Davita Shiloh 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: 50645 Based on observation, document review, and interview, it was determined that for 1 of 5 staff (E #1) observed performing initiation and/or discontinuation of dialysis for patients, the Facility failed to ensure staff adhered to hand hygiene practices as required. Findings include: 1. During an observational tour of the treatment floor conducted on 1/6/26 between 9:30 AM to 11:00 AM, the following was observed: -At approximately 10:00 AM, a Patient Care Technician (PCT-E #1) was observed at station #6 performing a discontinuation of dialysis treatment on a patient with an AV (arteriovenous) fistula (dialysis access). E #1, with gloved hands removed gloves and replaced gloves multiple times during discontinuation. E #1failed to perform hand hygiene between glove changes. 2. On 1/6/26, the Facility’s policy titled, “Infection Control for Dialysis Facilities” (revised 4/2023) was reviewed and stated, “...Hand Hygiene: 1. All teammates will perform hand hygiene ...b. prior to gloving and immediately after removal of gloves ...” 3. On 1/6/26, at approximately 11:40 AM, an interview was conducted with the Facility Administrator (E #2). E #2 verbally agreed all staff must perform hand hygiene between glove changes. E #2 stated that there will be another in-service regarding hand hygiene.”

“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: 50771 Findings include: 1. On 01/05/2026 from 12:00 PM to 1:00 PM, an observational tour was conducted in the dialysis treatment area. The following was observed: At approximately 1:00PM, Patient Care Technician (E#1) was observed cleaning dialysis station 6. After cleaning all surfaces, E#1 did not allow the dialysis chairs to fully air dry before returning to sitting position and closing the arms of the chairs. At approximately 1:10 PM, Patient Care Technician (E#3) was observed cleaning dialysis station 1. After cleaning all surfaces, E#3 did not allow the dialysis chairs to fully air dry before returning to sitting position and closing the arms of the chairs. 2. On 01/06/2026 the Facility’s policy titled, “Infection Control for Dialysis Facilities” (Revised April 2023), was reviewed and noted, “12... b... iii. Surfaces should 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).” 3. On 01/06/2026 at approximately 2:00 PM, an interview was conducted with the Facility Administrator (E #1). E #1 observed and verbally agreed that the dialysis chairs should be fully reclined with chair arms open to allow adequate time for surfaces to air dry in order to provide sufficient disinfectant contact time.”

“INVENTORY CONTROL CFR(s): 494.50(b)(1) 9.2 Inventory control Reprocessing supplies should be used on a first-in, first-out basis, and outdated supplies should be identified and discarded. This Standard is not met as evidenced by: 50645 Based on observation, document review, and interviews, it was determined that the Facility failed to ensure that all expired patient care supplies were discarded. Findings include: 1. A tour of the treatment and storage areas was completed on 1/5/2026 between 11:30 AM and 1:00 PM. During the tour, the following outdated supplies were found and were available for patient use. Vacutainers: 21 Clear top 6.0ml tubes expired 4/30/2025. 50 Blue top 2.7ml tubes expired 6/30/2025. 200 Green top 3.0ml tubes expired 10/31/2025. 100 Red top 3.5ml tubes expired 1/10/2025. 63 Red top tube expired 11/30/2025. 1 box Criterion powder-free nitrile gloves. Expired 10/18/2024. 2. On 1/6/2025 at approximately 2:30 PM, the policy titled, “Infection Control for Dialysis Facilities” (revised 4/2023) was reviewed and stated,” ...Supplies...b. Expiration date and package integrity will be verfied prior to use...” 3. On 1/6/2025 at approximately 2:45 PM, an interview was conducted with the Director of Operations (E #2). E #2 verbally agreed that the supplies had expired and should have been discarded and was not.”