Fmc Maplewood

“CFC-WATER & DIALYSATE QUALITY CFR(s): 494.40 This Condition is not met as evidenced by: 37656 Based on observation, staff interviews, and review of facility documents, it was determined that the facility failed to ensure the chlorine test strips available for use are not expired. Chlorine test strips are used to determine if the product water is safe to use by testing the amount of chlorine is less than 0.1 parts per million. (V-196). Findings include: The above findings resulted in an Immediate Jeopardy (IJ) on March 6, 2024 at 10:55 AM. The IJ template was provided to Staff (S) 4, Director of Operations, on 3/6/24 at 3:05 PM and a removal plan was requested. An IJ Removal plan was provided by the facility on 3/7/24 at 9:55 AM, and was accepted. On 3/7/24 at 10:30 AM, it was determined that the facility took the following steps to remove the immediacy of the IJ: All expired RPC Ultra Low Total Chlorine Test Strips were removed from the water treatment room and stock room and were replaced with non-expired strips; RO (reverse osmosis) water re-testing with unexpired RPC Ultra Low Total Chlorine Test Strips (documentation provided); Education for all clinical staff who test water (documentation provided); Governing Body meeting to develop and implement plan to remove immediacy (documentation provided). It was determined that the IJ removal plan was successfully implemented and the IJ was removed on 3/7/24 at 10:30 AM. Cross Reference: V196 - Carbon Adsorption - Monitor, Test Frequency”

“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: 48966 Based on observation, staff interviews, and review of facility documents, it was determined the facility failed to ensure that two (2) of two (2) emergency evacuation boxes contain all necessary equipment and updated information in the event of an emergency. Findings include: On 3/7/24 at 9:32 AM, Staff (S) 8, the Charge Nurse, provided a binder that contained the Monthly Emergency Evacuation checklist which indicated it was checked in March 2024 and the Employee Roster containing staff names and phone numbers, dated 12/27/17. The contents of the emergency box were inspected based upon the supplied checklist and revealed the following: Evacuation Box #1: Ten catheter caps with an expiration date of 2/4/24. The box also contained nine (9) Intravenous Tubing (IV) Administration sets. The par level on the checklist stated ten IV Administration sets were needed. Evacuation Box #2: Ten catheter caps with an expiration date of 2/4/24. The box also contained two D batteries. The par level on the checklist stated that four D batteries were needed. One portable radio not listed on the checklist was found not to be in working condition and contained corroded batteries. During an interview at 9:50 AM, S8 confirmed the catheter caps were past the expiration date. S8 discarded the expired catheter caps and replaced them with new catheter caps. S8 explained he/she was not sure if the portable radio should be in the evacuation box. S8 took out the corroded batteries and replaced them with new batteries but the radio still did not work. During an interview at 9:55 AM with S10, a supporting Clinical Manager from another facility, explained that every quarter the Employee Emergency Roster should be updated. During an interview at 11:29 AM, S8 stated, ‘The Monthly Emergency Evacuation Checklist’ was not updated in the Technical Maintenance System (TMS), the computer system utilized for documenting the checklist. S8 stated he/she was mixing the contents on the checklists together in the crash cart and evacuation boxes, and the Monthly Emergency Evacuation checklist in the binder is not the correct checklist. During an interview at 11:30 AM, S1, the Facility Administrator, explained the Emergency Box and Medication checklist was not loaded into TMS. Review of the facility policy titled, “Emergency Medications, Equipment and Supplies,” published 5/1/23, stated, “... Emergency Evacuation Box: ... [bullet] 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. [bullet] .... An itemized log must be kept indicating the contents and expiration dates of contents. Items approaching expiration must be reordered and replaced prior to the actual expiration date...” N.J.A.C. 8:43A-15.1(d)”

“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: 39223 Based on observation, staff interviews, and review of facility policies, it was determined that the facility failed to clearly designate clean areas from dirty areas in order to avoid possible cross contamination. Findings include: During a tour of the hemodialysis treatment area on 3/6/24 starting at 9:52 AM, the following was observed: A countertop containing several testing solutions was located next to a sink. This counter also contained a sink, an open three gallon jug of bleach, and a small plastic rectangular container labeled “Bleach Wipes.” Approximately 1.5 feet to the left was a large rectangular plastic container containing two white vascular clamps and one blue clamp, labeled “Bleach for Clamps.” Next to the “Bleach for Clamps” container was a test tube holder with one filled test tube. Adjacent to the counter was a 2-tiered rolling cart that contained 20 yellow top disinfectant bottles positioned upside down, open to the air. This created an area on the countertop where dirty items could potentially splash and contaminate clean items. During an interview on 3/6/24 at 10:00 AM, Staff (S) 8, a Patient Care Technician, stated that the rolling cart, “Bleach Wipes” container, and testing solutions areas are designated as a clean areas. S8 also stated that the sink, “Bleach for Clamps” containers, and test tube holder areas are designated as dirty areas. S8 stated that the dirty and clean areas were not clearly separated from each other. A review of facility policy titled, “Dialysis Precautions,” published on 1/4/12, stated, “... Clean Versus Dirty Areas ... Clean areas should be clearly designated for the preparation and handling and storage of medications and unused supplies and equipment. ... Clean areas should be clearly separated from dirty areas where used supplies, equipment or blood samples are handled or stored. ...””

“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: 49828 Based on observation, interview, and a review of facility documents, it was determined that the facility failed to ensure that all surfaces at the dialysis station are cleaned and disinfected after patient use. Findings include: On 3/06/24 at 11:30 AM in Station 13, a patient completed hemodialysis treatment and was discharged. Staff (S) 9, a Registered nurse (RN), cleaned and disinfected the station by wiping items and surfaces located inside the station with a bleach soaked cloth. S9 wiped the hemodialysis machine, the recliner chair, television, and the chaise wall with a bleach soaked cloth. S9 then wiped the blood pressure (BP) cuff with a bleach soaked cloth and placed it onto the unclean IV (intravenous) pole located on the hemodialysis machine. S9 did not wipe the IV pole located on the top of the hemodialysis machine, or the prime bucket with the bleach soaked cloth. During an interview on 3/06/24 at 11:40 AM, S9 stated that they did not clean the pole and the prime bucket. Immediately following the interview, S9 returned to the machine to clean the BP cuff and pole again. S9 then retrieved the prime bucket, emptied the contents and then cleaned the prime bucket and surrounding area before placing in back onto the clean machine. A review of facility policy titled, “Use of Priming Buckets,” revised on 01/24/24 stated, “At the completion of the patient treatment, remove the priming bucket ... and dispose of the normal saline in the utility room hopper or dirty sink.” A review of facility policy titled, “Cleaning and Disinfecting the Dialysis Station,” revised on 09/05/23 stated, “Use a cloth wetted with 1:100 bleach solution or EPA-approved disinfectant to clean and disinfect the dialysis station ( ... IV pole, B/P cuff) ...” N.J.A.C. 8:43A-24.8(b)”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 48966 Based on one (1) of one (1) observation of the initiation of hemodialysis using a central venous catheter (CVC), review of facility policy, and staff interview, it was determined the facility failed to ensure the initiation of hemodialysis, using a CVC, is performed in accordance with facility policy. Findings include: On 3/6/24 at 10:03 AM in Station 14, Staff (S) 9, a Registered Nurse, placed an under pad beneath the patients access limbs of the catheter. S9 removed the venous catheter cap from the end of the venous limb and wiped an alcohol wipe pad on the threads and the end of the hub. S9 then attached an empty syringe and aspirated blood from the catheter and clamped the line. S9 then discarded the blood-filled syringe. S9 proceeded to attach a pre-filled saline syringe and injected the saline before clamping the line closed. S9 removed the arterial catheter cap from the arterial limb and wiped an alcohol pad on the threads and the end of the hub. S9 then attached an empty syringe and aspirated blood from the catheter and clamped the line. S9 discarded the blood-filled syringe. S9 proceeded to attach a pre-filled saline syringe and injected the saline before claming the line closed. S9 disconnected both normal saline syringes from the arterial and venous limbs, leaving them exposed. The catheter limb ends were positioned in a manner that both catheter limb ends made contact with the under pad. S9 did not leave the pre-filled saline syringes on the catheter limbs and wipe with an alcohol pad to reduce the risk of contamination. During an interview at 10:25 AM, S9 stated he/she should leave the syringes on the catheter limbs and should not leave the catheter limbs exposed, touching the clean pad. S9’s personnel file was reviewed and indicated a Coaching Report was completed on 2/16/24, which included the annual skills checklist for Central Venous Catheter Skills. A review of the facility policy titled, “Initiation of Treatment Using a Central Venous Catheter and Optiflux Single Use Ebeam Dialyzer,” published 07/06/2021, 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% [percent] sterile alcohol pad (or other antiseptic such as chlorhexidine, ...) for 10 -15 seconds and any time caps are removed, or blood lines are disconnected (i.e. end of treatment or treatment interruption) to reduced risk of contamination. ... Step 3 ... Do not place uncapped catheter limbs on under pad to prevent contamination ...” N.J.A.C. 8:43A-24.8(b)”

“CARBON ADSORP-MONITOR, TEST FREQUENCY CFR(s): 494.40(a) 6.2.5 Carbon adsorption: monitoring, testing freq Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours. Results of monitoring of free chlorine, chloramine, or total chlorine should be recorded in a log sheet. Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. On-line monitors can be used to measure chloramine concentrations. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels described in [AAMI] 4.1.1 (Table 1) [which is a maximum level of 0.1 mg/L]. Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly. This Standard is not met as evidenced by: 39223 Based on observation, staff interviews, and review of facility documents, it was determined that the facility failed to ensure the chlorine test strips available for use are not expired. Chlorine test strips are used to determine if the product water is safe to use by testing the amount of chlorine is less than 0.1 parts per million. Findings include: On 3/6/24 starting at 10:40 AM, a tour of the Water Treatment Room was conducted in the presence of Staff (S) 3, the Area Technical Operations Manager. The Chlorine test strips available for use in the Water Treatment Room (RPC Ultra Low Total Chlorine Test Strips) had a manufacturer’s expiration date of 11/30/23. S3 stated that facility staff is responsible to check for the expiration date and competency education, which includes checking the expiration date. During an interview at 1:23 PM, S6, Patient Care Technician, confirmed that he/she completed chlorine testing in the morning and had used the expired test strips. S6 stated that he/she should have checked before using the test strips to make sure they were not expired. S6 stated that the bag of RPC Ultra Low Total Chlorine Test Strips had been used previously but was not sure how long the facility had been using that bag of expired test strips. A review of S6’s personnel file revealed that he/she completed annual training on “Residual Chlorine Test Strips” on 1/10/24. Facility procedure titled, “Total Chlorine Testing using RPC Ultra Low Total Chlorine Test Strips,” published 4/5/21, states, “ ... the following supplies will be needed for this procedure: ... Unexpired RPC Ultra Low Total Chlorine Test Strip ...” N.J.A.C. 8:43A-24.10(a)(3)”

“MIXING SYSTEMS-LABELING CFR(s): 494.40(a) 5.4.4.1 Mixing systems: labeling Labeling strategies should permit positive identification by anyone using the contents of mixing tanks, bulk storage/dispensing tanks, and small containers intended for use with a single hemodialysis machine. Mixing tanks: Prior to batch preparation, a label should be affixed to the mixing tank that includes the date of preparation and the chemical composition or formulation of the concentrate being prepared. This labeling should remain on the mixing tank until the tank has been emptied. Bulk storage/dispensing tanks: These tanks should be permanently labeled to identify the chemical composition or formulation of their contents. Concentrate jugs: At a minimum, concentrate jugs should be labeled with sufficient information to differentiate the contents from other concentrate formulations used at the facility. This Standard is not met as evidenced by: 39223 Based on observation, staff interview, and review facility documents, it was determined that the facility failed to ensure that the bicarbonate (bicarb) tank is labeled to ensure the proper storage time of the bicarb solution. Findings include: On 3/6/24 at 10:50 AM, during a tour of the Mixing Room in the presence of Staff (S) 11 (S11), Biomedical Technician, revealed that the Bicarbonate distribution tank was not labeled with a date and time it was mixed. The bicarbonate mixing log indicated that S7, a Patient Care Technician, had mixed the solution on 3/6/24 at 4:10 AM. Upon interview on 8/16/23 at 11:00 AM, S7 stated that he/she mixed the bicarbonate solution at 4:00 AM, but forgot to label the tank. A review of facility policy titled, “Concentrate Labeling Requirements,” published 9/5/23, stated, “... Policy Temporary Labeling (Incenter, Inpatient) ... When a mix tank contains a solution, a label identifying the solution must be conspicuously displayed on the tank and must remain until the mix tank is emptied. Mix tank labeling must include: Contents identification. For example, “Bicarb”, “Acid”, “RO Water” or “Disinfectant”. Chemical composition or formulation of concentrate. Concentrate family with appropriate symbol. Example: 45x [symbol of a triangle] Catalog number of product. Date and time of mixing ...” N.J.A.C. 8:43A-24.4(a)”

“MICROB MONITOR-SAMPLE BEFORE DISINFECT CFR(s): 494.40(a) 7.2 Microbial monitoring methods 7.2.1 General: samples before disinfect Samples should always be collected before sanitization/disinfection of the water treatment system and dialysis machines. This Standard is not met as evidenced by: 39223 Based on facility document review and staff interview, it was determined that the facility failed to ensure that microbiological samples are collected in the “worst case” scenario before sanitation and disinfection of the water treatment system. Findings include: Reference: Association for the Advancement of Medical Instrumentation (AAMI) RD52: 2004, Hemodialysis systems stated, “... 7.2 Microbial monitoring methods 7.2.1 General ... Samples should always be collected before sanitization/disinfection of the water treatment system and dialysis machines. ...” A review of Reverse Osmosis (RO) treatment system disinfection logs and the Culture and Endotoxin lab results for September 2023 through February 2024 revealed the following: In September 2023, the RO was disinfected with Minncare on 9/10/23. Four days later, on 9/14/23, water samples to test for bacteria and endotoxins were drawn from the RO treatment system. The RO treatment system was disinfected with Minncare on 1/7/24. Four days later, on 1/11/24, water samples to test for bacteria and endotoxins were drawn from the RO treatment system. The RO treatment system was disinfected with Minncare on 2/11/24. Eight days later on 2/19/24, water samples to test for bacteria and endotoxins were drawn from the RO treatment system. During an interview on 3/7/24 at 10:30 AM, Staff (S) 3, the Area Technical Operations Manager, stated that the water samples should have been drawn before the system was disinfected.”

“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: 39223 Based on observation, review of facility documents and staff interview, it was determined that the facility failed to ensure that the tubing for pHoenix meter calibration solutions and three of six conductivity standard solutions are maintained. Findings include: On 3/6/24 starting at 9:52 AM, a tour of the Dialysis Treatment Room was conducted and on a countertop located adjacent to Station 11, the following was revealed: The Mesa labs Standard Buffer Solution 7.0 pH (potential of hydrogen) bottle was connected to a clear, plastic tubing that contained a large amount of blackish brown discoloration throughout the inner tubing. This tubing is utilized when pHoenix meters (hand-held dialysate meter) are calibrated. The Standard Buffer Solution 7.0 pH bottle’s manufacturer label stated, “Expiry 2023-11-10” indicating that the solution was three months and 25 days beyond the expiration date. The Mesa Labs Standard Buffer Solution 4.00 pH bottle contained a handwritten label that stated, “... Discard on 2/5/24 [Initials] ...”, which indicated that the solution was one month beyond the date it should have been discarded. The Mesa Labs Standard Buffer Solution 10.00 pH bottle contained a handwritten label that also stated, “... Discard on 2/5/24 [Initials] ...”, which also indicated that the solution was one month beyond the date it should have been discarded. During an interview on 3/6/24 at 10:37 AM, Staff (S) 3, the Area Technical Operations Manager, stated that the blackish brown discoloration may contain algae growth and should not be there. S3 also confirmed that the above listed solutions were beyond the expiration dates and should not be available for use. N.J.A.C.8:43A-24.11(c)”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 48966 Based on one of two observations of initiating hemodialysis through an arteriovenous graft/fistula (AVG/F), review of facility policy and staff interview it was determined the facility failed to ensure that the access site was disinfected according to policy prior to cannulation (the action of inserting a metal tube into the body to draw off fluid or introduce medication). Findings Include: On 3/6/24 at 10:41 AM, in Station 1, Staff (S) 12, a Registered Nurse, prepared the patient’s left arm vascular access for cannulation. S12 rubbed first insertion site of the vascular access with an alcohol pad for 10 seconds and let the area air dry for 30 seconds before inserting the fistula needle. S12 rubbed the second insertion site of the vascular access with an alcohol pad for 12 seconds and let the area air dry for 30 seconds before cannulating with the fistula needle. This was not in accordance with facility procedure which required the cannulation site be wiped with an alcohol pad for 30 seconds. During an interview at 10:56 AM, S12 stated he/she thought the access should be wiped with an alcohol pad for 15 seconds and allow to dry for one minute. S12 stated, “I have to check the policy.” A review of S12’s personnel record indicated vascular access care education was completed on 3/13/23. A review of the facility policy titled, “Access Assessment and Cannulation,” stated, “... Skin Disinfection, Step 1. Disinfect cannulation site as follows using any of the disinfection 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 and allow to dry before cannulating ...” 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: 48966 Based on two (2) of two (2) initiation of hemodialysis observations, staff interviews and a review of facility documents, it was determined that the facility failed to ensure that pre-drawn heparin bolus syringes are labeled (Patient (P) 10 and P11) in accordance with the facility policy. Findings include: On 3/6/24 at 10:03 AM, during an observation of the initiation of hemodialysis in Station 14, Staff (S) 9 administered medication to P10 from a syringe labeled as containing Heparin. The syringe contained the following documentation: name of the medication, route, dosage, name of the patient and date. The syringe label did not contain the initials of the person who prepared it or the time it was prepared. During an interview at 10:24 AM, Staff (S) 9, a Registered Nurse, confirmed the Heparin syringe should indicate the time and initials of the person who prepared it. On 3/6/24 at 10:41 AM, during an observation of the initiation of hemodialysis in Station 1, S12 administered medication from a syringe, labeled as containing Heparin, to P11. The syringe filled with Heparin contained the following documentation: name of the medication, route, dosage, name of the patient and date. The syringe label did not contain the initials of the person who prepared it or the time it was prepared. During an interview at 10:52 AM, S12, a Registered Nurse, stated the initials of the person who prepared it and the time it was prepared should be on the syringe’s label. A review of the facility policy titled, “Medication Preparation and Administration,” published 4/5/21, stated, “... Labeling Reconstituted Medication Solutions and Syringes ... All medications in syringes not being administered immediately shall be labeled appropriately with the name of the medication, route, dose, name of patient, date, time and initials of the person who prepared the medication. ...” N.J.A.C. 8:43A- 24.4(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: 49828 Based on review of three of seven medical records (#2, #4, and #7) and staff interviews, it was determined the facility failed to ensure that the information in the medical record is complete and accurate. Findings include: A review of P2’s medical record revealed an order for hemodialysis treatments three times a week for 3 hours and 30 minutes on Tuesday, Thursday, and Saturday. The hemodialysis treatment flowsheets dated 2/8/24 through 3/7/24 revealed the following: The treatment sheet dated 2/8/24 stated, “ ...Treatment Status: Absent ...” At 4:47 PM, Staff (S) 16, Registered Nurse (RN), documented a “Nursing Evaluation” which stated, “... Notes: Patient came in. not in any distress noted. Easy and unlabored breathing. Denies any pain. 0/10. Will continue to monitor upon hd (hemodialysis). ...” The treatment sheet dated 2/24/24 stated, “... Treatment Status: Absent ...” At 4:10 PM, S16, documented a “Nursing Evaluation” which stated, “... Notes: Patient came in. not in any distress noted. Easy and unlabored breathing. Denies any pain. 0/10. Will continue to monitor upon hd (hemodialysis). ...” The treatment sheet dated 2/27/24 stated, “... Treatment Status: Absent ...” At 4:58 PM, S16, documented a “Nursing Evaluation” which stated, “... Notes: Patient came in. not in any distress noted. Easy and unlabored breathing. Denies any pain. 0/10. Will continue to monitor upon hd. ...” The treatment sheet dated 2/29/24 stated, “... Treatment Status: Absent ...” At 3:56 PM, S16, documented a “Nursing Evaluation” which stated, “... Notes: Patient came in. not in any distress noted. Easy and unlabored breathing. Denies any pain. 0/10. Will continue to monitor upon hd. ...” The treatment sheet dated 3/2/24 stated, “... Treatment Status: Absent ...” At 4:00 PM, S16, documented a “Nursing Evaluation” which stated, “... Notes: Patient came in. not in any distress noted. Easy and unlabored breathing. Denies any pain. 0/10. Will continue to monitor upon hd. ...” A review of P4’s medical record revealed an order for hemodialysis treatments three times a week for 3 hours on Tuesday, Thursday, and Saturday. The Hemodialysis Treatment flowsheets dated 2/8/24 through 3/7/24 revealed the following: The treatment sheet dated 2/8/24 stated, “... Treatment Status: Absent ...” At 9:50 AM, S16, documented a “Nursing Evaluation” which stated, “... Notes: Patient came in. not in any distress noted. Easy and unlabored breathing. Denies any pain. 0/10. Will continue to monitor upon hd. ...” The treatment sheet dated 2/13/24 stated, “... Treatment Status: Absent ...” At 9:24 AM, S16, documented a “Nursing Evaluation” which stated, “... Notes: Patient came in. not in any distress noted. Easy and unlabored breathing. Denies any pain. 0/10. Will continue to monitor upon hd. ...” The treatment sheet dated 2/22/24 stated, “... Treatment Status: Absent ...” At 9:24 AM, S16, documented a “Nursing Evaluation” which stated, “... Notes: Patient came in. not in any distress noted. Easy and unlabored breathing. Denies any pain. 0/10. Will continue to monitor upon hd. ...” The treatment sheet dated 2/29/24 stated, “... Treatment Status: Absent ...” At 9:43 AM, S16, documented a “Nursing Evaluation” which stated, “... Notes: Patient came in. not in any distress noted. Easy and unlabored breathing. Denies any pain. 0/10. Will continue to monitor upon hd. ...” A review of P7’s medical record revealed an order for hemodialysis treatments three times a week for 4 hours on Monday, Wednesday, and Friday. The hemodialysis treatment flowsheets dated 2/8/24 through 3/7/24 revealed the following: The treatment sheet dated 2/26/24 stated, “... Treatment Status: Absent ...” At 4:23 PM, S12, RN, documented a “Nursing Evaluation” which stated, “... Notes: Patient verbalized no falls or bleeding and has pain of 0 out of 10. No signs of infection. Assessed access with [+] thrill and bruit [indicative of a working fistula, dialysis access]. No SOB [shortness of breath]. Access visible, lines secured. ...” The above medical records were reviewed with Staff (S) 1, the Facility Administrator on 3/7/24 at 11:25 AM. At this time, S1 stated that the patients were not present for hemodialysis treatment on the above listed dates. S1 was not able to identify the reason for the documented nursing evaluations when the patients were not present at the facility. During an interview on 3/8/24 at 12:50 PM with S8, Charge Nurse, stated that the assessments are not auto populated by the charting system and on days the patients are absent there should not be a nursing evaluation completed in the patients’ medical record. During an interview on 3/8/24 at 1:25 PM, S12, a Registered Nurse, stated that he/she prepares for the day by “copy and pasting” a nursing evaluation “template” into the medical record prior to the patient’s arrival. The template included documentation for the “Nursing Evaluation.” S12 also stated that this is not something he/she should do when the patient is not present, has not been assessed, and would not do going forward. N.J.A.C. 8.43A-13.1(a)”