Davita Millington Dialysis

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 49570 Based on facility policy, observation, and interview, the facility failed to ensure adherence to infection control practices in four critical areas. The facility failed to provide and maintain an effective infection control program to prevent healthcare-associated infections and ensure patient safety. The deficient practices were observed across multiple infection control processes and staff roles, and involved improper handling of sterile supplies, improper use of medications, lack of environmental sanitation, and breaches during central venous catheter care. The lack of adherence to infection control protocols in environmental sanitation, medication handling, catheter care, and hand hygiene undermined the facility’s ability to protect patients from preventable infections. These widespread and repeated lapses placed all patients at risk for adverse health outcomes and reflect a serious deficiency in the facility’s infection control program. These failures reflect a systemic breakdown in the facility’s ability to comply with basic infection control standards. The findings included: 1.The facility failed to maintain a sanitary environment by not discarding supplies prior to their expiration date. The expired items were observed in patient care areas, posing a risk of compromised sterility and ineffective patient treatment. Refer to V-111 2. The facility failed to ensure staff adhered to infection prevention policies by allowing direct patient care staff to wear artificial fingernails. Artificial nails are known to harbor pathogens and reduce effective hand hygiene, increasing the risk of infection transmission. Refer to V-113 3. The facility failed to ensure proper disinfection of multi-dose vials during medication administration. Staff were observed accessing vials without disinfection the rubber septum with alcohol, increasing the risk for contamination and cross-infection among patients. Refer to V-143 4. The facility failed to ensure proper infection control practices were followed during the initiation of HD via a CVC. Observations during the initiation of HD included Open-air catheter hubs were observed coming into contact with non-sterile surfaces; the catheter exit site not properly disinfected and was recontaminated during the cleaning process and topical anesthetic was not given adequate dry time prior to application of the exit site dressing. These breaches compromised catheter site sterility and elevated the risk of catheter-related bloodstream infections. Refer to V-147”

“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 facility policy, observation, and interview, the facility failed to provide a safe environment by not ensuring that readily accessible patient care supplies were discarded prior to their expiration dates in 4 of 4 (storage cabinet, isolation room, supply room, and peritoneal dialysis room) patient care supply areas, increasing the risk for compromised patient safety and ineffective treatment. The findings included: 1. Review of facility policy, “Infection Control For Dialysis Facilities” published 042023 revealed, “ ...Supplies will be stored in a manner that maintains their integrity...Expiration date and package integrity will be verified prior to use...Anytime the integrity of a package with or without an expiration date is in question, i.e., torn, ripped, wet or contaminated, the package and its contents must be disposed of and not used ...” 2. Observations on the treatment floor on 06/16/2025, revealed the following expired supplies in the storage cabinet: Seventy-six (76) 3mL syringes with an expiration date of 02/28/2023, and Thirteen (13) Alcohol Prep Pads with an expiration date of 06/2024. During an interview on 06/16/2025 at 9:36 AM, the PCT verified the above expired supplies. 3. Observations in the isolation room on 06/16/2025, revealed the following expired supplies: One (1) ChloraPrep Swab stick (sterile skin antiseptic swab stick) with expiration dates of 06/21; One (1) ChloraPrep Swab stick with expiration dates of 06/23; Two (2) ChloraPrep Swab sticks with expiration dates of 07/23; One (1) ChloraPrep Swab stick with expiration dates of 10/24. Seventy-nine (79) Povidone Iodine Prep Pads (antiseptic wipes used for skin disinfection before medical procedures) with an expiration date of 10/2023; Two (2 ) [Brand Name] HD antimicrobial end caps (catheter end caps designed to reduce catheter related infections) with expiration dates of 04/27/2024, and One (1 ) [Brand Name] HD antimicrobial end caps with expiration date of 02/10/2024. During an interview on 06/16/2025 at 10:57 AM, RN #1 verified the above expired supplies. 4. Observations in the supply room on 06/16/2025, revealed the following expired supplies: One hundred seventy-seven (177) Recirculation Connectors (Extension for connecting arterial and/or venous fistula connectors to the hemodialysis blood tubing) with an expiration date of 05/29/2023; One (1) bottle of hand sanitizer with an expiration date of 11/2024, and One (1) bottle of moisturizing hand lotion with an expiration date of 01/2023. During an interview on 06/16/2025, the GFA verified the above expired supplies. 5. Observations in the back storage room on 06/16/2025, revealed the following damaged/expired supplies: Twenty-four (24) Citric Acid packages (A solution used to clean and descale the dialysis machine) that were wet and molded, with no expiration date found; One (1) bottle of Pure Bright Germicidal Bleach with expiration dates of 03/27/2025; One (1) bottle of Pure Bright Germicidal Bleach with expiration dates of 05/20/2025, and Three (3) bottles of Pure Bright Germicidal Bleach with expiration dates of 3 with illegible dates. 6. Observations in the PD room on 06/16/2025, revealed the following expired supplies: One (1) Bottle of Pure Bright Germicidal Bleach with expiration dates of 05/18/2025; During an interview on 06/16/2025, the GFA verified the above expired supplies. 7. During an interview on 06/18/2025 at 11:05 AM, the FA verified that all supplies should be routinely checked and discarded when expired.”

“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: 49570 Based on facility policy, observation, and interview, the facility failed to ensure adherence to infection control practices by allowing direct patient care staff to wear artificial fingernails on 1 of 1 (06/16/2025) observation days. The findings included: 1. Review of facility policy, “Infection Control for Dialysis Facilities” revised April 2023 stated, “It is a requirement for all [Facility] teammates whose primary location is working in a facility to have only natural nails and fingernail length should not extend more than ¼ inch. Traditional nail polish that is not chipped may be worn ...” 2. Observations on the treatment floor on 06/16/2025 at 10:00 AM revealed RN #1 wearing artificial nails that were hot pink in color. 3. During an interview on 06/18/2025 at 11:05 AM the FA stated that staff should follow facility policy regarding nails, and that nails should be natural, less than ¼ inch, and have natural polish that is not chipped.”

“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, CDC Injection Safety guidelines, observation, and interview, the facility failed to properly disinfect the rubber stoppers of multi-dose vials during the medication draw-up process on 2 of 2 observations, as required to prevent contamination and ensure safe infection practices. The findings included: 1. Review of the facility policy revealed no documentation of a facility policy regarding disinfection of the rubber septum of a medication vial during medication administration. Review of the CDCs Injection Safety guidelines dated August 15, 2023, revealed, “...Disinfect the top part of the vial (the vial stopper) with an alcohol prep pad every time you draw up...” 2. Observations on the treatment floor on 06/16/2025 at 2:50 PM, revealed RN #1 failed to disinfect the vial stopper on 4 of 5 medication vials. Three (3) of four (4) vials were while drawing heparin (an anticoagulant to prevent blood clots) and 1 of 1 vial stoppers were while drawing Venofer (medication used to treat severe iron deficiency anemia). 3. During an interview on 06/18/2025 at 11:05 AM, the FA verified that the facility policy should be followed when drawing up medications.”

“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, observation, and interview, the facility failed to ensure that direct patient care staff consistently followed appropriate infection control practices during the initiation of hemodialysis via a CVC on 1 of 1 (06/16/2025) observation days. Specifically, staff failed to prevent open-to-air catheter hubs from coming into contact with non-sterile surfaces; failed to appropriately disinfect the catheter exit site without recontamination during the cleaning process; and failed to allow sufficient dry time for the topical anesthetic prior to applying the exit site dressing. These failures are inconsistent with the facility’s own policies and placed patients at increased risk for catheter-related bloodstream infections. The findings included: 1. Review of facility policy, “Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure” Revised April 2025 revealed, “ ...Perform a 15 second hub scrub of the CVC during the process of connecting or disconnecting from the blood lines, including line reversal, or if the patient is disconnected during treatment for any reason ...Verify patient’s clothing is secured away from the exit site/work area ...Securing the patient’s clothing away from the work area minimizes the risk of cross-contamination ...apply to the CVC exit site in a “back and forth” pattern, using gentle friction progressing from the insertion site to the periphery using both sides of the swab ...Then wait 60 seconds for air dry time ...Effective contact time for 2% Chlorhexidine Gluconate/70% Isopropyl Alcohol is 30 seconds and dry time is 60 seconds ...Hold the limbs until the antiseptic has dried ...Verify open lumen is not placed on a non-sterile surface ...Set-up new clean field with appropriate supplies on a new clean, moisture proof barrier ...Discard used barrier that was used during treatment and place a new clean, moisture proof barrier under catheter to prevent contamination ...” 2. Observations on the treatment floor at Station #10 on 06/16/2025 at 11:35 AM revealed RN #1 initiating hemodialysis via a CVC and performing exit site care on Patient #5. RN #1 dropped the uncapped end of hub on barrier sheet for about four seconds before picking it back up. While performing exit site care RN #1 contaminated the site by touching Patient #5’s bra strap on multiple occasions while cleaning with Chloraxedine (antiseptic and disinfectant used to kill bacteria on the skin). RN #1 revisited the entry site multiple times during cleaning and did not allow any dry time for the antiseptic before covering area with dressing. 3. During an interview on 06/18/2025 at 11:05 AM the FA stated that facility policy should be followed during initiation of CVC and regarding exit site care.”

“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 facility policy, observations, and interview, the facility failed to maintain a safe and sanitary physical environemnt by not ensuring the exterior door was properly sealed to prevent pest entry. The findings included: 1. Review of facility policy revealed no facility policy could be found regarding the use and maintenance of outside doors. 2. Observations in the back storage room on 06/16/2025 at 1:45 PM revealed the back door that opened to the outside of building had been pushed out from the handle to the bottom of door and had left an open gap at the bottom of the door. The gap was large enough to let insects and potentially other critters inside the building. During the survey a live cricket was observed in the hallway and a live spider was observed in the kitchen. 3. During an interview on 06/18/2025 at 11:05 AM the FA stated that she thought the door had been damaged due to large pallets coming inside the door but agreed that it needed to be fixed.”

“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 review of facility policy, observation, and interview, the facility failed to ensure appropriate measures were taken by 1 of 2 (CCHT #1) staff members to effectively evaluate access and prevent infection before cannulation of an AVF and/or AVG prior to initiation of hemodialysis on 1 of 1 observation days. The findings included: 1. Review of facility policy, “AV Fistula or Graft Cannulation with [Brand Name] Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose” revised April 2025 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 ...” 2. Observations on the treatment floor in the Isolation Room on 06/16/2025 at 10:35 AM, revealed CCHT #1 initiated hemodialysis on Patient #2 via an AVG/AVF. CCHT #1 failed to ensure the access site was cleaned with soap and water before proceeding with skin antisepsis. 3. During an interview on 06/18/2025 at 11:05 AM the FA stated that staff should follow facility policy when preparing the AVG/AVG for hemodialysis.”