Davita Central City 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: 43999 Based on observation and interview, the facility failed to monitor and provide a sanitary environment to minimize the transmission of infectious agents within the unit. Findings : During a tour of the facility on 1/6/25 the following were observed: Throughout the treatment areas the flooring had dirt and unknown substances buildup in the corners, and the bases of the floor molding, large discoloration under the cabinets behind the patient treatment stations and the wall mounts . The flooring had a smeared appearance throughout he treatment area. The treatment floor tiles had dirt buildup inbetween the seams that cannot be cleaned effectively. During an interview with patient # 4 when entering the facility 1/5/26 it was expressed the cleanliness of the facility needs improvement. In an interview with Staff #1 on 1/7/25, the above findings were confirmed. Staff #1 shared the work orders had been initiated for new flooring in 2025 but there had been no confirmed time the repair would begin. The work orders were initiated in early 2025.”

“GOV-INTERNAL GRIEVANCE SYS ID/IMPLEMENTED CFR(s): 494.180(e) The facility’s internal grievance process must be implemented so that the patient may file an oral or written grievance with the facility without reprisal or denial of services. The grievance process must include- (1) A clearly explained procedure for the submission of grievances. (2) Timeframes for reviewing the grievance. (3) A description of how the patient or the patient’s designated representative will be informed of steps taken to resolve the grievance. This Standard is not met as evidenced by: 43999 Based on a review of documentation and interview, the facility failed to ensure the internal grievance process was implemented, including timeframe’s for reviewing the grievance. Specifically the Governing Body failed to implement and enforce the policy “Patient Grievance Procedure” for one of four patient grievances. Findings : Review of the facility policy : “TITLE: PATIENT GRIEVANCE Policy: 3-01-06 revised: April 2025” stated: “Grievances may be reported to a DaVita teammate either verbally or in writing. Grievances should be submitted to a DaVita teammate within 30 days of the date of the incident or when the person filing the grievance on behalf of the patient became aware of the issue. The DaVita teammate should report the grievance to the charge nurse. If a solution to the grievance is not reached through this discussion, the charge nurse is to notify the FA and the Regional Operations Director (ROD) within one business day for follow-up. The FA (or their designee) is to discuss grievance with the patient, investigate and take appropriate action towards a solution, if possible. This discussion should occur within 10 days of receipt of the grievance. If the patient’s grievance cannot be resolved by the FA, the ROD and Medical Director will be notified, and a formal grievance conference will be coordinated. This grievance conference should occur within 10 days of receipt of the grievance. If the patient grievance cannot be resolved by the ROD and/or Medical Director, the Divisional Vice President will be notified. The Divisional Vice President will discuss the grievance with the patient and take appropriate action towards a solution, if possible. The Divisional Vice President along with Group General Counsel will review and, if necessary, investigate the grievance. The Divisional Vice President will issue a written, final decision to the patient within 10 days of the grievance conference. “ Review of the 2025 grievance log on 1/7/26 revealed one out of four grievance reports (dated 10/4/25) did not provide documentation the grievance had been resolved once the investigation was completed. The facility staff did not follow the policy and procedure that requires additional investigation and followup with a formal grievance conference within 10 days of receipt of the grievance with a written , final decision to the patient within 10 days of the grievance conference. In an interview on 1/7/26 with the staff #1, #3 and #5 it was acknowledged the facility failed to enforce policies and procedures for one out of four patient grievances.”