Health inspection·June 5, 2025

F 0842 Level of Harm - Potential for minimal harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the Dialysis Communication Form was completed for two of four sampled residents (Residents 1 and 4). * Residents 1 and 4's pre and post-dialysis information sections on the Dialysis Communication Form were not completed by the licensed staff. Additionally, there was no documentation of the status of the dialysis access and general condition of the residents upon returning from the dialysis center. These failures had the potential to not provide the necessary care and services to these residents as their medical information was incomplete. Findings: Review of the facility's P&P titled Hemodialysis revised 6/5/23,showed the facility will provide the necessary care and treatment consistent with professional standards of practice, physician's orders, comprehensive person-centered care plan, and resident goals and preferences to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis. - The facility will monitor for and identify changes in the resident's behavior that may impact the safe administration of the dialysis before and after treatment and will inform the attending practitioner and dialysis facility of the changes. - The licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form or other form. - The nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications. - The nurse will ensure that the dialysis access site (e.g. AV shunt or graft) is checked before and after dialysis treatments and every shift for patency by auscultating for a bruit and palpating for a thrill. If absent, the nurse will immediately notify the attending physician, dialysis facility and/or nephrologist. 1. Medical record review for Resident 1 was initiated on 5/29/25. Resident 1 was admitted to the facility on [DATE] with diagnoses including ESRD. Review of Resident 1's Order Summary Report showed the following physician orders: (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055622 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055622 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bonita Hills Post Acute 1233 West LA Habra Boulevard LA Habra, CA 90631 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)