Mountainside Hospital

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 52927 Based on one of one observation of hand hygiene, staff interview, and review of facility documents it was determined the facility failed to ensure staff perform hand hygiene at the designated clean area to prevent cross contamination. Findings include: On 01/28/26 at 12:15 PM, Staff (S)12 was observed terminating hemodialysis through an arteriovenous fistula (AVF, a type of vascular access used for hemodialysis) in Station 21. S12 removed the arterial and venous needles in accordance with facility policy. S12 proceeded to perform hand hygiene at the designated “dirty” sink, across from Station 21, with the available soap and paper towels located in the area. S12 then donned (put on) new gloves, removed the hemodialysis lines from the machine and discarded them in accordance with facility policy. S12 removed his/her gloves, performed hand hygiene in the same designated “dirty” sink and donned a new pair of gloves. During an interview at 12:43 PM, S12 confirmed he/she performed hand hygiene in the designated “dirty” sink. S12 stated the sink is used for “discarding saline and other extra fluids.” S12 added, “I noticed I was using the dirty sink and then used the clean sink.” Facility policy titled, “Clean vs Dirty Area in the dialysis center,” approved 02/25/25, stated, “DEFINITIONS: Clean Area: A designated space or surface that has not been exposed to blood, body fluids, used supplies, or contaminated equipment and is reserved exclusively for clean supplies, medications, or procedures. Dirty (Contaminated) Area: Any area or surface that is exposed to blood, body fluids, used dialysis equipment, waste, or soiled supplies and requires cleaning and disinfection prior to use. Designation of Areas Clean Areas (Examples) ... Hand hygiene stations ... Dirty (Contaminated) Areas (Examples) ... Used dialysis machine surfaces prior to terminal cleaning and disinfection ... Staff Education and Compliance ... All staff receive initial and annual education on clean vs dirty area management ...” N.J.A.C. 8:43A-24.8(b)”

“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: 48966 Based on observation, staff interview, and a review of facility documents, it was determined the facility failed to ensure that: 1) all equipment in the dialysis station is cleaned and disinfected, and used bleach wipes are disposed of properly, in accordance with facility policy, in two of two cleanings and disinfections of a hemodialysis station and; 2) the plastic hemostat clamps are disinfected in accordance with facility policy. Findings include: On 01/29/26 at 10:40 AM, in Station 4, Staff (S) 9 was observed cleaning and disinfecting the hemodialysis station after the patient was discharged. S9 used a bleach-soaked cloth to clean and disinfect the dialysis machine, including the prime bucket, IV pole, blood pressure cuff, and wall box. S9 cleaned the chair, television, and countertop (chase wall) area, located behind the dialysis machine and chair, and disposed of the used bleach cloths on the bottom ledge of the clean hemodialysis machine. During an interview on 01/29/26 at 11:11AM, S9 confirmed he/she placed the used bleach cloths on the cleaned bottom ledge of the hemodialysis machine. S9 stated, “I’m not supposed to do that?” During an interview on 01/29/26 at 1:49 PM, S1 stated that used bleach wipes are to be disposed of in the regular trash receptacle not on a clean surface. 52927 On 01/28/26 at 12:34 PM, in Station 21, Staff (S)12 was observed cleaning and disinfecting the hemodialysis station. S12 emptied the prime bucket in the designated “dirty” sink and left the prime bucket in the sink. S12 then used a new bleach-soaked cloth to clean and disinfect the front, top, and right side, hemodialysis lines on the right side of the machine, bottom, and back and left side of the hemodialysis machine. S12 did not wipe the blood pressure (BP) holder on the left side of the machine. S12 used the same bleach-soaked cloth to wipe the BP cuff and cord and hung the BP cuff and cord on the IV [intravenous] pole before cleaning the IV pole. S12 then proceeded to clean the IV pole with the hanging BP cuff. S12 used a new bleach-soaked cloth to clean and disinfect the right tray table of the patient chair, reclined the chair, and wiped the back of the recliner, seat, footrest, left tray table, and left arm of the chair. S12 then wiped the TV [television] and the TV arm. S12 did not clean the chase wall behind the patient recliner. S12 then returned to the “dirty “sink and rinsed the prime bucket with water and then placed the prime bucket on the right side of the hemodialysis machine. S12 did not clean and disinfect the prime bucket with the pre-mixed bleach solution, required by facility policy. During an interview at 12:43 PM, the above findings were reviewed and confirmed with S12. S12 stated, “I should have cleaned the prime bucket with bleach.” Facility policy titled, “Infection Control Practices for Hemodialysis Unit,” approved 04/23/24, stated, “PROCEDURE: ... 10. Environmental Cleaning/Disinfection: Station Breakdown/cleaning ... d. All equipment will be wipes clean with a bleach solution of appropriate dilution after completion of procedures, before being used on another patient, after spill so blood, throughout the workday, and after each treatment as well as post sequester. These items include the dialysis delivery system, the interior and exterior of the prime container, the dialysis chair and side table including opening the chair to reach crevice, blood pressure equipment, television arms and control knobs or remote control devices if accessible to patients and team members, facility wheelchairs, outside of sharp containers, IV poles.” Facility policy titled, “Cleaning of Treatment Stations Between Patients,” approved 07/13/20 and effective 07/11/25, stated, “DEFINITIONS: Components of station - 1. Machine; 2. All jugs containing concentrate; 3. Drainage buckets of side of machine; 4. Chair, including arm trays; 5. Countertop behind machine; 6. T.V. [television] screens and arms; 7. Computer screens including keyboards; 8. Blood pressure cuffs; 9. Clamps ... EQUIPMENT/SUPPLIES: Pre-mixed solution 1:100 and/or 1:10 dilution; Disposable wipes ... PROCEDURE: 1. Clean all components of station with pre-mixed bleach solution 2. Wipe down all components of station with disposable wipes and discard ...” On 01/28/26 at 11:33 AM, during a tour of the Treatment Area, a clear plastic container labeled “1% Enzymatic detergent mix (1-100 ratio),” located at the designated “dirty” sink area next to Station 29, was observed. The container had 14 blue, plastic hemostat clamps that were submerged and soaking in the solution. Nine of 14 clamps were observed in a closed position which is not in accordance with facility policy. During an interview at 11:38 AM, Staff (S)11 confirmed the clamps were soaking in a 1:100 bleach solution and should be soaking in the open position. S11 opened all the clamps and submerged them in the bleach solution to disinfect. Facility policy titled, “Disinfection of Clamps,” approved 06/24/22 and effective 06/24/25, stated, “PROCEDURE: ... 2. Prepare a fresh, ready to use solution daily. Soak the clamps in warm water and detergent solution as designated above for 10 minutes, ensuring all clamps are thoroughly submerged in an open position ...” N.J.A.C. 8:43A-24.8(b)”

“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: 48966 Based on two of two observations of the initiation of hemodialysis through a Central Venous Catheter (CVC, a type of access used for hemodialysis), staff interview, and review of facility documents, it was determined the facility failed to ensure initiation of hemodialysis using aseptic technique. Findings include: On 01/28/26 at 10:48 AM, Staff (S) 7, initiated hemodialysis treatment through a right chest CVC on a patient in Station 3. S7 attached a 10 ml (milliliter) pre-filled saline to the arterial catheter limb then to the venous limb and instilled the solution. S7 then attached a heparin loading dose bolus syringe to the venous limb catheter. After two minutes, S7 removed the saline syringe from the arterial CVC limb and connected it to the arterial bloodline without scrubbing the hub with alcohol for 15 seconds. S7 proceeded to remove the heparin syringe from the venous CVC limb, and without first scrubbing the hub with alcohol for 15 seconds, connected it to the venous bloodline. During an interview on 01/28/26 at 11:01 AM, S7 stated every time he/she opened the CVC, the CVC ends needed to be wiped with alcohol for 30 seconds. S7 confirmed he/she did not perform a 15 second hub scrub when the bloodlines were connected to the CVC limbs. A review of S7’s training and education records indicated that the “Procedural Skills Verification Checklist” that included training in all aspects of CVC care was successfully completed on 03/22/25. On 01/28/26 at 11:09 AM, Staff (S) 6 initiated hemodialysis treatment through a right chest CVC, on a patient in Station 16. S6 placed, two 10 ml (milliliter) syringes, two 10 ml pre-filled saline syringes, and six to eight alcohol pads on the clean, disposable pad on the recliner table. S6 removed the venous end cap and wiped the end of the CVC limb with an alcohol prep pad before he/she attached an empty 10 ml syringe and aspirated approximately five mls of blood into the syringe. S6 removed the blood filled syringe from the venous limb, and placed it onto the clean, disposable pad, next to the clean supplies, potentially contaminating the clean supplies. S6 removed the arterial end cap and wiped the end of the CVC limb with an alcohol prep pad before he/she attached an empty 10 ml syringe and aspirated approximately five mls of blood into the syringe. S6 removed the blood filled syringe from the arterial limb, and placed it onto the clean, disposable pad, next to the clean supplies, potentially contaminating the clean supplies. Next, S6 attached a 10 ml pre-filled saline syringes to the venous and arterial limbs and instilled the saline. S6 then attached a heparin loading dose bolus syringe to the venous limb catheter. S6 immediately connected the bloodlines to the arterial and venous CVC limbs without scrubbing the hub with alcohol for 15 seconds. During an interview on 01/28/26 at 11:20 AM, S6 stated, when connecting the bloodlines to the CVC limbs, a 15 second hub scrub with alcohol is supposed to be completed. Also, S6 stated he/she should not place the blood filled syringes onto the disposable pad next to the clean supplies. A review of S6’s training and education records indicated that the “Procedural Skills Verification Checklist” that included training in all aspects of CVC care was successfully completed on 05/21/25. Facility policy titled, “Initiation of Hemodialysis Treatment with Central Venous Catheter (CVC) with MicroClave/Curos Antimicrobial Caps, Approval Date: 10/12/22, stated, “... Points Of Emphasis ... Perform a 15 second hub scrub every time a CVC is connected or disconnected from the blood lines, ... Procedure 11. Attach a sterile 10 ml syringes to the arterial and venous limbs. 12. Aspirate an amount greater than the arterial lumen, generally about 5 ml, then clamp lumen. Discard filled syringes. Repeat the same steps for the venous lumen. ... 19. ...” N.J.A.C. 8:43A-24.8(b)”

“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: 33557 Based on observation, staff interview, and review of facility documents, it was determined the facility failed to ensure: 1) the building is maintained free of defects to ensure the safety of the patients, staff, and public; and 2) all emergency eye wash stations are unobstructed and clearly visible for one of three emergency eyewash stations. Findings include: On 1/29/26 at 10:50 AM in the presence of Staff #15 (S15), the floor in the Acid Room was peeling and chipping between the acid tank and the handwashing sink. On 1/29/26 at 10:52 AM in the Acid Room in the presence of S15, build up of a white particulate was found on the discharge side of the acid pump. During an interview at 10:55 AM, S15 confirmed the above findings. On 1/29/26 at 11:00 AM in the Home Training Room in the presence of S15, the cabinet doors as well as the edges of the counter top, are delaminated exposing a porous surface that cannot be properly cleaned. 39228 2) Reference: ANSI/ISEA (American National Standards Institute/International Safety Equipment Association) Z358.1- 2014. 5.4.2 (eye wash) Be in accessible locations that require no more than 10 seconds to reach. The eyewash shall be located on the same level as the hazard and the path of travel shall be free of obstructions that may inhibit its immediate use. On 01/28/26 at 11:20 AM, during a tour of the Water Treatment Room with Staff (S)3, there were two hemodialysis machines stored in front of the emergency eye wash sink, obstructing the eyewash sinks visibility. Upon discovery, S3 stated that the machines were bleached yesterday and stored there. S3 further stated that the machines should be stored in another area of the Water Treatment Room and not in front of the eyewash sink. Facility policy titled, “Eyewash Stations and Drench Shower-PE-MMC,” approval date: 03/18/18, effective date: 09/10/25 stated, “... 2) Application and Installation ... c) Eyewash stations ... will be maintained in areas that are free from obstruction and clearly visible. ...” N.J.A.C. 8:43A-19.2 N.J.A.C. 8:43G-24.2(a)”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 39223 Based on medical record review, staff interview, and review of facility documents, it was determined the facility failed to ensure elevated blood pressures are communicated with the physician for 4 of 9 hemodialysis treatments reviewed. Findings include: A review of Patient (P)11’s medical records revealed an Annual Plan of Care dated 01/14/26, stated, “... Past Medical History ... Essential hypertension ... Adequacy of Dialysis ... Patient Specific Edema - pre-dialysis: no Shortness of breath: no Large fluid gains: no Action Plan to Meet Goals Educate patient to limit fluid intake ...” A review of the hemodialysis treatment documentation for 01/19/26 through 01/28/26 revealed the following: On 01/19/26 the pre-treatment blood pressure (BP) was 197/115. Treatment was as follows: 5:44 AM - BP 189/109 “... treatment started” 6:14 AM - BP 192/112 6:44 AM - BP 185/112 “clonidine 0.1 mg given for persistent high bp” 7:14 AM - BP 176/104 7:44 AM - BP 169/97 8:14 AM - BP 172/111 8:44 AM - BP 172/107 9:14 AM - BP 185/113 9:20 AM - BP 176/114 “treatment completed, blood returned” A post treatment BP timed for 9:27 AM was 168/106. There was no documented evidence that the patient’s physician was notified of the elevated blood pressures throughout or after hemodialysis treatment. On 01/21/26 the pre-treatment blood pressure (BP) was 183/85. Treatment was as follows: 6:00 AM - BP 182/85 “pt [patient] tx started” 6:30 AM - BP 184/85 7:00 AM - BP 174/86 7:30 AM - BP 166/87 8:00 AM - BP 170/89 8:30 AM - BP 178/89 9:00 AM - BP 166/88 9:30 AM - BP 173/92 A post treatment BP timed for 9:35 AM was 189/94. This was higher than the patient’s pre-treatment BP. There was no documented evidence that the patient’s physician was notified after one hour of hemodialysis treatment or that the patient received anti-hypertensive medication to lower his/her blood pressure. On 01/23/26 the hemodialysis treatment started at 5:43 AM with a pre-treatment blood pressure (BP) of 180/96. Treatment was as follows: 5:43 AM - BP 189/109 “Treatment started” 5:45 AM - BP 189/109 6:13 AM - BP 182/107 “BP remains elevated, no complaints, to monitor” 6:43 AM - BP 178/109 7:00 AM - BP 178/109 “bp remains elevated, rn aware” 7:13 AM - BP 161/103 7:30 AM - BP 161/103 7:43 AM - BP 172/106 8:13 AM - BP 169/100 8:30 AM - BP 169/100 8:43 AM - BP 169/106 9:13 AM - BP 179/96 “Treatment end, all blood returned” A post treatment BP timed for 9:19 AM was 171/95. There was no documented evidence that the patient’s physician was notified of the elevated blood pressures. On 01/28/26 the hemodialysis treatment started at 6:00 AM with an initial blood pressure (BP) of 167/83. Treatment was as follows: 6:00 AM - BP 172/80 ... “Tx [Treatment] started w/o [without] complaints ...” 6:30 AM - BP 191/90 7:00 AM - BP 176/87 7:30 AM - BP 183/88 8:00 AM - BP 182/90 8:30 AM - BP 185/89 9:00 AM - BP 175/93 9:30 AM - BP 200/102 ... “BP is higher, will retake BP again.” 9:32 AM - BP 195/114 ... “Tx terminated. BP is better, but still high. Will recheck BP for post treatment” A post treatment BP timed for 9:40 AM was 174/83. This was higher than the patient’s pre-treatment BP. There was no documented evidence that the patient’s physician was notified after one hour of hemodialysis treatment or that the patient received anti-hypertensive medication to lower his/her blood pressure. Facility policy titled, Hypertensive Treatment, approved 01/22/25, stated, “... POINTS OF EMPHASIS Hypertension is when systolic blood pressure is greater than 150 and diastolic pressure is greater than 90. ... PROCEDURE ... 4. After one hour of dialysis treatment, if systolic blood pressure has not been reduced by 10 to 20 points, notify physician. 5. Administer ant-hypertensive medication, if ordered by physician. 6. Monitor and record blood pressure every 15 minutes until symptoms related to hypertension have been resolved. DOCUMENTATION Accurately document event and treatment given on Hemodialysis Flowsheet to provide a record of continuity of care. ...” Facility policy titled, Abnormal Findings - Report to Patient’s Nurse, effective 07/11/2022, stated, “... PRE TREATMENT ... B/P Systolic [greater than] 200 OR [less than] 90 Diastolic [greater than] 100 OR [less than] 60 ... INTRADIALYTIC Blood Pressure Systolic [greater than] 200 OR [less than] 90 or any significant change in pressure ... POST TREATMENT ... Blood Pressure SBP [greater than] 160 OR [less than] 90 Diastolic BP [greater than] 100 OR [less than] 50 ... ALWAYS REPORT ANY COMPLAINTS OR UNUSUAL SIGNS AND SYMPTOMS TO THE NURSE AND DOCUMENT THAT THE NURSE WAS NOTIFIED””

“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: 48966 Based on two of two observations of the initiation of hemodialysis through an arteriovenous fistula/graft (AVF/G, a type of vascular access used for hemodialysis), staff interview, and review of facility documents, it was determined the facility failed to ensure staff perform skin disinfection of the access site prior to initiating the dialysis treatment in accordance with manufacturer’s instructions (MIFU) and facility policy. Findings include: On 01/28/26 at 10:38 AM, in Station 2, Staff (S)6, initiated dialysis through a patient’s left upper arm AVG. S6 cleansed the entire left upper arm AVG with one 2% Chlorhexidine applicator (ChloraPrep) in a circular motion for 24 seconds. This was six seconds less than the required 30 seconds according to facility policy and only one 2% Chlorhexidine applicator was used. S6 cannulated the arterial site then the venous site after allowing the area to dry for one minute. During an interview on 01/28/26 at 11:24 AM, S6 stated that the access site should be cleaned with ChloraPrep for 60 seconds and let dry for one minute. During an interview on 01/29/26 at 2:38 PM, S1 confirmed the effective contact time for ChloraPrep is 30 seconds when cleaning an access. A review of S6’s training and education records indicated that an “Annual Procedural Skills Verification Checklist,” that included AVF/AVG care, was successfully completed on 05/21/25. 52927 On 01/28/26 at 10:47 AM, in Station 27, Staff (S)11 was observed initiating hemodialysis through an AVF. S8 cleansed both sites of the AVF with ChloraPrep in a circular motion for a total 15 seconds. This was 15 seconds less than required per facility policy. S11 proceeded to insert the first (venous) needle and then the second (arterial) needle according to facility policy. S11 was unable to get blood return from the arterial needle. S11 then removed the arterial needle, and used a new ChloraPrep swab stick to clean the arterial area for 10 seconds before he/she immediately inserted the arterial needle. S11 cleansed the arterial site 20 seconds less than required by facility policy or documents, and did not allow the area to dry for 60 seconds as per facility policy or document. During an interview at 11:08 AM, S11 stated, “clean both sites at the same time when using ChloraPrep and allow to dry 30 seconds to dry.” During an interview on 01/30/26 at 10:55 AM, S1 stated, “the Cannulation-Site Preparation AVF/AVG document is posted around the unit and is how we train our staff.” A review of the MIFU for the BD ChloraPrep FREPP Clear, stated, “Directions ... dry surgical sites (e.g., abdomen or arm): use gentle repeated back-and-forth strokes for 30 seconds. Allow the area to dry for approximately 30 seconds.” Facility policy titled, “Initiation of Hemodialysis Graft/Fistula,” approved 01/07/23, stated, “PROCEDURE: ... 8. 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. (For contact and dry time refer to antiseptic guidelines) ...” Facility document titled, “Cannulation - Site Preparation AVF/AVG,” stated, “Disinfectant Solution ... Chlorhexidine (ChloraPrep) Constant Site use only ... Effective Volume ... Use single swab stick per site ... Effective Contact Time ... 30 seconds ... Air Drying Time ... 60 seconds - let skin dry naturally ...” N.J.A.C. 8:43A-24.8(b)”

“H-FAC RECEIVE/REVIEW PT RECORDS Q 2 MONTHS CFR(s): 494.100(b)(2),(3) The dialysis facility must - (2) Retrieve and review complete self-monitoring data and other information from self-care patients or their designated caregiver(s) at least every 2 months; and (3) Maintain this information in the patient ’ s medical record. This Standard is not met as evidenced by: 39223 Based on medical record review, review of facility policy, and staff interview, it was determined the facility failed to ensure the home dialysis nurse provided follow up after the Homechoice Claria Patient Clinical Data Report (Home Dialysis Treatment Flowsheets) indicated peritoneal dialysis (PD) was not provided in accordance with the prescriber’s orders for one of one PD patient (Patient (P)1). Findings include: A review of P1’s medical record revealed a physician’s order, starting on 09/25/25 and active until 01/28/26, for a dry weight of 80 kilograms (kg) and Continuous Cycling Peritoneal Dialysis treatments, six days a week as follows: “... If you weigh: ... 76.9 [kg] or less use: ... 2 [two] 1.5% 77 [kg] to 79.9 [kg] use: 1 [one] 1.5% ... 1 [one] 2.5% 80 [kg] to 83 [kg] use: 2 [two] 2.5% 83.1 [kg] to 85 [kg] use: 1 [one] 2.5% ... 1 [one] 4.25% 85.1 [kg] or more call clinic use 2 [two] 4.25% ...” P1’s Daily Home Treatment Records (Flowsheets) for 12/14/25 through 01/27/26 were reviewed. Documentation indicated that the patient did not follow the physician’s prescribed treatment prescription, as follows: On 12/14/25, the patient’s weight was 88.0 kg, which is above 85.1 kg. The patient used two bags of 2.5% dextrose solution instead of two bags of 4.25% dextrose solution. There was no documented evidence that the patient called the clinic. On 12/15/25, the patient’s weight was 87.8 kg, which is above 85.1 kg. The patient used two bags of 2.5% dextrose instead of two bags of 4.25% dextrose solution. There was no documented evidence that the patient called the clinic. On 12/16/25, the patient’s weight was 87.2 kg, which is above 85.1 kg. The patient used two bags of 2.5% dextrose instead of two bags of 4.25% dextrose solution. There was no documented evidence that the patient called the clinic. On 12/17/25, the patient’s weight was 87.2 kg, which is above 85.1 kg. The patient used two bags of 2.5% dextrose instead of two bags of 4.25% dextrose solution. There was no documented evidence that the patient called the clinic. On 12/18/25, the patient’s weight was 86.5 kg, which is above 85.1 kg. The patient used two bags of 2.5% dextrose instead of two bags of 4.25% dextrose solution. There was no documented evidence that the patient called the clinic. On 12/19/25, the patient’s weight was 87.0 kg, which is above 85.1 kg. The patient used two bags of 2.5% dextrose instead of two bags of 4.25% dextrose solution. There was no documented evidence that the patient called the clinic. On 12/20/25, the patient’s weight was 88.0 kg, which is above 85.1 kg. The patient used two bags of 2.5% dextrose instead of two bags of 4.25% dextrose solution. There was no documented evidence that the patient called the clinic. On 12/22/25, the patient’s weight was 87.6 kg, which is above 85.1 kg. The patient used two bags of 2.5% dextrose instead of two bags of 4.25% dextrose solution. There was no documented evidence that the patient called the clinic. On 12/23/25, the patient’s weight was 87.2 kg, which is above 85.1 kg. The patient used two bags of 2.5% dextrose instead of two bags of 4.25% dextrose solution. There was no documented evidence that the patient called the clinic. On 12/24/25, the patient’s weight was 86.7 kg, which is above 85.1 kg. The patient used two bags of 2.5% dextrose instead of two bags of 4.25% dextrose solution. There was no documented evidence that the patient called the clinic. On 12/27/25, the patient’s weight was 86.2 kg, which is above 85.1 kg. The patient used two bags of 2.5% dextrose instead of two bags of 4.25% dextrose solution. There was no documented evidence that the patient called the clinic. On 12/28/25, the patient’s weight was 86.0 kg, which is above 85.1 kg. The patient used two bags of 2.5% dextrose instead of two bags of 4.25% dextrose solution. There was no documented evidence that the patient called the clinic. On 12/29/25, the patient’s weight was 85.7 kg, which is above 85.1 kg. The patient used two bags of 2.5% dextrose instead of two bags of 4.25% dextrose solution. There was no documented evidence that the patient called the clinic. On 12/31/25, the patient’s weight was 86.3 kg, which is above 85.1 kg. The patient used two bags of 2.5% dextrose instead of two bags of 4.25% dextrose solution. There was no documented evidence that the patient called the clinic. On 01/01/26, the patient’s weight was 86.0 kg, which is above 85.1 kg. The patient used two bags of 2.5% dextrose instead of two bags of 4.25% dextrose solution. There was no documented evidence that the patient called the clinic. On 01/02/26, the patient’s weight was 85.8 kg, which is above 85.1 kg. The patient used two bags of 2.5% dextrose instead of two bags of 4.25% dextrose solution. There was no documented evidence that the patient called the clinic. On 01/03/26, the patient’s weight was 85.4 kg, which is above 85.1 kg. The patient used two bags of 2.5% dextrose instead of two bags of 4.25% dextrose solution. There was no documented evidence that the patient called the clinic. On 01/07/26, the patient’s weight was 85.3 kg, which is above 85.1 kg. The patient used two bags of 2.5% dextrose instead of two bags of 4.25% dextrose solution. There was no documented evidence that the patient called the clinic. On 01/01/26, the patient’s weight was 86.0 kg, which is above 85.1 kg. The patient used two bags of 2.5% dextrose instead of two bags of 4.25% dextrose solution. There was no documented evidence that the patient called the clinic. The above was reviewed with Staff (S)5. During an interview on 01/29/26 at 11:29 AM, S5 stated that the Claria program will only allow one program to be created. This prevents patients from choosing a different solution strength when needed. When asked how he/she ensures the patient has followed the prescribed dose of dialysis, S5 replied that he/she will review the patient’s weight and the prescription. S5 confirmed that there was no documented evidence that he/she reviewed the physician’s orders with the patient and the importance of following the prescription. Review of facility policy titled, PD Flowsheet Measurement Integrity (Scale-to-Flowsheet Match) and Provider Notification, approved 05/06/24, stated, “... Definitions ... Discrepancy Mismatch: Any of the following: ... Staff/patient uses a scale method different than flowsheet instructions (e.g., failure to tare, different bag type, differing conversion factor). ... POLICY STATEMENT ... 2. If the solution scale method does not match the PD flowsheet, staff must initiate the Discrepancy Response Procedure the same day identified and ensure documentation supports clinical decision making and the care plan. ...””

“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: 39223 Based on observation, staff interview, and review of facility policy, it was determined the medical director failed to ensure that: 1) medications are stored in the pyxis for one of two medication preparation areas; and 2) all staff administer heparin in accordance with facility policy. Findings include: 1) During a tour of the medication preparation and supply area on 01/28/26 at 11:38 AM the following medications were observed in the following locations: The cabinet located directly above the medication refrigerator contained a supply basket filled with over 20 sterile 10 milliliter (ml) syringes. Within the basket were two unopened vials of Heparin Sodium Injection 10,000 units, seven Calcitriol capsules 0.25 micrograms, and three Cinacalcet tablets 30 milligrams. A small box located in the cabinet directly above the dirty sink contained one opened, empty vial of Heparin Sodium Injection 10,000 units. During an interview at 11:42 AM, Staff (S)4 confirmed that the above medications were not stored in the designated area. S4 stated they should be stored in the Pyxis and not mixed with clean supplies. S4 removed the medications and returned them to the Pyxis. Facility policy titled, Medication Administration, approved 05/03/24, stated, “... 1. The Nurse Manager/designee is responsible for supervising the handlings, storing, disposing, administering, and controlling of medications ...” N.J.A.C. 8:43G-23.2(a)(5) 48966 2) On 01/28/26 at 10:48 PM, in Station 3, during the initiation of a hemodialysis treatment through a central venous catheter (CVC), the following was observed: Staff (S) 7, attached a heparin filled bolus syringe to the venous CVC limb and slowly injected the heparin with a back-and-forth motion. After waiting two minutes, S7 proceeded to attach the dialysis bloodlines to the CVC limbs and initiated treatment. S7 did not wait the three-five minutes after heparin administration before initiating treatment required by facility policy. During an interview on 01/28/25 at 11:31 AM, S7 stated after heparin bolus administration to wait three-five minutes before initiating treatment. S7 confirmed he/she did not wait the three-five minutes after administering the heparin bolus. On 01/28/26 at 11:09 AM, in Station 16, during the initiation of a hemodialysis treatment through a CVC, the following was observed: S6, attached a heparin filled bolus syringe to the venous CVC limb and slowly injected the heparin with a back-and-forth motion. Immediately after instilling the heparin, S6 proceeded to attach the dialysis bloodlines to the CVC limbs and initiated treatment. S6 did not wait the three-five minutes after heparin administration before initiating treatment required by facility policy. During an interview on 01/28/26 at 11:20 AM, S6 stated after the heparin bolus administration to wait for five minutes before initiating treatment. S6 continue to explain that some patients clot f treatment isn’t initiated immediately when utilizing the CVC. Facility policy titled, “Initiation of Hemodialysis Treatment with Central Venous Catheter (CVC) with MicroClave/Curos Antimicrobial Caps, Approval Date: 10/12/22, stated, “... Procedure ... 16. Attach the heparin-loading dose to the venous limb, as applicable. Unclamp and gently flush catheter back and forth 3-5 times. Reclamp. Wait at least 3-5 minutes after heparin administration to allow systemic circulation. ... 19. After a minimum of 3-5 minutes, remove the syringe from each access port one at a time, scrub hub for 15-seconds, then securely attach each bloodline carefully to avoid contaminating bloodline tips or catheter limbs. ...” N.J.A.C. 8:43A-9.3(a)”