Davita Sun Prairie 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 wear gloves when touching the dialysis machine for 3 of 11 patients (Patients #7, 8, 9) in a total of 16 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 ... 7. Disposable gloves will be worn when caring for the patient or touching the patient’s equipment at the dialysis station.” During an observation on 01/28/2026 at 9:34 AM, PCT E was observed touching Patient #9’s dialysis machine with a glove wrapped around the finger. During an observation on 01/28/2026 at 10:00 AM, PCT E was observed touching Patient #8’s dialysis machine with a glove wrapped around the finger. During an observation on 01/28/2026 at 10:43 AM, PCT E was performing exit site care on Patient #7’s CVC. PCT E was observed to remove gloves from hand and used the glove as a barrier between finger and the dialysis machine to silence an alarm on the dialysis machine During an interview on 01/29/2026 at 10:06 AM, the observation findings were discussed with Facility Administrator A who stated gloves need to be put on the hand all the way when touching any of the dialysis equipment.”

“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: 29963 Based on record review, observation and interview, the facility staff failed to disinfect all surfaces in the dialysis station between patients to prevent possible cross contamination for 2 of 2 patients (Patients #3,10) in a total of 2 observations of cleaning of the dialysis station. Findings include: A review of the facility’s policy #1-05-01 titled, “Infection Control for Dialysis Facilities,” last revised April 2023 revealed, “13. At the end of each treatment, the dialysis station will be cleaned and disinfected. a. Surfaces to disinfect include but are not limited to: all surfaces in contact with the patent or their belongings ... and frequently contacted by healthcare personnel...” During an observation on 01/28/2026 at 8:45 AM, Patient Care Technician (PCT) G was disinfecting the dialysis station after Patient #10 completed dialysis. PCT G did not wipe the outside of the dialysis chair under the tray table. During an observation on 01/28/2026 at 10:52 AM, PCT G was disinfecting the dialysis station after Patient #3 completed dialysis. PCT G did not recline the dialysis chair to ensure cleaning of all surfaces. During an interview on 01/29/2026 at 10:05 AM, the observation findings were discussed with Facility Administrator A who stated the dialysis chairs should be fully reclined during disinfection and all surfaces need to be wiped down.”

“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: 29963 Based on record review, observation and interview, the facility staff failed to dispose of expired medication from 2 of 2 medication storage areas (in-center dialysis and home dialysis program); failed to follow aseptic technique when drawing up 1 of 1 patient (Patient #17) medications into syringes; and failed to follow facility policy to draw up medication only for current shift receiving dialysis for 8 of 8 patients (Patients #2, 6, 7, 8, 13, 14, 15, 16) in a total universe of 22 patients. Findings include: A review of facility policy #1-06-01 titled, “Medication Policy,” last revised November 2023 revealed, “Medications preparation should be performed only for the current shift of patients, i.e. do not prepare medication for more than one shift of patients ... All syringes prepared for ... multidose vials should be prepared and administered within a four (4) hour ... period ... All medications are checked monthly for expiration dates ... An aseptic environment and aseptic technique is used when preparing medications ...” During an observation on 01/28/2026 at 8:33 AM, a bottle containing 50 tablets of Clonidine Hydrochloride 0.1 milligrams (mg) with an expiration date of 10/2025 was found in the in-center medication drawer. During an observation on 01/28/2026 at 9:07 AM, the medications (heparin) for the entire second shift of Patients (2, 6, 7, 8, 13, 14, 15, 16) were drawn up into syringes. The syringes were dated and timed as being prepared on 01/28/2026 at 8:00 AM. The first shift of patients was being treated for dialysis until 11:15 AM. The second shift of dialysis was scheduled to start at 10:00 AM and is completed between 1:30 PM and 3:30 PM (which is when the medications would be administered). During an observation on 01/28/2026 at 9:45 AM, Registered Nurse C was drawing up medications (heparin) into syringes for Patient #17. Registered Nurse C did not wipe the rubber septum on the vial prior to inserting the syringe into the septum to draw up the medication. During an observation on 01/29/2026 at 8:15 AM, the following expired medications were found in the home program medication storage area: (2) Epinephrine injection syringes dated 06/25, (1) Glucose Gel dated 05/25, (36) Ceftazidime vials dated 12/25, (18) Vancomycin vials dated 11/25, (25) Gentamicin vials dated 11/25. During an interview on 01/28/2026 at 9:07 AM, the observation findings were discussed with Facility Administrator A who stated the medications for the second shift should not have been drawn up that early, once they are drawn up, they need to be given within four hours. During an interview on 01/29/2026 at 8:20 AM, Facility Administrator A stated expired medication should be discarded. Facility Administrator A also stated the rubber septum of the vial should be wiped with alcohol every time a new syringe is inserted into the multidose vial.”

“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, the facility staff failed to cleanse central venous catheter (CVC) hubs per facility policy for 2 of 4 patients with a CVC observed (Patients #1, 6) and failed to perform central venous catheter exit site care using aseptic technique for 1 of 2 patients observed (Patient #7) in a total sample of 16 observations of patient care. 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, “... Perform a 15 second hub scrub every time a CVC is connected or disconnected from the blood lines ... Verify patient’s clothing is secured away from the exit site/work area.” During an observation on 01/28/2026 at 8:50 AM, Patient Care Technician (PCT) D was observed initiating Patient #1’s dialysis utilizing her CVC. PCT D disinfected each of Patient #1’s CVC hubs with alcohol for 10 seconds each, 5 seconds less than per policy. During an observation on 01/28/2026 at 10:00 AM, PCT D was observed initiating Patient #6’s dialysis utilizing her CVC. PCT D disinfected each of Patient #6’s CVC hubs with alcohol for 11 seconds each, 4 seconds less than per policy. During an observation on 01/28/2026 at 10:54 AM, PCT E was observed performing CVC exit site care for Patient #7. Patient #7 was observed wearing a flannel shirt. PCT E did not secure the shirt away from the exit site. Upon completion of exit site cleansing, Patient #7’s shirt was observed to be touching the exit site. During an interview on 01/29/2026 at 10:14 AM, the observation findings were discussed with Facility Administrator A who stated the CVC hubs should be wiped with alcohol for at least 15 minutes, and clothing should be taped back so it doesn’t touch the exit site once it is disinfected.”

“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: 29963 Based on observation and interview, the facility staff failed to label dialysis machines being stored in the biomed room to inform the staff if the machine is ready to be used for 1 of 2 dialysis machines out of a total of 2 extra dialysis machines stored in the biomed work area. Findings include: A review of facility policy #01-15-12, titled, “Dialysis Delivery System Failures,” last revised April 2025 revealed, “ ... If a dialysis delivery system has an intermittent problem ... the dialysis delivery system will be labeled post treatment with a description of the problem... The labeled dialysis delivery system will be removed from the treatment area for repairs.” During an observation on 01/28/2026 at 11:00 PM, the biomed technician storage area contained 2 extra dialysis machines. One machine was labeled, “Do not turn on,” the other machine was not labeled, indicating whether the machine was not working or if it was ready to be used. During an interview on 01/29/2026 at 8:37 AM, Biomed Technician I stated that all extra dialysis machines should be tagged to disposition.”

“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 2 of 4 in-center medical records reviewed (Patients #3, 4) in a total universe of 5 medical records reviewed. Findings include: A review of the facility’s policy #12-03-04 titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” last revised October 2025 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 inability to achieve or maintain prescribed blood flow rate) the reason will be documented in the electronic health record and the licensed nurse informed.” A review of Patient #3’s medical record revealed a physician order for the blood flow rate (BFR) of 400 milliliters per minute (mL/min). The treatment sheet dated 01/19/2026 revealed the BFR was set at 375 mL/min for the first hour of the treatment. There was no documentation in the medical record for the reason the BFR was lower than the ordered rate. A review of Patient #4’s medical record revealed a physician order for the BFR of 350 mL/min. The treatment sheet dated 01/26/2026 revealed the BFR was set at 300 mL/min after the first hour of the treatment. There was no documentation in the medical record for the reason the BFR was lower than the ordered rate. During an interview on 01/29/2026 at 11:26 AM, the medical record findings were discussed with and confirmed by Facility Administrator A who stated facility staff were expected to document a reason for not meeting prescribed blood 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 #4) observed for initiation of dialysis with an AV Fistula/Graft in a total of 16 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, “1. Have patient wash access site with appropriate antibacterial soap, if able. If patient unable to wash access site, patient care teammate will clean access extremity with skin cleansing agent and pat dry...Skin Antiseptic ...Povidone Iodine...Effective contact time: 30 seconds ... While maintaining aseptic technique, cleanse the sites by applying skin antiseptic using a circular rubbing motion, moving from the center out and allow to dry ...” During an observation on 01/28/2026 at 9:05 AM, Patient Care Technician (PCT) E used Povidone Iodine to cleanse Patient #4’s arm access sites prior to cannulation for a total of 13 seconds, 17seconds less than per policy. During an interview on 01/29/2026 at 10:06 AM, the observation findings were discussed with Facility Administrator A who stated the povidone iodine should be used for a 30 second scrub time.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 29963 Based on record review and interview, the facility staff failed to ensure that a comprehensive Registered Nurse assessment was completed prior to initiation of the first treatment at the facility in 1 of 1 newly admitted patient (Patient #1) reviewed in a total sample of 5 medical records reviewed. Findings include: A review of the facility’s policy #1-03-07 titled, “Initial Patient Nursing Assessment for New Patients” last revised April 2024 revealed, “... A registered nurse (RN) as required by federal regulation will perform an initial pre-treatment evaluation of all patients prior to the initiation of their first treatment at the facility...” A review of Patient #1’s medical record revealed Patient #1 was admitted for their first dialysis treatment on 01/19/2026. The first dialysis treatment started on 01/19/2026 at 5:40 AM. Patient #1’s “Initial Assessment” was completed on 01/19/2026 at 7:21 AM (I hour and 41 minutes after initiation of first dialysis treatment). During an interview on 01/29/2026 at 11:20 AM, the medical record review findings were reviewed with and confirmed by Facility Administrator A who stated the initial assessment should be done before the start of the first dialysis treatment.”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 29963 Based on record review and interview, the facility staff failed to ensure nursing staff were documenting their pre-dialysis treatment assessment within 1 hour of dialysis treatment initiation per facility policy for 2 of 4 patients (Patients #2, 3) in a total universe of 5 medical records reviewed. Findings Include: A review of the facility policy #12-03-04 titled, “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment” dated October 2025 revealed, “... The licensed nurse will round on those patients without reported abnormal findings and complete the nursing assessment within one (1) hour of dialysis treatment initiation or sooner as required by state law.” A review of Patient #2’s medical record revealed a treatment sheet dated 01/02/2026, treatment was documented as initiated at 11:51 AM and the pre-nursing assessment was documented at 1:41 PM. A review of Patient #3’s medical record revealed a treatment sheet dated 01/06/2026, treatment was documented as initiated at 6:54 AM and the pre-nursing assessment was documented at 8:11 AM. Treatment sheet dated 01/19/2026, treatment was documented as initiated at 6:55 AM, and the pre-nursing assessment was documented at 8:26 AM. Treatment sheet dated 01/21/2026, treatment was documented as initiated at 6:36 AM, and the pre-nursing assessment was documented at 8:29 AM. During an interview on 01/29/2026 at 11:26 AM, the medical record review findings were discussed with and confirmed by Facility Administrator A, who stated the pre-dialysis assessments should be completed and documented within 1 hour of the start of dialysis treatment.”