Davita Whitewater Valley 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: 44230 Based on observation, record review, and interview, staff failed to ensure adequate hand hygiene was performed for 2 of 2 AVF’s (dialysis access) discontinued. (Patient #1, 6) Findings Include: 1. A policy titled, “Infection Control for Dialysis Facilities” (April 2023) indicated all teammates will perform hand hygiene prior to gloving and immediately after removal of gloves, after contamination with blood or other infectious material, after patient and dialysis system contact and before touching clean areas such as supplies. 2. During an observation on 06/16/2025 at 2:51 PM, PCT 3 discontinued Patient #6’s AVF treatment. PCT 3 failed to perform hand hygiene prior to gloving and immediately after removal of gloves throughout the observation and was observed retrieving clean supplies from stock with contaminated gloves on. 3. During an observation on 06/16/2025 at 3:25 PM, PCT 3 discontinued Patient #1’s AVF treatment. PCT failed to perform hand hygiene prior to gloving and immediately after removal of gloves throughout the observation. 4. During an interview on 06/18/2025 at 10:07 AM, PCT 3 indicated the expectation when removing and putting on new gloves is to complete hand hygiene. 5. During an interview on 06/20/2025 at 12:14 PM, PCT 2 indicated the expectation is to complete hand sanitation when removing and prior to putting on new gloves.”

“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: 44230 Based on observation, record review, and interview, staff failed to ensure adequate disinfection of equipment for 1 of 1 RN assessments observed. (RN 1) Findings Include: A policy titled, “Infection Control for Dialysis Facilities” (April 2023) indicated stethoscopes are to be disinfected with an alcohol prep pad and/or 1:100 bleach solution if visibly contaminated. During an observation on 06/18/2025 at 10:37 AM, RN 1 was observed completing a patient assessment on Patient #3 using her stethoscope. RN 1 failed to disinfect her stethoscope after use. During an interview on 06/23/2025 at 9:50 AM, RN 1 indicated the expectation is to disinfect the stethoscope using bleach and/or an alcohol pad after use with each patient.”

“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: 44230 Based on observation, record review, and interview, the facility failed to ensure adequate disinfection of dialysis station for 2 of 2 dialysis station disinfections observed. (Station #7 and #11) Findings Include: 1. A policy titled, “Infection Control for Dialysis Stations” (April 2023) indicated at the end of each treatment, the dialysis station will be cleaned and disinfected. The dialysis station must be completely vacated by the previous patient before teammates can begin disinfection of the station. 2. During an observation of a station disinfection on 06/16/2025 at 3:01 PM, PCT 3 disinfected the dialysis machine using a bleach solution while Patient #6 was sitting in the dialysis chair holding his/her dialysis access sites after needle removal. 3. During an observation of a station disinfection on 06/16/2025 at 3:53 PM, PCT 3 disinfected the dialysis machine and patient television, using a bleach solution, while Patient #1 was sitting in the dialysis chair holding his/her dialysis access sites after needle removal. 4. During an interview on 06/18/2025 at 10:07 AM, PCT 3 indicated dialysis stations should be vacated by the previous patient prior to disinfection for the next patient. 5. During an interview on 06/23/2025 at 12:14 PM, PCT 2 indicated that patients must vacate the dialysis station prior to disinfecting for the next patient.”

“IC-CATHETERS:GENERAL CFR(s): 494.30(c)(2) (2) The “Guidelines for the Prevention of Intravascular Catheter-Related Infections” entitled “Recommendations for Placement of Intravascular Catheters in Adults and Children” parts I - IV; and “Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients,” Morbidity and Mortality Weekly Report, volume 51 number RR-10, pages 16 through 18, August 9, 2002. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR Part 51. This publication is available for inspection as the CMS Information Resource Center, 7500 Security Boulevard, Central Building, Baltimore, MD or at the National Archives and Records Administration (NARA). Copies may be obtained at the CMS Information Resource Center. For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_regulations/ibr_locations.html This Standard is not met as evidenced by: 44230 Based on observation, record review, and interview, staff failed to ensure adequate CVC disinfection measures were taken to prevent infection for 2 of 2 CVC exit site dressing changes (PCT 2, RN 1), and 1 of 2 CVC treatments discontinued, (PCT 3) Findings Include: 1. A policy titled, “Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure” indicates a 30 second disinfection time using 2% Chlorhexidine Gluconate (Chloraprep-skin disinfectant) when completing CVC exit site disinfection. For discontinuation of CVC treatment, discard used barrier and place a new clean, moisture proof barrier under the catheter to prevent contamination. Do not allow the CVC hub to touch non-sterile surfaces. 2. During an observation on 06/18/2025 at 10:10 AM, PCT 2 disinfected the CVC exit site for Patient #7 using Chloraprep (skin disinfectant) for 12 seconds. During an interview on 06/18/2025 at 10:22 AM, PCT 2 indicated the expectation for disinfecting a CVC exit site using Chlorprep was 30 seconds. 3. During an observation on 06/18/2025 at 10:37 AM, RN 1 disinfected the CVC exit site for Patient #7 using Chloraprep for 13 seconds. During an interview on 06/18/2025 at 10:51 AM, RN 1 indicated the expectation for disinfecting a CVC exit site using Chloraprep is 30 seconds. RN 1 indicated she felt like it was disinfected Patient #7’s CVC exit site for 30 seconds but should have timed it. 4. During an observation on 06/23/2025 at 10:05 AM, PCT 3 discontinued the CVC treatment for Patient #8. PCT 3 failed to replace the CVC barrier at the end of treatment and failed to secure the open ends of the CVC, leaving them open and lying of the dirty barrier, failing to secure the lines in her hands. During an interview on 06/23/2025 at 12:22 PM, PCT 3 indicated the CVC barrier would only be discarded and a new barrier replaced if it appears visibly soiled. The CVC limbs are considered sterile and should be always secured. During an interview on 06/23/2025 at 12:14 PM, PCT 2 indicated the CVC limbs should be secure in hands at all times when connecting/disconnecting with clean barrier used.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 44230 Based on observation, record review, and interview, the medical director failed to ensure policy and procedure were followed regarding securement of medications and water log documentation for 1 of 1 facility observed. Findings Include: Medications unsecured A policy titled, “Medication Policy” (October 2023) indicated all refrigerated medications are to be locked at the close of each business day or if not under supervision by the licensed teammate. During an observation on 06/16/2025 at 12:05 PM, the medication refrigerator housing Mircera (medication used to treat anemia) and vaccinations were found unlocked/unsecured. A second medication refrigerator housing Intradialytic Parenteral Nutrition (nutrient support therapy administered intravenously) was also found to be unlocked/unsecured. RN 1 was in the isolation room tending to a patient’s treatment. During an interview on 06/16/2025 at 12:17 PM, RN 1 indicated that all medications should be locked/secured when not in use. Documentation of Waterlogs A policy titled, “Medical Record Corrections” (October 2023) indicated that paper medical record entry is to be erased to include use of correction fluid, obliterated, altered or destroyed. Erroneous or unclear entries in a paper medical record are to be corrected or clarified by drawing a single line through the erroneous entry, write the word erroneous entry or error entry beside the crossed-out item with the date and teammate signature and credentials. Enter corrected data/information adjacent to the erroneous entry or on the next available line as an addendum. A document titled, “CWP Daily Water Log” dated 04/21/2025 evidenced lines 30, 31, 32, 34 and 35 had been altered using correction tape with data entered over the correction tape. During an interview on 06/18/2025 at 2:10 PM, the Biomed Manager indicated correction tape should never be used to correct paper charting. The incorrect information should have a line through it. During an interview on 06/18/2025 at 2:15 PM, the FA indicated that correction tape should not be used to make corrections to the waterlogs. She is unaware of who used the correction tape and indicated her initials are on the document, but she did not alter this record. During an interview on 06/20/2025 at 8:05 AM, PCT 1 indicated that PCT 3 was responsible for using the correction tape to alter the data on 04/21/2025. She further indicated PCT 3 was new and did not know she was not allowed to do this explaining to her that no records could be altered in that manner. PCT 1 caught this mistake and found other entries that were also altered with correction tape and had PCT 3 redo the entire page, but she missed this one. During an interview on 06/23/2025 at 12:22 PM, RN 1 indicated that correction tape should not be used to alter records. Staff should be putting a line through the erroneous data and initial it.”