Davita Ocean County Dialysis

“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 interview, and review of facility documents, it was determined that the facility failed to ensure that expired supplies are not available for use in one of one emergency evacuation box. Findings include: On 11/24/25 at 11:50 AM, the contents of the emergency evacuation box were reviewed and compared to the November 2025 “Emergency Evacuation Kit Checklist.” The emergency evacuation box contained a bag with 10 BD 10 ml (milliliter) Luer-Lok syringes, each with an expiration date of 10/31/25. During an interview on 11/24/25 at 12:02 PM, Staff (S)7 confirmed the 10 syringes were past the expiration date and should have been discarded when the evacuation box was checked on 12/03/25. Facility policy titled, “Facility Emergency Management Plan (ICHD [In-center hemodialysis], Home),” revised October 2025, stated, “... Emergency Evacuation Kit ... 7. FA [Facility Administrator] or designee will review the contents of the kit(s) and replace missing or expired supplies at least monthly ...” N.J.A.C. 8:43A-15.1(d)”

“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: 44833 Based on one of two arteriovenous fistula/graft (a surgically created connection between an artery and a vein, typically in the arm, forming a high-flow vessel for hemodialysis) dialysis initiation observation, staff interview, and review of facility documents, it was determined that the facility failed to ensure proper hand hygiene is performed to prevent cross contamination. Findings include: On 11/24/25 at 9:55 AM, Staff (S)9 was observed initiating hemodialysis treatment for a patient in Station 6 using the patient’s left upper arm vascular access. With gloved hands, S9 obtained the patient’s temperature using a no contact infrared digital thermometer and entered their findings into the computer which was adjacent to the treatment area. S9 then removed the gloves, disposed of them into the trash container, and walked to a nearby clean sink to perform hand washing. S9 wetted his/her hands, applied soap from the dispenser, began to lather his/her hands for approximately four seconds before rinsing his/her hands. This was 16 seconds less than required by facility policy. S9 then proceeded to obtain dialysis access cannulation supplies from the clean supply area, put on clean gloves, and returned to Station 6. S9 then removed his/her gloves, and without first performing hand hygiene, put on new gloves, obtained a stethoscope from the nurse station, and listened to the patient’s dialysis access. After an initial attempt of cannulation (the act of inserting a dialysis access needle into the dialysis access) failed, S9 removed the needle, held the patient’s cannulation site to stop any bleeding, and then removed his/her gloves. S9 then returned to the hand wash sink, wetted his/her hands, and lathered with soap for 10 seconds, before rinsing and drying his/her hands. This was 10 seconds less than required by facility policy. During an interview at 11:14 AM, S9 stated that they “sing happy birthday” when they wash their hands as a way of keeping time for hand hygiene. S9 was not able to verbalize what would be the appropriate amount of time required for lathering with soap when hand washing. During an interview on 11/26/25 at 9:45 AM, S2 stated that appropriate lather time with soap, when hand washing, was 20 seconds prior to rinsing hands, and any time less than that was unacceptable. Review of S9’s personnel files indicated that they were successfully evaluated on an “Annual Skills Checklist” for “Hand Washing” on 01/21/25. Facility policy titled, “Infection Control for Dialysis Facilities,” revised April 2023, indicated, “... Hand Hygiene 1. All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene a. upon entering and exiting the patient treatment area, b. prior to gloving and immediately after removal of gloves, ...” Facility policy titled, “Handwashing,” revised October 2020, indicated, “... Procedure ... 3. Cover hands (palms, back of hands, between fingers) and wrists with lather and wash vigorously for a minimum of 20 seconds ...” 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: 39228 Based on one of one observation of the cleaning and disinfection of a hemodialysis station, staff interview, and review of facility documents, it was determined that the facility failed to ensure that re-usable equipment and surfaces within the hemodialysis station are cleaned and disinfected in order to prevent cross contamination. Findings include: On 11/24/25 at 10:11 AM, during an observation of the cleaning and disinfection of Station 5, on the Hemodialysis Treatment Floor, the following was revealed: Staff (S)8 wiped the dialysis machine and the attached blood pressure (BP) cuff with 1:100 bleach solution (one part bleach to 100 parts water) soaked clothes. S8 then wrapped the attached BP cuff tubing around the BP cuff and placed it onto the dialysis machine. S8 did not clean and disinfect the BP cuff tubing prior to wrapping it around the clean cuff and placing it onto the clean dialysis machine. S8 continued to clean and disinfect the dialysis chair and the rest of the station, however he/she did not clean and disinfect the countertop area located directly behind the dialysis chair. At 10:19 AM, an interview was conducted with S8 who confirmed that he/she did not clean the tubing of the BP cuff prior to wrapping it around the BP cuff and placing it onto the machine. S8 stated, “I should have cleaned it.” S8 then further stated that the countertop area behind the dialysis chair should have also been cleaned. On 11/25/25 at 11:45 AM, the above findings were reviewed with S2 and S6. S6 stated that the countertop area located behind the dialysis chair should be cleaned and disinfected after each dialysis treatment. A review of S8’s personnel file indicated that S8 completed “New Jersey State Specific Education” which included “Infection Control for Dialysis Facilities” on 3/20/25. Facility policy titled, “Infection Control For Dialysis Facilities,” revised April 2023, stated, “... Disinfection ... 13. At the end of each treatment, the dialysis station will be cleaned and disinfected. a. Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings (e.g. ... blood pressure cuffs) and frequently contacted by healthcare personnel (e.g. ... top, front and sides of dialysis machine; ... countertops).” 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 of one observation of the termination of hemodialysis through a Central Venous Catheter (CVC, a type of access used for hemodialysis), staff interviews, a review of facility documents, it was determined that the facility failed to ensure that termination of hemodialysis using a CVC is performed in accordance with facility policy. Findings include: On 11/24/25 at 1:53 PM, Staff (S)10, discontinued hemodialysis treatment through a left chest CVC on a patient in Station 2. S10 disconnected the arterial bloodline from the CVC and attached a pre-filled 10 milliliter (ml) saline syringe to the arterial limb and instilled the contents into the arterial port. S10 did not clean the threads of the CVC with an alcohol pad for 15 seconds prior to attaching the syringe to the arterial limb. S10 disconnected the venous bloodline from the CVC and attached a pre-filled 10 ml saline syringe to the venous limb and instilled the contents into the venous port. S10 did not clean the threads of the CVC with an alcohol pad for 15 seconds prior to attaching the syringe to the venous limb. S10 connected heparin syringes to the arterial and venous limbs and instilled the solutions. S10 removed the syringe from the arterial limb and disinfected the CVC hub with a 70% alcohol prep pad for one second before attaching the CVC end cap. This was 14 seconds less than required by facility policy. S10 proceeded to remove the syringe from the venous limb and disinfected the CVC hub with a 70% alcohol prep pad for two seconds before attaching the CVC end cap. This was 13 seconds less than required by facility. During an interview on 11/24/25 at 2:08 PM, S10 stated he/she was not sure if when disconnecting the bloodlines from the catheter limbs that alcohol needs to be used on the threads prior to connecting the saline syringes. S10 stated when connecting the heparin syringes and the end caps to the CVC limbs a 15 second alcohol wipe of the CVC threads is to be completed. During an interview on 11/24/25 at 2:10 PM, S2 confirmed that a 15 second pad scrub with alcohol prep is to be performed when disconnecting the bloodlines from the catheter limbs, before attaching the pre-filled saline syringe and when attaching the end caps to the limbs of the CVC. A review of S10’s training and education records indicated that the Procedural Skills Verification Checklist that included training in discontinuation of dialysis with a CVC was successfully completed on 10/10/25. Facility policy titled, “Central Venous Catheter (CVC) With ClearGuards HD Antimicrobial End Caps Procedure,” revised April 2025, stated, “... Notes: ... Perform a 15 second hub scrub of the CVC during the process of connecting or disconnecting from the bloodlines, including line reversal, or if the patient is disconnected during treatment for any reason. ... Upon Completion Of Dialysis ... 30. Clamp arterial limb and blood line. Aseptically disconnect arterial blood line from arterial CVC limb attach a 10 ml syringe filled with normal saline to arterial limb ... 32. Clamp venous limb and blood line. Aseptically disconnect venous blood line and connect 10 ml syringe with normal saline to the venous catheter limb. ... 34. Remove syringes and disinfect with a new alcohol prep pad for each CVC hub. Scrub the sides, threads, and end of the hub thoroughly with friction for 15 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: 44833 Based on one of one observation of total chlorine testing, staff interview, and review of facility documents, it was determined that the facility failed to ensure accurate testing of the water treatment system for chlorine/chloramine removal. Findings include: On 11/24/25 at 12:55 PM, Staff (S)8 performed a test for total chlorine levels in the Water Treatment Room. S8 obtained a sample of water and, after filling and dumping the cup with water three times, S8 swished a RPC Ultra-Low Total Chlorine Test Strip back and forth in the water sample for the required time. S8 then removed the strip from the water and after 13 seconds, compared the test strip color to the color chart to determine the level of chlorine. S8 did not wait 20 seconds to compare the strip to the color chart. This was not in accordance with manufacturer’s instructions for use. During an interview immediately after the observation, S8 stated that the wait time should be 20 seconds. On 11/26/25 at 9:45 AM, the surveyor interviewed S2, who stated that the wait time for testing the total chlorine test strip once removed from the water sample should be 20 seconds, and that 13 seconds is not acceptable for an accurate reading. A review of S8’s personnel file revealed that he/she was last evaluated and educated on 07/15/25 for the routine chlorine testing procedure. Facility policy titled, “Total Chlorine Test Using RPC Ultra Low Total Chlorine Test Strips,” revised October 2023 stated, “... 5. After the 20 second wait period, immediately compare the strip color to the K100-0118 color chart to determine the Total Chlorine level in the sample ...” A review of the RPC Ultra-Low Total Chlorine Test Strips instructions for use stated, “... Test Procedure ... 2) Remove one test strip from its foil package and swish it in the sample for the amount of time indicated according to the following temperature ranges: ... 3) Remove the strip and shake once, briskly, to remove excess water. 4) Wait 20 seconds for the test strip color to develop. ... 5) After the 20 second wait period, immediately compare the strip color to the K100-0118 or K100-0118F color chart to determine the Total Chlorine level in the sample. ...” N.J.A.C. 8:43A-24.10(a)(3)”

“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: 44833 Based on one of one observation of the initiation of hemodialysis through a Central Venous Catheter (CVC, a type of access used for hemodialysis), staff interview and a review of facility documents, it was determined that the facility failed to ensure patient’s rights to privacy. Findings include: On 11/24/25 at 10:35 AM in Station 8, Staff (S)10 began the procedure of dressing change and cleaning of the CVC exit site on a patient’s left chest wall CVC. During the procedure, the curtain was not fully drawn on the right side of the patient. This created an opening of approximately three feet. The patient’s care being provided was visible to the treatment floor’s main entrance door as well as to an unoccupied treatment Station 5. During an interview on 11/26/25 at 9:45 AM, S2 stated that the curtains should be fully closed around the patient’s station when providing CVC care to conserve patient privacy. Facility policy titled, “Patient Rights,” revised April 2025, stated, “... Your Rights As A Patient ... 6. The right to privacy and confidentiality in all aspects of treatment. The dialysis facility will make accommodations to provide for patient privacy when patients are examined or body exposure is required, for example privacy screens or curtains ...” N.J.A.C 8:43A-16.2(a)10”

“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 two of two observations of the initiation of hemodialysis through an arteriovenous fistula/graft (AVF/G, a type of vascular access used for hemodialysis), staff interview, and a review of facility documents, it was determined that the facility failed to ensure that: 1) staff perform skin disinfection of the access site prior to initiating the dialysis treatment and; 2) staff maintain aseptic technique while initiating the dialysis treatment in accordance with facility policy. Findings include: 1. On 11/24/25 at 10:35 AM, in Station 4, Staff (S)8, initiated dialysis through a patient’s right lower arm AVF. S8 cleansed the AVF with a 70% isopropyl alcohol pad in a circular motion for 10 seconds then cleansed with a second 70% isopropyl alcohol pad in a circular for 10 seconds. After waiting 15 seconds, S8 cannulated (to insert a cannula into a bodily cavity, duct, or vessel, as for the drainage of fluid or the administration of medication) the arterial needle and then the venous needle using a fistula needle. This was 40 seconds less than required by facility policy and did not use four alcohol prep pads per site. During an interview at 10:59 AM, S8 stated the patient is sensitive to betadine and only alcohol is used to cleaned the access site. S8 stated two alcohol prep pads are to be used for 60 seconds when cleaning the access. A review of S8’s training and education records indicated that an “Annual Procedural Skills Validation Checklist” that included training in AVF/AVG cannulation was successfully completed on 1/20/25. Facility policy titled, “AV Fistula Or Graft Cannulation With Nipro or Medisystems Safety Needles (SFN) And Administration Of Heparin Loading Dose,” revised April 2025, stated, “... Notes: ... Use Isopropyl Alcohol 70% as the single antiseptic ONLY when the patient has documented allergies to other skin antiseptics ... Skin Antiseptic Isopropyl Alcohol 70% Effective Volume At least 4 prep pads per site Effective Contact time 60 seconds ... Procedure ... 12. For patients who have a documented allergy to povidone iodine or ExSept Plus, necessitating alcohol alone, apply alcohol using a circular rubbing motion, center out for 60 seconds and allow to dry for 15 seconds prior to cannulation ...” 44833 2. On 11/24/25 at 10:45 AM, in Station 8, the surveyor observed S8 initiating a patient’s hemodialysis treatment using the patient’s left upper arm dialysis access. S8 cleaned and disinfected the patient’s vascular access in accordance with facility policy. S8 then palpated (examined by touch) the patient’s vascular access and then removed his/her gloves. Next, S8 performed hand hygiene before he/she left the station and obtained cannulation supplies. Upon returning to Station 8, he/she performed hand hygiene and put on clean gloves. S8 used a stethoscope to listen to the patient’s vascular access by placing the bell of the stethoscope directly onto the patient’s cleaned and disinfected vascular access. S8 then returned the stethoscope to the IV pole and placed a tourniquet onto the clothed portion of the patient’s left upper arm, making contact with the clothing. With the same gloves on, S8 then palpated the vascular access again before inserting a fistula needle into the vascular access. S8 did not re-clean the patient’s vascular access after potential contamination of the vascular access site and before he/she inserted the needle. During an interview at 11:14 AM, S8 stated that the proper procedure is to listen and feel a patient’s dialysis access before scrubbing and prepping the site for cannulation. S8 further stated that gloves are to be changed once they are used to touch an unclean area such as a patient’s clothing or personal belongings. On 11/26/25 at 9:45 AM, the surveyor interviewed S2 who stated that once a patient’s arm or access site had been disinfected using alcohol prep pads and iodine, there should have been no more touching or listening to the prepped area to maintain infection control. S2 stated that using a stethoscope to listen and touching a patients clothing and then the prepped access site prior to cannulation is unacceptable. A review of S8’s training and education records indicated an “Annual Skills Checklist” education was successfully completed for “Vascular Access and AVF/AVG Cannulation” and dated 1/21/25. Facility policy titled, “AV Fistula Or Graft Cannulation With Nipro or Medisystems Safety Needles (SFN) And Administration Of Heparin Loading Dose,” revised April 2025, stated, “... Notes: ... Use Isopropyl Alcohol 70% as the single antiseptic ONLY when the patient has documented allergies to other skin antiseptics ... Skin Antiseptic Isopropyl Alcohol 70% Effective Volume At least 4 prep pads per site Effective Contact time 60 seconds ... Procedure ... 5. Perform inspection, auscultation (listening) and palpation on entire length of access. Determine presence of bruit (swishing sound) and thrill (buzzing sensation/vibration) ... 12. For patients who have a documented allergy to povidone iodine or ExSept Plus, necessitating alcohol alone, apply alcohol using a circular rubbing motion, center out for 60 seconds and allow to dry for 15 seconds prior to cannulation ... 13. Do not palate insertion site once area has been prepped. Once the access site has been prepped, touching it will contaminate the site and possibly allow for the introduction of bacteria during cannulation ...” 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: 39228 Based on observation, staff interview, medical record review, and review of facility documents, it was determined that the Medical Director failed to ensure that: 1) all medical records contain the required documentation by the Registered Nurse (RN) for when a prescribed dialysis treatment time is not met in accordance with facility policy and procedure for two of seven medical records reviewed [Patient (P)6 and P9]; 2) medications, needles and syringes are kept in locked storage areas in one of one observation and; 3) the facility medication administration policy for one of one heparin medication administration observed is implemented. Findings include: 1. A review of P6’s medical record revealed the following: The “Orders” section stated, “In-Center Hemodialysis Treatment ... Start Date 11/04/2025 ... Frequency/TX [treatment] Time Three times a week 4 hr [hour] 0 min [minute] (240 min) ...” The “Treatment Nurse Assessment” portion of the “Treatment Details Report” dated 11/13/25 stated, “... Prescribed Treatment Duration ... 4h 00m (240 min) Actual Treatment Duration 3h 05m (185 min) ...” P6’s dialysis treatment on 11/13/25 was shortened by 55 minutes. The medical record lacked documentation by the RN that the patient’s Nephrologist was notified, a description of the follow-up medical orders provided by the patient’s attending Nephrologist (if any), a description of all other interventions planned to address the shortened treatment, including recommendations to the patient, and a completed copy of the Early Termination of Treatment Against Medical Advice form for this treatment. A review of P9’s medical record revealed the following: The “Orders” section stated, “In-Center Hemodialysis Treatment ... Start Date 10/01/2025 ... Frequency/TX Time Three times a week 3 hr 15 min (195 min) ...” The “Treatment Nurse Assessment” portion of the “Treatment Details Report” dated 10/14/25 stated, “... Prescribed Treatment Duration ... 3h 15m (195 min) Actual Treatment Duration 2h 25m (145 min) ...” P9’s dialysis treatment on 10/14/25 was shortened by 50 minutes. The medical record lacked documentation by the RN of a completed copy of the Early Termination of Treatment Against Medical Advice form for this treatment. The “Orders” section stated, “In-Center Hemodialysis Treatment ... Start Date 10/17/2025 ... Frequency/TX Time Three times a week 3 hr 15 min (195 min) ...” The “Treatment Nurse Assessment” portion of the “Treatment Details Report” dated 10/17/25 stated, “... Prescribed Treatment Duration ... 3h 15m (195 min) Actual Treatment Duration 2h 17m (137 min) ...” P9’s dialysis treatment on 10/17/25 was shortened by 58 minutes. The medical record lacked documentation by the RN that the patient’s Nephrologist was notified, a description of the follow-up medical orders provided by the patient’s attending Nephrologist (if any), and a description of all other interventions planned to address the shortened treatment, including recommendations to the patient. The “Orders” section stated, “In-Center Hemodialysis Treatment ... Start Date 10/29/2025 ... Frequency/TX Time Three times a week 3 hr 15 min (195 min) ...” The “Treatment Nurse Assessment” portion of the “Treatment Details Report” dated 10/29/25 stated, “... Prescribed Treatment Duration ... 3h 15m (195 min) Actual Treatment Duration 2h 5m (125 min) ...” P9’s dialysis treatment on 10/29/25 was shortened by one hour and 10 minutes. The medical record lacked documentation by the RN that the patient’s Nephrologist was notified, a description of the follow-up medical orders provided by the patient’s attending Nephrologist (if any), a description of all other interventions planned to address the shortened treatment, including recommendations to the patient, and a completed copy of the Early Termination of Treatment Against Medical Advice form for this treatment. The “Treatment Nurse Assessment” portion of the “Treatment Details Report” dated 11/10/25 stated, “... Prescribed Treatment Duration ... 3h 15m (195 min) Actual Treatment Duration 2h 16m (136 min) ...” P9’s dialysis treatment on 11/10/25 was shortened by 59 minutes. The medical record lacked documentation by the RN that the patient’s Nephrologist was notified, a description of the follow-up medical orders provided by the patient’s attending Nephrologist (if any), a description of all other interventions planned to address the shortened treatment, including recommendations to the patient, and a completed copy of the Early Termination of Treatment Against Medical Advice form for this treatment. The “Orders” section stated, “In-Center Hemodialysis Treatment ... Start Date 11/12/2025 ... Frequency/TX Time Three times a week 3 hr 0min (180 min) ...” The “Treatment Nurse Assessment” portion of the “Treatment Details Report” dated 11/12/25 stated, “... Prescribed Treatment Duration ... 3h 00m (180 min) Actual Treatment Duration 2h 00m (120 min) ...” P9’s dialysis treatment on 11/12/25 was shortened by 60 minutes. The medical record lacked documentation by the RN that the patient’s Nephrologist was notified, a description of the follow-up medical orders provided by the patient’s attending Nephrologist (if any), a description of all other interventions planned to address the shortened treatment, including recommendations to the patient, and a completed copy of the Early Termination of Treatment Against Medical Advice form for this treatment. On 11/25/25 at 11:30 AM, the above findings were reviewed with Staff (S)2 and S6. S2 confirmed that the documentation by the RN on the above referenced dates was massing. Facility policy titled, “Prescribed Treatment Time Not Met”, revision date: October 2025, stated, “... Prescribed Treatment Time Not Met 1. If shortened/early termination of dialysis treatment exceeds 30 or more minutes, the RN will notify the patient’s attending nephrologist to discuss the appropriate intervention (if any), including what additional medical orders may be necessary to address the patient’s specific needs. ... 3. If a patient’s treatment is shortened/early terminated, the RN will document the event in the patient’s electronic health record. Documentation will include ... Whether the patient’s nephrologist was notified, A description of the follow-up medical orders provided by the patient’s attending nephrologist (if any), A description of all other interventions planned to address the shortened treatment, including recommendations to the patient 4. A completed copy of the Early Termination of Treatment Against Medical Advice form will be kept in the patient’s health record. ...” N.J.A.C. 8:43A-24.4(a) 2. On 11/24/25, during a tour of the Hemodialysis Treatment Area, the following was revealed: At 9:54 AM, the chairside table of the hemodialysis chair in Station 8, which was unoccupied by a patient, had two pre-filled syringes with the needles attached and were labeled “Heparin,” two 10 cc (cubic centimeter) syringes that did not contain any liquid, and two pre-filled 10 cc syringes that were labeled “Normal Saline.” The medications, needles and syringes were left unattended in the station until 10:26 AM, when a patient and S10 entered the station. At 10:26 AM, an interview was conducted with S10 who stated that one of the two pre-filled syringes with the needles attached contained 2,500 units of Heparin and the other contained 2,000 units of Heparin and were prepared by the Registered Nurse within the last hour. S10 then further stated that all medications, needles and syringes should be stored in a locked and secured area until use. Facility policy titled, “Medication Policy,” revision date October 2023 stated, “... Policy ... 23. Medications and needle/syringe storage are done in accordance with state regulations. ...” N.J.A.C. 8:43A-9.5(a) 48966 3. On 11/26/25 at 10:35 AM, in Station 4, S8 initiated hemodialysis through a right arm arteriovenous fistula (AVF). The following was observed: At 10:43 AM, S7 attached a pre-drawn heparin syringe to the venous access line and slowly injected the heparin with a back-and-forth motion. After waiting five minutes, S8 then initiated the hemodialysis treatment. When asked to see the label affixed to the heparin syringe, the time prepared line indicated 8:20 AM. This was one hour and 23 minutes beyond the time period permitted from preparation until administration according to the facility policy. During an interview on 11/26/25 at 10:45 AM, S7 confirmed that the pre-drawn heparin syringe was only good for one hour after preparation. Facility policy titled, “Medication Policy,” revised October 2023 stated, “... Policy ... 18. All syringes prepared from a single use vials/ampoules (without preservatives) or multidose vials should be prepared and administered within a four(4) hour [within one (1) hour for States of New jersey and South Carolina] period, unless there is a specific testing and documents on file which extends dating ...” N.J.A.C. 8:43A-9.3(a)”