Davita North Houston Dialysis Center

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 48020 Based on observation and interview, the facility’s staff assigned duties in the Water Room failed to verify that the acid mixer, acid storage tank, water softener, and water room is clean B) the facility’s direct care staff failed to clean debris underneath the chase cabinets behind the hemodialysis machines C) the facility failed to maintain a sanitary environment as evidenced by dead insects in the light covers throughout the facility D) the facility failed to maintain a safe environment as evidenced by expired supplies co-mingled with supplies in use in the facility for care and services of patients E) the facility failed to maintain a sanitary environment as evidenced by rusts on the lower legs and casters of 8 rolling stools Cross reference V 111 Based on observation, interview and record review, the facility’s direct care staff: failed to perform hand hygiene after removal of contaminated gloves per the facility’s policy in 4 of 6 staff observed: Patient Care Technician (F), (D), (E), (C) B) failed to change gloves when going from a “dirty” area or task to a “clean” area or task per the facility’s policy in 2 of 6 staff observed: Patient Care Technician (F), (E) Cross reference V 113 Based on observation, interview and record review, the facility’s direct care staff: failed to prevent cross contamination by storing several chairside computer carts in between hemodialysis machines in use (in the splash zone) B) failed to prevent cross contamination by storing a contaminated face shield on the clean computer cart keyboard: Patient Care Technician (C) Cross reference V 117 Based on observation, interview and record review, the facility’s direct care staff: failed to clean and disinfect stethoscopes, intravenous poles and rungs, hemodialysis machine, dialysate lines and chase counter tops behind the dialysis stations according to the facility’s policy in 4 of 6 staff observed: Patient Care Technician (F), (E), (O), (P) B) failed to prevent cross contamination by wiping the wall boxes and using the same towel to wipe the chase cabinet and dialysate lines in the back of the hemodialysis machine in 3 of 6 staff observed: Patient Care Technician (F), (O), (P) C) failed to ensure that infection control was maintained as evidenced by hemodialysis chairs with tape and tape residue in 13 of 24 chairs. D) failed to ensure that infection control was maintained as evidenced by tears in the vinyl of the hemodialysis chairs in 2 of 24 chairs. Cross reference V 122”

“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: 48020 Based on observation and interview: the facility’s staff assigned duties in the Water Room failed to verify that the acid mixer, acid storage tank, water softener, and water room is clean B) the facility’s direct care staff failed to clean debris underneath the chase cabinets behind the hemodialysis machines C) the facility failed to maintain a sanitary environment as evidenced by dead pest in the light covers throughout the facility D) the facility failed to maintain a safe environment as evidenced by expired supplies co-mingled with supplies in use in the facility for care and services of patients E) failed to maintain a sanitary environment as evidenced by rusts on the lower legs and casters of 8 rolling stools Findings: Water Room: Observation of the water room on 02/18/2025 at 6:55 a.m. revealed the following: “ Debris on the floor- cap top, strip of paper, small pieces of cardboard box and tape that was removed from a cardboard box of acid that was stored in the water room “ Crystallized build up on the acid storage tank hose clamp and a 1-inch mound of crystallized build up on the floor underneath it “ 1-inch mound of crystallized acid build up on the floor underneath the acid storage tank hose connector “ Acid residue on the floor underneath the acid mixer and storage tank “ Rust on the acid mixer metal holder and brown residue on from the rust dripped down the back of the acid mixer “ Black residue on the floor behind the acid mixer “ Brown residue dripped down the front of the water softener Interview with Biomedical Technician (M) at 9:28 a.m. revealed that he cleans the water room once a month and the staff assigned to water room duties should keep it clean as well. Treatment Area: Observation of the treatment area on 02/18/2025 at 7:24 a.m. revealed debris on the floor underneath the chase cabinet (gauze, dialyzer endcaps) between stations #s 2-3 and 7-8. Interview during walkthrough with Charge Nurse (A) at 8:00 a.m. confirmed the findings. Dead pests in light covers: Observation of the facility on 02/19/2025 starting at 8:48 a.m. revealed dead pests in the lights covers in the conference room, both teammate restrooms, the break room, and the offices of the social worker and the administrative assistant. Interview during the walkthrough with the Manager of Clinical Safety (N) at 4:36 p.m. confirmed the findings. Expired supplies: Observation on 02/19/2024 at 11:10 AM to 13:00 PM of the patient treatment area along with the Manager of Clinical Services, Staff ID #N the following was identified: 20 - packages of Chlora Prep Single Swab Sticks , Lot # 2257432, Expiration Date 08/2024. Nipro 14-gauge Fistula Needles: 1 - Lot #14C18, Expiration date 02/2019. 1 - Lot #18H23B, Expiration date 07/31/2021. 1 - Lot #17619A, Expiration date 06/30/2022. 18 - Lot #17H29C, Expiration date 07/31/2022. 7 - Lot #18H23B, Expiration date 08/31/2023. 1 - Lot #18K20B, Expiration date 10/31/2023. 14 - Lot #18I15B, Expiration date 11/30/2024. Interview with Staff ID #N on 02/19/2025 at 12:45 PM confirmed the above expired supplies should not have been available for use and were past their expiration date. Rusted stools: Subsequent observation revealed: 8 - rolling stools were identified to have visible rust on the lower leg segments and the wheel casters. Interview with Staff ID #N on 02/19/2025 at 12:45 PM confirmed the visible rust on the 8 rolling stools and should not been in use.”

“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: 48020 Based on observation, interview and record review, per the TAC 117.33(a)(1)(C)(ii), the facility’s direct care staff: failed to perform hand hygiene after removal of contaminated gloves per the facility’s policy in 4 of 6 staff observed: Patient Care Technician (F), (D), (E), (C) B) failed to change gloves when going from a “dirty” area or task to a “clean” area or task per the facility’s policy in 2 of 6 staff observed: Patient Care Technician (F), (E) Findings: Review of the facility’s current policy and procedure: Infection Control for Dialysis Facilities, Policy 1-05-01, directs the staff as follows: HAND HYGIENE 1. All teammate, Physicians and Non-Physician (NPP) will perform hand hygiene a. upon entering and exiting the patient treatment area, b. prior to gloving and immediately after removal of gloves, c. after contamination with blood or other infectious material, d. after patient and dialysis delivery system contact, e. after interacting with wall boxes ..., f. between patients even if the contact is casual, g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse ... 3. Use of an alcohol-based hand rub may be substituted for handwashing. a. Hand washing will be performed if hands are visibly contaminated with blood or body fluids and when caring for patients on isolation precautions for Clostridium difficile ... PPE 7. Disposable gloves will be worn when caring for the patient or touching the patient’s equipment at the dialysis station, this will include patients and visitors assisting with procedures such as self-cannulation or holding access sites. a. Gloves should be changed when: i. When soiled with blood, dialysate or other body fluids ii. When going from a “dirty” area or task to a “clean” area or task ... Patient Care Technician (F) Observation on 02/18/2025 at 9:32 a.m., revealed Patient Care Technician (F) was cleaning and disinfecting station #20 after the patient vacated the station. Patient Care Technician (F) wiped the wall box, removed her gloves, reached into the clean glove box and donned a clean pair of gloves without performing hand hygiene. Subsequent observation revealed Patient Care Technician (F) began to wipe the hemodialysis machine and the bleach towel fell to the ground. Patient Care Technician (F) picked up the bleach towel and a food wrapper from the floor and threw them in the waste receptacle. Patient Care Technician (F) then grabbed a new bleach towel that was sitting on the machine and continued to clean the machine with the contaminated gloves. Care Technician (F) failed to remove her gloves and perform hand hygiene after picking up trash on the floor. Interview with Patient Care Technician (F) at 10:07 a.m.: the Surveyor notified Patient Care Technician (F) that she failed to perform hand hygiene after removing her contaminated gloves from cleaning the wall box and she failed to perform a glove change with hand hygiene after picking up trash from the floor. Patient Care Technician (F) said, “Okay.” Patient Care Technician (D) Observation on 02/18/2025 at 9:54 a.m., revealed Patient Care Technician (D) remove the bloodlines from the hemodialysis machine at station #22 after the hemodialysis treatment. Patient Care Technician (D) placed the dirty blood lines into the biohazard, removed her gloves, grabbed clean gloves from the box on the chairside computer cart, donned the clean gloves and walked over to the patient at station #24 and applied the access clamp the patient’s vascular access. Patient Care Technician (D) failed to perform hand hygiene after removing her contaminated gloves. Interview with Patient Care Technician (D) at 10:10 a.m.: the Surveyor notified Patient Care Technician (D) that she failed to perform hand hygiene after removing his contaminated gloves. Patient Care Technician (D) said, “Yes, ma’am.” Patient Care Technician (E) Station #1 Observation of Patient Care Technician (E) on 02/18/2025 at 10:49 a.m. revealed her at station #1 terminating the patient’s hemodialysis treatment. Patient Care Technician (E) disconnected the patient’s blood lines from their vascular access, she removed her gloves, pulled up her face shield and began to type on the chairside computer keyboard without performing hand hygiene. Subsequent observation revealed Patient Care Technician (E) don clean gloves from the box on the chairside computer cart, push down the leg rest of the hemodialysis chair, pull out the footrest, and roll the Sharp’s container to the chairside from the center of the floor. With the same gloves, she picked up a roll of tape from the clean field, tore strips of tape and applied them to the patient’s vascular access for the patient to hold (apply pressure to) his vascular access. Patient Care Technician (E) did not perform a glove change with hand hygiene after touching contaminated objects. Patient Care Technician (E) then removed the dirty bloodlines and bibag from the hemodialysis machine as well as her contaminated gloves. She grabbed clean gloves from the box on the chairside computer cart, donned the gloves and then walked over to the clean supply counter and picked up supplies to set up the machine at station #3. Patient Care Technician (E) did not perform hand hygiene after removing her contaminated gloves. Station #3 Subsequent observation of Patient Care Technician (E) at station #3 revealed she set the clean supplies in the hemodialysis chair, walked over to the gray waste receptacle on wheels, and moved it closer to the hemodialysis machine. With the same gloves she opened the bloodline and dialyzer packages and threw the wrappers into the waste receptacle. She then began to set up the hemodialysis machine at station #3. After setting up the machine, Patient Care Technician (E) pushed the waste receptacle back to the center of the floor, removed her gloves and began to type on the chairside computer cart. Patient Care Technician (E) failed to change her gloves and perform hand hygiene after touching the waste receptacle with her gloves. Interview with Patient Care Technician (E) at 11:00 a.m.: the Surveyor notified Patient Care Technician (E) that she failed to perform hand hygiene after glove removal and she failed to perform a glove change and hand hygiene after touching contaminated objects. Patient Care Technician (E) said, “Okay.” Patient Care Technician (C) Observation of Patient Care Technician (C) on 02/18/2025 at 11:47 a.m. revealed her to cannulate a patient at station #9. The patient’s vascular access was pulsating and blood began to leak out of it. Patient Care Technician (C) immediately applied gauze and pressure to the patient’s vascular access. The patient’s vascular access continued to bleed and soak the gauze with blood. Patient Care Technician (C) continued to change out the bloody gauze until another Patient Care Technician relieved her and stopped the patient’s bleeding. After providing care to the patient, Patient Care Technician (C) removed her bloody gloves and used hand rub to clean her hands. She then grabbed clean supplies from the clean counter, took them to station #8 and began to set up the hemodialysis machine. She failed to wash her hands after contamination with blood or other infectious material as per policy. The Surveyor immediately notified Patient Care Technician (C) that she failed to wash her hands after her gloves became contaminated with visible blood. Patient Care Technician (C) said, “Oh, I was supposed to wash my hands?””

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 48020 Based on observation, interview and record review, the facility’s direct care staff failed to: prevent cross contamination by storing several chairside computer carts in between hemodialysis machines in use (in the splash zone) B) prevent cross contamination by storing a contaminated face shield on the clean computer cart keyboard: Patient Care Technician (C) Findings: Review of the facility’s current policy and procedure: Infection Control for Dialysis Facilities, Policy 1-05-01, directs the staff as follows: “DISINFECTION 15. The chair side cart, terminals mounted on the counter, monitor and keyboard are considered clean areas. FACILITY HYGIENE 16. Clean areas should be clearly designated for the preparation, handling, and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled.” Chairside Carts: Observation of the hemodialysis treatment area on 02/18/2025 at 7:13 a.m. revealed several chairside computer carts stored in between hemodialysis machines in use (in the splash zone). The chairside computer carts were stored between: Stations 1 & 2 Stations 3 & 4 Stations 5 & 6 Stations 7 & 8 Stations 9 & 10 Stations 11 & 12 Stations 17 & 18 Stations 19 & 20 Stations 21 & 22 Stations 23 & 24 The Surveyor notified Charge Nurse (A) during an interview at 8:00 a.m. that the staff failed to prevent cross contamination by storing several chairside computer carts in between hemodialysis machines in use. Charge Nurse (A) said, “Okay, we will pull them out.” Patient Care Technician (C) Observation of Patient Care Technician (C) on 02/18/2025 at 11:47 a.m. revealed her to cannulate a patient at station #9. After providing care the to patient at station #9, Patient Care Technician (C) walked over to station #7, removed her face shield that had condensation on the inside of it and laid it on the keyboard of the chairside computer. The Surveyor immediately notified Patient Care Technician (C) that she failed to prevent cross contamination by laying her contaminated face shield on the clean chairside computer keyboard. Patient Care Technician (C ) said, “Yes, ma’am.””

“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: 48020 Based on observation, interview and record review, the facility’s direct care staff: failed to clean and disinfect stethoscopes, intravenous poles and rungs, hemodialysis machine, dialysate lines and chase counter tops behind the dialysis stations according to the facility’s policy in 4 of 6 staff observed: Patient Care Technician (F), (E), (O), (P) B) failed to prevent cross contamination by wiping the wall boxes and using the same towel to wipe the chase cabinet and dialysate lines in the back of the hemodialysis machine in 3 of 6 staff observed: Patient Care Technician (F), (O), (P) C) failed to ensure that infection control was maintained as evidenced by hemodialysis chairs with tape and tape residue in 13 of 24 chairs. D) failed to ensure that infection control was maintained as evidenced by tears in the vinyl of the hemodialysis chairs in 2 of 24 chairs. Findings: Review of the facility’s current policy and procedure: Infection Control for Dialysis Facilities, Policy 1-05-01, directs the staff as follows: DISINFECTION 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). i. The Wall box, Drain and Water supply lines are considered part of the dialysis delivery system ...” Patient Care Technician (F) Station #19 Disinfection of the hemodialysis station: Observation on 02/18/2025 at 9:51 a.m. revealed Patient Care Technician (F) terminally cleaning station #19 post hemodialysis treatment of a patient. Patient Care Technician (F) failed to clean and disinfect the stethoscope, intravenous pole and rungs, dialysate lines and chase cabinet countertop behind the hemodialysis machine according to policy. Cross contamination of the hemodialysis station: Subsequent observation of Patient Care Technician (F) terminally cleaning station #19 revealed she wiped the wall box and with the same towel, wiped the chase cabinet The Surveyor immediately notified Patient Care Technician (F) that she failed to clean and disinfect the dialysis station according to policy. She was also notified that she failed to prevent cross contamination by wiping the wall box and with the same towel, wiping the chase cabinet at station #19. Patient Care Technician (F) said, “Okay.” Patient Care Technician (E) Station #3 Observation of Patient Care Technician (E) on 02/18/2025 at 10:42 a.m. revealed her at station #3 taping the vascular access of the patient. Patient Care Technician (E) returned to station #3 and began cleaning and disinfecting the blood pressure cuff, the cuff dropped and touched the ground, she wiped the cuff again and hung it on the IV pole of the hemodialysis machine that she did not disinfect. Subsequent observation revealed Patient Care Technician (E) walk over to the patient at station #1 and assist in terminating the patient’s hemodialysis treatment. Patient Care Technician (E) then returned to station #3 and began to clean and disinfect the hemodialysis chair and then she walked over to the clean counter, picked up supplies, returned to station #1 and began to set up the hemodialysis machine. The Surveyor continuously observed Patient Care Technician (E) at station #1 and station #3 and did not see her clean and disinfect the hemodialysis machine, dialysate lines, chase and wall box at station #1. The Surveyor immediately notified Patient Care Technician (E) that she failed to clean the hemodialysis machine, dialysate lines, chase and wall box at station #1. Patient Care Technician (E) said, “Okay. I did clean the machine.” The Surveyor asked her if she was trained to clean the chase and wall box and Patient Care Technician (E) said, “I know that I am supposed to wipe the wall box and chase.” Patient Care Technician (O) Station #17 Disinfection of the hemodialysis station: Observation on 02/19/2025 at 9:55 a.m. revealed Patient Care Technician (O) terminally cleaning station #17 post hemodialysis treatment of a patient. Patient Care Technician (O) failed to clean and disinfect the intravenous pole and rungs, dialysate lines and chase cabinet countertop behind the hemodialysis machine according to policy. Cross contamination of the hemodialysis station: Subsequent observation of Patient Care Technician (O) terminally cleaning station #17 revealed she wiped the wall box and with the same towel, wiped the chase cabinet. Station #18 Disinfection of the hemodialysis station: Observation on 02/19/2025 at 10:06 a.m. revealed Patient Care Technician (O) terminally cleaning station #18 post hemodialysis treatment of a patient. Patient Care Technician (O) failed to clean and disinfect the intravenous pole rungs and chase cabinet countertop behind the hemodialysis machine according to policy. Cross contamination of the hemodialysis station: Subsequent observation of Patient Care Technician (O) terminally cleaning station #18 revealed she wiped the wall box and with the same towel, wiped the chase cabinet and dialysate lines connected to the wall box. The Surveyor immediately notified Patient Care Technician (O) that she failed to clean and disinfect the dialysis station according to policy. She was also notified that she failed to prevent cross contamination by wiping the wall box and with the same towel wiping the chase cabinet and dialysate lines connected to the wall box at station #s 17 and 18. Patient Care Technician (O) said, “Okay.” Patient Care Technician (P) Station #2 Cross contamination of the hemodialysis station: Observation on 02/19/2025 at 10:29 a.m. revealed Patient Care Technician (P) terminally cleaning station #2 post hemodialysis treatment of a patient. Patient Care Technician (P) wiped the wall box and with the same towel, wiped the chase cabinet and dialysate lines connected to the wall box. The Surveyor immediately notified Patient Care Technician (P) that she failed to prevent cross contamination by wiping the wall box and with the same towel, wiping the chase cabinet and the dialysate lines connected to the wall box. Patient Care Technician (P) said, “Yes, ma’am.” Tape and tape residue on hemodialysis chairs: Observation of the hemodialysis treatment area on 02/18/2025 at 10:11 a.m. revealed the following: Stations #s 9, 10, 11, 12, 14, 17, 18, 22, 24- dirty pieces of tape and tape residue on the chairside tables of the hemodialysis chairs at station. Station #11 had clean supply set-up for the next patient on the chairside table with the dirty tape on it. Station #5- dirty pieces of tape and tape residue on the arms of the hemodialysis chair. Station #s 6, 7, 16- dirty pieces of tape and tape residue on the tray tables and arms of the hemodialysis chairs. Interview during the walkthrough with Facility Administrator (H) and Manager of Clinical Safety (N) at 10:20 a.m. confirmed the findings. Tears in vinyl of hemodialysis chairs: Observation of the hemodialysis treatment area on 02/18/2025 at 10:00 a.m. revealed the following: Two hemodialysis chairs had tears in the vinyl: Stations #22- The hemodialysis chair has three tears in the vinyl of the seat cushion the look like a cross. There is a vertical tear that runs from the back of the seat cushion to the middle and has some of the vinyl is missing exposing the material underneath. There are two horizontal tears, one on each side of the vertical tear. Both of the horizontal tears have the tape that is used to tape vascular accesses on them holding them together. The vinyl on the arms of the chair also has small tears. During the observation, the Surveyor observed a patient receiving a hemodialysis treatment and after the seat was vacated, Patient Care Technician (D) attempted to clean and disinfect the chair. Interview with Patient Care Technician (D) at 10:10 a.m. confirmed the hemodialysis chair should have been removed from the treatment area. Patient Care Technician (D) said, “It’s supposed to be pulled but it is still here, so I just cleaned it.” Station #16- The hemodialysis chair had small tears in the arms and seat cushion of hemodialysis chair. Interview during the walkthrough with Facility Administrator (H) and Manager of Clinical Safety (N) at 10:20 a.m. confirmed the findings above.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 48020 Based on observation, interview and record review, per the TAC 117.33(b)(1)(A), the facility’s nurses failed to perform the daily automated external defibrillator (AED) checks as required by the facility’s policy. Findings: Review of the facility’s current policy and procedure: Emergency Equipment Checks, Policy #05-02-08, directs staff as follows: PURPOSE: Verify that emergency equipment is maintained in a ready-to-use condition. POLICY: 1. Emergency equipment, including, but not limited to, oxygen, airways, suction, automated external defibrillator (AED), and artificial resuscitator (ambu bag), and emergency drugs will be on the premises at all times. 2. The following equipment checks will be performed by a licensed nurse teammate to verify the designated equipment is available and functional: Daily: “ Check Status Indicator light for Philips Heart Start FR2+ ... “ Check Status Indicator for green check for Zoll AED ... “ Manufacturer’s AED pads are present on cart “ Break away lock is intact Emergency Cart: Observation of the emergency cart on 02/18/2025 at 8:03 a.m. revealed a Zoll AED Plus automated external defibrillator sitting on top of the emergency cart. Review of the DAILY ZOLL AED and Emergency Medication Lock Log, Procedure: 1-02-08E revealed daily check was not performed on the following days: 08/06/2024, 08/13/2024, 11/15/2024, 12/02/2024, 12/10/2024, 12/19/2024, 01/07/2025, and 01/30/2025. Interview during the walkthrough with Facility Administrator (H) and Manager of Clinical Safety (N) at 10:20 a.m. confirmed the findings.”