Fmc Harrison

“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: 39228 Based on observation, staff interview, and review of facility documents, it was determined that the facility failed to ensure that all necessary medication and supplies are available in one of one emergency code cart and one of one emergency evacuation box. Findings include: On 3/5/25 at 11:30 AM, a review of the emergency code cart located on the treatment floor was conducted. Staff (S) 7, the Charge Nurse, stated it was last checked on 3/1/25 and provided the “Emergency Code Cart, Medications and Machine Crank Checklist.” The checklist stated that one “Solu-Medrol 125 mg (milligram) vial” was present in the cart. However, the cart did not contain a Solu-Medrol 125 mg (milligram) vial. At 11:39 AM, S7 agreed with the finding and stated that the Solu-Medrol was located inside the treatment floor medication cart. At 12:50 PM, the emergency evacuation box located on the treatment floor was reviewed. S7 stated that the box was last checked on 3/1/25 and provided the “Emergency Box Checklist” that stated there should be one pocket mask, five face shields, and one sharps container inside. However, the box did not contain the items. Upon interview with S7 at the time of discovery, S7 agreed that the items were missing and stated that the five face shields and the sharps container were stored in the emergency code cart. In addition, the emergency evacuation box did not contain staff and patient emergency contact information. During an interview at 12:56 PM, S7 stated the information is not located inside the box but is kept in a binder titled, “Evacuation Book” located on a countertop ledge near the box. The binder was reviewed and contained patient emergency contact information that was last updated on 12/5/24. Upon discovery, S7 stated that the patient emergency contact information is updated every six months. The staff emergency contact list was then reviewed with S7 who stated that the information on the form was not current. Upon further interview at 12:58 PM, S2, the Clinic Manager, stated that the patient contact information is updated quarterly, and the staff emergency contact information had not been updated for at least a couple of years. Facility policy titled, “Emergency Medications, Equipment and Supplies,” published 2/3/25, stated, “... Definitions Emergency Cart: An emergency cart, sometimes called ‘crash cart’ contains emergency equipment and medications for medical emergencies and cardiac arrest. ... Emergency Evacuation Box: An emergency evacuation box contains supplies primarily needed to emergently remove needles, cap catheters, ... once the patient is in a secure location ... Emergency Cart ... The emergency cart must be: ... Checked monthly or after use for contents ... Emergency Evacuation Box ... An emergency evacuation box must: ... Contain all patient and staff emergency contact information ... Be checked monthly or after use for contents, expiration dates and cleanliness ...” N.J.A.C. 8:43A-15.1(a)”

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 48966 Based on two of two observations of hand hygiene during the termination of dialysis through a CVC (central venous catheter) and the initiation of dialysis through an arteriovenous graft (AVG, a type of access used for hemodialysis), staff interview, and a review of facility documents, it was determined that the facility failed to ensure that hand hygiene is performed to prevent cross contamination in accordance with facility policy. Findings include: On 3/5/25 at 9:35 AM in Station 3, during an observation of the termination of dialysis through a CVC, Staff (S) 6, a Registered Nurse, with gloved hands, discontinued dialysis and returned the patient’s blood through a CVC. He/she clamped the arterial (red) and the venous (blue) CVC limbs of the catheter and then, with the same gloves on, left the patient station, walked to the clean supply cabinet and removed a clean blue under pad. Wearing the same gloves, S6 then returned to the patient station and proceeded to disconnect the patient from the hemodialysis machine. During an interview on 3/5/25 at 9:45 AM, S6 confirmed he/she should have used hand sanitizer after removing gloves and leaving the patient station. A review of S6’s “Coaching Report” indicated that his/her “Annual Skills Checklist” on Hand Hygiene was completed on 4/19/24. On 3/5/25 at 11:26 AM, while on the Treatment Floor, an observation of the initiation of dialysis through a left AVG was conducted in Station 5. S8, a Patient Care Technician, brought supplies to the hemodialysis chair and placed them on the side table beside the patient while wearing gloves. S8 then left the patient station, did not perform hand hygiene, and with the same gloves on, entered a clean supply cart drawer to retrieve fistula needles. S8 the removed his/her gloves, did not perform hand hygiene and donned a new pair of gloves. During an interview at 11:45 AM, S8 confirmed he/she should have performed hand hygiene after removing gloves and when leaving a patient station. A review of S8’s “Coaching Report” indicated that his/her “Annual Skills Checklist” on Hand Hygiene was completed on 4/9/24. Facility policy titled, “Hand Hygiene,” published 11/6/23, stated, “... Policy ... The table below identifies when hands shall be washed specifically with soap and water or when alcohol-based hand rubs can be used: ... Hands Will Be ... Decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water ... When ... Before and after direct contact with patients ... Entering and leaving the treatment area ... Immediately after removing gloves ... After contact with inanimate objects near the patient ... After contact with other objects within the patient station or treatment space ...” N.J.A.C 8:43A-24.8(d) 51990”

“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: 51990 Based on two of two observations of clean versus dirty, staff interview, and a review of facility documents, it was determined that the facility failed to ensure that clean supplies are separated from contaminated areas in order to avoid possible cross contamination. Findings include: On 3/5/25 at 10:26 AM in Station 3, Staff (S) 6, a Registered Nurse, initiated hemodialysis on Patient (P) 10 through a CVC (central venous catheter). S6, with gloved hands, removed the old CVC dressing then removed his/her gloves and placed the dirty dressing and dirty gloves onto a pad located on top of the treatment chair side table. The pad also contained clean supplies used to initiate hemodialysis including gloves, a blue pad, sterile alcohol pads, two packaged syringes, and two pre-filled saline syringes. The dirty dressing and dirty gloves were directly next to the clean supplies. S6 then performed hand hygiene and retrieved a pair of the gloves from the side table and donned them. He/she proceeded to clean the CVC exit site with a chlorhexidine swab and then placed the used swab on top of the dirty CVC dressing and dirty gloves which were directly next to the clean supplies. The dirty supplies were observed to touch the clean CVC supplies that were on the side table. S6 then used the remainder of the clean supplies to initiate hemodialysis. During an interview at 11:00 AM, S6 stated that he/she should have discarded the old dressing and used supplies on a separate pad and not on the pad that had the clean supplies. On 3/5/25 at 11:35 AM, during a tour of the Treatment Area, a tan trash can was touching a black supply cart that contained 27 unopened/unused gallon containers of Naturalyte, a dialysis solution used in hemodialysis machines to treat renal failure. There were 10 containers of 2K (Potassium) 2Ca (Calcium) on the top shelf; eight containers of 2K 3Ca in the middle shelf; and nine containers of 3K 2.5Ca on the bottom shelf. During the observation of the treatment area, staff discarded waste in the trash can touching the black cart containing clean Naturalyte containers. During an interview at 11:40 AM, S6, a Registered Nurse, stated that the trash can should not touch a cart that contains clean supplies. S6 then walked away and did not move the trash can away from the clean supply cart. Facility policy titled, “Dialysis Precautions,” published 1/4/12, stated, “... Clean Versus Dirty Areas ... Clean Area: An area designated for clean and unused equipment, supplies and medications ... Dirty Area: An area where this is a potential for contamination with blood or body fluids and areas where contaminated of used supplies, equipment, blood supplies or biohazard containers are stored or handled ... “ N.J.A.C. 8:43A-24.4(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: 37656 Based on 14 of 14 observations of the dialysis treatment stations and staff interview, it was determined that the facility failed to ensure that blood pressure cuffs are maintained to allow for adequate cleaning and disinfection of contaminated surfaces in the hemodialysis treatment station. Findings include: On 3/5/25, during tour of the hemodialysis treatment floor, the blood pressure cuffs in Stations 1, 2, 3, 4, 6, 9, 13, 14, 15, 17, 18, 19, and 20 contained large amount of white and black lint that was adhered to the Velcro portion of the cuffs, thus making the cuffs an uncleanable surface. In an interview on 3/5/25 at 11:30 AM, Staff (S) 7, Charge Nurse, stated that they haven’t changed the cuffs in a while, and it does need to be changed now. 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 termination and 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 that the facility failed to ensure that termination and initiation of hemodialysis using a CVC is performed in accordance with facility procedure for Patient (P) 10 and P11. Findings include: On 3/5/25 during a tour of the Treatment Floor, the following was revealed: At 9:35 AM in Station 3, Staff (S) 6, a Registered Nurse, disconnected the red (arterial) and blue (venous) bloodlines at the same time from P11’s right chest wall CVC. S6 then went to the dialysis machine and typed on the keyboard leaving the CVC limbs exposed for 10 seconds. S6 then scrubbed the blue end and threads of the hub of the CVC with a sterile alcohol pad for seven seconds, did not hold the limb to dry and did not immediately attach a prefilled saline syringe to the catheter limb. S6 then proceeded to scrub the red end and threads of the hub, did not hold the limb to dry and then attached the prefilled saline syringe the red and blue catheter limb. During an interview at 9:45 AM, S6 explained that during termination and initiation of CVC’s, the CVC hub and threads should be scrubbed for 15 seconds and that a saline syringe is immediately attached at the end of the catheter limb. At 10:26 AM in Station 3, S6 initiated hemodialysis on P10’s right chest wall CVC. S6 removed the red cap then scrubbed the end and threads of the hub with a sterile alcohol pad for five seconds. S6 then proceeded to remove the blue cap and scrubbed the end and threads of the hub with a sterile alcohol pad for seven seconds. A review of S6’s “Coaching Report” indicated that his/her “Annual Skills Checklist” for CVC was completed on 4/19/24. Facility policy titled, “Termination of Treatment Using a Central Venous Catheter and Optiflux Single Use Ebeam Dialyzer,” published 11/4/24, stated, “... Termination: Disinfection of Catheter and Disconnecting the Patient ... 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 ... for 10-15 seconds anytime caps are removed, or bloodlines are disconnected ( i.e. End of treatment or treatment interruption) ... Step ... 5. Disconnect the arterial blood line form the catheter limb 6. Using a sterile alcohol pad, (or other appropriate antiseptic product such as chlorhexidine or povidone ... scrub the sides (threads) and end of the hub thoroughly with friction, making sure to remove any residue (e.g., blood) 7. Hold the limb while allowing the antiseptic to dry 8. Immediately attached a prefilled saline syringe to the catheter limb 9. Repeat steps 5 through 8 for the venous end of the catheter limb ...” Facility policy titled, “Initiation of Treatment Using a Central Venous Catheter (CVC) and Optiflux Single Use Ebeam Dialyzer,” published 5/6/24, stated, “ ... Preparing the Catheter: Disinfection of the Catheter Connections, Heparin Removal, Flushing the Catheter and Heparin Administration ... 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 at any time caps are removed, or bloodlines are disconnected (i.e. end of treatment or treatment interruption) to reduce risk of infection... “ N.J.A.C. 8:43A-24.8(b)”

“CONC OUTLETS-SEPARATE/LABELED/CONNECT SAFETY CFR(s): 494.40(a) 5.5.5 Concentrate outlets: separate/labeled/connection safety To prevent mix-ups with delivery of two or more types of acid concentrate, each concentrate should have its own outlet. Concentrate outlets should be compatible with the dialysis machine and have a means of minimizing the risk that the wrong concentrate will be connected to an outlet. The dispensing outlets should be labeled with the appropriate symbol (see AAMI Table 3) indicating the proportioning ratio for the dialysis machine and should be color-coded blue for bicarbonate, red for acid. 6.5 Concentrate distribution A daily check to ensure that the appropriate acid and bicarbonate concentrate is connected to the corresponding concentrate delivery line is recommended if the storage tank is not permanently connected to its distribution piping. This Standard is not met as evidenced by: 48966 Based on observation, staff interview, and a review of facility documents, it was determined that the facility failed to ensure that 14 out of 20 hemodialysis station wall boxes are labeled with the appropriate symbol indicating the correct concentrate proportioning ratio. Findings include: On 3/5/25 at 10:28 AM, 14 out of 20 wall boxes on the hemodialysis treatment floor were not labeled with the correct concentrate proportioning ratio used at the facility. During an interview on 3/5/25 at 10:42 AM, Staff (S) 4, the Area Technical Manager, stated that the 14 wall boxes did not have the appropriate 45X symbol, indicating the correct concentrate proportioning ratio. During an interview on 3/5/25 at 11:02 AM, S3, the Biomedical Technician, stated the wall boxes were changed in November and had the original manufacturers labels on them. S3 explained he/she ordered the 45X labels and forgot to apply them when the stickers arrived. On 3/6/25, S3 showed the surveyor he/she applied the 45X stickers to the 14 wall boxes on the hemodialysis treatment floor. Facility policy titled, “Concentrate Labeling Requirements,” published 9/5/25, stated, “... Definitions and Acronyms: Term Valve Panel Definition A panel or wall box where bicarbonate concentrate, acid concentrate and RO [Reverse Osmosis] water are central delivered for use by hemodialysis machines. ... Permanent Labeling: Valve Panels (Incenter, Inpatient) ... Concentrate family with appropriate symbol. Example: 45X ...””

“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 one of one observation of the termination 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 3/5/25 at 9:35 AM in Station 3, Staff (S) 6, a Registered Nurse, terminated hemodialysis on Patient (P) 11 through a right chest CVC. There was no under pad below the CVC limbs and the patient’s chest was exposed. During the procedure, the curtains were drawn on both sides of Station 3 covering the left and the right side of P11. The curtains were not fully closed in front of the station leaving an approximate four feet opening. The patient’s chest was visible from the nurse’s station and to the patients in Station 18 and 19, located across from Station 3. During an interview at 9:45 AM, S6 stated that the curtains should be fully closed around the patient’s station when discontinuing hemodialysis. Facility policy titled, “Patient Rights and Responsibilities,” published 4/4/12, 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-IDT DEVELOPS PLAN OF CARE CFR(s): 494.90(a) The interdisciplinary team must develop a plan of care for each patient. This Standard is not met as evidenced by: 37656 Based on three of seven medical records reviewed (Patient (P) 2, P3, and P5), staff interview, and a review of facility documents, it was determined that the facility failed to ensure that all interdisciplinary team members interact and share information to facilitate the development of the plan of care (POC). Findings include: A review of P2’s medical record revealed that the 90-day POC meeting was held on 9/4/24. The Social Worker’s (SW) CIA (Comprehensive Interdisciplinary Assessment) was completed on 9/17/24, 13 days after the POC meeting on 9/4/24. On 3/7/25 at 9:46 AM, Staff (S) 13, the SW, stated that the CIA was initiated on 9/4/24 and was completed on 9/17/24. A review of P3’s medical record revealed the following: The POC meeting was held on 9/3/24. The Physician’s comprehensive assessment was documented on 9/24/24, 21 days after the POC meeting. The Registered Dietitian (RD) documented a comprehensive assessment on 9/30/24, 27 days after the POC meeting. The POC meeting was attended in-person by the Registered Nurse (RN), and Social Worker, who approved it on 9/4/24. The RD and the Physician attended remotely. The RD approved the plan of care on 9/24/24, 21 days after the POC meeting, and the physician approved the POC on 10/30/24, 57 days after the POC meeting. In an interview on 3/6/25 at 2:20 PM, S2, the Clinical Manager, confirmed that the comprehensive assessment should have been completed prior to the POC meeting and the POC should have been signed within 30 days for those who attended remotely. A review of P5’s medical record revealed that the annual POC meeting was held on 11/11/24. The “Team Approval Signatures” show that the RN, the SW, and the RD, attended the meeting in person and approved the POC at the time of the meeting. The POC indicated that the Physician attended the meeting remotely and approved the POC on 1/12/25, this was 62 days after the POC meeting was held. During an interview on 3/6/25 at 12:00 PM, S1, a Clinical Manager from another facility confirmed that the physician attending remotely should have signed the POC within 30 days of the meeting. Facility policy titled, “Comprehensive Interdisciplinary Assessment (CIA) and Plan of Care (POC),” published 7/3/2023, stated, “... The Comprehensive Assessment and Plan of Care (adult patient) must be completed electronically in the patient’s medical record. The Plan of care should be signed at the time of the interdisciplinary team meeting for those attending in person. If unable to sign at the time of the meeting or if attending remotely, the care plan must be signed by the IDP member within 30 days of the interdisciplinary team meeting. ... The patient’s plan of care will be developed from the findings gathered in the CIA. The IDT (Interdisciplinary team) members are expected to interact and share information from the comprehensive assessment to facilitate the development of the plan of care. ... Each patient’s plan of care must be signed by all members of the IDT ... The Attending Physician reviews CIA and indicates with his/her signature on the POC their oversight of the patient’s Plan of Care within 30 days. N.J.A.C. 8:43A-24.13(b) 51990”

“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: 48966 Based on observation, staff interview, and review of facility documents, it was determined that the Medical Director failed to ensure that: 1) Intravenous (IV) Iron is administered in accordance with the facility policy in one of one observation of medication administration; 2) patients are assessed for pre (before) and post (after)-treatment pain in six of seven medical records reviewed (Patient (P) 1, P3, P4, P5, P7, P8); and 3) medications, needles and syringes are secure in two of two observations on the treatment floor. Findings include: 1. On 3/5/25 at 11:50 AM, Staff (S) 6, a Registered Nurse, was observed administering 50 mg (milligrams) Venofer (iron replacement medication) to a patient. S6 entered Station 4 and wiped the venous chamber of the hemodialysis lines with an alcohol pad and attached the syringe. S4 then quickly administered the full 2.5 ml (milliliters) dose of Venofer into the venous chamber, within one to two seconds. This was not in accordance with the facility policy. During an interview at 12:15 AM, S6 stated that Venofer administration is to be given slowly followed by a normal saline flush. A review of S6’s “Coaching Report” indicated that his/her “Annual Skills Checklist,” which included Dialysis Medication, was completed on 4/19/24. Facility policy titled, “Special Considerations: Venofer,” published 7/1/24, stated, “... Administration: Venofer may be administered undiluted as a slow intravenous injection over 2 to 5 minutes, ...” N.J.A.C. 8:43A-9.3(a) 2. A review of P1’s “Nursing Evaluation,” on the “Treatment Sheet For Facility” dated 2/11/25 through 3/4/25, revealed the following: The post-treatment pain assessment was not documented on the following treatment dates: 2/12/25 and 2/14/25. The pre and post-treatment pain assessment was not documented on the following treatment dates: 2/17/25, 2/19/25, 2/21/25, 2/26/25 and 3/3/25. During an interview on 3/6/25 at 11:26 AM, Staff (S) 1, a Clinical Manager from another facility stated that pain should be assessed pre and post-treatment and the “Pain Assessment Tool” should be used. A review of P3’s “Nursing Evaluation,” on the “Treatment Sheet For Facility” revealed the following: P3’s treatment sheet for the following dates did not contain a pre and post dialysis pain assessment: 2/12, 2/13, 2/15, and 3/1/25. P3’s treatment sheet for the following dates did not contain post treatment pain assessments: 2/25 and 3/4/25. On 3/6/25 at 2:25 PM, the above treatment sheets were reviewed with S2, Clinic Manager, and he/she confirmed that the staff should always document a pre and post treatment pain assessment. A review of P4’s “Nursing Evaluation,” on the “Treatment Sheet For Facility” dated 2/12/25 through 3/3/25, revealed the following: There were no documented pre-treatment pain assessments on the following treatment dates: 2/12/25, 2/17/25, 2/19/25, 2/21/25, 2/26/25, 2/28/25, and 3/3/25. There were no documented post-treatment pain assessments on the following treatment dates: 2/12/25, 2/14/25, 2/17/25, 2/19/25, 2/21/25, 2/26/25, 2/28/25, and 3/3/25. During an interview on 3/6/25 at 12:15 PM, S2 stated that pain should be assessed pre and post treatment. The numeric pain assessment needs to be entered in the electronic medical record under the notes section. A review of P5’s “Nursing Evaluation,” on the “Treatment Sheet For Facility” revealed the following: P5’s treatment sheet for the following dates did not contain a pre and post dialysis pain assessment on: 2/12/25, 2/14/25 and 2/17/25. During an interview on 3/6/25 at 12:00 PM, the above treatment sheets were reviewed with S1, who confirmed that the staff should document a pre and post treatment pain assessment. A review of P7’s “Nursing Evaluation,” on the “Treatment Sheet For Facility” dated 2/11/25 through 3/4/25, revealed the following: The post-treatment pain assessment was not documented on the following treatment dates: 2/11/25, 2/15/25 and 2/18/25. The pre and post-treatment pain assessment was not documented on the following treatment dates: 2/25/25 and 3/4/25. A review of P8’s “Nursing Evaluation,” on the “Treatment Sheet for Facility” dated 2/11/25 through 3/4/25, revealed the following: The post-treatment pain assessment was not documented on the following treatment dates: 2/25/25 and 3/4/25. The pre and post-treatment pain assessment was not documented on the following treatment dates: 2/13/25, 2/15/25 and 3/1/25. During an interview on 3/6/25 at 12:14 PM, S7, the Charge Nurse, confirmed the above pain assessments were missed. Facility policy titled, “Pain Assessment and Management,” published 7/3/25, stated, “... Policy ... All patients will be assessed for pain using a 0-10 scale for adults or a 0-10 Wong-Baker faces pain tool for children, elderly or cognitive impaired and documented in the patient’s electronic medical record ...” N.J.A.C 8:43A-16.2(a)(14) 3. On 3/5/25 at 9:50 AM, a tour of the Treatment Floor was conducted and revealed the medication storage cart located on ‘Side B’ across from Station 11, was unsecured. There were several types of injectable and oral medications present in the first drawer of the cart. The second and third drawers contained needles and syringes. At 9:57 AM, S7, the Charge Nurse, explained that the locking mechanism on the cart hasn’t been working and stated, “We have to keep tapping the battery on the back of the cart to get it to lock.” S7 then stated that he/she notified the Biomedical Technician of the issue. On 3/5/25 at 9:50 AM, on ‘Side A’ of the Treatment Floor, there was an unopened box of “BD Eclipse Injection Needles with BD Luer- Lock Syringes” and an opened box of unused vacutainers (adapters with needles use to draw blood) found on a countertop located next to a locked medication cart. During an interview at 11:26 AM, S6, a Registered Nurse, stated that the syringes and the vacutainers should be stored in the locked medication cart. Facility policy titled, “Medication Preparation and Administration” revised 2/6/23, stated the following: “... Securement: The following steps must be taken for the securement: All medications will be kept in a locked cabinet except when in use ... There are states that may require securement of syringes and or needles in addition to medications (example: New Jersey). Ensure syringes and or needles are secure if per state requirements ...” N.J.A.C. 8:43A-9.3(b)(6) N.J.A.C. 8:43A-9.5(a) 37656 51990 39228”