Davita Capital City Dialysis

“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: 49530 Based on record review, review of the facility’s policies and procedures, observations, and staff interviews, the facility failed to identify and remove expired supplies from the supply storage room, the pack room (room used to bundle hemodialysis (HD) supplies), and the home peritoneal dialysis (HPD) training rooms. This failed practice had the potential to affect all 48 in-center hemodialysis (ICHD) patients and all 6 HPD patients on census to expired supplies. Findings are: A. Review of the facility’s policy titled Infection Control for Dialysis Facilities, dated 4/2023, revealed all supplies will be checked for expiration dates prior to use. B. Observation of the supply storage room on 1/20/26 at 11:25 AM, revealed 54, 22 Gauge x 1 ½ inch (size of needle) Eclipse needles, with an expiration date of 12/31/25. C. Observation of the pack room on 1/20/26 at 11:30 PM, revealed 23, 17 Gauge 1.5 X 300 mm (size of a needle) Nipro safety fistula needles (used for vascular access for hemodialysis), with an expiration date of 10/31/25. D. Observation of HPD training room 1, on 1/20/26 at 3:00 PM, revealed 1 box of 44 Band-Aids with an expiration date of 12/4/25. E. Observation of HPD training room 2, on 1/20/26 at 3:00 PM, revealed 1 Clearguard HD cap (antimicrobial barrier cap to prevent bloodstream infections), with an expiration date of 12/1/25. F. Review of the facility’s 2025 expiration log, used for monitoring expired supplies, revealed Eclipse injection 22 Gauge needles expired 12/2025. G. During staff interview on 1/21/25 at 9:50 AM, the Administrator Assistant (AA, Staff K), confirmed the AA is responsible for monitoring supplies for expiration dates for supplies in the supply storage room and documents expiration dates on an expiration log. Patient Care Technicians (PCTs) bundle the HD supplies in the pack room. The PCTs take supplies from the supply storage room to the pack room. The AA does not monitor the supplies in the pack room or the HPD training rooms. H. During staff interview on 1/21/26 at 12:30 PM, the Facility Administrator (FA, Staff L) confirmed: 1. The existence of expired supplies in the supply storage room, pack room, and the 2 HPD training rooms. 2. The AA monitors expiration dates for supplies in the supply storage room, documents expiration dates on the expiration log and submits the log to the FA. 3. The HPD training nurse is responsible for monitoring supplies for expiration dates in the HPD training rooms. 4. The agency failed to have a process for monitoring the supplies for expiration dates in the pack room.”

“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: 49530 Based on review of the facility’s policies and procedures, observations, and staff interviews, the facility failed to: 1. Maintain the cleanliness of the cabinetry in the hemodialysis (HD) treatment area and the home peritoneal dialysis (HPD) training rooms. 2. Maintain cleanliness of the refrigerators in the HD treatment area. 3. Have a written process to ensure cleanliness of the HD treatment area and the HPD training rooms. These failed practices had the potential to increase the risk for growth of infectious organisms with the potential for affecting the health and safety of staff and all 48 HD patients and all 6 HPD patients on census. Findings are: A. Review of the facility policy titled Physical Environment, dated 4/2018, revealed the building in which dialysis services are furnished will be maintained for the safety of patients and staff. B. Tour of the patient HD treatment area on 1/20/26 at 8:30 AM, revealed: 1. The inside cabinetry appeared dusty throughout. 2. The medication refrigerator (used to store medication requiring refrigeration) had brown debris on the bottom shelf. 3. The laboratory refrigerator (used to store blood products prior to shipment for analysis) had dark brown debris on the bottom shelf and the freezer on top had a thick layer of frost on all sides. C. Tour of the PD training rooms 1 and 2 on 1/20/26 at 3:00 PM revealed the inside cabinetry appeared dusty and dirty throughout. D. During staff interview on 1/20/26 at 10 AM, the Facility Administrator (FA, Staff L) confirmed the HD treatment area’s inside cabinetry, the medication refrigerator, and the lab refrigerator were dirty and needed cleaning, and the lab freezer had frost on all sides and needed defrosting. In addition, the FA confirmed the facility failed to have a written process to monitor these areas for cleanliness. E. During staff interview on 1/21/26 at 4:00 PM, the HPD training nurse (Staff B), and the FA, confirmed the inside cabinetry of HPD training rooms 1 and 2 were dusty and dirty and needed cleaning, and confirmed the facility failed to have a written process to monitor the HPD training rooms 1 and 2 for cleanliness.”