Davita Speedway 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: 44232 Based on observation, record review, and interview, the facility failed to ensure the PCTs utilized infection control practices in 4 of 4 treatment floor observations (Employee: PCT 1 (three times), and 2 (twice)) and failed to ensure Patients were encouraged or offered hand hygiene post dialysis treatment in 4 of 4 observations. (Patient: #9, 10, and 14) Findings include: 1. A review of a DaVita Inc. policy revision date April 2023, titled “Infection Control For Dialysis Facilities” indicated but was not limited to, “Purpose: To minimize the spread of infections or bloodborne pathogens in the dialysis facility environment ... Hand Hygiene 1. All teammates, Physician and Non-Physician (NPP) will perform hand hygiene a. upon entering and exiting the patient treatment/training area b. prior to gloving and immediately after removal of gloves c after contamination with blood or other infectious material d. after patent and dialysis delivery system contact ...f. between patients even if the contact is casual g. before touching clean areas such as supplies, supply cart and chairside keyboard ... 2. Patients and caregivers will be encouraged to a. Wash their hands and access extremity upon entering the treatment/training are prior to initiation of dialysis b. Perform hand hygiene after treatment before leaving treatment/training area. 3. Use of an alcohol-based hand rub may be substituted for handwashing ... “ 2. On 12/15/2025 at 1:30 PM, PCT 2 reviewed Patient #1’s dialysis prescription at Station #4 on the dialysis machine, observed PCT 2 removing their gloves and discarding the gloves in the trash receptacle. PCT 2 obtained and donned new gloves and reviewed Patient #2’s dialysis prescription at Station #9 on the dialysis machine. PCT 2 failed to perform hand hygiene after removing their gloves and prior to donning new gloves. 3. On 12/15 /2025 at 1:45 PM, observed PCT 2 removing Patient #10’s glove from their right hand after holding pressure to their lower left access. Patient #10 obtained their weight, provided the weight slip to PCT 2, gathered their belongings and left the treatment area. Patient #10 had not been offered hand hygiene or encouraged to perform hand hygiene prior to leaving the treatment area. 4. On 12/15 /2025 at 1:58 PM, observed PCT 1 obtaining a glove and used the glove to turn off the dialysis machine alarm at Station #12. PCT 1 failed to perform hand hygiene prior to obtaining the glove and failed to apply the glove prior to touching the dialysis machine. 5. On 12/15 /2025 at 2:11 PM, observed PCT 1 discontinuing Patient #1’s dialysis treatment. PCT 1 discarded their gloves, without performing hand hygiene. PCT 1 obtained the thermometer from the computer stand and obtained Patient #1’s temperature. PCT 1 then went to Station #2, obtained a glove and using the glove reset the dialysis machine alarm, without performing hand hygiene, or without applying the glove. 6. On 12/15 /2025 at 2:25 PM, observed PCT 2 discontinuing Patient #8’s dialysis treatment. Patient #8 removed their mask and the clean barrier from under their CVC ports, PCT 2 obtained a new barrier and mask from the middle supply island, placed the new barrier under Patient #8’s CVC ports, handed Patient #8 a mask and donned gloves without performing hand hygiene, and continued disconnecting the blood lines from Patient #8’s CVC ports. 7. On 12/15/2025 at 2:28 PM observed PCT 1 at Station #12 obtain a glove and use the glove to reset the dialysis machine alarm, with performing hand hygiene or applying the glove. PCT 1 discarded the glove in the trash receptacle and failed to perform hand hygiene. 8. On 12/15 /2025 at 2:30 PM, observed Patient #9 removed their glove from right gloved hand after holding pressure to their left upper access. Patient #9 obtained their weight, provided the weight slip to PCT 1, gathered their belongings and left the treatment area. Patient #9 had not been offered hand hygiene or encouraged to perform hand hygiene prior to leaving the treatment area. During an interview on 12/15/2025 at 3:30 PM, when asked about infection control training when hand hygiene should be completed, PCT 1 communicated hand hygiene should had been completed after removing gloves, after touching a patient, after touching the machines, between glove changes, before applying gloves, and the patients should be offered hand hygiene after holding their access. 9. On 12/17 /2025 at 9:05 PM, observed PCT 2 remove Patient #14’s glove from their right hand after holding pressure to their left lower access. Patient #14 obtained their weight, provided the weight slip to RN 1, gathered their belongings and left the treatment area. Patient #14 had not been offered hand hygiene or encouraged to perform hand hygiene prior to leaving the treatment area. During an interview on 12/17/2025 at 7:40 AM, when asked about when hand hygiene is to be performed to prevent infection, PCT 2 communicated hand hygiene should be completed prior to applying gloves, after removing gloves, after touching the dialysis machines, after touching a patient, prior to entering the treatment floor. PCT 2 confirmed the patients are to be offered hand hygiene entering the treatment area and after holding the access after dialysis treatment. 10. A review of the personnel record for PCT 1, contained a facility document dated 08/18/2025, titled “Star Learning” that indicated PCT 1 had successfully completed health and safety training. 11. A review of the personnel record for PCT 2, contained a facility document dated 12/18/2025, titled “Star Learning” that indicated PCT 2 had successfully completed blood borne pathogens exposure control training.”

“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: 44232 Based on observation, record review, and interview, the agency failed to ensure all items taken to the dialysis station were disposed of after use, cleaned and disinfected, and stored without risk of exposure to containments in 4 of 4 treatment room observations. (Employees: RN 2 (6 times), PCT 1 (2 times) PCT 2 (one time), and PCT 6 (one time)) Findings Include: 1. A review of a DaVita Inc. policy with a revision date April 2023, titled “Infection Control For Dialysis Facilities,” 1-05-01 indicated but was not limited to, “ ... 10. Unused supplies ( ... tape ...) ... taken into the station should be used only for that patient and should not be returned to a common clean area or used on other patients ... 14. Non disposable items are to be disinfected after each patient use ... Stethoscopes will be disinfected with alcohol prep pad ... “ 2. On 12/15/2025 at 1:55 PM, observed strips of white tape hanging off the dialysis arm tray at Station #9. PCT 2 removed one cannulation needle and used the strips of tape to keep the gauze dressing in place for Patient #2 to hold pressure on their dressing with their left gloved hand. 3. On 12/15/2025 at 1:58 PM, observed strips of white tape and tape roll hanging off the dialysis arm tray at Station #12. PCT 1 used the strips of tape to adhere the new gauze pressure dressing in place for Patient #3. 4. On 12/15/2025 at 2:19 PM, observed strips of white tape and tape roll hanging off the dialysis arm tray at Station #11. PCT 1 changed the gauze pressure dressing from Patient #9’s access site used the strips of tape hanging off the tray to adhere the new gauze pressure dressing in place for Patient #9. 5. On 12/17/2025 at 5:30 AM, observed PCT 6 hanging strips of white tape off the dialysis arm tray at Station #9. PCT 6 used the strips of tape to keep the cannulation needles in place for initiating dialysis treatment for Patient #15. During an interview on 12/17/2025 at 7:45 AM, when questioned PCT 2 and PCT 6 about infection control practices and hanging tape off the dialysis chair tray, PCT 2 stated “No, we should not hang tape strips on the tray. I know I was doing it yesterday and stopped today.” PCT 6 communicated they were unaware they could not hang tape strips off the dialysis chair tray. When asked PCT 6 what could carry onto the tape from the air, PCT 6 indicated blood from other patients and germ particles. 6. On 12/17/2025 at 5:43 AM, observed RN 2 removing a black stethoscope from around their neck and auscultated Patient #15’s lung and heart sounds at Station #13. The bell of the stethoscope was not cleaned prior to contact with Patient #15. 7. On 12/17/2025 at 5:45 AM, observed RN 2 removing a black stethoscope from around their neck and auscultated Patient #14’s lung and heart sounds at Station #1. The bell of the stethoscope was not cleaned prior to contact with Patient #14. 8. On 12/17/2025 at 5:48 AM, observed RN 2 removing a black stethoscope from around their neck and auscultated Patient #17’s lung and heart sounds at Station #5. The bell of the stethoscope was not cleaned prior to contact with Patient #17. 9. On 12/17/2025 at 5:51 AM, observed RN 2 removing a black stethoscope from around their neck and auscultated Patient #13’s lung and heart sounds at Station #9. The bell of the stethoscope was not cleaned prior to contact Patient #13. 10. On 12/17/2025 at 6:00 AM, observed RN 2 removing a black stethoscope from around their neck and auscultated Patient #12’s lung and heart sounds at Station #10. The bell of the stethoscope was not cleaned prior to contact with Patient #12. 11. On 12/17/2025 at 6:05 AM, observed RN 2 removing a black stethoscope from around their neck and auscultated Patient #19’s lung and heart sounds at Station #7. The bell of the stethoscope was not cleaned prior to contact with Patient #19. 12. On 12/17/2025 at 6:09 AM, observed RN 2 removing a black stethoscope from around their neck and auscultated Patient #22’s lung and heart sounds at Station #4. The bell of the stethoscope was not cleaned prior to contact with Patient #22. During an interview on 12/17/2025 at 7:10 AM, when questioned about infection control and safe practices preventing infection when using their stethoscope carried around their neck between patients and if the bell should have been cleaned, RN 2 stated, “The bell should have been cleaned prior to using on each patient, and I didn’t.””

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 44232 Based on observation, record review, and interview, the facility failed to ensure equipment was not exposed to contamination in 4 of 5 observations of the treatment area. Findings Include: 1. A review of a DaVita Incorporated policy with a revision date of April 2018, titled “Physical Environment,” indicated but was not limited to, “ ... the building in which dialysis services are furnished will be constructed and maintained for safety of the patients, the teammates and the public ... The space for treating each patient will be ... provide needed care and services prevent cross contamination ... “ 2. On 12/15/2025 at 12:10 PM, observed during the flash tour two black stethoscopes on the surround wall unit shelf behind Station #6 and a box of large gloves on the surround wall unit behind Station #7, the isolation room. 3. On 12/15/2025 at 1:20 PM, observed during treatment area observations, two black stethoscopes on the surround wall unit shelf behind Station #6 and a box of large gloves on the surround wall unit behind Station #7, the isolation room. 4. On 12/17/2025 at 5:20 AM, observed during treatment area observations, two black stethoscopes on the surround wall unit shelf behind Station #6 and a box of large gloves on the surround wall unit behind Station #7, the isolation room. 5. On 12/17/2025 at 7:20 PM, observed during treatment area observations, two black stethoscopes on the surround wall unit shelf behind Station #6 and a box of large gloves on the surround wall unit behind Station #7, the isolation room. During an interview on 12/17/2025 at 7:40 AM, when asked about items being on the wall unit shelf behind stations and infection control, PCT 2 removed the stethoscopes from behind Station #6 and stated, “Nothing is to be on the ledge on the shelf of the wall unit.””

“IC-O-SIGHT-MONITOR ACTIVITY/IMPLEMENT P&P CFR(s): 494.30(b)(1) The facility must- (1) Monitor and implement biohazard and infection control policies and activities within the dialysis unit; This Standard is not met as evidenced by: 44232 Based on record review and interview, the facility failed to ensure employees had a 1st step and 2nd step baseline tuberculosis (TB) (a serious contagious disease affecting the lungs) skin test for 1 of 3 staff ( Employee: PCT 3) and a 2nd step baseline tuberculosis (TB) for 2 of 3 with direct contact with patients on the treatment floor for 3 of 3 staff’s personnel records reviewed. (Employees: PCT 2 and RN 2) Findings Include: 1. A review of a DaVita Inc. policy with a revision date April 2019, titled “ Teammate Health Monitoring Program” indicated but was not limited to, “ ... DaVita will regularly monitor teammates for infectious diseases according to current guidelines and/or recommendations established by the Centers for Disease Control ... DaVita will regularly monitor teammates for Hepatitis C, Hepatitis B as indicated on immunity status, and for tuberculosis infection ...” New teammates will be: Screened for Hepatitis B, Hepatitis C, and Tuberculosis ... “ 2. A review of a DaVita Inc. document titled “Teammate Health Monitoring Job Aid” indicated but was not limited to, “ ... New hire situation ... TB ... A. No previous TST [Tuberculosis Skin Test] 3 months before start date ... required tests TST 2 step ... B. Previous documented negative one-step, 3 months before start date ... required tests single TST ... Previous documented negative Two step TST or IGRA [Interferon-Gamma Release Assays] (a blood test measuring immune system’s response to TB specific antigens) required tests none ...Previous documented positive TST or IGRA required tests negative x-ray ... “ 3. A review of the personnel record for PCT 2, date of hire 04/01/2019, contained a DaVita Inc. document titled, “Tuberculin Skin Test (TST) PPD Mantoux Record” indicated initial dose administered 04/01/2019 at 8:45 AM, and date and time results read 0 millimeters (mm), listed 04/03/2019 at 9:15 AM. The section 2nd dose (two Step Only) had been left blank. The personnel record for PCT 2 failed to evidence a 2nd step TB Skin Test upon hire. A review of a DaVita Inc. document titled “Tuberculosis Risk Appraisal Questionnaire” dated 06/24/2025, and signed by PCT 2 and a licensed teammate, contained completed symptom screening questions, but had left blanks for the risk assessment questions. 4. A review of the personnel record for PCT 3, date of hire 06/01/2017, failed to evidence a 1st or 2nd step TB Skin test. A review of a DaVita Inc. document titled “Tuberculosis Risk Appraisal Questionnaire” dated 10/23/2025, and signed by PCT 3 and a licensed teammate, contained completed symptom screening questions, but had left blanks for the risk assessment questions. 5. A review of the personnel record for RN 2, date of hire 02/21/2021, contained a DaVita Inc. document titled, “Tuberculin Skin Test (TST) PPD Mantoux Record” indicated initial dose administered 02/23/2021 at 3:35 PM, and date and time results read 0.1 millimeters (mm), listed 02/25/2021 at 3:00 PM. The section 2nd dose (two Step Only) had been left blank. The personnel record for RN 2 failed to evidence a 2nd step TB Skin Test upon hire. During an interview on 12/16/2025 at 2:41 PM, when questioned regarding the facilities policy regarding direct care staff being tested for TB and process, the FA reported upon review it is the DaVita policy to require a 1st and 2nd TB test for all direct care staff upon hire, then a yearly risk assessment questionnaire were to be completed.”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 44232 Based on observation, record review, and interview, the agency failed to ensure the safety of the patients and staff, as noted over 3 of 4 observations of the supply and water room areas. Findings include: 1. A review of a DaVita Inc. policy with a revision date April 2018, titled “Physical Environment” indicated but was not limited to “ ... The dialysis facility will be ... maintained to provide dialysis patients, teammates, and the public a safe, functional, and comfortable treatment environment ... “ 2. On 12/15/2025 at 12:00 PM, during a flash tour observed in the supply room an empty plastic container, 5 empty oxygen tanks, and 2 boxes on the floor in front of a wooden flat beside the door leading outside. During an interview on 12/15/2025 at 12:03 PM, the Biomed Technician, communicated the empty oxygen tanks were there at the back door for pick up, and confirmed items should be stored on flats, not on the floor. 3. On 12/15/2025 at 12:05 PM, during a flash tour of the water room observed 2 bags of salt on the floor beside the brine tank and the flat of salt bags. When question about items being stored on the floor, the Biomed Technician stated, “No ma’am salt bags should not be on the floor.” 4. On 12/17/2025 at 4:45 AM observed 3 boxes and a plastic container on the floor, in front of the back door of the supply room. When questioned about the boxes and plastic container being on the floor, PCT 2 moved the boxes and container and stated, “No, nothing is to be in front of the door or on the floor.””