Davita Cleve Hill Dialysis Center

“CFC-QAPI CFR(s): 494.110 This Condition is not met as evidenced by: 42572 Based on policy review, document review, and interview, the quality assurance program failed to monitor data/information to prioritize areas for improvement; determine potential root causes; and to develop, implement, evaluate, and revise plans that result in improvements in care related to the physical environment due to continuous flooding and disruption of patient care services (TAG #V-0626) and to ensure an adverse event reports were completed for all flooding occurrences in order identify issues, analyze for trends/causes, and to implement corrective actions if necessary (TAG #V-0634). Cross Reference: 494.110 QAPI-Covers Scope of Service 494.110 (a)(2)(vi) QAPI- Indicator-Medical Injuries/errors”

“CFC-GOVERNANCE CFR(s): 494.180 This Condition is not met as evidenced by: 42572 Based on interview, document review, and policy review, the governing body failed to be responsible for the oversight of facility operations related to the the identification of Evac (wastewater and sewer system) issues and ensure the implementation of actions to correct the these issues affecting patient care (TAG #V-0756). The governing body failed to ensure the End Stage Renal Disease (ESRD) Network was notified for the disruption of patient services requiring the discontinuation of treatment and/or rescheduling of patient treatments to different shifts, days, or units for four of four documented flooding events (TAG #V-0772). Cross Reference: 494.180 (a)(4) Goverance/Adminstration Response for Resources for QAPI 494.180 (i) Governance- Responds to Network Request/Work Towards Goals”

“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: 42572 Based on interview, observations, and document review, the faciltiy failed to maintain the plumbing system to ensure the safety of patients, staffing, and the public. Findings include: Interview on 12/27/24 at 10:00 AM with Staff (A), Registered Nurse, revealed the facility has had an ongoing problem with wastewater overflowing from a specific wall of dialysis wall box drains and leaks on to the floor. There was a flooding issue that occurred in the middle of October 2024. Interview on 12/27/24 at 11:00 AM with Staff (B), Biomedical Operations Manager (BOM), revealed they have been having issues with the sewer drainage system since the facility opened in 2020. The facility was built at a low elevation level and required a vacuum powered sewer system installed to facilitate the flow of wastewater into the municipal sewer system. The system includes a large above ground vacuum tank with pumps and controllers located in the storage room of the facility. The vacuum tank is connected to toilets and smaller wastewater collection tanks by pipes which run up and over the ceiling. The dialysis station wall box drains by gravity into the collection tanks. There are pressure sensors in the collection tanks which trigger valves to open, allowing the vacuum pressure in the pipes to lift the wastewater through the pipes and into the vacuum tank. When the vacuum tank is full, a sensor is triggered, and the sewage is pumped out to the municipal sewer system. Staff (B) stated most of the flooding issues have come from the dialysis wall box drains overflowing at Station #9-19. Staff (B) stated “the six wall box drains at Station #14-19 are the most troublesome.” The pressure sensors in the collection tanks periodically fail. Staff (B) stated the sensors seem to be plugging. When this happens the wall boxes overflow, and they must manually activate the sensor to make the tank drain, then blow air into the sensor to free it up. There is no warning when the sensors become plugged, but it usually happens first thing in the morning. All these stations are located on the wall farthest from the vacuum tank. This distance is believed to be one of the compounding factors leading to the flooding events. Another factor is the quantity of wall box drains feeding into each collection tank. The six drains for Station #14 -19 gravity feed into one collection tank and the five drains at Stations #9-13 gravity feed into another collection tank. Staff (B) said the maximum quantity of stations draining into a collection tank should have been limited to four. Staff (B) stated that other components of the system have failed resulting in flooding. Last winter a broken sewer line was identified under the slab of the next-door building. Every time the vacuum tank would eject the sewage, it would leak out of the broken line and back into the facility, seeping up through the floor. A valve failed back in October 2024 resulting in an overflow of wastewater from the wall box drains. Approximately six months ago one of the two vacuum pumps failed and seemed to coincide with more frequent wastewater overflows from the wall boxes. The two vacuum pumps normally alternate in operation so if one fails the system can still function. The pump manufacturer stopped making the pump, so another vacuum sewer company was contacted to retrofit a different vacuum pump. The pump was installed from 12/17/24 to 12/19/24. On 11/01/24, the facility started shutting down Station #14-19 to reduce flooding. On 11/08/24, Station #14 -19 were completely shut down. Staff (B) stated they may try using the stations again since it seems to be working better after the pump was replaced but are not sure. The facility has been looking into different long-term options to rectify the flooding issues. There has been no flooding since the pump was replaced on 12/19/24 and Station #14-19 were shut down. Observations on 12/27/24 at 09:50 AM in the patient treatment area revealed there are 23 patient stations and an isolation room. Each patient station has a wall box located behind the chair that contain connections for the dialysis machine to receive treatment concentrates and treated water, and a drain to dispose of waste fluids. The patient treatment area was clean with no wastewater observed on the patient treatment floor. The treatment area space is in the right half of the facility with the isolation room and stations #23-20 on the back wall and stations #19-9 on the right wall (east wall). There is an information technology and a conference room located on the other side of the back wall. A storage room located on the left side of the facility towards the back, houses a large, above ground vacuum tank with pumps and controllers, which stores wastewater and sewage before it is pumped out to the municipal sewer system (Evac System). Review on 01/06/25 of the facility confidential Quality Assurance Performance Improvement (QAPI) documentation, Risk Event Management reports, service tickets, and work orders revealed the following: - Flooding events occurred at the facilility on 01/17/24, 01/22/24, 01/23/24, 01/26/24, 01/29/24, 01/30/24, 02/09/24, 02/12/24, 02/16/24, 02/18/24, 02/24/24, 03/07/24, 03/13/24, 04/24/24, 04/25/24, 05/20/24, 10/09/24, 10/10/24, 10/11/24, and 10/18/24. - On 01/29/24, 02/12/24, 03/07/24 and 10/18/24, patient treatments were disrupted or stopped requiring rescheduling to a different shift, different day, and/or to a sister unit. - On 04/25/24, flooding occurred at Station #13-19. Patients continued to receive treatment and were assisted by staff to walk throught the waste water to get to their assigned stations.”

“QAPI-COVERS SCOPE SERV/EFFECTIVE/IDT INVOL CFR(s): 494.110 The dialysis facility must develop, implement, maintain, and evaluate an effective, data-driven, quality assessment and performance improvement program with participation by the professional members of the interdisciplinary team. The program must reflect the complexity of the dialysis facility’s organization and services (including those services provided under arrangement), and must focus on indicators related to improved health outcomes and the prevention and reduction of medical errors. The dialysis facility must maintain and demonstrate evidence of its quality improvement and performance improvement program for review by CMS. This Standard is not met as evidenced by: 42572 Based on policy review, document review, and interview, the quality assurance program failed to monitor data/information to prioritize areas for improvement; determine potential root causes; develop, implement, evaluate, and revise plans that result in improvements in care related to the physical environment due to continuous flooding and disruption of patient care services. Findings include: Review of the policy “Quality Assurance Performance Improvement Program- QAPI,” revised 04/2021, indicated the purpose of the program is to improve patient safety and outcomes according to the requirements in the CMS Conditions for Coverage. Each facility will have a continuous quality improvement (CQI) committee comprised of an interdisciplinary team. The facility administrators will conduct periodic facility health meeting (FHM- also known as QAPI) with the CQI committee to review issues and indicators regarding the facilities management and performance monthly. Written documentation and plans of action will be documented within the FHM application. The medical director is responsible for participation and execution of the program including implementation, continuous monitoring, development of actions plans, and program evaluation. The facility administrator or designee will serve as the facility program coordinator. The facility will measure, analyze, and track quality indicators or other aspects of performance including, but not limited to the following: Patient safety including trends of adverse patient occurrences; and other indicators reflected in the facility health report (FHR) application. Continuous monitoring of indicators will be reflected in meeting minutes. Any area identified as underperforming will be reviewed to identify root causes for underperformance, will have an action plan identified that will result in performance improvement, and will track the change in performance over time to verify improvements are sustained. Each action plan will be evaluated, with the Patient Safety and Clinical Outcomes indicators considered for the highest priority. Review on 01/06/24 of the confidential quality assurance monthly meeting documentation for “Facilities,” revealed the following: In January 2024: -On 01/17/24, 01/26/24, 01/29/24, and 01/30/24: The facility experienced flooding on the east wall affecting Station #13-17. Biomed and a repair company were alerted. A permanent fix is currently being worked on. The facility is also experiencing flooding by Station #23, in the isolation room, in the IT room, and in the conference room. The facility experienced a loss of water from the public water system due to fire sprinklers being turned off to the plaza on 01/24/24. In February 2024: There were three “Evac (wastewater and sewer system),” flooding events. -On 02/09/24: Water was leaking in IT, the conference room, the isolation room, and Station #23. Biomed was alerted as water was cleaned up. Plumbers were called out to access the situation and find a solution. No patients were affected. -On 02/12/24: The “Evac” sensor was dirty which flooded the Evac pumps, which flooded the clinic. Patients affected were offered treatments at other sister units and offered times on Tuesday (next day) to be treated. Five patients chose to get treatment at other units. -On 02/24/24: There was flooding of the building due to a blocked sewer line and broken pipe. Patients were not affected. In March 2024: -On 03/07/24: The Evac system failed due to a dirty sensor at 05:30 AM before treatments were started and patients arrived. Biomed was alerted. The Evac system was up and running by 07:45 AM. Three patients were rescheduled to Friday (next day) and were treated. All other patients were treated incenter. -On 03/13/24: The facility flooded along the east wall. Biomed was alerted. The team was able to flush the system twice and clean up the water by the time patients arrived for their treatments. No patients were disrupted. DaVita Facility Maintenance is working with several plumbers to get quotes to re-plumb the east wall as the pipes are too high in the ceiling causing too much stress and pressure. The first plumber enlisted backed out due to the scope of work was too much. As of 04/09/24, another plumber has submitted a quote to plumb the wall. In April 2024: -On 04/24/24: There was flooding in the clinic at Station #23. Biomed determined the flooding was from a machine overnight. The water was sucked up and a professional company was called to clean all rug areas affected. Patients were not affected. -On 04/25/24: There was flooding in the clinic on the east wall. Biomed was called. Wall boxes continue to be the focus due to the waste buildup at the specific wall box. The water was vacuumed up and the wall was temporarily fixed. Patients were not affected for treatments. October 2024: -No date: The Evac controller failed on the inside wall causing the system to lose the vacuum which caused flooding in the entire clinic. All patients were taken off machines as normal.12 patients refused to wait for the system to be fixed. One of the 12 patients choose to go to the hospital for dialysis. One patient went to a sister unit, two patients were rescheduled for Saturday. All patient that were left were advised to seek treatment at the hospital since they refused to wait or be rescheduled. All nephrologists were notified as soon as we could safely do so. The Evac controller in the wall was replaced, fluid was cleaned up by biomed, and additional controllers were ordered to have on hand. (The quality assurance monthly meeting documentation by the interdisciplinary team did not address the additional flooding that occurred on 01/22/24,01/23/24, 02/16/24, 02/18/24, 05/20/24, 10/09/24, 10/10/24, or 10/11/24. No evidence was found to indicate the quality assurance team analyzed the findings and/or developed an action plan to address the ongoing flooding issues). Interview on 01/06/25 at 11:00 AM with Staff (D), Manager of Clinical Services, verified these are the QAPI documents related to the facility flooding.”

“QAPI-INDICATOR-MEDICAL INJURIES/ERRORS CFR(s): 494.110(a)(2)(vi) The program must include, but not be limited to, the following: (vi) Medical injuries and medical errors identification. This Standard is not met as evidenced by: 42572 Based on policy review, document review, and interview, the quality assurance program failed to ensure an adverse event report was completed for all flooding occurrences in order identify issues, analyze for trends/causes, and to implement corrective actions if necessary. Finding include: Review of the policy “Risk Event Reporting Policy,” dated 10/2024, indicated any unexpected event that is inconsistent with the routine operation of a dialysis facility, routine provision of acute dialysis of ancillary renal-related services may be a risk event. Such events include, but not limited to: property damage, equipment failure, and floods. All risk reports will be promptly reported to the facility administrator/manager or designee. The teammate involved in the risk event will complete a Risk Event Management (REM) report as soon as possible after the event, but no later than completion of the teammates shift during which the risk event happened. The facility administrator/manager or designee will review the report for completeness and ask the teammate to provide further information and/or make necessary corrections. The REM reports are to be trended and reviewed during the Facility Health Meeting (FHM). Any negative trend should result in a plan of action. The Risk Department will review and analyze all REM reports to determine whether the occurrence requires further action and/or should be reported to the insurance carrier. Review of facility confidential quality assurance “Risk Event Management Reports (REM-adverse event reports),” revealed no evidence REM reports were documented for flooding events that occurred on 01/22/24, 01/23/24, 01/26/24, 02/09/24, 02/18/24, 02/24/24, 05/20/24, 10/09/24, 10/10/24, and 10/11/24. No evidence was found to indicate adverse event reports were completed for these adverse events. Interview on 01/06/2025 at 11:30 AM with Staff (D), Manager of Clinical Services, revealed these are the adverse event reports related to the facility flooding.”

“GOV-ADM RESP FOR RESOURCES FOR QAPI CFR(s): 494.180(a)(4) The governing body or designated person responsible must appoint an individual who serves as the dialysis facility’s chief executive officer or administrator who exercises responsibility for the management of the facility and the provision of all dialysis services, including, but not limited to- (4) Allocation of necessary staff and other resources for the facility’s quality assessment and performance improvement program as described in §494.110. This Standard is not met as evidenced by: 42572 Based on interview and document review, the governing body failed to be responsible for the oversight of facility operations related to the the identification of sewer system issues and implementation of actions to correct these issues affecting patient care. Findings include: Telephone interview on 12/27/24 at 01:00 PM with Staff (C), Facility Administrator, revealed the facility did not have any evidence that the governing body was providing oversight to the facility regarding the sewer system issues affecting patient care or the reduction in patient chairs from 24 to 18. Review on 01/06/25 of Governing Body Meeting minutes with Staff (B), Biomed Operations Manager, revealed the following two late entries were documented by Staff (C), Facility Administrator after the initial onsite for this investigation on 12/27/24. There were no documented Governing Body Meeting minutes discussing the decrease in patient chairs and flooding issues prior to the onsite for this investigation on 12/27/24: -The first Governing Body Meeting document (no date) lists the “Discussion Topic,” as “Missing governing body.” The discussion points/action plan section documents “On 12/27/24 the Department of Health (DOH) arrived to the facility due to a complaint from 10/13/24 that was submitted to the DOH on 12/10/24. During the review of the complaint, the DOH asked for the governing body that was done that approved going from 24 stations to 18 stations due to the failed pump. This governing body is to acknowledge there is not a governing body in place that discusses the pump failure or change of patient schedule due to the water and flooding concerns, under the previous facility administrator.” -The second Governing Body Meeting document (no date) lists the Discussion Topic, as “Change of chairs in operation due to failed pump in the water system.” The discussion points/action plan section documents “On 10/28/24 a new patient schedule was created that changed operations from utilizing 24 chairs daily to 18 chairs. This change was approved on 11/01/24 for 11/08/24. There are 6 chairs that will not be utilized while the flooding issue is investigated and repaired. Patients who were treated in those chairs have been moved to different treatment times and days within the current facility.” The “Other Items of Discussion, including sentinel events, issues specific to facility- discussion points/action plan section documents, “On 12/17/24 the new plumbing for the pump was installed and on 12/19/24 the new pump was tested and confirmed working. The facility is still not operating all 24 chairs as of 12/30/24.” (No other Governing Body Meeting minutes or documentation was received from the facility).”

“GOV-RESPONDS TO NW REQUEST/WORKS TOWARD GOALS CFR(s): 494.180(i) The governing body receives and acts upon recommendations from the ESRD network. The dialysis facility must cooperate with the ESRD network designated for its geographic area, in fulfilling the terms of the Network’s current statement of work. Each facility must participate in ESRD network activities and pursue network goals. This Standard is not met as evidenced by: 42572 Based on policy review, document review, and interview, the facility failed to notify the End Stage Renal Disease (ESRD) Network for the disruption of patient services requiring the discontinuation of treatment and/or rescheduling of patient treatments to different shifts, days, or units for four of four documented flooding events (01/29/24, 02/12/24, 03/07/24, and 10/18/24). Findings include: Review of the policy “Risk Event Reporting Policy,” dated 10/2024, indicated any unexpected event that is inconsistent with the routine operation of a dialysis facility, routine provision of acute dialysis of ancillary renal-related services may be a risk event. Such events include, but not limited to: property damage, equipment failure, and flood. All risk reports will be promptly reported to the facility administrator/manager or designee. The facility administrator/manager or designee is responsible for complying with any state specific and ESRD Network reporting requirements. Review on 01/06/25 of the confidential quality assurance “Risk Event Management Reports (REM- adverse event reports),” revealed patient hemodialysis treatments were not started, were discontinued, and/or rescheduled to other shifts/dates/units due to flooding on 01/29/24, 02/12/24, 03/07/24 and 10/18/24. No evidence was documented to indicate the ESRD Network was notified of the disruption of patient services on these dates. Interview on 01/06/25 at 12:00 PM, with Staff (D), Manager Clinical Services, and Staff (E), Facility Administrator, revealed they did not have any records showing the ESRD Network was notified that patients services were disrupted during flooding events.”

“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: 32261 Based on policy review, observation, and interview, staff do not follow the facility process for verification of emergency equipment. This has the potential to cause a delay in responding to a medical emergency and/or lead to an adverse patient outcome. Findings include: Review on 04/17/24 of policy “Emergency Equipment Checks”, last review 04/2024, revealed that manufacturer’s automatic external defibrillator (AED- used to monitor heart rates and treat cardiac arrest) pads are to be present on the cart. A list of all dated supplies will be posted, with the expiration dates, on the cart and is to be checked weekly. Observations on 04/15/24 at 10:00 AM in the incenter hemodialysis area and at 01:30 PM in the home modality clinic revealed each area had a crash cart that lacked documentation of the supply contents (suction tubing and equipment, oxygen tubing, five normal saline intravenous bags, stethoscope, one Epinephrine pen, blue clamps to close dialysis/intravenous lines, gauze, gloves, and two boxes of AED pads) and a weekly equipment check list. Additionally, the incenter crash cart AED pads were located inside the locked cart and not readily available with the AED machine located on top of the cart. Interview on 04/17/24 at 11:00 AM with Staff (A), Facility Administrator, and Staff (O), Clinical Services Manager, confirmed these findings.”

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 40430 Based on policy review, observation, and interview, the facility failed to manage supplies and equipment in a safe and sanitary manner. This lapse in infection control practice places staff and patients at risk for facility-acquired infections. Findings include: Review on 04/16/24 of policy “Infection Control for Dialysis Facilities” last revised 04/2023 revealed clean areas should be clearly designated for the preparation, handling, and storage of unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. The use of battery operated, electrical, or ceiling mounted fans are not allowed in patient treatment areas. Observations on 04/15/24 from 10:15 AM to 02:30 PM in the incenter patient treatment area revealed the storage of intravenous infusion pumps between Stations #9 and #10, #17 and #18, at Station #20, and between Stations #21 and #22, #22 and #23. Observation on 04/16/24 from 08:45 AM to 02:00 PM in the incenter patient treatment area revealed the storage of intravenous infusion pumps at Station #1, #9, and #11 and between Stations #17 and #18, and Stations #22 and #23. Observation on 04/17/24 from 09:00 AM to 12:00 PM in the incenter patient treatment area revealed the storage of intravenous infusion pumps at Station #19, and between Stations #9 and #10, #11 and #12, #15 and #16, and #22 and #23. Observation on 04/15/24 from10:15 AM to 02:30 PM, on 04/16/24 from 08:45 AM to 02:00 PM, and on 04/17/24 from 09:00 AM to 12:00 PM in the incenter patient treatment area revealed the storage of oxygen concentrators at Stations #3, #4, and #19 and between Stations #6 and #7, #10 and #11, #12 and #13, and #16 and #17. The storage of blankets, neck pillows, patient duffle bags and/or headphones were observed on the counter behind and/or between treatment Stations #1, #2, #7, #8, #9, #10, #12, #13, #14, #15, #16, #17, #20, #21, #22 and #23. An electrical fan was stored behind the dialysis chair at Station #5, on the floor. Interview on 04/17/24 at 11:00 AM with Staff (A), Facility Administrator, and Staff (O), Clinical Services Manager, confirmed these findings. THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 06/28/17.”

“IC-HANDLING INFECTIOUS WASTE CFR(s): 494.30(a)(4)(i) [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- (i) Handling, storage and disposal of potentially infectious waste; This Standard is not met as evidenced by: 16136 Based on observation and interview, the facility does not ensure that the regulated medical waste room or reusable regulated medical waste containers are secure. Failure to secure containers has the potential for spillage of contents and/or unauthorized access to contents. Findings include: Observation on 04/17/24 09:55 AM revealed that two regulated medical waste reusable containers were located under the clean sink in the nurse’s station and one regulated medical waste reusable container was located under the clean sink across from Station #19. The containers all had medical waste inside of them and were not secured to prevent spillage. Observation on 04/17/24 at 10:10 AM revealed that the regulated medical waste room doors located in the clinic and another in the back corridor were not secured. This room must be secure to prevent unauthorized access. Interview on 04/17/24 at 10:15 AM with Staff (E), Biomedical Technician, verified this finding.”

“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: 40430 Based on policy review, observation, and interview, the facility does not ensure staff follow infection control procedures, as evidenced by: 1. Staff do not clean and disinfect all contaminated surfaces at the dialysis stations between patient treatments. 2. Staff do not ensure that two of two bleach solution containers were labeled. This lapse in infection control practices places staff and patients at risk for transmission of bloodborne pathogens and facility acquired infections. Findings #1: Review on 04/15/24 of the policy “Infection Control for Dialysis Facilities” last revised 04/2023 revealed cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible and prior to returning to clean/designated areas. At the end of each treatment, the dialysis station will be cleaned and disinfected. Surfaces to disinfect include, but are not limited to, all surfaces in contact with the patient or their belongings and frequently contacted by healthcare personnel. The sharps containers are not stored on the chairside cart. Observation on 04/15/24 from 10:15 AM to 01:00 PM, on 04/16/24 from 09:30 AM to 12:30 PM, and on 04/17/24 from 09:30 AM to 10:30 AM revealed staff did not disinfect: the back counters behind the patient stations #1 -#23 where patients place their belongings during treatment; the wall boxes behind the machine; the television screen or pole; and/or the blue emergency disconnect bags located on the IV poles attached to the machines. Observations on 04/15/24 at 10:30 AM at Station #12 revealed Staff (I), Patient Care Technician, discontinued treatment for fistula (hemodialysis access type) Patient #2. Staff did not disinfect the sharps container that was brought into Station #12, prior to placing the container and bin back in the common area. At 10:45 AM at Station #6, Staff (M), Patient Care Technician, discontinued treatment for fistula Patient #3. Staff did not disinfect the sharps container that was brought into Station #6, prior to placing the container and bin back in the common area. At 11:15 AM at Station #9, Staff (I), Patient Care Technician, discontinued treatment for fistula Patient #8. Staff did not disinfect the sharps container that was brought into Station #9, prior to placing the container and bin back in the common area. Interview on 04/17/24 at 11:00 AM with Staff (A), Facility Administrator, and Staff (O), Clinical Services Manager, confirmed these findings. Findings #2: Review on 04/15/24 of the policy “Preparation of 1% or 10% Bleach Solution Utilizing the On-Demand Bleach Auto-dilution System,” last revised 03/2015, indicated that the disinfectant container is to be labeled with expiration date/time and the preparers initials. Observation on 04/15/24 at 10:25 AM revealed two containers located across from Station #1 and #19 contained a clear solution. The containers did not have any indication of what the solution was, the date/time of preparation and/or the preparers initials. Interview on 04/15/24 at 10:30 AM with Staff (J), Patient Care Technician revealed that one container held a 1% bleach solution and the other held a 10% bleach solution. Interview on 04/17/24 at 02:30 PM with Staff (A), Facility Administrator, and Staff (O), Clinical Services Manager, confirmed these findings.”

“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: 40430 Based on policy review, observation, and interview, nursing staff did not perform hand hygiene while performing central venous catheter care. Failure to follow central venous care policy places patients at increased risk for infection. Findings include: Review on 04/15/24 of the policy “Central Venous Catheter with Clearguard HD Antimicrobial End Caps Procedure,” last revised 10/2023 indicated that staff are to remove gloves, perform hand hygiene, and re-glove after removing the old dressing and discarding, prior to cleaning the central venous catheter exit site (site where the catheter enters to body). Observation on 04/15/24 at 12:00 PM at Station #15 with Patient #16 and on 04/16/24 at 10:40 AM at Station #19 for Patient # 15 revealed that Staff (L), Licensed Practical Nurse initiated treatment for both patients via a central venous catheter access. Staff (L) removed the old dressings covering the catheter exit site/ports and removed gloves. Staff (L) did not perform hand hygiene prior to applying clean gloves, to continue with catheter care. Interview on 04/17/24 at 11:00 AM with Staff (A), Facility Administrator, and Staff (O), Clinical Services Manager, confirmed these findings.”

“SOFTENERS: TESTING HARDNESS/LOG CFR(s): 494.40(a) 6.2.4 Softeners: Testing hardness/log Users should ensure that test accuracy and sensitivity are sufficient to satisfy the total hardness monitoring requirements of the reverse osmosis machine manufacturer. Total hardness of the water exiting the water softener should be measured at the end of each treatment day. Water hardness test results should be recorded in a water softener log. This Standard is not met as evidenced by: 16136 Based on document review and interview, the facility does not ensure that the water hardness is tested at the end of each treatment day for three of three months. (December 2023, January 2024, and February 2024). Findings include: Review on 04/16/24 of the document “Central Water Plant- CWP Daily Water Log,” revealed that the water hardness testing was not performed after the last dialysis patient treatment on 12/08/23, 12/11/23, 12/18/23, 12/22/23, 12/30/23, 01/12/24, 01/17/24, 02/12/24, and 02/17/24. Interview on 04/17/24 at 10:30 AM with Staff (E), Biomedical Technician, verified this finding.”

“HOT H2O DISINF SYS-TEMP/TIME/FOLLOW DFU/PIPE CFR(s): 494.40(a) 5.3.4.3 Hot water disinfection systems: temp/time/follow DFU/piping Refer to RD62:2001, 4.3.14 Hot water disinfection systems: When used to control bacterial proliferation in water treatment, storage, and distribution systems, the water heater of a hot water disinfection system shall be capable of delivering hot water at the temperature and for the exposure time specified by the manufacturer. 5.3.4.3 Hot water disinfection systems Hot water disinfection systems can be used only in systems constructed from heat-resistant materials, such as crosslinked polyethylene, polypropylene, and stainless steel (see [AAMI] 5.3.3). The manufacturer’s instructions for using hot water disinfection systems should be followed. If no manufacturer’s instructions are available, the effectiveness of the system can be demonstrated by verifying that the system maintains a specified temperature for a specified time and by performing ongoing surveillance with bacterial cultures and endotoxin testing. This Standard is not met as evidenced by: 16136 Based on document review and staff interview, the facility does not ensure that an acceptable hot water return temperature on the Central Water Plant (CWP) has been obtained when water returns to the Central Water Plant for three of three months (December 2023, January 2024, and February 2024). Findings include: Review on 04/16/24 of the “Central Water Plant-CWP Daily Water Log,” revealed that the “Low Disinfection Temperature Alarm” was continuously present and documented on the log with a “Y”, indicating that technical assistance was required to investigate the alarm. This log indicated that this alarm (alarm indicates a low temperature) was present for 20 of 24 days in December 2023, for 23 of 26 days in January 2024 and six of 25 days in February 2024. Interview on 04/16/24 at 03:15 PM with Staff (E), Biomedical Technician, verified these findings and did not have knowledge of why staff were recording this parameter in this manner.”

“HOT H20 DISINF SYS-MONITORING CFR(s): 494.40(a) 6.3.4 Bacterial control devices 6.3.4.3 Hot water disinfection systems: monitoring Hot water disinfection systems should be monitored for temperature and time of exposure to hot water as specified by the manufacturer. Also, hot water disinfection should be performed at least as often as recommended by the manufacturer. The temperature of the water should be recorded at a point farthest from the water heater-that is, where the lowest water temperature is likely to occur ...and measured each time a disinfection cycle is performed. A record that verifies successful completion of the heat disinfection should be maintained. Successful completion is defined as meeting temperature and time requirements specified by the equipment manufacturer. This Standard is not met as evidenced by: 16136 Based on policy review, document review, and staff interview, the facility does not ensure that weekly disinfection is performed on the Central Water Plant (CWP) or that the chemical residual of disinfectant was negative after completion of the disinfection. Findings include: Review on 04/16/24 of the policy “Water Treatment System Disinfection,” last revised 10/2021 indicated that the Reverse Osmosis (RO-water purification system) unit was disinfected at least weekly using Peracetic Acid solution and that the system was tested to ensure that residual disinfectant was not present. Review on 04/16/24 of the document “Central Water Plant-CWP Daily Water Log,” revealed that the Reverse Osmosis unit in the Central Water Plant was not disinfected weekly with Peracetic Acid solution for the weeks of 12/04/23, 12/11/23, 12/18/23, 01/15/24, 02/19/24 and 03/11/24. Chemical residual testing was not performed on 01/11/24, 02/22/24 and 03/21/24 after the Reverse Osmosis unit was disinfected, to ensure that the chemical residual was negative. Interview on 04/16/24 at 03:20 PM with Staff (E), Biomedical Technician, verified this finding.”

“ACID BULK STORAGE TANKS-SAFETY CONTROLS CFR(s): 494.40(a) 5.4 Concentrate preparation 5.4.3 Bulk storage tanks (acid concentrate): safety controls Procedures should be in place to control the transfer of the acid concentrate from the delivery container to the storage tank to prevent the inadvertent mixing of different concentrate formulations. If possible, the tank and associated plumbing should form an integral system to prevent contamination of the acid concentrate. The storage tanks and inlet and outlet connections, if remote from the tank, should be secure and labeled clearly. This Standard is not met as evidenced by: 16136 Based on document review, manufacturer recommendations, and interview, the facility does not ensure that the specific gravity (determination for the electolyte concentration of acid solutions) of prepared acid solution is within facility established parameters for the OFB2251-3B central acid unit for two of two months (02/2024 and 03/2024) or that the one micron filter was replaced after six batches of acid was prepared for 3 of 3 months in 2024 (January, February, and March). Findings include: Review on 04/16/24 of the document “Granuflo (132 Gallon) Batch Production Record,” revealed that the specific gravity for the prepared acid solution was not within parameters: -On 02/07/24, the documented specific gravity was 1.190 (acceptable range was 1.192-1.204). -On 03/08/24, the documented specific gravity was 1.240 (acceptable range was 1.190-1.202). Review on 04/16/24 of the manufacturer’s recommendations for the dry acid dissolution unit revealed that the one micron filter will be changed after mixing six batches of acid solution. Review 04/16/24 of the document “Granuflo (132 Gallon) Batch Production Record,” for 01/2024, 02/2024, and 03/2024 revealed no indication that the one micron filter was changed after six batches of acid had been prepared. Interview on 04/16/24 at 12:45 PM with Staff (E), Biomedical Technician, verified this finding.”

“MICROB MONITOR-SAMPLE BEFORE DISINFECT CFR(s): 494.40(a) 7.2 Microbial monitoring methods 7.2.1 General: samples before disinfect Samples should always be collected before sanitization/disinfection of the water treatment system and dialysis machines. This Standard is not met as evidenced by: 16136 Based on policy review, document review, and staff interview, staff did not document the time that monthly water cultures are obtained for five of 12 months (05/2023, 07/2023, 08/2023, 09/2023, and 10/2023). A time is needed to ensure the water culture sample is collected prior to the water loop disinfection. Findings include: Review on 04/16/24 of the policy “Water Culture,” last revised 04/2024, indicated that routine water cultures are collected monthly within 72 hours prior to the scheduled disinfection of the distribution system. Review on 04/16/24 of the reports for water cultures and the “Water Loop Disinfection Log,” revealed that for 05/2023, 07/2023, 08/2023, 09/2023, and 10/2023, staff did not document the time of obtaining the water culture or the time the water loop was disinfected. It was not possible to verify that the water culture samples were collected prior to water loop disinfection. Interview on 04/16/24 at 03:35 PM with Staff (E), Biomedical Technician, and Staff (W), Biomed Operations Manager, verified this finding.”

“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: 16136 Based on observation and interview the facility does not ensure that exit doors are accessible and operate properly, that the mechanical exhaust is operational, that oxygen tanks are properly stored, and that the generator is inspected/tested routinely. Findings include: Observation on 04/15/24 at 10:40 AM, revealed that the marked exit door in the clinic area, adjacent to Station #9, was obstructed with two privacy screen panels. Interview with Staff (I), Patient Care Technician, verified this finding. Observation on 04/17/24 between 10:10 AM and 12:30 PM, revealed that the mechanical exhaust was not operational in the regulated medical waste room, the housekeeping closet, and the patient toilet room. Observation on 04/17/24 at 10:20 AM, revealed that the marked exit door in the clinic area, leading into the shared space, did not close and latch. Interview with Staff (E), Biomedical Technician, verified this finding. Observation on 04/17/24 at 09:30 AM, that 12 “E” sized oxygen tanks and one “B” oxygen tank were stored together in the same rack adjacent in the clean utility room. Interview with Staff (Z), Registered Nurse, revealed they did not know which oxygen tanks full and which tanks were empty. Interview on 04/16 24 at 01:20 PM, with Staff (E), Biomedical Technician, and Staff (W), Biomed Operations Manager, revealed that the emergency generator is not inspected weekly or tested every 20-40 days under a 30% rated load.”

“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: 16136 Based on policy review, document review, manufacturer recommendations, and interview, the facility does not ensure that descaling procedure is performed after each dialysis treatment or that a citric thermal procedure is performed at the end of each treatment day for three of three months (01/2024, 02/2024 and 03/2024). Findings include: Review on 04/15/24 of the manufacturer recommendations indicates that an automatic descaling process (for removal of calcification/precipitate) is required after each dialysis treatment if the hemodialysis machine is equipped with a Diacap Ultrapyrogen Filter (DF-a bacterial and pyrogen filter for manufacturing ultrapure dialysis fluid in a Dialog dialysis machine). Review on 04/15/24 of the document “B. Braun Dialysis Delivery System Clean and Disinfect Log,” did not provide evidence that a descaling process was performed after each patient treatment in 01/2024, 02/2024 and 03/2024. Review on 04/16/24 of the policy “B. Braun Dialog Series-Citric Thermal Procedure,” last revised 04/2021, indicated that an acid cleanse (for removal of calcification/precipitate) must be performed for a hemodialysis machine before the heat disinfection cycle to minimize the accumulation of precipitate. This procedure must be performed every treatment day after the last treatment of the day. Review on 04/16/24 of the document “B. Braun Dialysis Delivery System Clean and Disinfect Log,” revealed that a citric thermal procedure was not performed daily for hemodialysis machines after the last patient treatment for the following days: 01/15/24, 01/24/24, 01/30/24, 02/08/24, 02/22/24, 02/28/24, 03/21/24, 03/29/24 and 03/30/24. Interview on 04/16/24 at 11:30 AM with Staff (E), Biomedical Technician, verified these findings.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 40430 Based on policy review, observation, and interview, staff do not ensure all hemodialysis access sites are visible and the face of patients are uncovered throughout the hemodialysis treatment. Failure to view access site during treatment has the potential for an adverse patient event. Findings include: Review on 04/16/24 of the policy “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” last revised 04/2024 indicated that the vascular access site, blood line connections, and the patient’s face should be visible throughout the dialysis treatment. Observation on 04/15/24 at 01:40 PM at Station #4 revealed Patient #35’s fistula (access used to provide hemodialysis) and bloodlines were covered by their blanket. At Station #19, Patient #38’s central venous catheter access and bloodlines were covered by their clothing. Observation on 04/16/24 at 08:45 AM at Station #10 revealed Patient #36’s fistula and bloodlines were covered by a blanket. At Station #19, Patient #33’s central venous catheter access and bloodlines were covered by their clothing and blanket. Observation on 04/17/24 at 09:20 AM at Station #4 revealed Patient #6’s face was covered by a blanket. At Station #16 Patient #28’s central venous catheter access and blood lines were covered beneath clothing. Interview on 04/17/24 at 11:00 AM with Staff (A), Facility Administrator, and Staff (O), Clinical Services Manager, confirmed these findings. THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 06/28/17.”

“PA-ASSESS CURRENT HEALTH STATUS/COMORBIDS CFR(s): 494.80(a)(1) The patient’s comprehensive assessment must include, but is not limited to, the following: (1) Evaluation of current health status and medical condition, including co-morbid conditions. This Standard is not met as evidenced by: 40430 Based on policy review, medical record review, and interview, registered nurse pre-treatment and catheter assessments were not completed timely for two of four patients (Patient #15, and #16). Lack of assessment has the potential for adverse patient outcomes. Findings include: Review on 04/16/24 of policy “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” last revised 04/2024 indicated the nursing assessment will be performed and documented by a registered nurse within one hour of dialysis treatment initiation or sooner as required by state law. Review on 04/16/24 of policy “Central Venous Catheter Care (New York State Specific),” last revised 10/2022 indicated that in New York State, the registered nurse will verify a catheter assessment within 45 minutes of treatment if treatment was initiated by a Licensed Practical Nurse. Review on 04/16/24 of treatment flowsheets for Patient #15 revealed the following: -On 03/21/24 at 11:00 AM, treatment was initiated via central venous catheter by the registered nurse. The registered nurse pre- assessment, including catheter assessment,was not documented until 12:16 PM. -On 03/28/24 at 10:50 AM, treatment was initiated via central venous catheter by the licensed practical nurse. The registered nurse pre-assessment, including catheter assessment, was not performed until 12:02 PM. -On 03/30/24 at 10:25 AM, treatment was initiated via central venous catheter by the registered nurse. The registered nurse pre-assessment, including catheter assessment, was not documented until 12:52 PM. -On 04/02/24 at 11:30 AM, treatment was initiated via central venous catheter by the licensed practical nurse. The registered nurse pre-assessment, including catheter assessment, was not performed until 12:37 PM. -On 4/09/24 at 10:35 AM, treatment was initiated via central venous catheter by the registered nurse. The registered nurse pre-assessment, including catheter assessment, was not documented until 12:00 PM. -On 04/13/24 at 10:27 AM, treatment was initiated via central venous catheter by the licensed practical nurse. The registered nurse pre-assessment, including catheter assessment, was not performed until 11:37 AM. Review on 04/16/24 of treatment flowsheets for Patient #16 revealed the following: -On 03/22/24 at 11:57 AM, treatment was initiated via central venous catheter by the licensed practical nurse. The registered nurse pre-assessment, including catheter assessment, was not performed until 01:00 PM. -On 03/27/24 at 11:27 AM, treatment was initiated via central venous catheter by the licensed practical nurse. The registered nurse pre-assessment, including catheter assessment, was not performed until 12:52 PM. -On 04/08/24 at 11:55 AM, treatment was initiated via central venous catheter by the licensed practical nurse. The registered nurse pre-assessment, including catheter assessment, was not performed until 01:00 PM. Interview on 04/17/24 at 11:00 AM with Staff (A), Facility Administrator, and Staff (O), Clinical Services Manager, confirmed these findings.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 40430 Based on policy review, medical record review, and interview, the facility does not ensure that blood flow rates are maintained per physician order for one of four patients (Patient #18). Failure to maintain the ordered blood flow rate has the potential for an inadequate hemodialysis treatment and/or a delay in identifying an issue with the access. Findings include: Review on 04/16/24 of the policy “Pre-Intra-Post Treatment data collection, Monitoring and Nursing Assessment,” last revised 04/2024 revealed that if the dialysis prescription is not being met (including dialysis blood flow rate), the reason will be documented, and the licensed nurse will be informed. Review on 04/16/24 of the treatment flowsheets for Patient #18 from 03/18/24 to 04/12/24 revealed a prescribed blood flow rate of 400 ml/hour was not maintained on 03/19/24, 03/28/24, 04/01/24, 04/03/24, and 04/08/24. There was no documentation in the medical record to indicate why the blood flow rate was not maintained as ordered. Interview on 04/17/24 at 11:00 AM with Staff (A), Facility Administrator, and Staff (O), Clinical Services Manager, confirmed these findings.”

“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: 40430 Based on policy review, medical record review, and interview, nursing staff did not assess post treatment standing blood pressures for Patient #15 for seven of ten hemodialysis treatments (03/21/24, 03/23/24, 03/26/24, 03/30/24, 04/06/24, 04/11/24, and 04/13/24). Failure to address post treatment standing blood pressure has the potential for adverse patient outcome. Findings include: Review on 04/17/24 of policy “Pre-Intra-Post Treatment Data collection, Monitoring and Nursing Assessment,” last revised 04/2024 indicated that patient data will be documented by the patient care technician or a licensed nurse to include sitting and standing blood pressure measurements pre and post treatment. Review on 04/17/24 of the treatment flowsheets for Patient #15 revealed on 03/21/24, 03/23/24, 03/26/24, 03/30/24, 04/06/24, 04/11/24, and 04/13/24, there is no documented post treatment standing blood pressure or reason why a standing blood pressure could not be obtained. Nursing staff documented that Patient #15 was ambulatory with no assistance needed. Review of nursing notes revealed no documented evidence that Patient #15 refused standing blood pressures and/or signed out against medical advice. Interview on 04/17/24 at 11:00 AM with Staff (A), Facility Administrator, and Staff (O), Clinical Services Manager, confirmed these findings.”

“QAPI-ONGOING;USES INDICATORS=IMPROVEMENT CFR(s): 494.110(a)(1) The program must include, but not be limited to, an ongoing program that achieves measurable improvement in health outcomes and reduction of medical errors by using indicators or performance measures associated with improved health outcomes and with the identification and reduction of medical errors. This Standard is not met as evidenced by: 34528 Based on policy review, document review, and interview, the facility does not ensure all quality indicator data was analyzed for trends to ensure the quality of the patient care provided as evidenced by: 1. Staff do not review data collected for patients receiving home peritoneal dialysis. 2. Staff do not review patient mortality. This has the potential for missed opportunities to improve care and services. Findings #1: Review on 04/16/24 of the policy “Continuous Quality Improvement Program,” last revised 04/2021 revealed the facility will measure, analyze, and track quality indicators. The program must include but not be limited to indicators as reflected in the Facility Health Record (location of documentation and topics of discussion for the quality meetings) application. Any area identified as underperforming will be reviewed to identify root causes for underperformance and will have an action plan identified that will result in performance improvement. The change in performance will be tracked over time to verify improvements are sustained. Review on 04/16/24 of the document “Peritoneal Dialysis Fluid and Blood Pressure Reports,” dated from 10/17/23 to 02/29/24 revealed data collected included pre-treatment blood pressure, post-treatment blood pressure, pre-treatment weight, post-treatment weight, target weight, interdialytic weight gain (weight gain between dialysis treatments), interdialytic weight gain as a percentage of total weight, and ultra filtration rate (speed at which fluid is removed). Review on 04/16/24 of the “Monthly Peritoneal Census Data,” revealed the following: -In October 2023, there were 23 peritoneal dialysis patients. -In November 2023, there were 22 peritoneal dialysis patients. -In December 2023, there were 21 peritoneal dialysis patients. -In January 2024, there were 21 peritoneal dialysis patients. -In February 2024, there were 23 peritoneal dialysis patients. Review on 04/16/24 of the “Facility Health Record,” for the peritoneal dialysis fluid management indicator dated between 11/2023 and 03/2024 revealed the only topic of analysis was target weight assessments for post-hospitalized peritoneal dialysis patients. No evidence of discussion or analysis was found for pre-treatment blood pressure, post-treatment blood pressure, pre-treatment weight, post-treatment weight, target weight, interdialytic weight gain, interdialytic weight gain as a percentage of total weight, and/or ultra filtration rate data for trends in the fluid management section for non-hospitalized peritoneal dialysis patients. Interview on 04/17/24 at 02:30 PM with Staff (A), Clinical Coordinator, confirmed findings. Findings #2 Review 04/16/24 of policy “Continuous Quality Improvement Program”, last revised April 2021 revealed the facility will measure, analyze, and track quality indicators. The program must include Mortality- review of deaths. Continuous monitoring of the above indicators will be reflected in the meeting minutes. Any area identified as underperforming will be reviewed to identify root causes for underperformance, will have an action plan identified that will result in performance improvement, and will track this change in performance over time to verify improvements are sustained. Review on 04/16/24 of document “Cleve Hill Mortality Log,” not date, revealed the following patient deaths: Patient #24 on 10/09/23, Patient #17 on 10/14/23, Patient #21 on 11/26/23, Patient #25 on 12/12/23, Patient #22 on 01/11/24, and Patient #20 on 01/22/24. Review on 04/16/24 of document “Quality Meeting Minutes,” from 11/2023 to 02/2024 revealed no evidence that patient mortality is reviewed. Interview on 04/17/24 at 02:30 PM with Staff (A), Clinical Coordinator confirmed these findings.”