Fmcna Villa Rica

“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: 50523 Based on observation, staff interviews, and a review of the facility’s Policy and Procedures (P&P), it was determined that the facility failed to ensure that the building in which dialysis services were provided, was clean and maintained free from damage and defects to ensure the safety of the patients and staff. Unsanitary environments and excessive moisture could contribute to mold growth on surfaces and materials that could cause various respiratory issues, including allergic reactions, asthma attacks, and infections. Failure to maintain the integrity of all surfaces could hinder effective cleaning and disinfection of the surfaces, thereby creating a potential environment for microbial growth. These environmental concerns were observed in one of one Patient Treatment Room, and one of one Dialysate Preparation/Storage Room. The facility census was 63. Findings include: During observation on 1/7/26 from 10:33 a.m. to 11:40 a.m., the following was revealed: In the Patient Treatment Room: - The second drawer on the left side of the laboratory (lab) refrigerator was missing. - One of the two doors was missing from the cabinet to the right of the lab refrigerator. - The medication cabinets were missing locks, that prevented the medications from being securely stored. - Dried adhesive residue with whitish and brown discoloration was present across vinyl and laminated floors in the center of the Treatment Room. Multiple cracks in the vinyl flooring were observed, that hindered effective cleaning and disinfection of the surfaces. - Duplex electrical outlets with metal faceplates behind Station (S) 8, S10, and S15 were loosely detached from the wall, that posed a potential electrical hazard. In the Dialysate Preparation Room and Storage Room: - The concrete floor beneath the Solution Delivery System (SDS - prepares, controls, and delivers dialysate to dialysis machines) was visibly wet, with pooling water and streaks. There were brown rust-colored stains on the floor surface and along the baseboard to the left of the SDS. - The wall-mounted “Sample Station” (attached to the primary and secondary concentrate tanks) was covered with a white crusty buildup. The drain basin located directly beneath the “Sample Station” was partially filled with a solid crystalline substance, with the same substance also present on the adjacent lower wall and baseboard. - The mixer motor on top of the dry acid dissolution unit (automatically mixes powdered dry acid concentrate with purified water to create liquid acid concentrate) was covered with a white chalky crust and brown colored substance. The above findings were confirmed with the Clinical Manager (CM) on 1/7/26 at 11:45 a.m. She stated that the above issues would be properly addressed, repaired, and thoroughly cleaned to ensure patient and staff safety. On 1/7/26 at 11:59 a.m. the Area Technical Operations Manager (ATOM) stated there was a leak in the pipes connected to the chase boxes built into the central counter in the Patient Treatment Room, supplying 10 hemodialysis machines. Water seeped through the floor, causing glue to rise through the vinyl and laminated flooring, which has since dried. The ATOM confirmed that the whitish substance on the floors was glue. A review of Policy: Version 2, titled, “Receiving and Stocking Medications” with latest revision date of November 7, 2022, showed the following: Stocking Medications: When putting away or stocking received medications the Licensed Nurse shall: 1. Ensure that all medications are secured in a lockable cabinet or medication refrigerator. A review of Policy: Version 9, titled, “General Cleanliness and Infection Control Guidelines” with latest revision date of September 2, 2025, showed the following: All areas must be kept clean and organized, including but not limited to treatment areas, water/supply rooms ... A review of Policy: Version 3, titled, “Electrical Receptacle Verification Procedure” with latest revision date of February 28, 2024, showed the following: 2. Inspect receptable for damage, discoloration, cover plate conditions, security of the wall box. Document the physical condition of receptacle on the RATL-1.”