Davita Plainsboro Dialysis

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 44833 Based on observation, review of facility documents, and interview with staff, it was determined that the facility failed to ensure that: 1) fans are not used on the treatment floor (V0111); 2) hand hygiene is performed to prevent cross contamination (V0113); 3) clean items are not stored in designated dirty areas (V0117); 4) all visible blood-contaminated surfaces are cleaned and disinfected with the appropriate bleach solution and all surfaces at the dialysis station are cleaned and disinfected after patient use (V0122); 5) proper exit site care and initiation of hemodialysis using a Central Venous Catheter (CVC, a type of access used for hemodialysis) (V0147); and 6) proper discontinuation of hemodialysis through a CVC (V0147). Cross Reference: 494.30 - IC - Sanitary Environment 494.30(a)(1) - IC - Wear Gloves/Hand Hygiene 494.30(a)(1)(i) - IC- Clean/Dirty; Med Prep Area; No Common Carts 494.30(a)(4)(ii) - IC- Disinfect Surfaces/Equip/Written Protocol 494.30(a)(2) - IC- Staff Education-Catheters/Catheter Care”

“CFC-PHYSICAL ENVIRONMENT CFR(s): 494.60 This Condition is not met as evidenced by: 39223 Based on observation, review of facility documents, and interview with staff, it was determined that the facility failed to ensure that: 1) the Reverse Osmosis Room walls and flooring are maintained (V0402); 2) an eyewash station and emergency shower are readily available to staff who handle chemicals in one of one Reverse Osmosis Room (V0402); and 3) all equipment, including water treatment equipment, is maintained for one of one Reverse Osmosis Room (V0403). Cross Reference: 494.60(a) - PE-Building-construct/maintain for safety 494.60(b) - PE- Equipment maintenance - manufacturer’s DFU [directions for use]”

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 49828 Based on one of one observation of an operating fan on the Hemodialysis Treatment Floor and review of facility policy, it was determined that the facility failed to ensure that fans are not used on the Treatment Floor. Findings include: On 12/17/25 at 9:30 AM, during a tour of the Hemodialysis Treatment Floor, a fan was observed plugged into the wall to the right of Station 7. The fan was on and operating and was observed blowing air toward Station 7, and Station 2 which were both occupied by patients. Facility policy titled, “Infection Control for Dialysis Facilities,” revised April 2023 stated, “... Facility Hygiene ... 20. Use of battery operated, electrical or ceiling mounted fans are not allowed in patient treatment areas. ...” N.J.A.C. 8:43A-24.8(b)”

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 48966 Based on two of four staff observed for hand hygiene, staff interview, and a review of facility documents, it was determined that the facility failed to ensure that hand hygiene is performed to prevent cross contamination. Findings include: On 12/17/25 at 11:43 AM in Station 5, during an observation of performing Central Venous Catheter (CVC, a type of access used for hemodialysis) exit site care, Staff (S)5, with gloved hands, cleaned the exit site with a 2% Chlorhexidine swab for five seconds. S5 removed his/her gloves and without the benefit of hand hygiene first, donned (put on) a new pair of gloves. S5 placed a sterile 2x2 gauze over the CVC exit site and applied paper tape to the edges of the 2x2. S5 removed his/her gloves and donned a new pair of gloves without performing hand hygiene first. During an interview on 12/17/25 at 12:03 PM, S5 confirmed he/she did not perform hand hygiene after removing gloves and before donning new gloves during CVC exit site care. S5 stated when removing gloves, he/she should perform hand hygiene before putting new gloves on. 44833 On 12/17/25 at 11:37 AM, S3 was observed crossing past the privacy divider curtain from the patient occupied Station 3 to the patient occupied Station 4 while wearing the same gloves. S3 proceeded to connect the pressure monitoring lines (transducer connections) of the dialysis treatment tubes (extracorporeal lines) to the treatment machine and the dialysate lines from the machine to the dialyzer. While still wearing the same gloves, S3 left Station 4 and went to the medication preparation area and proceeded to touch each pre-drawn heparin (medication used to treat clotting) syringe. S3 then brought a package of supplies for CVC treatment initiation, and while still wearing the same gloves, opened the supplies including two sterile 10 cc (cubic centimeter) syringes and two 10 cc prefilled normal saline syringes. S3 then while still wearing the same gloves, obtained a paper cup and a pH (potential of hydrogen) test strip from the dirty sink area before he/she returned to Station 4 and tested a sample of the dialysate solution. During an interview with S3 at 12:00 PM, he/she stated that there should have been glove changes when going from one treatment station to another, and that glove changes and hand hygiene should have been performed after coming in contact with the dialysis equipment and before touching medication and dialysis supplies. S3 stated “I should bring more gloves to the patient station to change it more.” Facility policy titled, “Infection Control For Dialysis Facilities,”Revision Date: April 2023, stated, “... 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, c. after contamination with blood or other infectious material, d. after patient and dialysis delivery system contact, e. after interacting with wall boxes (i.e., plugging/unplugging acid/bicarb [bicarbonate] lines form dialysis machine, changing acid types, when exchanging a dialysis machine) f. between patients even if the contact is casual, g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse, ...” 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: 44833 Based on observation, staff interview, and review of facility documents, it was determined that the facility failed to ensure that clean items are not stored in designated dirty areas. Findings include: During a tour of the Hemodialysis Treatment Area on 12/17/25 at 11:05 AM, the following was observed: In front of Station 4 was a sink area with two storage cabinets above labeled “dirty sink” with a large sharps container placed on the floor, in an open area with no cabinet, underneath the sink. Alongside the sink, against the wall and set on the floor, was a plastic, three drawer storage bin in which two drawers contained more than 20 clean scissor clamps, and placed on top of the storage bin was a plastic basket with no lid and contained 10 clean vascular access clamps. Alongside this plastic storage bin was a small sharps container also set on the floor and in contact with the left side of the clean storage bin. To the right of the dirty sink was a clean supply, wheeled cart which was in contact with the dirty sink area. The clean supply cart contained three unopened packs of disposable towels and one opened pack of disposable towels which was more than half used, and a plastic bin labeled 1:100 bleach solution (one part bleach to 100 parts water) used for cleaning and disinfecting on the top rack. The bottom rack of this cart had a one-gallon container of acid solution which did not appear to be opened, and two plastic bins, one containing six clean bicarbonate wands and the other contained four clean acid wands. The above findings were confirmed at the time of discovery with Staff (S)5, who stated clean supplies should not be stored in proximity of or in contact with the floor or dirty areas. 39223 During a tour of the Soiled Utility Room on 12/18/25 at 10:10 AM, the following was revealed: Over 150 green top blood collection tubes, over 200 purple top blood collection tubes, over 300 gold top blood collection tubes, and nine boxes containing four acid concentrate jugs each were stored within this area. These supplies were unused and stored, awaiting patient use. Also contained within the room was a dirty sink and hopper. This created a mixed environment of clean storage within a designated dirty room. The above findings were confirmed with S2 and S8 at the time of discovery. Facility policy titled, “Infection Control for Dialysis Facilities,” revised April 2023, stated, “... FACILITY HYGIENE 16. 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. ...” N.J.A.C. 8:43A-24.8(d)”

“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: 48966 Based on two of two observations of the cleaning and disinfection of hemodialysis stations, staff interviews, and a review of facility documents, it was determined that the facility failed to ensure that: 1) all visible blood-contaminated surfaces are cleaned and disinfected with the appropriate bleach solution and; 2) all surfaces at the dialysis station are cleaned and disinfected after patient use. Findings include: 1. On 12/17/25 at 9:58 AM, in Station 6, Staff (S)6 was observed discontinuing hemodialysis through an arteriovenous fistula (AVF, type of access used for dialysis). S6 removed the venous (top) needle and placed a gauze pad at the site. The gauze filled with blood and the blood seeped down the patient’s arm, under the chair, and onto the floor. S6 obtained a cloth, dipped it into the 1:100 bleach solution (one part bleach to 100 parts water), and cleaned the blood on the floor. When asked about the bleach solution strength, S6 stated he/she used a 1:100 bleach soaked cloth initially because the 1:10 bleach solution (one part bleach to 10 parts water) had not been prepared earlier in the morning. S6 then prepared the correct 1:10 solution and cleaned the floor again with a 1:10 bleach soaked cloth. This was not in accordance with facility policy, which required staff to clean visible blood with a 1:10 bleach soaked cloth and clean the area a second time with another 1:10 bleach soaked cloth. On 12/17/25 at 10:55 AM, in Station 6, S6 was observed cleaning the visible blood on the back and side of the hemodialysis chair with a 1:10 bleach soaked cloth then went over the chair a second time with a 1:100 bleach soaked cloth. This was not in accordance with the facility policy, which required staff to clean visible blood with a 1:10 bleach soaked cloth and clean the area a second time with another 1:10 bleach soaked cloth. During an interview on 12/17/25 at 11:11 AM, S6 stated for all visible blood on floors and surfaces to use 1:10 bleach solution first, followed by 1:100 bleach solution. During an interview on 12/18/25 at 1:00 PM, S2 stated for all visible blood spills to use 1:10 bleach solution first followed by 1:100 bleach solution. During an interview on 12/18/25 at 1:02 PM, S8 stated visible blood on the surfaces or equipment to use 1:10 bleach solution first followed by 1:10 bleach solution a second time. A review of S6’s personnel file indicated that S6 successfully completed the “NJ Specific Infection Control For Dialysis Facilities” which included cleaning and disinfection of equipment and work surfaces on 03/17/25. 49828 2. On 12/17/25 at 9:55 AM in Station 2, S5 and S6, were observed cleaning the station. S5 wiped the blood pressure (BP) cuff that was lying on the treatment chair with a bleach-soaked cloth and placed it in the basket located on the left side of the hemodialysis machine that had not been cleaned. The basket contained a BP cuff and a bottle of hand sanitizer. S5 used a new bleach-soaked cloth to wipe the treatment chair. S5 then left the station. S6 removed the prime bucket from the right side of the machine, took it to the dirty sink where he/she dumped its contents and used a bleach-soaked cloth to clean it. S6 then returned it to the station and placed it back onto the right side of the machine which had not been cleaned and left the station At 10:16 AM, S5 returned to Station 2 and began cleaning the hemodialysis machine from the top. He/she wiped down the front of the machine with a bleach-soaked cloth. S5 did not wipe the left or right side of the hemodialysis machine or reclean the BP cuff and prime bucket that were cleaned and placed back onto the dirty machine in the prior observation. During an interview at 10:23 AM, the observation was reviewed with S5 who confirmed he/she did not clean left or right side of the machine and confirmed the BP cuff and prime bucket were cleaned but placed on the dirty machine and not recleaned. Following the interview S5 returned to Station 2 with new bleach-soaked cloth and cleaned the left and right sides of the machine and cleaned the BP cuff and prime bucket. A review of S5 and S6’s personnel files indicated that both successfully completed the “NJ Specific Infection Control For Dialysis Facilities,” which included cleaning and disinfection of equipment and work surfaces, in March 2025. Facility policy titled, “Infection Control for Dialysis Facilities,” revised April 2023 stated, “... Disinfection 12. Cleaning and or disinfection of equipment or work surfaces will be performed as soon as possible following exposure to blood ... a. Prior to routing disinfection remove all visible blood ... i. For visible blood or gross blood spills, a 1:10 (one to ten) bleach solution must be utilized. ii. After all visible blood is cleaned with the 1:10 (one to ten) bleach solution, teammates are to use a new disposable towel soaked with 1:10 (one to ten) bleach solution and clean the area a second time. iii. Cleaning of visible blood should be performed when first observed ... 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 patient or their belongings (e.g., dialysis chair, tray tables, blood pressure cuffs) and frequently contacted by healthcare personnel (e.g., control panel; top, front and sides of dialysis machine; touchscreens; 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 observations, staff interviews, and a review of facility documents, it was determined that the facility failed to ensure that: 1) the exit site care and initiation of hemodialysis using a Central Venous Catheter (CVC, a type of access used for hemodialysis) in two of two observations is performed in accordance with facility policy and; 2) the discontinuation of hemodialysis through a CVC in one of one observation is performed in accordance with the facility policy. Findings include: 1. On 12/17/25 at 11:43 AM, in Station 5, Staff(S)5, was observed initiating hemodialysis through a right CVC. S5 placed multiple clean gloves, two 10 ml (milliliter) syringes, two 10 ml pre-filled saline syringes, and eight to 10 alcohol preparation (prep) pads on the clean, disposable pad on the right recliner table. During CVC exit site care, S5 cleansed the exit site with a prepackaged 2% Chlorhexidine swab for 5 seconds and then cleansed with a 70% alcohol prep pad for two seconds. This was 25 seconds less than required by facility policy. After cleaning the arterial (red) and venous (blue) limbs with an alcohol prep pad, S5 proceeded to remove the arterial end cap and wiped the sides, threads and end of hub with an alcohol prep pad for 13 seconds. This was two seconds less than required by facility policy. S5 allowed the clean catheter limb to touch the 4 x 4 gauze underneath before the 10 ml syringe was attached. S5 aspirated approximately five mls of blood into the syringe. S5 removed the syringe from the arterial limb, and placed it onto the clean, disposable pad, next to the pile of clean gloves, potentially contaminating the clean supplies. S5 then flushed with the pre-filled normal saline syringe. S5 removed the venous end cap and wiped the sides, threads and end of hub with an alcohol prep pad for 10 seconds. This was five seconds less than required by facility policy. S5 removed the syringe from the venous limb, and placed it onto the clean, disposable pad, next to the pile of clean gloves, potentially contaminating the clean supplies. S5 then flushed with the pre-filled normal saline syringe. After instilling the Heparin loading dose into the venous limb, S5 attached the blood lines to the CVC limbs without performing a 15 second alcohol wipe of the CVC limbs. During an interview on 12/17/25 at 12:03 PM, S5 stated to use a Chlorhexidine swab for 15-30 seconds on the CVC exit site. S5 confirmed placing the used blood filled syringes next to clean supplies and gloves and indicated to dispose of them in the sharps container. Also, a 15 second hub scrub should be performed before connecting the bloodlines to the CVC limbs. 44833 On 12/17/5 at 11:44 AM, in Station 4, S3 was observed initiating a hemodialysis treatment using a patient’s CVC. The patient had a surgical mask on below his/her nose, only covering his/her mouth during the entire process of CVC care. After performing CVC exit site care, S3 used two stacked alcohol prep pads to scrub the arterial limb threads for six seconds (nine seconds less than required by facility policy) and then venous limb threads for 10 seconds (five seconds less than required by facility policy) using two new stacked alcohol prep pads. S3 then proceeded to connect the dialysis treatment lines to the patient’s CVC and initiated treatment. 49828 2. On 12/17/25 at 9:40 AM, in Station 2, S5, discontinued hemodialysis through a right chest wall CVC and the following was observed: S5 disconnected the arterial blood line from CVC limb and attached a 10 ml normal saline flush, flushed, and clamped the limb. S5 then rinsed back the patient’s blood. S5 then changed his/her gloves, performed hand hygiene and put on new gloves. S5 disconnected the venous blood line and connected a 10 ml normal saline flush, flushed, then clamped the limb. S5 then disconnected the saline flush from the arterial limb and connected a syringe with heparin (blood thinning medication) and instilled the medication. S5 repeated this process on the venous limb. Upon removal of the heparin syringe from the arterial limb, S5 used one alcohol preparation (prep) pad and scrubbed the CVC hub for eight seconds, this was seven seconds less than required by facility policy and immediately placed a new catheter cap on the hub. S5 then removed the heparin syringe from the venous limb and used a new alcohol prep pad and scrubbed the CVC hub for three seconds, this was 12 seconds less than required by facility policy and immediately place a new catheter cap on the hub. S5 did not allow the antiseptic to dry on either hub prior to placing the new catheter caps as required by facility policy. During an interview at 9:51 AM, S5 stated he/she is required to scrub the CVC hubs for 15 seconds and that he/she does not think that he/she scrubbed long enough. Facility policy titled, “Central Venous Catheter (CVC) With Clearguard HD Antimicrobial End Caps Procedure,” Revision date: April 2025, stated, “1. ... Put on PPE [personal protective equipment] and provide a mask to the patient Teammate and patient will wear masks covering the nose and mouth during this procedure. ... Notes: Perform a 15 second hub scrub of the CVC during process of connecting or disconnecting from the blood lines ... Procedure ... 8. ... clean exit site with 2% Chlorhexidine Gluconate 70% Isopropyl Alcohol swab for a minimum of 30 seconds, ... 16. ... One at a time, disinfect each CVC hub with a new alcohol prep pad. Scrub each CVC hub for 15 seconds including the sides, threads and end of the hub thoroughly ... 17. Attach a sterile 10 ml syringes to the arterial and venous limbs. 18. ... Aspirate an amount greater than the catheter limb lumen, generally about 5 ml from each limb. ... 21. Aseptically discard syringe containing indwelling solution ... Upon Completion of Dialysis ... 34. Remove syringes and disinfect the CVC hubs with a new alcohol prep pad for each CVC hub. Scrub the sides, threads and end of hub thoroughly with friction for 15 seconds. ... Hold catheter until the antiseptic has dried ...” 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 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 12/17/25 at 1:15 PM, Staff (S)6 performed a test for total chlorine levels in the Water Treatment Room. S6 obtained a sample of water and, after filling and dumping the cup with water three times, S6 dipped a RPC E-Z Chek Sensitive Total Chlorine Test Strip into the water sample and swished it back and forth for 60 seconds. S6 then removed the strip from the water and immediately compared the test strip color to the color chart to determine the level of chlorine. S6 did not wait 20 seconds to compare the strip to the color chart. During an interview immediately after the observation, S9 stated that the color should be read immediately after removing the test strip from the water sample. A review of S6’s personnel file revealed that he/she successfully completed “Total Chlorine/Chloramine Testing” education on 11/12/25. A review of facility policy titled, “Total Chlorine Test Using RPC Ultra Low Total Chlorine Test Strip,” revised October 2023, stated, “... Procedure ... 3. Remove the strip and shake once, briskly, to remove excess water. 4. Wait 20 seconds for the test strip color to develop. ... 4. 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. ...” N.J.A.C. 8:43A-24.10(a)(3)”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 39223 Based on observation, staff interview, and review of facility documents, it was determined that the facility failed to ensure that: 1) the Reverse Osmosis Room walls and floor are maintained; and 2) an eyewash station and emergency shower are readily available to staff who handle chemicals in one of one Reverse Osmosis Room. Findings include: 1. On 12/18/25 starting at 10:40 AM, a tour of the Reverse Osmosis Room revealed the following: The flooring surrounding the Acid Mixer and Acid Solution Storage Tank had surface gouges and in the areas where the paint had worn off, exposing the base layer, which was crumbling. The paint on the wall surfaces were bubbled and peeled off, exposing the porous base layer that was separating from the base of the wall in the following areas: behind the booster pump and brine tank, behind the primary and secondary carbon tanks, underneath the First Water Out outlet, the corner behind Pump 1 and Pump 2, and the lower corner behind the Water Storage Tank. Black scuffing staining was evident on the wall behind the entry door. A moderate amount of white precipitate was present on the drainage grate located on the floor between the Bicarb (Bicarbonate) Mixer and the Acid Solution Storage Tank. Dry, rust-colored flakes were present on the edges of the drainage grate located on the floor, adjacent to the primary carbon tank. The drainage grate appeared to be crumbling and several small fragments had broken off the grate. Dry, rust-colored flaking was present on the top of metal plating which secured the ultrafilters to the wall. The above findings were reviewed with Staff (S)4 at 10:50 AM who stated that the areas were in need of repair. During an interview on 12/18/25 at 11:50 PM, S10 stated that the physical environment of the facility has been discussed with the “higher ups” by telephone, texting, emails and leadership meetings, and described the process, “It is slow going.” During an interview on 12/18/25 at 12:40 PM, S2 stated that repairs to the facility’s building had been an on-going issue. Communication had been conducted with higher levels of leadership and, “they have promised that it will be done in the first quarter.” Email documentation was provided for review, which included a quotation for work to be completed, however there lacked documented evidence that the work for repairs was approved for completion. 51040 During tour of the Hemodialysis Treatment Floor on 12/17/25, the following was observed: At 10:55 AM, the ceiling support frame and tiles, located above the wall cabinets behind the nurses station, were hanging down. At 11:00 AM, the wall surface had black marks on the surface and peeling paint behind the patient treatment chair at Station 3. At 11:03 AM, the wall surface had black marks on the surface and peeling paint behind the patient treatment chair at Station 5. At 11:09 AM, in the Isolation Room, 11 of 24 white ceiling tiles were stained with a brown colored substance. These findings were confirmed at the time of discovery by S3. N.J.A.C. 8:43A-17.3(a) N.J.A.C. 8:43A-17.3(j) N.J.A.C. 8:43A-24.15(c) 2. During a tour of the Reverse Osmosis (RO) Room starting on 12/17/25 at 10:34 AM, in the presence of S4, there was no emergency eye wash station located in the RO room, where the staff handle hazardous chemicals. Additionally, the emergency drench shower was obstructed by an equipment cart, preventing easy access to the drench shower. Emergency shower signage was obstructed by a job pocket that was hanging from the wall. This obstructed the view of the sign indicating the location of the designated drench shower unit. During an interview at 10:40 AM, when asked where the closest eye wash station was located, S4 stated “the eye wash is located at the entry of the treatment floor.” This location was approximately 30 feet from the RO room, with three doors in the path of any staff member whom would require to use the eye wash station. Reference: ANSI/ISEA (American National Standards Institute/International Safety Equipment Association) Z358.1- 2014. 5.4.2 (eye wash) Be in accessible locations that require no more than 10 seconds to reach. The eyewash shall be located on the same level as the hazard and the path of travel shall be free of obstructions that may inhibit its immediate use. Reference: ANSI/ISEA Z358.1-2014, 4.5.2 (emergency shower) Be in accessible locations that require no more than 10 seconds to reach. The emergency shower shall be located on the same level as the hazard and the path of travel shall be free of obstructions that may inhibit its immediate use. N.J.A.C. 8:43A-19.2”

“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 and staff interview, it was determined that the facility failed to ensure that all equipment, including water treatment equipment, is maintained for one of one Reverse Osmosis (RO) Room. Findings include: During a tour of the RO Room on 12/18/25 at 10:40 AM, a large amount of white precipitate and dust was observed covering the motor located adjacent to the Bicarb (bicarbonate) mixer, which extended down onto the floor. White precipitate was also present on piping located behind the Bicarb mixer tanks. During an interview at the time of discovery, Staff (S)3 confirmed the above findings.”

“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: 48966 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 review of facility documents, it was determined that the facility failed to ensure each patient’s right to privacy. Findings include: On 12/17/25 at 11:43 AM in Station 5, an initiation of hemodialysis via a right chest CVC was performed by Staff (S)5. In Station 5, the curtain on the left side was not drawn fully in the station to ensure patient privacy in front of the patient. The curtain did not fully extend in the front of the station, leaving a two-foot opening. The patient’s exposed right chest was visible to any patients or staff members that walked by the station. During an interview at 12:03 PM, S3 confirmed the curtains should be fully around the patient sitting in Station 5 during initiation of dialysis. Facility policy titled, “Patient’s Rights,” Revision Date: April 2025, stated, “... 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: 52927 Based on one of two observations of the cannulation (the act of inserting a needle) of a vascular access, staff interview, and review of facility policy, it was determined that the facility failed to ensure that the staff perform skin disinfection of the access site in accordance with facility policy prior to cannulation of the vascular site. Findings include: On 12/17/25 at 11:40 AM, in Station 9, Staff (S)7 initiated dialysis through an arteriovenous graft (AVG, a type of access used in hemodialysis). S7 cleaned the first site (arterial) with one alcohol preparation (prep) pad in a circular motion for 42 seconds. This was 18 seconds less than required by facility policy and S7 did not use at least four alcohol pads for the site. S7 continued to clean the second site (venous) with one alcohol prep pads in a circular motion for 20 seconds. This was 40 seconds less than required by facility policy and S7 did not use at least four alcohol prep pads for the site. During an interview at 12:02 PM, S7 stated that each site is to be cleaned with one alcohol prep pad for 30 seconds. Facility policy titled, “AV Fistula or Graft Cannulation with Nipro or Medisystems Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose,” revised April 2025, stated, “... Skin Antiseptic ... Isopropyl Alcohol 70% ... Effective Volume ... At least 4 prep pads per site ... Effective Contact Time ... 60 seconds ... Air Drying Time ... 15 seconds ...” N.J.A.C. 8:43A-24.8(b)”

“PQ-STAFF LIC AS REQ/QUAL/DEMO COMPETENCY CFR(s): 494.140 All dialysis facility staff must meet the applicable scope of practice board and licensure requirements in effect in the State in which they are employed. The dialysis facility’s staff (employee or contractor) must meet the personnel qualifications and demonstrated competencies necessary to serve collectively the comprehensive needs of the patients. The dialysis facility’s staff must have the ability to demonstrate and sustain the skills needed to perform the specific duties of their positions. This Standard is not met as evidenced by: 52927 Based on one of two Medical Director credential and competency files reviewed, and staff interview, it was determined that the facility failed to ensure that the alternate Medical Director meets the personnel qualifications and demonstrates competency in water treatment standards training. Findings include: A review of the alternate Medical Directors credentialing file was conducted. There was no documented evidence that the alternate Medical Director completed the annual “Medical Director Water Treatment Standards Training Attestation” for 2025. During an interview at 9:55 AM, Staff (S)2, confirmed the alternate Medical Director did not complete the “Water Treatment Standards Training” in 2025. During an interview at 11:42 AM, S8 confirmed there was no documented evidence the alternate Medical Director completed the Water Treatment Standards Training in 2025. Facility policy titled, “Teammate Qualifications Licensure and Adequate Teammate Staffing,” revised October 2017, stated, “Policy ... 3. The dialysis facility’s teammates (or contractors) will meet the personnel qualifications and demonstrated competencies necessary to serve collectively the comprehensive needs of the patients. The dialysis facility’s teammates (or contractors) will have the ability to demonstrate and sustain the skills needs to perform specific duties to their positions ...” N.J.A.C. 8:43A-24.10(a)(7)”

“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: 49828 Based on observations, staff interviews, and review of facility documents, it was determined that the Medical Director failed to ensure that: 1) consumption of food is discouraged in the Hemodialysis Treatment Area during two of two observations and; 2) heparin (a medication used to prevent blood clotting) is administered in accordance with facility policy for one of one medication administration observed. Findings include: 1. On 12/17/25 at 11:25 AM, food and beverages were noted on the trays of the treatment chairs in the following treatment stations: Station 5 with an opened bag of grapes, an apple, a banana, and two small bottles of water; Station 3 with an apple; Station 2 with a bag of grapes and a yogurt parfait; and Station 8 with a hand full of various candies. At 11:35 AM, in Station 2, the patient was observed having their arteriovenous fistula (AVF, a type of access used for hemodialysis), located on their left bicep, cannulated (the act of inserting needles for hemodialysis access) by Staff (S)6. During the procedure, the patient lowered his/her mask and was using their right arm to spoon the yogurt parfait located on the tray on the right side of the chair into his/her mouth. S6 continued the procedure and did not discourage the patient from eating in accordance with facility policy. At 11:39 AM, in Station 8, the patient was observed eating various candies located on the tray of the right side of the chair. S6 entered the station to perform to check on the patient’s hemodialysis machine. S6 was seen speaking with the patient about the status of the hemodialysis machine but had not discouraged the patient from eating in accordance with facility policy. Facility policy titled, “Food and Beverages in the Treatment Area,” dated September 2015 stated, “Policy: 1. Consumption of food and beverages is discouraged in the treatment area. ...” Facility policy titled, “Infection Control for Dialysis Facilities,” revised April 2023 stated, “... Facility Hygiene ... 7. Food and drinks in the treatment area will be limited to patients. Sharing and storage in the treatment area is not allowed. ...” N.J.A.C 8:43A-24.4(a)(5) 52927 2. On 12/17/25 at 11:40 AM, S7 was observed initiating hemodialysis treatment through an arteriovenous graft (AVG, a type of vascular access used for hemodialysis). S5 attached a heparin filled syringe to the venous needle and slowly injected the heparin into the patient with one motion. S5 did not inject the heparin in a pull and plunge (back-and-forth) motion with the syringe plunger, in accordance with facility policy. During an interview at 12:04 PM, S5 stated, the nurses are supposed to push and pull the heparin three times. S5 stated, “I think I did it twice.” Facility policy titled, “AV Fistula or Graft Cannulation with Nipro or Medisystems Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose,” revised April 2025, stated, “... Procedure ... 28. Attach heparin loading dose to venous fistula needle, as applicable. Unclamp and gently flush heparin back and forth 3-5 times into fistula or graft. Reclamp ... Rationale ... 28. Flushing promotes heparin administration systematically ...” N.J.A.C. 8:43A-9.4(b)”