Health inspection·January 19, 2024

F 0580 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to contact and notify the hospice agency (health care service that focuses on the care, comfort, and quality of life of a person with serious illness who is approaching the end of life) that one of five sampled residents (Resident 1) had missed dialysis treatments (mechanical process of removing waste products and toxins, and excess fluid from the body) on [DATE], [DATE], [DATE] and [DATE] due to issues with transportation from the facility to the dialysis center. This deficient practice resulted in Resident 1 being sent out via 911 (emergency medical transport) to a general acute care hospital (GACH) for emergency dialysis on [DATE]. Resident 1 ultimately expired (died) at 9:32 p.m. (3 hours 23 minutes after arriving to the GACH ' s Emergency Department) on [DATE] after receiving multiple rounds of life saving medications (names of medications not specified). Cross reference F698 Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on [DATE] and readmitted on [DATE] with diagnoses of dependence on renal (kidney) dialysis and hypertensive heart disease (high blood pressure) without heart failure (heart is unable to pump blood around the body properly). During a review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool) dated [DATE], the MDS indicated Resident 1 was cognitively (thinking, reasoning, or remembering) intact. The MDS indicated Resident 1 was receiving dialysis. During a review of Resident 1 ' s last laboratory tests (diagnostic tests from a sample of blood), dated [DATE], Resident 1 ' s potassium level was 5.6 milliequivalent per liter (mEq/L, a unit of measure) (Normal range 3.5 mEq/L to 5.5 mEq/L). During a review of Resident 1 ' s Discharge Order from the GACH dated [DATE], the Discharge Order indicated Resident 1 was to discharge back to the facility under the hospice agency and to receive antibiotics (medicines that fight bacterial infections) for two weeks during his dialysis treatments. During a review of Resident 1 ' s (readmission) Order Summary Report dated 1/2024, the Order Summary Report indicated orders were entered on [DATE] for the following: Page 1 of 12 055758 055758 01/19/2024 Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

F 0580 1. Continue orders for 45 days unless otherwise specified. Level of Harm - Actual harm 2. Dialysis: Tuesdays, Thursdays, Saturdays. Chair time 4:45 a.m., transportation pick up time 3:45 a.m. Residents Affected - Few During a review of Resident 1 ' s care plans, an untitled care plan initiated on [DATE] indicated Resident 1 was receiving dialysis every Tuesday, Thursday, and Saturday with a dialysis chair time (appointment time) of 4:45 a.m. and was to be picked up by transportation at 3:45 a.m. The care plan goal indicated Resident 1 ' s clinical condition was to be managed. The care plan interventions included communicating with the dialysis center and the hospice agency as needed and to coordinate transportation as needed with the transportation company and the hospice agency. During a review of Resident 1 ' s Physicians ' Certification for Hospice Benefits dated [DATE], the Physician ' s Certificate indicated Resident 1 was admitted to the facility (on [DATE]) under a hospice agency ' s care and the diagnosis that qualified him for hospice was hypertensive heart disease without heart failure. Resident 1 was admitted to hospice under routine medical care. The Physician ' s Certificate indicated the facility staff were informed and aware to call the hospice agency for any concerns or changes of condition. During a review of Resident 1 ' s Nurses Progress Notes dated [DATE] (Saturday), the progress note indicated Resident 1 ' s scheduled transportation company did not pick him up for his scheduled dialysis treatment and a make-up dialysis treatment was scheduled for [DATE] (Monday). The Nurse Progress Note did not indicate the hospice agency was notified of Resident 1 not receiving his dialysis treatment on [DATE]. During a review of Resident 1 ' s Nurses Progress Notes dated [DATE], the progress note indicated Resident 1 again missed his make-up dialysis appointment due to transportation issues. The Nurse Progress Note did not indicate the hospice agency was notified of Resident 1 not receiving his dialysis treatment on [DATE]. During a review of Resident 1 ' s Nurses Progress Notes dated [DATE] (Tuesday), there was no mention in the progress notes that Resident 1 missed his scheduled dialysis appointment again or that the hospice agency was notified. During a review of the Physician ' s Progress Note dated [DATE], the Physician ' s Progress Note indicated Resident 1 wished to continue dialysis treatment while on hospice and staff were to communicate with the HSPC for dialysis treatment. During a review of Resident 1 ' s Hospice Agency Communication Log dated [DATE], the Hospice Agency Communication Log indicated the facility informed the hospice agency that Resident 1 had missed dialysis (this is the first communication to the hospice agency regarding missed dialysis) due to transportation issues and Resident 1 had not received dialysis since [DATE] but Resident 1 was currently stable and dialysis was scheduled for the next morning ([DATE], Thursday). During a review of Resident 1 ' s Hospice Agency Communication log dated [DATE] at 1:35 p.m., the Hospice Agency Communication log indicated the facility informed the hospice agency that Resident 1 missed dialysis again that morning due to transportation issues. During a review of Resident 1 ' s Hospice Agency Communication log dated [DATE] at 2:24 p.m., the 055758 Page 2 of 12 055758 01/19/2024 Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

F 0580 Level of Harm - Actual harm Residents Affected - Few Hospice Agency Communication log indicated the Hospice Agency reached out to Resident 1 ' s dialysis center to try to schedule an emergency dialysis treatment but the dialysis center informed the hospice agency that Resident 1 did not qualify for dialysis at their center, Resident 1 required emergency dialysis due to missing more than two ([DATE], [DATE] and [DATE]) consecutive dialysis appointments. The facility was instructed to call 911 to send Resident 1 to the GACH. During a review of Resident 1 ' s Hospice Agency Communication Log dated [DATE] at 2:53 p.m., the Hospice Agency Communication Log indicated the hospice agency spoke to the facility again and reiterated the urgency and instructed the facility to call 911. During a review of Resident 1 ' s Change of Condition Evaluation dated [DATE], the Change of Condition Evaluation indicated the hospice agency recommended sending Resident 1 to the GACH for dialysis after Resident 1 missed three consecutive, scheduled dialysis treatments ([DATE], [DATE], and [DATE]). During a review of Resident 1 ' s Order Summary Report dated 1/2024, the Order Summary Report indicated an order dated [DATE] indicating Resident 1 may transfer to the GACH due to missed dialysis ([DATE], [DATE], [DATE] and [DATE]) with a seven-day bed hold (reserve resident ' s bed while receiving care in the hospital). During a review of Resident 1 ' s GACH ED (Emergency Department) Note dated [DATE], the GACH ED Note indicated Resident 1 arrived at the ED at 6:09 p.m. with a chief complaint of missing dialysis for one week and was last dialyzed on [DATE]. The ED Note indicated Resident 1 presented with worsening SOB (shortness of breath) due to the missed dialysis. The GACH ED Note indicated that Resident 1 informed the ED physician that there was trouble with his transportation to the dialysis center and that was why he had missed dialysis for one week. During a review of Resident 1 ' s GACH ED Note dated [DATE], the GACH ED Note indicated Resident 1 ' s laboratory results came back with a potassium (a substance that is needed by all tissues in the body) level of 8.2 mEq/L and a hyperkalemia (high potassium level that can cause life-threatening abnormal heart beats) order set was initiated (Resident 1 received medications to try to lower the potassium level), Resident 1 ' s SOB was likely due to hypervolemia (fluid overload, too much fluid volume in the body), and the plan was to admit Resident 1 to the intensive care unit (ICU a higher level of care for critically ill patients) for emergency dialysis. During a review of Resident 1 ' s GACH ED Note dated [DATE], the GACH ED Note indicated Resident 1 ' s heart rate began to drop to the 30 ' s (very low heart rate, normal range 60 to 100 beats per minute) and he became unconscious. During a review of Resident 1 ' s GACH ED Note dated [DATE], the GACH ED Note indicated Resident 1 had refused intubation (insertion of a breathing tube) and cardiopulmonary resuscitation (CPR chest compressions done when the heart stops beating or beats ineffectively) but lifesaving medications (names of medications not specified) were to be given. Resident 1 received a total of 5 rounds of life saving medications in the ED before he finally went asystole (no pulse, resident expired). During a review of Resident 1 ' s GACH Discharge summary dated [DATE], the Discharge Summary indicated Resident 1 ' s admitting diagnoses were as follows: 1. Severe hyperkalemia secondary to missed dialysis 055758 Page 3 of 12 055758 01/19/2024 Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

F 0580 2. Fluid overload due to missed dialysis Level of Harm - Actual harm 3. Uremia (a condition involving abnormally high levels of waste products in the blood) secondary to missed dialysis Residents Affected - Few 4. Acidosis (buildup of acid in the blood stream) secondary to missed dialysis After multiple rounds of life saving medications in the ED, Resident 1 had asystole and expired at 9:32 p.m. on [DATE]. Reason for death was cardiopulmonary arrest. Discharge diagnoses were as follows: 1. Cardiopulmonary arrest 2. Severe hyperkalemia 3. Missing dialysis During an interview on [DATE] at 11:53 a.m., Resident 1 ' s family member (FM1) stated Resident 1 had been released from the GACH on [DATE] on hospice. FM1 stated Resident 1 chose to be on hospice because Resident 1 was getting gangrene (death of body tissue due to a lack of blood flow or serious bacterial infection) infections on his limbs (hands, legs, feet) and did not want to get any more amputations (removal of limbs) but Resident 1 did not want to stop his dialysis treatments while on hospice. During an interview on [DATE] at 11:53 a.m. with FM1, FM1 stated he was not aware that Resident 1 missed multiple dialysis treatments ([DATE], [DATE], [DATE]) besides the one on [DATE]. FM1 stated he found out when Resident 1 went back to the GACH on [DATE]. FM1 stated the ED physician had called him and informed him that Resident 1 had missed a week of dialysis appointments due to transportation issues and that Resident 1 ' s laboratory results in the ED had come back catastrophic (involving or causing great damage or suffering) and Resident 1 ' s potassium level was twice what it should be. During an interview on [DATE] at 11:53 a.m. with FM1, FM1 stated the next call he received was from the ED physician telling him that Resident 1 had passed away. FM1 stated the hospice agency called FM1 after his death and said it was in the orders that Resident 1 was to continue dialysis at the facility and the hospice agency was not aware that the facility was having issues with transportation or why the resident missed all those dialysis days ([DATE], [DATE], [DATE], [DATE]). During an interview on [DATE] at 12:13 p.m., the HSPC administrator (ADM2) stated Resident 1 ' s wishes were to continue dialysis treatment while on hospice and that was to be respected. ADM2 stated the HSPC was first alerted on [DATE] that there were issues going on with Resident 1 ' s transportation to the dialysis center and Resident 1 had a dialysis appointment the next day for [DATE]. ADM2 stated the HSPC was informed [DATE] that Resident 1 missed his dialysis appointment again that day and the facility was directed to call 911 to send Resident 1 to the GACH for emergency dialysis. During an interview on [DATE] at 12:13 p.m., ADM2 stated the protocol for residents on hospice while residing in a facility was the facility was to inform the hospice agency with any issues, right away so the hospice agency could intervene and be aware. ADM2 stated the hospice agency should have been made aware when Resident 1 missed the first dialysis on [DATE] but they were not notified until 4 055758 Page 4 of 12 055758 01/19/2024 Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

F 0580 days later ([DATE]). Level of Harm - Actual harm During an interview on [DATE] at 1:16 p.m., a registered nurse supervisor (RN1) stated Resident 1 was supposed to attend dialysis appointments on Tuesdays, Thursdays, and Saturdays as ordered by the physician. RN1 stated Resident 1 missed dialysis on [DATE], [DATE] (make up dialysis for [DATE]), [DATE], and [DATE] due to the transportation company not picking up the resident. Residents Affected - Few During an interview on [DATE] at 1:16 p.m. with RN1, RN1 stated when he informed Resident 1 ' s attending physician (MD1) on [DATE] regarding the missed dialysis she told RN1 to contact the hospice agency to manage Resident 1 ' s care. RN1 stated the hospice agency was informed on [DATE] regarding the missed dialysis sessions. RN1 stated when Resident 1 missed dialysis again on [DATE], he reached out to the hospice agency and was told to send Resident 1 to the GACH. During an interview on [DATE] at 11:17 a.m., with the SSD, the SSD stated when a resident was on hospice, facility staff have to inform the hospice agency of any issues the resident was encountering right away, and the hospice agency should have been made aware of the first missed dialysis on [DATE] on that same day. During an interview on [DATE], at 11:17 a.m., with the SSD, the SSD stated she was not informed of the number of missed dialysis appointments until [DATE] and if she had been aware prior to that day, she would have helped contact the hospice agency sooner for assistance. The SSD stated it was not okay for a resident to miss their dialysis appointments. The SSD stated dialysis was a very important treatment and the potential consequence of a resident missing dialysis was death. During an interview on [DATE] at 2:36 p.m., with licensed vocational nurse (LVN1), LVN 1 stated when Resident 1 was having problems with transportation on Saturday, [DATE], and missed dialysis, she did not contact the hospice agency. LVN1 stated on Monday, [DATE] when Resident 1 missed his make-up dialysis, she did not inform the hospice agency again. LVN1 stated facility staff must notify the hospice agency right away, if a resident on hospice was having any issues, so they could get orders from them on what needed to be done. During an interview on [DATE] at 4:12 p.m., with the Director Of Nursing (DON), the DON stated she was not informed of the issues regarding Resident 1 missing dialysis until [DATE] and she told RN1 (on [DATE]) to communicate with the hospice agency about what was going on. The DON stated when RN1 communicated with the hospice agency on [DATE], the hospice agency made the decision to transfer Resident 1 to the GACH for emergency dialysis. The DON stated she was notified at 2 a.m. (on [DATE]) that Resident 1 had expired in the GACH (on [DATE] at 9:32 p.m.). During an interview on [DATE] at 4:12 p.m., with the DON, the DON stated that all decisions for residents on hospice needed to go through the hospice agency, and the hospice agency should have been informed right away when Resident 1 was not making his dialysis appointments due to transportation issues. During an interview on [DATE] at 4:12 p.m., with the DON, the DON stated the risks of not receiving dialysis treatments were fluid overload, respiratory distress, toxin (a poisonous substance) build up in the body, altered level of consciousness (confusion) and death. The DON stated the facility management should have been notified of transportation issues right away so they could help the nurses make the arrangements to get the residents to their dialysis appointments. 055758 Page 5 of 12 055758 01/19/2024 Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

F 0580 Level of Harm - Actual harm During an interview on [DATE] at 8:36 a.m., with LVN2, LVN2 stated she was assigned to Resident 1 on [DATE] (Resident 1 ' s scheduled dialysis day). LVN2 stated Resident 1 ' s transportation to dialysis was late on [DATE]. LVN2 stated Resident 1 was finally picked up late, at 5:40 a.m. (regular pick-up time was 3:35 a.m.) by the transportation company to go to dialysis. Residents Affected - Few During an interview on [DATE] at 8:36 a.m., with LVN2, LVN2 stated she later learned that the dialysis center had sent Resident 1 back to the facility [DATE] because he was late and missed his dialysis chair time. LVN2 stated she did not inform the HSPC of the transportation issues on her shift [DATE]. During a review of the facility ' s policy and procedure (P/P) titled Notification of Changes revised [DATE], the P/P indicated the facility must promptly inform .the resident ' s physician when there is a change requiring notification. During a review of the facility ' s P/P titled Coordination of Hospice Services dated [DATE], the P/P indicated when a resident chose to receive hospice services, the facility staff was to coordinate and provide care in cooperation with hospice staff to promote the resident ' s highest practicable physical, mental, and psychosocial well-being. The P/P indicated the facility was to contact and communicate with hospice staff regarding any significant changes in the resident ' s status, clinical complications, or emergent situations. During a review of the HSPC Contract Agreement with the facility for Resident 1 dated [DATE], the Contract Agreement indicated the HSPC was to be notified if there were clinical complications that suggested a need to alter the resident ' s plan of care and/ or a need to transfer the patient from the facility. 055758 Page 6 of 12 055758 01/19/2024 Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) received dialysis (process of mechanically removing waste products/ toxins and excess fluid from the body) according to the physician ' s orders and plan of care for dialysis management by failing to: Residents Affected - Few 1. Ensure Resident 1 did not miss three scheduled dialysis treatments ([DATE], [DATE], and [DATE]) and one make-up dialysis treatment ([DATE]). 2. Notify the hospice (health care service that focuses on the care, comfort, and quality of life of a person with serious illness who is approaching the end of life) agency overseeing Resident 1 ' s care while in the facility when Resident 1 missed his first dialysis treatment in the facility ([DATE]). The hospice agency was not being notified of each missed dialysis treatment until [DATE] after Resident 1 had missed three dialysis treatments ([DATE], [DATE], and [DATE]). Resident 1 ' s last dialysis was on [DATE]. These deficient practices resulted in Resident 1 getting sent out via 911 (emergency medical transport) to a general acute care hospital (GACH) for emergency dialysis on [DATE]. Resident 1 was found to have severe hyperkalemia (high potassium [a substance that is needed by all tissues in the body] levels that can cause life-threatening abnormal heart beats) at a level of 8.2 milliequivalent per Liter (mEq/L, a unit of measure. A dialysis patient ' s optimal range of blood potassium levels is 3.5 mEq/L to 5.5 mEq/L), shortness of breath (SOB, trouble breathing), and hypervolemia (fluid overload, too much fluid volume in the body). Resident 1 expired (died) at 9:32 p.m. (3 hours 23 minutes after arriving to the GACH ' s Emergency Department) on [DATE] after receiving multiple rounds of life saving medications (names of medications not specified). Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on [DATE] and readmitted on [DATE] with diagnoses of dependence on renal (kidney) dialysis and hypertensive heart disease (high blood pressure) without heart failure (heart is unable to pump blood around the body properly). During a review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool) dated [DATE], the MDS indicated Resident 1 was cognitively (thinking, reasoning, or remembering) intact. The MDS indicated Resident 1 was receiving dialysis. During a review of Resident 1 ' s last laboratory tests (diagnostic tests from a sample of blood), dated [DATE], Resident 1 ' s potassium level was 5.6 mEq/L, (Normal range 3.5 mEq/L to 5.5 mEq/L). During a review of Resident 1 ' s Discharge Order from the GACH dated [DATE], the Discharge Order indicated Resident 1 was to discharge back to the facility under the hospice agency and to receive antibiotics (medicines that fight bacterial infections) for two weeks during his dialysis treatments. During a review of Resident 1 ' s (readmission) Order Summary Report dated 1/2024, the Order Summary Report indicated orders were entered on [DATE] for the following: 055758 Page 7 of 12 055758 01/19/2024 Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

F 0698 1. Continue orders for 45 days unless otherwise specified. Level of Harm - Actual harm 2. Dialysis: Tuesdays, Thursdays, Saturdays. Chair time 4:45 a.m., transportation pick up time 3:45 a.m. Residents Affected - Few During a review of Resident 1 ' s care plans, an untitled care plan initiated on [DATE] indicated Resident 1 was receiving dialysis every Tuesday, Thursday, and Saturday with a dialysis chair time (appointment time) of 4:45 a.m. and was to be picked up by transportation at 3:45 a.m. The care plan goal indicated Resident 1 ' s clinical condition was to be managed. The care plan interventions included communicating with the dialysis center and the hospice agency as needed and to coordinate transportation as needed with the transportation company and the hospice agency. During a review of Resident 1 ' s Physicians ' Certification for Hospice Benefits dated [DATE], the Physician ' s Certificate indicated Resident 1 was admitted to the facility (on [DATE]) under a hospice agency ' s care and the diagnosis that qualified him for hospice was hypertensive heart disease without heart failure. Resident 1 was admitted to hospice under routine medical care. The Physician ' s Certificate indicated the facility staff were informed and aware to call the hospice agency for any concerns or changes of condition. During a review of Resident 1 ' s Nurses Progress Notes dated [DATE] (Saturday), the progress note indicated Resident 1 ' s scheduled transportation company did not pick him up for his scheduled dialysis treatment and a make-up dialysis treatment was scheduled for [DATE] (Monday). The Nurse Progress Note did not indicate the hospice agency was notified of Resident 1 not receiving his dialysis treatment on [DATE]. During a review of Resident 1 ' s Nurses Progress Notes dated [DATE], the progress note indicated Resident 1 again missed his make-up dialysis appointment due to transportation issues. The Nurse Progress Note did not indicate the hospice agency was notified of Resident 1 not receiving his dialysis treatment on [DATE]. During a review of Resident 1 ' s Nurses Progress Notes dated [DATE] (Tuesday), there was no mention in the progress notes that Resident 1 missed his scheduled dialysis appointment again or that the hospice agency was notified. During a review of the Physician ' s Progress Note dated [DATE], the Physician ' s Progress Note indicated Resident 1 wished to continue dialysis treatment while on hospice and staff were to communicate with the hospice agency for dialysis treatment. During a review of Resident 1 ' s Hospice Agency Communication Log dated [DATE], the Hospice Agency Communication Log indicated the facility informed the hospice agency that Resident 1 had missed dialysis (this is the first communication to the hospice agency regarding missed dialysis) due to transportation issues and Resident 1 had not received dialysis since [DATE] but Resident 1 was currently stable and dialysis was scheduled for the next morning ([DATE], Thursday). During a review of Resident 1 ' s Hospice Agency Communication log dated [DATE] at 1:35 p.m., the Hospice Agency Communication log indicated the facility informed the HSPC that Resident 1 missed dialysis again that morning due to transportation issues. During a review of Resident 1 ' s Hospice Agency Communication log dated [DATE] at 2:24 p.m., the 055758 Page 8 of 12 055758 01/19/2024 Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

F 0698 Level of Harm - Actual harm Residents Affected - Few Hospice Agency Communication log indicated the hospice agency reached out to Resident 1 ' s dialysis center to try to schedule an emergency dialysis treatment but the dialysis center informed the hospice agency that Resident 1 did not qualify for dialysis at their center, Resident 1 required emergency dialysis due to missing more than two ([DATE], [DATE], [DATE] and [DATE]) consecutive dialysis appointments. The facility was instructed to call 911 (an emergency service) to send Resident 1 to the GACH. During a review of Resident 1 ' s Hospice Agency Communication Log dated [DATE] at 2:53 p.m., the Hospice Agency Communication Log indicated the hospice agency spoke to the facility again and reiterated the urgency and instructed the facility to call 911. During a review of Resident 1 ' s Change of Condition Evaluation dated [DATE], the Change of Condition Evaluation indicated the hospice agency recommended sending Resident 1 to the GACH for dialysis after Resident 1 missed three consecutive, scheduled dialysis treatments ([DATE], [DATE], and [DATE]). During a review of Resident 1 ' s Order Summary Report dated 1/2024, the Order Summary Report indicated an order dated [DATE] indicating Resident 1 may transfer to the GACH due to missed dialysis ([DATE], [DATE], [DATE] and [DATE]) with a seven-day bed hold (reserve resident ' s bed while receiving care in the hospital). During a review of Resident 1 ' s GACH ED (Emergency Department) Note dated [DATE], the GACH ED Note indicated Resident 1 arrived at the ED at 6:09 p.m. with a chief complaint of missing dialysis for one week and was last dialyzed on [DATE]. The ED Note indicated Resident 1 presented with worsening SOB due to the missed dialysis. The GACH ED Note indicated that Resident 1 informed the ED physician that there was trouble with his transportation to the dialysis center and that was why he had missed dialysis for one week. During a review of Resident 1 ' s GACH ED Note dated [DATE], the GACH ED Note indicated Resident 1 ' s laboratory results came back with a potassium level of 8.2 mEq/L and a hyperkalemia order set was initiated (Resident 1 received medications to try to lower the potassium level); Resident 1 ' s SOB was likely due to hypervolemia; and the plan was to admit Resident 1 to the intensive care unit (ICU a higher level of care for critically ill patients) for emergency dialysis. During a review of Resident 1 ' s GACH ED Noted dated [DATE], the GACH ED Note indicated before getting transferred to the ICU, Resident 1 ' s heart rate began to drop to the 30 ' s (very low heart rate, normal range 60 to 100 beats per minute) and he became unconscious. During a review of Resident 1 ' s GACH ED Note dated [DATE], the GACH ED Note indicated Resident 1 had refused intubation (insertion of a breathing tube) and cardiopulmonary resuscitation (CPR chest compressions done when the heart stops beating or beats ineffectively), but life saving medications were to be given. Resident 1 received a total of 5 rounds of life saving medications (names of medications not specified) in the ED before he finally went asystole (no pulse, resident expired). During a review of Resident 1 ' s GACH Discharge summary dated [DATE], the Discharge Summary indicated Resident 1 ' s admitting diagnoses were as follows: 1. Severe hyperkalemia secondary to missed dialysis 055758 Page 9 of 12 055758 01/19/2024 Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

F 0698 2. Fluid overload due to missed dialysis Level of Harm - Actual harm 3. Uremia (a condition involving abnormally high levels of waste products in the blood) secondary to missed dialysis Residents Affected - Few 4. Acidosis (buildup of acid in the blood stream) secondary to missed dialysis After multiple rounds of life saving medications (names of medications not specified) in the ED, Resident 1 had asystole and expired at 9:32 p.m. on [DATE]. Reason for death was cardiopulmonary arrest. Discharge diagnoses were as follows: 1. Cardiopulmonary arrest 2. Severe hyperkalemia 3. Missing dialysis During an interview on [DATE] at 11:53 a.m. with Resident 1 ' s family member (FM1), FM1 stated Resident 1 had been released from the GACH on [DATE] on hospice. FM1 stated Resident 1 chose to be on hospice because Resident 1 was getting gangrene (death of body tissue due to a lack of blood flow or serious bacterial infection) infections on his limbs (hands, legs, feet) and did not want to get any more amputations (removal of limbs) but Resident 1 did not want to stop his dialysis treatments while on hospice. During an interview on [DATE] at 11:53 a.m. with FM1, FM1 stated he was not aware that Resident 1 missed multiple dialysis treatments ([DATE], [DATE], [DATE]) besides the one on [DATE]. FM1 stated he found out when Resident 1 went back to the GACH on [DATE]. FM1 stated the ED physician had called him and informed him that Resident 1 had missed a week of dialysis appointments due to transportation issues and that Resident 1 ' s laboratory results in the ED had come back catastrophic (involving or causing great damage or suffering) and Resident 1 ' s potassium level was twice what it should be. During an interview on [DATE] at 11:53 a.m. with FM1, FM1 stated the next call he received was from the ED physician telling him that Resident 1 had passed away. FM1 stated the hospice agency called FM1 after his death and said it was in the orders that Resident 1 was to continue dialysis at the facility and the hospice agency was not aware that the facility was having issues with transportation or why the resident missed all those dialysis days ([DATE], [DATE], [DATE], [DATE]). During an interview on [DATE] at 12:13 p.m., the hospice agency administrator (ADM2), ADM2 stated Resident 1 ' s wishes were to continue dialysis treatment while on hospice and that was to be respected. ADM2 stated the hospice agency was first alerted on [DATE] that there were issues going on with Resident 1 ' s transportation to the dialysis center and Resident 1 had a dialysis appointment the next day for [DATE]. ADM2 stated the hospice agency was informed on [DATE] that Resident 1 missed his dialysis appointment again that day and the facility was directed to call 911 to send Resident 1 to the GACH for emergency dialysis. During an interview on [DATE] at 12:13 p.m., ADM2 stated the protocol for residents on hospice while residing in a facility was the facility was to inform the hospice agency with any issues, right 055758 Page 10 of 12 055758 01/19/2024 Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

F 0698 Level of Harm - Actual harm Residents Affected - Few away so the hospice agency could intervene and be aware. ADM2 stated the hospice agency should have been made aware when Resident 1 missed the first dialysis on [DATE] but they were not notified until 4 days later ([DATE]). During an interview on [DATE] at 1:16 p.m., a registered nurse supervisor (RN1) stated Resident 1 was supposed to attend dialysis appointments on Tuesdays, Thursdays, and Saturdays as ordered by the physician. RN1 stated Resident 1 missed dialysis on [DATE], [DATE] (make up dialysis for [DATE]), [DATE], and [DATE] due to the transportation company not picking up the resident. During an interview on [DATE] at 1:16 p.m. with RN1, RN1 stated when he informed Resident 1 ' s attending physician (MD1) on [DATE] regarding the missed dialysis she told RN1 to contact the hospice agency to manage Resident 1 ' s care. RN1 stated the hospice agency was informed on [DATE] regarding the missed dialysis sessions. RN1 stated when Resident 1 missed dialysis again on [DATE], he reached out to the hospice agency and was told to send Resident 1 to the GACH. During an interview on [DATE] at 11:17 a.m., the social services director (SSD) stated if the facility was having issues with transportation for dialysis and the resident was on hospice, facility staff should inform the hospice company so they could coordinate another transportation company to ensure the resident made it to their dialysis appointments. During an interview on [DATE] at 11:17 a.m., with the SSD, the SSD stated when a resident was on hospice, facility staff have to inform the hospice agency of any issues the resident was encountering right away, and the hospice agency should have been made aware of the first missed dialysis on [DATE] on that same day. During an interview on [DATE], at 11:17 a.m., with the SSD, the SSD stated she was not informed of the number of missed dialysis appointments until [DATE] and if she had been aware prior to that day, she would have helped contact the hospice agency sooner for assistance. The SSD stated it was not okay for a resident to miss their dialysis appointments. The SSD stated dialysis was a very important treatment and the potential consequence of a resident missing dialysis was death. During an interview on [DATE] at 2:36 p.m., with licensed vocational nurse (LVN1), LVN 1 stated when Resident 1 was having problems with transportation on Saturday, [DATE], and missed dialysis, she did not contact the hospice agency. LVN1 stated on Monday, [DATE] when Resident 1 missed his make-up dialysis, she did not inform the hospice agency again. LVN1 stated facility staff must notify the hospice agency right away, if a resident on hospice was having any issues, so they could get orders from them. During an interview on [DATE] at 3:04 p.m., the Minimum Data Set nurse (MDSN), MDS N stated the facility nurses should have informed the hospice agency immediately that Resident 1 had missed a dialysis appointment (on [DATE]). The MDSN stated it was very important that the facility had good communication with the hospice agency, so they could be informed of what was going on with the resident because all orders for hospice patients needed to go through the hospice agency. The MDSN stated the importance of ensuring a resident received their dialysis treatments was a matter of life or death. During an interview on [DATE] at 4:12 p.m., with the Director Of Nursing (DON), the DON stated she was not informed of the issues regarding Resident 1 missing dialysis until [DATE] and she told RN1 (on [DATE]) to communicate with the hospice agency about what was going on. The DON stated when RN1 communicated with the hospice agency on [DATE], the hospice agency made the decision to transfer 055758 Page 11 of 12 055758 01/19/2024 Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

F 0698 Resident 1 to the GACH for emergency dialysis. The DON stated she was notified at 2 a.m. (on [DATE]) that Resident 1 had expired in the GACH (on [DATE] at 9:32 p.m.). Level of Harm - Actual harm Residents Affected - Few During an interview on [DATE] at 4:12 p.m., with the DON, the DON stated that all decisions for residents on hospice needed to go through the hospice agency, and the hospice agency should have been informed right away when Resident 1 was not making his dialysis appointments due to transportation issues. During an interview on [DATE] at 4:12 p.m., with the DON, the DON stated the risks of not receiving dialysis treatments were fluid overload, respiratory distress, toxin (a poisonous substance) build up in the body, altered level of consciousness (confusion) and death. The DON stated the facility management should have been notified of transportation issues right away so they could help the nurses make the arrangements to get the residents to their dialysis appointments. During an interview on [DATE] at 8:36 a.m., with LVN2, LVN2 stated she was assigned to Resident 1 on [DATE] (Resident 1 ' s scheduled dialysis day). LVN2 stated Resident 1 ' s transportation to dialysis was late on [DATE]. LVN2 stated Resident 1 was finally picked up late, at 5:40 a.m. (regular pick-up time was 3:35 a.m.) by the transportation company to go to dialysis. During an interview on [DATE] at 8:36 a.m., with LVN2, LVN2 stated she later learned that the dialysis center had sent Resident 1 back to the facility on [DATE] because he was late and missed his dialysis chair time. LVN2 stated she did not inform the hospice agency of the transportation issues during her shift on [DATE]. During a review of the facility ' s P/P titled, Coordination of Hospice Services dated [DATE], the P/P indicated when a resident chose to receive hospice services, the facility staff was to coordinate and provide care in cooperation with hospice staff to promote the resident ' s highest practicable physical, mental, and psychosocial well-being. The P/P indicated the facility was to contact and communicate with hospice staff regarding any significant changes in the resident ' s status, clinical complications, or emergent situations. During a review of the HSPC Contract Agreement with the facility for Resident 1 dated [DATE], the Contract Agreement indicated the HSPC was to be notified if there were clinical complications that suggested a need to alter the resident ' s plan of care and/ or a need to transfer the patient from the facility. 055758 Page 12 of 12