Davita Green Lake County Dialysis

“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: 29963 Based on record review, observation and interview the facility staff failed to perform glove changes and/or hand hygiene when moving from “dirty” to “clean” tasks while providing cares for 3 of 10 patients (Patients #7, 10, 11); failed to ensure patients completed hand hygiene after glove removal and holding dialysis access sites until bleeding stopped for 2 of 2 patients (Patient #7, 11) observed holding access sites; and failed to wear gloves when touching the dialysis machine for 3 of 10 patients (Patients #6, 8, 10) in a total of 17 observations of patient care. Findings include: A review of the facility’s policy 1-05-01 titled, “Infection Control for Dialysis Facilities,” last revised April 2023 revealed, “All teammates ... will perform hand hygiene ... b. prior to gloving and immediately after removal of gloves, ... after patient and dialysis delivery system contact ... before touching clean areas such as supplies, supply cart, and chairside keyboard/mouse ...7. Disposable gloves will be worn when caring for the patient or touching the patient’s equipment at the dialysis station... a. Gloves should be changed when: ii. When going from a ‘dirty’ area or task to a ‘clean’ area or task... iv. After touching one patient or their dialysis delivery system and before arriving to care for another patient or touch another patient’s dialysis delivery system.” A review of the facility’s policy #1-04-01B titled, “Post Dialysis Vascular Access Care: Fistula/Graft Using Safety Fistula Needles” last revised April 2023 revealed, “... When the patient holds their cannulation sites, the patient will be offered gloves and performs hand hygiene when completed...” Examples of staff failing to complete hand hygiene: During an observation on 01/20/2026 at 10:00 AM, Patient Care Technician (PCT) C touched Patient #12’s dialysis machine then walked over to Patient #11’s dialysis machine with the same gloves and touched Patient #11’s dialysis machine without changing gloves or completing hand hygiene. During an observation on 01/20/2026 at 11:10 AM, Patient Care Technician (PCT) C was initiating dialysis on Patient #1’s Central Venous Catheter (CVC). PCT C administered heparin to Patient #1’s CVC. PCT C with same gloves walked over to Patient #7’s dialysis machine and touched the machine screen to silence an alarm. PCT C then removed gloves and put on new gloves without completing hand hygiene. During an observation on 01/20/2026 at 1:45 PM, PCT C was observed touching Patient #9’s dialysis machine and then touched Patient #10’s dialysis machine without changing gloves or completing hand hygiene. Examples of staff failing to ensure patients completed hand hygiene after glove removal after holding dialysis access sites: During an observation on 01/20/2026 at 1:35 PM, Patient #11 was observed holding dialysis access site with a gloved hand. Patient #11 removed the glove and used the scale prior to leaving the facility. Patient #11 did not perform hand hygiene prior to exiting the treatment area. During an observation on 01/20/2026 at 2:05 PM, Patient #7 was observed holding dialysis access site with a gloved hand. Patient #7 removed the glove and used the scale prior to leaving the facility. Patient #7 did not perform hand hygiene prior to exiting the treatment area. Examples of staff touching the dialysis machines with a bare hand or a glove wrapped around the finger: During an observation on 01/20/2026 at 10:35 AM, PCT D was observed to touch Patient #6’s dialysis machine without gloves. During an observation on 01/20/2026 at 10:01 AM, Biomed F touched Patient #10’s dialysis machine with her finger without putting on a glove. During an observation on 01/20/2026 at 10:20 AM, PCT C touched Patient #8’s dialysis machine with her finger without putting on a glove. During an interview on 01/21/2026 at 12:00 PM, the observation findings were discussed with Manager of Clinical Services A who stated the expectation is that staff perform hand hygiene with glove removal and that staff should be offering hand gel to every patient at the completion of dialysis. Manager of Clinical Services A stated gloves should be fully worn on the hand when touching the dialysis machine and staff should not be touching the dialysis machine without gloves.”

“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: 29963 Based on record review, observation and interview, facility staff failed to perform CVC exit site care using aseptic technique for 1 of 3 patients (Patient #1) with a CVC observed in a total sample of 7 observations of care of patients with a CVC. Findings Include: A review of the facility’s policy #1-04-02B titled, “Central Venous Catheter (CVC) With Clearguard HD Antimicrobial End Caps Procedure,” last revised April 2025 revealed, “Verify patient’s clothing is secured away from the exit site/work area ...Rationale- Securing the patient’s clothing away from the work area minimizes the risk of cross-contamination ...Holding catheter ... and using aseptic technique, clean the exit site with 2% Chlorhexidine Gluconate/70 % Isopropyl Alcohol swab for the minimum of 30 seconds ...” During an observation on 01/20/2026 at 11:10 AM, Patient Care Technician C was observed performing CVC exit site care for Patient #1. Patient #1 was observed to be wearing a t-shirt. Patient Care Technician C was observed moving the collar of the sweatshirt away from Patient #1’s exit site but did not secure the shirt away from the site. Upon completion of exit site cleansing, Patient #1’s shirt was observed to be touching the right side of the exit site. Patient Care Technician C moved the shirt away with gloved hand and placed a new dressing over the exit site without repeat cleansing. Patient Care Technician C used 2% Chlorhexidine Gluconate/70 % Isopropyl Alcohol swab and cleansed Patient #1’s CVC site for 25 seconds, 5 seconds less than per facility policy. During an interview on 01/21/2026 at 10:20 AM, the observation findings were discussed with Manager of Clinical Services A who stated that staff need to clean the CVC exit site for 30 seconds and clothing needs to be taped away from exit site.”

“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: 29963 Based on record review and interview, the facility staff failed to ensure that abnormal blood pressure readings during dialysis treatment were reported to a Registered Nurse (RN) and that patients received a documented assessment by a RN as a result of abnormal blood pressure readings, per facility policy, in 1 of 4 (Patient #1) in-center hemodialysis patient medical records reviewed in a total universe of 5 medical records reviewed. Findings include: A review of the facility’s policy #1-03-08 titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” last revised April 2024 revealed, “ ...Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately ...All findings, interventions and patient response will be documented in the patient’s medical record ...Abnormal Findings ...Members of the patient care team should report ANY changes in patient conditions or concerns of patient well-being immediately to the licensed nurse at any time ...Blood Pressure-Intradialytic: Difference of 20 mm/Hg (millimeters of Mercury) increase or decrease from patient’s last intradialytic treatment BP (blood pressure) reading ...” A review of Patient #1’s medical record revealed a physician order for the systolic blood pressure to be maintained between 90 and 180 mm/Hg. The treatment sheet dated 01/12/2026 revealed Patient #1’s systolic blood pressure was greater than 180 mm/Hg for 1.5 hours into treatment. There was no documentation found within the medical record to indicate that the RN was notified of Patient #1’s blood pressure being elevated during the start of treatment, that the patient was assessed by the RN as a result, or that interventions were taken to lower the blood pressure. During an interview on 01/21/2026 at 11:10 AM, the medical record review findings were discussed with and confirmed by Facility Administrator A who stated, “The RN should have been notified and the RN should have documented a focused assessment and interventions.””

“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: 29963 Based on record review and interview, the facility staff failed to complete documentation of why physician orders were not followed for prescribed blood flow rates and/or dialysate flow rates for 3 of 4 in-center medical records reviewed (Patients #1, 2, 3) in a total universe of 5 medical records reviewed. Findings include: A review of the facility’s policy #1-03-08 titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” last revised April 2024 revealed, “ ...Intradialytic Data Collection/Assessment ...At a minimum, obtain and document the following ...Blood and dialysate flows ...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 ...” A review of Patient #1’s medical record revealed a physician order for the blood flow rate (BFR) of 350 mL/min (milliliters per minute). The treatment sheet dated 01/05/2025 revealed the BFR was set at 250 mL/min for the entire treatment. There was no documentation in the medical record for the reason the BFR was lower than the ordered rate. A review of Patient #2’s medical record revealed a physician order for the blood flow rate BFR of 400 mL/min. The treatment sheet dated 01/12/2026, 01/14/2026, and 01/16/2026 revealed the BFR was turned down to 350 mL/min during treatment. There was no documentation in the medical record for the reason the BFR was lower than the ordered rate. A review of Patient #3’s medical record revealed a physician order for the DFR of 700 mL/min. The treatment sheet dated 01/16/2026 revealed the DFR was set at 800 mL/min for the entire treatment. There was no documentation in the medical record for the reason the DFR was higher than the ordered rate. During an interview on 01/21/2026 at 11:05 AM, the medical record findings were discussed with and confirmed by Manager of Clinical Services A who stated facility staff were expected to document a reason for not meeting prescribed blood and dialysate flow rates.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 29963 Based on record review, observation and interview, the facility staff failed to perform skin antisepsis prior to cannulation per policy for 1 of 2 patients (Patient #7) observed for initiation of dialysis with an AV Fistula/Graft in a total of 17 observations of patient care. Findings Include: A review of the facility’s policy #1-04-01D titled, “AV Fistula or Graft Cannulation..., “ last revised April 2025 revealed, “Skin Antiseptic ... Povidone Iodine...Effective contact time: 30 seconds... While maintaining aseptic technique, cleanse the sites by applying skin antiseptic using a circular motion, moving from the center out and allow to dry ...Do not palpate insertion site once area has been prepped.” During an observation on 01/20/2026 at 10:26 AM, Patient Care Technician C used Povidone Iodine to cleanse Patient #7’s arm access sites prior to cannulation for a total of 10 seconds, 20 seconds less than per policy. Patient Care Technician C then palpated the site prior to cannulation. During an interview on 01/21/2026 at 12:15 PM, Manager of Clinical Services B stated that Povidone Iodine should be applied for 30 seconds, and the sites should not be palpated once cleansed.”

“QAPI-MEASURE/ANALYZE/TRACK QUAL INDICATORS CFR(s): 494.110(a)(2) The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves. This Standard is not met as evidenced by: 29963 Based on record review and interview, the facility staff failed to ensure mortality review is conducted for 2 of 4 patient (Patient #13,14) deaths in 1 of 1 quality program reviewed. Findings Include: A review of the facility’s policy #1-14-06 titled, “Continuous Quality Improvement Program” last revised April 2021 revealed, “... The facility will measure, analyze, and track quality indicators... The program must include, ... Mortality- review of deaths...” A review of the facility’s “Morality Review Summary” from January 2025 through current revealed 4 patient deaths and no documentation that a mortality review was initiated or completed for Patient #13 or Patient #14. During an interview on 01/21/2026 at 12:30 PM, the above findings were discussed with Manager of Facility Administrator B who stated the mortality reviews were not completed.”

“QAPI-INDICATOR-MEDICAL INJURIES/ERRORS CFR(s): 494.110(a)(2)(vi) The program must include, but not be limited to, the following: (vi) Medical injuries and medical errors identification. This Standard is not met as evidenced by: 29963 Based on record review and interview the facility staff failed to document the follow up completed for 3 of 5 events (involving Patients #7, 15) recorded on the Adverse Occurrence Log in the Risk Event Management (REM) Reporting System in a total universe of 9 events reviewed. Findings Include: A review of the facility’s policy #13-01-02 titled, “Risk Event Reporting Policy,” last revised October 2024, revealed, “ ...B. Handling Of The Risk Event Management (REM) Report by the Administrator/Manager or designee 1. The Facility Administrator/Manager or designee will receive an email notification that a Risk Event Management (REM) Report has been completed and submitted by a teammate. The Facility Administrator/Manager or designee will review the report for completeness... All additional information pertaining to the Risk Event will be entered in the ‘Event Reporting Follow Up’ in the Risk Event Management (REM) Reporting System ...” A review of the facility’s adverse events log for the past 12 months revealed incomplete follow-up for 3 patient events: A review of the adverse event involving Patient #7 revealed that Patient #7 developed pain from the needle in the access site on 12/27/2025. There was no follow-up documented regarding an investigation into the root cause of the event or what interventions were put in place in attempt to prevent incident from re-occurring. A review of the adverse event involving Patient #15 revealed Patient #15 had a clotted access on 08/22/2025 and 07/31/2025. There was no follow-up documented regarding an investigation into the root cause of the event or what interventions were put in place in attempt to prevent incident from re-occurring. During an interview on 01/21/2026 at 11:43 AM, the adverse events were reviewed with Facility Administrator B who stated, “There should be more follow-up documented.””