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: Page 1 of 2 055622 055622 06/05/2025 Bonita Hills Post Acute 1233 West LA Habra Boulevard LA Habra, CA 90631

F 0842 - dated 5/8/25, for hemodialysis treatments on Tuesday, Thursday, and Saturday at the dialysis center. Level of Harm - Potential for minimal harm - dated 5/8/25, to monitor the RUA AVF every shift for bruit and thrill. Residents Affected - Some Review of Resident 1's Dialysis Communication Form dated 5/10/25, failed to show an entry for the shunt location/status under pre-dialysis information section. Review of Resident 1's Dialysis Communication Form dated 5/13/25, failed to show an entry for the shunt location/status, medications administered prior to dialysis, and additional information under the pre-dialysis information section. 2. Medical record review for Resident 4 was initiated on 6/5/25. Resident 4 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including ESRD. Review of Resident 4's Order Summary Report showed the following physician orders: - dated 4/16/25, for hemodialysis treatments on Monday, Wednesday and Friday at the dialysis center. - dated 4/16/25, to monitor the right upper chest perma-cath access site every shift. Review of Resident 4's Dialysis Communication Form dated 5/12/25, failed to show an entry for the catheter status in the pre-dialysis information section. The form further failed to show an entry for the general condition of resident in post-dialysis information section. Review of Resident 4's Dialysis Communication Form dated 5/14/25, failed to show an entry for the entire pre-dialysis information section. Review of Resident 4's Dialysis Communication Form dated 5/15/25, failed to show an entry for the catheter status in the pre-dialysis information section and the general condition of resident was left blank in post-dialysis information section. Review of Resident 4's Dialysis Communication Form dated 5/19/25, failed to show an entry for the catheter status in the pre-dialysis information section. The form further failed to show an entry for the general condition of resident in post-dialysis information section. On 6/5/25 at 1605 hours, an interview and concurrent medical record review for Residents 1 and 4 was conducted with RN 1. RN 1 acknowledged the findings and stated that it was important to conduct pre and post dialysis assessments with the residents to evaluate the residents' condition and status of the dialysis access to ensure appropriate care and interventions were provided timely as needed. RN 1 further stated the completed documentation of the Dialysis Communication Forms also validated the services and care were rendered accordingly. On 6/5/25 at 1620 hours, during an interview, the DON was informed and acknowledged the above findings. 055622 Page 2 of 2