available for review NFPA 101: 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. NFPA 25 13.4.4.2.2.2* Every 3 years and whenever the system is altered, the dry pipe valve shall be trip tested with the control valve fully open and the quick-opening device, if provided, in service. NFPA 25 14.2.1 Except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and facility maintenance department at the exit conference.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Smoke barrier doors shall be a minimum of 1-3/4 inches thick, solid-bonded wood core or equivalent with self-closing or automatic-closing devices in accordance with 21.2.2.4. Latching hardware is not required. Doors are not required to swing in the direction of egress travel. 21.3.7.9, 21.3.7.10 This Standard is not met as evidenced by: 47557 Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain smoke barriers in accordance with NFPA 101 and NFPA 80 1.Fire/Smoke door annual inspection was not available for review NFPA 80 5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ. NFPA 80 5.2.4.2 As a minimum, the following items shall be verified: (1) No open holes or breaks exist in surfaces of either the door or frame. (2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped. (3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage. (4) No parts are missing or broken. (5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7. (6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position. (7) If a coordinator is installed, the inactive leaf closes before the active leaf. (8) Latching hardware operates and secures the door when it is in the closed position. (9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame. (10) No field modifications to the door assembly have been performed that void the label. (11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and facility maintenance department at the exit conference.”

“HVAC CFR(s): NFPA 101 HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer’s specifications. 20.5.2.1, 21.5.2.1, 9.2 This Standard is not met as evidenced by: 47557 Based on observation and staff interview, it was determined that the facility failed to maintain smoke dampers in accordance with Life Safety Code Section NFPA 105 1. A 4-year fire damper report was available for review NFPA 105, 6.5.1 Smoke dampers for dedicated and non-dedicated smoke control systems shall be inspected and tested in accordance with NFPA 92A, Standard for Smoke-Control Systems Utilizing Barriers and Pressure Differences. 6.5.2* Each damper shall be tested and inspected one year after installation. The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years. 6.5.3 Care shall be exercised that all tests are completed in a safe manner wearing the appropriate personal protective equipment. 6.5.4 Full unobstructed access to the damper shall be verified and corrected as required. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and facility maintenance department at the exit conference.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 21.7.1.4 through 21.7.1.7 This Standard is not met as evidenced by: 47557 Based on record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.6 1.Fire Drills not conducted using fire alarm system | Suite was completed “table top” drill during the day. The suite will need to coordinate with Facility Manager for these drills as required by NFPA 101 NFPA 101, 21.7.1.4* Fire drills in ambulatory health care facilities shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and facility maintenance department at the exit conference.”

“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 of Participation §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 observation, staff interview, and review of the facility’s policy, the facility failed to ensure two of two patients, who were observed holding pressure to their access sites (locations where needles were inserted and then removed for treatment), performed hand hygiene following the removal of soiled gloves and prior to leaving the treatment area. V146 - The facility must demonstrate that it follows standard infection control precautions by implementing-] (2) The “Guidelines for the Prevention of Intravascular Catheter-Related Infections” entitled “Recommendations for Placement of Intravascular Catheters in Adults and Children” parts I - IV; and “Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients.” Based on observations, interviews, and document review, the facility failed to ensure patient care staff performed hand hygiene when a central venous catheter (CVC)(a device inserted through the skin for direct access to a large vein in the patient for dialysis treatment) was accessed according to facility policy in one of three observations. Additionally, the facility failed to ensure patient care staff allowed dry time after the hub of the CVC catheter was cleaned in two of two observations.”

“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 observation, staff interview, and review of the facility’s policy, the facility failed to ensure two of two patients, who were observed holding pressure to their access sites (locations where needles were inserted and then removed for treatment), performed hand hygiene following the removal of soiled gloves and prior to leaving the treatment area. 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. 1. The facility failed to ensure patients performed hand hygiene following the removal of soiled gloves. A. Observations i. On 6/26/24 at 2:55 p.m., an observation was conducted at station #4. The patient was observed holding pressure to their access site with a gloved right hand following the removal of the needles used for treatment. After stabilization of the site, the patient ambulated to the scale, obtained their weight by pressing the button, ambulated back to station #4, removed the soiled glove, picked up their personal belongings, and left the facility. Staff members did not educate or request the patient to perform hand hygiene following glove removal. ii. On 6/27/24 at 9:27 a.m., an observation was conducted at station #5. The patient was observed holding pressure to their site with a gloved right hand following the removal of the needles used for treatment. After stabilization of the site, staff applied a clean dressing, the patient ambulated off the treatment floor to the scale, removed the soiled glove from their right hand, and obtained their weight by pressing the button with their right hand. The patient returned to station #5 and hand hygiene was performed. B. Interviews i. On 6/27/24 at 2:48 p.m., an interview was conducted with patient care technician (PCT) #1. PCT #1 stated after the patient’s access site was stabilized, the patient was to remove their glove and perform hand hygiene before going to the scale to obtain their weight. PCT #1 stated there was a risk of the patient having blood on their hand which could have been an infection risk. ii. On 6/27/24 at 3:01 p.m., an interview was conducted with registered nurse (RN) #2. RN #2 stated after the patient’s access site was stabilized, the patient was to remove their glove and perform hand hygiene. RN #2 stated patients were not to go to the scale wearing the soiled glove and hand hygiene should have been performed before touching the scale. RN #2 stated if a patient did not perform hand hygiene after glove removal, there was a risk of infection. This was in contrast to facility policy which read, patients were to be encouraged to perform hand hygiene after treatment before leaving the treatment area.”

“IC-CATHETERS:GENERAL CFR(s): 494.30(c)(2) (2) The “Guidelines for the Prevention of Intravascular Catheter-Related Infections” entitled “Recommendations for Placement of Intravascular Catheters in Adults and Children” parts I - IV; and “Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients,” Morbidity and Mortality Weekly Report, volume 51 number RR-10, pages 16 through 18, August 9, 2002. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR Part 51. This publication is available for inspection as the CMS Information Resource Center, 7500 Security Boulevard, Central Building, Baltimore, MD or at the National Archives and Records Administration (NARA). Copies may be obtained at the CMS Information Resource Center. For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_regulations/ibr_locations.html This Standard is not met as evidenced by: 45020 Based on observations, interviews, and document review, the facility failed to ensure patient care staff performed hand hygiene when a central venous catheter (CVC)(a device inserted through the skin for direct access to a large vein in the patient for dialysis treatment) was accessed according to facility policy in one of three observations. Additionally, the facility failed to ensure patient care staff allowed dry time after the hub of the CVC catheter was cleaned in two of two observations. Findings include: Facility policies: The CVC with Clearguard Hemodialysis (HD) (cleaning the blood using a machine and a filter) Antimicrobial End Caps Procedure read, perform a 15-second hub scrub of the CVC during the process of connecting or disconnecting from the bloodlines, or if the patient is disconnected during treatment for any reason. Perform hand hygiene per procedure. Remove old dressing and discard. Verify that both arterial and venous catheter limbs (tubing) are clamped. Remove gloves and discard. Perform hand hygiene per procedure and re-glove. Holding catheter and using aseptic technique, clean exit site with 2% Chlorhexidine Gluconate/70% Isopropyl Alcohol for a minimum of 30 seconds, and apply to the CVC exit site in a “back and forth” pattern. Then wait 60 seconds for air dry time. Clean each CVC limb and cap with a new large alcohol prep pad. Remove gloves and discard, perform hand hygiene per procedure and re-glove. Apply antibiotic ointment to exit site, if prescribed. Place sterile 2x2 gauze over the catheter exit site leaving connections accessible. Seal edges of gauze with tape. Apply label to the dressing indicating date the dressing change was performed and initials of the teammate performing procedure. Remove gloves and discard, perform hand hygiene per procedure and re-glove. Holding catheter, place sterile 4x4 under catheter limbs. Using aseptic technique, remove each cap. One at a time, disinfect each CVC hub (the ends of the CVC connecting to the bloodlines or cap) with a new alcohol prep pad. Scrub each CVC hub for 15 seconds. Hold the limbs until the antiseptic has dried. The Infection Control policy read, all teammates will perform hand hygiene prior to gloving and immediately after removal of gloves, after contamination with blood or other infectious material, and after patient and dialysis delivery system contact. Disposable gloves will be worn when caring for the patient or touching the patient’s equipment at the dialysis station. Gloves should be changed when soiled, when going from a “dirty” area or task to a “clean” area or task, and when moving from a contaminated body site to a clean body site of the same patient. 1. The facility failed to ensure patient care staff performed hand hygiene before the CVC access site was cleaned according to facility policy. Additionally, the facility failed to ensure patient care staff allowed dry time after the hub of the CVC catheter was cleaned. A. Observations i. On 6/26/24 at 10:30 a.m., an observation was conducted of a CVC initiation of treatment at station #11. Patient care technician (PCT) #3 removed the gauze covering the patient’s CVC access and the gauze around the catheter limbs. PCT #3 swabbed the area on and around the CVC access for 60 seconds. Hand hygiene was not observed between these steps. PCT #3 removed the caps of the CVC and scrubbed the hubs for 15 seconds, after which they immediately attached a syringe to each hub and withdrew blood. The hubs were visibly wet when the syringe was attached. When asked if there was a dry time to the hubs after alcohol scrub, PCT #3 stated they were unsure. This was in contrast to the CVC Procedure which read, old dressing was to be removed and discarded. Gloves were to be removed, discarded and hand hygiene was to be performed. This was also in contrast to the Infection Control policy which read, gloves were to be changed when soiled, going from a “dirty” area or task to a “clean” area or task, and going from a contaminated body site to a clean body site of the same patient. Additionally, this was in contrast to the CVC with Clearguard Hemodialysis (HD) Antimicrobial End Caps Procedure policy, which read, one at a time, each CVC hub was to be disinfected with a new alcohol prep pad. Each CVC hub was to be scrubbed for 15 seconds. The limbs were to be held until the antiseptic was dry. ii. On 6/26/24 at 2:38 p.m., an observation was conducted of a CVC initiation of treatment at station #1. PCT #4 removed the gauze covering the patient’s CVC access and the gauze around the catheter limbs. PCT #4 swabbed the area on and around the CVC access for 60 seconds. Hand hygiene was not observed between these steps. PCT #4 removed the caps of the CVC and scrubbed the hubs for 15 seconds, after which they immediately attached a syringe to each hub and withdrew blood. The hubs were visibly wet when the syringe was attached. When asked if there was a dry time to the hubs after alcohol scrub, PCT #4 stated they were unsure. This was in contrast to the CVC Procedure which read, old dressing was to be removed and discarded. Gloves were to be removed, discarded and hand hygiene was to be performed. This was also in contrast to the Infection Control policy which read, gloves were to be changed when soiled, going from a “dirty” area or task to a “clean” area or task, and going from a contaminated body site to a clean body site of the same patient. Additionally, this was in contrast to the CVC with Clearguard Hemodialysis (HD) Antimicrobial End Caps Procedure policy, which read, one at a time, each CVC hub was to be disinfected with a new alcohol prep pad. Each CVC hub was to be scrubbed for 15 seconds. The limbs were to be held until the antiseptic was dry. B. Interviews i. On 6/27/24 at 2:48 p.m., an interview was conducted with PCT #1. PCT #1 stated CVC care required multiple glove changes because patients were prone to infection. PCT #1 stated CVC hubs were to be scrubbed with an alcohol pad for 15 seconds, and allowed to air dry before a syringe was attached to withdraw blood from the line. PCT #1 stated CVC care was important because there was a risk of infection which could cause sepsis or death. ii. On 6/27/24 at 3:01 p.m., an interview was conducted with registered nurse (RN) #2. RN #2 stated CVC hubs were to be scrubbed with alcohol and allowed to air dry because alcohol needed dry time to disinfect the area. RN #2 stated air dry meant the hub was no longer visibly wet or shiny and this was to have been observed before attaching a syringe to the hub. RN #2 stated it was important to follow the policies for CVC care because the CVC line went directly to the heart. RN #2 stated policies were in place to prevent infection. RN #2 stated the risk of an infection to a CVC site included sepsis and possible death.”