Davita Charter Colony Dialysis Center

“EP Training and Testing CFR(s): §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: 46466 Based on interview, medical record and facility documentation review, it was determined the facility failed to perform quarterly patient fire safety training, per facility policy, for six (6) of seven (7) patient records sampled. The findings include: A review of the facility’s policy “Facility Emergency Management Plan (ICHD, Home)”, revised October 2024, indicated in part: “...Fire Safety Preparedness, 1. FA, or designee, is responsible to...b. Conduct and review quarterly fire safety and evacuation training and drills for compliance, identify additional training and education needs...”. Reviews of Patient #1, #2, #3, #4 #5 and #6’s medical records conducted on August 25-26, 2025, revealed that all patients did not have quarterly fire drills performed in 2025. On August 26, 2025, interviews conducted with Staff Members #1 and #2 who confirmed that the 2025 quarterly fire drills for the patients listed were not found.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 46466 Based on observations and facility document review, it was determined the facility failed to maintain aseptic technique for a CVC (central venous catheter) dressing change. The findings include: A review of the facility’s policy “Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure”, last revised April 2025, indicated in part: “...Procedure...4. Remove old dressing and discard, 5. Observe site for signs and symptoms of infection...6. Verify that both arterial and venous catheter limbs are clamped, 7. Remove gloves and discard. Perform hand hygiene per procedure and re-glove...”. Observations conducted on August 25, 2025 at 11:15 AM and at 11:45 AM found Staff Member #10 performing CVC exit site care on the patients at stations #9 and #11, respectively. Staff Member #10 was observed removing both patients exit site bandages and disinfecting the area without removing gloves, performing hand hygiene and replacing clean gloves.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 46466 Based on medical record and facility document reviews, the facility failed to document abnormal findings and notification to the Charge RN or physician per facility policy for: (A) unmet target weights (TW) post treatment, (B) abnormal blood pressure (BP) measurements and (C) the reason for standing blood pressures not being obtained. The findings include: A review of the facility’s policy “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT”, last revised April 2024, indicated in part: “ ...1. Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse...1. Sitting and standing BP measurement required pre and post treatment (if patient unable to stand, document reason in the patient electronic record or flow sheet)...PRE-TREATMENT DATA COLLECTION/ASSESSMENT...4. Any abnormal findings or findings outside of any patient specific physician ordered parameters discovered during the pre-treatment data collection will be documented and immediately reported to the licensed nurse (refer to “Abnormal Findings” section of this policy). If an abnormal finding is reported to the licensed nurse pre-treatment, the nurse will assess the patient prior to the initiation of dialysis ...INTRADIALYTIC DATA COLLECTION/ASSESSMENT...11. Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately (refer to “Abnormal Findings” section in this policy)...POST TREATMENT DATA COLLECTION/ASSESSMENT...16. If an abnormal finding(s) or concern is identified post treatment, this needs to be reported to the licensed nurse. The licensed nurse will assess the patient prior to discharge...ABNORMAL FINDINGS...The following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record...Fluid status...Post-treatment, - If patient is above or below 1 kg from the target weight...Blood pressure: Pre dialysis: - Systolic greater than 180 mm/Hg or less than 90 mm/Hg...Blood Pressure - Intradialytic: - Systolic greater than 180 mm/Hg or less than 90 mm/Hg...Blood Pressure Post Treatment: If the patient can stand: - Standing systolic BP greater than 140 mm/Hg or less than 90 mm/Hg...If patient is not able to stand, document reason and sitting BP...”. Patient 1: Six (6) treatment records were reviewed from August 12-23, 2025. (C) Four (4) of six (6) treatment records (August 16, 19, 21 and 23) failed to document the patient’s standing blood pressure. All treatment records documented that the patient was ambulatory. Patient #2: Six (6) treatment records were reviewed from July 11-August 22, 2025. (A) Two (2) of six (6) treatment records (July 16, August 1) recorded post treatment weights of 1 kg or more over the TW with no documentation that the charge nurse was notified of the abnormal findings. (B) One (1) of six (6) treatment records (August 1) recorded abnormal Intradialytic BP’s with no documentation that the charge nurse was notified of the abnormal findings. Patient #3: Four (4) treatment records were reviewed from August 15 - 22, 2025. (A) Three (3) of four (4) treatment records (August 15, 18, 20) recorded post treatment weights of 1 kg or more over the TW with no documentation that the charge nurse was notified of the abnormal findings. (B) Two (2) of four (4) treatment records (August 15, 22) recorded abnormal pre, Intradialytic and/or post BP’s with no documentation that the charge nurse was notified of the abnormal findings. (C) Three (3) of four (4) treatment records (August 15, 20, 22) failed to document the patient’s standing blood pressure. All treatment records documented that the patient used either a wheelchair or walker and was ambulatory. Patient #5: Seven (7) treatment records were reviewed from August 8-22, 2025. (B) Five (5) of seven (7) treatment records (August 8, 11, 13, 20, 22) recorded abnormal pre, Intradialytic and/or post BP’s with no documentation that the charge nurse was notified of the abnormal findings. (C) Six (6) of seven (7) treatment records (August 11, 13, 15, 18, 20, 22) failed to document the patient’s standing blood pressure. All treatment records documented that the patient ambulated with no assistance, except for August 11, which documented that the patient used a walker, but was ambulatory. Patient #6: Four (4) treatment records were reviewed from August 12-23, 2025. (A) One (1) of four (4) treatment records (August 12) recorded post treatment weights of 1 kg or more over the TW with no documentation that the charge nurse was notified of the abnormal findings. Patient #7: Five (5) treatment records were reviewed from August 13-22, 2025. (A) Two (2) of five (5) treatment records (August 13, 20) recorded post treatment weights of 1 kg or more over the TW with no documentation that the charge nurse was notified of the abnormal findings. (B) One (1) of five (5) treatment records (August 18) recorded abnormal pre, Intradialytic and/or post BP’s with no documentation that the charge nurse was notified of the abnormal findings.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 46466 Based on medical record and facility document review, it was determined the facility staff failed to follow physician’s orders for the prescribed dose of dialysis BFR (blood flow rate) and/or DFR (dialysis flow rate) for two (2) of seven (7) patients included in the sample. The findings include: A review of the facility’s policy “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment”, revised April, 2024, indicated in part: “...10. If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed...”. Patient #3: The physician ordered a DFR of 800. On August 15, 18 and 22, 2025, the DFR’s were documented at 500. The patient’s medical record failed to document the reason why the DFR’s were not administered as prescribed. Patient #5: The physician ordered a BFR of 250. On August 15, 2025, the BFR was documented at 400. The patient’s medical record failed to document the reason why the BFR was not administered as prescribed.”

“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: 46466 Based on interview and facility document review, it was determined the facility failed to follow facility policy when investigating and providing solutions for patient grievances. The findings include: A review of the facility’s policy “Patient Grievance”, revised April, 2025, indicated in part: “...Internal Grievance Process...C. The FA (or their designee) is to discuss the grievance with the patient, investigate and take appropriate action towards a solution, if possible...”. On August 25, 2025 at 1:40 PM, a review of the facility’s grievance log was conducted. The review found one (1) grievance documented in February, 2025. The log indicated that Staff Member #4 had a discussion with the patient, but failed to document the solution or the completion date of the grievance. During an interview with Staff Member #2 on August 26, 2025, Staff Member #2 stated that the grievance log should have documentation about the solution and completion date of the grievance.”