Davita Mena Dialysis Center

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 37145 Based on observation and interview, the facility failed to ensure that the integrity of all physical surfaces were intact, clean, and free from damage. The failed practice promoted the spread of infection and had the likelihood to affect all 30 in-center hemodialysis patients on census. The findings were: A. On 11/18/24 from 10:50 AM through 11:30 AM, the following observations were made on tour of the facility: 1) The water room showed: a) There was a buildup of white residue on the bicarb mixer and acid tank. b) The floor had a buildup of dirt, grime, and rust colored stains, and the floor drain by the bicarb mixing tank was outlined with a black substance. c) There were areas throughout the room that had peeling paint and holes in the walls. d) The acid mixer stand was covered with a rust-colored substance. e) The pipes leading in from the city water source over to the backflow preventer had a heavy green colored buildup. f) The wall behind the water pipes and backflow preventer had a purple color stain and dirt and grime buildup. 2) The Storage room showed: a) There were four boxes of gloves and several boxes of biohazard trash bags stored on the floor. b) There were supplies for patient use stored on a wooden pallet inside the storage/water room area. 3) The medication storage and lab areas inside the nurse’s station showed: a) The medication refrigerator shelves had a buildup of dirt and grime and several dead insects lying on the lower shelf where medications were stored. b) The drawers where medications and protein bars for patient use had a buildup of dirt and grime on the outside and inside of the drawers. c) The lab drawers where blood tubes for patient use were labeled with a clear label that was peeling back, and the sticky area underneath was exposed. d) The medication area sink drain had a rust-colored residue. e) The lab area sink had a white residue to the bottom of the sink and the drain had a rust-colored residue. B. During an interview on 11/18/24 at 10:50 AM, the findings in A were verified with the Interim Facility Administrator.”

“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: 37145 Based on observation, policy review and interview, the facility failed to ensure an open vial of Tubersol was discarded within manufacturer recommended guidelines after opened, and approximately 30 bottles of Hectorol 4 mcg (micrograms/2 ml (milliliter) vials with expiration date of 10/20/24 were removed from the medication refrigerator to prevent patient use. The failed practice could not ensure the efficacy of the medications. The failed practice had the likelihood to affect all 30 in-center hemodialysis patients on census and staff. The findings were: A. Review of the Tubersol package insert showed, “Storage, A vial of Tubersol, which has been entered and in use for 30 days should be discarded.” B. Review of the facility Medication policy with revision date of October 2023, showed, “Disposal of expired medications, including all over the counter and nutritional product samples are moved from the treatment and inventory areas and disposed of per state/local regulations.” C. On 11/18/24 at 11:15 AM, an opened bottle of Tubersol removed from the medication refrigerator was dated opened on 10/08/2024 and discard on 11/04/28. The Interim Administrator removed it from use. D. On 11/18/24 at 11:20 AM, 30 bottles of Hectorol 4 mcg (micrograms/2 ml(milliliter) vials with expiration date of 10/20/2024 were observed in the medication refrigerator. The Interim Administrator removed them from use. E. During an interview on 11/18/24 at 11:20 AM, the Interim Administrator confirmed the findings in B-C.”