Davita Carlisle Regional Dialysis

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 39671 Based on treatment area observations, and an interview with the facility Administrator, it was determined failed to ensure all liquids in the patient treatment areas were labeled and contained lids for one (1) of one (1) container observations. (Container Observation #1) and failed to ensure staff members maintained a clean treatment area for one (1) of three (3) Treatment Area Observations. (Treatment Area Observation # 1) Findings: Policy regarding labeling liquids was request. No policy was provided. Observations conducted in the patient treatment area on April 14, 2025 between approximately 9:47 a.m. and 4:07 p.m. revealed the following: Container Observation #1: On April 14, 2025 at approximately 8:37 a.m. surveyor observed a clear pitcher with a clear liquid. The container did not have any label identifying what the liquid inside the pitcher was and no label that included the date, time and initials of the individual that filled the pitcher. Treatment Area Observation # 1: On April 14, 2025 at approximately 3:58 p.m. Surveyor observed gloves, used facemasks, scrapes of paper, and caps from supplies on the treatment area floor, including around dialysis stations, under dialysis machines and under dialysis chairs. Surveyor asked employees to clean up the trash on the treatment floor. Employee # 4 cleaned up a few pieces and then stopped. Surveyor was told by employee # 4 stated, “We are told to just leave it. We are also sent home during turnover at times because we are constantly told about the budget.” Employee #3 verbalized agreement with employee # 4’s statement. An interview with the facility Administrator on April 15, 2025 at approximately 2:00 p.m. confirmed the above findings.”

“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: 39671 Based on treatment area observations, and an interview with the facility Administrator (EMP# 1), it was determined the facility failed to ensure the staff followed infection control protocols, included but not limited to, hand hygiene/don clean gloves for one (1) of four (4) ‘Cleaning and Disinfection of the Dialysis Station’ observations. (Cleaning and Disinfection of the Dialysis Station Observation #3) and for one (1) of three (3) treatment area observations (Treatment Area Observation # 2) Findings: A review was conducted of facility policy titled, ‘Infection Control for Dialysis Facilities 1-05-01’ on April 14, 2025 at approximately 12:00 p.m. ‘Hand Hygiene’ section, reads, “...1. All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene...b. prior to gloving and immediately after removal of gloves, c. after contamination with blood or other infectious material, d. after patient and dialysis delivery system contact...” Observations conducted in the patient treatment area on April 14, 2025 between approximately 9:47 a.m. and 4:07 p.m. revealed the following: Cleaning and Disinfection of the Dialysis Station Observation #3: On April 14, 2025 at approximately 10:22 a.m. employee #4 failed to remove gloves, perform hand hygiene and don clean gloves after emptying prime waste receptacle and before disinfecting and wiping the dialysis machine. Treatment Area Observation # 2: On April 14, 2025 at approximately 11:50 employee # 5 removed gloves, went into isolation room, used a glove to push a button on dialysis machine in the isolation room. Employee failed to perform hand hygiene after removing gloves and prior to donning on clean gloves. An interview with the facility Administrator on April 15, 2025 at approximately 2:00 p.m. confirmed the above findings.”

“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: 39671 Based on treatment area observations, and an interview with the facility Administrator (EMP# 1), it was determined the facility failed to ensure the staff followed infection control protocols, included but not limited to, using clean bleach soaked wipes to disinfect dialysis equipment for one (1) of four (4) ‘Cleaning and Disinfection of the Dialysis Station’ observations. (Cleaning and Disinfection of the Dialysis Station Observation #4) Findings: A review was conducted of facility policy titled, ‘Infection Control for Dialysis Facilities 1-05-01’ on April 14, 2025 at approximately 12:00 p.m. ‘Disinfection’ section, reads, “...b. Use an appropriate disinfectant such as 1:100 (one to one hundred) bleach solution for routine disinfection of environmental surfaced...” Observations conducted in the patient treatment area on April 14, 2025 between approximately 9:47 a.m. and 4:07 p.m. revealed the following: Cleaning and Disinfection of the Dialysis Station Observation #4: On April 14, 2025 at approximately 3:18 p.m. surveyor observed employee # 4 drop bleach wipes on the floor at station # 1, pick up the wipes and then proceed to wipe dialysis machine. Surveyor requested that employee # 4 get new bleach wipes. Employees #4 stated to surveyor “I don’t understand why, it has bleach on it. It doesn’t make any sense why I need to get new bleach wipes.” An interview with the facility Administrator on April 15, 2025 at approximately 2:00 p.m. confirmed the above findings.”

“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: 39671 Based on a review of facility policy/procedure, treatment area observations, and an interview with the facility Administrator, the facility failed to ensure medications were labeled appropriately for one (1) of one (1) medication observations. (Observation #1). Findings: A review was conducted of facility policy titled, ‘Medication Policy 1-06-01’ on April 14, 2025 at approximately 1:00 p.m. ‘Policy’ section, reads, “...20. If the medication is not immediately administered or is to be administered by another teammate, the medication must be labeled with the patient name, name of medication, date, time prepared, dose and initials of teammate preparing the medication...” Observations conducted in the patient treatment area on April 14, 2025 between approximately 9:47 a.m. and 4:07 p.m. revealed the following: Medication Observation #1: Observation #1: On April 14, 2025 at approximately 8:34 a.m. the following was observed on top of the medication station countertop: - One (1) prefilled syringe with Heparin Pork 1,500 units for patient # 1- the section on the label that read, ‘initials’ and ‘time” was left blank. - One (1) prefilled syringe with Heparin Pork 1,600 units for patient # 1- the section on the label that read, ‘initials’ and ‘time” was left blank. - One (1) prefilled syringe with Heparin Pork 1,600 units CVC Venous for patient # 2- the section on the label that read, ‘initials’ and ‘time” was left blank. - One (1) prefilled syringe with Heparin Pork 1,600 units CVC Arterial for patient # 2- the section on the label that read, ‘initials’ and ‘time” was left blank. - One (1) prefilled syringe with Heparin Pork 2,000 units for patient # 2- the section on the label that read, ‘initials’ and ‘time” was left blank. - One (1) prefilled syringe with Heparin Pork 2,100 units for patient # 2- the section on the label that read, ‘initials’ and ‘time” was left blank. - One (1) prefilled syringe with Heparin Pork 1,800 units CVC Venous for patient # 3- the section on the label that read, ‘initials’ and ‘time” was left blank. - One (1) prefilled syringe with Heparin Pork 1,800 units CVC Arterial for patient # 3- the section on the label that read, ‘initials’ and ‘time” was left blank. - One (1) prefilled syringe with Heparin Pork 1,800 units CVC Venous for patient # 6- the section on the label that read, ‘initials’ and ‘time” was left blank. - One (1) prefilled syringe with Heparin Pork 1,800 units CVC Arterial for patient # 6- the section on the label that read, ‘initials’ and ‘time” was left blank. - One (1) prefilled syringe with Heparin Pork 2,500 units for patient # 6- the section on the label that read, ‘initials’ and ‘time” was left blank. - One (1) prefilled syringe with Heparin Pork 1,800 units CVC Venous for patient # 7- the section on the label that read, ‘initials’ and ‘time” was left blank. - One (1) prefilled syringe with Heparin Pork 1,800 units CVC Arterial for patient # 7- the section on the label that read, ‘initials’ and ‘time” was left blank. - One (1) prefilled syringe with Heparin Pork 2,600 units for patient # 11- the section on the label that read, ‘initials’ and ‘time” was left blank. - One (1) prefilled syringe with Heparin Pork 2,100 units for patient # 11- the section on the label that read, ‘initials’ and ‘time” was left blank. - One (1) prefilled syringe with Heparin Pork 1,800 units CVC Venous for patient # 12- the section on the label that read, ‘initials’ and ‘time” was left blank. - One (1) prefilled syringe with Heparin Pork 1,800 units CVC Arterial for patient # 12- the section on the label that read, ‘initials’ and ‘time” was left blank. - One (1) prefilled syringe with Heparin Pork 1,600 units CVC Venous for patient # 13- the section on the label that read, ‘initials’ and ‘time” was left blank. - One (1) prefilled syringe with Heparin Pork 1,600 units CVC Arterial for patient # 13- the section on the label that read, ‘initials’ and ‘time” was left blank. - One (1) prefilled syringe with Heparin Pork 1,000 units for patient # 13- the section on the label that read, ‘initials’ and ‘time” was left blank. - One (1) prefilled syringe with Heparin Pork 1, 200 units for patient # 13- the section on the label that read, ‘initials’ and ‘time” was left blank. An interview with the facility Administrator on April 15, 2025 at approximately 2:00 p.m. confirmed the above findings.”

“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: 39671 Based on treatment area observations, and an interview with the facility Administrator (EMP# 1), it was determined the facility failed to ensure the staff followed infection control protocols, included but not limited to, no food or drink in the patient treatment area for one (1) of three (3) treatment area observations (Treatment Area Observation # 3) Findings: A review was conducted of facility policy titled, ‘Infection Control for Dialysis Facilities 1-05-01’ on April 14, 2025 at approximately 12:00 p.m. ‘Facility Hygiene’ section, reads, “...17. Food and drinks in the treatment area will be limited to patients....” Observations conducted in the patient treatment area on April 14, 2025 between approximately 9:47 a.m. and 4:07 p.m. revealed the following: Treatment Area Observation # 3: On April 14, 2025 at approximately 8:44 a.m. surveyor observed a water bottle sitting on the nurse’s station desk. Surveyor asked whose water bottle it was and employee # 4 replied, “It’s mine.” and removed the water bottle from the treatment floor. An interview with the facility Administrator on April 15, 2025 at approximately 2:00 p.m. confirmed the above findings.”