Davita Silver Springs Shores 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: 15234 Based on observation, interview and record review the facility failed to ensure 8 patients, Patient #2, Patient #6, Patient #7, Patient #8, Patient #9, Patient #12, Patient #13, and Patient #14 of 10 patients observed followed acceptable infection control practices to include hand washing/hand hygiene before entering the treatment floor, prior to initiation of treatment or after discontinuation of dialysis treatment and before leaving the dialysis treatment room and failed to ensure staff members followed acceptable infection control practices during 1 of 4 discontinuations of treatment observations. Findings include: On 3/31/2025 at 10:11 AM, Patient #9 was observed entering the treatment floor of the facility with no handwashing/sanitation completed. Facility staff were not observed to remind or encourage Patient #9 to wash or sanitize her hands before entering the treatment floor. On 3/31/2025 at 10:20 AM, Patient #12 was observed leaving facility after dialysis treatment with no handwashing/sanitation completed. Facility staff were not observed to remind or encourage Patient #12 to wash or sanitize her hands before leaving the facility. On 3/31/2025 at 10:44 AM, Patient #2 was observed leaving facility after dialysis treatment with no handwashing/sanitation completed. Facility staff were not observed to remind or encourage Patient #2 to wash or sanitize her hands before leaving the facility. On 3/31/2025 at 10:47 AM, Patient #13 was observed leaving facility after dialysis treatment with no handwashing/sanitation completed. Facility staff were not observed to remind or encourage Patient #13 to wash or sanitize her hands before leaving the facility. On 3/31/2025 at 10:48 AM, Patient #14 was observed entering the treatment floor of the facility with no handwashing/sanitation completed. Facility staff were not observed to remind or encourage Patient #14 to wash or sanitize his hands before entering the treatment floor. On 3/31/2025 at 10:50 AM, Patient #8 was observed leaving facility after dialysis treatment with no handwashing/sanitation completed. Facility staff were not observed to remind or encourage Patient #8 to wash or sanitize her hands before leaving the facility. On 3/31/2025 at 10:59 AM, Patient #6 was observed entering the treatment floor of the facility with no handwashing/sanitation completed. Facility staff were not observed to remind or encourage Patient #6 to wash or sanitize her hands before entering the treatment floor. On 3/31/2025 at 11:07 AM, Patient #7 was observed leaving facility after dialysis treatment with no handwashing/sanitation completed. Facility staff were not observed to remind or encourage Patient #7 to wash or sanitize her hands before leaving the facility. On 3/31/2025 at 9:27 AM, Staff A, Patient Care Technician, was observed during discontinuation of dialysis of Patient #10. At 9:34 AM, Staff A removed Patient #10’s needles, applied a bandage to Patient #10’s access site and assisted Patient #10 to apply pressure to the access site. Staff A doffed her gloves and donned a new pair of gloves. Staff A did not sanitize her hands after she doffed her gloves. Staff A donned a new pair of gloves and placed her hand on Patient #10’s second access site. After assisting Patient #10 with her second access site, Staff A doffed her gloves and donned a new pair of gloves. Staff A did not sanitize her hands after she doffed her gloves. Staff A then walked to another station, worked with the dialysis machine at the other station and then returned to Patient #10’s station. Staff A did not doff her gloves, sanitize her hands and don a new pair of gloves before she left Patient #10’s station and walked to another station. Staff A did not doff her gloves, sanitize her hands and don a new pair of gloves before she returned to Patient #10’s station. During interview on 4/1/2025 at 1:45 PM, the Facility Administrator confirmed patients were expected to sanitize or wash their hands before exiting the treatment floor. She confirmed staff members should sanitize their hands after doffing gloves and before donning a new pair of gloves. Review of the policy titled “Infection Control for Dialysis Facilities,” revised April 2023, read “HAND HYGIENE 1. All teammates, Physicians and Non-Physicians will perform hand hygiene a. upon entering and exiting the patient treatment area, b. prior to gloving and immediately after removal of gloves, c. after contamination with blood or other infectious material, d. after patient and dialysis delivery system contact, e. after interacting with wall boxes...f. between patients even if the contact is casual, g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse. 2. Patients and caregivers will be encouraged to a. Wash their hands and access extremity upon entering the treatment area prior to the initiation of dialysis. b. Perform hand hygiene after treatment before leaving treatment area.””

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 51504 Based on record review and interview the facility failed to ensure a comprehensive reassessment was completed monthly for 2 patients, Patient #2 and Patient #17, of 2 patients reviewed who had been deemed unstable. Findings include: 1.) Review of Patient #2’s plan of care, interdisciplinary team meeting date 11/19/2024, revealed Patient #2 had been deemed unstable. Review of Patient #2’s plan of care, interdisciplinary team meeting date 3/13/2025, revealed Patient #2 remained unstable. Review of Patient #2’s clinical records failed to show documentation a comprehensive reassessment was completed during December 2024 for Patient #2. 15234 2.) Review of Patient #17’s plan of care, interdisciplinary team meeting date 12/5/2024, revealed Patient #17 had been deemed unstable. Review of Patient #17’s plan of care, interdisciplinary team meeting date 3/6/2025, revealed Patient #17 remained unstable. Review of Patient #17’s clinical records failed to show documentation a comprehensive reassessment was completed during February 2025 for Patient #17. During interview on 4/2/2025 beginning at 10:06 AM, the Facility Administrator confirmed Patient #2 had been deemed unstable continuously since November 2204. She confirmed that a comprehensive reassessment had not been completed for Patient #2 during December 2024. The Facility Administrator confirmed Patient #17 had been deemed unstable continuously since December 2024. She confirmed that a comprehensive reassessment had not been completed for Patient #17 during February 2025. Review of the facility policy titled “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care, revision date October 2024, showed the policy read “7. A comprehensive re-assessment of each patient and a revision in the plan of care will be conducted: At least monthly for unstable patients including, but not limited to, patients with the following: Extended or frequently hospitalizations Marked deterioration in health status Significant changes in psychosocial needs Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis.””

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 51504 Based on record review and interviews, the center failed to ensure the patient plans of care for 2 patients, Patient #2, Patient #17, of 7 sampled patients were signed by the patient or a reason the patient chose not to sign their plan of care was documented. Findings include: Review of the unstable plan of care developed for patient #2, dated 03/11/2025, failed to reveal documentation that Patient #2 had signed her patient plan of care. There was no entry on the care plan that documented Patient #2 had declined to sign her plan of care. Review of the unstable plans of care developed for Patient #17, dated 12/5/2024 and 1/31/2025, failed to reveal documentation that Patient #17 or her representative had signed the plans of care. There was no entry on the plans of care that documented Patient #17 or her representative had declined to sign the plans of care. During interview on 4/1/2025 at 1:38 PM, the Facility Administrator confirmed that Patient #2 and Patient #17 had not signed their plans of care and the unsigned plans of care were not in adherence with facility policy standards. She stated she had not mailed Patient #17’s unstable plans of care to her representative and she was waiting on patient #17’s representative to come to the facility to sign the plans of care. Review of the center policy titled “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care,” revised October, 2024 read “14- The patient’s plan of care will be completed by the facility’s interdisciplinary team, including patient or personal representative and be signed by team members including the patient or the patient’s personal representative. If the patient chooses not to sign the plan of care, this choice will be documented on the plan of care, along with the reason the signature was not provided.””

“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: 15234 Based on observation, interview and record review the facility failed to ensure infection control measures (handwashing) were implemented during discontinuation and initiation of 4 patients’, Patient #9, Patient #11, Patient #7 and Patient #10, dialysis treatments of 9 patients observed during dialysis treatment. Findings include: On 1/16/2024 at 9:42 AM, Staff A (Patient Care Technician) was observed during discontinuation of Patient #9’s central venous catheter. Staff A sanitized Patient #9’s catheter ports, doffed her gloves and donned new gloves. Staff A failed to sanitize her hands after she doffed gloves and before she donned new gloves. On 1/16/2024 at 10:17 AM, Staff A was observed during discontinuation of Patient #11’s arteriovenous fistula. Staff A removed Patient #11’s access needles then doffed gloves and donned new gloves without sanitizing her hands. Staff A then taped Patient #11’s access sites. On 1/16/2024 at 10:27 AM, Staff A was observed during initiation of Patient #7’s central venous catheter. After removing and discarding Patient 7’s old dressing, Staff A doffed gloves, sanitized her hands, donned new gloves and began to work on the computer keyboard at the dialysis station. Staff A then approached Patient #7 and began to clean his access area without doffing gloves, sanitizing hands and donning new gloves. On 1/16/2024 at 10:28 AM, Staff A doffed gloves, sanitized her hands and left Patient #7’s treatment station area. Staff A returned to Patient #7’s treatment station area and donned new gloves without sanitizing her hands and began to sanitize Patient #7’s catheter ports. On 1/16/2024 at 11:05 AM, Staff B (Registered Nurse) was assessing Patient #10. Staff B dropped a glove on to the floor, picked the glove up off the floor and returned to assess Patient #10 by directly touching his leg. On 1/16/2024 at 11:22 AM, Staff A was observed during initiation of Patient #10’s arteriovenous fistula. Staff A applied antiseptic over Patient #10’s cannulation sites, doffed her gloves, donned new gloves and began to work on the treatment station computer keyboard. Staff A did not sanitized her hands after she doffed gloves and before she donned new gloves. Staff A then approached Patient #10, touched his access sites and inserted his cannulation needles. During an interview on 1/17/2024 beginning at 1:28 PM, the Facility Administrator confirmed staff members should sanitize their hands after doffing gloves and before donning a new pair of gloves. She confirmed staff should have sanitized their hands after picking a used glove up off the floor and before touching a patient. Review of the facility policy titled “Infection Control for Dialysis Facilities”, revised April 2023, showed the policy read “PURPOSE: To minimize the spread of infections or bloodborne pathogens in the dialysis facility environment.” The policy continued “HAND HYGIENE 1. All teammates, Physician’s and Non-Physician (NPP) will perform hand hygiene a. upon entering and exiting the patient treatment area, b. prior to gloving and immediately after removal of gloves, c. after contamination with blood or other infectious material, d. after patient and dialysis delivery system contact, e. after interacting with wall boxes (i.e. plugging/unplugging acid/bicarb lines from dialysis machine, changing acid types, when exchanging a dialysis machine) f. between patients even if the contact is casual, g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse.””

“PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This Standard is not met as evidenced by: 15234 Based on record review and interview the facility failed to ensure an initial comprehensive assessment was conducted for 1 newly admitted patients, Patient #7, of 2 sampled newly admitted patients within 30 calendar days of admission or after 13 hemodialysis sessions beginning with the first dialysis session. Findings include: Review of Patient #7’s clinical records showed Patient #7’s first dialysis treatment in the facility was 12/9/2023. Review of Patient #7’s treatment records, for 12/2023 and 1/2024, revealed Patient #7 completed 10 dialysis treatment sessions during 12/2023 and 5 dialysis treatment sessions during 1/2024 (a total of 15 sessions). Review of Patient #7’s draft patient plan of care, undated, showed the entry “No goals or long-term interventions set in the areas of access, adequacy, anemia, care coordination, comorbidities, general, health maintenance/safety, home environment, infection/vaccination, medication, mineral/bone disorder and modality. During an interview on 1/17/2024 beginning at 10:54 AM, the Facility Administrator confirmed Patient #7 was admitted to the facility on 12/7/2023. She confirmed Patient #7’s initial plan of care was incomplete. Review of the facility policy titled “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care” revised July 2023, showed the policy read “4. A comprehensive assessment will be conducted on all new patients within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis) beginning with the first outpatient dialysis treatment or per state guidelines.””

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 15234 Based on record review and interview the facility failed to ensure a comprehensive reassessment was completed monthly of 1 patient, Patient #12, of 1 patient reviewed who had been deemed unstable. Findings include: Review of Patient #12’s plan of care, finalized date 11/30/2023, revealed Patient #12 had been deemed unstable on 11/30/2023. Review of Patient #12’s clinical records failed to show documentation a comprehensive reassessment was completed monthly of Patient #12. During an interview on 1/17/2024 beginning at 11:05 AM, the Facility Administrator confirmed Patient #12 had been deemed unstable on 11/30/2023 related to shortened treatments and not meeting Kt/V (K-dialyzer clearance of urea; t-treatment time; V-volume of distribution of urea, approximately equal to the patient’s total body water). She confirmed the facility had not completed a comprehensive reassessment monthly of Patient #12 since he was deemed unstable. Review of the facility policy titled “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care, revision date July 2023, showed the policy read “7. A comprehensive re-assessment of each patient and a revision in the plan of care will be conducted: At least monthly for unstable patients including, but not limited to, patients with the following: Extended or frequently hospitalizations Marked deterioration in health status Significant changes in psychosocial needs Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis.””

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 15234 Based on record review and interview the facility failed to ensure the plans of care 3 patients, Patient #11, Patient #13, Patient #14, of 7 sampled patients were signed by the team members, including the patient or patient’s designee if the patient desired. Findings include: Review of Patient #11’s clinical records revealed Patient #11 was admitted to the facility 10/5/2023. Review of Patient #11’s plan of care, finalized 11/2/2023, failed to reveal documentation Patient #11’s plan of care had been signed by the registered nurse and by Patient #11 or Patient #11’s responsible party. Review of Patient #11’s plan of care signature page failed to show documentation Patient #11 had chosen not to sign her plan of care along with the reason the signature was not provided. Review of Patient #13’s clinical records revealed Patient #13 was admitted to the facility 6/1/2023. Review of Patient #13’s plan of care, finalized 8/25/2023, failed to reveal documentation Patient #13’s plan of care had been signed by by Patient #13 or Patient #13’s responsible party. Review of Patient #13’s plan of care signature page failed to show documentation Patient #13 had chosen not to sign his plan of care along with the reason the signature was not provided. Review of Patient #14’s plan of care, finalized 11/30/2023, failed to reveal documentation Patient #14’s plan of care had been signed by Patient #14 or Patient #14’s responsible party, the registered nurse, the registered dietician, the social or the provider. Review of Patient #14’s plan of care signature page failed to show documentation Patient #14 had chosen not to sign his plan of care along with the reason the signature was not provided. During an interview on 1/17/2024 beginning at 10:51 AM, the Facility Administrator confirmed the facility had not yet obtained all pertinent team member’s signatures on the patients’ care plans. Review of the facility policy titled “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care”, revised July 2023, showed the policy read “1. The facility’s interdisciplinary team (IDT) consists of, at a minimum, the patient or the patient’s personal representative, a registered nurse, a physician or Non-Physician Practitioner (NPP), if allowed by state ESRD (end stage renal disease) licensure regulations, treating the patient for ESRD, a social worker, and a dietitian.” `The policy continued “14. The patient’s plan of care will be completed by the facility’s interdisciplinary team, including patient or personal representative and be signed by team members including the patient or the patient’s personal representative. If the patient chooses not to sign the plan of care, this choice will be documented on the plan of care with the reason the signature was not provided.”