Davita Hartford Dialysis

“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: 47491 Based on observations, interview, and review of clinical records for two (2) of five (5) patients observed during treatment initiation/termination, the facility failed to perform hand hygiene following glove removal, . The findings included: 1. Patient #12 had diagnoses that included ESRD. Physician’s order directed to hemodialysis treatment three (3) times weekly for three (3) hours and thirty (30) minutes utilizing a left upper arm arteriovenous graft (AVG). Staff Person #5 was observed on 12/2/25 at 10:22 AM preparing Patient #12’s access for treatment initiation at Station #22. Staff Person #5 had instilled heparin through the patient’s access, removed his/her gloves, and proceeded to a different dialysis station to obtain/ don new gloves without performing hand hygiene. Staff Person #3 returned to Station #22 and connected the dialysis lines to patient #12’s access and initiated the patient’s treatment. 2. Patient #13 had diagnoses that included ESRD. Physician’s orders directed to hemodialysis three (3) times weekly for two (2) hours utilizing a left upper arteriovenous graft (AVG). Staff Person #4 was observed on 12/4/25 at 9:13 AM terminating Patient #13’s treatment. Staff Person #4 had removed Patient #13’s needles, removed his/her gloves, and proceeded to start typing on the computer at Patient #13’s dialysis station without performing hand hygiene after glove removal. Interview with the Clinical Services Manager on 12/4/25 at 1:47 PM identified staff should be performing hand hygiene following glove removal. Review of the Infection Control for Dialysis Facilities policy directed all teammates, physicians, and non-physicians to perform hand hygiene prior to gloving and immediately after removal of gloves.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 44675 Based on observations, facility documentation, facility policy and interviews the facility failed to ensure hospital cleaning staff were provided with and donned Personal Protective Equipment (PPE) while on the treatment floor per facility policy. The findings include: Observation on 12/3/25 at 10:20 AM identified a hospital staff member with a large rolling dumpster emptying the garbage’s of Pod B, Pod C, Pod D and Pod A during turnover without being offered and or wearing a gown. The hospital staff member left the clinic at 10:27 AM. Observation on 12/4/25 at 10:12 AM identified a hospital staff member with a large rolling dumpster emptying the garbage’s of Pod B, Pod C, Pod D and Pod A during turnover without being offered and or wearing a gown. The hospital staff member left the clinic at 10:27 AM. Interview with the FA on 12/4/25 at 3:05 PM identified the facility has had issues with the contracted hospital staff member not wearing PPE on the treatment floor and bringing the large rolling dumpster into the clinic pods. He has been told not to bring the large rolling dumpster into the clinic pods due to the infection control risks. The FA identified this staff member’s supervisor has been made aware. Review of the infection control for dialysis facilities policy directed that appropriate fluid resistant/fluid impervious gowns will be worn by all teammates, physicians and visitors when in the treatment area.”

“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: 44675 Based on observation, clinical record review, interview and review of facility policy, the facility failed to clean and disinfect the hemodialysis station after hemodialysis treatment per facility policy. The finding included: Observation conducted on 12/3/25 at 10:25 AM of Station #18 identified Staff Person #2 cleaning and disinfecting the hemodialysis station after a patient treatment. Staff Person #2 failed to clean and disinfect the station wallbox. Observation conducted on 12/3/25 at 10:30 AM of Station #14 identified Staff Person #1 cleaning and disinfecting the hemodialysis station after a patient treatment. Staff Person #1 failed to clean and disinfect the station wallbox. Review of the infection control for dialysis facilities policy directed at the end of each treatment, the dialysis station will be cleaned and disinfected. It directed the wall box, drain and watery supply lines are considered part of the dialysis delivery system.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 38422 Based on facility documentation and interviews, the facility failed to ensure that the fire alarm, sprinkler system was inspected, failed to ensure power strips were used appropriately, and failed to ensure that the facility was safe and sanitary. The findings include: I. On 12/03/25 at 11:30 AM the surveyor was not provided with documentation from the Bio Med Techs or the landlord to indicate that the facility fire alarm is being inspected, tested & maintained, as required by section # 14.3.1 of NFPA 72,”National Fire Alarm Code “and by the facility’s procedures & policies; i.e. there was no sensitivity testing report supplied. ii. On 12/03/25 at 11:30 AM the surveyor was not provided with documentation from the Bio Med Techs or the landlord to indicate that the wet-pipe sprinkler system is inspected quarterly, as required by NFPA 25, “Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems” and as part of the facilities’ preventative maintenance program; i.e. facility did not provide documentation that inspections for the Second, Third, and Fourth Quarters were completed as required. iii. On 12/03/25 during a tour of the treatment floor, the surveyor observed a relocatable power tap (power strip) installed above a suspended ceiling in the patient treatment area. The power strip was plugged into a standard receptacle and was being used to supply power to equipment located above the ceiling. This failure to maintain safe electrical conditions has the potential to cause overheating, electrical fire, and interruption of dialysis services, placing all patients receiving treatment in the affected area at risk. iv. On 12/03/25 during a tour of the treatment floor, the surveyor observed multiple voids, openings, in the suspended ceiling located above the patient treatment area. These gaps compromised the ceiling’s intended function as part of the smoke and fire barrier. v. On 12/03/25, the surveyor observed that the floor in the water-treatment (water room) area was damaged. There were visible areas where the flooring material was degraded, chipped, or lifting, creating tripping hazards and making proper cleaning and sanitization difficult.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 38422 Based on observation the facility failed to ensure that equipment was free from rust. The findings include: i. On 12/03/25, during a tour of the treatment floor, the surveyor observed multiple pieces of equipment with visible rust. Findings included: “ Rusted metal frames of television ceiling mounting brackets at treatment stations, with corrosion present above the patient chairs. “ Rusted metal frames of lighting fixtures at treatment stations, with corrosion present above the patient chairs. The presence of rusted equipment compromises the ability to clean and disinfect surfaces, posing a risk for contamination and potential infection exposure to patients receiving dialysis treatments.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 44675 Based on a review of clinical records, interview, and policy review for four (4) out of eleven (11) hemodialysis patients reviewed for prescriptions (Patient #1 #4 #5 and #8), the facility failed to ensure the patient’s hemodialysis treatment was in accordance with the physician orders. The findings include the following: 1. Patient #1 was admitted to the facility with diagnoses that included End Stage Renal Disease (ESRD). Review of the physician’s orders directed hemodialysis three (3) times weekly for four (4) hours with a right central venous catheter (CVC), a dialysate Dialysis Flow Rate (DFR) of 800 and Blood Flow Rate (BFR) of 400. A sample review of Patient #1’s treatment flowsheets identified the following: i. On 10/27/25 Patient #1’s treatment was initiated at 10:55 AM without complication with the administered BFR at 400. At 11:50 AM Patient #1’s BFR was decreased to 350 with no rationale as to why the prescribed BFR of 400 was not met. ii. On 11/07/25 Patient #1’s treatment was initiated at 11:57 AM without complication with the administered BFR at 400. At 2:27 PM Patient #1’s BFR was decreased to 350 with no rationale as to why the prescribed BFR of 400 was not met. iii. On 11/14/25 Patient #1’s treatment was initiated at 10:34 AM without complication with the administered BFR at 400. At 10:54 AM Patient #1’s BFR was decreased to 350 with no rationale as to why the prescribed BFR of 400 was not met. iv. On 11/28/25 Patient #1’s treatment was initiated at 11:47 AM without complication with the administered BFR at 400. At 1:55 PM Patient #1’s BFR was decreased to 300 with no rationale as to why the prescribed BFR of 400 was not met. v. On 12/1/25 Patient #1’s treatment was initiated at 10:36 AM without complication with the administered BFR at 400. At 11:08 AM Patient #1’s BFR was decreased to 350 with no rationale as to why the prescribed BFR of 400 was not met. 2. Patient #4 had diagnoses that included ESRD, a physician’s order for hemodialysis treatments three (3) times weekly, for three (3) hours and thirty (30) minutes, at a blood flow rate (BFR) of 450 and dialysate flow rate (DFR) of 800 while using a left upper arm arteriovenous graft (AVG). Review of the following treatment sheets identified the following: i. On 11/21/25, Patient #4’s treatment was initiated at a BFR of 450, however was decreased twenty-eight (28) minutes later to 410, to 400 six (6) minutes later, and to 350 twenty-five (25) minutes later where it remained for five minutes. At 1:58 PM, Patient #4’s BFR was increased to 430, but decreased to 400 after twenty-five minutes, and remained at 400 until treatment termination. Review of the treatment record failed to identify a reason why the BFR was lowered or that the registered nurse was informed. ii. On 11/28/25, Patient #4’s treatment was initiated at a BFR of 450, however was decreased to 400 thirty-two (32) minutes later and remained at 400 for the remainder of the treatment without documentation indicating why the prescribed BFR of 450 was not achieved. 3. Patient #5 was admitted to the facility with diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis three times weekly for three (3) hours and thirty (30) minutes with a left upper arteriovenous graft (AVG) a dialysate blood flow rate (DFR) of 600 and blood flow rate (BFR) of 450. A sample review of Patient #5’s treatment flowsheets identified the following: i. On 10/30/25 Patient #5’s treatment was initiated at 8:10 AM without complication with the administered BFR at 400 with no rationale as to why the prescribed BFR of 450 was not met. ii. On 11/11/25 Patient #5’s treatment was initiated at 12:07 PM without complication with the administered BFR at 450. At 2:07 PM Patient #5’s BFR was decreased to 400 with no rationale as to why the prescribed BFR of 450 was not met. iii.. On 11/18/25 Patient #5’s treatment was initiated at 12:23 PM without complication with the administered BFR at 450. At 2:05 PM Patient #5’s BFR was decreased to 400 with no rationale as to why the prescribed BFR of 450 was not met. iv. On 11/22/25 Patient #5’s treatment was initiated at 12:07 PM without complication with the administered BFR at 450. At 1:35 PM Patient #5’s BFR was decreased to 400 with no rationale as to why the prescribed BFR of 450 was not met. v. On 11/29/25 Patient #5’s treatment was initiated at 12:10 PM without complication with the administered BFR at 450. At 12:40 PM Patient #5’s BFR was decreased to 400 with no rationale as to why the prescribed BFR of 450 was not met. 4. Patient #8 had diagnoses that included ESRD, a physician’s order for hemodialysis treatments three times weekly, for three (3) hours at a blood flow rate (BFR) of 350 and dialysate flow rate (DFR) of 600 while using a left upper arm graft. Review of the following treatment sheets identified the following: i. On 11/17/25, Patient #8’s treatment was run at a blood flow rate of 450 for two (2) hours and forty-eight (48) minutes without documentation of why the ordered BFR of 350 was not maintained. ii. On 11/19/25, Patient #8’s treatment was run at a DFR of 500 throughout the entire treatment without documentation of why the ordered DFR of 600 was not achieved. Interview with the Manger of Clinical Services on 12/4/25 at 1:42 PM identified the patients’ blood flow rate should be as prescribed. If it is not, the reason should be documented in the treatment flowsheet or nursing note as to why it is not met. Review of the pre-intra-post treatment data collection, monitoring and assessment policy directed that during treatment if the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed.”

“PA-IMMUNIZATION/MEDICATION HISTORY CFR(s): 494.80(a)(3) The patient’s comprehensive assessment must include, but is not limited to, the following: Immunization history, and medication history. This Standard is not met as evidenced by: 44675 Based on clinical record review, interview and policy for two (2) of six (6) Patients (Patient #7 and Patient #11) the facility failed to complete a two-step PPD test per facility policy. The finding included: 1. Patient #7 was admitted to the facility on 7/15/25 with diagnoses that included End Stage Renal Disease (ESRD). Review of the physician’s orders directed hemodialysis three (3) times a week for four (4) hours with a right Central Venous Catheter (CVC). Hospital chest x-ray dated 6/30/25 (prior to admission to the facility) identified Patient #7’s lungs were clear. Review of Patient #7’s Tuberculin purified protein derivative (PPD is a type of test which helps diagnose a tuberculosis infection) results identified Patient #7 had a PPD placed on 7/19/25 and was unable to be read in 72 hours. Patient #7 had then had a PPD placed on 7/24/25 and was unable to be read in 72 hours. Review of Patient #7’s PPD results dated 10/16/25 (approximately three months after admission) identified the result was 0 mm. This was Patient #7’s first documented PPD test with result in the clinic. The medical record failed to identify a second PPD test was administered and read within twenty-eight (28) days per facility policy. Interview with the Clinical Coordinator on 12/3/25 at 1:40 PM identified Patient #7 was non-compliant with treatments therefore the first two attempts at PPD were unable to be read. She further identified Patient #7 should have had a second PPD administered. Interview with the Manager of Clinical Services on 12/4/25 at 1:40 PM identified if a chest x-ray is completed before admission, the patient will need a two-step tuberculin skin test (TST) testing series in the clinic. Review of the tuberculosis infection control policy directed that if a tuberculin skin test (TST) or interferon-gamma release assay (IGRA) test documentation is not available, prior to the first treatment a chest x-ray needs to be completed. Upon admission administer a one step TST followed by a second TST (2nd step of two-step TST) one (1) to three (3) weeks after the admission TST. 2. Patient #11 was admitted to the facility on 4/21/25 with diagnoses that included end stage renal disease. Review of the physician’s orders directed continuous cyclic peritoneal dialysis once a day with a middle quadrant peritoneal dialysis catheter. Review of Patient #11’s PPD results identified Patient #11 had a PPD placed on 5/12/25 and was 0 mm. This was Patient #11’s first documented PPD test with result in the clinic. The medical record failed to identify a second PPD test was administered and read within twenty-eight (28) days per facility policy. Interview with the Peritoneal Dialysis Nurse on 12/4/25 at 1:27 PM identified Patient #11 was in a skilled nursing facility (SNF) when he/she was admitted to the clinic. She identified she asked the SNF to send over Patient #11’s PPD results but they did not send it. Although requested, a chest x-ray prior to Patient #11’s admission to the clinic was not provided. Interview with the Manager of Clinical Services on 12/4/25 at 1:40 PM identified if a prior PPD is negative from an outside facility, the clinic needs to obtain and maintain documentation of the first PPD and administer a second one in the clinic. Review of the tuberculosis infection control policy directed that if documentation of a negative TST is available, there is no action needed prior to the first treatment. Upon admission administer a second TST (2nd step of two-step TST) one (1) to three (3) weeks after the pre-admission TST was obtained or as soon as possible following admission if three (3) weeks or more have passed.”

“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: 47491 Based on observation, interview, and review of facility documents and policy related to glucometer calibration, the facility failed to ensure the glucometer was calibrated to accurately assess blood glucose levels, based on observation, and review of facility documents and policy related to medication administration, the facility failed to cleanse the septum of a heparin vial prior with withdrawing a medication. The findings included: 1. Review of October through December 2025 Glucometer Calibration Log Sheet identified the following: Glucometer #1 entries dated 10/4/25, 10/10/25, 0/11/25, 11/3/25, and 11/6/25 identified low control results exceeded the established range of 91-121 and failed to identify the glucometer was retested. Interview with the Clinical Services Manager (CSM) on 12/4/25 at 1:39 PM identified if the glucometer tested outside of the established range, staff were to retest the glucometer and document the new results. Review of the Embrace Pro Blood Glucose Monitor Quality Control policy directed daily quality control procedures or more often as required by state regulations and that if the control results fell outside of the acceptable range, the test must be repeated. 2. Observation on 12/2/25 at 9:24 AM identified Staff Person # 6 drawing heparin ( A blood thinner) for Patient #10, prior to inserting the needle into the vial, Staff Person #6 failed to cleanse the septum of the vial. Interview with Staff Person #6 on 12/2/25 at 9:26 AM identified facility practice was to wipe the septum of the vial prior to withdrawing the medication. Interview with the Clinical Services Manager on 12/4/25 at 1:45 PM identified the top of the heparin bottle with an alcohol pad prior to each entry. Review of the Anticoagulation policy directed aseptic technique was to be used for disinfection of the stopper prior to any entry of a vial.”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 32738 Based on review of clinical records, interview, and review of facility documentation and policy for one (1) of two (2) patients (Patient #10) reviewed for treatments, the facility failed to document the patient’s deviation from physician’s orders, documentation that training was provided to patients for home intravenous antibiotic administration (Patient #10), and failed to document communications with a patient who did not come to treatment on several occasions.(Patient #2). The findings included: 1. Patient #10 had diagnoses that included End Stage Renal Disease. A physician’s order directed daily treatments of five (5), 2,200 milliliter exchanges using varied dialysate concentrations over a nine (9) hour timeframe, using a mid-abdominal peritoneal dialysis catheter. Review of Patient #10’s daily treatment records dated 8/1/25 through 8/31/25 identified the patient was compliant with dialysis treatments, however failed to identify the patient had followed specific fluid use guidelines related to dialysate use with twenty-seven (27) of the thirty-one (31) treatments completed. Review of Patient #10’s daily treatment records dated 9/1/25 through 9/30/25 identified the patient was compliant with dialysis treatments, however failed to identify the patient had followed specific fluid use guidelines related to dialysate use with twenty-six (26) of the thirty (30) treatments completed. Review of Patient #10’s daily treatment records dated 10/1/25 through 10/21/25 identified the patient was compliant with dialysis treatments, however failed to identify the patient had followed specific fluid use guidelines related to dialysate use with sixteen (16) of the twenty-one (21) treatments completed. Interview with the Peritoneal Dialysis Nurse (PDN) on 12/4/25 at 12:15 PM identified he/she was aware Patient #10 had deviated from physician’s orders regarding dialysate concentration use, that he/she trusted the patient knew what he/she was doing when selecting which dialysate concentrations to use with treatment, and that the physician was aware of the patient’s deviation from his/her orders. However, the PDN failed to document the deviation in nursing notes or the physician’s agreement with the patient’s choice of dialysate use. The PDN further identified he/she had educated the patient regarding compliance with the fluid guidelines orders, however failed to document that education was provided. Review of the Daily Home Treatment Record policy directed the registered nurse was responsible for reviewing the treatment record and noting any discrepancies within the patient’s medical record. 2. Review of nursing notes dated 7/28/25 identified Patient #10 was discharged from the hospital on 7/28/25 with orders to continue administration of one (1) gram of Cefepime daily through 8/11/25. Review of physician’s orders directed 1000 milligrams of Cefepime to be administered daily intraperitoneally (via the peritoneal dialysis catheter) from 7/28/25 through 8/11/25. Interview with the Peritoneal Dialysis Nurse on 12/4/25 at 1:21 PM identified Patient #10 was trained on how to instill antibiotics (Cefepime) into a dialysate solution bag for treatment; however, he/she was unable to provide documentation identifying the training was given. Although requested, the policy for Medication Self-Administration was not provided. 3. Patient #2 had diagnoses that included end stage renal disease. Physician’s orders directed hemodialysis treatments twice weekly, for three (3) hours utilizing an arteriovenous graft. Review of Patient #2’s September 2025 treatment log identified he/she missed treatments on 9/5/25, 9/13/25, and 9/27/25 without documentation noting why or that contact with the patient was attempted. Review of Patient #2’s October 2025 treatment log identified he/she missed treatments on 10/8/25, 10/15/25, 10/24/25, and 10/25/25 without documentation noting why or that contact with the patient was attempted. Review of Patient #2’s November 2025 treatment log identified he/she missed treatments on 11/8/25, 11/14/25, 11/19/25, 11/21/25, 11/24/25, and 11/26/25 without documentation noting why or that contact with the patient was attempted. Interview with the Clinical Coordinator on 12/3/25 at 9:02 AM identified that facility practice was to contact the patient that has a no call/no show treatment the day of their missed treatment and to document the attempt/contact was made. The Clinical Coordinator further indicated that Patient #2 was contacted following each missed treatment, however documentation in Patient #2’s medical chart failed to identify that this had occurred. Although requested, the facility did not have a policy regarding missed treatments.”