Davita Town and Country West 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: 17026 Based on observations and staff interview, the facility staff failed to wear gloves when they adjusted the dialysis machines or failed to change their gloves and sanitize their hands in between changing gloves during four observations in the dialysis treatment area. This had the potential to effect all patients on dialysis and cause an increase in cross contamination and infection risk. The facility census was 78. Findings included: 1. Observation on 6/3/25 at 8:37 AM showed staff (E) adjusted the dialysis machine at station # 5 without gloves on her hands. 2. Observation on 6/2/25 at 1:35 PM showed staff (B) adjusted the dialysis machine at station # 6 and then adjusted the dialysis machine at station # 5 without changing gloves or sanitizing her hands in between changing gloves. 3. Observation on 6/2/25 at 1:09 PM showed staff (C) assisted the patient at station # 5. Staff (C) then changed her gloves but did not sanitize her hands in between changing gloves, and started disinfecting station # 1. 4. Observation on 6/2/25 at 1:12 PM showed staff (C) adjusted the dialysis machine at station # 2 and then returned to disinfecting station # 1 without changing gloves or sanitizing her hands. 5. During an interview on 6/4/25 at 2:50 PM, the facility administrator said staff should wear gloves when they adjust the dialysis machines and they should change their gloves and sanitize their hands when going from one dialysis machine to another.”

“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: 17026 Based on observations and staff interview, the facility staff failed to ensure medications and residual test strips were not expired, and staff failed to date and initial when they opened two heparin (medication used to prevent blood clots) vials to know when it needed to be discarded. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 78. Findings included: 1. Observation on 6/2/25 at 11:21 AM of the water room showed a container of approximately 30 residual test strips that expired 3/20/25. 2. Observation on 6/2/25 at 11:38 AM of the dialysis treatment area showed an approximately half full vial of heparin not initialed or dated when staff opened the vial. 3. Observation on 6/2/25 at 11:51 AM of the home dialysis medication area showed 2 units of epinephrine (medication used to treat severe allergic reactions) 0.3 milligrams that expired 2/28/25. 4. Observation on 6/3/25 at 8:44 AM of the dialysis treatment area showed an approximately three fourths full vial of heparin not initialed or dated when staff opened the vial. 5. During an interview on 6/3/25 at 1:55 PM, the facility administrator said staff need to ensure supplies and medications were not expired, and staff also need to initial and date when they open heparin vials.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 17026 Based on record review and staff interview, the facility staff failed to follow the physician order for the dialysate flow rate or blood flow rate for two (Patient # 18 and # 24) patients out of eight clinical records reviewed. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 78. Findings included: 1. Review of the treatment flow sheet dated 5/31/25 for Patient # 18 showed the physician directed staff to set the dialysate flow rate at 800, but staff set the dialysate flow rate at 600 for the patient’s dialysis treatment. 2. Review of the treatment flow sheet dated 5/27/25 for Patient # 18 showed the physician directed staff to set the blood flow rate at 450, but staff set the blood flow rate at 400 for the patient’s dialysis treatment. 3. Review of the treatment flow sheet dated 5/31/25 for Patient # 24 showed the physician directed staff to set the dialysate flow rate at 800, but staff set the dialysate flow rate at 600 for the patient’s dialysis treatment. 4. During an interview on 6/3/25 at 1:55 PM, the facility administrator said staff should follow the physician order for the dialysate flow rate and blood flow rate.”

“PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This Standard is not met as evidenced by: 17026 Based on record review and staff interview, the facility staff failed to complete the nursing assessment portion of a care plan within 30 days of a patient starting on dialysis services for three (Patient # 2, # 24, and # 32) patients out of eight clinical records reviewed. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 78. Findings included: 1. Review of the clinical record for Patient # 24 showed the patient started on dialysis services on 3/6/25 but staff did not complete the nursing assessment portion of the 30 day care plan for the patient. 2. Review of the clinical record for Patient # 2 showed the patient started on dialysis services on 4/7/25 but staff did not complete the nursing assessment portion of the 30 day care plan for the patient. 3. Review of the clinical record for Patient # 32 showed the patient started on dialysis services on 4/23/25 but staff did not complete the nursing assessment portion of the 30 day care plan for the patient. 4. During an interview on 6/3/25 at 1:55 PM, the facility administrator said staff did not complete the nursing assessment portion of the care plan for a few patients, but staff should complete that within 30 days of a patient starting on dialysis treatment.”

“PA-F/U REASSESSMENT-WITHIN 3 MO OF INITIAL CFR(s): 494.80(b)(2) A follow up comprehensive reassessment must occur within 3 months after the completion of the initial assessment to provide information to adjust the patient’s plan of care specified in §494.90. This Standard is not met as evidenced by: 17026 Based on record review and staff interview, the facility staff failed to complete the nursing assessment portion a care plan within 90 days of completing the 30 day care plan for two (Patient # 15 and # 17) patients out of eight clinical records reviewed. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 78. Findings included: 1. Review of the clinical record for Patient # 15 showed the patient started on dialysis services on 12/4/24, but staff did not complete the nursing assessment portion of a care plan within 90 days after they completed the 30 day care plan for the patient. 2. Review of the clinical record for Patient # 17 showed the patient started on dialysis services on 1/4/25, but staff did not complete the nursing assessment portion of a care plan within 90 days after they completed the 30 day care plan for the patient. 3. During an interview on 6/3/25 at 1:55 PM, the facility administrator said staff were behind on the nursing assessment portion of the care plan for some patients.”

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 17026 Based on record review and staff interview, the facility failed to complete a monthly care plan for one (Patient # 28) of one applicable patient’s determined by facility staff to be unstable. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 78. Findings included: 1. Review of the medical record for Patient # 28 showed staff completed the most recent care plan for the patient on 2/6/25. Further review of the clinical record showed staff determined the patient to be unstable due to hospitalizations, significant change, and a decline in health status, but staff did not complete a monthly care plan for the patient in March, April, or May of 2025. 2. During an interview on 6/3/25 at 1:55 PM, the facility administrator said staff determined the patient to be unstable a few months ago after the patient had a significant change, hospitalizations, and a decline in health status. She said staff should complete a monthly care plan for patients determined to be unstable.”