Davita Wausau Dialysis

“CFC-PHYSICAL ENVIRONMENT CFR(s): 494.60 This Condition is not met as evidenced by: 49038 Based on observation, record review, and interview, facility staff failed to prevent leakage from the facility from entering adjacent non-clinical occupied space for 2 of 2 offices observed (Office A, Office B). Findings include: Facility staff failed to implement and maintain a proactive maintenance plan for identifying and repairing sources of leakage in 2 of 3 headwalls. See tag V402. Failure to take proactive maintenance measures has the potential to compromise the structural integrity of the building and affect the health and safety of patients, visitors, and staff.”

“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: 49038 Based on observation, record review, and interview, facility staff failed to implement and maintain a proactive maintenance plan for identifying and repairing sources of leakage from dialysate wall boxes, piping, and associated components for 2 of 3 headwalls observed with evidence of leakage (Headwall 1, Headwall 2). Findings include: On 7/29/2024 at 10:18 AM, observation of the occupied building space directly below the dialysis facility revealed the following in Office A: a build-up of corrosion as well as a white crystallized substance on the metal piping and steel joists above the ceiling tile adjacent to the light fixture. The top side (side above the ceiling) of the light fixture contained red/brown particles that appeared to be rust particles. A wet, brown substance approximately ½-inch diameter was also observed on the light fixture. On the top side of the ceiling tiles in the cavity between the ceiling and floor, a green towel and a plastic container were also observed. On 7/29/2024 at 10:25 AM, observations of Office B revealed a white, crystallized substance on the window frame and windowsill. Observation above the ceiling directly adjacent to the window in the exterior wall revealed corrosion on the underside of the metal floor deck, piping, and on the metal joists. A white crystallized substance was observed on the underside of the metal joists, piping, and on some of the batt-insulation between the wall studs. There was also a metal pan approximately 8.5-inch by 11-inches placed on top of the ceiling tile in the cavity that was covered with a rust-colored corrosion. The top side of the ceiling tile adjacent to this pan contained a dark colored stain approximately 14-inches by 6-inches. During an interview on 07/29/2024 at 9:32 AM, Building Occupant A stated their office is located directly below the dialysis facility. Occupant A stated there has been sporadic leaking into their office space since they moved into the building in 12/2016, with the most recent leak occurring on 7/15/2024. During an interview on 07/29/2024 at 9:46 AM, Building Occupant D stated, “We had a leak two weeks ago in [Office A] ... It was dripping from the corner of the light fixture. It dripped on the floor and on the chair.” Occupant D stated there was a leak in their meeting room in December 2023 and “it had such [a chemical] odor that we closed the office. “ Per D, “Those leaks have been occurring since we moved in.” During a phone interview on 07/29/2024 at 10:38 AM, Building Manager E stated, “Davita operates with a certain type of water that helps their system work. They have stations set up with tubing that at times forms leaks. Each time we are informed, we contact Davita and help with the remediation. Davita will repair the leaks. They have a specific tech in their operation that handles that.” Per Manager E, the leaks entering the space below the facility are not from any building plumbing or pipes located in the cavity between the lower level and main level. Manager E stated he believes the leaks are coming from Davita’s equipment in their space and leaks through the floor/ceiling assembly. Per E, when a leak is reported, Davita is notified of the approximate location of the leak and Davita then repairs the leak. When asked if there were numerous leaks, Manager E stated, “it’s been on and off with the leaks and there’s no consistency.” On 07/29/2024 at 11:05 AM, observation of the facility’s dialysis treatment area revealed a headwall that ran continuous along the exterior wall of the building, directly above Office B. There was a total of (3) head walls in the treatment area. The 2nd head wall (headwall located in the middle of the treatment area) appeared to be consistent with the location of the reported leak in Office A. Observation of the interior piping behind the enclosure cabinet of the 2nd headwall revealed white crystallized material in multiple locations on plastic piping and at valve connections; a build-up of material light brown in color in multiple locations where the plastic piping terminated at a threaded connection to a larger off-white colored container. This light brown material was also observed on top of black foam insulation on one of the pipes and underneath the plastic piping within the headwall enclosure. Review of the facility floor plan revealed the facility’s head wall locations were consistent with evidence of leaking observed in the floor space below the facility in Office A and Office B. During a telephone interview on 07/29/2024 at 3:19 PM, Biomed Technician C stated, “It’s common for dialysis equipment to have leaks. Most places don’t have a tenant below.” Technician C stated that typically the cabinets that house the dialysis equipment have a gap between the floor and the cabinet so if a leak occurs, it can be noticed quickly, but the cabinets at the facility are continuous to the floor and no one is aware until it has permeated through the floor. Technician C stated, “it seeps through the concrete floor from the piping in the headwall. Sometimes a line cracks or a valve breaks, and it leaks to the basement.” Per Technician C, the solution in the piping is a potassium, calcium, and sodium mixture. When asked if the sporadic leaking has occurred for the past six years, C stated, “yes, that’s accurate.” There was no evidence that facility staff had a plan in place to identify leaks, parts in need of repair or other preventive measures to mitigate equipment leaks prior to the point of affecting adjacent occupied spaces outside of the facility.”