Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 852539 (X3) Date Survey Completed 06/10/2021
Name of Provider or Supplier Eatonton Kidney Center Street Address, City, State 103 N Washington Avenue, Eatonton, GA
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
V0402 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:
Based on observations and staff interviews, it was determined that the facility failed to ensure that there was a safe environment for all 10 in-center hemodialysis patients as evidenced by: standing water on the floor around the booster pump in one of one Dialysate Preparation room, which could promote microbial growth; two ceiling tiles in one of one isolation room that had yellowish-brown water stains approximately 7 - 12 inches in circumference; and four of four oxygen tanks along the wall toward the supply room were free standing and unsecured. This failure to maintain a safe environment could negatively affect the health and safety of all six staff and all 10 patients who were under the care of this facility. Findings include: During a tour of the facility with the Administrative Assistant on 6/8/21 at 10:00 a.m., the following was observed: Isolation Room: There were two ceiling tiles in the isolation room (one tile above the entrance door and one above the left side of the room) that had yellowish-brown water stains approximately 7 - 12 inches in circumference. Hallway to the Supply Room: There were four oxygen tanks along the wall toward the supply room that were unsecured and free standing. According to Occupational Safety and Health Administration (OSHA) 1910.253(b)(2)(ii)... ... Oxygen cylinders ... assigned storage spaces shall be located where cylinders will not be knocked over or damaged by passing or falling objects or subject to tampering by unauthorized persons... Additionally, oxygen tanks should be stored in a stand or cart to prevent tipping and falling... Do not allow tank to stand or lean in an upright position while unsecured... Dialysate Preparation Room: There was a pool of standing water, approximately three to four feet in circumference, on the floor around the booster pump. According to the Biomed Technician (BMT) on 6/8/21 at 12:00 p.m., he stated that the pipe under the booster pump was leaking and needed to be repaired. On 6/10/21 at 3:00 p.m., this surveyor observed that the standing water remained on the floor of the Dialysate Preparation Room and the leaking pipe was still not repaired. The Administrative Assistant and Human Resource personnel acknowledged this observation on 6/10/21 at 3:00 p.m.