Davita Kankakee County Dialysis

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 52207 Based on observation, document review, and interview, it was determined for 3 of 7 employees, the Facility failed to ensure proper disinfection of the Handheld Electronic Thermometer being used for patient care was performed to prevent the potential for cross contamination. Findings include: 1. On 12/17/2025 at approximately 1:50 PM the Patient Care Technician (PCT) E #11 was observed performing a temperature check with gloved hands on a patient at station #13. After performing the temperature check E #13 placed the thermometer in the basket on the computer on wheels that is positioned between dialysis station #13 and #14 and did not disinfect the thermometer. PCT E #12 working at station #16, asked for the thermometer from E #11, E #11 removed the thermometer from the basket on the computer at station #13 with their gloved hand and handed it to E # 12’s gloved hands, who proceeded to take the temperature of the patient at station # 16 without disinfecting it. E #11 then place the thermometer in the basket on the computer in between stations # 15 and #16 without disinfecting it. 2. On 12/18/2025 at approximately 1:40 pm the Registered Nurse (RN) E #13 was observed performing a temperature check with gloved hands on a patient at station #11. After performing the temperature check E #13 placed the thermometer in the basket on the computer on wheels that is positioned between dialysis station #11 and #12 and did not disinfect the thermometer. PCT E #9 working, at station #10, walked over and removed the thermometer from the basket on the computer at station #11 with their bare hand to take the temperature of the patient at station # 10 without disinfecting the thermometer, E #9 then place the thermometer in the basket on the computer in between stations # 9 and # 10 without disinfecting the thermometer. 3. On 12/17/2025 at approximately 2:30 PM, the policy titled “Infection Control for Dialysis Facilities” (Revised April 2023) was reviewed. The policy states, “14. Non-Disposable items are to be disinfected after each patient use, prior to removal from treatment area/station and if contaminated between uses ....” 3. An interview was conducted with the Facility Administrator (E #1) on 12/18/2025 at approximately 2:30 PM. E #1 verbally agreed the Thermometer should be disinfected between uses.”

“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: 52206 A. Based on observation, document review, and interview the Facility failed to ensure 4 of 5 bleach filled containers, used for disinfecting dialysis chairs/machines, were properly labeled, and covered. Findings include: 1. During the observation tour of the treatment area on 12/17/2025 at approximately 1:10 pm, the following was noted: a. 2 containers (1 container located at the Pod #4 clean sink and 1 container between Pod #2 and Pod #3 on the clean sink) labeled 1:100 (1 part bleach: 100 parts water) did not have lids securely covering them from 1:00PM to 3:15PM. This had the potential to allow for the bleach solution to evaporate and lose its proper disinfection strength and prevents complete disinfection of dialysis stations/chairs. 2. During the observation tour of the treatment area on 12/18/2025 at approximately 10:30Am, the following was noted: a. 3 containers (1 clamp container near Pod#4 on the dirty sink, 1 container near Pod #4 on the clean sink, and 1 clamp container near Pod #2 on the dirty sink) labeled 1:100 (1 part bleach: 100 parts water) and 1container ( located near Pod #4 on the clean sink) labeled 1:10 (1 part bleach: 10 parts water) did not have lids securely covering them. 3. On 12/18/2025 at approximately 9:00AM, the policy titled “Bleach Policy” (Revised October 2023) was reviewed. The policy states, “5. Bleach solution needs to be covered with a secure lid and the solution should not be placed in the splash zone. NOTE: Without a secure lid, the bleach solution is open to air causing the solution to degrade over time and become less effective.” 4. On 12/18/2025 at approximately 10:30AM, during the observational tour, an interview was conducted with the Facility Administrator (E #1). E #1 verbally agreed the containers should have been covered with lids, securely fastened to prevent evaporation of the solution. B. Based on document review, observation, and interview, it was determined that for 2 of 5 Patient Care Technicians (E #9 and E # 10) observed cleaning and disinfecting dialysis stations, the Facility failed to follow infection control precautions by not cleaning/disinfecting equipment, as required. 1. On 12/17/2025 from 1:00 PM to 3:15 PM, an observational tour was conducted in the dialysis treatment area. The following was observed: a) At approximately 1:00 PM, the Patient Care Technician (E # 9) did not fully recline the dialysis chair to disinfect all surfaces of the dialysis chair at Station #7. E # 9 did not clean the countertop behind the dialysis station. E #9 immediately closed the dialysis chair after cleaning without allowing sufficient contact time to air dry. b) At approximately 1:30pm, the Patient Care Technician (E # 9) did not fully recline the dialysis chair to disinfect all surfaces of the dialysis chair at Station #11. E # 9 did not clean the countertop behind the dialysis station. E #9 immediately closed the dialysis chair after disinfecting without allowing sufficient contact time to air dry. 2. On 12/18/2025 from 12:30 PM to 2:00 PM an observational tour was conducted in the dialysis treatment area. The following was observed: a) At approximately 1:30pm, the Patient Care Technician (E # 10) did not fully recline the dialysis chair to disinfect all surfaces of the dialysis chair at Station #12. E # 10 did not clean the countertop behind the dialysis station. E #10 immediately closed the dialysis chair after disinfecting without allowing sufficient contact time to air dry. b) At approximately 1:30pm, the Patient Care Technician (E # 9) did not fully recline the dialysis chair to disinfect all surfaces of the dialysis chair at Station #11. E # 9 did not clean the countertop behind the dialysis station. E #9 immediately closed the dialysis chair after disinfecting without allowing sufficient contact time to air dry. 3. On 12/17/2025 the Facility’s policy titled, “Infection Control for Dialysis Facilities” (Revised April 2023), was reviewed and stated, “12. (b) iii. Surface be allowed to air dry in order to provide sufficient disinfectant contact time. ... 13. At the end of each treatment, the dialysis station will be cleaned and disinfected. a. Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings (e.g., dialysis chair, tray tables, blood pressure cuffs) and frequently contacted by healthcare personnel (e.g., control panel; top, front and sides of dialysis machine; touchscreens; countertops).” 4. On 12/18/2025 at approximately 2:30 pm, an interview was conducted with the Facility Administrator (E #1). E #1 verbally agreed the dialysis chair should be fully reclined to complete disinfection of all surfaces of the dialysis chair and left open to be given enough time to air dry. E # 1 noted they should also be wiping down the countertops directly behind each dialysis station.”

“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: 50688 Based on observation, document review, and staff interview, it was determined the facility failed to ensure outdated biologicals were not available for patient use. Findings Include: 1. On 12/18/2025 at approximately 10:00 AM, an observational tour of the Home Services training/treatment area was conducted. The following was observed: a. One open box of Dynarex Povidone-Iodine Prep Pads, containing 94 pads, with a manufacturer tag on the box exterior displaying an expiration date of 06/2025, was found in the supply cabinet in Room 1. b. Six BD 30 mL syringes with an expiration date of 04/30/2025 were found in the supply cabinet in Room 1. c. Seven BD Vacutainer Blood Collections Sets (butterfly needle sets) with an expiration date of 02/28/2025 were found in the supply cabinet of Room 1. d. One open box of Ertapenem 1 gram, containing 2 unused vials with an expiration date of November 2025 were found in the medication cabinet of Room 3. 2. On 12/18/2025 at approximately 1:45 PM, The policy “Infection Control for Dialysis Facilities” (Revised April 2023) was reviewed. The policy states, “SUPPLIES ...8. Supplies will be stored in a manner that maintains their integrity ...d. Anytime the integrity of a package with or without an expiration date is in question ...the package and its contents must be disposed of and not used. 3. On 12/18/2025 at approximately 10:30 AM, E #1 reviewed the expired biologicals and agreed the biologicals were expired and should not have been available for patient use.”

“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: 49555 Based on observation, document review and interview, it was determined the Facility failed to ensure proper hand hygiene measures to prevent contaminant transmission for 2 of 5 Patient Care Technicians (PCT). Findings include: 1. During observation of the patient treatment floor on 9/3/2024 from 1:00 PM to 3:45 PM the following was observed: a. At 1:45 PM E#3 was observed adjusting their mask and touching their glasses with gloved hands. E#3 then disconnected the lines from a patient’s CVC (Central Venous Catheter) without first performing hand hygiene and changing gloves. b. At 3:30 PM E#3 was observed adjusting their mask and touching their glasses with gloved hands. E#3 then disconnected the lines from a patient’s fistula without first performing hand hygiene and changing gloves. 2. During observation on the patient treatment floor on 9/4/2024 from 8:30 AM to 11:30 AM the following was observed: a. At 8:50 AM E#5 was observed adjusting their mask with gloved hands. E#5 then accessed the patient’s fistula without first performing hand hygiene and changing gloves. b. At 9:30 AM E#5 was observed touching the dialysis machine at station 10. E#5 then moved to station #11 and touched the machine without performing hand hygiene and changing gloves. c. At 9:50 AM E#5 was observed setting up the dialysis machine at station #11 with gloved hands. E#5 then removed gloves and put a new pair of gloves on as they moved to station #12 to address an alarm, without performing hand hygiene before applying the new pair of gloves. E#5 subsequently removed gloves and put a new pair of gloves on as they returned to station #11 to complete the dialysis machine setup, without performing hand hygiene before applying the new pair of gloves. 3. On 9/4/2024 the policy titled “Infection Control for Dialysis Facilities” (Revised April 2023), was reviewed, and requires, “All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene ...b. prior to gloving and immediately after removal of gloves ...d. after patient and dialysis delivery system contact, ...f. between patient even if the contact is casual, ...g. before touching clean areas such as supplies, supply cart and chair-side keyboard/mouse.” 4. On 9/4/2024 at approximately 1:00 pm, an interview was conducted with the Facility Administrator (E #1). E #1 verbally agreed hand hygiene and/or glove changes should be completed in these situations.”

“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: 49555 A. Based on observation, document review, and interview the Facility failed to ensure 2 of 4 bleach filled containers, used for disinfecting dialysis chairs/machines, were properly labeled, and covered. Findings include: 1. During the observation tour of the treatment area on 9/3/2024 at approximately 1:00 pm, the following was noted: a. 2 containers labeled 1:10 (1 part bleach: 9 parts water) did not have lids covering them from 1:00PM to 1:45PM. This had the potential to allow for the bleach solution to evaporate and lose its proper disinfection strength and prevents complete disinfection of dialysis stations/chairs. b. 1 opaque container containing a clear solution was not labeled. 2. On 9/4/2024 at approximately 3:00 PM, the policy titled “Bleach Policy” (Revised October 2023) was reviewed. The policy states, “5. Bleach solution needs to be covered with a secure lid and the solution should not be placed in the splash zone. NOTE: Without a secure lid, the bleach solution is open to air causing the solution to degrade over time and become less effective.” 3. On 9/3/2024 at approximately 1:45 PM, during the observational tour, an interview was conducted with the Facility Administrator (E #1). E #1 verbally agreed the containers should have been covered with lids, securely fastened to prevent evaporation of the solution, and that the lids should have been marked with the solution strength. E#1 additionally verbally confirmed the opaque container as containing bleach solution and agreed the container should be labeled as containing bleach solution. B. Based on document review, observation, and interview, it was determined that for 1 of 1 Patient Care Technicians (E #3) observed cleaning and disinfecting dialysis stations, the Facility failed to follow infection control precautions by not cleaning/disinfecting equipment, as required. Findings Include: 1. On 9/3/2024 from 1:00 PM to 3:45 PM, an observational tour was conducted in the dialysis treatment area. The following was observed: - At approximately 2:00 PM, the Patient Care Technician (E # 3) did not fully recline the dialysis chair to disinfect all surfaces of the dialysis chair at Station #11. - At approximately 3:40pm, the Patient Care Technician (E # 3) did not fully recline the dialysis chair to disinfect all surfaces of the dialysis chair at Station #2. 2. On 9/4/2024 the Facility’s policy titled, “Infection Control for Dialysis Facilities” (Revised April 2023), was reviewed and noted, “13. At the end of each treatment, the dialysis station will be cleaned and disinfected. a. Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings (e.g., dialysis chair, tray tables, blood pressure cuffs) and frequently contacted by healthcare personnel (e.g., control panel; top, front and sides of dialysis machine; touchscreens; countertops).” 3. On 9/4/2024 at approximately 1:00 pm, an interview was conducted with the Facility Administrator (E #1). E #1 verbally agreed the dialysis chair should be fully reclined to complete disinfection of all surfaces of the dialysis chair.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 49555 Based on observation, document review, and interview, it was determined that for 3 of 3 Patient Care Technicians - PCT (E #3, E #4, E #6) observed performing CVC (central venous catheter- used for dialysis access) care, the Facility failed to ensure that CVC care was performed as required. Findings include: 1. On 9/3/2024 between 1:00 PM to 3:45 PM, an observational tour of the dialysis treatment area was conducted. At approximately 2:00 PM, the PCT (E #3) was observed disinfecting the CVC hubs after disconnection at station #11. E #3 disinfected the CVC hub with an alcohol wipe for 2 seconds then applied a cap to the CVC hubs. 2. On 9/4/2024, the Facility’s policy titled, “Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure” (revised October 2023) was reviewed and indicated, “Perform a 15 second hub scrub of the CVC during the process of connecting or disconnecting from the blood lines, including line reversal, or if the patient is disconnected during treatment for any reason.” 3. On 9/4/2024 at approximately 1:15 PM, an interview was conducted with the Facility Administrator (E #1). E #1 stated, “The CVC hubs should be disinfected for 15 seconds each with alcohol.” 4. On 9/4/2024 between 8:30 AM to 11:30 AM, an observational tour of the dialysis treatment area was conducted. a) At approximately 10:15 AM, the PCT (E #4) was observed performing CVC care. PCT cleansed the CVC insertion site with a Chlorhexidine Gluconate/70% Isopropyl Alcohol swab. While E #4 allowed the site to air dry the patient’s clothing fell onto the cleansed area. PCT then pulled the patient’s clothing back and applied a dressing to CVC insertion site. b) At approximately 10:50 AM, the PCT (E #6) was observed performing CVC care. PCT cleansed the CVC insertion site with a Chlorhexidine Gluconate/70% Isopropyl Alcohol swab. While E #6 allowed the site to air dry the patient’s clothing fell onto the cleansed area. PCT then pulled the patient’s clothing back and applied a dressing to CVC insertion site. 5. On 9/4/2024, the Facility’s policy titled, “Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure” (revised October 2023) was reviewed and indicated, “Verify patient’s clothing is secured away from the exit site/work area ...Securing the patient’s clothing away from the work area minimizes the risk of cross-contamination.” 6. On 9/4/2024 at approximately 1:15 PM, an interview was conducted with the Facility Administrator (E #1). E #1 verbally agreed patient’s clothing should be secured away from the exit site while performing CVC care.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 30383 Based on document review and staff interview, it was determined for 2 of 6 patient records reviewed for Blood Flow Rate (BFR) and Dialysate Flow Rate (DFR), the ESRD Facility failed to ensure the patient’s BFR and/or DFR was achieved and maintained in accordance with the dialysis prescription. Findings include: 1. The Facility policy titled “Pre-Intra-Post Treatment Data Collection, Monitoring, And Nursing Assessment” (Policy 1-03-08, revised April 2024) was reviewed on 9/05/24 at approximately 8:30 AM. The policy required, “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. Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately (refer to “Abnormal Findings” section in this policy). The licensed nurse will use his/her clinical judgement based on individual patient needs to determine if any clinical interventions are necessary. The licensed nurse notifies the physician (or NPP if applicable) as needed of changes in patient status. All findings, interventions and patient response will be documented in the patient’s medical record.” 2. On 9/04/24 at approximately 11:30 AM, Pt #4’s record was reviewed. Pt #4 was admitted to the facility on 02/14/2024 with a diagnosis of ESRD. Pt #4’s clinical record contained a physician order that noted the Blood Flow Rate (BFR) of 350 ml/min. Pt #4’s treatment sheets dated 8/7/24, 8/9/24, 8/19/24, 8/28/24, and 8/30/24 (5 of 12 treatments) indicated the following: 8/7/24 BFR ran at 300 during the treatment. 8/9/24 BFR ran at 300 the entire treatment. 8/19/24 BFR ran at 300 at 06:30 AM until the end of treatment at 08:51 AM 8/28/24 BFR ran at 300 at 06:05 AM until the end of treatment at 08:20 AM 8/30/24 BFR ran at 300 at 07:01 AM, 07:31 AM, and 7:35 AM The record lacked documentation as to why the prescribed blood flow/dialysis flow rates were not maintained or any notification to the physician about any changes to those rates along with patient response. 3. On 9/04/24 at approximately 10:00 AM, Pt #8’s record was reviewed. Pt #8 was admitted to the facility on 11/10/22 with a diagnosis of ESRD. Pt #8’s clinical record contained an order that noted the BFR of 400 ml/min and a Dialysate Flow Rate (DFR) of 800 ml/min. Pt #8’s treatment sheets dated 8/7/24, 8/9/24, 8/14/24, 8/16/24, and 8/19/24 (5 of 12 treatments) indicated the following: 8/7/24 BFR ran at 200 the entire treatment and the DFR ran at 510 at 14:56 (2:56 PM), 15:00 (3:00 PM), 15:59 (3:59 PM), 490 at 15:29 (3:29 PM), 16:30 (4:30 PM), 16:59 (4:59 PM), and 17:30 (5:30 PM). 8/9/24 DFR ran at 510 at 14:11 (2:11 PM), 500 at 14:41 (2:41 PM), 15:11 (3:11 PM), 15:41 (3:41 PM), 16:11 (4:11 PM), 16:41 (4:41 PM), 17:11 (5:11 PM), and 17:14 (5:14 PM), and 490 at 17:40 (5:40 PM). 8/14/24 BFR ran at 350 the entire treatment. 8/16/24 BFR ran at 320 the entire treatment. DFR ran at 500 the entire treatment. 8/19/24 BFR ran at 350 the entire treatment. The record lacked documentation as to why the prescribed blood flow/dialysis flow rates were not maintained or any notification to the physician about any changes to those rates along with patient response 4. An interview with Facility Administrator (E #1) was conducted on 9/05/24 at approximately 1:00 PM and E#1 stated “the chart should reflect the reason for any changes to the DFR/BFR and notification to the physician of needed changes.””

“POC-P/S COUNSELING/REFERRALS/HRQOL TOOL CFR(s): 494.90(a)(6) The interdisciplinary team must provide the necessary monitoring and social work interventions. These include counseling services and referrals for other social services, to assist the patient in achieving and sustaining an appropriate psychosocial status as measured by a standardized mental and physical assessment tool chosen by the social worker, at regular intervals, or more frequently on an as-needed basis. This Standard is not met as evidenced by: 30383 Based on document review and staff interview, it was determined in 2 of 2 (Pt #2, and Pt #5) PD (peritoneal dialysis) patient’s records reviewed, the Facility failed to ensure a KDQOL-36 assessment survey was administered and documented within 4 months of initiating treatment and annually. Findings include: 1. The clinical records were reviewed throughout the survey on 9/4/24 at approximately 10:00 AM. The following records lacked documentation that a KDQOL-36 assessment survey was administered: a) Pt #2 SOC: 9/5/23, Diagnosis: End Stage Renal Disease. b) Pt #5 SOC: 08/12/23, Diagnosis: End Stage Renal Disease. 2. During an interview on 9/4/24 at approximately 12:00 PM, E#7 (Social Worker) verbally agreed the KDQOL-36 assessment survey had not been completed on the 2 PD patients.”