Davita Hopkins Road 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: 46466 Based on observations and interviews, the facility failed to provide a sanitary environment to minimize the transmission of infectious agents by not removing torn patient chairs from patient use. The findings include: On December 9, 2025, at 10:25 AM, observations were made on the treatment floor. Two (2) patient chairs were observed with visible tears in the seats at patient stations #8 and #15. On December 9, 2025, at 3:30 PM, Staff Member #1 stated that they were in the process of replacing all of the patient chairs on the treatment floor, but they did not have enough new chairs to replace all of them yet. A review of the facility’s policy “Infection Control For Dialysis Facilities”, Policy: 1-05-01, revised April 2023, did not contain documentation on the replacement of torn patient chairs. A request was made by email to Staff Member #1 on December 11, 2025, for a policy addressing this issue, but one was not provided.”

“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: 46466 Based on four (4) infection control observations, and facility document review, it was determined the facility failed to properly clean and disinfect contaminated surfaces of the medical devices and equipment, and failed to maintain bleach cleaning solution according to facility policy and procedure. The findings include: A review of the facility’s policy “Infection Control For Dialysis Facilities”, Policy: 1-05-01, revised April 2023, stated in part: “...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 limiter 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...ii. Priming containers are to be emptied prior to disinfection...”. A review of the facility’s policy “Preparation of One to One Hundred (1:100) Bleach Solution”, revised October 2023, indicated in part, “...12. with indelible marking pen and label, label container with expiration date, time and initials. The solution is good for 24 hours only. 12. The solution must be changed when the maximum allowable time is exceeded (24 hours)...”. On December 9, 2025, at 10:15 AM, a bleach container was observed and labeled with a mix date of December 6, 2025, at 4:45 AM and expiration date of December 7, 2025, at 4:45 AM. On December 9, 2025 at 10:45 AM, a staff member was observed disinfecting dialysis machine #11. The staff member failed to remove and disinfect the prime waste bucket. On December 9, 2025 at 10:50 AM, a staff member was observed disinfecting patient station #15. The staff member did not disinfect the prime waste bucket, the blue emergency take off bag on the back of the television screen and the blood pressure tubing. On December 9, 2025, at 11:15 AM, a staff member was observed disinfecting dialysis machine #2. The staff member removed the prime waste bucket, but did not disinfect the bucket before placing back onto the machine.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 46466 Based on observations and facility document review, it was determined that the facility staff failed to maintain a safe environment for dialysis patients by not properly labeling open vials of medication and not discarding expired medications. The findings include: A review of the facility’s policy “Medication Preparation and Administration”, revised October 2023, indicated in part “...Policy...18. All syringes prepared from...multidose vials should be prepared and administered within a four (4) hour...period...20...If the medication is not immediately administered or is to be administered by another teammate, the medication must be labeled with the patient name, name of medication, date, time prepared, dose and initials of the teammate preparing the medication...29. Medications containing a preservative must be discarded 28 days after opening or accessed...Each vial is labeled with the initials of the person opening the vial and the expiration date. Examples of manufacturers differing time lengths are but are not limited to: - Epogen multidose vials must be discarded 21 days after opening or access (e.g., needle punctured) ...30. All medications in the facility are checked monthly. Insulin and other medications with preservatives are dated and initialed once opened. All medications are checked monthly for expiration dates. Expired Medications: -Expiration dates for all stored medications are to be monitored on a monthly basis. -Expired medications are to be discarded...”. A review of the package inserts for Tubersol indicated in part: “...STORAGE...A vial of TUBERSOL which has been entered and in use for 30 days should be discarded. (22) Do not use after expiration date...”. On December 9, 2025, at 10:15 AM, one (1) opened vial of heparin and one (1) opened multidose vial of Epogen was found at the medication preparation area on the treatment floor. Neither vial was labeled with an open date nor the initials of the staff member that opened them. On December 2, 2025, at 10:20 AM, one (1) syringe was found on the treatment floor labeled as heparin. The syringe label did not include the time nor initials of the staff member who drew up the medication. On December 9, 2025, at 11:20 AM, an opened vial of Tubersol and seven (7) vials of the medication Korsuva were found in the medication refrigerator. The Tubersol was dated November 3, 2025, and the Korsuva was expired on November 30, 2025.”

“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 review, and facility document review, it was determined the facility staff failed to monitor blood pressures according to facility policy for four (4) of six (6) patient records reviewed. 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: “...POLICY: 1. Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse. a. Data collection includes but is not necessarily limited too...ii. Measurement of Blood Pressure (BP) 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)...”. Patient #1: Three (3) of the six (6) flowsheets reviewed from November 25 to December 6, 2025, did not document standing blood pressures. The record indicated that the patient was ambulatory, no assistance needed. Patient #2: Five (5) of the six (6) flowsheets reviewed from November 26 to December 8, 2025, did not document standing blood pressures. The record indicated that the patient was ambulatory, no assistance needed. Patient #4: Four (4) of the six (6) flowsheets reviewed from November 25 to December 6, 2025, did not document standing blood pressures. The record indicated that the patient was ambulatory, no assistance needed. Patient #6: Six (6) of the six (6) flowsheets reviewed from November 25 to December 6, 2025, did not document standing blood pressures. The record indicated that the patient had a walker and that an ambulatory device was needed for mobility.”

“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 three (3) of six (6) in-center dialysis 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 #1: One (1) of six (6) treatment records evidenced an order for a DFR of 800. On December 2, 2025, the DFR was documented as 500. The patient’s record did not contain documentation of why the DFR was not administered as prescribed and/or that the nurse was notified of the change. Patient #3: Two (2) of six (6) treatment records for evidenced an order for BFR of 450 and a DFR of 800. On December 3 and December 5, 2025, the BFR’s were documented as 400 and DFR’s were documented as 500. The patient’s record did not contain documentation of why the BFR’s and DFR’s were not administered as prescribed and/or that the nurse was notified of the change. Patient #5: Four (4) of six (6) treatment records for evidenced an order for BFR of 450 and DFR of 500. On November 25, 26, and December 4, 2025, the BFR’s were documented as 400. On December 2, 2025, the DFR was documented as 300. The patient’s record did not contain documentation for why the BFR’s and DFR’s were not administered as prescribed and/or that the nurse was notified of the change.”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 46466 Based on interviews, medical record reviews and facility document reviews, it was determined the facility failed to document signatures from all members of the interdisciplinary team (IDT) and the patient for three (3) of six (6) medical records reviewed. The findings include: A review of the facility policy “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care”, revised October 2024, indicated in part: “...Plan of Care...14. The patient’s plan of care will be completed by facility interdisciplinary team, including patient or personal representative and be signed by team members including the patient or the patient’s representative. If the patient chooses not to sign the plan of care, this choice will be documented on the plan of care, along with the reason the signature was not provided...”. A review of the governing body meeting minutes from December 9, 2025, confirmed that the lack of signatures found on the POC’s (Plan of Care) was discussed with the Medical Director on this date and a plan of correction was put into place. On December 9, 2025, a review of patients #4, #5 and #6 records revealed Plans of Care that were not signed by of all members of the IDT and the patients. Patient #4 and #5’s POCs were completed on October 31, 2025. Patient #5’s POC was completed on June 28, 2025. On December 9, 2025, at 3:30 PM, Staff Members #1 and #2 advised that they had a governing body meeting this morning (December 9, 2025) to put a plan of correction in place to make sure POC’s are signed.”