Bma Rosenberg

“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: 48020 Based on observation, interview and record review, the facility’s direct care staff failed to: clean and disinfect the IV poles/rungs, Hansen connectors, prime bucket, blood pressure cuff holders, hand sanitizer/holders, chase counter tops and walls, and wall boxes in 1 of 2 staff observed: Patient Care Technician (C) B) prevent cross contamination by wiping the dialysate lines that were touching the ground and using the same towel to wipe the hemodialysis machine in 1 of 2 staff observed: Patient Care Technician (C) Findings: Review of facility’s current policy and procedure: Cleaning and Disinfecting the Dialysis Station, reference # 47806 directs staff as follows: “The Centers for Medicare and Medicaid Services (CMS) has regulations that in order to prevent cross contamination, a dialysis station must be cleaned and disinfected between dialysis patients. The chair and dialysis equipment are used by multiple patients during a treatment day, and it is critical that these items be thoroughly cleaned and disinfected between uses.” Review of the Center for Disease Control (CDC) Dialysis Safety: Dialysis Wall Boxes and Drains states: “ wall boxes need to be cleaned, disinfected, and properly maintained to decrease risk of patient infections. Wall boxes are part of the immediate patient care environment and are considered contaminated or dirty.” Disinfection of the hemodialysis station: Patient Care Technician (C) Station #14 Observation on 04/22/2025 at 12:30 p.m. revealed Patient Care Technician (C) terminally cleaning station #14 post hemodialysis treatment of a patient. Patient Care Technician (C) failed to clean and disinfect the IV pole rungs, blood pressure cuff holder, hand sanitizer/holder, chase counter top and wall, and wall box. Station #15 Observation on 02/25/2025 at 12:37 p.m. revealed Patient Care Technician (C) terminally cleaning station #15 post hemodialysis treatment of a patient. Patient Care Technician (C) failed to clean and disinfect the IV pole/rungs, Hansen connectors, prime bucket, blood pressure cuff holder, and hand sanitizer/holder. Cross contamination of the hemodialysis station: Subsequent observation of Patient Care Technician (C) terminally cleaning station #15 revealed she: wiped the dialysate lines that were touching the ground and used the same towel to wipe the front of the hemodialysis machine. B) wiped the blood pressure cuff and draped it on the hand sanitizer bottle that she did not clean and disinfect. C) wiped the television remote and placed it in the blood pressure cuff holder that she did not clean and disinfect. The Surveyor immediately notified Patient Care Technician (C) that she failed to clean and disinfect the dialysis station per policy at station #s 14 and 15. Patient Care Technician (C) said, “Okay.””

“PR-RECEIVE SERVICES OUTLINED IN POC CFR(s): 494.70(a)(12) The patient has the right to- (12) Receive the necessary services outlined in the patient plan of care described in §494.90; This Standard is not met as evidenced by: 48020 Based on observation, record review and interview, the facility’s licensed nurses and direct care staff failed to administer patients’ hemodialysis treatments based on physicians’ orders in 1 of 11 sampled and 2 closed record patients: Patient #4 Findings: Review of the facility’s current Policy and Procedure on Pre-Treatment Safety Checks; Policy #47798 directs staff as follows: Policy The clinician initiating treatment must verify the prescribed set up matches the patient: “ Patient’s identity per policy “ Prescription o Dialyzer o Dialysate composition o Dialysate flow rate o Time o Goal set o Needle size o Temperature “ Special attention orders are followed “ Na modeling (SVS) and/or UFR profiling if applicable “ Heparin dose. If a heparin pump is used check to see if it is primed, turned on and set at the proper prescribed infusion rate. “ OLC volume “ Blood pressure and parameters are set Review of the facility’s current Policy and Procedure on Nursing Supervision and Delegation; Policy #45265 directs staff as follows: Policy The registered nurse must evaluate each patient preferably within an hour or according to state requirements to: ... “ Review accuracy and completeness of treatment and patient data “ Review patient treatment prescription and equipment parameters to verify correct settings, and if dialysis prescription is being followed. Dialysate Composition Patient #4 Observation on 04/22/2025 at 11:27 a.m. revealed Patient #4 was seated at station #7 machine #41 receiving hemodialysis treatment at a blood flow rate of 350 mL/min and a dialysate flow rate of 500 mL/min via left upper arm vascular access. The patient was utilizing an Optiflux 160 non reuse dialyzer. The dialysate settings were: 2.9 potassium, 2.5 calcium, 35 bicarbonate, 137 sodium. Potassium Bath: Review of the patient’s clinical record located in the chairside computer with Registered Nurse (D) at chairside, revealed a physician’s order for Potassium 2.0 (mEq/L). Interview during observation with Registered Nurse (D), the Surveyor informed Registered Nurse (D) that the dialysate potassium was not set on the hemodialysis machine as prescribed by the physician. Registered Nurse (D) said, “I don’t know who set it up but I am responsible.””

“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: 48020 Based on observation, record review and interview, the facility’s registered nurses failed to conduct assessments post treatment when patients experienced a change in condition before the hemodialysis treatment per the facility’s policy in 7 of 11 sampled and 2 of 2 closed record patients: Patient #s 1, 2, 6, 7, 8, 10, 11, 12 and 13 Findings: Review of the facility’s current policy and procedure on Patient Assessment and Monitoring; Policy # 45284 directs staff as follows: “o The RN will notify the patient’s physician/physician extender of any abnormal findings, if necessary, based on clinical judgment for additional instruction. The Registered Nurse will assess/re-assess any findings addressed pre or during treatment as needed. Post-Treatment Lungs sounds Edema Heart sounds The registered nurse will assess/re-assess post treatment as indicated.” Patient #1 Observation on 04/22/2025 at 11:20 a.m. revealed Patient #1 was seated at station #15 machine #49 receiving hemodialysis treatment at a blood flow rate of 400 mL/min and a dialysate flow rate of a800 mL/min via left upper arm vascular access. Review of the patient’s clinical record on 04/23/2025 revealed the following: Treatment sheet review: Review of treatment sheet dated 04/12/2025 revealed the following documentation: 8:02 a.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms Lower Leg - Severity: 1+: 2 mm or less, disappears rapidly Ankle - Severity: 1+: 2 mm or less, disappears rapidly Edema Ankle - Location: Bilateral Edema Lower Leg - Location: Bilateral 12:31 p.m.: registered nurse documented the post treatment assessment which revealed Notes: Hypotension noted during tx, resolved. No complaints reported upon discharge, VSS.” The RN did not document a reassessment of edema found during the pretreatment assessment. Review of treatment sheet dated 04/10/2025 revealed the following documentation: 8:00 a.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms Lungs - Decreased breath sounds Lower Leg - Severity: 1+: 2 mm or less, disappears rapidly Ankle - Severity: 1+: 2 mm or less, disappears rapidly Edema Ankle - Location: Bilateral Edema Lower Leg - Location: Bilateral 12:42 p.m.: registered nurse documented the post treatment assessment which revealed Notes: No complaints, VSS upon discharge .” The RN did not document a reassessment of decreased breath sounds and edema found during the pretreatment assessment. Patient #2 Observation on 04/22/2025 at 11:22 a.m. revealed Patient #2 was seated at station #12 machine #2 receiving hemodialysis treatment at a blood flow rate of 400 mL/min and a dialysate flow rate of a600 mL/min via left upper arm vascular access. Review of the patient’s clinical record on 04/23/2025 revealed the following: Treatment sheet review: Review of treatment sheet dated 04/15/2025 revealed the following documentation: 10:45 a.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms Ankle - Severity: 1+: 2 mm or less, disappears rapidly Edema Ankle - Location: Bilateral 13:45 p.m.: documented blood pressure of 102/64 mmHg and pulse rate of 90 beats per minute - patient care technician documented “ ...Treatment Discontinued Without Problem” 15:19 p.m.: registered nurse documented the post treatment assessment which revealed Notes: Pt tolerated tx well, edw was adjusted to 86.5kg per Dr. ____, no complaints verbalized. VSS.” The RN documented the post treatment assessment 1 hour and 26 minutes after the completion of the hemodialysis treatment. The RN did not document a reassessment of edema found during the pretreatment assessment. Patient #6 Observation on 04/22/2025 at 11:50 a.m. revealed Patient #6 was seated at station #14 holding her left upper arm vascular access after the completion of the hemodialysis treatment. Review of the patient’s clinical record on 04/23/2025 revealed the following: Treatment sheet review: Review of treatment sheet dated 04/12/2025 revealed the following documentation: 7:57 a.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms Lower Leg - Severity: 1+: 2 mm or less, disappears rapidly Ankle - Severity: 1+: 2 mm or less, disappears rapidly Edema Lower Leg - Location: Bilateral Edema Ankle - Location: Bilateral 12:28 p.m.: registered nurse documented the post treatment assessment which revealed Notes: Pt tolerated tx well, BP improved, no complaints reported. VSS.” The RN did not document a reassessment of edema found during the pretreatment assessment. Review of treatment sheet dated 04/10/2025 revealed the following documentation: 7:28 a.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms Lower Leg - Severity: 1+: 2 mm or less, disappears rapidly Ankle - Severity: 1+: 2 mm or less, disappears rapidly Edema Ankle - Location: Bilateral Edema Lower Leg - Location: Bilateral 12:31 p.m.: registered nurse documented the post treatment assessment which revealed Notes: Tx well tolerated, no complaints. V/S stable upon discharge.” The RN did not document a reassessment of edema found during the pretreatment assessment. Patient #7 Observation on 04/22/2025 at 12:52 p.m. revealed Patient #7 was seated at station #13 machine #9 receiving hemodialysis treatment at a blood flow rate of 350 mL/min and a dialysate flow rate of 600 mL/min via left lower arm vascular access. Review of the patient’s clinical record on 04/23/2025 revealed the following: Treatment sheet review: Review of treatment sheet dated 04/12/2025 revealed the following documentation: 12:00 a.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms Lower Leg - Severity: 1+: 2 mm or less, disappears rapidly Ankle - Severity: 1+: 2 mm or less, disappears rapidly Edema Ankle - Location: Bilateral Edema Lower Leg - Location: Bilateral 16:29 p.m.: registered nurse documented the post treatment assessment which revealed Notes: Pt tolerated tx well, BP improved, no complaints reported. VSS.” The RN did not document a reassessment of edema found during the pretreatment assessment. Patient #8 Observation on 04/22/2025 at 12:54 p.m. revealed Patient #8 was seated at station #11 machine #42 receiving hemodialysis treatment at a blood flow rate of 250 mL/min and a dialysate flow rate of 600 mL/min via left upper arm vascular access (arterial) and right central venous catheter (venous). Review of the patient’s clinical record on 04/23/2025 revealed the following: Treatment sheet review: Review of treatment sheet dated 04/15/2025 revealed the following documentation: 7:36 a.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms Lungs - Decreased breath sounds Ankle - Severity: 1+: 2 mm or less, disappears rapidly Lower Leg - Severity: 1+: 2 mm or less, disappears rapidly Lungs - Sound Location: Bilateral Edema Lower Leg - Location: Bilateral Edema Ankle - Location: Bilateral 12:18 p.m.: registered nurse documented the post treatment assessment which revealed Notes: Post tx wt 1kg above edw, no c/o SOB. Instructed to adhere to fluid/diet restrictions, receptive. VSS. MD was notified, no new orders. Will continue to monitor.” The RN did not document a reassessment of decreased breath sounds and edema found during the pretreatment assessment. Patient #10 Review of the patient’s clinical record on 04/23/2025 revealed the patient was admitted to the facility 06/03/2024 with the diagnoses of end stage renal disease, atherosclerotic heart disease, hypertension, and type 2 diabetes mellitus, on hemodialysis three times a week. Treatment sheet review: Review of treatment sheet dated 04/14/2025 revealed the following documentation: 06:51 a.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms Ankle - Severity: 1+: 2 mm or less, disappears rapidly Lower Leg - Severity: 1+: 2 mm or less, disappears rapidly Edema Ankle - Location: Bilateral Edema Lower Leg - Location: Bilateral 13:00 p.m.: registered nurse documented the post treatment assessment which revealed Notes: RN Evaluation - No Unusual findings noted. AAOX3, no c/o, vss, tolerated tx well, educated fluid/ salt restriction, not in distress, d/c home stable.” The RN did not document a reassessment of edema found during the pretreatment assessment. Review of treatment sheet dated 04/02/2025 revealed the following documentation: 06:53 a.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms Ankle - Severity: 1+: 2 mm or less, disappears rapidly Edema Ankle - Location: Bilateral 11:24 p.m.: registered nurse documented the post treatment assessment which revealed Notes: RN Evaluation - No Unusual findings noted. Tolerated tx well, left 4.7 kg over edw, denies c/o, educated about fluid/ salt restriction, voice understanding, vss, discharged without any distress. PT left via w/c. Extra tx offered, pt stated he will call in the morning. SOB relieved post tx.” The RN did not document a reassessment of edema found during the pretreatment assessment. Patient #11 Review of the patient’s clinical record on 04/23/2025 revealed the patient was admitted to the facility 03/29/2025 with the diagnoses of end stage renal disease and type 2 diabetes mellitus, on hemodialysis three times a week. Treatment sheet review: Review of treatment sheet dated 04/10/2025 revealed the following documentation: 13:43 a.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms Lower Leg - Severity: 1+: 2 mm or less, disappears rapidly Ankle - Severity: 1+: 2 mm or less, disappears rapidly Edema Ankle - Location: Bilateral Edema Lower Leg - Location: Bilateral 17:38 p.m.: registered nurse documented the post treatment assessment which revealed Notes: Tx well tolerated, no complaints. V/S stable upon discharge.” The RN did not document a reassessment of edema found during the pretreatment assessment. Patient #12 Review of the patient’s clinical record on 04/23/2025 revealed the patient was admitted to the facility 06/28/2023 with the diagnoses of end stage, congestive heart failure, cyst of kidney, hypertension and type 2 diabetes mellitus, on hemodialysis three times a week. Treatment sheet review: Review of treatment sheet dated 03/05/2024 revealed the following documentation: 05:27 a.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms Ankle - Severity: 1+: 2 mm or less, disappears rapidly Lower Leg - Severity: 1+: 2 mm or less, disappears rapidly Edema Lower Leg - Location: Bilateral Edema Ankle - Location: Bilateral 09:57 a.m.: registered nurse documented the post treatment assessment which revealed Notes: Post tx wt 2.7kg above edw, no c/o SOB, lungs CTA. Instructed to adhere to fluid/diet restrictions, seek medical attention if she develops SOB, receptive. VSS. MD was notified, no new orders. Will continue to monitor.” The RN did not document a reassessment of edema found during the pretreatment assessment. Patient #13 Review of the patient’s clinical record on 04/23/2025 revealed the patient was admitted to the facility 02/06/2025 with the diagnoses of acute kidney injury, congestive heart failure, hypertension and type 2 diabetes mellitus, on hemodialysis three times a week. The patient also had the diagnoses of morbid obesity, hyperlipidemia and anemia. Treatment sheet review: Review of treatment sheet dated 03/19/2025 revealed the following documentation: 14:59 p.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms Lungs - Decreased breath sounds Ankle - Severity: 1+: 2 mm or less, disappears rapidly Lower Leg - Severity: 1+: 2 mm or less, disappears rapidly 19:13 p.m.: registered nurse documented the post treatment assessment which revealed Notes: RN Evaluation - No Unusual findings noted. Pt. completed and tolerated HD tx. w/no complications. UF goal of met at EDW VSS. Pt denies complaints. CVC intact/secured. Discharged to home stable per w/c.” The RN did not document a reassessment of decreased breath sounds and edema found during the pretreatment assessment. Review of treatment sheet dated 03/14/2025 revealed the following documentation: 15:36 p.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms Ankle - Severity: 1+: 2 mm or less, disappears rapidly Lower Leg - Severity: 1+: 2 mm or less, disappears rapidly Edema Ankle - Location: Bilateral Edema Lower Leg - Location: Bilateral 19:58 a.m.: registered nurse documented the post treatment assessment which revealed Notes: Tx well tolerated, left 0.7 kg under edw, denies c/o, vss, educated about fluid/salt restriction, voice understanding, discharged without any distress.” The RN did not document a reassessment of edema found during the pretreatment assessment. Notification during record review on 04/23/2025 at 2:05 p.m. with Clinical Manager (G) and Director of Operations (H) confirmed Patient #13 did not receive a reassessment by the registered nurse on the edema found pretreatment. The Surveyor also notified Clinical Manager (G) and Director of Operations (H) Patient #s 1, 2, 6, 7, 8, 10, 11 and 12 did not receive a reassessment by the registered nurse on the breath sounds and/or edema found pretreatment. Clinical Manager (G) and Director of Operations (H) said, “Okay.””

“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: 48020 Based on observation, interview and record review, the facility’s direct care staff failed to clean and disinfect the IV pole, Hansen connectors, blood pressure cuff holders, hand sanitizer and holder, sharps disposal container, dialysate lines, back of the machine, and chase cabinet behind the dialysis station in 3 of 7 sampled staff observed: Licensed Vocational Nurse (F), Patient Care Technician (H), and Registered Nurse (E). Findings: Review of facility’s current policy and procedure on cleaning and disinfecting the dialysis station published 09/05/2023, reference number 47806 version 14 directs staff as follows: “The Centers for Medicare and Medicaid Services (CMS) has regulations that in order to prevent cross contamination, a dialysis station must be cleaned and disinfected between dialysis patients. The chair and dialysis equipment are used by multiple patients during a treatment day, and it is critical that these items be thoroughly cleaned and disinfected between uses.” Review of the Center for Disease Control (CDC) Dialysis Safety: Dialysis Wall Boxes and Drains states: “ wall boxes need to be cleaned, disinfected, and properly maintained to decrease risk of patient infections. Wall boxes are part of the immediate patient care environment and are considered contaminated and dirty.” Licensed Vocational Nurse (F) Station #21 hemodialysis machine #1 Observation on 01/08/2024 at 11:27 p.m. revealed Licensed Vocational Nurse (F) terminally cleaning station #21 post hemodialysis treatment of a patient. During terminal cleaning of the hemodialysis machine #1 at station #21, Patient Care Technician (F) failed to clean and disinfect the IV pole, Hansen connectors, blood pressure cuff holder, hand sanitizer and holder, sharps container, dialysate lines, back of the machine, and chase cabinet behind the dialysis station. Station #24 hemodialysis machine #6 Observation on 01/08/2024 at 11:42 a.m. revealed Licensed Vocational Nurse (F) terminally cleaning station #24 post hemodialysis treatment of a patient. During terminal cleaning of the hemodialysis machine #6 at station #24, Patient Care Technician (F) failed to clean and disinfect the IV pole, Hansen connectors, blood pressure cuff holder, hand sanitizer and holder, sharps container, dialysate lines, back of the machine, and chase cabinet behind the dialysis station. Station #23 hemodialysis machine #2 Observation on 01/08/2024 at 12:30 p.m. revealed Licensed Vocational Nurse (F) terminally cleaning station #24 post hemodialysis treatment of a patient. During terminal cleaning of the hemodialysis machine #6 at station #24, Patient Care Technician (F) failed to clean and disinfect the IV pole, Hansen connectors, blood pressure cuff holder, hand sanitizer and holder, sharps container, dialysate lines, back of the machine, and chase cabinet behind the dialysis station. Interview with Licensed Vocational Nurse (F) at 12:45 p.m., the Surveyor notified Licensed Vocational Nurse (F) the IV pole, Hansen connectors, blood pressure cuff holder, hand sanitizer and holder, sharps container, dialysate lines, back of the machine, and chase cabinet behind the dialysis station were not cleaned during station disinfection. Licensed Vocational Nurse (F) said “Okay.” Patient Care Technician (H) Station #25 hemodialysis machine #48 Observation on 01/09/2024 at 09:45 a.m. revealed Patient Care Technician (H) terminally cleaning station #25 post hemodialysis treatment of a patient. During terminal cleaning of the hemodialysis machine #48 at station #25, Patient Care Technician (H) failed to clean and disinfect the IV pole, Hansen connectors, hand sanitizer and holder, dialysate lines, back of the machine, and chase cabinet behind the dialysis station. Interview with Patient Care Technician (H) at 10:02 a.m., the Surveyor notified Patient Care Technician (H) the IV pole, Hansen connectors, hand sanitizer and holder, dialysate lines, back of the machine, and chase cabinet behind the dialysis station were not cleaned during station disinfection. Patient Care Technician (H) said “Okay.” 10802 Registered Nurse (E) On 01/08/2024 at 10:56 a.m. Registered Nurse (E) was observed at station # 14 hemodialysis machine #54. The registered nurse was terminally cleaning the unit post hemodialysis of a patient. The registered nurse did not clean/ disinfect the chase, hoses and red box (sharp container) attached to the hemodialysis machine. On 01/08/2024 at 11:10 a.m. Registered Nurse (E) was observed priming clean external blood lines and dialyzer in preparation for an oncoming patient. After priming the blood lines and dialyzer, an open alcohol swab was observed lying on the floor of the station. The registered nurse picked up the swab with his gloved hand, then returned to the hemodialysis machine and positioned the external blood line on the machine. On 1/08/2024 at 11:20 a.m. The Patient Care Technician assigned to the bay was observed engaging the hemodialysis machine to pre- test for the on- coming patient. On 1/08/2023 at 11: 55 a.m. The Surveyor notified registered Nurse (E) of break in infection control technique of him not cleaning /disinfecting the chase, hoses and red box (sharp container) attached to the hemodialysis machine and that he had contaminated the hemodialysis machine after picking up the swab off the floor then using his contaminated gloved hands to reposition the external blood line. Registered Nurse (E) states” I apologize, I will break it down.””

“GOV-ID GOV BODY W/FULL AUTHORITY/RESPONS CFR(s): 494.180 The ESRD facility is under the control of an identifiable governing body, or designated person(s) with full legal authority and responsibility for the governance and operation of the facility. The governing body adopts and enforces rules and regulations relative to its own governance and to the health care and safety of patients, to the protection of the patients ’ personal and property rights, and to the general operation of the facility. This Standard is not met as evidenced by: 48020 Based on observation, interview, and record review the facility’s governing body failed to ensure expired medications and supplies are not stored, and in use in the facility for care and services of patients. Findings: Review of the Facility’s Policy and Procedure on Medication Preparation and Administration; Policy #47488 directs staff as follows: “expiration dose for all stored medications are to be monitored on a monthly basis. Expired Medications are to be discarded via Fresenius Kidney Care off -site return program or in accordance local and / or state Law.” Review of the facility’s current policy and procedure: Emergency Medications, Equipment and Supplies: published 05/01/2023, reference number: 46865, version 6 directs the staff as follows: “Emergency Cart “ The emergency cart must be: o Checked monthly or after use for contents, expiration dates, cleanliness, and proper functioning of all equipment. “ An itemized log must be kept indicating the contents and expiration dates of contents. Items approaching expiration must be reordered and replaced prior to the actual expiration date. Emergency Evacuation Box “ An emergency evacuation box must: o Be checked monthly or after use for contents, expiration dates and cleanliness “ An itemized log must be kept indicating the contents and expiration dates of contents. Items approaching expiration must be reordered and replaced prior to the actual expiration date.” Observation on 01/08/2024 during tour of the facility revealed the following expired supplies were observed co-mingled with supplies in use for patient care: Supply Room- storage bins on the shelves: 23 packages 0.9% Sodium Chloride 100 mL normal saline bags (4 bags per package) Lot# US012058 expired Sep 23 2 boxes 3 M Transpore Tape Lot# 2022-07 MB expired 2022-07 Treatment Area - Emergency Evacuation Box: 1 box AICARE disposable masks 50 pcs P/N# 17-LT03-0 expired 04/18/2022 Interview on 01/08/2024 at 12:49 p.m. with Clinical Manager (J), the surveyor notified Clinical Manager (J) of the expired supplies found in the Supply Room and the Emergency Evacuation Box. Clinical Manager (J) said “Okay, we will dispose of them.” 10802 Observation on 1/08/2024 at 11:30 a.m. of the facility’s crash cart (emergency cart) revealed the following expired supplies: Two packets with Yankauer suctions, lot # H2018041614; expired April 15, 2023. Eleven AMD RIT Med Sterile sponges Code # A2240; expired 08/2023 Two BD Luer Lok 60 mls syringes reference # 309653 and Lot # 7027737; expired February 28/2022 Observation on 01/08/2024 of the peritoneal dialysis (crash cart) emergency cart revealed the following expired supplies: I Hydrophobic Bemis Suction Canister, Catalog number 424410; expired November 2016. One packet with Yankauer suction, lot # H2018041614; expired April 15, 2023. One box of 40 stay safe cap; lot # C1ZE052; expired April 30 2022 One blood culture bottle maroon top Lot number 0001057538 expired 2/6/2022. One blood culture bottle green top Lot number 0004100414 expired 2/6/2022.”