Davita South Holland Renal Center

“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: 36774 Based on observation, document review, and interview, for 1 of 3 PCTs/Patient Care Technicians (E #13) observed discontinuing patients’ hemodialysis with AV/arteriovenous graft (dialysis access), the facility failed to ensure that Pt. #13 performed hand hygiene after holding the cannulation site. Findings include: 1. On 8/13/2025 approximately between 9:30 AM through 12: 15 PM, an observational tour of the dialysis treatment floor was conducted. At approximately 10:00 AM, E #13 was observed discontinuing dialysis access for Pt. #13. With a gloved hand, Pt. #13 was holding Pt. #13’s right forearm AV graft. At approximately 10:20 AM, Pt. #13 removed the gloves and left the treatment floor without performing hand hygiene. 2. On 8/13/2025, the facility’s policy titled, “Post dialysis Vascular Access Care: Fistula/Graft Using Safety Fistula Needles” (4/2023) was reviewed and required, “... Procedure... 9... When the patient holds their cannulation sites, the patient will be offered gloves and performs hand hygiene when completed.” 3. On 8/13/2025 at approximately 10:30 AM, findings were discussed with E #13 (PCT). E #13 stated that Pt. #13 was not offered to perform hand hygiene. E #13 stated, “Were we supposed to do that?” 4. On 8/14/2025 at approximately 3:00 PM, findings were discussed with E #1 (Facility Administrator). E #1 stated that Pt. #13 should have been asked to perform hand hygiene to prevent cross-contamination.”

“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: 36774 Based on observation, document review, and interview, for 1 of 3 PCTs/Patient Care Technicians (E #15) observed initiating patients’ hemodialysis, the facility failed to ensure that E #15 was wearing appropriate PPE (personal protective equipment). Finding include: 1. On 8/13/2025 between approximately 9:30 AM through 12:15 PM, an observational tour of the dialysis treatment floor was conducted. At approximately 12:05 PM, E #15 was observed initiating dialysis for Pt. #14 with a CVC/central venous catheter. Although E #15 was wearing a face shield and a mask, E #15’s nose was exposed. 2. On 8/13/2025, the facility’s policy titled, “Central Venous Catheter (CVC) with Clearguard HD Antimicrobial end Caps Procedure” (4/2025) was reviewed and indicated, “... Materials required: PPE-personal equipment... Procedure... Teammate and patient will wear masks covering the nose during this procedure. These measures are vital to preventing the exposure of the catheter and exit site to nasal droplet...” 3. On 8/14/2025 at approximately 3:00 PM, findings were discussed with E #1 (Facility Administrator) E #1 stated that the employee’s nose should be covered when initiating dialysis for patients with central venous catheter.”

“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: 36774 Based on document review and interview, for 1 of 1 weekly (8/7/2025) hemodialysis machine bleach disinfection, the facility failed to ensure that the secondary bleach residual check was documented. Findings include: 1. On 8/12/2025, the facility’s policy titled, “Nipro Surdial Dx Chemical Disinfection (Bleach Solution) Procedure (4/2024) was reviewed and included, “... Notes: Equipment should not be used for patient treatments until results from residual chemical test are acceptable. Residual chlorine level less than or equal to 0.5 ppm (parts per million)...” 2. On 8/12/2025, the facility’s hemodialysis machine disinfection log for August 2025 was reviewed. The log indicated, “... Note: circle any daily cleaning and disinfection process performed... Legend: BR: Secondary Bleach Residual...”. The log indicated that on 8/7/2025, bleach disinfection for the 30 hemodialysis machines were completed. However, the log did not include documentation that the secondary bleach disinfection was performed. 3. On 8/12/2025 at approximately 12:00 PM, an interview was conducted with E #2 (Biomed Specialist). E #2 confirmed that the log lacked documentation that the bleach residual check was completed. 4. On 8/13/2025 at approximately 11:30 AM, interviews were conducted with E #13 and E #15 (PCTs). E #13 and E #16. E #13 and E #16 were able to appropriately describe the process and normal values for checking the secondary bleach residual for hemodialysis machines. However, stated that they were not instructed proper documentation when secondary bleach residual is completed. 5. On 8/15/2025 at approximately 8:45 AM, E #1 (Facility Administrator) stated that the log has been changed and inservices were provided to the staff.”

“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: 52591 Based on document review and interview, for 3 of 9 patients’ (Pt. #2, Pt. #5, and Pt. #7) clinical records reviewed, the facility failed to follow the prescribed BFR (blood flow rate), to ensure that the dialysis prescription was evaluated. Findings include: 1. On 8/14/2025, the facility’s policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” (4/2024) was reviewed and required, “... Policy... Intradialytic Data Collection/Assessment.. 9. Intradialytic treatment monitoring and data collection which may be performed by the PCT (patient care technician) or licensed nurse includes... At a minimum, obtain and document the following... iii Blood and dialysate flows... 10. If the dialysis prescription not being met (including... inability to obtain prescribed blood flow rate) the reason will be documented, and the licensed nurse informed. ... 12. The licensed nurse notifies the physician... as needed of changes in patient status...” 2. On 8/14/2025, the clinical record for Pt. #2 was reviewed. On 8/6/2019, Pt. #2 was admitted with a diagnosis of ESRD (end stage renal disease). The clinical record included a hemodialysis prescription for Pt. #2 with a BFR of 400 for four hours. The following were noted: - On 8/2/2025, Pt. #2 was dialyzed with a BFR between 300 to 350 from 7:32 AM through 11:27 AM (3 hours and 55 minutes) - On 8/7/2025, Pt. #2 was dialyzed with a BFR of 350 from 8:02 AM through 11:05 AM (3 hours and 3 minutes) - On 8/9/2025, Pt. #2 was dialyzed with a BFR between 200 through 295 from 7:29 AM through 11:30 AM (4 hours and 1 minute). 3. On 8/14/2025, the clinical record for Pt. #5 was reviewed. On 1/13/2024, Pt. #5 was admitted with a diagnosis of ESRD. The clinical record included a hemodialysis prescription to dialyze Pt. #5 with a BFR of 400 for four hours and fifteen minutes. The following were noted: - On 7/19/2025, Pt. #5 was dialyzed with a BFR of 335 from 9:10 AM through 1:07 PM (3 hours and 57 minutes) - On 8/9/2025, Pt. #5 was dialyzed with a BFR between 200 to 350 from 10:48 AM through 12:13 PM (1 hour and 25 minutes) 4. On 8/14/2025, the clinical record for Pt. #7 was reviewed. On 9/21/2020, Pt. #7 was admitted with a diagnosis of ESRD. The clinical record included a hemodialysis prescription to dialyze Pt. #7 was a BFR of 350 for three hours and forty-five minutes. However, the following were noted: - On 8/4/2025, Pt. #7 was dialyzed with a BFR between 200 through 250 from 11:32 AM through 3:08 PM (3 hours and 36 minutes) - On 8/6/2025, Pt. #7 was dialyzed with a BFR between 210 through 250 from 11:33 AM through 3:01 PM (3 hours and 28 minutes) - On 8/8/2025, Pt. #7 was dialyzed with a BFR of 250 from 11:02 AM through 2:56 PM (3 hours and 54 minutes) 5. On 8/15/2025 at approximately 8:45 AM, findings were discussed with E #1 (Facility Administrator). E #1 confirmed that the dialysis prescription was not followed for the above patients. E #1 stated that when the prescription is not followed, there should also be documentation that the provider was notified. E #1 was not able to provide documentation that the provider was made aware when the dialysis prescription was not followed.”

“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: 52591 Based on document review and interview, for 1 of 1 patient’s (Pt. #5) clinical record reviewed classified as “unstable”, the facility failed to complete the required monthly reassessment and care planning. Findings include: 1. On 8/14/2025, the facility’s policy titled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care” (10/2024) was reviewed and required, “... Assessment: 1. The facility’s interdisciplinary team (IDT) consist of, at a minimum, the patient... a registered nurse, a physician... treating the patient for ESRD (end stage renal disease), a social worker and a qualified renal dietitian... 22. Implementation of assessments and plans of care are detailed in table below... Monthly until patient is determined by interdisciplinary team to be stable...” The policy also indicated, “Complete patient plan of care meeting within 15 days of the completion of the reassessment and POC (plan of care). 2. On 8/14/2025, the clinical record for Pt. #5 was reviewed. On 1/13/2023, Pt. #5 was admitted with a diagnosis of ESRD. On 7/10/2025, P#5 was designated as unstable due to missed treatments/psychosocial issue. There no was no explanation or intervention of the psychosocial issues contributing to Pt. #5’s missed treatments. As of 8/15/2025, there was no IDT reassessment or plan of care for Pt. #5. Pt #5 had dialysis treatments at the facility on 8/9/2025, 8/12/2025, and 8/14/2025. 3. On 8/15/2025 at approximately 9:15 AM and 1:00 PM, interviews were conducted with E #5 (Social Worker). E #5 stated that on 7/10/2025, E #5 has not identified the reason for Pt. #5’s missed treatments. E #5 confirmed that as of August 15, the IDT’ monthly assessment and care planning is not yet complete.”