Davita Pearsall 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.) nurse ratio to patient’s were appropriate to ensure patients’ needs are meet appropriate to the level of dialysis; and in accordance with Texas Administrative Code (TAC), 117.41(g). The charge nurse was the only registered nurse on shift without other licensed nurses and was assigned to all direct patient care during dialysis treatments for all 12 dialysis stations which included up to 5 of the 12 patients with cardiovascular venous catheters (CVC). Refer to Federal Tag V-0757 for specific evidence and State Tag E-0406 2.) 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 158 patients. Refer to Federal Tag V-0757 for specific evidence and State Tag E-0843”

“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: On 7/28/25 during the tour of the facility at 11:00AM revealed the following: 11:00AM Observation of the outside grounds of the facility revealed approximately 15 wooden pallets stacked up near the the outside storage shed and about 8 red biohazard buckets stacked up. The pallets and biohazard buckets were not enclosed and was accessible to the public. The stacked wood pallets and biohazard buckers presents with potential pest harborage and fire risk and was not maintained to ensure safety of patients, staff or visitors. Interview with facility staff #1 at the time of the observation revealed they were not sure how long the pallets and biohazards buckets were there and did not see an issue with the pallets and biohazard buckets being stacked there. Interview with facility staff #2 at the time of the observation revealed that they were not sure how long the pallets and buckets were there and thought they might be picked up next week. 11:05AM observation in the patient lobby revealed a dust covered AC Vent overhead. 12:20PM Observations in the patient dialysis center area revealed: 12:21PM Observation in a clean clean sink revealed a rust covered drain. A ceiling tile had a brown stain and AC vents were dusty. 12:26PM Patient dialysis chair in Bay 6 had a trash can right up against a dialysis machine. 12:30PM Surveyor ran the hot water on the hand washing sink for 2 minutes no hot water nor warm water. -Water black when first turned on for the first 5 seconds. . Interview at the time of the observation with facility staff #1 revealed the water in “this area” is really bad and no one drinks the water and brings their own water to drink. Interview with facility staff #2 reveals the water is always cold and even the staff hate the cold water as they can not wash dishes in the break room. 12:40PM Throughout the facility under the wall boxes were exposed PVC pipes, which were dusty and rust colored on the PVC pipes and the floor. Under the wall boxes were also lifted flooring, exposing concrete. At the nurses station, the ledge under the counters revealed the floor was dusty. 12:48PM Observations in the Patient’s bathroom revealed there was no hot or warm water when the surveyor ran the hot water faucet. The cold water faucet was missing the “emblem” in the middle of the faucet exposing a screw which was covered in “gunk”. The AC vent in the patient bathroom was dusty and fuzzy with dust. 1:00PM observation in bay 10 revealed a nurse took the hand held thermometer to the patient sitting in the dialysis chair, the nurse did not wipe down the thermometer when returning the hand help thermometer back to the clean area. Interview with facility staff #2 at the time of the observation revealed staff are supposed to wipe down the hand help thermometer before returning to the clean area, regardless if it touches a patient or not. 1:28PM Observation of the facility Crash cart revealed it was dusty between the wall and the floor behind the crash cart. 1:30PM Observation of the facility laboratory Freezer/fridge had an abundance of ice build up in freezer portion revealing a huge “block of ice” protruding past the freezer section. Interview with facility staff #1 at the time of the observation, “no patient belongings go in that fridge so that shouldn’t matter”, When questioned about the ice. Record review of the laboratory refrigerator log revealed the refrigerator limits should be between 36 to 46 degrees. Several days in the log for July had a temperature reading at 32 degrees, with no action taken. July 3 - 34 degrees. -No action taken July 8 - 34 degrees -No action taken July 10 - 32 degrees -No action taken July 11 - 32 degrees -No action taken July 15 - 32 degrees -No action taken July 17 - 34 degrees -No action taken July 24 - 34 degrees. -No action taken 1:50PM Observations of open dialysis chairs 4,6 and 9 revealed the chair were dusty in the metal frame. Record review of facility policy titled Infection Control for Dialysis Facilities, revised April 2023, states in part... 13. At the end of each treatment, the dialysis station will be cleaned and disinfected. e.g. dialysis chairs. Teammates will monitor and address wall box residue/build up and patency issues. 14. Non-disposable items are to be disinfected after each patient use. 19. Sinks must be plumbed with both hot and cold water. 23. The facility Medical Director and the Quality Improvement Committee will be made aware of infection control issues. Record review of facility policy titled Infection Control for Dialysis Facilities, revised April 2023, states in part... 13. At the end of each treatment, the dialysis station will be cleaned and disinfected. e.g. dialysis chairs. Teammates will monitor and address wall box residue/build up and patency issues. 14. Non-disposable items are to be disinfected after each patient use. 19. Sinks must be plumbed with both hot and cold water. 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”

“IC-SINKS AVAILABLE CFR(s): 494.30(a)(1)(i) A sufficient number of sinks with warm water and soap should be available to facilitate hand washing. This Standard is not met as evidenced by: 26870 Based on observation and interview, the facility staff failed to ensure that 3 of 3 sinks in the in-center treatment area had warm water available. This deficient practice had the likelihood to cause harm to patients, staff members, and the public by increasing the risk of transmission of infectious agents within the facility. Findings include: Observations on 7/28/25 at 12:30PM revealed when surveyor ran the hot water for the hand washing sink for 2 minutes, no hot water nor warm water was felt. The water was black when first turned on during the first 5 seconds. Record review of facility policy titled Infection Control for Dialysis Facilities, revised April 2023, states in part... 19. Sinks must be plumbed with both hot and cold water. Interview at the time of the observation with facility staff #1 revealed the water in “this area” is really bad and no one drinks the water and brings their own water to drink. Interview with facility staff #2 revealed the water is always cold and even the staff hate the cold water as they can not wash dishes in the break room. 45179”

“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 possible exposure to infectious material. Findings include: On 7/28/25 during the tour of the facility at 11:00AM with staff #1 and staff #2 present revealed the following: 11:00AM Observation of the outside grounds of the facility revealed approximately 15 wooden pallets stacked up near the the outside storage shed and about 8 red biohazard buckets stacked up. The pallets and biohazard buckets were not enclosed and was accessible to the public. The stacked wood pallets and biohazard buckers presents with potential pest harborage and fire risk and was not maintained to ensure safety of patients, staff or visitors. Interview with facility staff #1 at the time of the observation revealed they were not sure how long the pallets and biohazards buckets were there and did not see an issue with the pallets and biohazard buckets being stacked there. Interview with facility staff #2 at the time of the observation revealed that they were not sure how long the pallets and buckets were there and though they might be picked up next week. 11:05AM observation in the patient lobby revealed a dust covered AC Vent overhead. 12:20PM Observations in the patient dialysis center area revealed: 12:00PM through 1:30PM observations of patient sitting in Bay 9 revealed his access site was covered with a blanket while he slept. At no time was the patient encouraged to uncover his access site. Interview with facility staff #2 at 3:00 PM revealed staff should have talked to or educated the patient on keeping his access site visible. 12:21PM Observation in a clean clean sink revealed a rust covered drain. A ceiling tile had a brown stain and AC vents were covered with dust. 12:26PM Patient dialysis chair in Bay 6 had a trash can right up against a dialysis machine. 12:30PM Surveyor ran the hot water on the hand washing sink for 2 minutes, no hot water nor warm water. -Water black when first turned on for the first 5 seconds. . Interview at the time of the observation with facility staff #1 revealed the water in “this area” is really bad and no one drinks the water and brings their own water to drink. Interview with facility staff #2 reveals the water is always cold and even the staff hate the cold water as they can not wash dishes in the break room. 12:40PM Throughout the facility under the wall boxes were exposed PVC pipes, which were dusty and rust colored on the PVC pipes and the floor. Under the wall boxes were also lifted flooring, which exposed concrete. At the nurses station, the ledge under the counters were dusty. 12:48PM Observations in the Patient’s bathroom revealed there was no hot or warm water when the surveyor ran the hot water faucet. The cold water faucet was missing the “emblem” in the middle of the faucet exposing a screw which was covered in “gunk”. The AC vent in the patient bathroom was fuzzy with dust. 1:00PM observation in bay 10 revealed a nurse took the hand held thermometer to the patient sitting in the dialysis chair, the nurse did not wipe down the thermometer when returning the hand help thermometer back to the clean area. Interview with facility staff #2 at the time of the observation revealed staff are supposed to wipe down the hand help thermometer before returning to the clean area, regardless if it touches a patient or not. 1:28PM Observation of the facility Crash cart revealed the floor was dusty between the wall and the crash cart. 1:30PM Observation of the facility laboratory Freezer/fridge had an abundance of ice build up in freezer portion revealing a huge “block of ice” protruding past the freezer section. Interview with facility staff #1 at the time of the observation, Facility staff #1 stated “no patient belongings go in that fridge so that shouldn’t matter”. When questioned about the ice. Record review of the laboratory refrigerator log revealed the refrigerator limits should be between 36 to 46 degrees. Several days in the log for July had a temperature reading at 32 degrees, with no action taken. July 3 - 34 degrees. -No action taken July 8 - 34 degrees -No action taken July 10 - 32 degrees -No action taken July 11 - 32 degrees -No action taken July 15 - 32 degrees -No action taken July 17 - 34 degrees -No action taken July 24 - 34 degrees. -No action taken 1:50PM Observations of open dialysis chairs 4,6 and 9 revealed the chair were dusty in the metal frame. Record review of facility policy Pre-Intra-Post Treatment Date Collection, Monitoring and Nursing Assessment Policy states in part.... 2. iv. verification that the patient access is visible. 9.b.v. Vascular access visible and line connections intact. Record review of facility policy titled Infection Control for Dialysis Facilities, revised April 2023, states in part... 13. At the end of each treatment, the dialysis station will be cleaned and disinfected. e.g. dialysis chairs. Teammates will monitor and address wall box residue/build up and patency issues. 14. Non-disposable items are to be disinfected after each patient use. 19. Sinks must be plumbed with both hot and cold water. 23. The facility Medical Director and the Quality Improvement Committee will be made aware of infection control issues. 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.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 26870 Based on observation, interview, and policy review, the facility’s direct patient care (DPC) failed to ensure continuous visual observation of patient vascular access sites during hemodialysis treatment for 1 of 15 patients (Patient #4) observed actively dialyzing. Ensuring proper visualization of the hemodialysis access is important for the early recognition and prevention of bleeding from the patient’s vascular access site, accidental needle dislodgement or a line disconnection to go undetected. This dislodgement or disconnection could result in exsanguination and possible immediate death. Findings included: Observations on 7/28/25 at 12:25PM through 1:30PM, revealed patient #4 was observed sitting in Bay 9, his access site was covered with a blanket while he slept. At no time was the patient encouraged by facility staff to uncover his access site nor educated about keeping his access site visible. Interview with facility staff #2 at 3:00 PM revealed staff should have talked to or educated the patient on keeping his access site visible. Record review of facility policy Pre-Intra-Post Treatment Date Collection, Monitoring and Nursing Assessment Policy states in part.... 2. iv. verification that the patient access is visible. 9.b.v. Vascular access visible and line connections intact.”

“GOV-STAFF # & RATIO MEET PT NEEDS CFR(s): 494.180(b)(1) The governing body or designated person responsible must ensure that- (1) An adequate number of qualified personnel are present whenever patients are undergoing dialysis so that the patient/staff ratio is appropriate to the level of dialysis care given and meets the needs of patients; This Standard is not met as evidenced by: 45179 Based on observation, record review, and staff interviews, the Governing Body failed to ensure: 1.) nurse ratio to patient’s were appropriate to ensure patients’ needs are meet appropriate to the level of dialysis. The charge nurse was the only registered nurse on shift without other licensed nurses and was assigned to all direct patient care during dialysis treatments for all 12 dialysis stations which included up to 5 of the 12 patients with cardiovascular venous catheters (CVC). 2.) the dietitian met the required ratio of no more than 125 patients. The facility’s RD was providing services for 158 patients. Findings include: 1.) The facility’s patient schedule revealed that the facility has a current census of 57 patients, 12 dialysis stations, and operates 3 shifts on Monday, Wednesday, and Friday; and 2 shifts on Tuesday, Thursday, and Saturday. The first patient shift starts at 6:00 AM. Review of the patient daily assignments for 07/28/2025 revealed Registered Charge Nurse (CN) #7 was the only RN, and the only licensed nurse on shift. CN #7 was responsible and provided all licensed nursing duties for all 12 patients for 1st, and 2nd shifts and 9 patients on 3rd shift including initiating and terminating all 3 CVC’s for the 2nd shift, 5 CVC patients on 3rd shift, medication administration, patient assessments and reassessments. In the event of a patient emergency or change in condition requiring immediate nursing assistance where the CN was in the process of initiation or termination of a CVC patient, the CN would not be immediately available to intervene or assist another patient’s emergent needs; delaying care and affecting patient safety. There was no consideration given to the acuity and care needs of the patients by only having one licensed nurse in the facility. Review of the patient daily assignments for 07/29/2025 revealed Registered Charge Nurse (CN) #8 was the only RN, and the only licensed nurse on shift. CN #8 was responsible and provided all licensed nursing duties for all 12 patients for 1st and 2nd shifts, including initiating and terminating all 5 CVC patients on 2nd shift, medication administration, patient assessments and reassessments. In the event of a patient emergency or change in condition requiring immediate nursing assistance where the CN was in the process of initiation or termination of a CVC patient, the CN would not be immediately available to intervene or assist another patient’s emergent needs; delaying care and affecting patient safety. There was no consideration given to the acuity and care needs of the patients by only having one licensed nurse in the facility. Observation of the facility’s in-center treatment floor on 7/28/25 from 12:00 PM-2:00 PM, the surveyor observed Staff #7 answering phones, conducting patient assessments, administering patient medications, performing CVC care, and initiating dialysis treatments. There was no other licensed nurse observed in the facility to oversee staff and patient care when Staff #7 was observed taking her lunch break away from the treatment floor, or when taking personal breaks. An interview was conducted with Facility Staff #7 on 07/30/2025 at 11:00 AM. Facility Staff #7 reported being the only licensed nurse working at the facility. Facility Staff #7 reported that the assigned duties included overseeing the Patient Care Tech (PCT), answering the phones, conducting all patient assessments and reassessments, administering medications to patients, and performing all cardiovascular venous catheter (CVC) procedures. Additionally, Facility Staff #7 reported being responsible for monitoring patient safety and removal process of CVC’s. “If I had more help, I could be more aggressive with getting them removed faster but patient safety is never jeopardized.” An interview was conducted with Facility Staff #8 7/30/2025 at 11:40 AM revealed in part, “There is only one nurse scheduled per day and can be dangerous. It is hard to manage all the responsibilities especially when the Facility Administrator (FA) is not in the building.” An interview was conducted on 7/29/2025 with Facility Staff #4 at 10:45 AM confirmed that Facility Staff #7 was the only licensed nursing staff working at the facility but stated that the “Facility Administrator is a nurse and can help.” 2.) Record review of the facility’s current Staffing Roster revealed Registered Dietician/ Facility Staff #3 was assigned to all 57 patients. An interview with Facility Staff #3 conducted on 7/29/2025 @ 1:00 PM confirmed that Facility Staff #3 was assigned to all 57 patients for this facility-A, and another 101 additional patients at facility- B; in another city, for a total of 158 patients. An interview with Facility Staff #4 conducted on 7/29/2025 @ 1:05 PM confirmed that Facility Staff #3 was responsible for covering all 158 patients with a potential plan to meet minimum staffing guidelines in approximately 1 year. An employment offer will be made to a new Dietitian Graduate if she passes the state boards. She will be assigned to this facility and another facility to increase her staffing ratio. She will be mentored by another Dietitian until she has the 1 year of renal experience to meet state regulations. “It is hard to staff a rural facility.””