Fkc Tenafly

“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 two of two observations of the emergency evacuation boxes, staff interview, and review of facility documents, it was determined that the facility failed to ensure that the emergency boxes contain supplies for every licensed patient station and all patient and staff emergency contact information is available. Findings include: On 2/25/25 at 11:05 AM, Staff (S) 1, the Facility Administrator, stated that the facility had 2 emergency evacuation boxes. S1 confirmed that the in-center hemodialysis (ICHD) evacuation box was located on the Treatment Floor and that the PD (peritoneal dialysis)/HHD (home hemodialysis) box was located in the Home Training area. At 10:55 AM, the in-center hemodialysis emergency evacuation box was reviewed, and contained a checklist titled, “Emergency Box Contents.” The checklist was last reviewed on 2/3/25 and identified the following par levels for each supply listed below: Access clamps - 4 Catheter caps - 12 3 cubic centimeter (cc) Syringe with needles - 12 10cc Syringe with needles - 12 Under pads 12x17 - 12 Fistula needles 16 gauge - 2 Fistula needles 17 gauge - 1 The ICHD emergency evacuation box, per the facility policy, did not have the required supply count for the above items to cover 19 patient stations in the event of an emergency evacuation. During an interview at 11:08 AM, S1 confirmed that the facility had 19 licensed stations and that there should be a sufficient amount of supplies in the box for 19 patients for every shift. At 11:49 AM, in the Home Training area, the PD/HHD emergency evacuation box was reviewed. The box had a checklist titled “Emergency Box Content.” The checklist last reviewed on 2/3/25 and indicated that the Staff and Patient Emergency Contact Information list was present in the box. The box did not contain any staff emergency contact information, and the Emergency Patient Contact Information List was last printed on 10/24/24. During an interview at 12:14 PM, S5, the Home Therapy Manager, stated that the Emergency Patient Information Contact List should be updated monthly, and that the emergency box should also contain staff emergency contact information. Facility policy titled, “Emergency Medications, Equipment and Supplies,” published 2/3/25 stated, “... Definitions ... Emergency Evacuation Box: An emergency evacuation box contains supplies primarily needed to emergently remove needles, cap catheters, and provide saline as needed for every licensed station once the patient is in a secure location ... Emergency Evacuation Box ... Contain all patient and staff emergency contact information ... Be checked monthly or after use for contents, expiration dates and cleanliness ...” N.J.A.C. 8:43-15.1(a)”

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 50912 Based on one of two observations in the initiation of hemodialysis treatment via Central Venous Catheter (CVC, a type of access used for hemodialysis), review of facility documents, and staff interview, it is determined the facility failed to ensure that staff perform hand hygiene in accordance with facility policy. Findings include: On 2/26/25 at 10:30 AM in Station 2, Staff (S) 13, a Registered Nurse (RN) initiated hemodialysis treatment via a CVC on Patient (P) 8. S13 performed hand hygiene, donned (put on) new gloves and placed a clean blue pad under the CVC access site area. He/she then cleaned the CVC access site according to facility policy and procedure. With the same gloved hands, S13 then touched the hemodialysis machine and control panel and adjusted and checked P8’s hemodialysis treatment settings. S13 then, with the same gloved hands, proceeded to attach the bloodlines to the venous and arterial limbs. He/she then removed the gloves and rubbed his/her hands with an alcohol-based antiseptic hand rub. During an interview at 10:42 AM, S13 stated that he/she forgot to remove his/her gloves, wash his/her hands and put on new clean gloves prior to attaching the bloodlines to the CVC catheter ports after touching the hemodialysis machine and control panel. On 2/27/25, S13’s personnel file was reviewed and indicated he/she completed the web-based learning activity “Infection Prevention Fundamentals Course” for hemodialysis patients on 6/7/24 and “Annual Skills Validation for RNs” on 5/24/24 that included courses on Hand Hygiene and CVC Care. Facility policy titled, “Hand Hygiene” published 11/6/23, stated, “... Policy ... Hands will be ... Decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water ... before and after direct contact with patient ... After contact with inanimate objects near the patient ... When moving from a contaminated body site to a clean body site of the same patient ... After contact with other objects within the patient station or treatment space. ...” N.J.A.C. 8.43A-24.8(b)”

“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: 51990 Based on two of two observations of the dirty sink area, staff interview, and review of facility documents, it was determined that the facility failed to ensure that clean supplies are not stored in designated dirty areas to avoid possible cross contamination. Findings include: On 2/26/25 at 10:38 AM, during a tour of the In-Center Treatment Floor, the following was revealed: A sink area labeled “Lab (laboratory)/Dirty Sink” located across from Station 11, had a container on the countertop that had 10 used/dirty blue clamps inside. Below the sink area inside a cabinet, there were 10 unopened/unused gallon containers of 2K (Potassium) 2Ca (Calcium) Naturalyte (a dialysis solution used in hemodialysis machines to treat renal failure) stored. A second sink area labeled “Lab/ Dirty Sink” located across from Station 12, had a container on the countertop that had 16 (14 blue and two yellow) used/dirty clamps inside. Below the sink area inside a cabinet there were 12 unopened/unused gallon containers of 2K and 2Ca Naturalyte stored underneath the dirty sink. During an interview at 11:05 AM, Staff (S) 11, the Charge Nurse, confirmed that the clamps in both containers located in the dirty sink areas were used on patients. When questioned by the surveyor why clean supplies were being stored at a dirty sink area, S11 stated, “I don’t know why they are there.” S11 then walked away without moving the Naturalyte gallon containers to a designated clean area. Facility policy titled, “General Cleanliness and Infection Control Guidelines,” published 11/4/24, stated, “... Clean supplies may not be kept under dirty sinks... “ N.J.A.C. 8:43A-24.8(b)”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 51990 Based on two of two observations of medication storage in the Peritoneal Dialysis (PD)/ Home Hemodialysis (HHD) training area, staff interview, and a review of facility documents, it was determined that the facility failed to ensure that expired medications are not available for use. Findings include: On 2/25/25, during a tour of the PD/HHD training rooms, the following was revealed: At 11:35 AM, in Room 108, there was an opened multidose Heparin Sodium Injection 30,000 USP Units/30 ml (milliliter) vial located in a locked supply cabinet. The vial was labeled, “O (opened) 1/2/25 E (expiration) 1/30/25.” The open vial was 26 days past its beyond use date. At 11:45 AM, in Room 107, there were two open tubes of Gentamycin Cream, an antibiotic ointment. One tube was labeled, “O: 12/3/24.” This was 55 days past its maximum time period for use. The second tube was labeled, “O: 1/6/25.” This is 22 days past its maximum time period for use. During an interview at 1:21 PM, Staff (S) 5, the Home Therapy Manager, explained that Heparin multidose vials are discarded 28 days from the date the vials are opened and that the Gentamycin Cream is discarded according to the manufacturer’s expiration date. During an interview at 1:23 PM, S4, a PD Registered Nurse (RN), indicated that medications are monitored weekly for expiration. Facility policy titled, “Medication Preparation and Administration,” published 2/6/23, stated, “... Monitoring Expired Medications Expiration dates for all stored medication are to be monitored on a monthly basis. ... Any open multi dose vials must be discarded 28 days after opening ... The following table includes expiration date of bulk type items or outpatient dialysis floor stock. Medication Product Category ... Floorstock topical medication such as ointments, ophthalmic etc. ... Expiration Date/ Maximum Time Period for Use ... 28 days after opening ... “ N.J.A.C. 8:43A-9.3(b)”

“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 review of facility documents and staff interview, it was determined that the facility failed to ensure that the hemodialysis machine is disinfected and documented in accordance with the facility policy for 22 of 22 hemodialysis machines. Findings include: A review of the ‘Hemodialysis Heat Disinfection’ logs for January and February 2025 revealed that all machines were heat disinfected on 1/31/25. The logs indicated that on 2/3/25, the hemodialysis machines were not heat disinfected due to issues with the Reverse Osmosis machine. This was longer than 48 hours since the last heat disinfection. During an interview on 2/27/25 at 9:39 AM, Staff (S) 3, the Biomedical Technician, stated that the machines would normally have been heat disinfected on 2/1/25, but it did not occur because repairs to the centralized water processing system were made that day. S3 stated that the machines should have been heat disinfected on 2/3/25, prior to being used on patients. Facility policy titled, “Hemodialysis Machines: Acid Clean, Chemical Rinse, and Heat Disinfection,” published 5/2/22, stated, “... Policy ... The following defines the minimum dialysis machine cleaning and disinfection requirements. ... At the end of each treatment day of use, the dialysis machine must be: ... Chemical rinse or heat disinfection must be performed before treatment if the machine has not been disinfected within the previous 48 hours. ...” N.J.A.C 8:43A-24.11(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: 50912 Based on medical record review, staff interview and review of facility documents, it was determined that the facility failed to ensure that: 1) post hemodialysis nursing assessments are completed in one of seven medical records reviewed (Patient (P) 1); and 2) abnormal blood pressure (BP) readings occurring during hemodialysis treatment are reported to, assessed by, and acknowledged by, a Registered Nurse (RN) in one of seven medical records reviewed (P4). Findings include: 1. A review of P1’s plan of care, dated 1/29/25, stated, “Area of Focus BP and Fluid Management ... Open Goal: Achieve BP Control as specified by the patient’s physician ... Patient meets BP and fluids goals for most treatments ...” On 2/26/25, a review of the “Treatment Sheet for Facility” from 2/7/25 through 2/24/25 in P1’s medical record revealed the following: On 2/7/25 at 2:16 PM, the pre-treatment “Nursing Evaluation” stated “bilateral ankle edema, plus one: two mm [millimeters] or less, disappears rapidly.” The post-treatment “Nursing Evaluation” at 6:34 PM lacked documented evidence of a re-assessment of the bilateral ankle edema. On 2/10/25 at 3:16 PM, the pre-treatment “Nursing Evaluation” stated “bilateral [affecting both sides] ankle edema, two plus: two to four mm indent, disappears 10-15 seconds.” The post-treatment “Nursing Evaluation” at 7:19 PM lacked documented evidence of a re-assessment of the bilateral ankle edema. On 2/12/25 at 4:20 PM, the pre-treatment “Nursing Evaluation” stated “bilateral ankle edema, one plus: two mm or less, disappears rapidly.” The post-treatment “Nursing Evaluation” at 7:35 PM lacked documented evidence of a re-assessment of the bilateral ankle edema. On 2/14/25 at 3:30 PM, the pre-treatment “Nursing Evaluation” stated “bilateral ankle edema, one plus: two mm or less, disappears rapidly.” The post-treatment “Nursing Evaluation” at 7:41 PM lacked documented evidence of a re-assessment of the bilateral ankle edema. On 2/24/25 at 5:13 PM, the pre-treatment “Nursing Evaluation” stated “bilateral ankle edema, one plus: two mm or less, disappears rapidly.” The post-treatment “Nursing Evaluation” at 7:05 PM lacked documented evidence of a re-assessment of the bilateral ankle edema. During an interview on 2/26/25 at 2:14 PM, Staff (S) 1, the Facility Administrator, reviewed the above findings and confirmed that the post hemodialysis re-assessment of edema was not documented on the above-mentioned hemodialysis flowsheets. S1 stated that staff nurses should reassess and document post-treatment edema if abnormal findings were found pre-treatment. Facility policy titled, “Patient Assessment and Monitoring,” published 05/01/23, stated, “... Purpose ... provide guidance to (facility name) direct patient care staff on assessment and monitoring patients before, during and after treatment ... Post Treatment ... Follow the steps below for obtaining post-treatment assessment data ... Edema ... The Registered Nurse will assess/reassess post treatment as indicated. ... Document findings in the patient’s medical record. ...” 2. On 2/26/25, a review of P4’s hemodialysis treatment flowsheets from 2/5/24 through 2/24/25 revealed the following: The hemodialysis treatment flowsheet, dated 2/5/25, stated: 3:26 PM BP (blood pressure) 188/80, a PCT (Patient Care Technician) noted, “... Denies Complaints ...” 4:15 PM BP 181/77 4:46 PM BP 194/82, a PCT noted, “... Denies Complaints ...” 5:06 PM BP 198/78 5:35 PM BP 191/77 5:59 PM BP 191/76, a PCT noted, “... Denies Complaints ...” There was no documented evidence that the PCT notified the RN of the above elevated systolic BPs greater than 180 mm/HG (millimeters of mercury). The hemodialysis treatment flowsheet, dated 2/14/25, stated: 2:49 PM BP 201/81 3:25 PM BP 201/81, a PCT noted, “... Denies Complaints ...” 5:21 PM BP 186/74 6:01 PM BP 167/110, a PCT noted, “... Denies Complaints ...” 6:38 PM BP 197/77 There was no documented evidence that the PCT notified the RN of the above elevated systolic BPs greater than 180 mm/Hg and the elevated diastolic BP greater than 100 mm/Hg. The hemodialysis treatment flowsheet, dated 2/17/25, stated: 2:08 PM BP 190/83, a PCT noted, “... Denies Complaints ...” 2:46 PM BP 182/79 3:21 PM BP 193/81 5:40 PM BP 200/72 There was no documented evidence that the PCT notified the RN of the above elevated systolic BPs greater than 180 mm/HG. A review of the hemodialysis treatment flowsheet, dated 2/24/25, stated: 2:01 PM BP 191/81 2:31 PM BP 181/82, a PCT noted, “... Denies Complaints ...” 4:09 PM BP 187/78 4:30 PM BP 190/79 4:50 PM BP 193/76 5:19 PM BP 185/73, a PCT noted, “... Denies Complaints ...” 5:40 PM BP 189/75, a PCT noted, “... Denies Complaints Treatment Discontinued without problem ...” There was no documented evidence that the PCT notified the RN of the above elevated systolic BPs greater than 180 mm/Hg. The above hemodialysis treatment flowsheets were reviewed with S1, the Facility Administrator, on 2/26/25 at 12:45 PM. S1 confirmed that the above blood pressures were elevated, that there was no documented evidence that the PCT notified the RN of the elevated blood pressures. S1 stated that if the blood pressure is that high the PCT should have notified the nurse. Facility policy titled, “Patient Assessment and Monitoring,” published 5/1/2023, stated, “... Purpose ... provide guidance to (name of facility) direct patient care staff on assessments and monitoring patients ... during ... treatment ... Responsibility Direct patient care staff (RN, ... PCT) ... Data Collection Direct patient care staff may collect data such as ..., BP, ... If the PCT... note any changes or abnormal findings in the patients condition ... the Registered Nurse must assess the patient ... The Registered Nurse will assess/re-assess any findings addressed ... during treatment as needed. ... During Treatment ... Step 1 Record blood pressure ... Report to the nurse: Systolic blood pressure greater than 180 mm/Hg [millimeters of mercury] or Diastolic blood pressure greater than 100 mm/Hg ... Step 4 Document findings and interventions in the medical record. ...” N.J.A.C. 8:43A-24.4(a)”

“POC-INITIAL IMPLEMENTED-30 DAYS/13 TX CFR(s): 494.90(b)(2) Implementation of the initial plan of care must begin within the latter of 30 calendar days after admission to the dialysis facility or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session. This Standard is not met as evidenced by: 51990 Based on one of seven medical records reviewed (Patient (P) 7), staff interview, and a review of facility documents, it was determined that the facility failed to ensure that patient’s interdisciplinary team (IDT) Comprehensive Interdisciplinary Assessments (CIA) are completed within 15 days of each other and that an initial Plan of Care (POC) is developed within 30 calendar days of admission. Findings include: On 2/27/25, a review of P7’s medical record revealed the following: P7 was admitted to the facility on 11/4/24 as an in-center hemodialysis patient. On 12/17/24, P7 changed his/her modality to Peritoneal Dialysis (PD), a treatment for kidney failure that uses the lining of the abdomen (peritoneum) as a filter to remove waste products and excess fluid from the blood. The initial POC meeting was held on 1/24/25. This was 38 days after P7’s admission date to PD. The IDT completed the CIAs on the following dates: ESRD (End Stage Renal Disease) Comprehensive Registered Nurse (RN) Assessment - 1/2/25 Nutrition History and Assessment - ESRD- 1/13/25 ESRD Comprehensive Social Worker Assessment - 1/15/25 ESRD Comprehensive Physician (MD) Assessment - 1/29/25. The MD’s CIA was completed 29 days after the RN’s assessment dated 1/2/25 and five days after the initial POC meeting on 1/24/25. During an interview on 2/27/25 at 10:05 AM, Staff (S) 5, the Home Therapy Manager, and S4, the Peritoneal Dialysis (PD) Nurse, confirmed that the initial POC meeting was held on 1/24/25 and that the MD’s CIA was completed after the meeting. Facility policy titled, “Comprehensive Interdisciplinary Assessment and Plan of Care,” published 7/3/23, stated, “ ... CIA and POC for Patients New to Dialysis ... An initial Comprehensive Interdisciplinary Assessment (CIA) and Plan of Care (POC) must be conducted on all patients new to dialysis within the later 30 calendar days or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session. Patients changing modality are classified as new patients and must have comprehensive interdisciplinary assessment and plan of care with the same frequency as patients new to dialysis ... Implementation of monthly or annual updates of the plan of care must be performed within 15 days of the completion of the additional patient assessments ... “ N.J.A.C 8:43A-24.13(b)”

“H-FAC RECEIVE/REVIEW PT RECORDS Q 2 MONTHS CFR(s): 494.100(b)(2),(3) The dialysis facility must - (2) Retrieve and review complete self-monitoring data and other information from self-care patients or their designated caregiver(s) at least every 2 months; and (3) Maintain this information in the patient ’ s medical record. This Standard is not met as evidenced by: 39223 Based on medical record review, staff interview, and a review of facility documents, it was determined the facility failed to ensure that the Interdisciplinary Team (IDT) reviewed all home therapy patients’ treatment records for adherence to the prescribed dose of dialysis for two of two Home Therapy medical records reviewed (Patient (P) 6 and P7). Findings include: A review of P6’s medical record, a Home Hemodialysis (HHD) patient, revealed the following: A document titled, “Patient Transfer,” stated, “... Hemodialysis... BFR [blood flow rate] 400... Start Date 9/16/2024... End Date 9/15/25... Patient Management Services... Adjust BFR to Maintain Arterial Pressure (AP) of negative (-) 250 or Greater... Start Date 3/4/24... End Date 3/3/25... Treatment Medications- Outpatient Dialysis Anticoagulation... Heparin Pork 1000 Units/ml [milliliter] Catheter Lock Self Admin Home Arterial Red Port 1700 units every Treatment... Heparin Pork 1000 Units/ Milliliters(ml) Catheter Lock Self Admin Home Venous Blue Port 1800 units every Treatment... Heparin Pork 1000 Units/ml Systemic Self Administer Home Admin Method: Bolus 5000 units Intravenous Push (IVP) every Treatment... Start Date 3/4/24... End Date 3/3/25...” The Nx2Me (an electronically transmitted treatment report) HHD treatment sheets completed by the patient or the care partner from 2/4/25 to 2/24/25, indicated that there were 13 HHD treatments that lacked documented evidence as to the reason the BFR was not delivered to 400 and that Heparin was received every treatment as prescribed by the Physician. The documented BFR delivered per treatment and the AP documented during the 3 hour treatment were as follows: 2/04/25- BFR 370; the AP ranged from -139 to -158 2/05/25- BFR 370; the AP ranged from -132 to -153 2/06/25- BFR 370; the AP ranged from -139 to -157 2/09/25- BFR 370; the AP ranged from -98 to -150 2/10/25- BFR 370; the AP ranged from -136 to -157 2/12/25- BFR 370; the AP ranged from -147 to -159 2/13/25- BFR 370; the AP ranged from -129 to -147 2/16/25- BFR 370; the AP ranged from -127 to -145 2/17/25- BFR 370; the AP ranged from -138 to -159 2/19/25- BFR 360; the AP ranged from -130 to -149 2/21/25- BFR 370; the AP ranged from -146 to -153 2/23/25- BFR 370; the AP ranged from -133 to -160 2/24/25- BFR 370; the AP ranged from -138 to -152 The RN Clinical Notes Report dated 2/24/25 was reviewed and lacked documented evidence that the HHD treatment flowsheets were reviewed and that the BFR and Heparin were discussed with the patient and/or the care giver at the patient’s monthly clinic visits. During an interview on 2/25/25 at 1:24 PM, Staff (S) 12, a HHD Nurse, stated the BFR is delivered based on AP to be maintained at -250. S12 explained that Heparin does not need to be documented on the flowsheet as it is a standing order. Facility policy titled, “Review and Documentation of Home Therapies Patient Health Data,” Published 5/1/23, stated, “... Review and Documentation of Health Data ... Actionable health data will be reviewed and addressed by the home therapies nurse or appropriate staff member in a timely manner. Follow up communication with the patient, including interventions or instructions as needed, will be documented in the patient’s medical record. ...” A review of P7’s medical record, a Peritoneal Dialysis (PD, a treatment for kidney failure that used the lining of the abdomen (peritoneum) as a filter to remove waste products and excess fluid from the blood) patient, revealed a physician’s order, starting 1/13/25 that stated, “... Special Attention: May use 2 [two bags] - 1.5% LM/LC dextrose on TuThurSatSun [Tuesday Thursday Saturday and Sunday] and 1 [one bag] -1.5% and 1 [one bag] -2.5% LM/LC dextrose on MonWedFri [Monday, Wednesday, Friday] per MD [medical doctor], Every Treatment, ...” Review of the “KNX Treatment Summary: PD” for 1/26/25 through 2/24/25 revealed the following: On 1/26/25 (Sunday), 1/28/25 (Tuesday), and 2/1/25 (Saturday), the patient documented that one bag of 1.5% Dextrose, and one bag 2.5% Dextrose were used. This was not in accordance with the above physician order, which required two 1.5% Dextrose bags. On 2/5/25 (Wednesday), 2/7/25 (Friday), 2/10/25 (Monday), 2/14/25 (Friday), 2/17/25 (Monday), and 2/19/25 (Wednesday) the patient documented that two bags of 1.5% Dextrose were used. This was not in accordance with the above physician order, which required one bag of 1.5% Dextrose and one bag of 2.5% Dextrose. During an interview on 2/27/25 at 11:00 AM, Staff (S) 4, the Peritoneal Dialysis Registered Nurse, stated that he/she reviews the patient’s documented treatments every week. S4 confirmed that he/she did not document follow up communication with P7 about following the physician’s peritoneal dialysis orders. Facility policy titled, “Review and Documentation of Home Therapies Patient Health Data,” Published 5/1/23, stated, “... Review and Documentation of Health Data ... Actionable health data will be reviewed and addressed by the home therapies nurse or appropriate staff member in a timely manner. Follow up communication with the patient, including interventions or instructions as needed, will be documented in the patient’s medical record. ...” N.J.A.C. 8:43A-24.20(a) 51990”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 51990 Based on two of two observations of medication storage in the Peritoneal Dialysis (PD)/ Home Hemodialysis (HHD) area, staff interview, and a review of facility documents, it was determined that the Medical Director failed to ensure that opened, needle punctured, multidose medication vials are discarded and not available for patient use after being taken into a patient room in accordance with facility policy and procedure and CDC (Center for Disease Control and Prevention) guidelines. Findings include: Reference: CDC, “Preventing Unsafe Injection Practices,” dated 3/26/24, Preventing Unsafe Injection Practices | Injection Safety | CDC; states, “ ... Assign medications packaged as multi-dose vials to a single patient whenever possible. Multi-dose vials that are used for more than one patient should be kept and accessed in a clean medication preparation area away from immediate patient treatment areas. If a multi-dose vial enters an immediate patient treatment area, dedicate it for single patient use only. Examples of immediate patient treatment areas include ... patient rooms or bays ...” On 2/25/25 at 11:35 AM, during a tour of PD/HHD Training Room 108, a Training Room used for patient care, there were two open, needle punctured, multi-dose Heparin Sodium Injection 30,000 USP Units/30 ml (milliliter) vials located in a locked supply cabinet that were available for use. One of the vials was labeled, “O (opened) 1/2/25.” The other vial was labeled “O 2/24/25.” During an interview on 2/26/25 at 9:57 AM, Staff (S) 4, a PD Registered Nurse (RN), explained that the Heparin multidose vials are stored in the locked drawer in the training room and used on multiple patients that come in for training when needed. S4 explained that the Heparin is prepared aseptically in the training room on the clean counter space or on a tray with proper disinfection. S4 clarified that one of the open Heparin vials observed in Room 108 that was labeled opened on 2/24/25, was used for a new PD patient seen in the facility on 2/24/25 for a PD catheter flush. Facility policy titled, “Medication Preparation and Administration,” published 2/6/23, stated, “... IV (intravenous) Solutions ... Once an IV solution is taken into a patient station or room it cannot be used for any other patient ...” N.J.A.C. 8:43A-9.3(a)”