Davita North Jackson 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: 49570 Based on review of facility policy, observation, and interview, the facility failed to ensure a sanitary environment was maintained in order to minimize the risk of transmission of infectious agents. This deficient practice had the potential to place all patients at risk for cross-contamination and healthcare-associated infections. The findings included: 1. Review of facility policy, “Infection Control For Dialysis Facilities,” revised April 2023 revealed, “To minimize the spread of infections ...8. Supplies will be stored in a manner that maintains their integrity ...Expiration date ...will be verified prior to use ...Supplies will not be opened until time of use ...” 2. Observations on the treatment floor on 07/29/2025 beginning at 10:30 AM revealed the following items in a drawer at nurses’ station #3: “ One (1) 10 mL syringe with 4.5 mL of 0.9% Normal Saline left “ One (1) used/empty 10 mL 0.9% Normal Saline syringe “ Two (2) contaminated blue masks The above items were confirmed by Teammate #2 at 10:36 AM. “ One (1) bottle of pH Test Strips were found at Station #14 at 10:37 AM - Expiration date: 06/30/2024 “ One (1) 571 mL bag of Protein Infusion Therapy was found spiked in a small black fridge on the dialysis floor at 10:45 AM. The bag was not labeled with any information as to when it had been spiked. During an interview on 09/05/2025 at 8:20 AM, the Facility Administrator stated that supplies should be checked on a regular basis and discarded if expired. She stated that protein bags should not be spiked until they are ready to be administered to the patient and they should never be spiked and then stored in the refrigerator.”

“PR-RESPECT & DIGNITY CFR(s): 494.70(a)(1) The patient has the right to- (1) Respect, dignity, and recognition of his or her individuality and personal needs, and sensitivity to his or her psychological needs and ability to cope with ESRD This Standard is not met as evidenced by: 49570 Based on review of facility policy and interviews, the facility failed to ensure patients were treated with respect and dignity. This failure had the potential to negatively impact the psychosocial wellbeing of patients receiving dialysis treatments at the facility. The findings included: 1. Review of facility policy, “Patient’s Rights” revised April 2025 revealed, “YOUR RIGHTS AS A PATIENT: ...5. To be treated with (i) respect, dignity ...(7). To be free from abuse ...by the facility’s teammates...” Review of facility policy, “Conduct, Counseling and Corrective Action Policy,” revised 06/13/2025 revealed, “ ...[Facility Name] requires all teammates to conduct themselves in an appropriate and professional manner ...” Review of facility policy, “Standards of Performance and Civility Policy,” revised 06/13/2025 revealed, “[Facility Name] expects all teammates to diligently, professionally, and ethically perform their duties ...teammates are expected to maintain appropriate, respectful working relationships with one another, as well as patients ...work toward a civil and cooperative work environment with managers, teammates, patients ...by avoiding insulting, bullying, and malicious behavior ...Avoid abuse and bullying conduct, including severe or repeated infliction of verbal abuse ...that a reasonable person would find threatening, intimidating, or humiliating. Verbal abuse includes maliciously false remarks, insults ...” 2. During an interview on 07/30/2025 at 10:36 AM, Patient #5 stated that Teammate #1 asked him if he had been pregnant after he had been complaining during treatment about cramping. He stated, “I felt completely disrespected as a man.” During an interview on 07/30/2025 at 3:12 PM with Teammate #1, two separate incidents of unprofessional conduct were discussed. The first incident occurred during the week ending 07/25/2025, when Teammate #1 stated that Patient #5 had complained of cramping during his dialysis treatment. Teammate #1 admitted that she laughed due to being unable to understand Patient #5 when another patient overheard the conversation and spoke up, stating that Patient #5 had expressed to her that he had been cramping. Teammate #1 admitted that she then made the comment, “Oh you pregnant” to Patient #5. Teammate #1 felt that the comment was “light-hearted and funny” but stated to the Surveyor, it was “not funny. I see that now. I haven’t talked to Patient #5 since that happened.” Regarding the second incident, which occurred around the same time, Teammate #1 acknowledged that Patient #6 was leaving the treatment area and had been speaking with another patient saying their goodbyes. One of the patients stated, “See you later alligator,” the other stated, “After while crocodile,” and Teammate #1 stated, “See you soon baboon.” Teammate #1 stated to the Surveyor that she had heard that phrase all of her life and had not thought much about saying it. The FA had been out of town during both incidents, and although the Social Worker had been informed and addressed the matters, Teammate #1 had not received any reprimand for either incident as of the survey exit date. 3. During an interview on 07/30/2025 at 5:10 PM, the Social Worker stated that he had been made aware of both incidents involving Teammate #1 and had spoken directly with Teammate #1 about the concerns. He reported that he informed the FA of the “baboon” comment via email; however, he had not completed any grievance forms related to the incident. The Social Worker further stated he had not personally reported the incident regarding the “pregnancy” comment to the FA, as he believed the charge nurse had reported that incident. He felt the FA would fill out any grievance forms if they were necessary. He stated that he had not officially been left in charge while the FA was out on vacation that week, because normally the GFA or another FA would be left in charge. However, he had not been sure that anyone else was on the premises during the time both incidents occurred. During an interview on 09/05/2025 at 8:20 AM, the Facility Administrator stated that she had been made aware of the comment regarding the Baboon and had spoken with Teammate #1 regarding the inappropriateness of the comment. The FA encouraged Teammate #1 to not make comments like that to patients in the future. She did not formally discipline Teammate #1 for this incident. The FA stated that she had not been made aware of any pregnancy comments that Teammate #1 had made to a patient.”

“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: 19001 Based on policy review, observation and interview the facility failed to ensure hand hygiene was performed when retrieving clean supplies and during the discontinuation of treatment for a patient with a fistula for 1 of 4 (PCT #1) PCT’s observed. The findings included: 1. Review of the facility policy “Infection Control for Dialysis Facilities” revised April 2023, revealed, “Purpose: To minimize the spread of infections or bloodborne pathogens in the dialysis facility environment...Hand Hygiene 1. All teammates...will perform hand hygiene...before touching clean areas such as supplies, supply cart...” Review of the facility policy Post Dialysis Access Care: Fistula/Graft...” revised April 2023 revealed, “...Procedure 1. Perform hand hygiene. Rationale Hand hygiene protects patient and teammate from cross contamination...5... Remove tape from one needle insertion site...Place gauze gently but firmly over needle insertion site...Remove needle...” 2. Observation on 2/24/2025 at 10:10 AM revealed PCT #1 touched the handle to a red biohazard container on wheels with gloved hands, then retrieved clean supplies from a drawer. PCT #1 did not remove her gloves or perform hand hygiene before retrieving the clean supplies. Observation on 2/24/2025 at 10:30 AM revealed PCT #1 touched the dialysis machine at Dialysis Station #3 with gloved hands, then removed supplies from a clean area. PCT #1 did not remove her gloves or perform hand hygiene before retrieving the clean supplies. Observation on 2/24/2025 at 10:31 AM revealed PCT #1 donned clean gloves, sat down on a stool at Station #3, touched the handle to a red biohazard container on wheels and moved it closer to her. PCT #1 then removed an access needle from RP #1’s arm. PCT #1 did not perform hand hygiene after touching the biohazard container and before providing care to RP #1’s access site. 3. During an interview on 2/26/2025 at 10:25 AM the FA stated she expected staff to perform hand hygiene when moving from dirty to clean areas. The FA stated PCT #1 should have performed hand hygiene before retrieving clean supplies and after touching the biohazard container.”

“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: 49570 Based on policy review, observation, and interview, the facility failed to ensure infection control measures were taken to prevent potential cross contamination between patients on 1 of 2 (2/24/2025) days observed. The findings included: 1. Based on facility policy, “Infection Control for Dialysis Facilities” revised April 2023 revealed, “...Measures will be taken to prevent cross contamination between patients...” 2. Observations on 2/24/2025 at 9:27 AM at Dialysis Station #21 revealed CCHT #1 used an electronic thermometer to check a patient’s temperature and did not clean the thermometer after contamination. 3. During an interview on 2/26/2025 at 11:41 AM, the GFA confirmed that electronic thermometers should be cleaned after each patient use.”

“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: 49570 Based on facility policy review, observation, and interview, the facility failed to ensure syringes and needles used for medication administration remained sterile in 2 of 2 (Drawer #1 and Drawer #2) medication preparation areas observed. The findings included: 1. Review of facility policy, “Infection Control for Dialysis Facilities” revised April 2023 revealed, “...Supplies will be stores in a manner that maintains their integrity...package integrity will be verified prior to use...supplies will not be opened until time of use...” 2. Observation on 2/24/2025 at 8:25 AM in the medication preparation area revealed Drawer #1 contained three 10 mL syringes with 21-gauge needles attached and Drawer #2 contained two 3 mL syringes with 21-gauge needles attached open to air and readily available for use. 3. During an interview on 2/24/2025 at 8:37 AM, RN #1 confirmed all five syringes and needles were open to air and available for use. RN #1 stated, “No, those [syringes and needles] should not be unwrapped.””

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 49570 Based on facility policy review, observation, and interview, the facility failed to ensure measures to prevent CVC related infections were followed by 1 of 2 (LPN #1) nurses observed performing direct patient care to patients with CVCs before initiation of hemodialysis. The findings included: 1. Review of facility policy, “Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure” revised October 2024 revealed, “... [named Dialysis corporation] first choice for CVC care is 2% Chlorhexidine/70% Alcohol Swab...8. Holding catheter with the non-dominant hand and using aseptic technique, clean exit site with 2% Chlorhexidine Gluconate/70% Isopropyl Alcohol swab for a minimum of 30 seconds...9. Clean each CVC limb/cap with a new LARGE alcohol prep pad, starting close to the exit site and finishing with the cap...13. Apply label to the dressing indicating: Date dressing change was performed; Initials of TM [team member] performing procedure...16. One at a time, disinfect each CVC hub with a new alcohol prep pad. Scrub each CVC hub for 15 seconds...” 2. Observations on 2/24/2025 at 10:35 AM at Dialysis Station #1 revealed LPN #1 performing exit site care and initiation of dialysis to RP #4. LPN #1 was observed cleaning CVC catheter cap #1 with an alcohol prep pad for 6 seconds and observed cleaning CVC catheter cap #2 for 8 seconds. LPN #1 failed to clean the CVC limb with a large alcohol pad per facility policy and failed to put a label on the exit site dressing per facility policy. LPN #1 was observed cleaning the CVC exit site for RP #4 with an alcohol prep pad instead of a 2% Chlorohexidine Gluconate/70% Isopropyl Alcohol Swab per facility policy. 3. During an interview on 2/26/2025 at 10:06 AM, the MCS confirmed CVC catheter caps should be cleaned with an alcohol prep pad for at least 15 seconds per hub, confirmed the entire CVC limb should be cleaned with an alcohol prep pad, and confirmed all exit site dressings should have a label placed on them per facility policy. The MCS confirmed CVC exit sites should be cleaned with a 2% Chlorohexidine Gluconate/70% Isopropyl Alcohol unless there is a contraindication indicated in the patients’ medical record. The MCS confirmed that RP #4 did not have any contraindications for Chlorohexidine usage mentioned in his medical record.”

“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: 49570 Based on observation and interview, the facility failed to provide a safe and sanitary environment for dialysis patients on 2 of 3 (2/24/2025 and 2/26/2025) observation days by allowing items to be stored in cabinets underneath 2 of 2 (lab area and medication prep area) sinks. The findings included: 1. Observations on 2/24/2025 at 8:20 AM and 2/26/2025 at 10:34 AM revealed three plastic rectangle containers, one cardboard box, and one bottle of air duster stored under the sink in the lab area. Observations revealed multiple spray bottles of cleaning solutions, one bottle of bleach, an emergency radio, a flashlight, and garbage bags stored under the sink in the medication prep area. 2. During an interview on 2/26/2025 at 10:06 AM, the MCS confirmed that nothing should be stored in the cabinets under sinks.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 49570 Based on manufacturer’s guidelines for use, policy review, observation, and interview, the facility failed to ensure appropriate measures were taken by 2 of 2 (CCHT #1 and PCT #2) staff members to reduce the risk of infection during cannulation of an AVF and/or AVG prior to initiation of hemodialysis. The findings included: 1. Review of the manufacturer’s guidelines for use for [brand name] wipes revealed, “Directions: tear open packet, remove towelette, wipe hand/wrist areas for 15 seconds and discard...” 2. Review of the facility policy, “AV Fistula or Graft Cannulation with [Brand Name] or [Brand Name] Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose” revised October 2022 revealed, “ ...Have patient wash access site with appropriate antibacterial soap, if able. If patient unable to wash access site, patient care teammate will clean access extremity with skin cleansing agent and pat dry...8. Locate and palpate the needle cannulation sites prior to skin preparation. 10. While maintain aseptic technique, prep each planned needle site by applying a 70% alcohol prep pad to each site using a circular rubbing motion, center out. 11. While maintaining aseptic technique, cleanse the site by applying skin antiseptic using a circular rubbing motion, moving from the center out and allow to dry. (For contact and dry time refer to the table above). [TABLE: Skin Antiseptic: Povidone Iodine - Effective Volume: At least 1 prep pad per site or 1 saturated sterile gauze pad per site. - Effective Contact Time: 30 seconds - Air Drying Time: 2 minutes] ...Do not palpate insertion site once area has been prepped. Once the access site has been prepped, touching it will contaminate the site and possibly allow for the introduction of bacteria during cannulation...” 3. Observations on 2/24/2025 at 9:42 AM revealed CCHT #1 initiated hemodialysis on RP #2 via an AVF/AVG. CCHT #1 cleaned the access site with a [brand name] antimicrobial hand wipe for 3 seconds instead of the recommended 15 seconds. CCHT #1 failed to clean the access site per facility policy by scrubbing with a Povidone Iodine/Betadine wipe in a back-and-forth motion instead of circular motion per facility policy. After cleansing the access site with a Povidone Iodine/Betadine wipe, CCHT #1 walked away from RP #2 to gather supplies and perform the machine water testing. RP #2 was observed bending her arm and allowing both sites to touch RP #2’s clothing and upper arm, recontaminating the site. After CCHT #1 performed the water testing, she returned to RP #2’s dialysis station and cannulated the sites and initiate hemodialysis. CCHT #1 failed to reclean the access sites prior to cannulation. 4. Observations on 2/25/2025 at 9:44 AM revealed PCT #2 initiating hemodialysis on RP #3 via an AVF/AVG. PCT #2 cleaned the access site with [brand name] antimicrobial hand wipe for 6 seconds instead of the recommended 15 seconds. PCT #2 failed to clean the access sites per facility policy by not following the appropriate contact time and air-drying time with Povidone Iodine/Betadine. PCT #2 scrubbed both access sites with Povidone Iodine/Betadine for 6 seconds instead of 30 seconds per facility policy and failed to allow the Povidone Iodine/Betadine to dry for 2 minutes before cannulation. Both access sites were immediately cannulated after the Povidone Iodine/Betadine was applied. PCT #2 touched both insertion sites with a gloved finger immediately before cannulation and failed to reclean the area. 3. During an interview on 2/26/2025 at 11:41 AM, the GFA confirmed staff were expected to “follow the policy” for cleaning and initiation of dialysis with an AVG/AVF. The GFA stated that if an access site was re contaminated before cannulation it must be recleaned with Povidone Iodine/Betadine and allowed to dry for 2 minutes before cannulation. She stated that staff were expected to know that access sites should not be touched where the cannulation needle enters the skin after the area has been cleaned.”