Davita Lakewood Community 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: 46647 . Based on document reviews, observations, and interviews, the facility failed to provide and monitor a sanitary environment to minimize the transmission of infectious agents by failing to prevent the tracking of blood from the isolation room to the general treatment area. Failure to provide a sanitary environment to minimize the transmission of infectious agents places patients at risk of exposure to infectious agents from lack of infection prevention practices. Findings included: 1. Document review of the facility policy titled, “Infection Control for Dialysis Facilities,” revised April 2023, showed no evidence to address infection prevention procedures for visitors in the isolation room. - Document review of the facility policy titled, “Hepatitis B Surveillance, Vaccination. Infection Control Measures, and Isolation Guidance,” revised October 2025, showed no evidence to address infection prevention procedures for visitors in the isolation room. 2. On 12/03/25 at 10:20 AM, Surveyor #7 observed Patient #708’s family member enter the isolation room, remove their isolation gown and retract a cellphone from Patient #708. In the process, they stepped on splattered blood on the floor then proceeded to exit the room into the general treatment area without proper disinfection. 3. On 12/03/25 at 11:10 AM, Surveyor #7 interviewed the Care Coordinator (Staff #722) regarding Patient #708’s family member exiting the isolation room without infection prevention and tracking of blood into the general treatment area. Staff #722 confirmed the findings and stated that they were unable to stop the family member before exiting the isolation room. - On 12/03/25 at 2:00 PM, Surveyor #7 interviewed the Facility Administrator (Staff #721) and the Care Coordinator (Staff #722) regarding the policy for proper infection prevention procedures for visitors before exiting the isolation room. Staff #721 and Staff #722 confirmed that the facility did not have a policy to address the infection prevention procedures for visitors in the isolation room. .”

“IC-HBV-ISOLATION-MACHINES/EQUIP/SUPPLIES CFR(s): 494.30(a)(1)(i) Isolation of HBV+ Patients To isolate HBsAg positive patients, ... dedicate machines, equipment, instruments, supplies, and medications that will not be used by HBV susceptible patients. This Standard is not met as evidenced by: 46647 . Based on observations, document review, and interviews, the facility failed to dedicate equipment used for dialysis treatment of hepatitis B antigen (HBsAg) positive patients. Failure to dedicate equipment used for dialysis treatment of HBsAg positive patients risks cross-contamination and use of the equipment by hepatitis B virus (HBV) susceptible (non-immune) patients. Findings included: 1. Document review of the facility policy “Hepatitis B Surveillance, Vaccination, Infection Control Measures, and Isolation Guidance,” dated 04/24, showed that a designated dialysis machine will be used for treatment in the isolation room. The dialysis machine should have a visible label on the front stating “Isolation Machine only” or “Temporary Isolation Machine.” 2. On 12/03/25 at 10:00 AM, Surveyor #7 observed that the dialysis machines being used in isolation rooms #1 and #2 were missing the isolation signage. 3. On 12/03/25 at 12:40 PM, Surveyor #7 interviewed the Biomed Manager (Staff #723) regarding the missing isolation machine signage. Staff #723 confirmed that the isolation signage was missing from the machines used in the isolation rooms. .”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 46647 . Based on document review and interview, the facility failed to ensure all equipment, including dialysis machines, was maintained in accordance with manufacturer recommendations. Failure to ensure that all equipment is maintained in accordance with manufacturer recommendations places patients at risk of harm from equipment malfunctions. Findings included: 1. Document review of the facility policy “Fresenius Dialysis Delivery System Cleaning and Disinfection Policy,” dated 04/19, showed that dialysis machine disinfection is a daily requirement. 2. Document review of the facility’s dialysis machine preventative maintenance records showed that the facility failed to record the daily disinfection of the following dialysis machines accurately: -Machine serial number 0T0S254167 on 10/28/25 and 10/30/25. -Machine serial number 0T0S254171 on 10/27/25, 10/28/25, and 10/30/25. -Machine serial number 0T0S254173 on 10/27/25, 10/28/25, and 10/30/25. 3. On 12/03/25 at 1:30 PM, Surveyor #7 interviewed the Facility Administrator (Staff #721) and Biomedical Technician (Staff #723) regarding the preventative maintenance record discrepancies. Staff #721 and #732 acknowledged the findings. .”

“PR-PRIVACY & CONFIDENTIALITY-RECORDS CFR(s): 494.70(a)(4) The patient has the right to- (4) Privacy and confidentiality in personal medical records; This Standard is not met as evidenced by: 46647 . Based on observation, document review, and interview, the facility failed to ensure privacy and confidentiality in personal medical records by failing to secure mobile computer station containing personal information. Failure to ensure privacy and confidentiality of medical records risks disclosure of private patient information to other patients and visitors who have no right to the information. Findings included: 1. Document review of the facility’s policy titled, “DaVita Workstation Use and Security Guidelines,” dated 2021, showed the following: - Appropriate measures must be taken when using workstations to ensure confidentiality, integrity and availability of sensitive information, including protected health information (PHI). - Workforce members using workstations will consider sensitivity of information and minimize the possibility of unauthorized access. - Secure workstations prior to leaving area to prevent unauthorized access. 2. On 12/03/25 at 10:35 AM, Surveyor #7 observed that the mobile computer station screen between chair #19 and #20 was open and unattended with patient specific information on display. 3. On 12/03/25 at 11:30 AM, Surveyor #7 interviewed the Registered Nurse (Staff #731) about open and unattended computer station with patient’s medical records on display. Staff #731 acknowledged the findings and stated that all computer stations should be secured when unattended. .”

“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: 46647 . Based on document review and interview, the facility failed to provide the necessary care and services to manage patients’ dose of dialysis by failing to manage patient blood pressure (BP) in 3 of 11 patient medical records reviewed (Patients #701, #706, and #710) (1) and failing to ensure post dialysis fluid volume status is reported and assessed per facility policy in 2 of 11 patient medical records reviewed (Patients #706, and #710) (2). Failure to provide the necessary care and services to manage patients’ dose of dialysis places patients at risk for ineffective treatments and at risk for undetected complications. Findings included: Item #1: Abnormal BPs not reported 1. Document review of the facility policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revised date April 2024, showed the following: - Abnormal findings or findings outside any patient specific physician ordered parameters will be reported to the licensed nurse. - The licensed nurse will use clinical judgment and determine necessary clinical interventions based on the patient’s needs. - All findings, interventions and patient response will be documented in the medical records. - Abnormal BP findings were defined as follows: - Pre-dialysis: Systolic BP greater than (>) 180 millimeters of mercury (mm/Hg) or less than (<) 90 mm/Hg; Diastolic BP > or equal to 100 mm/Hg or < 50 mm/Hg. -Intra-dialysis: Systolic BP >180 mm/Hg or < 90 mm/Hg; Diastolic BP >or= to 100 mm/Hg or < 50 mm/Hg. - Post-dialysis: Standing Systolic BP > 140 mm/Hg or < 90 mm/Hg; Diastolic BP >90 mm/Hg or < 50 mm/Hg. Sitting Systolic BP >140 mm/Hg or < 90 mm/Hg; Diastolic BP >90 mm/Hg or < 50 mm/Hg. 2. Document review of hemodialysis treatment records showed that the Patient Care Technician (PCT) failed to report the abnormal BP readings to the licensed nurse for the following: a. The hemodialysis treatment records for Patient #701 showed the following unreported abnormal BP readings: - On 11/19/25, the post-dialysis sitting BP was 126/99 by Staff #732. - On 11/21/25, the post-dialysis sitting BP was 141/108 by Staff #732. - On 11/24/25, the post-dialysis sitting BP was 156/121 by Staff #732. - On 11/26/25, the pre-dialysis sitting BP was 139/106 and post-dialysis sitting BP was 162/98 by Staff #733. - On 11/28/25, the intra-dialysis BP at 2:02 PM was 98/41by Staff #734 and at 3:00 PM BP was 89/33 by Staff #732. - On 12/01/25 at 11:24 AM, intra-dialysis BP was 85/51 by Staff #735. b. The hemodialysis treatment records for Patient #706 showed the following unreported abnormal BP readings: - On 11/18/25, the intra-dialysis BP at 9:18 AM was 90/53 by Staff #737, then at 9:32 AM was 61/47, and 82/59 at 9:47 AM by Staff # 738. - On 11/29/25, the intra-dialysis BP at 8:01 AM was 76/55, at 8:29 AM was 85/53, and at 8:39 AM was 72/53 by Staff #736. c. The hemodialysis treatment records for Patient #710 showed the following unreported abnormal BP readings: - On 11/17/25, the intra-dialysis BP at 3:33 PM was 84/48 and at 3:35 PM was 96/49 by Staff #737. - On 11/21/25, the intra-dialysis BP at 3:33 PM was 99/43 by Staff #739. - On 12/03/25, the pre-dialysis Standing BP was 159/136 and an intra-dialysis BP at 3:32 PM was 88/56 by Staff # 738. 3. On 12/04/25 at 2:15 PM, Surveyor #7 interviewed the Facility Administrator (Staff #721) and the Care Coordinator (Staff #722) about the missing documentation of reporting and assessment of abnormal BP readings. Staff #721 and Staff #722 acknowledged the findings. Item #2 - Not achieving dry weight 1. Document review of facility policy, “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment,” revised 04/2024, showed the following: - The Patient Care Technician (PCT) or licensed nurse will obtain and document basic data on each patient post dialysis and compare it to pre-dialysis findings. - Abnormal findings or concerns about post treatment need to be reported to the licensed nurse and the licensed nurse will assess the patient prior to discharge. - Members of the patient care team should immediately report any changes in patient conditions or concerns of patient well-being to the licensed nurse including pots-treatment weight if above or below 1 Kilogram (Kg) from target weight (TW). 2. Document review of treatment records showed no evidence that the PCT reported the abnormal post treatment weights to the licensed nurse and no evidence that the licensed nurse addressed fluid volume status of patients not achieving target weight (TW), the ideal weight of a patient without excess fluid retention, post dialysis for the following: a. Patient #706’s medical records showed the following: - On 11/18/25, the TW was 64.5 Kg, post weight was 53.4 Kg which was 11.1 Kg below TW. - On 11/20/25, TW was 64.5 Kg, post weight was 55.8 Kg which was 8.7 Kg below TW. - On 11/22/25, TW was 63.5 Kg, post weight was 57.0 Kg which was 6.5 Kg below TW. - On 11/25/25, TW was 63.5 Kg, post weight was 58.0 Kg which was 5.5 Kg below TW. - On 11/27/25, TW was 62.5 Kg, post weight was 47.4 Kg which was 15.1 Kg below DW. b. Patient #710’s medical records showed a TW of 52 Kg. - On 11/21/25, post weight was 53.5 Kg which was 1.5 Kg above DW. - On 11/26/25, post weight was 53.6 Kg which was 1.6 Kg above DW. - On 11/28/25, post weight was 53.2 Kg which was 1.2 Kg above DW. 3. On 12/04/25 at 2:15 PM, Surveyor #7 interviewed the Facility Administrator (Staff #721) and the Care Coordinator (Staff #722) about the missing post-treatment fluid volume status assessments and documentation prior to patient’s discharge. Staff #721 and Staff #722 acknowledged the findings. .”

“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: 46647 . Based on document review and interview, the facility failed to ensure all members of the interdisciplinary team (IDT) signed each patient’s plan of care (POC) according to regulation requirements and facility policy in 3 of 11 patient medical records reviewed (Patients #704, #708, and #707). Failure to ensure all members of the IDT sign each patient’s POC places patients at risk for having incomplete or unapproved plans of care. Findings included: 1. Document review of the facility policy titled, “Interdisciplinary Team (IDT) and Patient Assessment and Plan of Care (POC),” revised date October 2024, showed that the patient’s POC will be completed and signed by the IDT including the patient or patient’s personal representative. If the patient chooses not to sign the POC, it will documented on the POC that includes the reason why the signature was not provided. 2. Document review of medical records showed no evidence of the patient’s or their designee’s signature for the following POC: a. Patient #704, POC dated 08/05/25. b. Patient #708, POC dated 09/19/25. c. Patient #707, POC dated 08/21/25. 3. On 12/04/25 at 2:15 PM, Surveyor #7 the Facility Administrator (Staff #721) and Care Coordinator (Staff #722) regarding the missing patient’s or designee’s signature in the POC. Staff #721 and Staff #722 acknowledged the findings. .”