Fmc Hackensack

“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: 50912 Based on observation, staff interview, and review of facility documents, it was determined that the facility failed to ensure that one of one In-Center Hemodialysis (ICHD) emergency evacuation box contains supplies for every licensed patient station. Findings include: On 12/10/25 at 11:30 AM, the ICHD Emergency Evacuation Box was reviewed and contained a checklist titled, “Emergency Box Contents.” The checklist was last reviewed on 12/1/25 and identified the following par levels (periodic automatic replacement, the ideal minimum quantity of an inventory item) for each supply listed below: Fistula needles 16 gauge - 2 Fistula needles 17 gauge - 1 Upon inspection of the Emergency Box, there were four, 16 gauge fistula needles and two, 17 gauge fistula needles inside. The ICHD Emergency Evacuation Box, did not have the required supply count for the above items to cover 19 patient stations in the event of an emergency evacuation. During an interview on 12/10/25 at 11:39 AM, Staff (S)5, confirmed that the facility had 19 licensed stations and that there should be a sufficient number of supplies in the box for 19 patients for every shift. Facility policy titled, “Emergency Medications, Equipment and Supplies,” published 2/03/25 stated, “... Definitions ... Emergency Evacuation Box: An emergency evacuation box contains supplies primarily needed for every licensed station once the patient is in a secure location ...” 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: 37656 Based on one of two observations of hand hygiene, staff interview, and a review of the facility documents, it was determined that the facility failed to ensure that staff remove gloves and perform hand hygiene prior to accessing supplies in the clean areas to prevent cross contamination. Findings include: On 12/10/25 at 10:45 AM, on the Hemodialysis Treatment Floor, Staff (S)7 was observed cleaning and disinfecting Station 13. S7 with gloved hands, removed the dialysis bloodlines from the hemodialysis machine and discarded them in a red biohazard bin. S7 then, with same gloves on, carried a blood tube from Station 13 in his/her left hand, and walked to a dirty sink area near the Nurse’s Station. S7 then placed the blood tube in a tube rack located on the dirty sink counter. S7 did not remove gloves and perform hand hygiene. With the same gloves on, went to a clean sink area and obtained 1:100 (one part bleach to 100 parts water) bleach solution soaked clothes. S7 then brought the cloths to Station 13, placed them on top of the uncleaned hemodialysis machine, then removed his/her gloves and performed hand hygiene. S7 did not remove his/her gloves and did not perform hand hygiene after disposing the bloodlines and after placing the blood tube in the dirty sink area. There was a potential for cross contamination of the clean supplies. During an interview on 12/10/25 at 10:49 AM, S7 stated that he/she should have removed his/her gloves and performed hand hygiene after touching the bloodlines and the blood tube and prior to obtaining clean cloths from the clean sink. A review of S7’s personnel file indicated a certificate of completion dated 03/28/25, for “Infection Prevention Fundamentals” which included education on the Hand Hygiene policy. Facility policy titled, “Hand Hygiene,” published 11/06/23, stated, “... Policy ... Hands Will Be ... Decontaminated using alcohol- based hand rub or by washing hands with antimicrobial soap and water ... Entering and leaving 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)”

“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: 37656 Based on one of one observation of a dirty sink area, staff interview, and review of facility documents, it was determined that the facility failed to ensure that clean supplies are not stored in a dirty sink area. Findings include: On 12/10/25 at 11:20 AM, during a tour of the Hemodialysis Treatment Floor, Staff (S)7 removed two unopened acid jugs from a clean storage area and placed them on the countertop of a dirty sink. Upon interview at the time of discovery, S7 stated that the two unopened acid jugs will be used for the patient coming to Station 13 for hemodialysis treatment. Facility policy titled, “Dialysis Precautions,” published 01/04/12, stated, “... Dirty Area: An area where this is a potential for contamination with blood or body fluids and areas where contaminated or used supplies, equipment, blood supplies or biohazard containers are stored or handled. ...” 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 observations, staff interview, and a review of facility documents, it was determined that the facility failed to ensure that: 1) seven out of 18 blood pressure (BP) cuffs are maintained and; 2) all equipment and surfaces within the dialysis station are cleaned and disinfected in accordance with facility policy. Findings include: 1. On 12/10/25 at 10:15 AM, during a tour of the Hemodialysis Treatment Floor, the BP cuffs in Stations 3, 4, 8, 9, 14, 15 and 16 were covered with white lint on the Velcro portion of the cuff, which rendered the BP cuffs uncleanable. On 12/10/25 at 11:45 AM, the above findings were confirmed with Staff (S)8 who stated that he/she will have staff change the BP cuffs covered with lint immediately. 37656 2. On 12/10/25 at 10:50 AM, on the Hemodialysis Treatment Floor, S8 was observed cleaning and disinfecting Station 13. S8 did not clean the hook portion of the IV (intravenous) pole that was attached to the hemodialysis machine and the black stethoscope that was hanging on the hook portion of the IV pole. During an interview on 12/10/25 at 11:00 AM, S8 confirmed that he/she was finished cleaning the station and confirmed that the hook was not cleaned, and stated that he/she was going to clean the stethoscope separately with alcohol. Facility policy titled, “Cleaning and Disinfection of the Dialysis Station,” published 09/05/23, stated, “... General Cleaning ... The dialysis station could become contaminated with blood and other body fluids during treatment. After use, any non-disposable equipment and supplies brought into the dialysis station (ex. Stethoscope) must be disinfected with 1:100 [one part bleach to 100 parts water] bleach ... before being removed from the dialysis station ... Procedure ... Follow the steps below to disinfect the dialysis station after each dialysis treatment: ... 3. Use a cloth wetted with 1:100 bleach solution or EPA (Environmental Protection Agency) approved disinfectant to clean and disinfect the dialysis station (chair/bed, tables, machine, television, IV pole, B/P [blood pressure] cuff, hand sanitizer dispenser and holder, chaise wall behind chair ...” N.J.A.C. 8:43A-24.8(b)”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 50912 Based on one of one observation in the Medication Preparation Area, staff interview, and a review of manufacturer’s instructions for use (MIFU), it was determined that the facility failed to ensure that expired medications are not available for use. Findings include: On 12/10/25 at 11:38 AM, during a tour of the Medication Preparation Area, a medication refrigerator contained an opened, half full, multidose vial of Tuberculin Purified Protein Derivative (Mantoux) Tubersol that was available for use. The vial was labeled opened on 11/03/25. A review of the Tuberculin Purified Protein Derivative (Mantoux) Tubersol MIFU stated, “... A vial of Tubersol which has been entered and in use for 30 days should be discarded. Do not use after expiration date. ...” The vial was seven days past it’s beyond use date. On 12/10/25 at 11:40 AM, this finding was confirmed with Staff (S)5 who stated that Mantoux multidose vials should be discarded 30 days from the date the vials are opened. N.J.A.C. 8:43A-9.3(b)”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 50912 Based on one of two observations of the 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 catheter exit site care is performed in accordance with facility procedure. Findings include: On 12/10/25 at 10:39 AM, in Station 4, S6 initiated hemodialysis on a patient through a CVC. During catheter exit site care, S6 swabbed the site with 2% Chlorhexidine for 15 seconds. This was not in accordance with the facility’s procedure. During an interview on 12/10/25 at 10:46 AM, S6 stated that he/she did not time it and will do it longer next time. A review of S6’s personnel file indicated that he/she had completed Infection Control Fundamentals that contained training and education on the initiation of hemodialysis treatment through CVC on 10/15/25. Facility procedure titled, “Changing the Catheter Dressing Procedure,” published 2/5/2024, stated, “... Cleaning the Site ... 2% Chlorhexidine ... Using gentle back and forth friction, clean the exit site beginning in the center and continuing outward the area of the size of the dressing to be applied (2 inches) in a concentric circle for 30 seconds and allow to dry a minimum of 30 seconds. ...” 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: 51990 Based on staff interview and a review of facility documents, it was determined that the facility failed to ensure that total chlorine testing is conducted every four hours in accordance with facility policy. Findings include: A review of the document titled “Post Worker Carbon Tank - TCL (Total Chlorine)” for October 2025 stated that on 10/17/25, a chlorine test was performed by staff at 11:35 AM, followed by a test performed at 4:38 PM. This was five hours and three minutes after the last chlorine test was performed. On 10/30/25, a chlorine test was performed by staff at 10:45 AM, followed by a test performed at 2:56 PM. This was four hours and 11 minutes after last chlorine test was performed. Furthermore, the document titled “Post Worker Carbon Tank - TCL (Total Chlorine)” for November 2025 stated that on 11/05/25, a chlorine test was performed by staff at 7:05 AM, followed by a test performed at 11:30 AM. This was four hours and 25 minutes after the last chlorine test was performed. During an interview on 12/10/25 at 12:30 PM, Staff (S)3 stated that a chlorine test is performed every four hours and confirmed the above findings. Facility policy titled, “Carbon Filtration Monitoring for Incenter Central Water System Policy,” published 05/05/25, stated, “... Policy ... Total Chlorine Test will be performed prior to initial treatment and every four hours ...” N.J.A.C. 8:43A-24.10(a)(3)”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 33556 Based on observation and staff interview, it was determined that the facility failed to ensure a defect free environment is maintained at all times. Findings include: On 12/10/25 at 11:00 AM, during a facility tour conducted with Staff (S)4, the following was observed: Uncleanable defective gaping seams were discovered on the monolithic floor surface located on the Hemodialysis Treatment Floor at Station 1, Station 10, and Station 11. Wall damage exposing uncleanable base material was identified at the emergency exit adjacent to Station 12. S4 confirmed the above findings upon discovery. N.J.A.C. 8:43A-17.4(a)15”

“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 observation and staff interview, it was determined that the facility failed to ensure supplies are monitored and discarded in accordance with the manufacturer’s expiration dates. Findings include: On 12/11/25 at 12:40 PM, a tour of the HHD/HPD (Home Hemodialysis/Home Peritoneal Dialysis) training rooms revealed the following: There was one “Stay Safe Cap” (used for closure of peritoneal dialysis connecting system) with an expiration date of 09/30/25. In an interview on 12/11/25 at 12:45 PM, Staff (S)11 confirmed that the stay safe cap was expired. N.J.A.C. 8:43A-24.11(c)”

“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: 37656 Based on two of two observations of initiation and discontinuation of hemodialysis through a Central Venous Catheter (CVC, a type of access used for hemodialysis), staff interview and a review of facility documents, it was determined that the facility failed to ensure patient’s right to privacy. Findings include: On 12/10/25 at 9:50 AM, Staff (S)8 was observed during initiation of dialysis through a CVC in Station 12. The curtain was was not fully drawn on the right side of the patient leaving an approximate two-foot opening which renders the chest area of the patient visible to other people passing the station and to the staff at the nurse’s station. During an interview on 12/10/25 at 10:10 AM, S8 stated that the curtains don’t close all the way and he/she should have used clamps to put the curtains together. On 12/10/25 at 10:29 AM in Station 6, S6 discontinued hemodialysis on a patient through a right chest wall CVC. During the procedure, the curtain was not fully drawn on the right side of the patient leaving an approximate four-foot opening. The patient’s chest was visible from the patients in Stations 7 and 8, which was located on the right side of Station 6. During an interview on 12/10/25 at 10:35 AM, S6 confirmed that the curtains should be fully closed around the patient’s station when discontinuing hemodialysis. Facility policy titled, “Patient Rights and Responsibilities,” published 04/04/12, stated, “... Purpose ... Ensure that patients’ rights are respected and protected by the facility ... All facility staff are responsible for ensuring that patients’ rights are respected and protected by the facility ... 3. Privacy and confidentiality in all aspects of treatment ...” N.J.A.C 8:43A-16.2(a)10 50912”

“PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This Standard is not met as evidenced by: 51990 Based on one of seven medical records reviewed (Patient [P]4), staff interviews, and a review of facility documents, it was determined that the facility failed to ensure that a Comprehensive Interdisciplinary Assessment (CIA) and Plan of Care (POC) are completed by the IDT [Interdisciplinary Team, includes a Physician, a Registered Nurse (RN), a Social Worker (SW), and a Registered Dietitian (RD)] on a new patient within 30 days. Findings include: A review of P4’s medical record revealed the following: P4 was admitted to the facility on 08/25/25 for Peritoneal Dialysis (PD, a type of dialysis that uses the lining of the abdomen) training. The CIA was completed by the Physician on 10/21/25, this was 27 days overdue; the RN on 10/06/25, this was 12 days overdue; the SW on 10/13/25, this was 19 days overdue; and the RD on 10/21/25, this was 27 days overdue. The POC meeting was held on 10/28/25. This was 34 days after the start of P4’s dialysis training on 08/25/25. During an interview on 12/11/25 at 12:09 PM, Staff (S)9 stated that P4’s physician was on vacation and resulted in the delay of completing the CIA and conducting the POC meeting. Facility policy titled, “Comprehensive Interdisciplinary Assessment (CIA) and Plan of Care (POC),” published 07/03/23, stated, “... General Policy for Patient Assessment and Plan of Care ... The comprehensive Interdisciplinary Assessment and Plan of Care must be developed and implemented by an Interdisciplinary Team (IDT) consisting of at a minimum, the patient, or patient’s designee, a registered nurse, the patient attending physician (or physician extender where allowed by State regulations) ... CIA and POC for Patients New to Dialysis ... An initial comprehensive (CIA) and plan of care (POC) must be conducted on all new patients new to dialysis within the later of 30 calendar days or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session ...” Facility policy titled, “Home Dialysis Patient Education and Training Guidelines,” published 005/05/25, stated, “... Home Dialysis Training Requirements ... 6. Completion of the initial Comprehensive Interdisciplinary Assessment (CIA) and Plan of Care (POC) must be completed within 30 days or 13 treatments of the patient’s admission according to the Comprehensive Interdisciplinary Assessment and Plan of Care Policy, regardless of when the patient begins contiguous modality training ...” N.J.A.C. 8:43A-24.13(b)”

“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: 50912 Based on three of four medical records reviewed (Patient [P]1, P2, and P7), staff interviews, and a review of facility documents, it was determined that the facility failed to ensure that post (after) hemodialysis nursing assessments are completed according to facility policy. Findings include: A review of P1’s Plan of Care (POC), dated 11/25/25, stated, “Area of Focus BP [Blood Pressure] and Fluid Management Open Goal Achieve BP Control as specified by the patient’s physician ...” A review of the “Treatment Sheet for Facility” from 11/14/25 through 12/08/25 in P1’s medical record revealed the following: On 12/05/25 and 12/08/25, the pre-treatment (before treatment) “Nursing Evaluation” section stated, “... Lungs: Decreased breath sounds bilateral [affecting both sides]. ...” The post treatment “Nursing Evaluation” lacked documented evidence of a re-assessment of the patient’s lung sounds by a RN (Registered Nurse). A review of P2’s POC, dated 09/23/25, stated, “Area of Focus BP and Fluid Management Open Goal Achieve BP Control as specified by the patient’s physician ... Add, adjust or discontinue BP medications ... Educate patient/family /caregiver on signs and symptoms of fluid overload ...” A review of the “Treatment Sheet for Facility” from 11/13/25 through 12/09/25 in P2’s medical record revealed the following: On 11/15/25, 11/18/25, 11/20/25, 11/22/25, 11/24/25, 11/29/25/ 12/02/25, 12/04/25 and 12/06/25, the pre-treatment “Nursing Evaluation” section stated, “... Edema Ankle bilateral, 1+ [plus]: 2 mm [millimeter] or less, disappears rapidly ...” The post treatment “Nursing Evaluation” lacked documented evidence of a re-assessment of the patient’s edema by a RN. On 11/15/25, 11/18/25/ 11/22/25/ 11/24/25 and 11/26/25, the pre-treatment “Nursing Evaluation” section stated, “... Lungs: Decreased breath sounds bilateral. ...” The post treatment “Nursing Evaluation” lacked documented evidence of a re-assessment of the patient’s lung sounds by a RN. A review of P7’s POC, dated 11/05/25, stated, “Area of Focus BP and Fluid Management Open Goal Achieve BP Control as specified by the patient’s physician ... Educate on importance of limiting fluid and sodium intake ... Educate patient/family/caregiver on signs and symptoms of fluid control ... sodium control ... blood pressure medications ...” A review of the “Treatment Sheet for Facility” from 11/04/25 through 12/05/25 in P7’s medical record revealed the following: On 11/14/25, 11/21/25 and 12/05//25 the pre-treatment “Nursing Evaluation” section stated, “... Edema Ankle bilateral, 1+: 2 mm or less, disappears rapidly ...” The post treatment “Nursing Evaluation” lacked documented evidence of a re-assessment of the patient’s edema by a RN. On 11/23/25, 11/25/25, 11/28/25 and 12/01/25, the pre-treatment “Nursing Evaluation” section stated, “... Edema Ankle bilateral 2+: 2-4 mm indent, disappears 10-15 seconds. ...” The post treatment “Nursing Evaluation” lacked documented evidence of a re-assessment of the patient’s edema by a RN. On 11/14/25, 12/01/25 and 12/05/25, the pre-treatment “Nursing Evaluation” section stated, “... Lungs: Decreased breath sounds bilateral ...” The post treatment “Nursing Evaluation” lacked documented evidence of a re-assessment of the patient’s lung sounds by a RN. On 12/11/25 at 2:21 PM, above findings were reviewed and confirmed with Staff (S)2 who stated that ankle edema and abnormal breath sounds assessed pre-treatment should be reassessed post-treatment. Facility policy tilted, “Patient Assessment and Monitoring,” published 05/01/2023, stated, “... Pre-Treatment 2 ... During nursing rounds, the Registered Nurse will review the data collected and assess the following parameters as needed: ... Edema (as indicated by patient condition) Assess the patient for edema: Location: foot, ankle, lower leg and sacrum Right, Left or Bilateral Severity (None, 1+, 2+, 3+ or - 4+) ... Post-Treatment 1 ... Lung sounds Edema Heart Sounds. The registered nurse will assess/re-assess post treatment as indicated. ...” N.J.A.C. 8:43A-24.4(a)”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 50912 Based on staff interviews, review of four of five medical records ((Patient [P]1, P3, P6 and P7), and review of facility documents, it was determined that the facility failed to ensure the patients receive the prescribed BFR (Blood Flow Rate, the speed at which blood is pumped through the dialyzer) and DFR (Dialysate Flow Rate, the rate at which the dialysate passes through the dialyzer) during hemodialysis treatments. Findings include: A review of P1’s medical record revealed the following: The Plan of Care (POC), dated 11/05/25, stated, “... Area of Focus: Dialysis Adequacy Access Open ... Goal: spKT/V [measurement of hemodialysis adequacy] greater than or equal to 1.4 ...” The “Dialysis Orders” section dated 11/17/2025, contained a physician order for, “... BFR 400, DFR Manual 800 ml [milliliter]/min [minute] ...” A review of the “Treatment Details Report” from 11/17/25 to 12/08/25 indicated that the prescribed BFR order of 400 ml/min was not followed on the following treatment dates. On 11/28/25, hemodialysis treatment was initiated at 1:50 PM with the BFR set at 300 ml/min. The BFR remained at 300 ml/min until the termination of the hemodialysis treatment at 5:50 PM. On 12/01/25, hemodialysis treatment was initiated at 2:58 PM with the BFR set at 350 ml/min. The BFR remained at 350 ml/min until the termination of the hemodialysis treatment at 5:45 PM. On 12/08/25, hemodialysis treatment was initiated at 2:54 PM with the BFR set at 300 ml/min. The BFR remained at 300 ml/min until the the termination of the hemodialysis treatment at 5:55 PM. The medical records lacked documented evidence of a rationale for the BFR not being administered according to the physician’s order on the above dates. On 12/11/25 at 1:09 PM, the above findings were reviewed and confirmed with Staff (S)2. Upon interview at 1:12 PM, S2 stated that staff members should write a comment about why they cannot achieve the prescribed BFR. A review of P3’s medical record revealed the following: The POC, dated 10/28/25, stated, “... Area of Focus: Dialysis Adequacy Access Open ... Goal: spKT/V Patient met goal 1.53 ... Patient will sustain Kt/V greater than or equal to greater than or equal to 1.4 consistently. ... Educate patient/family/caregiver on adequacy principles ...” The “Dialysis Orders” section dated 11/21/2025, contained a physician order for, “... BFR 350, DFR Manual 600 ml/min ...” A review of the “Treatment Details Report” from 11/21/25 to 12/08/25 indicated that the prescribed BFR order of 350 ml/min was not followed on the following treatment dates. On 11/28//25, hemodialysis treatment was initiated at 6:25 PM with the BFR set at 350 ml/min until 6:56 PM. At 6:56 PM the BFR was lowered to 300 mL/min and remained at 300 mL/min until the termination of the hemodialysis treatment at 8:22 PM. On 12/01/25, hemodialysis treatment was initiated at 6:12 PM with the BFR set at 300 mL/min. The BFR remained at 300 ml/min until the termination of the hemodialysis treatment at 8:59 PM. The medical records lacked documented evidence of a rationale for the BFR not being administered according to the physician’s order on the above dates. On 12/11/25 at 1:09 PM, the above findings were reviewed and confirmed with S2. A review of P6’s medical record revealed the following: The Plan of Care, dated 11/05/25, stated, “... Area of Focus: Dialysis Adequacy Access Open ... Goal: spKt/V greater than or equal to 1.4 ... open ...” The “Dialysis Orders” section dated 11/21/2025, contained a physician order for, “... DFR 800 mL ...” A review of the “Treatment Details Report” dated, 12/08/25 and 12/10/25 indicated that the prescribed DFR order of 800 ml/min was not followed. P6 was dialyzed with a DFR of 700 ml/min instead of 800 ml/min from the initiation of treatment at 6:30 AM to the end of treatment at 10:30 AM on both of the above dates. The flow sheet lacked documented evidence of the reason for not following the prescribed DFR. The above flow sheets were reviewed with S1 on 12/11/25 at 2:00 PM and he/she confirmed the findings. A review of P7’s medical record revealed the following: The POC, dated 11/05/25, stated, “... Area of Focus: Dialysis Adequacy Access Open ... Goal: Patient met goal, [he/she] adheres with the prescribed HD [Hemodialysis] orders ... Educate patient/family/caregiver on adequacy principles ...” The “Dialysis Orders” section dated 11/12/2025, contained a physician order for, “... BFR 400, DFR Manual 800 ml/min ...” A review of the “Treatment Details Report” from 11/12/25 to 12/08/25 indicated that the prescribed BFR order of 400 ml/min was not followed on the following treatment dates. On 11/23/25, hemodialysis treatment was initiated at 5:58 AM with the BFR set at 350 ml/min. The BFR remained at 350 ml/min until termination of hemodialysis treatment at 9:00 AM. On 11/25/25, hemodialysis treatment was initiated at 5:15 AM with the BFR set at 400 ml/min until 5:29 AM. At 5:29 AM the BFR was changed to 350 ml/min until termination of hemodialysis treatment at 9:00 AM. The medical records lacked documented evidence of a rationale for the BFR not being administered according to the physician’s order on the above dates. On 12/11/25 at 1:09 PM, the above findings were reviewed and confirmed with S2. Facility policy titled, “Nursing Supervision and Delegation” published 11/06/23, stated, “... Reporting of Patient Care Findings to the Team Nurse in Charge ... The staff member who collects information pre [before], post [after] and during treatment will document their findings. Any observed changes or abnormal findings ... must be reported to the registered nurse who will assess the patient. ... Daily Treatment Record Review Prior to discharge, the RN must review the treatment record ... The record must be reviewed for: ... correct dialysate prescription was delivered. ...” Facility policy titled, “Patient Assessment and Monitoring” published 05/01/23, stated, “... Data Collection ... Direct patient care staff may collect data ... If the PCT... note any changes in the patient’s condition or vascular access ... the registered nurse must assess the patient. ... The Registered Nurse will assess/re-assess any findings addressed pre or during treatment as needed. ... During Treatment ... Document machine parameters ... every 30 or more often as needed ... Follow the steps below for monitoring ... machine parameters during treatment ... Machine Parameters and Extracorporeal Circuit ... Check machine settings and measurements: Check prescribed blood flow is being achieved, or reason is documented in the medical record if unable to meet prescribed blood flow. Check dialysate flow rate setting is correct, and the prescribed flow is being delivered ... Document any findings and interventions in the medical record” N.J.A.C. 8:43A-24.4(a) 37656”

“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 one of seven medical records reviewed (Patient [P]4), staff interview, and review of facility documents, it was determined that the Medical Director failed to ensure that Peritoneal Dialysis (PD, a type of dialysis that uses the lining of the abdomen) solution guidelines/orders are followed as prescribed by the physician in five of 19 PD treatments reviewed for P4. Findings include: A review of P4’s medical record revealed the following: The patient was admitted on 08/25/25 for PD training. A review of the “Solution Guidelines” by the physician dated 09/23/25 stated, “... Per Blood Pressure ... SBP [Systolic Blood Pressure, top number of a BP reading, measuring the pressure in arteries when the heart beats] sitting or standing .... Solution to Use ... Less than 110 ... 1.5% solution ... 110 to 140 ... 1.5% alternating 2.5% solution ... 141 to 170 ... 2.5% solution ... 170 or higher ... Call clinic ...” A review of the “CCPD [Continuous Cycling Peritoneal Dialysis] Treatment Summary” dated 11/12/25 through 12/03/25 revealed P4’s blood pressure (BP) and dialysis solutions used. On 11/18/25, the BP was 172/85 and a 2.5% solution was used by the patient. There was no documented evidence that the facility was contacted by the patient for guidance. On 11/19/25, the BP was 128/73 and on 11/22/25, the BP was 137/86; a 2.5% solution was used by the patient on both dates. The “Solution Guidelines” indicated that 1.5% alternating with 2.5% solution should have been used. On 11/20/25, the BP was 143/92; a 1.5% alternating with 2.5% solution was used by the patient. The “Solution Guidelines” indicated, 2.5% solution only. On 11/26/25, the BP was 175/84; a 1.5% alternating with 2.5% solution was used by the patient. There was no documented evidence that the facility was contacted by the patient for guidance. During an interview on 12/12/25 at 11:45 AM, Staff (S)9 and S16 confirmed the above findings. S16 stated he/she should have reviewed the treatment sheets closely during monthly clinic visits to ensure that P4 followed the guidelines prescribed by the physician and called the facility when SBP was over 170. Facility policy titled, “Physician Order Documentation,” published 07/03/23, stated, “... General Policy ... Nurse practice act require nurses to carry out treatment care, medication administration, lab test, procedure and other treatments based on physician orders ...” Facility policy titled, “Review and Documentation of Home Therapies Patient Health Data,” published 05/01/23, stated, “... Policy ... The patient will create a treatment record every dialysis treatment ... Treatment data will be reviewed by the home therapies nurse in order to identify trends, determine if patient are following their treatment plan or having problems with their dialysis at home ...” 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: 51990 Based on review of one of seven medical records [Patient (P)4], staff interviews, and a review of facility documents, it was determined that the facility failed to ensure that the initial Peritoneal Dialysis (PD, a type of dialysis that uses the lining of the abdomen) training flowsheet is completed and accurately documented in the medical record. Findings include: A review of P4’s medical record revealed the following: The patient was admitted on 08/25/25 for PD training. The Continuous Ambulatory Peritoneal Dialysis (CAPD) orders by the physician indicated initial training began on 08/25/25. However, there was no documented evidence of a training flowsheet for 08/25/25. During an interview on 12/12/25 at 11:42 AM, Staff (S)16 confirmed that P4 was trained at the facility on the above date and stated that there was a delay in the registration process in “PatientHub” (PD electronic medical record). Hence, a flowsheet was not documented electronically. During an interview on 12/12/25 at 11:57 AM, S9 stated a paper flowsheet should have been completed on 08/25/25. Facility policy titled, “Review and Documentation of Home Therapies Patient Health Data,” published 05/01/23, stated, “... Background ... Clinicians are responsible for completing documentation within the medical record that captures the accurate representation of the care and services provide to each patient ... All documentation must be completed at the time of service and accessible ...” N.J.A.C. 8:43A-13.3(a)(9)”