Davita Quad Counties 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: 44714 Based on observation, record review, and interview, the facility failed to ensure employees followed hand hygiene practices for 1 of 2 CVC exit site care observations (RN 1), 1 of 2 CVC discontinuation observations (PCT 1), 1 of 2 observations of the initiation of dialysis with a fistula (RN 1), 1 of 2 observations of dialysis station disinfection (PCT 3), and employee use of hand sanitizer for 1 of 2 observation days (PCT 1). Findings include: 1. The facility policy, “Infection Control for Dialysis Facilities,” last revised April 2023, indicated hand hygiene was required prior to gloving and immediately after removal of gloves, after contamination with blood or other infectious material, after contact with the patient or dialysis machine, and before touching clean items or supplies. 2. During an observation on 12/29/2025 at 10:08 AM, PCT 1 discontinued Patient # 5’s dialysis with a CVC. During the process, PCT 1 had completed hand hygiene and donned clean gloves, then pulled the sharps container over to the patient station with their gloved hands. PCT 1 then connected syringes with saline to flush the CVC lines. PCT 1 failed to complete hand hygiene and glove change after touching the sharps container. During an interview on 12/30/2025 beginning at 2:50 PM, PCT 1 indicated hand hygiene (use of hand sanitizer and donning new gloves) was required after touching something “dirty” and doing a clean task. PCT 1 indicated the sharps container was considered dirty and required hand hygiene prior to touching the patient access sites. 3. During an observation on 12/29/2025 at 10:26 AM, PCT 1 used hand sanitizer after removing their gloves. PCT 1 then waved their hands back and forth. PCT 1 failed to allow hand sanitizer to air dry. During an interview beginning at 2:50 PM, PCT 1 acknowledged they waved their hands to dry the hand sanitizer more quickly. 4. During an observation on 12/30/2025 at 5:39 AM, RN 1 prepared to initiate Patient #12’s dialysis via a fistula. RN 1, wearing gloves, washed the skin from elbow to wrist to ensure the access site was clean. RN 1 then removed gloves, used hand sanitizer, and charted on the CWOW (computer work on wheels). RN 1 donned gloves without using hand sanitizer. RN 1 used an antiseptic on Patient #12’s access site. RN 1 failed to use hand sanitizer prior to donning clean gloves. 5. During an observation on 12/30/2025 at 6:36 AM, RN 1 completed CVC exit site care for Patient #13. RN 1 removed the old dressing covering the CVC exit site. RN 1 completed hand hygiene, documented on the CWOW, donned gloves, and cleansed the CVC exit site. RN 1 failed to use hand sanitizer after using the CWOW and prior to donning gloves. During an interview on 12/30/2025 beginning at 2:30 PM, the Alternate Administrator indicated hand sanitizer was required prior to donning gloves. 6. During an observation on 12/30/2025 at 9:45 AM, PCT 3 disinfected the dialysis station. After emptying the prime waste bucket, PCT 3 continued to disinfect the dialysis machine. PCT 3 failed to complete hand hygiene and don new gloves after emptying the prime waste bucket. During an interview on 12/30/2025 beginning at 03:10 PM, the Alternate Administrator indicated their policy did not address hand hygiene after emptying the prime waste bucket.”

“IC-SINKS AVAILABLE CFR(s): 494.30(a)(1)(i) A sufficient number of sinks with warm water and soap should be available to facilitate hand washing. This Standard is not met as evidenced by: 44714 Based on observation and interview, the facility failed to ensure there was warm water at the handwashing sink on the treatment floor for 1 of 1 facility surveyed. Findings include: 1. On 12/29/2025 beginning at 9:00 AM, this surveyor used the handwashing sink on the treatment floor by stepping on the floor pedal to operate the water. Surveyor noted the water to be cold even though the hot water pedal was used. When checked, the hot water temperature was 72° after running for 3 minutes. During an interview on 12/29/2025 beginning 11:12 AM, the biomedical technician indicated they do not check the water temperature. During an interview on 12/29/2025 beginning 2:10 PM, Corporate Person 1, the administrator from another facility, indicated the water temperature was cool. During an observation on 12/30/2025 at 10:15 AM, this surveyor noted Corporate Person 3, a maintenance employee, on the treatment floor checking the water temperature on the handwashing sink. Corporate Person 3 indicated the water was still too cold.”

“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: 44714 Based on observation, record review, and interview, the facility failed to ensure direct care staff did not chew gum while on the treatment floor for 1 of 2 PCTs observed on 12/30/2025 (PCT 1). Findings include: 1. The facility policy, “Infection Control for Dialysis Facilities,” last revised April 2023, stated, “Food and drinks in the treatment area will be limited to patients.” 2. During an observation on 12/30/2025 at 02:50 PM, surveyor observed PCT 1 chewing gum while on the treatment floor. During an interview beginning at 0:250 PM, PCT 1 acknowledged chewing gum and indicated they did not know if it was allowed. During an interview beginning at 03:10 PM, the Alternate Administrator indicated they did not allow food on the treatment floor.”

“SOFTENERS-AUTO REGENERATE/TIMERS/SALT LVL CFR(s): 494.40(a) 5.2.4 Softeners: auto regen/timers/salt/salt level Prior to exhaustion, softeners should be restored; that is, new exchangeable sodium ions are placed on the resin by a process known as “regeneration,” which involves exposure of the resin bed to a saturated sodium chloride solution. 5.2.4 Softeners Refer to RD62:2001, 4.3.10 Automatically regenerated water softeners: Automatically regenerated water softeners shall be fitted with a mechanism to prevent water containing the high concentrations of sodium chloride used during regeneration from entering the product water line during regeneration. The face of the timers used to control the regeneration cycle should be visible to the user. 6.2.4 Softeners Timers should be checked at the beginning of each day and should be interlocked with the RO system so that the RO is stopped when a softener regeneration cycle is initiated. The softener brine tank should be monitored daily to ensure that a saturated salt solution exists in the brine tank. Salt pellets should fill at least half the tank. Salt designated as rock salt should not be used for softener regeneration since it is not refined and typically contains sediments and other impurities that may damage O-rings and pistons and clog orifices in the softener control head. This Standard is not met as evidenced by: 44714 Based on observation, record review, and interview, the facility failed to maintain a brine tank per industry standards for 1 of 1 facility surveyed. Findings include: 1. During an observation of the facility water room on 12/29/2025 beginning at 11:12 AM, the brine tank was not half filled with salt pellets and water was visible above the salt. The brine tank had a label on it with instructions to verify the salt level was above the water line. During an interview on 12/29/2025 beginning at 11:12 AM, the Biomedical Technician indicated the brine tank was not half full of salt pellets and the water line was visible. During an interview on 12/29/2025 beginning at 02:10 PM, Corporate Person 1 indicated the brine tank should be half full of salt and the water level should not be visible.”

“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: 44714 Based on observation, record review, and interview, the facility failed to secure oxygen cylinders for 1 of 1 facility surveyed. Findings include: 1. During an observation on 12/29/2025 beginning at 09:05 AM, this surveyor noted 9 oxygen cylinders in an alcove. Three cylinders were not secured. During an interview on 12/29/2025 beginning at 09:20 AM, RN 1 indicated there were three unsecured oxygen tanks in the alcove and they were unsure of the need to secure them.”

“POC-VA MONITOR/PREVENT FAILURE/STENOSIS CFR(s): 494.90(a)(5) The patient’s vascular access must be monitored to prevent access failure, including monitoring of arteriovenous grafts and fistulae for symptoms of stenosis. This Standard is not met as evidenced by: 44714 Based on observation, record review, and interview, the facility failed to ensure direct care staff assessed the fistula access sites prior to cannulation for 2 of 2 fistula cannulation observations. Findings include: 1. Facility policy, “AV Fistula or Graft Cannulation ...,” last revised April 2025, stated “Perform inspection, auscultation [listen to internal sounds of the body] and palpation [ using touch to assess blood flow] on entire length of access.” 2. During an observation on 12/30/2025 at 05:39 AM, RN 1 prepared to initiate Patient #12’s dialysis via a fistula. RN 1 failed to evaluate access by palpating the cannulation sites (location of needle insertion). 3. During an observation on 12/30/2025 at 05:52 AM, PCT1 prepared to initiate Patient #6’s dialysis via a fistula. PCT 1 failed to evaluate access by palpating the cannulation sites. During an interview on 12/30/2025 beginning at 02:50 PM, PCT 1 indicated the cannulation sites should be assessed by listening and feeling the blood flow, prior to cannulation. During an interview on 12/30/2025 beginning at 03:10 PM, Corporate Person 1 indicated the fistula access sites should be assessed by palpation prior to canulation.”