Fmc Kenvil

“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 observation, staff interviews, and a review of facility documents, it was determined that the facility failed to ensure that one of one emergency cart contains a comprehensive checklist of supplies and expired equipment is not available for use; and one of one emergency evacuation box has complete monthly checks and is documented in the electronic system in accordance with facility policy. Findings include: On 07/21/25, in the In-Center Treatment Area, the facility’s emergency cart and emergency evacuation box, were reviewed and revealed the following: At 11:50 AM, Staff (S)5 stated that the facility has one emergency cart and one emergency evacuation box for the In-Center Hemodialysis and Peritoneal Dialysis (PD, a type of dialysis that uses the lining of the abdomen) modalities. The emergency cart binder located on the emergency code cart contained a manual checklist titled, “Emergency/Evacuation Cart Checklist,” dated 07/01/25. The checklist indicated that the cart contained one box of Diphenhydramine 50 mg (milligrams) vials, expiration date 04/2026. However, the expiration date on the box Diphenhydramine located in the cart was 01/2026. The manual checklist also stated that one bottle of Nitroglycerin 0.4 mg tablets was present in the cart however, the cart contained two bottles of Nitroglycerin 0.4 mg tablets. S5 also provided an electronic checklist completed by staff for the emergency cart titled “Emergency Code Cart and Medication Checklist (Monthly),” dated 07/01/25. The electronic checklist stated that a suction canister was present in the cart and that it had no expiration date. However, the cart contained a suction canister that expired in 01/2024. The electronic checklist also stated that Adrenalin 1:100 was not approved by the Medical Director; however, the emergency cart contained four Adrenalin 1:100 vials. A review of the manual checklist list stated that four Adrenalin 1:100 vials were present in the cart which is not in accordance with the electronic checklist documentation. During an interview at 07/01/25 at 12:20 PM, S5 confirmed that the cart was checked monthly and stated he/she was not aware that the suction canister had an expiration date. S5 also confirmed all of the findings indicated above. At 12:25 PM, the manual checklist for the emergency evacuation box titled “Emergency/Evacuation Cart Checklist Box Contents,” dated 07/01/25, was provided and reviewed. The manual checklist documented the lock number on the evacuation box as 7714965 however, the lock number on the box was 7714964, which did not match the recorded information. Upon discovery, S4 and S5 confirmed the discrepancy. During an interview on 07/21/25 at 12:30 PM, S5 stated only a manual checklist was completed for the emergency evacuation box and that is was not documented electronically. A follow-up interview on 07/22/25 at 9:20 AM was conducted with S1 who confirmed that the monthly check of the emergency evacuation box was not documented in the electronic system. Facility policy titled, “Emergency Medications, Equipment and Supplies,” published 07/07/25, stated, “... Policy... The following minimum emergency supplies and equipment must be on the premises at all times, clean, functional, accessible and immediately available: ... Suction machine, disposable catheter and canisters ... Emergency Cart ... The emergency cart must be: ... An itemized log must be kept indicating the contents and expiration dates and contents ... Emergency Evacuation Box ... An emergency evacuation box must: ... Complete the monthly check in the approved electronic documentation system ...” On 07/23/25 at 9:10 AM, S1 stated that the prior version of the facility policy titled “Emergency Medications, Equipment, and Supplies,” was published on 02/03/25 and that it had been archived and was no longer available to print. A document titled “Clinical Services Policy and Procedure Updates Crosswalk,” dated 07/07/25, was provided that outlined the changes to the policy which stated “... Emergency Medications, Equipment and Supplies ... Added that the emergency box should be locked when not in use ... Added the Solu- Medrol 125mg vial is preferable, however SoluCortef 100mg may be used (if solumedrol is unavailable) ...” N.J.A.C. 8:43A-15.1(a)”

“IC-TRANSDUCER PROTECTORS-NOT WETTED/CHANGED CFR(s): 494.30(a)(1)(i) Use external venous and arterial pressure transducer filters/protectors for each patient treatment to prevent blood contamination of the dialysis machines’ pressure monitors. If the external transducer protector becomes wet, replace immediately and inspect the protector. If fluid is visible on the side of the transducer protector that faces the machine, have qualified personnel open the machine after the treatment is completed and check for contamination. This includes inspection for possible blood contamination of the internal pressure tubing set and pressure sensing port. If contamination has occurred, the machine must be taken out of service and disinfected using either 1:100 dilution of bleach (300-600 mg/L free chlorine) or a commercially available, EPA-registered tuberculocidal germicide before reuse. Change filters/protectors between each patient treatment, and do not reuse them. Internal transducer filters do not need to be changed routinely between patients. This Standard is not met as evidenced by: 37656 Based on one of one observation, document review, and staff interview, it was determined that the facility failed to ensure that the external transducer protectors are replaced immediately when it becomes wet with blood or fluid and the machine side (back) is inspected to prevent blood contamination of the hemodialysis machines’ (HD) pressure monitor per facility policy and procedure. Findings include: On 07/21/25 at 10:35 AM, during the flash tour of the In-Center Hemodialysis Treatment Floor, the arterial external transducer protector on the dialysis machine in Station 3 was wet with a pink colored liquid. At 10:43 AM, the venous external transducer protector was wet with blood. At 11:00 AM, Staff (S)7, checked the machine but did not check the lines and the transducer protectors. At 11:02 AM, the machine was alarming showing high arterial pressure. S18 then checked and reset the alarm and did not do safety checks (checking of vital signs, patient access, inspection of the external transducer protectors) in accordance with facility policy. At 11:20 AM, the machine was alarming showing high arterial pressure. S4, then checked the alarm and inspected the venous and arterial transducer protectors. S4 retrieved two new external transducer protectors from the clean utility cart, flushed the line with saline and changed the wet venous and arterial transducer protectors. At 11:25 AM, S4 was about to discard the wet venous and arterial external transducer protectors into a sharps container when this surveyor intervened. An interview with S4 was conducted by this surveyor and he/she was asked what they were supposed to do before discarding the wet transducers, S4 did not know how to respond and discarded the wet transducer protectors into the sharp’s container. S4 did not inspect the sides of the transducer protectors facing the dialysis machine prior to discarding. A review of S4 personnel file on 07/23/25 indicated he/she had an “Annual Clinical Skills Validation” which stated that it was completed, but did not contain the date it was completed. Upon interview on 7/23/25 at 1:30 PM, S1 stated the educator was on vacation but will reach out to Manager of Clinical Education. An e-mail sent by S1 on 07/24/25 from Manager of Clinical Education stating that changing wet transducers was taught during staff orientation and not re-taught after orientation. The only time they will re-educate is during annual skills observation if the staff perform a safety check and the wet transducer is not changed. Facility policy titled, “Patient Assessment and Monitoring,” published 05/01/23, states, “... During Treatment ... safety checks every 30 minutes or more often as needed ... Step 3 ... Observe and ensure that the transducer protectors are dry, unclamped, and pressure lines is free of fluid. ...” Facility procedure titled, “Maintenance of Transducer Protectors Procedure,” published 11/21/21, states, “... Policy ... External transducer protectors must be changed immediately when they become wet with blood or other fluid. Wet external transducers must be thoroughly examined to determine if any blood or other fluid contamination is visible on the machine side (back) of the transducer protector prior to replacement. ...” N.J.A.C. 8:43A-24.8(c)”

“IC-HANDLING INFECTIOUS WASTE CFR(s): 494.30(a)(4)(i) [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- (i) Handling, storage and disposal of potentially infectious waste; This Standard is not met as evidenced by: 51990 Based on observation of the handling and disposal of medical and potentially infectious (bio-hazardous) waste, staff interviews, and review of facility documents, it was determined that the facility failed to ensure that four out of four red bio-hazardous waste containers are covered with tight-fitting lids to prevent the potential for cross contamination. Findings include: On 07/21/25 at 9:37 AM, during a tour of the In-Center Hemodialysis Treatment Area, the lids of four red bio-hazardous waste containers were observed to not fit properly, leaving an approximate three-inch opening on one side of each container. On 7/21/25 at 9:55 AM in Station 15, following the discontinuation of hemodialysis, Staff (S)6 lifted the lid of a red bio-hazardous waste container and discarded the dialysis bloodlines into it. The lid was loose and did not completely cover the container. During an interview at the time of observation, S6 stated that the lids to the bio-hazardous containers had been that way and do not fit properly. During a follow- up interview on 07/21/25 at 1:00 PM, S1 stated that the facility had recently changed contractors/vendors and acknowledged awareness of the issue. Facility plan titled, “Medical Waste Management Plan,” review date: 11/20/23, stated, “... Medical Waste Containers & Proper Disposal ... All medical and potentially infectious (Bio-hazardous) waste must be disposed in either sharps containers, red bags or other designated containers in accordance with local, state, and federal regulations ... All medical and potentially infectious (Bio-hazardous) waste storage bags shall be securely tied in containers and all containers shall be covered with a tight-fitting lid before being moved to a storage area for transportation ...” N.J.A.C. 8:43A-17.5(a)(b) 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: 50912 Based on observation, staff interview, and a review of facility documents, it was determined that the facility failed to ensure that 11 out of 18 blood pressure (BP) cuffs are maintained to allow for adequate cleaning and disinfection in accordance with facility policy. Findings include: On 07/21/25 at 10:40 AM, during a tour of the Hemodialysis Treatment Floor, the BP cuffs in Stations 1, 4, 5, 7, 8, 9, 11, 12, 14, 15 and 18 were covered with white lint on the Velcro portion of the cuff, which rendered the BP cuffs uncleanable. On 07/21/25 at 11:20 AM, the above findings were confirmed with Staff (S)1 and S6. Upon further interview at 11:24 AM, 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. ...” 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: 51990 Based on two of two observations of the initiation/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 initiation and termination of hemodialysis using a CVC is performed in accordance with facility policy. Findings include: On 07/21/25, during a tour of the In-Center Hemodialysis Treatment Area, the following was revealed: At 10:45 AM in Station 17, Staff (S)6 terminated hemodialysis on Patient (P)14 through a right chest CVC. S6 disconnected the red (arterial) blood line using a sterile alcohol pad but did not scrub the threads and end of the hub. S6 then disconnected the blue (venous) blood line, scrubbed the threads and end of the hub with a sterile alcohol pad for eight seconds. At 12:30 PM in Station 19, S6 initiated hemodialysis on P15 through a right chest CVC. S6 removed the red end cap, scrubbed the threads and the end of the hub with a sterile alcohol pad but did not move from the hub at least several centimeters towards the body of the catheter with the alcohol pad. S6 then removed the blue end cap, scrubbed the threads and the end of the hub with a sterile alcohol pad but did not move from the hub at least several centimeters towards the body of the catheter with the alcohol pad. S6 then proceeded to initiate treatment and primed Normal Saline Solution (NSS) through the arterial and venous blood lines prior to connecting to P15’s CVC. During an interview on 07/21/25 at 12:55 PM, S6 stated that the catheter threads should be scrubbed for 10 seconds. When this surveyor asked about disinfecting the body of the CVC, S6 responded, “I have to look it up.” S6 also confirmed priming 50 mL (milliliters) of NSS from the arterial line and 250 mL NSS from the venous line. Facility policy titled, “FX CorAL: Termination of Treatment Using a Central Venous Catheter,” published 01/19/24, stated, “... Termination: Disconnection of Catheter and Disconnecting the Patient ... Follow the steps below to disinfect the catheter and to disconnect the patient from the extracorporeal system: Threads and end of the luer lock (hub) must be scrubbed with 70% sterile alcohol pad (or other appropriate antiseptic product such as chlorhexidine or povidone if required by the hospital) for 10-15 seconds any time the caps are removed, or bloodlines are disconnected (i,e. End of treatment of treatment interruption to reduce risk of contamination ...” Facility policy titled, “FX CorAL Dialyzer: Initiation of Treatment Using a Central Venous Catheter,” published 05/05/25, stated, “... Preparing the Catheter: Disinfection of the Catheter Connections, Heparin Removal, Flushing the Catheter and Heparin Administration ... Follow the steps below to disinfect the catheter connections: Threads and end of the luer lock hub must be scrubbed with 70% sterile alcohol pad (or other antiseptic such as chlorhexidine, povidone if required by the hospital) for 10-15 seconds and anytime the caps are removed, or bloodlines are disconnected (i.e. [in Latin, id est, which means that is] end of treatment or treatment interruption) to reduce risk of infection ... Step ... 4. Using the same sterile alcohol pad (or other antiseptic such as Chlorhexidine, povidone if required by the hospital) applying friction to remove any blood or residue, move from the hub at least several centimeters towards the body of the catheter ... Initiation of Treatment: Connecting the Blood Lines ... Follow the steps below to connect the blood lines to the catheter: ... The practice commonly referred as “Bleeding on” or “Displacing Prime”is prohibited. (This practice involves connecting the arterial bloodlines to the access while saline is being displaced by blood until the blood reaches the venous air trap.). This method of connecting the patient to the dialysis machine is prohibited ...” 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 and staff interview, it was determined that the facility failed to ensure that: 1) all doors and walls are maintained in good condition and; 2) all storage areas and dialysis equipment is restricted to authorized personnel only. Findings include: 1. On 7/23/25 at 10:25 AM, in the presence of Staff (S)8 and S11, the door to the Staff Toilet Room did not close fully. During an interview upon discovery, S8 confirmed the above finding. At 10:30 AM in the presence of S8 and S11, the automatic door closer was loose on the Large Storage Room door next to the Conference Room which prevents the door from fully closing. During an interview upon discovery, S8 confirmed the above finding. At 11:15 AM in the presence of S8 and S11, there was a quarter of an inch gap on three sides of the double doors between the Large Storage Room and the outside which can allow insects and rodents to enter the building. During an interview upon discovery, S8 confirmed the above finding. 2. On 7/23/25 at 11:00 AM, in the presence of S8 and S11, the door from the Patient Treatment Floor to the Storage Room, which also contained the acid and bicarb (bicarbonate) mixing tanks and equipment was not equipped with a lock to prevent unauthorized access. During an interview upon discovery, S8 confirmed the door does not have a lock installed. N.J.A.C 8:43A-17.3(l)”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 37656 Based on one of one observation, staff interview, and a review of manufacturer’s instructions for use (MIFU), it was determined that the facility failed to ensure that the expired RPC E-Z check Blood leak test strips (used to detect blood leaks in dialysis machines) are not available for use. Findings include: On 07/21/25 at 11:15 AM, in the third drawer of the clean utility cart, a bottle of RPC E-Z check Blood leak test strips, with an expiration date of 11/30/24 , were available for use. Upon interview at the time of discovery, Staff (S)7, stated it was not used in the morning, and it should have been discarded.”

“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: 51990 Based on two of two observations of the termination and initiation 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 07/21/25, during a tour of the In-Center Hemodialysis Treatment Area, the following was revealed: At 10:45 AM in Station 17, Staff (S)6 terminated hemodialysis on Patient (P)14 through a right chest CVC. During the procedure, the privacy curtains were not fully closed, leaving an approximate two foot opening in front of the patient’s station. As a result, P14’s chest was visible from Station 11, where a patient was receiving hemodialysis. At 12:30 PM in Station 19, S6 initiated hemodialysis on P15 through a right chest CVC. The privacy curtains were not fully closed, leaving an approximate three foot opening in front of the patient’s station. As a result, P15’s chest was visible from Station 1, where a patient was receiving hemodialysis. During an interview 07/21/25 at 12:55 PM, S6 confirmed that the curtains should be fully closed around the patient’s station when initiating and terminating hemodialysis. Facility policy titled, “Patient Rights and Responsibilities,” published 04/04/12, stated, “... Policy: Privacy Rights ... Patients have the right to privacy during activities that may require the exposure of private body parts while in the dialysis facility. Privacy screens or curtains may be used to provide privacy ...” 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 staff assess patients for edema (fluid build-up in the body tissues) and lung sounds post (after) hemodialysis treatment in accordance with facility policy in eight of ten medical records reviewed (Patient (P) P1, P2, P4, P5, P6, P7, P8 and P9). Findings include: A review of P1’s Plan of Care (POC), dated 05/20/25, stated, “Area of Focus BP [blood pressure] and Fluid Management: Goal Achieve BP Control as specified by the patient’s physician ... Intervention (s): ... Educate patient/family/caregiver on fluid control ...Completed ... Met Goal: Continue to monitor patient ...” A review of the “Treatment Sheets for Facility” from 06/30/25 through 07/19/25 in P1’s medical record revealed the following: On 07/07/25, 07/14/25 and 07/19/25, the pre-treatment (before treatment) “Nursing Evaluations” indicated “bilateral [affecting both sides] ankle, 1+ [plus]: 2 mm [two millimeters] or less, disappears rapidly. ... Lungs decreased breath sounds, Bilateral ...” The post (after)-treatment “Nursing Evaluations” lacked documented evidence of a re-assessment of the bilateral ankle edema and lung sounds. On 07/16/25, the pre-treatment “Nursing Evaluation” indicated “bilateral ankle, 1+: 2 mm or less, disappears rapidly. ... Lungs Rales (Crackles), Bilateral ...” The post-treatment “Nursing Evaluation” lacked documented evidence of a re-assessment of the bilateral ankle edema and lung sounds. A review of P2’s POC, dated 01/21/25, stated, “Area of Focus BP and Fluid Management: Goal Achieve BP Control as specified by the patient’s physician ... Met ... Intervention (s): ... Monitor fluid gains ... Completed ...” A review of P2’s “Treatment Sheets for Facility” from 06/30/25 through 07/21/25 revealed the following: On 06/30/2025 and 07/04/25, the pre-treatment “Nursing Evaluations”, stated, “... Fluid Assessment Symptoms ... Rales (Crackles) Bilateral ...” The post-treatment “Nursing Evaluations” lacked documented evidence of a re-assessment of the lung sounds. On 07/02/2025 and 07/07/25, the pre-treatment “Nursing Evaluations”, stated, “... Fluid Assessment Symptoms ... Decreased breath sounds ...” The post-treatment “Nursing Evaluations” lacked documented evidence of a re-assessment of the lung sounds. On 07/11/25, the pre-treatment “Nursing Evaluation” stated “... Fluid Assessment Symptoms ... Lungs Rhonchi, Bilateral ...” The post-treatment “Nursing Evaluation” lacked documented evidence of a re-assessment of the lung sounds. On 07/14/25 and 07/19/25, the pre-treatment “Nursing Evaluations” indicated “bilateral ankle, 1+: 2 mm or less, disappears rapidly. ... Lungs decreased breath sounds, Bilateral ...” The post-treatment “Nursing Evaluations” lacked documented evidence of a re-assessment of the bilateral ankle edema and lung sounds. A review of P4’s POC, dated 04/15/25, stated, “Area of Focus BP and Fluid Management ... Goal Achieve BP Control as specified by the patient’s physician ... Intervention(s): ... Met Goal: Continue to monitor patient ...” A review of P4’s “Treatment Sheets for Facility” from 06/27/25 through 07/19/25 revealed the following: On 06/27/25, the pre-treatment Nursing Evaluation, stated, “Fluid Assessment Symptoms ... Shortness of breath Lungs Decreased breath sounds Ankle - severity, 1+: 2 mm or less, disappears rapidly Edema Ankle -Location ... Bilateral ...” The post-treatment Nursing Evaluation lacked documented evidence of a re-assessment of the lung sounds and ankle edema. On 07/01/25, the pre-treatment Nursing Evaluation, stated, “Fluid Assessment ... Lungs Decreased breath sounds Lower leg - Severity, 1+: 2 mm or less, disappears rapidly ... Edema Lower Leg -Location ... Bilateral ...” The post-treatment Nursing Evaluation lacked documented evidence of a re-assessment of the lung sounds and lower leg edema. A review of P5’s POC, dated 04/15/25, stated, “Area of Focus BP and Fluid Management ... Goal Achieve BP Control as specified by the patient’s physician ... Intervention(s): ... Met Goal: Continue to monitor patient ...” A review of P5’s “Treatment Sheets for Facility” from 06/30/25 through 07/18/25 revealed the following: On 06/30/25, the pre-treatment “Nursing Evaluation” stated, “Fluid Assessment ... Lower Leg - Severity, 1+: 2 mm or less, disappears rapidly Edema Lower Leg -Location ... Bilateral ...” The post-treatment “Nursing Evaluation” lacked documented evidence of a re-assessment of the lower leg edema. On 07/07/25, 07/09/25 and 07/11/25, the pre-treatment “Nursing Evaluations” stated, “Fluid Assessment... Ankle - Severity 1+: 2 mm or less, disappears rapidly ... Lower leg - Severity 1+: 2 mm or less, disappears rapidly Edema Ankle - Location ... Bilateral Edema Lower Leg -Location ... Bilateral ...” The post-treatment “Nursing Evaluations” lacked documented evidence of a re-assessment of the lower leg and ankle edema. On 07/18/25, the pre-treatment “Nursing Evaluation” stated, “Fluid Assessment ... Ankle - severity, 1+: 2 mm or less, disappears rapidly Edema Ankle -Location ... Bilateral ...” The post-treatment “Nursing Evaluation” lacked documented evidence of a re-assessment of the ankle edema. A review of P6’s POC, dated 06/17/25, stated, “Area of Focus BP and Fluid Management: Goal Achieve BP Control as specified by the patient’s physician ... Met ... Intervention (s): ... Monitor fluid gains ... Completed ...” A review of P6’s “Treatment Sheets for Facility” from 06/30/25 through 07/18/25 revealed the following: On 07/04/25, 07/07/25 and 07/18/25, the pre-treatment “Nursing Evaluations” indicated “bilateral ankle, 2+: 2-4 mm or less, disappears in 10-15 seconds ... Lungs decreased breath sounds, Bilateral ...” The post-treatment “Nursing Evaluations” lacked documented evidence of a re-assessment of the bilateral ankle edema and lung sounds. On 07/9/25, 07/11/25 and 07/16/25, the pre-treatment “Nursing Evaluations” indicated “bilateral ankle, 1+: 2 mm or less, disappears rapidly. ... Lungs decreased breath sounds, Bilateral ...” The post-treatment “Nursing Evaluations” lacked documented evidence of a re-assessment of the bilateral ankle edema and lung sounds. A review of P7’s POC, dated 01/21/25, stated, “Area of Focus BP and Fluid Management: Goal Achieve BP Control as specified by the patient’s physician ... Met ... Intervention (s): ... Educate patient/family/caregiver on fluid control ...Completed ... Met Goal: Continue to monitor patient ...” A review of the “Treatment Sheets for Facility” from 07/01/25 through 07/19/25 in P7’s medical record revealed the following: On 07/01/25, 07/03/25, 07/05/25, 07/08/25, 07/10/25, 07/12/25 and 07/19/25, the pre-treatment “Nursing Evaluations” indicated “bilateral ankle, 1+: 2 mm or less, disappears rapidly. ... Lungs decreased breath sounds, Bilateral ...” The post-treatment “Nursing Evaluations” lacked documented evidence of a re-assessment of the bilateral ankle edema and lung sounds. On 07/15/25, the pre-treatment “Nursing Evaluation” indicated “bilateral ankle, 1+: 2 mm or less, disappears rapidly ...” The post-treatment “Nursing Evaluation” lacked documented evidence of a re-assessment of the bilateral ankle edema. A review of P8’s POC, dated 04/15/25, stated, “Area of Focus BP and Fluid Management: Goal Achieve BP Control as specified by the patient’s physician ... Met ... Intervention (s): ... Monitor fluid gains ... Completed ... Continue to monitor patient ...” A review of P8’s “Treatment Sheets for Facility” from 07/01/25 through 07/19/25 revealed the following: On 07/01/25, 07/03/25, 07/05/25, 07/08/25, 07/10/25, 0712/25, 07/15/25 and 07/19/25 the pre-treatment “Nursing Evaluations” stated, “... Fluid Assessment Symptoms ... Decreased breath sounds, Bilateral ...” The post-treatment “Nursing Evaluations” lacked documented evidence of a re-assessment of the lung sounds. A review of P9’s POC, dated 05/20/25, stated, “Area of Focus BP and Fluid Management ... Goal Achieve BP Control as specified by the patient’s physician ...” A review of P9’s “Treatment Sheets for Facility” from 06/30/25 through 07/18/25 revealed the following: On 07/07/25, the pre-treatment “Nursing Evaluation” stated, “Fluid Assessment Lungs Decreased breath sounds ... Lower leg - Severity 1+: 2 mm or less, disappears rapidly ... Lower Leg -Location ... Bilateral ...” The post-treatment “Nursing Evaluation” lacked documented evidence of a re-assessment of the lung sounds and lower leg edema. On 07/09/25, the pre-treatment “Nursing Evaluation” stated, “Fluid Assessment Lungs Decreased breath sounds ... Lower leg - Severity 1+: 2 mm or less, disappears rapidly Ankle - Severity 1+: 2 mm or less, disappears rapidly ... Edema Ankle - Location ... Bilateral Edema ... Lower Leg -Location ... Bilateral ...” The post-treatment “Nursing Evaluation” lacked documented evidence of a re-assessment of the lung sounds and lower leg and ankle edema. On 07/11/25, the pre-treatment “Nursing Evaluation” stated, “Fluid Assessment Lower leg - Severity 1+: 2 mm or less, disappears rapidly ... Lower Leg -Location ... Bilateral ...” The post-treatment “Nursing Evaluation” lacked documented evidence of a re-assessment of the lower leg edema. On 07/14/25, the pre-treatment “Nursing Evaluation” stated, “Fluid Assessment... Ankle - Severity 1+: 2 mm or less, disappears rapidly ... Lower leg - Severity 1+: 2 mm or less, disappears rapidly Edema Ankle - Location ... Bilateral Edema Lower Leg -Location ... Bilateral ...” The post-treatment “Nursing Evaluation” lacked documented evidence of a re-assessment of the lower leg and ankle edema. On 07/18/25, the pre-treatment “Nursing Evaluation” stated, “Fluid Assessment ... Lower leg - Severity 2+: 2-4 mm indent, disappears in 10-15 seconds Ankle - Severity 2+: 2-4 mm indent, disappears in 10-15 seconds ... Edema Ankle - Location ... Bilateral Edema ... Lower Leg -Location ... Bilateral ...” The post-treatment “Nursing Evaluation” lacked documented evidence of a re-assessment of the lung sounds and lower leg and ankle edema. During staff interviews on 07/22/25 at 1:29 PM and 07/23/25 at 10:45 AM, the above treatment sheets were reviewed with Staff (S)1. S1 confirmed that the post hemodialysis re-assessment of edema and lung sounds were not documented on the above-mentioned hemodialysis flowsheet dates. S1 confirmed the above findings and agreed that if there were abnormal findings in the pre-assessment of the patients, the staff should document a re-assessment of the abnormal findings post treatment. Facility policy titled, “Patient Assessment and Monitoring,” published 05/01/23, stated, “... Purpose ... provide guidance to (facility name) direct patient care staff on assessment and monitoring patients before, during and after treatment ... Pre-Treatment ... Lung sounds ... Auscultate lung sounds ... Edema ... Assess the patient for edema ... Location ... Severity ... Post Assessment ... Post-Treatment 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: 50912 Based on one of two observations of the initiation of hemodialysis through an arteriovenous fistula/graft (AVF/G, a type of vascular access used for hemodialysis) for Patient (P)13, staff interview, and a review of facility documents, it was determined that the facility failed to ensure that staff clean and disinfect the patient’s vascular access site prior to initiating hemodialysis treatment in accordance with the facility policy. Findings include: On 07/21/25 at 10:51 AM, at Station 16, Staff (S)4, initiated hemodialysis treatment on P13 through a right arm AVF. S4 cleaned the arterial access site with a sterile alcohol pad for 15 seconds and then immediately cannulated the site with a fistula needle. The venous site was then cleaned with a new sterile alcohol pad for 18 seconds, followed by immediate cannulation with a fistula needle. During an interview on 07/21/25 at 10:57 AM, S4 confirmed that each needle site should have been cleaned with an alcohol pad for 30 seconds. A review of S4’s training records revealed that he/she had completed AVG/AVF Monitoring/Surveillance and Vascular Access - Look, Listen and Feel Education and Training in January 2023. 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)”

“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 medical record review, staff interview, and review of facility documents, it was determined that the staff failed to ensure that Peritoneal Dialysis (PD, a type of dialysis that uses the lining of the abdomen) training orders are followed as prescribed by the physician in two out of five PD training sessions reviewed for Patient (P)3. Findings include: A review of P3’s medical record revealed the following: The patient was admitted on 06/25/25 for PD training. The Physician’s order dated 06/25/25 stated, “... Special Attention: Day 1 of PD training. Perform 1 exchange using stay safe system. Fill with 1.7L [liters] 2.5% LCLM solution ...” A review of the “Clinical Notes Report” dated 06/25/25 by the Registered Nurse (RN) stated, “... Patient came ambulatory AOx3 (awake and oriented times three) for 1st PD Training ... PD exchange performed by staff connected to stay safe using 1.5% dextrose solution ...” The dextrose solution administered during PD training on 06/25/25 documented in the clinical note was not as prescribed by the physician. The Physician’s order dated 07/02/25 stated, “... Special Attention: Day 5 of PD training. Perform 1 exchange using stay safe system. Fill with 1.7L 1.5% LCLM solution ...” A review of the “Clinical Notes Report” dated on 07/02/25 by the RN stated, “... Patient into the clinic ambulatory AOx3 for day 5 of CCPD (Continuous Cycler Peritoneal Dialysis, a type of home dialysis that uses a machine to perform exchanges of dialysis solution while patient sleeps) training ... 1 exchange, fill volume 1.7L, dwell time 2 hrs [hours] solution used 2.5% dextrose ...” The dextrose solution administered during PD training on 07/02/25 documented in the clinical note was not as prescribed by the physician. During an interview on 07/23/25 at 9:57 AM, Staff (S)10 confirmed the above findings and stated, “I don’t have an explanation as to why the physician orders were not followed by the RN.” Facility policy titled, “Physician Order Documentation,” published 07/03/23, stated, “ ... Background ... It is the nurse’s responsibility to ensure that all treatments, medications, labs or any care provided to the patient have an accurately documented physician order ... General Policy ... Nurse practice act require nurses to carry out treatment care, medication administration, lab test, procedure and other treatments based on physician orders ...” N.J.A.C. 8:43A-8.4(a) N.J.A.C. 8:43A-24.4(a)”