Davita Brown Street Dialysis

“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: 49974 Based on review of facility policies/procedures and personnel files, observational tour, and based on interview with the Facility Administrator, the facility failed to ensure the hemodialysis (HD) chair was properly disinfected during the disinfection process performed by one (1) of six (6) Patient Care Technician (PCT). PCT#3. Findings include: On September 26, 2025 at approximately 12:00 PM, review of the facility revealed the following: Policy: 1-05-01 Title: Infection Control for Dialysis Facilities Purpose: To minimize the spread of infections or bloodborne pathogens in the dialysis facility environment. Policy: The Centers for Disease Control (CDC) Recommendations for Preventing Transmission of Infections among Chronic Hemodialysis Patients (Dialysis Precautions) will be followed when caring for all patients. Disinfection 12. Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infectious materials (i.e. used or brought into the station) and prior to returning to clean/designated area or removal from treatment area. a. Prior to routine disinfection, remove all visible blood i. For visible blood or gross blood spills, a 1:10 (one to ten) bleach solution must be utilized. 13. At the end of each treatment, the dialysis station will be cleaned and disinfected. a. Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings (e.g., dialysis chair, tray tables, blood pressure cuffs) and frequently contacted by healthcare personnel (e.g., control panel; top, front and sides of dialysis machine; touchscreens; countertops)..... During observational tour conducted between September 23, 2025 from approximately 10:00 AM - 2:35 pm and September 24, 2025 from approximately 9:00 AM - 11:00 AM revealed the following: PCT #3: During the HD machine disinfection process performed at Station #7 on September 23, 2025 at approximately 2:00 PM, the PCT failed to properly disinfect the dialysis chair. PCT failed to open the sides of the chair to disinfect properly. During interview on September 26, 2025 at approximately 2:00 PM, the Facility Administator, Operations Director, Group Facility Administrator and Service Specialist confirmed that the HD dialysis chair should be disinfected properly, including opening up the sides of the chair should be completed after each patient treatment.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 49974 Based on reviews of observations, facility policy, and an interview with the facility administrator, the facility failed to ensure proper inventory control. Findings include: Review of facility policy on September 26, 2025 at approximately 12:00 pm revealed the following: Policy: 4-07-01 TITLE: FACILITY EMERGENCY MANAGEMENT PLAN (ICHD, HOME) Emergency Evacuation Kit 1. Each facility will maintain an evacuation kit(s) with specified patient care supplies for use in case of an emergency evacuation. Facilities with home modalities may share Kit if: a. Easily accessible by both in-center and home modality teammates b. If not, home modality will be required to maintain a separate kit(s) 2. The contents of the evacuation kit(s) will include, at a minimum, enough supplies to provide care for a full shift of patients, including home patients, likely to be present in the facility at any given time. a. Only to provide immediate patient care after an evacuation of the facility b. For large facilities, more than one (1) evacuation kit may be required c. Refer to Emergency Evacuation Kit Checklist 3. The evacuation kit(s) should be portable, made of sturdy material, and easy to transport a. Larger facilities should consider using a container that is mobile with wheels 4. The evacuation kit(s) will be maintained in a central location, such as the nurses ’ station and clearly labeled “ Evacuation Kit “ . It will be clean, free of dust, dirt, etc. 5. Each facility shall designate specific teammates responsible for ensuring the evacuation kit(s) are removed during an emergency evacuation. 6. Each evacuation kit(s) should contain: a. Copy of each patient ’ s treatment orders and medication list. FA or designee will verify patient information is updated and replaced at least monthly. b. A copy of the facility EMP. Replace with updated plan as needed. c. A roster of all facility teammate ’ s emergency contact information. Update information as needed. d. A copy of the physician contact roster. Update information as needed. 7. FA or designee will review the contents of the kit(s) and replace missing or expired supplies at least monthly. 8. Evacuation kit will be sealed with a breakaway lock and is only to be opened in the event of an emergency situation, monthly review, and/or the replacement of an outdated item. 9. FA or designee shall assign teammate(s) to transport kit(s) to appropriate safe area. Refer to Emergency Evacuation Worksheet 10. Any changes to supply list for Emergency Evacuation Kit must be approved by Governing Body and documented. Observations conducted on the facility patient floor on September 22, 2025 at 10:40 am revealed the following: The following items were located in the medication room in a drawer titled: 1CC Needles” at approximately 11:15 am: Twelve (12) alcohol prep pads with an expiration date of 6/2024. Three (3) 25 gauge hypodermic needles with an expiration date of 2/29/2024. The following items were located on the “B” side of the treatment floor in the supply drawer at approximately 12:20 pm: Six (6) providone-iodine prep pad with an expiration date of 3/15/2025 and one (1) with an expiration date of 12/10/2024. The following expired item was found in Emergency Box #2 at approximately 12:50 pm - One (1) bag of 0.9% Normal Saline Solution with an expiration date of 5/2025. The following expired items were located in the Isolation Room at approximately 1:30 pm: Seven (7) single use Triple Antibiotic Ointment packets with an expiration date of 8/2025 and one (1) with an expiration date of 3/2024. A Luer Lock Cap with an expiration date of 10/9/2021 and a Recirculation Line Connector with an expiration date of 3/31/2025. During interview on September 26, 2025 at approximately 2:00 PM, the Facility Administator, Operations Director, Group Facility Administrator and Service Specialist confirmed the above findings.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 49974 Based on a review of facility policy, observations of the treatment area, and an interview with the Clinical Manager and the Administrator, the facility failed to follow its policy regarding assessment and monitoring of patient’s access site for five (5) patients of twenty (20) patients observed while receiving incenter hemodialysis. (Patients at station #7, 9, 11, 13 and 27) Findings include: A review of facility policy conducted on September 26, 2025 at approximately 12:00 PM states: Policy: 1-03-08 TITLE: PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT PURPOSE: To obtain and document baseline and ongoing information about the patient before, during and after the dialysis treatment through data collection and nursing assessment. This information will be used in planning and documenting the patient ’ s dialysis treatment, monitoring during treatment and for reviewing the patient ’ s response to the treatment and status prior to discharge. 2. The Nursing assessment will be performed and documented by a licensed nurse; specifically, a Registered Nurse (RN) or if performance of a nursing assessment is permitted by state law, a Licensed Practical Nurse (LPN) / Licensed Vocational Nurse (LVN). a. The assessment includes the following components: i. Review of patient reports, data collection, complaints and response to treatment.... iv. Verification that the patient access is visible and face is not covered INTRADIALYTIC DATA COLLECTION/ASSESSMENT c. The vascular access site, blood line connections and the patient ’ s face should be visible throughout the dialysis treatment. During an observation conducted on 9/23/2025 at approximately 10:10 am revealed the following: Patients assigned to seat #7, 9 and 13 had sites covered. Patient assigned to seat #27 was covered from head to toe with a blanket. During an observation conducted on 9/24/2025 at approximately 10:20 am - patient assigned to seat #11 had the site covered. Staff did not redirect patients about the importance of being visible during treatment. Site remained covered throughout the remaining duration of their treatment. During interview on September 26, 2025 at approximately 2:00 PM, the Facility Administator, Operations Director, Group Facility Administrator and Service Specialist confirmed that the staff should instruct the patients about having the sites and the patient visible for the duration of the treatment, as per facility policy.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 49974 Based on a review of facility policy, medical records (MR), and an interview with the facility administrator, the facility did not follow its policy for patient assessment and monitoring for four (4) of seven (7) MRs reviewed, (MR # 1,2, 4 and 6). Findings include: A review of facility policy conducted on September 26, 2025 at approximately 12:00 PM states: Policy: 1-03-08 TITLE: PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT PURPOSE: To obtain and document baseline and ongoing information about the patient before, during and after the dialysis treatment through data collection and nursing assessment. This information will be used in planning and documenting the patient ‘s dialysis treatment, monitoring during treatment and for reviewing the patient ‘s response to the treatment and status prior to discharge. INTRADIALYTIC DATA COLLECTION/ASSESSMENT c. The vascular access site, blood line connections and the patient ’ s face should be visible throughout the dialysis treatment. 11. Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately (refer to “ Abnormal Findings “ section in this policy). The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. POST TREATMENT DATA COLLECTION/ASSESSMENT 16. If an abnormal finding(s) or concern is identified post treatment, this needs to be reported to the licensed nurse. The licensed nurse will assess the patient prior to discharge. ABNORMAL FINDINGS Unless other abnormal parameters are established by the facility Governing Body and documented in the Governing Body Meeting minutes, the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient ’ s medical record. Within each category, definitions may be adjusted by a patient specific physician order. In addition, the teammate who is observing or collecting information should report to the licensed nurse whenever there is concern for the patient ’ s condition or the potential safety of initiating dialysis, even in the absence of specific abnormal findings. Members of the patient care team should report ANY changes in patient conditions or concerns of patient well-being immediately to the licensed nurse at any time. Blood pressure: Pre-dialysis: Systolic greater than 180 mm/Hg or less than 90 mm/Hg Diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg Blood Pressure-Intradialytic: Systolic greater than 180 mm/Hg or less than 90 mm/Hg Diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg Blood Pressure Post Treatment: If the patient can stand: Standing systolic BP greater than 140 mm/Hg or less than 90 mm/Hg Standing diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg If patient is not able to stand, document reason and sitting BP Sitting BP for patient ’ s that cannot stand: Sitting systolic BP greater than 140 mm/Hg or less than 90 mm/Hg Sitting diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg Heart or Pulse Rate Pre/Intra/Post: Less than 60 beats per minute or greater than 100 beats per minute and/or an irregular heart beat A review of Medical Record (MR) was conducted on September 24, 2025 at approximately 9:30 AM. MR#1 - Start of Care - 10/13/2020 9/13/2025 indicated the following blood pressure readings: 177/114 at 10:45 am- PCT indicated the following note: Treatment started without complications 160/110 at 11:16 am - PCT indicated the following note: Patient face; vascular access; and blood line connections visible. No documentation throughout treatment that the Nurse was informed about the elevated blood pressure readings. 9/16/2025 indicated the following blood pressure reading: 136/106, HR: 43 at 14:20 - PCT indicated the following note: Treatment terminated. No documentation that the Nurse was informed about the elevated blood pressure reading obtained. MR#2 - Start of Care - 10/26/2023 9/16/2025 indicated the following blood pressure readings: 187/93 at 7:47 am- PCT indicated the following note: Patient appears to be tolerating treatment well at this time. 204/102 at 8:16 am PCT indicated the following note: Patient appears to be tolerating treatment well at this time. 202/100 at 8:48 am- PCT indicated the following note: Patient appears to be tolerating treatment well at this time. 208/97 at 9:08 am - PCT indicated the following note: Treatment terminated. No documentation throughout treatment that the Nurse was informed about the elevated blood pressure readings. 9/18/2025 indicated the following blood pressure readings: 186/92 at 8:57 am - PCT indicated the following note: Patient monitored; watching tv no complications 180/92 at 9:27 am - PCT indicated the following note: Patient appears to be tolerating treatment well at this time. 192/97 at 9:30 am - PCT indicated the following note: Treatment terminated. No documentation throughout treatment that the Nurse was informed about the elevated blood pressure readings. MR#4 - Start of Care - 10/13/2020 9/9/2025 indicated the following blood pressure reading: 99/44 at 7:31 am - PCT indicated the following note: Patient blood pressure low; Patient monitored eyes closed; patient resting 95/43 at 7:32 am - PCT indicated the following note: BP rechecked; BP still low; UF decreased to 3.0 kg; Patient no c/o at this time. No documentation during treatment that the Nurse was informed about the decrease blood pressure. 9/13/2025 indicated that following blood pressure reading: 191/70 at 5:00 am - PCT indicated the following note: Treatment started without complications: Patient face; vascular access; and blood line connections visible; Patient blood pressure is elevated; pt states she took home bp meds prior to tx 184/58 at 5:01 am - PCT indicated the following note: Patient access cannulated with difficulty; Patient blood pressure is elevated No documentation during treatment that the Nurse was informed about the elevated blood pressure. 9/18/2025 indicated the following blood pressure reading: 189/74 at 8:05 am - PCT indicated the following note: Patient awake; alert; and states no complaints at this time 185/97 at 9:02 am - PCT indicated the following note: Patient monitored; watching tv no complications 211/106 at 9:17 am - PCT indicated the following note: Treatment terminated; rechecking bp. No documentation that the Nurse was informed about the blood pressure and no notes from the nurse in the post assessment regarding the elevated blood pressure. MR#6 - Start of Care - 9/16/2025 9/16/2025 indicated the following blood pressure readings: 84/43 at 11:11 am - PCT indicated the following note: UF off. Pt resting. 89/54 at 11:13 am - PCT indicated the following note: rechecked. 61/39 at 12:20 pm - PCT indicated the following note: rechecking. No documentation that the Nurse was informed about the abnormal blood pressure readings. 9/18/2025 indicated the following blood pressure readings: 103/44 at 11:26 am - PCT indicated the following note: Patient appear to be tolerating treatment well at this time 102/45 at 12:30 pm - PCT indicated the following note: Patient awake; alert; and states no complaints at this time; dialyzer reset and treatment restarted No documentation that the Nurse was informed about the abnormal blood pressure readings. No nursing post assessment was documented for 9/18/2025 for this patient. During interview on September 26, 2025 at approximately 2:00 PM, the Facility Administator, Operations Director, Group Facility Administrator and Service Specialist confirmed the above findings and indicated that the nurse should be informed about abnormal vital signs and should perform an assessment on the patient.”

“POC-MANAGE ANEMIA/H/H MEASURED Q MO CFR(s): 494.90(a)(4) The interdisciplinary team must provide the necessary care and services to achieve and sustain the clinically appropriate hemoglobin/hematocrit level. The patient’s hemoglobin/hematocrit must be measured at least monthly. The dialysis facility must conduct an evaluation of the patient’s anemia management needs. This Standard is not met as evidenced by: 46632 Based on a review of medical records (MR), and an interview with the facility administrator, the facility did not provide the necessary care and services to achieve and sustain the clinically appropriate hemoglobin/hematocrit level for one (1) of one (1) MR. MR#1. Findings include: A review of MRs was conducted on June 13, 2024 at approximately 8:37 AM. MR # 1 Admission date: 12/9/2024. Limited Encounter dated 5/23/24 Nurse Practitioner, Assessment and Plan : Anemia, Monitor Hemoglobin weekly.Comprehensive Encounter by Medical Director on 6/4/24 Assessment and Plan : Anemia, Goal for hemoglobin will be 10-12: waste blood for hemoglobin > 12. Check hemoglobin weekly. A review of lab results on June 13, 2024 at approximatley 9:54 a.m. revealed the following: . There was no hemoglobin result for the week of 5/5/25- 5/11/24. An interview with the facility administrator conducted on July 1, 2024 at 2:20 pm confirmed the above findings.”