Alaris Health at Chateau

“CFC-RESPONSIBILITIES OF THE MEDICAL DIRECTOR CFR(s): 494.150 This Condition is not met as evidenced by: 37656 Based on staff interviews and review of facility documents, it was determined that the Medical Director failed to ensure the delivery of quality patient care by failing to implement all policies and procedures relevant to patient admission, patient care, and safety are adhered to by all staff (Tag V715). This failure resulted in an Immediate Jeopardy (IJ), posing serious risk of harm to the patients. On 3/21/25 at 1:38 PM, an IJ was identified for the facility’s failure to ensure that policies and procedures for medication administration were adhered to by staff. The Facility Administrator and the Regional Clinical Director were informed of the IJ findings, and a copy of the IJ template was provided at 4:19 PM. An acceptable removal plan was received on 3/24/25 at 10:55 AM. Verification of implementation of the removal plan was completed at 11:10 AM on 3/24/25. The facility implemented the following: the Medical Director and the CEO (Chief Executive Officer) were informed, a Governing Body (GB) meeting was held to execute a Removal Plan for the immediacy of the IJ, the medication administration policy was revised and approved by the GB and staff re-education was conducted. On 3/24/25 at 11:10 AM, the surveyors were able to verify implementation of the Removal Plan through facility document review, staff interviews, and review of the staff education documentation. The IJ was removed on 3/24/25 at 11:10 AM and Condition level non-compliance remains. Cross reference: 494.150(c)(2)(i) - MD Resp (Medical Doctor Responsibilities)- ensure all adhere to P&p (policies and procedures).”

“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: 51990 Based on observation, staff interview, and review of facility documents, it was determined that the facility failed to ensure that all necessary supplies are available in one of one emergency evacuation kit. Findings include: On 3/19/25 at 11:03 AM, the Evacuation Kit located on the Treatment Floor was reviewed. Staff (S) 1, the Director of Nursing, stated the evacuation kit was checked in the beginning of March 2025 and provided the “Emergency Evacuation Kit Checklist” for review. The checklist indicated that the evacuation kit should contain a flashlight with batteries and 18 Blue clamps. Upon review of kit, there was no flash light, batteries, or 18 blue clamps in the kit. During an interview 3/19/26 at 11:36 AM, S1 stated that all missing supplies should be in the kit. Facility policy titled, “Evacuation Kit,” revised 12/15/22, stated, “... Evacuation kit will be checked monthly to verify contents ... The evacuation kit is located at the [sic] next to the Emergency Cart and contain the following items: ... Flashlight with batteries ... Blue clamps (18) ...””

“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: 51990 Based on two of two observations of hand hygiene during the initiation of dialysis 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 that hand hygiene is performed to prevent cross contamination in accordance with facility policy. Findings include: On 3/19/25, during a tour of the Treatment Floor, the following was revealed: At 9:35 AM, Staff (S) 5, a Registered Nurse, initiated hemodialysis on Patient (P) 7 through a right chest wall CVC. With gloved hands, he/she connected the bloodlines on the machine to the red (arterial) and the blue (venous) catheter limbs. S5 then touched the dialysis machine and typed on the keyboard to enter the patient’s treatment information. He/she then exited the patient station, removed his/her gloves, did not perform hand hygiene, donned (put on) clean gloves and then entered another patient station. At 9:55 AM, during the initiation of hemodialysis on P9 through a right chest wall CVC in Station 5, S5, with gloved hands, applied the blood pressure cuff to the patient’s right arm. He/she then touched the patient’s legs and ankles to assess for swelling. S5 then did not perform hand hygiene, and with the same gloved hands, exited Station 5, removed supplies from a clean supply cabinet, then returned to Station 5 to initiate hemodialysis. During an interview at 10:12 AM, S5 stated that he/she should have removed gloves and used hand sanitizer when leaving the patient station and should have changed his/her gloves before initiating hemodialysis. A review of S5’s “Unit Orientation Checklist” indicated that “Infection Control” including “Hand Hygiene for department” was acknowledged and the materials were reviewed on 1/15/25. Facility policy titled, “Infection Prevention and Control Practices,” effective 2/15/17, stated, “... Hand Hygiene shall be followed by all staff ... Hands always shall be washed after gloves are removed and between patient contact, as well as after touching blood, body fluids, secretions, excretions and contaminated items. (See Hand Hygiene Policy) ... Hand hygiene shall be performed after contact with the chair-side computer keyboards/screen ... “ Facility policy titled, “Hand Hygiene-CDC [Centers for Disease Control and Prevention] Guidelines,” revised 5/22/24, stated, “... All staff will use the hand hygiene techniques, as set forth in the following procedure. The CDC has recommended guidelines on when to use antimicrobial soap and water, an antimicrobial soap and alcohol- based hand rub ... Before each patient encounter ... Before applying gloves ... After coming in contact with patient’s intact skin, i.e., taking patient’s blood pressure, pulse, lifting and moving patient ... After contact with medical equipment/ supplies in patient area ...””

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 37656 Based on observations, staff interviews, and a review of facility documents, it was determined that the facility failed to ensure that: 1) all equipment in the dialysis station is cleaned and disinfected in one of two observations of the cleaning of the dialysis stations and; 2) five of five blood pressure (BP) cuffs are maintained to allow for adequate cleaning and disinfection of contaminated surfaces in the hemodialysis treatment station. Findings include: 1. On 3/19/25 at 10:55 AM, Staff (S) 8, a Patient Care Technician, placed white towels moistened with 1:100 bleach solution (one part bleach with 100 parts water) on all the equipment and surfaces in Station 2. At 11:10 AM, S8 cleaned and disinfected all of the equipment and surfaces in the station except for the TV (television) console that had the bleached soaked wipe on it. S8 then exited the station. S8 was questioned by this surveyor if he/she was done cleaning the station, and S8 stated that he/she was coming back. At 11:25 AM, S8 did not come back to Station 2 and the wet towel remained on the TV console. At 11:26 AM, S7 was observed in Station 2. When asked by this surveyor, he/she stated that S8 went on break and he/she was going to get the station ready for the next patient. This surveyor told S7 that the TV console had not been cleaned. S7 then took a new wipe with 1:100 bleach and cleaned the TV. 2. On 3/19/25 during a tour of the Treatment Floor, Stations 1, 2, 3, 4, and 5 contained BP cuffs covered with white lint, which renders them uncleanable. Facility policy titled, “Cleaning and Disinfection of Medical Devices and Equipment,” revised 12/20/22, stated, “Dialysis Services staff shall clean and disinfect surfaces, medical devices and equipment per manufacturer’s instructions and using a facility-approved disinfectant. ... Environmental surfaces to be cleaned and disinfected include: patient chair ... Dialysis machine ... Prime bucket ... television ... IV [intravenous] pole ... B/P cuff ... Hoyer lift ... Hand sanitizer dispenser and holder ... adjacent tables and work surfaces, back counter and wall ... ancillary equipment, clamps, stethoscope, etc. ...””

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 51990 Based on three of three observations of the care of 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 the initiation and termination of hemodialysis through a CVC is performed in accordance with facility policy and procedure to prevent catheter related infections. Findings include: On 3/19/25 at 9:55 AM in Station 5, Staff (S) 5, a Registered Nurse, initiated hemodialysis on Patient (P) 9 through a right chest CVC. S5 cleaned the catheter exit site with a Chlorhexidine swab for 15 seconds, allowed the site to dry for 15 seconds and then applied a dressing. S5 then, without first cleaning the end cap and then moving up the catheter limb with an alcohol pad, proceeded to remove the red (arterial) end cap and scrubbed the threads with an alcohol pad for eight seconds. This was seven seconds less than required by facility policy. S5 then, without first cleaning the end cap and then moving up the catheter limb with an alcohol pad, removed the blue end cap and scrubbed the threads with an alcohol pad for seven seconds. This was eight seconds less than required by facility policy. During an interview on 3/19/25 at 10:12 AM, S5 stated the threads should be scrubbed for 10 seconds. A review of S5’s Central Venous Catheter Competency Checklist indicated that this was “Met” on 1/15/25. 48966 On 3/19/25 at 9:58 AM in Station 14, S3, a Registered Nurse, initiated hemodialysis through a left chest CVC. S3, without first cleaning the end cap and then moving up the catheter limb with an alcohol pad, removed the red (arterial) cap off the end of the CVC, used a sterile alcohol pad and scrubbed the threads of the catheter for five seconds an then attached a syringe on the end of the arterial limb. This was ten seconds less than required by facility policy. S6, without first cleaning the end cap and then moving up the catheter limb with an alcohol pad, proceeded to remove the blue (venous) cap off the end of the CVC, used a sterile alcohol pad and scrubbed the threads of the catheter for eight seconds. This was seven seconds less than required by facility policy. During an interview on 3/19/25 at 10:11 AM, S3 stated that the threads of the CVC are to be cleaned with an alcohol pad for 10 seconds and to move up the catheter limb with the alcohol pad to clean. S3’s personnel file was reviewed and indicated that he/she received and signed Central Venous Catheter Competency on 6/19/24. On 3/19/25 at 1:16 PM in Station 6, S5, a Registered Nurse, discontinued hemodialysis treatment with a CVC on P8. S5 clamped the hemodialysis bloodlines and CVC limbs. S5 then disconnected the red (arterial) bloodline from the CVC, did not clean the threads of the CVC with an alcohol pad for 15 seconds, and attached a pre-filled normal saline syringe and flushed the red limb. S5 then disconnected the blue (venous) bloodline from the CVC, did not clean the threads of the CVC with an alcohol pad for 15 seconds, and attached a pre-filled normal saline syringe and flushed the blue limb. During an interview 3/19/25 at 1:34 PM, S5 stated the threads of the catheter do not need to be cleaned with an alcohol pad prior to attaching the normal saline syringe flush. S5’s personnel file was reviewed and indicated that he/she received and signed Central Venous Catheter Competency on 1/15/25. Facility policy titled, “Initiation/Termination of Hemodialysis Using Dual Lumen Catheter,” revised 6/28/22, stated, “... Procedure: Dressing Change... Clean the site with disinfecting swab (if patient is allergic to Chlorhexidine, may use except or povidone) in a gentle back and forth technique for 30 seconds. Allow site to dry before applying dressing. (30 sec.) ... Procedure: Initiation of Treatment ... Open alcohol pad and clean end caps then move up catheter limb (Approx. [approximately] 4 inches) ... Take second alcohol remove end cap and clean threads vigorously for 15 seconds ... Procedure: Termination of Treatment ... clamp limbs and blood lines Open alcohol pad and disconnect one limb from bloodlines. Take alcohol pad and clean thread vigorously for 15 seconds. Attach pre-filled 10 ml NS (normal saline) syringe and flush. Open alcohol pad and disconnect other limb from bloodline. Take alcohol pad and clean other thread vigorously for 15 seconds Attach pre-filled 10 ml NS syringe and flush second limb ...””

“MIXING SYSTEMS-PERM RECORD/VERIF TEST CFR(s): 494.40(a) 5.4.4.1 Mixing systems: perm record/verification testing In addition to container labeling, there should be permanent records of batches produced. These records should include the concentrate formula produced, the volume of the batch, the lot numbers of powdered concentrate packages, the manufacturer of the powdered concentrate, the date and time of mixing, any test results, the person performing the mixing, the person verifying mixing and test results, and the expiration date (if applicable). 6.4.1 Mixing systems Acid and bicarbonate concentrates may be tested by using conductivity or by using a hydrometer. Concentrates should not be used or transferred to holding tanks or distribution systems until all tests are completed. The test results and verification that they meet all applicable criteria should be recorded and signed by the individuals performing the tests. This Standard is not met as evidenced by: 39228 Based on staff interview and a review of facility documents, it was determined that the facility failed to ensure that the Bicarbonate System operation log, used to document the mixing of bicarbonate in the facility contained the initials of the staff member that performed the conductivity verification on 3 of 25 dates reviewed. Findings include: Review of the “Distribution loop conductivity in range verification two staff initial” portion of the “Bicarbonate System operation log” for February and March 2025 revealed that on 2/11/25 and 2/19/25, the form lacked one of the two staff member’s initials that performed the conductivity verification and on 3/1/25, the form lacked two of two staff member’s initials that performed the conductivity verification. On 3/20/25 at 12:11 PM, the findings were reviewed with Staff (S) 10, the Biomedical Technician, who agreed that the initials of the staff members were missing. Facility policy titled “Bicarbonate Concentrate Mixing,” revised 4/14/20, stated “... Policy: ... 2. Only staff who have been trained to operate the bicarbonate concentrate system may complete the procedures to rinse, disinfect and prepare bicarbonate solution. ... 11. Preparation of bicarbonate concentrate is documented on a log at the time of preparation prior to dispensing. the log should include: ... verification test results ...””

“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 the facility failed to ensure that a defect free environment is maintained at all times. Findings include: During a tour conducted on 3/21/25 at 10:30 AM, in the presence of Staff (S) 10, the Biomedical Technician, it was discovered that the walls of the service hallway adjacent to the treatment floor, were found to have surface damage exposing uncleanable gypsum-like base material particularly at floor level. The above finding was acknowledged by S10 upon discovery.”

“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: 39228 Based on review of facility documents and staff interview, it was determined that the facility failed to ensure that: 1) the hemodialysis machine is disinfected and documented in accordance with the facility policy for 22 of 22 hemodialysis machines; 2) water system disinfection logs reflect the accurate time of rinsing procedures in four of five water system disinfection logs reviewed and; 3) blood glucose test strips are maintained in accordance with the MIFU (Manufacturer’s Instructions for Use) for one of two Assure Platinum Blood Glucose Test Strip (test strips used in blood glucose meters for measuring blood sugar) vials. Findings include: 1. On 3/20/25 at 11:30 AM, during an interview with S (Staff) 10, the Biomedical Technician, S10 stated that the facility has 22 dialysis machines (18 plus four back up machines) and that they are bleach disinfected weekly on Thursdays. The “Daily machine disinfection & Weekly diasafe filter testing logs” for February and March 2025 were reviewed. The log sheet dated 2/15/25 to 2/21/25 revealed there was no documented bleach disinfection of the machines. The log stated that on Thursday 2/20/25, all machines were heat disinfected only. On 3/20/25 at 12:57 PM, the log was sheet was reviewed with S10. S10 stated, “I think it is a documentation error so I’m going to check the machines to see if they keep a record of the bleach disinfection.” S10 was unable to provide evidence that the machines were bleach disinfected. Further review of the logs indicated that the machines were bleach disinfected on 3/6/25 and not disinfected again until 3/14/25, eight days after the last bleach disinfection. On 3/20/25 at 1:13 PM, the log was reviewed with S10, and he/she agreed that the bleach disinfection occurred past the seven days. Facility policy titled, “Fresenius Dialysis Machine Cleaning And Disinfection Policy,” revised 4/14/20, stated, “... Policy ... Cleaning/disinfection intervals depend on the facility’s operations Procedure ... Chemical Disinfection (bleach) ... Weekly ...” 2. On 3/20/25 at 1:56 PM, the “Minncare Water System Disinfection Log Sheets” from September 2024 to January 2025 were reviewed with S10. On 10/18/25, 11/14/25, 12/23/25, and 1/31/25. The “Pre Disinfect Safety Checklist” section of the log stated, “All Patients Have Left the Facility ... (staff members initials were documented).” The “Rinsing Procedures” section of the log stated, “Time Rinsing Stated: 12:00 (12:00 PM) Dwell Time: 1 hr (hour) Time Rinsing Completed: 13:30 (1:30 PM).” S10 stated that the rinsing procedure times documented on the logs were during patient care hours. S10 further explained that he/she made a mistake and documented the rinsing procedure times incorrectly and then further stated that he/she disinfects the water system monthly at 8:00 PM after all patient treatments are completed. Facility policy titled, “Water Treatment System Disinfection,” revised 4/14/20, stated, “... Policy ... 1. System disinfection is performed when the treatment area is patient-free ... 12. Facility-specific procedures contain step-by-step instructions. These instructions include: ... The rinse out process ... Documentation requirements ...” 50912 3. On 3/19/25 at 11:25 AM, during a tour of the dialysis treatment area, an open container of “Assure Platinum” blood glucose test strips was located inside the top drawer of the medication preparation area. The blood glucose test strip container did not have a label indicating the date it was opened. At 11:35 AM, this finding was confirmed with S6, Registered Nurse. S6 stated that he/she did not know who opened the container of test strips or when it was opened. S6 stated the blood glucose test strips expire 30 days after opening. S6 then discarded the container since he/she was unable to determine when it was opened and then opened a new container and labeled it with his/her initials, the date and the time. A review of the MIFU (Manufacture’s Instructions for Use) for the Assure Platinum Test Strips stated, “... When you first open the vial, write the date on the vial label. Use the test strips within 3 (three) months of first opening the vial ... “ Facility policy titled, “Blood Glucose Screening,” revised 11/20/17, stated, “... Policy ... The expiration date for the strips must be current in order to produce accurate results. Test strips must be used immediately when taken out of packet ...””

“PR-PRIVACY & CONFIDENTIALITY-TREATMENT CFR(s): 494.70(a)(3) The patient has the right to- (3) Privacy and confidentiality in all aspects of treatment; This Standard is not met as evidenced by: 51990 Based on three of three observations 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 3/19/25, on the Treatment Floor, the following was revealed: At 9:35 AM in Station 6, Staff (S) 5, a Registered Nurse, initiated hemodialysis on Patient (P) 7 through a right chest wall CVC. During the procedure, the curtains were drawn on both sides of Station 6 covering the left and the right side of P7. The curtains were not fully closed in front of the station leaving an opening of approximately three feet. The patient’s chest was visible from the patient in Station 8, located across from Station 6. At 9:55 AM in Station 5, S5 initiated hemodialysis on P9 through a right chest wall CVC. S5 failed to close the privacy curtain, exposing the patient’s chest. P8 chest was visible from the patient in Station 9, across from Station 5. During an interview at 10:12 AM, S5 stated that the curtains should be fully closed around the patient’s station when initiating hemodialysis with a CVC 48966 At 11:03 AM, the discontinuation of dialysis through a CVC was observed in Station 16. The curtain on the left side was drawn in Station 16 fully extending to ensure patient privacy on the left of the patient. The curtain did not fully extend in the front of the station, leaving a three-foot opening. The patient’s exposed chest was visible to the Nurses Station where staff members sit and prepare medications. During an interview at 11:07 AM, S3, a Registered Nurse, confirmed the curtains should be fully around the patient sitting in Station 16. S3 stated the curtain in the front of Station 16 is not working properly. Facility policy titled, “Respect and Dignity For Residents On Dialysis,” effective: 08/15/2017, stated, “Policy: The Dialysis Staff will be responsible to ensure that the dignity and privacy of the resident dialysis patient is maintained while they are being treated in the dialysis unit. This includes: ... Every patient has the right to the personal privacy of not only his/her own physical body, but also of his/her personal space ...””

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 51990 Based on one of one observation of a patient with high blood pressure (BP) during hemodialysis (Patient (P) 5), staff interview, medical record review and review of facility documents, it was determined that the facility failed to ensure that abnormal BP readings during hemodialysis are addressed by the Registered Nurse (RN) and that appropriate interventions are implemented. Findings include: On 3/19/25 at 12:30 PM while on the Treatment Floor, Staff (S) 8, a Patient Care Technician (PCT), was observed discontinuing hemodialysis on P5 in Station 7. The patient’s post dialysis treatment BP (BP after hemodialysis) was 190/101. S8 reported the reading to S6, a RN, who was sitting at the nurse’s station. At 12:35 PM, S8 adjusted the BP cuff on the patient’s right arm, rechecked the BP, which was 199/100 and then reported the reading to S6. The surveyor did not observe S6 assess P5 and no intervention was given to the patient. During an interview on 3/19/25 at 1:10 PM, S5, a RN, stated P5 took Midodrine (a medication used to treat low BP) at home before coming to dialysis and that was the reason for patient’s BP readings being high. When the surveyor asked if he/she made the Charge Nurse or Nephrologist aware, S5 stated, “No.” On 3/20/25, a review of P5’s “Hemodialysis Session Data” portion of the Hemodialysis Flowsheet, dated 3/19/25 indicated the following BP readings and “Comments”: 9:36 AM 188/98; S5 commented, “... Tx [treatment] initiated. No complaints. Patient (Pt) stable...” 10:00 AM 180/104; S8 commented, “... BP high, RN aware ...” 10:30 AM 200/109; S5 commented, “... Rechecking BP. Asymptomatic ...” 10:32 AM 219/98; S5 commented, “... Pt reports [he/she] took [his/her] Midodrine at 9 AM before [he/she] came in. No complaints...” 10:55 AM 163/102; S5 commented, “... Pt awake, No complaints ...” 11:00 AM 187/101; S5 commented. “... Pt stable. No complaints ...” 11:30 AM 194/108; S7, a PCT, commented, “Pt resting ...” 12:00 PM 224/104; S5 commented, “... Awake. No complaints ...” 12:02 PM 208/104; S5 commented. “... No complaints. All lines visible and secured ...” 12:30 PM 190/101; S5 commented. “... Awake, no complaints ...” 12:35 PM 191/100; S5 commented, “... Awa [Sic] and stable ...” 12:37 PM 176/87; S5 commented, “... Denies pain ...” The above findings had no RN documentation of interventions implemented for the SBP (systolic blood pressure) greater than 170 and DBP (diastolic blood pressure) greater than 100 mmHg (milliliters of mercury) or that the Charge Nurse or Nephrologist was informed of the high blood pressure readings. Review of the “Meds [medications] and Reasons” portion of the “HEMO Dialysis Orders” included a medication order for Clonidine (medication used to treat high BP), 0.1 Mg (milligram), PRN (as needed), PO (by mouth). Reason: (times) X 3 for SBP (Systolic BP) greater than (>)170 with a start date on 6/14/24. On 3/21/25 at 12:55 PM, during an interview, S1, the Director of Nursing, stated that PRN Clonidine is prescribed by the Physician and should be given as needed. Facility policy titled, “Intradialytic Assessment and Monitoring,” revised 3/17/19, stated, “... The Dialysis service staff RN shall be responsible for evaluating the patient’s response to dialysis treatment, performing patient’s assessment, including blood pressure, ... Any abnormality detected listed below during the course of the hemodialysis treatment should be brought to the attention of the Charge Nurse for the referral to the Attending Nephrologist. If no resolution of the problem after interventions have been implemented 911 will be called to be transport patient to the ED for further evaluation ... Acute or persistent change in B/P < [less than] 90 mmHg or >180 mmHg ...” Facility policy titled, “Hypertension,” effective 2/15/17, stated, “... Dialysis Service Staff shall be able to recognize the signs and symptoms of hypertension and to initiate appropriate treatment ... Sign and Symptoms: ... Elevated blood pressure: Diastolic above 100 mm/Hg ... Procedure: An abnormal diastolic blood pressure reading shall be reported promptly to the Nephrologist ... Administer antihypertensive medication as prescribed by the physician ... “”

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 51990 Based on one of seven medical records reviewed (Patient (P) 1), staff interview, and a review of facility documents, it was determined that the facility failed to ensure that the “Unstable” Comprehensive Interdisciplinary Assessment and POC (Plan of Care) are updated monthly until the patient returns to a stable status. Findings include: A review of P1’s medical record revealed the following: P1 was made “Unstable” in August 2024. The Unstable Hemodialysis Interdisciplinary Assessment and POC meetings for P1 were held on 8/20/24 and 9/17/24. P1’s medical record lacked documented evidence of a completed “Unstable” comprehensive reassessment by the Registered Nurse, Social Worker, Registered Dietitian and Nephrologist during the months of October 2024 and November 2024. The medical record contained a A STCP (Short Term Care Plan) Hemodialysis Interdisciplinary Assessment and POC dated 12/10/24, that stated “Health Status, Comorbidities and Physical Exam... ESRD- STABLE.” During an interview on 3/21/25 at 9:40 AM, Staff (S) 11, the Regional Clinical Director, stated P1 is chronically unstable. He/she confirmed that there were no unstable POC’s completed in the months of October 2024 and November 2024. Facility policy titled, “Comprehensive Interdisciplinary Assessment and Plan of Care,” revised on 3/2/23, stated, “... 8. Unstable patient’s will follow the Unstable Policy ... “ Facility policy titled, “Identification of the Unstable Patient,” revised 3/2/23, stated, “... Unstable renal patients will have their plan of care updated at least monthly ... Reassessment of unstable patient will be done when they return to stable status ...””

“POC-GOALS=COMMUNITY-BASED STANDARDS CFR(s): 494.90 The interdisciplinary team as defined at §494.80 must develop and implement a written, individualized comprehensive plan of care that specifies the services necessary to address the patient’s needs, as identified by the comprehensive assessment and changes in the patient’s condition, and must include measurable and expected outcomes and estimated timetables to achieve these outcomes. The outcomes specified in the patient plan of care must be consistent with current evidence-based professionally-accepted clinical practice standards. This Standard is not met as evidenced by: 48966 Based on one of one observation of the discontinuation of hemodialysis on a patient with a tracheostomy (Patient (P) 14), staff interview, medical record review, and review of facility documents, it was determined the facility failed to ensure patient’s individualized respiratory needs are met by checking oxygen saturation post (after) treatment in accordance with facility policy. Findings include: On 3/19/25 at 11:03 AM in Station 16, Staff (S) 3, a Registered Nurse was observed discontinuing dialysis on P14, a tracheostomy patient. S3 failed to obtain an oxygen saturation on P14 post dialysis treatment and before the patient was transported off the unit. During an interview on 3/19/25 at 11:12 AM, when questioned if any special nursing care is needed for a patient with a tracheostomy, S3 stated suction pre (before) treatment if secretions are present and check the patient’s blood pressure. S3 also stated that he/she assesses for secretions throughout treatment and suctions as needed. A review of P14’s medical record revealed the following: The “Hemodialysis Interdisciplinary Assessment and Plan of Care,” date of conference 9/9/24, stated, “... Health Status, Comorbidities and Physical Exam ... Current problem list: ... Start Date ... 7/15/24 DX [Diagnosis] Code Tracheostomy Status ...” The “Hemodialysis Flowsheet” dated 3/19/25, had a documented post dialysis “O2 (oxygen) Sat [saturation]” of “99.” During an interview on 3/19/25 at 2:35 PM, when asked about the documented oxygen saturation level recorded on the flowsheet dated 3/19/25, S3 confirmed a post oxygen saturation level was not obtained. S3 stated “you made me nervous.” S3 then stated that he/she should document that it was not done. Facility policy titled, “Nursing Care Of The Tracheostomy Patient During Dialysis,” effective 7/14/2022, stated, “... Policy: ... 3. The oxygen saturation must be obtained and documented by the Registered Nurse pre [before]-dialysis, prn [as needed] and post dialysis ...””

“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 three observations of the initiation of hemodialysis through an arteriovenous fistula (AVF, a type of vascular access used for hemodialysis), staff interviews, and a review of facility documents, it was determined that the facility failed to ensure that staff perform skin disinfection of the access site prior to initiating the dialysis treatment in accordance with facility policy. Findings include: On 3/19/25 at 10:23 AM in Station 15, Staff (S) 4, a Patient Care Technician (PCT), initiated dialysis through a patient’s left AVF. S4 cleansed the entire AVF with an alcohol pad in a circular motion for 10 seconds then applied a tourniquet. S4 cleansed the entire AVF again with an alcohol pad for three seconds then cannulated (the act of inserting a needle into the vascular access) the first (arterial) site and second (venous) site. During an interview at 10:32 AM, S4 stated he/she should have cleaned the access for 30 seconds with alcohol. S4’s personnel file was reviewed and indicated that he/she received and signed Vascular Access and Treatment Initiation Competency on 3/4/2024. 50912 On 3/19/25 at 10:29 AM, S9, a Patient Care Technician (PCT), initiated dialysis through Patient (P) 13’s AVF in Station 18. S9 cleansed the first site of the AVF with an alcohol pad in a circular motion for 10 seconds. S9 cleansed the second site of the AVF with an alcohol pad in a circular motion for 5 seconds. Upon interview at 10:38 AM, S9 stated he/she should clean the sites with an alcohol pad for 15 seconds and then allow them to dry. Facility policy titled, “Initiation Of Dialysis With AVF or AVG [arteriovenous graft],” revised 4/17/23, stated, “... Procedure: ... Clean arterial site with 70% alcohol pad for 30 seconds. ... Repeat above steps with venous site and secure needle in place ...””

“POC-PTS SEEN BY MED STAFF 1X/MO CFR(s): 494.90(b)(4) The dialysis facility must ensure that all dialysis patients are seen by a physician, nurse practitioner, clinical nurse specialist or physician’s assistant providing ESRD care at least monthly, as evidenced by a monthly progress note placed in the medical record, and periodically while the hemodialysis patient is receiving in-facility dialysis. This Standard is not met as evidenced by: 37656 Based on medical record review, staff interview, and review of facility documents, it was determined that the facility failed to ensure that a physician examines the patient and documents monthly progress notes for three of five months reviewed for Patient (P) 6. Findings include: A review of P6 medical record indicated that the patient was hospitalized from 11/28/24 to 1/8/25. P6 was discharged from dialysis due to hospitalization for more than 30 days. P6 was readmitted on 1/9/25. The medical record lacked physician’s monthly progress notes for January, February, and March 2025. During an interview on 3/20/25 at 12:50 PM, Staff (S) 2, Facility Administrator, stated that the physician for P6 has not seen the patient during dialysis. S2 also stated that they perform chart audits and had spoken to P6’s physician regarding writing monthly progress notes. Facility policy titled, “Physician Visits and Medical Orders,” states, “... The attending physician shall see the patient minimally once every month. ...” The above policy did not contain an effective date and did not indicate it was approved by the governing body. According to S2, the policy manual reviewed by the governing body in January 2024 was inclusive of the above policy.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 48966 Based on observation, medical record review, staff interviews, and a review of facility documents, it was determined that the facility medical director failed to ensure that: 1) oral nutritional supplements are ordered by the physician and administered to patients by a Registered Nurse (RN) in one of one observation of oral nutritional supplement administration (Patient (P) 12); and 2) medications administered to patients during hemodialysis treatments are prescribed by the physician in one of seven medical records reviewed (P16). Findings include: 1. On 3/19/25 at 10:58 AM, Staff (S) 4, a Patient Care Technician, was observed retrieving a bottle of “Nepro” (oral nutritional supplement) from the nurses’ station countertop. S4 opened the bottle of Nepro and handed it to P12 who was sitting in Station 15. A review P12’s “Medication Orders” and the “Hemodialysis Flowsheet” from 3/19/25 revealed no documentation that an oral nutritional supplement was ordered by the physician. During an interview on 3/19/25 at 10:59 AM, S4 confirmed he/she opened and handed the oral nutritional supplement to P12. S4 confirmed oral nutritional supplement is ordered by the physician. When asked if the oral nutritional supplement is to be administered by a Registered Nurse (RN), S4 stated that he/she asks the RN if they want me to give it to the patient or the RN will instruct him/her to give it to the patient. During an interview on 3/19/25 at 11:27 AM, S3, a RN, confirmed the oral nutritional supplement is a prescribed order from the physician and a RN is to administer the oral nutritional supplement. During an interview on 3/19/25 at 11:35 AM, S1, the Director of Nursing, confirmed the oral nutritional supplement is ordered by the physician and a RN is to administer the oral supplement. 37656 2. A review of P16’s hemodialysis flow sheet dated 12/2/24, stated, “07:10 Patient compliant [sic] anxierty [sic], RN called to first floor to tell first floor RN [Registered Nurse]. RN is going to bring anxiety medication. ... 07:30 1st floor RN given [sic] the oxycodone 5.325mg by feeding tube. ... 8:04 AM- Pt [patient] found unresponsive. Unable to get a blood pressure. 8:06: BP [blood pressure] taken 43/22 HR [heart rate] 38. Blood rinsed back. No pulse present, CPR [cardiopulmonary resuscitation] initiated by DON [Director of Nursing]. 911 called, as well as the respiratory team. ... 8:15 AM ... ongoing CPR paramedics arrived, took over CPR, able to get pulse. 8:30 AM - patient left the facility to ___ [name of hospital].” The above flow sheet did not contain documentation that the physician was notified by the dialysis RN and the medical record did not contain an order for the Oxycodone that was administered to P16. In an interview on 3/21/25 at 1:55 PM, S3, a RN stated that on 12/2/24, P16 was anxious, and he/she notified S1, the DON. According to S3, S1 called the RN at the Nursing Home who came down and administered Oxycodone 5.325 mg via the PEG tube (Percutaneous Endoscopic tube). Per S3, he/she did not notify the physician and confirmed that there was no Oxycodone ordered for P16. S3 also confirmed that the Oxycodone came from the Nursing Home and was given by the RN from the Nursing Home where P16 resides. Facility policy titled, “Medication Administration,” revised 7/24/2018, stated, “Policy: Medications will be administered only upon the order of physicians ... Administration will be by a physician, LIP [licensed independent practitioner], or registered nurse. Registered nurses may administer all parental, oral, rectal and topical medication, if not specifically excluded elsewhere by medical by-laws ...” Facility policy titled, “Hemodialysis Orders,” effective 2/15/2017, stated, “... Policy: ... Additional orders for medications during dialysis will be entered in the In-Center Medication Section of the Electronic Health Record as prescribed by attending nephrologist.””

“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 three of three observations for the cleaning and disinfection of hemodialysis treatment stations, staff interview and a review of facility documents, it was determined that the facility failed to ensure that: 1. Equipment is cleaned and disinfected after each patient use and; 2. Surfaces and equipment are not cleaned and disinfected before the patient vacates the station. Findings include: 1. On 2/6/24 at 10:22 AM in Station 1, the patient completed hemodialysis treatment and was disconnected from the hemodialysis machine. Staff (S) 5, a Registered Nurse, utilized a Hoyer lift (a mechanical device used to lift patients) to transfer the patient from the dialysis chair into a recliner. S5 removed the Hoyer lift from the station and placed it into a hallway located adjacent to the Station 1. Once in the hallway, S5 did not clean and disinfect the Hoyer lift after patient use. During an interview at 11:00 AM, S4, the Charge Nurse, explained that S5 should have cleaned and disinfected the Hoyer lift after patient use. A review of S5’s training file indicated that S5 received infection control education regarding cleaning and disinfection procedures of dialysis equipment and environmental surfaces on 2/14/23. Review of an undated facility policy titled, “Guideline for use of Hoyer Lift,” stated, “... Policy: Disinfection After each use of the Hoyer lift it shall be cleaned thoroughly with 1:100 bleach. ... Wet service completely and allow 2 minutes of contact time for proper disinfection. ...” 2. At 10:53 AM, in Station 2, the patient completed hemodialysis treatment via a CVC (central venous catheter) and was disconnected from the hemodialysis machine. While the patient was still seated in the chair, S7, a Patient Care Technician, cleaned and disinfected all surfaces of the dialysis machine by wiping them with a bleach soaked cloth. At 10:56 AM, S7 exited Station 2 and entered the vacated Station 1 and proceeded to wipe the surfaces and equipment in the station with a bleach soaked cloth. S7 did not clean and disinfect the television, a freestanding portable blood pressure cuff, and the back counter and wall of the station. Upon interview at 11:00 AM, S7 stated that the station was clean and that, “I should have cleaned the television, blood pressure cuff, counter and wall.” S7 then cleaned and disinfected the equipment and surfaces. At 11:10 AM in Station 2, transportation staff transferred the patient from the dialysis chair onto a stretcher. During the transfer, S7 re-entered the station and began to clean and disinfect the television. The patient then left the station with the transporters, and S7 completed cleaning and disinfection the station. S7 did not reclean the dialysis machine or the television after the patient left the station. Upon interview at 11:13 AM, S7 stated that he cleaned the dialysis machine and the television before the patient left and that he should have waited until they were gone to clean the station. S7 stated he should have recleaned the surfaces. A review of S7’s training file indicated that S7 received infection control education regarding cleaning and disinfection procedures of dialysis equipment and environmental surfaces on 12/1/22. Review of facility policy and procedure titled, “Cleaning and Disinfection of Medical Devices and Equipment,” revised 12/20/22, stated, “Policy: ... Dialysis station cannot be cleaned until patient vacates the station. Environmental surfaces shall be cleaned and disinfected after each patient use ... Environmental surfaces to be cleaned and disinfected include: ... Dialysis machine ... Television ... B/P cuff ...back counter and wall, Ancillary equipment ...” 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 two observations of the initiation of hemodialysis using a central venous catheter (CVC), review of facility policy, and staff interview, it was determined that the facility failed to clean the end caps then move up the catheter limb and clean the threads for fifteen seconds when initiating dialysis according to facility policy. Findings Include: On 2/6/24 at 10:40 AM in Station 16, Staff (S) 6, a Registered Nurse, initiated hemodialysis through a right chest CVC. S6 removed the arterial thread cap of the CVC and scrubbed only the threads of the arterial end for five (5) seconds. S6 cleaned the end cap and did not move up the catheter limb with an alcohol prep pad. S6 attached a syringe on the end of the arterial limb. S6 then proceeded to remove the venous thread cap of the CVC and scrubbed only the threads of the venous end for five (5) seconds. S6 cleaned the end cap and did not move up the catheter limb with an alcohol prep pad. S6 attached a syringe on the end of the venous limb. S6 did not clean the end caps then move up the catheter limbs and clean the threads for the 15 seconds in accordance with the facility’s policy and procedure. Upon interview at 10:55 AM, S6 confirmed the catheter limbs should be wiped down along with the threads of the catheter. When asked about the scrub time for the thread caps, S6 explained the threads of the catheter should be wiped for 20-30 seconds. S6 stated, “I didn’t do that.” S6’s personnel file had an undated and signed Central Venous Catheter Competency Checklist. S1, the Facility Administrator, could not confirm the date of completion. A review of the Facility policy titled, “Initiation/Termination Of Hemodialysis Using Dual Lumen Catheter,” revised 11/26/17, stated, “... Procedure: Initiation of treatment ... Open alcohol pad and clean end caps then move up catheter limb (Approx.[approximately] 4 inches). Take second alcohol remove end cap and clean thread vigorously for 15 seconds. Attach 10 ml [milliliter] syringe ...” N.J.A.C. 8:43A-24.8(b)”

“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 the facility failed to ensure that a defect free physical environment is maintained at all times. Findings include: During a tour conducted on 2/6/24 at 11:10 AM, the door sweep installed on the exterior doors of the main storage room was damaged and torn, leaving a visible gap. This gap between the door and floor could allow the entrance of insects and vermin to the interior of the building. S3, the Biomedical Technician confirmed the damaged floor sweep upon discovery and stated it would be repaired as soon as possible.”

“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: 33556 Based on observation and staff interview, it was determined the facility failed to ensure that all safety equipment is maintained in good order and suitable for emergency use at all times. Findings include: Reference: Fisher Scientific Generic Bleach Material Safety Data Sheet (MSDS) stated, “... Section 4 - First Aid Measures ... Eyes: Flush eyes with plenty of water for at least 15 minutes, occasionally lifting the upper and lower eyelids. Get medical aid immediately...”. During a tour conducted at 11:10 AM, the wall mounted bottle eyewash installed in the patient treatment area was found to have a thirty-two (32) once capacity of saline solution. 32 ounces of saline solution would not be adequate to provide the required fifteen minutes of eye flushing as per the MSDS. The inadequate capacity of the eyewash was confirmed by S3, the Biomedical Technician and he stated it would be replaced as soon as possible.”

“PR-PTS INFORMED OF RIGHTS WHEN BEGIN TX CFR(s): 494.70 The dialysis facility must inform patients (or their representatives) of their rights (including their privacy rights) and responsibilities when they begin their treatment and must protect and provide for the exercise of those rights. This Standard is not met as evidenced by: 48966 Based on one of two new patient medical record reviews (Patient 1), staff interviews, and review of facility documents, it was determined that the facility failed to ensure that all patients are informed of their rights and responsibilities upon admission. Findings include: A review of Patient (P) 1’s medical record revealed that the following admission documents, that include but are not limited to the following, were not signed by the patient: 1. Acknowledgement Of Receipt Of Patient Rights, Responsibilities, Grievance Procedures, Facility Rules And Emergency Preparedness 2. Authorization To Bill Insurance and Assignment Of Insurance Benefits 3. Acknowledgement & Consent Notice Of Privacy Practices 4. Medical Record Release 5. Clinic Code Of Conduct Policy 6. Patient Eating And/Or Drinking Policy In The Dialysis Facility During Treatment 7. Emergency Procedure For Dialysis Unit 8. Patient Process During an interview at 11:19 AM, Staff (S) 1, the Facility Administrator, confirmed the required admission packet was not completed. S1 stated, “I will make sure the Registered Nurse and the Social Worker does their part going forward.” S1 provided a blank example copy of the admission packet. S1 explained that this packet needs to be signed on admission and placed into the patient’s hard chart. Upon interview at 12:20 PM, S2, the Regional Coordinator, stated that the admission packet should be filled out upon admission for all new patients. Review of the facility policy titled, “Admission Policy,” effective 2/15/17, stated, “... Procedure: Upon admission (within the first six (6) treatments after admission to the Dialysis Services Facility, patients and/or their representative shall be informed of their rights (including their privacy rights) and responsibilities when they begin treatment. This facility shall protect and provide for the exercise of those rights. ... Each patient shall be given written materials addressing Patient Rights and Responsibilities. ... Staff shall document in the patient’s medical record that this material was given to the patient. ... Additional educational materials are available to the patient upon their admission to the unit ...” N.J.A.C. 8:43A-16.2(a)(1)”

“POC-GOALS=COMMUNITY-BASED STANDARDS CFR(s): 494.90 The interdisciplinary team as defined at §494.80 must develop and implement a written, individualized comprehensive plan of care that specifies the services necessary to address the patient’s needs, as identified by the comprehensive assessment and changes in the patient’s condition, and must include measurable and expected outcomes and estimated timetables to achieve these outcomes. The outcomes specified in the patient plan of care must be consistent with current evidence-based professionally-accepted clinical practice standards. This Standard is not met as evidenced by: 39223 Based on medical record reviewed for tracheostomies (Patient 3 and Patient 8), staff interview, and review of facility policy, it was determined that the facility failed to ensure patient’s individualized respiratory needs are met by implementing physician oxygen orders and checking patient oxygen saturation levels as required by facility policy. Findings include: A review of Patient (P) 3’s medical record indicated that the patient was receiving oxygen by ventilator through a tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea from outside the neck). The following was revealed: The “Hemodialysis Interdisciplinary Assessment and Plan of Care” dated 1/19/24, stated, “... Health Status, Comorbidities and Physical Exam ... Current problem list: ... Start Date ... 9/8/23 ... Dependence on Respirator ...” A physician’s order dated 9/8/23, instructed for, “FiO2 [fraction of inspired oxygen] 30%” to be delivered by a ventilator through P3’s tracheostomy at every hemodialysis treatment. The reason listed, “... Patient is ventilator dependant ...” A review of P3’s “Hemodialysis Flowsheets” dated 1/17/24 through 2/7/24 revealed the following: An FiO2 of 40% was documented on the following dates: 1/17, 1/19, 1/22, 1/31, 2/2, and 2/5/24. This was higher than the prescribed FiO2 dose of 30%. No FiO2 concentration was documented on 1/26 and 1/29/24. There was no documented evidence of an oxygen saturation level before hemodialysis treatment on the following dates: 1/26, 1/29, and 2/5/24. During an interview on 2/7/24 at 12:15 PM, Staff (S) 2, the Regional Coordinator, stated that the ordered dose of FiO2 was 30% and not 40%. S2 also stated that the oxygen saturation should have been checked and documented before and after each hemodialysis treatment. 39228 A review of P8’s medical record indicated that P8 was a tracheostomy patient. Review of S8’s “Hemodialysis Flowsheets” revealed the following: The “Hemodialysis Interdisciplinary Assessment and Plan of Care” date of conference 10/27/23, stated, “... Health Status, Comorbidities and Physical Exam ... Current problem list: ... Start Date ... 6/24/22 Respiratory Failure, Unspecified, ... Comments: on Trach (tracheostomy)...” The flowsheet dated 1/25/24 lacked documented evidence that an oxygen saturation was obtained on the patient prior to the initiation of dialysis. The following flowsheets lacked documented evidence that an oxygen saturation was obtained on the patient post dialysis: 1/24/24, 1/30/24, and 2/3/24. During an interview on 2/7/24 at 12:15 PM, Staff (S) 2, the Regional Coordinator, stated that the oxygen saturation should have been checked and documented before and after each hemodialysis treatment. A review of facility policy titled, “Nursing Care of the Tracheostomy Patient During Dialysis,” effective 7/14/22, stated, “... Policy: ... 1. Upon arrival in the dialysis unit the Registered Nurse will ensure that patient is connected appropriately to oxygen if prescribed. ... 3. The oxygen saturation must be obtained and documented by the Registered Nurse pre-dialysis, prn [as needed], and post dialysis. ...” N.J.A.C. 8:43A-24.13(c)”

“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: 39223 Based on medical record review and interview, it was determined that the facility failed to ensure that the delivered dose of dialysis is based on the ordered Target Weight for eight of nine hemodialysis treatments reviewed for Patient (P) 3. Findings include: A review of P3’s medical record indicated that a Target Weight of 51.5 kilograms (kg) was ordered on 1/17/24. The following was revealed: The “Hemodialysis Interdisciplinary Assessment and Plan of Care” dated 1/19/24, stated, “... Dialysis Prescription/Fluid Management/ BP [Blood Pressure] Control ... Dialysis Orders for last 3 months: ... 12/11/23 ... Target Weight ... 55.5 ... Treatment History for most recent 2 weeks: ... 1/12/24 ... Post Wt [Weight] ... 51.5 ... Goal: EDW [Estimated Dry Weight] Achieved Consistently ... No ... Fluid Management/BP Control Plan of Care: ... Pay close attention when weight patient to obtain accurate weight, Adjust EDW as needed ...” The “Hemodialysis Flowsheets” dated 1/17/24 through 2/5/24 were reviewed and the following was revealed: On 1/17/24, P3’s post treatment weight was 56.0 kg. This was 4.5 kg above the ordered Target Weight. There was no documented evidence that the post weight was reported to the physician. On 1/19/24, P3’s post treatment weight was 54.5 kg. This was 3 kg above the ordered Target Weight. There was no documented evidence that the post weight was reported to the physician.. On 1/22/24, P3’s post treatment weight was 58.0 kg. This was 6.5 kg above the ordered Target Weight. There was no documented evidence that the post weight was reported to the physician.. On 1/29/24, P3’s post treatment weight was 60.0 kg. This was 8.5 kg above the ordered Target Weight. There was no documented evidence that the post weight was reported to the physician.. On 1/31/24, P3’s post treatment weight was 59.0 kg. This was 7.5 kg above the ordered Target Weight. There was no documented evidence that the post weight was reported to the physician.. On 2/2/24, P3’s post treatment weight was 58.2 kg. This was 6.7 kg above the ordered Target Weight. There was no documented evidence that the post weight was reported to the physician.. On 2/5/24, P3’s post treatment weight was 61.00 kg. This was 9.5 kg above the ordered Target Weight. There was no documented evidence that the post weight was reported to the physician.. During an interview on 2/7/24 at 12:15 PM, Staff (S) 2, the Regional Coordinator, confirmed that the ordered Target Weight on 51.5 kg was in place during the time reviewed. S2 stated that the Target Weight was changed on 2/6/24, and that for the above dates, the physician should have been informed of the patient’s weight after hemodialysis treatment. A review of facility policy titled, “Estimated Dry Weight,” revised 7/25/18, stated, “... Procedure: ... 7. Any deviation from EDW or target weight under or above 1.0 kg consistently should be reported to the nephrologist for re-evaluation. ...” N.J.A.C. 8:43A-24.13(c)”