Davita Loma Vista Dialysis Center

“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, record review, and staff interview, the facility staff failed to ensure a clean and sanitary environment was monitored and maintained in the treatment area. The CDC defines a “sanitary environment” as an environment that meets the “Standard Precautions” for an inpatient hospital setting plus the more stringent precautions that are recommended for hemodialysis units because of the increased potential for contamination with blood and pathogenic microorganisms. During observation of the facility on 3/5/25 the following were observed: -Throughout the treatment areas the flooring had black substance at the seams on the floor where the laminate connected and where the laminated had been patched. - Underneath Bay 1 nursing station the flooring had a brown substance with raised laminate observed. - The flooring across from the staff restrooms had a black substance at the laminate seams and in the corners of the wall base. - Six cabinet drawers in the clean area on the treatment floor do not properly close, one missing a handle and the others would not properly close. -The door to the loading dock located in the supply room had light coming from underneath the door which could allow pest to enter the facility. In an interview with Staff #10 on 03/05/25 during the facility observation, the above findings were confirmed. Staff #10 shared work orders had been requested for repair of the findings, currently waiting approval. In an article published by Spectrum Health in July, 2014 it was stated “The heavier corrugated cardboard shipping boxes might harbor vermin or insects and spread the pests to areas where the boxes are stored after delivery. Corrugated cardboard boxes are not appropriate as storage units in medical or clean supply rooms. These boxes are not appropriate because they are an excellent harbor for insects and pests.” Tour of the facility supply room on 03/05/25 revealed the following: - Clean supplies were stored with corrugated shipping boxes on the shelves in the storage room. - Clean supplies were observed in opened shipment boxes in the supply room. - Clean supplies were placed on shelves instead of in closed containers. This practice could lead to cross contamination. The above findings were confirmed during the tour on 03/05/25 with staff #10.”

“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: 43999 Based on observation, interview and record review, the facility’s direct care staff failed to perform hand hygiene between between each patient or station. Findings: Facility policy and procedure: “ TITLE: INFECTION CONTROL FOR DIALYSIS FACILITIES- Policy 1-05-01 11/06/2023, revised April 2023, directs the staff as follows: HAND HYGIENE 1. All teammates, 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 (i.e., plugging/unplugging acid/bicarb lines form dialysis machine, changing acid types, when exchanging a dialysis machine) f. between patients even if the contact is casual, g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse” During a tour of the facility’s in-center treatment area on 03/13/25 at 1420, 3 of 5 staff observed providing direct patient care did not perform hand hygiene per facility policy. Staff # 9 failed to perform hand hygiene after providing care to patient at chair # 2, the staff removed and disposed of gloves but did not sanitize hands before using the bedside laptop ( laptop is designated clean ). Staff #19 did not perform hand hygiene or change gloves between patient contact at chair #9 and contact with the dialysis machine and clean supplies. Staff # 24 was observed touching the dialysis machine and keyboard at chair 48 with the same gloves that were used to touch the patient at chair # 44. Staff # 24 did not perform hand hygiene or change gloves between the two patient interactions. During the observation on 3/13/15 the surveyor immediately notified the three staff when they failed to perform hand hygiene per facility policy. Each staff acknowledged the findings and immediately followed hand hygiene per facility policy.”

“IC-HANDLING INFECTIOUS WASTE CFR(s): 494.30(a)(4)(i) [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- (i) Handling, storage and disposal of potentially infectious waste; This Standard is not met as evidenced by: 43999 Based on facility observation and staff interviews, the facility failed to meet the handling, storage and disposal of potentially infectious waste. Findings : Facility policy entitled, “On-Site Storage of Medical Waste- PURPOSE: To provide guidelines on the storage of on-site medical waste. Policy: 4-03-09 Origination Date: August 2006 POLICY: 3. Outdoor storage areas (including containers and trailers) will, in addition to the above criteria, be locked and conspicuously marked with the international biohazard symbol (minimum of six [6] inches in diameter) as described in policy: Packaging and Labeling of Medical Waste. 4. Containers will be rigid, leak resistant, fluid-resistant and impervious to moisture and of sufficient strength to prevent tearing or bursting under normal conditions of handling and will be sealed to prevent leakage during transport. “ On 03/04/25 during the tour of the facility outside storage area with staff #10 , the following was observed: The facility storage area just outside the back exit door of the facility home program contained the facility onsite biohazard waste building that housed the facility’s sealed biohazard waste prepared for the vendor disposal. The building has a gate made of cyclone fencing with a combination lock for security, the combination lock was not engaged. Six contaminated closed biohazard sharps containers were not in the vendor provided transport containers , sealed and ready for transport. The containers were accessible to the public due to the cyclone gate. The clean vendor supplied containers were stored next to the contaminated waste sealed for transport by the vendor. The above findings were confirmed during an interview with Staff #10, #1 and # 3 on 03/04/25.”

“QAPI-MONITOR/ACT/TRACK/SUSTAIN IMPROVE CFR(s): 494.110(b) The dialysis facility must continuously monitor its performance, take actions that result in performance improvements, and track performance to ensure that improvements are sustained over time. This Standard is not met as evidenced by: 31690 Based on interview and review of documentation, it was determined that the facility failed to continuously monitor its performance and take action that resulted in performance improvement. Findings : Review of the QAPI meeting notes for the months of August 2024 through January 2025, the facility did not reevaluate and update actions/ interventions implemented to improve adherence to infection control policy and procedures and follow physician prescription orders based on the improvement plans. The facility monthly audits with improvement plans were compiled in QAPI for the months of August 2024 through January 2025, with no changes or updated action/interventions documented. In an interview with the Facility Administrator (FA) on the morning of 3/5/25, it was acknowledged that the existing QAPI program was not updating action plans based on the data. The FA verified that the QAPI action plan and interventions are not updated when the previous plan does not work.”