Davita Fairfax Dialysis Center

“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: 42725 Based on observation and document review, it was determined the facility staff failed to remove expired supplies from the emergency evacuation box. Findings: A review of the facility’s policy titled, Emergency Equipment Checks, revealed the following: “... 11. In addition, the FA or designee will review the contents of the emergency evacuation kit(s) and replace missing or expired supplies at least monthly...”. During the flash tour on 05/13/2024, a surveyor conducted a review of the contents in the facility’s emergency evacuation kit. The following were discovered during the review: Twenty (20) prefilled 10 ml saline syringes - expired 4/30/2024 The expired supplies were removed from the kit and handed to Staff Member #11 who immediately disposed of them. The finding was discussed with Staff Member #1 at the end of the day on 05/13/2024 and again with staff prior to exit on 05/14/2024.”

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 42725 Based on observation, interview and document review, it was determined the facility failed to maintain a sanitary environment by not removing two (2) damaged dialysis chairs from the treatment floor that could not be adequately sanitized, and failing to mix/prepare and properly use bleach for equipment disinfection. Findings: During the observations on 05/13/2024, a surveyor observed a tear in the seat of the recliner at station #4. The surveyor informed Staff Member #1 of the observation; Staff Member #1 acknowledged that it was at a station currently not in use. During the observations on 05/14/2024, a surveyor observed a tear in the seat of the recliner at station #10, which was at a station in use. The observations were reviewed again with Staff Member #1 prior to the exit on 05/14/2024. Staff Member #1 acknowledged that the recliners cannot be properly disinfected if there are tears present and should be removed from the treatment floor. On 05/13/2024 at 3:15 p.m., Staff Member #9 placed a used clamp in a full container with other used clamps and hemostats that did not contain bleach solution. On 05/13/2024 at 3:30 p.m., Staff Member #9 placed another used clamp to the full container of other used clamps and hemostats that did not contain bleach solution. The surveyor observed the container was labeled for a bleach mixture, prepared on 05/13/2024 at approximately 5:30 a.m. There was no liquid in the container. The surveyor asked Staff Member #9 about the liquid. The Staff Member confirmed there was no liquid in the container and proceeded to mix a 1:10 (one to ten) bleach solution. The clamps and hemostats in the container were not submerged in the solution after it was added. The container was left uncovered for approximately twenty-two (22) minutes before another staff member replaced the lid. The time on the lid had not been updated to reflect when the solution was mixed and added. On 05/14/2024 at 11:22 a.m., a surveyor observed Staff Member #12 standing at the cart with two (2) bins of “clean” bleach solution (used for disinfecting stations), cloths and a container of disinfected clamps and hemostats. After a disinfected clamp fell to the floor, Staff Member #12 picked it up, dunked it in the “clean” bleach solution, rinsed it off and returned it to the disinfected pile of clamps and hemostats. A review of the facility’s policy titled, “Infection Control For Dialysis Facilities,” policy #1-05-01, revision date: April 2023, states, in part: “... Disinfection ... 12. ... b. Use an appropriate disinfectant such as 1:100 (one to one hundred) bleach solution for routine disinfection of environmental surfaces. ... iv. Items disinfected via submersion will be fully submerged. ... ... 14. Non-disposable items are to be disinfected after each patient use .... ... b. Hemostats (blood line clamps) should be in the open position and fully submerged in an appropriate disinfectant solution.” The above concerns were discussed with SM #1 at the exit conference on 1/9/2024.”

“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: 49355 Based on four (4) infection control observations and document review, it was determined the facility staff failed to conduct hand hygiene and glove changes to minimize the spread of infections or bloodborne pathogens in the dialysis facility environment. The findings include: On 05/13/2024 at 10:49 a.m., this surveyor observed Staff Member #7 pick up a piece of trash from the treatment room floor with gloved hands and dispose of the waste in a trash receptacle. The Staff Member then returned to Station #8 to continue setting the machine up for the next patient, never removing the soiled gloves, performing hand hygiene or donning new gloves. On 05/13/3034 at 3:00 p.m., Staff Member #8 was observed removing and discarding gloves without performing hand hygiene prior to donning a new pair. On 05/14/2024 at 10:25 a.m. and 10:38 a.m. Staff Member #18 was observed removing and discarding gloves without performing hand hygiene prior to donning a new pair. In a interview with Staff Member #1 on 05/13/2024 and 05/14/2024, the need to change gloves and perform hand hygiene per policy was discussed and the Staff Member agreed. A review of the facility’s policy, entitled, “Infection Control for Dialysis Facilities,” policy #1-05-01, revision date April 2023, reads, in part: “... Hand Hygiene 1. All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene ... b. prior to gloving and immediately after removal of gloves ... PPE (i.e. gown, gloves, eye protection, face shield) ... 7. Disposable gloves will be worn when caring for the patient or touching the patient’s equipment at the dialysis station... ... a. Gloves will be changed when: ... ii. When going from a “dirty” area or task to a “clean” area or task.” The above concerns were discussed with Staff Members #1, 3, 4, 13, 21, 22 and 23 at the exit conference on 05/14/2024 at 4:39 p.m.”

“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: 49355 Based on six (6) infection control observations, interviews and document review, it was determined the facility staff failed to ensure that dialysis stations were appropriately disinfected between patients. The findings include: On 05/13/2024 at 10:49 a.m., Staff Member #7 started cleaning Station #9 before the patient, who had just completed treatment, had vacated the station. While the patient’s belongs were still at the station (the patient had gone to the bathroom), Staff Member #7 left the machine he was cleaning, retrieved new supplies for the next scheduled patient, brought them back to Station #9 and placed them on top of the dirty machine. On 05/13/2024 at 2:15 p.m., this surveyor observed Staff Member #12 cleaning Station #10. The Staff Member failed to clean both sides of the chair, under the chairside tables. On 05/13/2024 at 3:15 p.m., a surveyor observed Staff Member #9 cleaning Station #19. Staff Member #19 failed to disinfect the left side of the machine and underneath the side trays. On 05/13/2024 at 3:30 p.m., Staff Member #9 was observed by a surveyor cleaning Station #20. Staff Member #9 failed to disinfect underneath the side trays of the recliner. On 05/14/2024 at 10:30 a.m., Staff Member #17 was observed by a surveyor cleaning Station #11. The area underneath the side trays was not disinfected, the sharps container was not wiped and the hemostats hanging on the pole were not removed. At 11:36 a.m. on 05/14/2024, Staff member #12 was observed by a surveyor cleaning Station #10. The prime container was removed, disinfected and returned to the “dirty” machine because the area on the machine where the container hangs was not disinfected. These observations were discussed with Staff Member #1 at the end of the day on 05/13/2024 and 05/14/2024, prior to the exit interview. Staff Member #1 concurred with the impressions of the above findings. A review of the facility’s policy titled, “Infection Control For Dialysis Facilities,” policy #1-05-01, revision date: April 2023, states, in part: “... Disinfection ... 12. ... b. Use an appropriate disinfectant such as 1:100 (one to one hundred) bleach solution for routine disinfection of environmental surfaces. ... iv. Items disinfected via submersion will be fully submerged. ... 13. At the end of each treatment, the dialysis station will be cleaned and disinfected. a. Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings (e.g. dialysis chair, tray tables...) and frequently contacted by healthcare personnel (e.g. ... top, front and sides of dialysis machine, ...) ... b. Dialysis station must be completely vacated by the previous patient before teammates can begin to bring disinfection supplies to the station, clean or disinfect the station and set up for the next patient. ... 14. Non-disposable items are to be disinfected after each patient use .... ... b. Hemostats (blood line clamps) should be in the open position and fully submerged in an appropriate disinfectant solution.” The above concerns were discussed with SM #1 at the exit conference on 1/9/2024.”

“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: 49355 Based on observation, interview, and document review, it was determined the facility staff failed to remove expired medications from the treatment area, properly label prepared medication syringes and ensure aseptic technique when preparing medications. The findings include: On 05/13/2024 at 10:05 a.m., this surveyor inspected the medication storage areas on the treatment floor, to include cabinets and refrigerators, for out-of-date medications. The following were discovered: - Parsabsiv 2.5 mg/0.5ml and 5 ml/ml, #25 single dose vials and #10 single dose vials, respectively, with an expiration date of 02/24 - Tuberculin PPD, with a date opened on the box of 04/01/2024 - Compounded IDPN/IPN protein therapy for a specific patient, #3 bags that expired on 05/01/2024 and #3 bags that expired on 05/08/2024 On 05/13/2024 at 3:30 p.m., a surveyor observed supplies and an unlabeled syringe of liquid laying on the tray at Station #21. The surveyor inquired about the set up. Staff Member #9 said “the patient didn’t show up.” The surveyor clarified that the patient was scheduled for the first shift which begins between 5:30 a.m. and 6:15 a.m. The surveyor asked Staff Member #8 about the unlabeled syringe of liquid. Staff Member #8 replied, “I don’t know, it’s probably heparin.” At 4:04 p.m. on 05/13/2024, the surveyor observed Staff Member #12 drawing up heparin in the designated area. After being called over by a patient, Staff Member #12 left the designated area, while continuing to draw up the heparin in the syringe, and walked over to the patient’s station. After speaking with the patient, Staff Member #12 returned to the designated area, retrieved another syringe and inserted the needle into the vial. Staff Member #12 did not clean the rubber stopper with an alcohol swab prior to inserting the new needle. A review of the facility’s policy titled “Medication Policy,” policy #1-06-01, revision date October 2023, states, in part: “... Policy: ... 13. ... Do not use any medication that has been stored improperly or has expired. ... 20. ...If the medication is not immediately administered or is to be administered by another teammate, the medication must be labeled with the patient name, name of medication, date, time prepared, dose and initials of teammate preparing the medication. ... 29. Medication containing a preservative must be discarded 28 days after opening or accessed (e.g. needle punctured).... ... 30. ... All medications are checked monthly for expiration dates.” The above concerns were discussed with Staff Members #1, 3, 4, 13, 21, 22 and 23 at the exit conference on 05/14/2024 at 4:39 p.m.”

“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: 42725 Based on observations and document review, it was determined the facility staff failed to aseptically initiate treatment for two (2) of four (4) patients with a central venous catheter. Findings: On 05/13/2024 at 4:22 p.m., Staff Member #12 was observed initiating treatment for a patient with a central venous catheter (CVC). Staff Member #12 cleansed the area around the CVC exit site, allowing approximately five (5) seconds of drying time before applying a new dressing. After applying the sterile dressing, Staff Member #12 continued to wear the same gloves to complete the remaining tasks. During the disinfection of the CVC hubs, Staff Member #12 wiped each hub for approximately five (5) seconds before connecting the sterile syringes. The observation was discussed with Staff Member #1 at the end of the day on 05/13/2024. On 05/14/2024 at 11:20 a.m., Staff Member #12 was observed initiating treatment for a patient with a central venous catheter (CVC). Staff Member #12 cleansed the area around the CVC exit site, only allowing approximately five (5) seconds of drying time. The patient’s clothing was not secured during the process and touched the “clean” site after it was disinfected. After applying the sterile dressing, Staff Member #12 continued to wear the same gloves to complete the remaining tasks. The observations were reviewed with staff prior to exit on 05/14/2024. A review of the facility’s policy titled, Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure, revealed the following under “Procedure”, “... 3... Verify patient’s clothing is secured away from the exit site/work area... 8... clean exit site... wait 60 seconds for air dry time... 12. Place sterile 2x2 gauze over the catheter exit site... 14. Remove gloves and discard, perform hand hygiene per procedure and re-glove... 16... One at a time, disinfect each CVC hub with a new alcohol prep pad. Scrub each CVC hub for 15 seconds...”.”

“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: 49355 Based on medical record review, staff interviews, and policy review, it was determined the facility staff failed to document notification to the charge nurse of variations between post treatment weight (PTW) and target weight (TW) (exceeding +/- 1 kg) and blood pressure (BP) measurements outside of facility guidelines in four (4) out of six (6) patient records reviewed. The findings include: The six (6) most recent flowsheets for six (6) in-center hemodialysis patients were reviewed on 05/13/2024. Four (4) of the six (6) patients were missing documentation of notification to the charge nurse concerning discrepancies between TW and PTW and BP readings outside facility guidelines. Patient #2: Treatment date 05/10/2024 - TW was 78.9 kg, PTW was 84.4 kg, a variation of 5.5 kg. No documentation was noted in the flowsheet from the technician or the charge nurse. Patient #4: Treatment date 04/16/2024 - TW was 61.0 kg, PTW was 62.2 kg, a variation of 1.2 kg. No documentation was noted in the flowsheet from the technician or the charge nurse. Patient #5: Treatment date 04/16/2024 - TW was 84.0 kg, PTW was 85.2 kg, a variation of 1.2 kg. No documentation was noted in the flowsheet from the technician or the charge nurse. Treatment date 04/26/2024 - TW was 84.0 kg, PTW was 86.2 kg, a variation of 2.2 kg. No documentation was noted in the flowsheet from the technician or the charge nurse. Treatment date 04/29/2024 - TW was 84.0 kg, PTW was 86.3 kg, a variation of 2.3 kg. No documentation was noted in the flowsheet from the technician or the charge nurse. Treatment date 05/03/2024 - TW was 84.0 kg, PTW was 87.0 kg, a variation of 3.0 kg. No documentation was noted in the flowsheet from the technician or the charge nurse. Patient #6: Treatment date 04/29/2024 - TW was 69.5 kg, PTW was 72.6 kg, a variation of 3.1 kg. No documentation was noted in the flowsheet from the technician or the charge nurse. Treatment date 05/01/2024 - TW was 69.5 kg, PTW was 71.6 kg, a variation of 2.1 kg. No documentation was noted in the flowsheet from the technician or the charge nurse. Treatment date 05/03/2024 - TW was 69.5 kg, PTW was 70.9 kg, a variation of 1.4 kg. No documentation was noted in the flowsheet from the technician or the charge nurse. Treatment date 05/06/2024 - TW was 70.0 kg, PTW was 72.4 kg, a variation of 2.4 kg. No documentation was noted in the flowsheet from the technician or the charge nurse. Treatment date 05/08/2024 - TW was 70.0 kg, PTW was 71.3 kg, a variation of 1.3 kg. No documentation was noted in the flowsheet from the technician or the charge nurse. Treatment date 05/10/2024 - BP reading at 10:32 a.m. was 166/111 mm/Hg, at 11:03 a.m. reading was 183/112 mm/Hg, at 11:32 a.m. reading was 183/121 mm/Hg, and at 12:02 p.m. reading was 176/111 mm/Hg. No documentation was noted in the flowsheet from the technician or the charge nurse. During interviews with Staff Members #12 and #17, they both verbalized expectations that a technician would document on the flowsheet any disparities between the dialysis prescription and occurrences and let the charge nurse know. A review of the facility’s document, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” policy # 1-03-08, revision date April 2024, states, in part: “... 2. The Nursing assessment will be performed and documented by a licensed nurse .... ... iii. Verification of prescription including machine parameters ... 10. If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed. ... Abnormal Findings ... the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record. ... Fluid Status: ... Post-treatment: If the patient is above or below 1 kg from the target weight ... Blood Pressure - Intradialytic: Systolic greater than 180 mm/Hg.... Diastolic greater than or equal to 100 mm/Hg....” The above concerns were discussed at the exit conference on 05/14/2024 at 4:39 p.m. with Staff Members #1, 3, 4, 13, 21, 22 and 23.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 49355 Based on medical record review, staff interviews and policy review, it was determined that the facility staff failed to document notification to the charge nurse of changes from the prescribed blood flow rate (BFR) for two (2) of six (6) patients sampled. The findings include: The six (6) most recent flowsheets for six (6) in-center hemodialysis patients were reviewed on 05/13/2024. Two (2) of the six (6) patients were missing documentation of notification to the charge nurse concerning changes in the prescribed BFR for dialyzed patients. Patient #3: The prescribed BFR was 400 ml/min for a treatment duration of 3 hours 45 minutes Treatment date 04/29/2024 - BFR was 450 ml/min for the first three (3) hours of the prescribed treatment time. The BFR was then decreased to the prescribed rate of 400 ml/min. No documentation was noted in the flowsheet from the technician or the charge nurse. Treatment date 05/03/2024 - BFR was 300 ml/min for the entire treatment cycle. No documentation was noted in the flowsheet from the technician or the charge nurse. Treatment date 05/10/2024 - BFR was 300 ml/min for the entire treatment cycle. No documentation was noted in the flowsheet from the technician or the charge nurse. Patient #5: The prescribed BFR was 350 ml/min for a treatment duration of 3 hours 30 minutes Treatment date 04/26/2024 - BFR was 300 ml/min for the last three (3) hours of the treatment. No documentation was noted in the flowsheet from the technician or the charge nurse. During interviews with Staff Members #12 and #17, they both verbalized expectations that a technician would document on the flowsheet any disparities between the prescribed BFR and the actual rate and let the charge nurse know. A review of the facility’s document, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” policy # 1-03-08, revision date April 2024, states, in part: “... 2. The Nursing assessment will be performed and documented by a licensed nurse .... ... iii. Verification of prescription including machine parameters ... 10. If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed.” The above concerns were discussed at the exit conference on 05/14/2024 at 4:39 p.m. with Staff Members #1, 3, 4, 13, 21, 22 and 23.”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 49355 Based on medical record review, staff interview and policy review, it was determined the facility staff to complete required Plans of Care (PoC) for four (4) of six (6) patients. The findings include: Patient #1: Review date 05/14/2024 at 9:23 a.m. Last completed PoC on the chart was dated 05/03/2023. Upon request for a more recent document, the surveyor was provided with a PoC dated 05/14/2024 but no signatures from the Interdisciplinary Team (IDT) or the patient were present on the document. Patient #3: Review date 05/14/2024 at 10:36 a.m. The PoC present on the chart was dated 03/20/2024, but the signatures for the IDT and the patient were absent. Patient #7: Review date 05/14/2024 at 8:50 a.m. Last completed PoC on the chart was dated 04/10/2023. Upon request for a more recent document, the surveyor was provided with a PoC dated 05/14/2024 but no signatures from the IDT or the patient were present on the document. Patient #8: Review date 05/14/2024 at 12:07 p.m. Last completed PoC on the chart was dated 08/18/2022. A PoC dated 09/20/2023 was also present, but signatures from the IDT and the patient were missing and the information contained on the document was minimal. While discussing the findings with Staff Member #1 on 05/14/2024, prior to the exit conference, there was acknowledgement that current completed PoC for these patients were not available and there should have been. A review of the facility’s policy entitled, “Medical Records Documentation Guidance,” policy # 3-02-02, revision date October 2023, reads, in part: “... Definition... ... Interdisciplinary team (IDT) Assessments and Plan of Care (POC).... ... Documentation Guidance... ... 18. A teammate’s full signature consists of first name, last name and credentials.” The facility’s document entitled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care,” policy #5-15-02, revision date July 2023, reads, in part: “... Assessment... ... 7. A comprehensive re-assessment of each patient and a revision in the plan of care will be conducted: At least annually for stable patients.... ... Annual (stable patients) ... Ongoing annual reassessments will be completed 1 year after the annual reassessment....” The above findings were discussed at the exit conference on 05/14/2024 at 4:39 p.m. with Staff Members #1, 3, 4, 13, 21, 22 and 23.”

“QAPI-MONITOR/ACT/TRACK/SUSTAIN IMPROVE CFR(s): 494.110(b) The dialysis facility must continuously monitor its performance, take actions that result in performance improvements, and track performance to ensure that improvements are sustained over time. This Standard is not met as evidenced by: 40084 Based on observation, interview and document review, it was determined the facility’s Quality Assurance and Performance Improvement (QAPI) program failed to take action to ensure sustained improvement over time. Specifically, the QAPI program failed to correct known issues identified during the previous recertification survey. The findings include: Tag V-0113 Current Recertification Survey Based on four (4) infection control observations and document review, it was determined the facility staff failed to conduct hand hygiene and glove changes to minimize the spread of infections or bloodborne pathogens in the dialysis facility environment. Recertification Survey Ending March 24, 2021 Based on three (3) infection control observations, interview, and a review of the dialysis facility’s policy, it was determined that staff failed to follow required infection control and prevention practices related to hand hygiene. Tag V-0143 Current Recertification Survey Based on observation, interview, and document review, it was determined the facility staff failed to remove expired medications from the treatment area, properly label prepared medication syringes and ensure aseptic technique when preparing medications. Recertification Survey Ending March 24, 2021 Based on observations, staff interviews and document review, it was determined the facility staff failed to ensure expired medications were not available for patient use.”