Davita San Antonio West Dialysis

“CFC-COMPLIANCE WITH FED/STATE/LOCAL LAWS CFR(s): 494.20 This Condition is not met as evidenced by: 45179 Based on observation, interviews and record reviews, the facility was not in compliance with applicable Federal and State regulatory licensing requirements relevant to patient health and safety. Specifically, the facility’s Governing Body failed to ensure: 1) the dietitian met the required ratio of no more than 125 patients; in accordance with TAC 117.45(g)(5). The facility’s RD was providing services for 141 patients. Refer to State Tag E-0843 for specific evidence. 2) the licensed social worker met the required ratio of no more than 125 patients; in accordance with TAC 117.45(h)(5). The facility’s LMSW (Licensed Master Social Worker) was providing services for 147 patients. Refer to State Tag E-0851 for specific evidence.”

“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: 26870 Based on observation and interview, the facility failed to monitor and maintain a sanitary environment to minimize the transmission of infectious agents within the dialysis center. These findings have the likelihood to cause harm by increasing the risk of infection to all patients receiving care at the dialysis facility. Findings Include: Observations conducted during a tour of the facility on 8/12/25 at 11:00AM revealed the following: 11:15AM tour of the facility supple room revealed a dust like appearance in the plastic container of iodine pads. The floors in the supply room had a dust like appearance. The plastic pallets in the supply room also had a dust like appearance on the pallets as well as between the pallet slats. The floor in the Biomed office had a very dust like appearance. Clean equipment “ready for use” for patients, was stored in the Biomed office. 11:21 AM tour of the facility water room revealed water damaged ceiling tiles. On the ceiling was a metal grid securing and holding up the ceiling tiles, the metal grid had a “orange/born” rust like color to it. One ceiling tile had black/gray colored spots on the ceiling tile. A floor base board was lifting up exposing a rust like appearance. Plastic pallets in the water room had a dust like appearance on the plastic pallets and between the plastic pallet slats. Interview with the Facility Administrator (FA) at the time of the observation stated, “We have put in many tickets to get this fixed.” 11:30AM walking through the facility supply room revealed the plastic ceiling light covers had what appeared to be “insect silhouettes”. Interview with the FA at the time of the observation revealed the FA also noticed the appearance of insects through the clear light cover. 11:40AM during the tour of the facility clinic floor revealed all the Computer on Wheels (COW) through out the clinic floor had a dust particle appearance on the keyboard. 11:45AM surveyor had FA open chair #10 chair #17, and, chair #17. The open chairs had a dusty and rust like appearance through out the chair frame. Chair #10 had a dusty like appearance on the frame and a candy wrapper was noted. Interview with the FA at the time of the observation revealed she saw the observation. 11:52AM surveyor opened wall boxes at station 19- 24, which revealed syringe caps underneath the wall boxes on the floor; within the wall boxes were dust like particles, cob webs and bugs. 12:00PM Blood pressure cuffs at Pod 5, Pod 6, Pod 9, Pod 15, and Pod 17 revealed what appeared to have white fabric like debris stuck on the Velcro of the blood pressure cuff which was ready for patient use. Interview with the FA at the time of the observation confirmed the findings. 12:15PM during the tour of the Peritoneal Dialysis (PD) floor revealed the following: 12:18PM Surveyors had the FA open the PD chair which revealed the metal frame of the chair to be covered in a dust like substance. Interview with the FA at the time of the observation confirmed the findings. 12:28PM observation the facility PD Supply closet revealed the floor had a dust like appearance, Clean supplies were stored over the dirty sink, a pair of scissors with a orange/brown rust like appearance was mixed in the drawer of patient supplies. 12:35PM Observation of the PD refrigerator revealed the refrigerator was unlocked.; 41 boxes of medication, Mircera, was kept inside the unlocked refrigerator. Interview with the FA at the time of the observation confirmed the findings. 12:40PM Surveyors noticed a long crack, about 3 feet in length over the PD/Home Training room door frame. Interview with the FA at the time of the observation revealed they were aware of the crack and had put in many tickets to get the crack repaired. Interview with S#2 at the time of the observation revealed that they have been trying to get these things repaired and now that the facility is being surveyed it will become a priority to the leadership that approves work orders. 12:42PM observation inside the PD/Home Training room, surveyor saw a supply cart in room with multiple rust like areas on the stainless steel shelves. Record review of the facility policy titled Physical Environment states in part....The dialysis facility will be....maintained to provide dialysis patients, teammates and the public a safe, functional and comfortable treatment environment.”

“SOFTENERS-AUTO REGENERATE/TIMERS/SALT LVL CFR(s): 494.40(a) 5.2.4 Softeners: auto regen/timers/salt/salt level Prior to exhaustion, softeners should be restored; that is, new exchangeable sodium ions are placed on the resin by a process known as “regeneration,” which involves exposure of the resin bed to a saturated sodium chloride solution. 5.2.4 Softeners Refer to RD62:2001, 4.3.10 Automatically regenerated water softeners: Automatically regenerated water softeners shall be fitted with a mechanism to prevent water containing the high concentrations of sodium chloride used during regeneration from entering the product water line during regeneration. The face of the timers used to control the regeneration cycle should be visible to the user. 6.2.4 Softeners Timers should be checked at the beginning of each day and should be interlocked with the RO system so that the RO is stopped when a softener regeneration cycle is initiated. The softener brine tank should be monitored daily to ensure that a saturated salt solution exists in the brine tank. Salt pellets should fill at least half the tank. Salt designated as rock salt should not be used for softener regeneration since it is not refined and typically contains sediments and other impurities that may damage O-rings and pistons and clog orifices in the softener control head. This Standard is not met as evidenced by: 26870 Based on observation and interview, the facility staff failed to check and maintain the salt pellets above the water halfway mark in the brine tank. This deficient practice had the likelihood to cause the water to become hard; failure to ensure adequate salt levels in the brine tank can lead to water hardness in the system at levels unacceptable for dialysis being performed on patients. Findings include: During a tour of the facility’s water room on 08/12/2025 at 11:25 AM observed that the salt pellets were below the water level in the side of the brine tank, and the water was brown and bubbly. An interview with Staff #1 on 08/12/2025 at 11:25 AM, stated she would have to refer to biomed. Interview with Staff #2 on 8/12/25 at 1:30PM, stated he didn’t know and would refer with another biomed. Interview with Staff #4 on 8/12/25 at 1:20PM, when surveyor stated the brown and bubbly water in the brine tank concerning, Staff #4 had no comment. Interview with Staff #8 on 8/12/25 at 2:30PM, confirmed the salt pellets should cover the water where the water can not be visible. Record review of the manufacture recommendations states in part...Salt bridge prevention: The design should prevent “salt bridging”, where solidified appears to fill the tank but if actually hollow underneath. This is often achieved by ensuring proper water flow and recommending salt pellets over coarse rock salt.”

“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: 26870 Based on observation and interview, dialysis facility failed to be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This deficient practice has the likelihood of causing harm to dialysis patients receiving treatment at the facility due to possible exposure to infectious material. Findings Include: Observations conducted during a tour of the facility on 8/12/25 at 11:00AM revealed the following: 11:15AM tour of the facility supply room revealed a dust like appearance in the plastic container of iodine pads. The floors in the supply room had a dust like appearance. The plastic pallets in the supply room also had a dust like appearance on the pallets as well as between the pallet slats. The floor in the Biomed office had a very dust like appearance. Clean equipment “ready for use” for patients, was stored in the Biomed office. 11:21 AM tour of the facility water room revealed water damaged ceiling tiles. On the ceiling was a metal grid securing and holding up the ceiling tiles, the metal grid had a “orange/born” rust like color to it. One ceiling tile had black/gray colored spots on the ceiling tile. A floor base board was lifting up exposing a rust like appearance. Plastic pallets in the water room had a dust like appearance on the plastic pallets and between the plastic pallet slats. . Interview with the Facility Administrator (FA) at the time of the observation stated, “We have put in many tickets to get this fixed.” 11:30AM walking through the facility supply room revealed the plastic ceiling light covers had what appeared to be “insect silhouettes”. Interview with the FA at the time of the observation revealed the FA also noticed the appearance of insects through the clear light cover. 11:40AM during the tour of the facility clinic floor revealed all the Computer on Wheels (COW) through out the clinic floor had whitish dust particle appearance on the keyboard. 11:45AM surveyor had FA open chair #10 chair #17, and, chair #24. The open chairs had a dusty and rust like appearance through out the chair frame. Chair #10 had a dust like appearance and a candy bar wrapper on the frame. Interview with the FA at the time of the observation revealed she saw the observation. 11:52AM surveyor opened wall boxes at station 19- 24, which revealed syringe caps underneath the wall boxes on the floor; within the wall boxes were dust like particles, cob webs and bugs. 12:00PM Blood pressure cuffs at Pod 5, Pod 6, Pod 9, Pod 15, and Pod 17 revealed what appeared to be a white fabric like debris stuck to the Velcro of the blood pressure cuff which was ready for patient use. Interview with the FA at the time of the observation confirmed the findings. 12:15PM during the tour of the Peritoneal Dialysis (PD) floor revealed the following: 12:18PM Surveyors had the FA open the PD chair which revealed the metal frame of the chair to be covered in a dust like substance. Interview with the FA at the time of the observation confirmed the findings. 12:28PM observation the facility PD Supply closet revealed the floor had a dust like appearance, clean supplies were stored over the dirty sink, a pair of scissors with a orange/brown rust like appearance was mixed in the drawer of patient supplies. 12:35PM Observation of the PD refrigerator revealed the refrigerator was unlocked; 41 boxes of medication, Mircera, was kept inside the unlocked refrigerator. Interview with the FA at the time of the observation confirmed the findings. 12:40PM Surveyors noticed a long crack, about 3 feet in length over the PD/Home Training room door frame. Interview with the FA at the time of the observation revealed they were aware of the crack and had put in many tickets to get that crack repaired. Interview with S#2 at the time of the observation revealed that they have been trying to get these things repaired and now that the facility is being surveyed it will become a priority to the leadership that approves work orders. 12:42PM observation inside the PD/Home Training room, surveyor saw a supply cart with multiple rust like areas on the stainless steel shelves. Record review of the facility policy titled Physical Environment states in part....The dialysis facility will be....maintained to provide dialysis patients, teammates and the public a safe, functional and comfortable treatment environment. 45179”

“PA-IMMUNIZATION/MEDICATION HISTORY CFR(s): 494.80(a)(3) The patient’s comprehensive assessment must include, but is not limited to, the following: Immunization history, and medication history. This Standard is not met as evidenced by: 45179 Based on record review and interview the facility failed to ensure the patient’s history and physical; comprehensive assessment “medication history” included a review of the patients allergies. Specifically, the facility failed to ensure patient allergies were accurately documented for 10 out of 10 patient medical records reviewed. (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, and P#10). The findings were: Review of the History and Physicals for P#1, P#2, P#3, P#4, P#6, P#7, P#8, P#9 and P#10 revealed allergies were not identified in their History and Physicals in the medical record. Interview on 8/13/2025 at 2:45PM with the FA at the time of the observation revealed that the electronic health record was missing accurate allergy information. No explanation was given. Medical Record for P#5: Record review of the Annual Plan of Care for #5 revealed P#5 had an allergy to Vancomyocin. Record review of P#5 medical record revealed on the physical medical record binder, P#5 had “no known allergies”s on the label spine of the binder. Record review of the patients prescription order did not identify allergies. Record review of P#5’s History and Physical did not identify allergies. Review of policy Medical Records Documentation Guidance 03-03-03 rev. Apr. 2025 states in part, Definition 1. The medical record refers to any document or electronic system used to record information regarding the patient’s diagnosis, treatment and care, including but not limited to: ...History and Physical...Documentation Guidance....8. Document accurately and concisely but completely. Review of the facility policy, History and Physical (H&P) Policy 03-02-28 rev. Oct. 2021 states in part, Recommended Elements of a History and Physical (H&P) 1. Patient Name, MPI#, Date of Birth....5. Current medications with dosage including over the counter medications and vitamins... 10. Allergies Interview on 8/13/25 at 3:26PM with the facility Facility Staff #2 (FS#2) revealed the program to identify allergies in the History and Physical is not embedded in the program. Physician’s do not have a drop down box to identify patient allergies but need to add that manually. This oversight can be taken up with the support team at CWOW to adjust.”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 26870 Based on record review and interview, the facility failed to maintain complete, accurate, and accessible records on all patients. Specifically, the facility failed to ensure patient allergies were documented for 10 out of 10 patient medical records reviewed, (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, and P#10). The findings were: Record review of patient History and Physicals for P#1, P#2, P#3, P#4, P#6, P#7, P#8, P#9 and P#10 revealed allergies were not identified in their History and Physicals in the medical record. Medical Record for P#5: Record review of the Annual Plan of Care for #5 revealed P#5 had an allergy to Vancomyocin. Record review of the Initial Nursing Assessment for P#5 identified P#5 to have an allergy to Vancomyocin. Record review of P#5 medical record revealed on the physical medical record binder, P#5 had “no known allergies” label on the spine of the binder. Record review of P#5’s History and Physical did not identify allergies. Review of the facility policy, History and Physical (H&P) Policy 03-02-28 rev. Oct. 2021 states in part, Recommended Elements of a History and Physical (H&P) 1. Patient Name, MPI#, Date of Birth....5. Current medications with dosage including over the counter medications and vitamins...10. Allergies Interview on 8/13/25 at 3:26PM with the facility Facility Staff #2 (FS#2) revealed the program to identify allergies in the History and Physical is not embedded in the program. Physician’s do not have a drop down box to identify patient allergies.”