Fmc Kings Court Flemington

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 51990 Based on observations, staff interview, and a review of facility documents, it was determined that the facility failed to ensure that the In-Center Hemodialysis emergency cart and emergency evacuation box are properly maintained and contain a comprehensive list of contents and that the emergency box contains supplies for every licensed patient station in the event of an emergency. Findings include: On 06/23/25, in the In-Center Treatment Area, the emergency cart, and the emergency evacuation box were reviewed and revealed the following: At 10:45 AM, the emergency cart checklist titled, “Emergency Code Cart and Medication Checklist (Monthly),” dated 06/2025, was reviewed. It listed that tongue blades were present, however, the cart did not contain the item. The cart also contained supplies not listed on the checklist which included: two 14g (gauge) AVF (arteriovenous fistula) needles, two 15g AVF needles, 16g AVF needles, two 17g AVF needles, four 1 ml (milliliter) syringes with 29g needles attached, four 3 cc (cubic centimeter) syringes with 23g needles attached, 18-10cc syringes with 21g needles attached, three butterfly tubing infusion sets, 10-10ml NSS (Normal Saline Solution), five 1L (liter) NSS, five IV (intravenous) sets, one box of alcohol pads, one box of band aides, 10-4X4 gauze pads, 14-2X2 gauze pads, 15 tourniquets, 10 gowns, one box of mask, two face shields, two boxes of medium gloves, five kidney basins, three laryngoscope blades, one stethoscope, one flashlight, two D batteries, one extension cord, and a container of safety locks. Upon further review, the checklist indicated the cart contained the following: Two vials of Calcium Chloride (CaCl2) 10% with an expiration date of 08/31/25, however, there were four vials of CaCl2 instead of two; one Naloxone vial with an expiration date of 08/31/25, however, there were two Naloxone vials instead of one and the additional Naloxone vial expires on 01/2026; and four Epinephrine 1:1000 vials with an expiration date of 06/2025, however, there were six Epinephrine vials instead of four and the additional Epinephrine vials expire on 10/2025. During an interview on 06/23/25 at 11:25 PM, Staff (S)10 (Clinical Educator) confirmed that the cart is checked monthly. He/she also confirmed the missing tongue blades, and the supplies and additional medication vials that were not included on the checklist. At 11:30 AM, the emergency evacuation box checklist titled, “Emergency Box Contents Log In-Center - Monthly,” dated 06/2025 was reviewed. The checklist indicated that there was a pocket mask in the box, however, the box did not contain the item. The checklist also indicated to have four vascular arm clamps, and 16 bags of NSS, however, there were only 14 bags of NSS present in the box. The vascular clamps and NSS were not enough supplies to cover 16 patient stations in the event of an emergency evacuation. The box also contained 16 CVC (Central Venous Catheter) caps that were not listed on the checklist. During a follow-up interview at 12:05 PM, S10 confirmed that the facility has 16 licensed stations and that there should be enough supplies in the box for 16 patients for every shift. He/she also confirmed the missing items in the emergency evacuation box. Facility policy titled, “Emergency Medications, Equipment and Supplies,” published 02/03/25 stated, “... Definitions ... Emergency Evacuation Box: An emergency evacuation box contains supplies primarily needed to emergently remove needles, cap catheters, and provide saline as needed for every licensed station once the patient is in a secure location ... Emergency Cart ... The emergency cart must be: ... Checked monthly or after use for contents, expiration dates, cleanliness, and proper functioning of all equipment ... An itemized log must be kept indicating the contents and expiration dates and contents ... Emergency Evacuation Box ... An emergency evacuation box must: ... Be checked monthly or after use for contents, expiration dates and cleanliness ... An itemized log must be kept indicating the contents and expiration dates of contents ...” N.J.A.C. 8:43A-15.1(a)”

“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: 50912 Based on observation, staff interview, and a review of facility documents, it was determined that the facility failed to ensure that: 1) five out of 16 blood pressure (BP) cuffs are maintained to allow for adequate cleaning and disinfection and; 2) clean, plastic hemostat clamps are stored in accordance with facility policy. Findings include: 1. On 06/23/25 at 9:40 AM, during a tour of the Hemodialysis Treatment Room, the BP cuffs at Stations 2, 5, 10, 11, and 12 were covered with white lint on the Velcro portion of the cuff, which rendered the BP (Blood Pressure) cuffs uncleanable. On 06/23/25 at 9:55 AM, the above findings were confirmed with Staff (S)6 (Interim Charge Nurse) and S4 (Patient Care Technician). S6 stated that he/she will have staff change the BP cuffs covered with lint immediately. Facility policy titled, “Cleaning and Disinfecting the Dialysis Station,” published 09/05/23, stated, “... Definition ... Area including the dialysis machine, chair bed and other reusable equipment or supplies utilized during treatment ... may include ... IV [intravenous] pole, BP cuff ... after use, any non-disposable equipment ... must be disinfected with 1:100 bleach or EPA [Environmental Protection Agency] registered disinfectant. 2. On 06/23/25 at 10:10 AM, on the right side of a clean sink located across Station 12 and 13, was an unmarked drawer. Inside the drawer were 16 pieces of blue plastic hemostat clamps along with three black marker pens and three yellow highlighter pens. A second clean sink area located across from Stations 2 and 3, had an unmarked drawer on its left side. Inside the drawer were 10 pieces of blue plastic hemostat clamps along with one black marker pen, one yellow highlighter pen, a phone charger and a metal clip binder. These findings were confirmed with Staff (S)9 (Patient Care Technician) and S7 (Registered Nurse) on 6/23/25 at 10:12 AM. Upon interview at 10:14 AM, S9 stated that the blue clamps are clean, and once disinfected by soaking in 1:100 bleach solution (one part bleach to 100 parts water) for 15 minutes and dried, they are then stored inside the unmarked drawers. S9 stated that he/she is not sure if the pens inside the drawers with the blue hemostat clamps are cleaned by staff after each use. These findings were also confirmed with S10 (Clinical Educator) on 6/23/25 at 10:45 AM. Upon interview at 10:48 AM, S10 stated, “It is not very ideal to mix disinfected clean blue hemostat clamps with other office supplies.” Facility policy titled, “Cleaning and disinfecting Plastic Hemostat Clamps and Plastic Vascular Clamps” published 07/01/24, stated, “Once completely dry, store the plastic hemostat clamps in a covered storage container when not in use. ... Note: recommended placing a label on the storage container labelled [sic] as CLEAN clamps. ...” 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: 50912 Based on one of two observations of the termination of hemodialysis through a Central Venous Catheter (CVC, a type of access used for hemodialysis), staff interview, a review of facility documents, it was determined that the facility failed to ensure that termination of hemodialysis using a CVC is performed in accordance with facility policy. Findings include: On 06/23/25 at 9:35 AM, Staff (S)7 (Registered Nurse), discontinued hemodialysis treatment through a CVC on a patient in Station 11. S7 disconnected the arterial bloodline from the CVC, scrubbed the end and the thread of the hub using a 70 % isopropyl alcohol pad for five seconds. This was 10 seconds less than the 15 second minimum required by facility policy. S4 then proceeded to disconnect the venous bloodline from the CVC and scrubbed the end and thread of the hub for five seconds. This was 10 seconds less than required by facility policy. During an interview on 06/23/25 at 9:42 AM, S7 stated the catheter threads and ends need to be scrubbed for 15 seconds per facility policy. A review of S7’s training and education records indicated that an Annual Skills Validation that included training in discontinuation of dialysis with a CVC was completed on 04/23/25. Facility policy, titled “Termination of Treatment Using a Central Venous Catheter Optiflux Single Use Ebeam Dialyzer,” published 11/04/2024, stated, “... Termination: Disinfection of Catheter and Disconnecting the Patient ... Threads and ends of the luer lock (hub) must be scrubbed with 70 % sterile alcohol pad (or other appropriate aseptic product ... for 10-15 seconds any time caps are removed, or bloodlines disconnected ... to reduce risks of contamination. ...” N.J.A.C. 8:43A-24.8(b)”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 33556 Based on observation and staff interview, it was determined the facility failed to provide a defect free environment while maintaining all surfaces cleanable and in good repair. Findings include: During a tour conducted on 06/23/25 at 11:15 AM with Staff (S)3 (Biomedical Technician), the lower front surface of the water chase structure installed throughout the patient treatment area was identified as surface worn and/or moisture damaged while exposing unfinished wood-like base material. Unfinished wood-like base material is not a cleanable substance. The water chase structure exposed base material was confirmed by S3 upon discovery. N.J.A.C. 8:43A-17.4(a)(15)”

“PR-PRIVACY & CONFIDENTIALITY-TREATMENT CFR(s): 494.70(a)(3) The patient has the right to- (3) Privacy and confidentiality in all aspects of treatment; This Standard is not met as evidenced by: 50912 Based on one of one observation of the discontinuation of hemodialysis through a Central Venous Catheter (CVC, a type of access used for hemodialysis), staff interview and a review of facility documents, it was determined that the facility failed to ensure patient’s rights to privacy. Findings include: On 06/23/25 at 9:35 AM in Station 11, Staff (S)7 (Registered Nurse) discontinued hemodialysis on a patient through a right chest wall CVC. During the procedure, the curtain was not fully drawn on the right side of the patient leaving an approximate two feet opening. The patient’s chest was visible from the patients in Stations 9 and 10, which was located on the right side of Station 11. During an interview on 06/23/25 at 9:43 PM, S7 confirmed that the curtains should be fully closed around the patient’s station when discontinuing hemodialysis. S7 stated that he/she will make sure that the curtains are fully closed next time. A review of S7’s personal file indicated that “Patient Rights Training and Education” was completed on 07/07/24. Facility policy titled, “Patient Rights and Responsibilities,” published 04/04/12, stated, “... Purpose ... Ensure that patients’ rights are respected and protected by the facility ... All facility staff are responsible for ensuring that patients’ rights are respected and protected by the facility ... 3. Privacy and confidentiality in all aspects of treatment ...” N.J.A.C 8:43A-16.2(a)10”

“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: 39228 Based on medical record review, staff interviews, and a review of facility documents, it was determined that the facility failed to ensure that post (after) hemodialysis nursing assessments are completed according to facility policy in four of seven medical records reviewed (Patient [P]3, P4, P5 and P7). Findings include: A review of P3’s plan of care, dated 01/13/25, stated, “Area of Focus BP [blood pressure] and Fluid Management Open Goal Achieve BP Control as specified by the patient’s physician ... Intervention (s): ... Educate patient/family/caregiver on fluid control ... In progress ... Met Goal: Continue to monitor patient ...” A review of the “Treatment Sheets for Facility” from 06/03/25 through 06/21/25 in P3’s medical record revealed the following: On 06/03/25 at 05:28 AM, the pre-treatment (before treatment) “Nursing Evaluation” indicated “bilateral [affecting both sides] ankle, 1+ (plus): 2 mm (millimeters) or less, disappears rapidly. ... Lungs decreased breath sounds, Bilateral, Rales (Crackles) ...” The post-treatment “Nursing Evaluation” at 9:40 AM lacked documented evidence of a re-assessment of the bilateral ankle edema and lung sounds. On 06/04/25 at 05:28 AM, the pre-treatment “Nursing Evaluation” indicated “bilateral ankle edema, 1+: 2 mm or less, disappears rapidly ... Lungs decreased breath sounds, Rales ...” The post-treatment “Nursing Evaluation” at 8:27 AM lacked documented evidence of a re-assessment of the bilateral ankle edema and lung sounds. On 06/07/25 at 5:38 AM pre -treatment “Nursing Evaluation” indicated “Lungs: Decrease breath sounds, Rales.” The post-treatment “Nursing Evaluation” at 10:02 AM lacked documented evidence of a re-assessment of the lung sounds, On 06/10/25 at 6:11 AM, the pre-treatment “Nursing Evaluation” indicated “bilateral ankle edema, 1+: 2 mm or less, disappears rapidly.” The post-treatment “Nursing Evaluation” at 10:07 AM lacked documented evidence of a re-assessment of the bilateral ankle edema. On 06/14/25 at 6:10 AM, the pre-treatment “Nursing Evaluation” indicated “bilateral ankle edema, 1+: 2 mm or less, disappears rapidly.” The post-treatment “Nursing Evaluation” at 11:47 AM lacked documented evidence of a re-assessment of the bilateral ankle edema. On 06/17/25 at 5:55 AM pre -treatment “Nursing Evaluation” indicated “Lungs: Decrease breath sounds. Bilateral.” The post-treatment “Nursing Evaluation” at 11:55 AM lacked documented evidence of a re-assessment of the lung sounds. On 06/19/25 at 5:35 AM, the pre-treatment “Nursing Evaluation” indicated “bilateral ankle edema, 1+: 2 mm or less, disappears rapidly ... Lungs decreased breath sounds, Rales.” The post-treatment “Nursing Evaluation” at 9:35 AM lacked documented evidence of a re-assessment of the bilateral ankle edema and lung sounds. On 06/21/25 at 6:09 AM pre-treatment “Nursing Evaluation” indicated “Lungs: Decrease breath sounds. Rales.” The post-treatment “Nursing Evaluation” at 9:32 AM lacked documented evidence of a re-assessment of the lung sounds, A review of P4’s plan of care, dated 06/13/25, stated, “Area of Focus BP and Fluid Management Open Goal Achieve BP Control as specified by the patient’s physician ... Intervention (s): ... Monitor fluid gains ... In Progress ...” A review of P4’s “Treatment Sheets For Facility” from 06/14/25 through 06/21/25 revealed the following: On 06/14/2025, the pre-treatment “Nursing Evaluation” at 10:13 AM, stated, “... Fluid Assessment Symptoms ... Dyspnea on Exertion Lungs Decreased breath sounds, Rales ...” The post-treatment Nursing Evaluation at 1:54 PM, lacked documented evidence of a re-assessment of the lung sounds. On 06/17/2025, the pre-treatment “Nursing Evaluation” at 11:36 AM, stated, “... Fluid Assessment Symptoms ... Dyspnea on Exertion Lungs Decreased breath sounds ... Notes: lungs diminished all fields ...” The post-treatment Nursing Evaluation at 3:16 PM, lacked documented evidence of a re-assessment of the lung sounds. On 06/19/25, the pre-treatment “Nursing Evaluation” at 10:09 AM, stated, “... Fluid Assessment ... Lungs Decreased breath sounds Ankle - Severity 1+: 2 mm (millimeter) or less, disappears rapidly ... Edema Ankle - Location Bilateral ... Notes: lungs diminished all fields ...” The post-treatment Nursing Evaluation at 1:45 PM, lacked documented evidence of a re-assessment of the lung sounds and ankle edema. On 06/21/2025, the pre-treatment “Nursing Evaluation” at 10:01 AM, stated, “... Fluid Assessment ... Lungs Decreased breath sounds ... Notes: decreased breath sounds bl [bilateral] bases. ...” The post-treatment Nursing Evaluation at 1:36 PM, lacked documented evidence of a re-assessment of the lung sounds. A review of P5’s plan of care, dated 06/13/25, stated, “Area of Focus BP and Fluid Management Goal Achieve BP Control: Open ... Achieve BP Control as specified by the patient’s physician ... Open ... Educate patient/family/caregiver on ... In Progress ... Educate patient/family/caregiver on fluid control ... In progress ... Change patients’ dry weight algorithm ... In progress ...” A review of the “Treatment Sheets for Facility” from 06/03/25 through 06/21/25 in P5’s medical record revealed the following: On 06/14/25 at 9:28 AM, the pre-treatment “Nursing Evaluation” indicated “bilateral ankle edema, 1+: 2 mm or less, disappears rapidly.” The post-treatment “Nursing Evaluation” at 2:11 PM lacked documented evidence of a re-assessment of the bilateral ankle edema. On 06/17/25 at 9:52 AM, the pre-treatment “Nursing Evaluation” indicated “bilateral ankle edema, 1+: 2 mm or less, disappears rapidly.” The post-treatment “Nursing Evaluation” at 3:04 PM lacked documented evidence of a re-assessment of the bilateral ankle edema. A review of P7’s plan of care, dated 06/14/25, stated, “Area of Focus BP and Fluid Management Goal Achieve BP Control: Open ... Achieve BP Control as specified by the patient’s physician ... Open ... Educate patient/family/caregiver on ... In Progress ... Educate patient/family/caregiver on fluid control ... In progress ... Monitor fluid gains and discuss high weight gains with patient ... In progress ...” A review of the “Treatment Sheets for Facility” from 06/02/25 through 06/20/25 in P7’s medical record revealed the following: On 06/16/25 at 11:17 AM, the pre-treatment “Nursing Evaluation” indicated “Bilateral ankle edema, Bilateral lower leg edema, 1+: 2 mm or less, disappears rapidly ... Lungs: Decrease breath sounds, bilateral.” The post-treatment “Nursing Evaluation” at 3:25 PM lacked documented evidence of a re-assessment of the bilateral ankle edema and lung sounds. On 06/18/25 at 11:37 AM pre -treatment “Nursing Evaluation” indicated “Lungs: Decrease breath sounds, Bilateral” The post-treatment “Nursing Evaluation” at 3:20 PM lacked documented evidence of a re-assessment of the lung sounds. On 06/20/25 at 11:10 AM pre -treatment “Nursing Evaluation” indicated “Lungs: Decrease breath sounds, Bilateral” The post-treatment “Nursing Evaluation” at 3:19 PM lacked documented evidence of a re-assessment of the lung sounds. During an interview on 06/24/25 at 1:14 PM, Staff (S)1 (Clinical Manager) reviewed the above findings and confirmed that the post hemodialysis re-assessment of edema and lung sounds were not documented on the above-mentioned hemodialysis flowsheets. S1 stated, staff nurses should reassess, and document post-treatment edema and lung sounds if abnormal findings were found pre-treatment. Facility policy titled, “Patient Assessment and Monitoring,” published 05/01/23, stated, “ “... Purpose ... provide guidance to ... direct patient care staff on assessment and monitoring patients before, during and after treatment ... Pre-Treatment ... Lung sounds ... Auscultate lung sounds for: Sound: ... Decreased breath sounds Rales (crackles) ... Location: ... Bilateral ... Edema (As indicated by patient condition): Assess the patient for edema ... Location ... Severity ... Post Assessment ... Follow the steps below for obtaining post-treatment assessing data: ... 1. The direct patient care staff may obtain the following: Lung sounds Edema ... The Registered Nurse will assess/re-assess post treatment as indicated ... 2. Document findings in the patient’s record ...” N.J.A.C. 8:43A-24.4(a) 50912”

“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: 39228 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 interviews, and a review of facility documents, it was determined that the facility failed to ensure that staff perform skin disinfection of the access site prior to initiating the dialysis treatment in accordance with facility policy. Findings include: On 06/23/25 at 10:15 AM, in Station 9, Staff (S)9 (Patient Care Technician), initiated dialysis through a patient’s right upper arm AVG. S9 cleansed the first site of the AVG with a 70% isopropyl alcohol pad in a circular motion for 15 seconds then cannulated (the act of inserting a needle into the vascular access). This was 15 seconds less than required by facility policy. S4 then cleansed the second site of the AVG with an alcohol pad in a circular motion for 17 seconds then cannulated the site. This was 13 seconds less than required by facility policy. During an interview at 10:21 AM, S9 stated he/she should clean each site of the access for at least 30 seconds with alcohol. S9 stated, he/she thought that he/she cleaned the sites long enough. A review of S9’s training and education records revealed that he/she completed the Annual Skills Training on 05/05/25 which included training in AVG/F Cannulation. On 06/23/25 at 10:25 AM, in Station 3, S5 (PCT) initiated hemodialysis through a patient’s left forearm AVF. S5 cleansed the first site of the AVF with an alcohol pad in a circular motion for 4 seconds and immediately cannulated the site with a fistula needle. This was 26 seconds less than required by facility policy. S5 then cleansed the second site of the AVF with an alcohol pad in a circular motion for 5 seconds then cannulated the site with a fistula needle. This was 25 seconds less than required by facility policy During an interview on 06/23/25 at 10:29 AM, when asked by the surveyor about disinfecting access sites, S5 stated, “The sites should be cleaned with alcohol for 15 seconds.” A review of S5’s training and education records indicated that an Annual Skills Validation that included training in access evaluation and preparation of the access for an AVF was completed on 12/07/2024. Facility policy titled, “Access Assessment and Cannulation,” published 05/05/25, stated, “... Skin Disinfection ... Step ... 1. Disinfect cannulation site as follows using any of the disinfectants below: 70% isopropyl alcohol pad: Using gentle friction, clean the access site beginning in the center and continuing outward 2 inches in a concentric circle for 30 seconds ...” N.J.A.C. 8:43A-24.8(b) 50912”

“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: 51990 Based on a observation, staff interview, and a review of facility documents, it was determined that the facility failed to ensure that all pre-drawn medication is secured in accordance with facility policy. Findings include: On 06/23/25 at 10:03 AM, in Station 9, which was unoccupied by a patient at the time of observation, a pre-drawn medication labeled “Heparin (a medication used to prevent blood clots)” was found unattended on top of a dialysis machine. The syringe contained 7cc (cubic centimeters) of Heparin and was labeled with the patient’s name, the dose (Heparin 1mL (milliliter):1000 units), the date (06/23/25), the time (9:20 AM), and the RN (Registered Nurse) initials. During an interview at 10:10 AM, Staff (S)9 (Patient Care Technician) stated, “That’s for the next patient. The RN placed it there.” S9 confirmed that the pre-drawn heparin syringe should be stored in the locked medication cabinet until ready for patient administration. Facility policy titled, “Medication Preparation and Administration,’ published 02/06/23, stated, “... Pre-Drawn Medications Medications may be pre-drawn up tp 4 hours prior to administration (unless state specific requirements such as New Jersey, ... where there is a 1 hour maximum for pre drawing medications.) These pre-drawn medications shall be labeled and must be kept under the preparer’s control or in a locked designated medication storage area or refrigerated, if necessary until delivery to the patient for administration ...” N.J.A.C. 8:43A-9.5(a)”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 51990 Based on a review of one of seven medical records (Patient [P]1) for a home patient receiving oral nutritional supplements (ONS), staff interviews, and a review of facility documents, it was determined that the facility failed to ensure that LiquaCel administration is completely and accurately documented in the medical record. Findings include: A review of P1’s medical record revealed the following: The Nutritional Supplement Order, dated 06/07/24 stated, “LiquaCel- 1oz [ounce] PO [by mouth] 3X [times] Week.” A review of CCPD (Continuous Cycling Peritoneal Dialysis) Treatment Sheets, dated from 05/12/25 to 06/23/25, contained no documentation of LiquaCel intake in the treatment record. During an interview on 06/23/25 at 2:00 PM, when the surveyor asked where LiquaCel is documented, Staff (S)2 (Home Therapy Nurse) responded that Patient (P)1 takes it at home, and it does not need to be documented like the rest of the patient’s home medications. This was not in accordance with facility policy. There was no documented evidence that the Home Registered Nurse or Registered Dietitian (RD) instructed the patient to record LiquaCel administration on the form titled “Oral Nutritional Supplements Program Documentation: Home Therapies Record of Nutritional Supplement Use” and to bring the completed form to clinic visits. During an interview on 06/25/25 at 10:00 AM, S11 (RD) stated, “We don’t ask home patients to fill the ONS form.” Facility policy titled, “Oral Nutritional Supplement Program (ONSP) Administration Procedure,” published 09/06/22, stated, “.. Document Administration ... Home Therapies patients shall be instructed by the Home Therapies RD or RN to track oral nutritional supplement usage at home and document on the treatment record or on the Oral Nutritional Supplements Program Documentation: Home Therapies Record of Nutrition Supplement Use form ... If using paper form, instruct patient to bring to next clinic visit... Upon completion of prescribed oral nutritional supplement doses, completed paper forms shall be returned to the clinic and maintained in the patient’s medical record ...” N.J.A.C. 8:43A-13.3(a)(11)”