Health inspection·December 26, 2025

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident's Minimum Data Set (MDS - a resident assessment tool), accurately reflected the resident's medical diagnoses for one of four sampled residents (Resident 1). This deficient practice had the potential to delay the provision of necessary care and services to Resident 1 and negatively affect Resident 1's well-being. Findings: During a review of Resident 1's admission Record, dated 12/26/2025, the admission Record indicated the facility originally admitted Resident 1 on 7/2/2021, and readmitted on [DATE] with diagnoses including end stage renal disease (ESRD- irreversible kidney failure), dependence on renal dialysis, anemia (a condition where blood lacks enough healthy red blood cells to carry adequate oxygen to the body) and acute on chronic combined systolic and diastolic heart failure (a long-standing heart problem affecting both the heart's ability to pump (systolic) and relax/fill (diastolic), leading to fluid buildup and inefficient blood flow). During a review of Resident 1's History and Physical (H&P - a comprehensive assessment of a resident's medical condition), dated 8/11/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. The H&P indicated Resident 1 had diagnoses of dementia (a progressive state of decline in mental abilities). During a concurrent interview and record review on 12/26/2025 at 12:42 p.m. with the MDS Coordinator, Resident 1's MDS, dated [DATE] was reviewed. The MDS indicated Resident 1 did not have diagnoses of dementia. The MDS Coordinator stated MDS diagnoses should reflect Resident 1's H&P provided by the primary physician. The MDS Coordinator stated the during the MDS assessment and documentation the facility staff should have reviewed Resident 1's H&P for potential new diagnoses such as dementia rather than reviewing Resident 1's diagnoses on the already existing admission Record (face sheet). The MDS Coordinator stated the failure to accurately update Resident 1's diagnoses in the MDS had the potential to delay Resident 1's care. During an interview on 1226/2025 at 2:31 p.m. with the Director of Nursing (DON), the DON stated it is the MDS Coordinator's responsibility to review and update residents' diagnoses as needed. The DON stated Resident 1's diagnoses should be based on primary physician's notes and be reflective in Resident 1's MDS and Care Plan. The DON stated the MDS is the overall assessment of the resident's condition and should include all resident's diagnoses. The DON stated the failure to ensure MDS was accurate had the potential to delay care for Resident 1 due to inaccuracy of the assessment. During a review of the current facility-provided policy and procedure titled, RAI Process, last reviewed on 6/19/2025, the policy and procedure indicated, To ensure that the Resident Assessment Instrument (RAI) is used, in accordance with specified format and timeframes, in conducting comprehensive assessments as part of an ongoing process through which the facility identifies each resident's preferences and goals of care, functional and health status, strengths and needs, as well as offering guidance for further assessment once problems have been identified. C. All information recorded within the MDS Assessment must reflect the resident's status at the time of the Assessment Reference Data (ARD). Residents Affected - Few Page 1 of 21 056084 056084 12/26/2025 Astoria Healthcare Center 14040 Astoria Street Sylmar, CA 91342

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Implement the care plan (a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial [relating to the interrelation of social factors and individual thought and behavior] and functional needs) for one of four sampled residents (Resident 1) which included interventions related to hemodialysis (a medical treatment that acts as an artificial kidney, filtering waste products and extra fluid from the blood when kidneys are not working well) care that required monitoring of Resident 1's left upper arm arteriovenous fistula (AV fistula or shunt - a surgically created connection between an artery and a vein to provide hemodialysis access where a needle is inserted allowing blood to be drawn, cleaned, and returned to the body) for bleeding upon return to the facility following hemodialysis treatment. On [DATE], at approximately 7:10 p.m., the facility failed to monitor Resident 1's AV Fistula site as indicated in the care plan. Resident 1, who had a diagnosis of anemia (a condition where blood lacks enough healthy red blood cells to carry adequate oxygen [a colorless, odorless reactive gas and the life-supporting component of the air] to the body), was receiving Eliquis (a medication used to prevent and treat blood clots [gel-like clumps of blood that forms inside the body when blood vessels [a tube through which the blood circulates in the body] are injured or damaged] by slowing down the body's clotting process and increase the risk for bleeding), and had a known history of removing the pressure dressing (specialized bandage applied to access site to provide firm, consistent pressure after dialysis to stop bleeding) from her (Resident 1) left upper arm AV fistula after a hemodialysis treatment, which had previously resulted in bleeding. As a result, on [DATE], at approximately 7:50 p.m., Certified Nurse Assistant 1 (CNA 1) found Resident 1 bleeding from the AV fistula site. Resident 1 was found, unresponsive, in a sitting position at the edge of the bed, with upper body leaning on the bed, without the pressure dressing in place at the AV fistula site and with blood all over the bed and floor in Resident 1's room. On [DATE] at 8:18 p.m., the paramedics (persons trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) pronounced Resident 1 deceased in the facility. 2. Develop and implement a person-centered care plan for one of three sampled residents (Resident 5) to address Resident 5's admission to hospice (compassionate care for people who are near the end of life). This failure had the potential for delays in the delivery of necessary care and services to Resident 5. On [DATE] at 1:31 p.m., while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's non-compliance with one or more requirements of participations has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) in the presence of the Director of Staffing Department (DSD), the Infection Preventionist (IP), and the Administrator (through telephone), due to the facility's failure to implement Resident 1's care plan related to hemodialysis care that required monitoring of Resident 1's left upper arm AV fistula for bleeding upon return to the facility following hemodialysis treatment on [DATE] under S483.21(b) Comprehensive Care Plans, which resulted in Resident 1's death on [DATE] at 8:18 p.m. (The Certificate of Death dated [DATE] indicated a time of death of 8:18 p.m., while the facility's Progress Note dated [DATE] indicated the time of death as 8:15 p.m.) On [DATE] at 5:22 p.m., the Administrator provided an acceptable IJ removal plan (a plan that identifies all actions the facility will take to immediately address the non-compliance that has resulted to the IJ situation) for the facility's failure to implement Resident 1's care plan related to hemodialysis care that required monitoring of Resident 1's left upper arm AV fistula for bleeding upon return to the facility following 056084 Page 2 of 21 056084 12/26/2025 Astoria Healthcare Center 14040 Astoria Street Sylmar, CA 91342

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few hemodialysis treatment on [DATE], which resulted in Resident 1's death on [DATE] at 8:18 p.m. On [DATE] at 6:27 p.m., while onsite at the facility, the SSA verified and confirmed the facility's full implementation of the IJ Removal Plan through observations, interviews, and record reviews, and determined the IJ situation regarding the facility's failure to implement Resident 1's care plan related to hemodialysis care that required monitoring of Resident 1's left upper arm AV fistula for bleeding upon return to the facility following hemodialysis treatment on [DATE], which resulted in Resident 1's death on [DATE] at 8:18 p.m. was no longer present. The SSA removed the IJ situation, while onsite, on [DATE] at 6:27 p.m. in the presence of the Administrator and the Director of Nursing (DON). The acceptable IJ Removal Plan included the following summarized actions: 1. On [DATE] at 4 p.m., the DON conducted a comprehensive review of Resident 1's hemodialysis-related care upon Resident 1's return from the hemodialysis treatment on [DATE]. The DON conducted interviews with Registered Nurse 1 (RN 1), and Licensed Vocational Nurse 1 (LVN 1), who were assigned to Resident 1 on [DATE] during the 3 p.m. to 11 p.m. shift (scheduled work period). The DON reviewed the facility's policy and procedure (P&P) on Dialysis Care, forms used for dialysis care (Nursing Facility Pre (before) and Post (after) Dialysis Assessment forms - a crucial clinical evaluation after a hemodialysis treatment to check for complications and access site issues like bleeding), nurses progress notes, and communication related to Resident 1's return from the dialysis treatment. The DON identified failures related to post-dialysis assessment, monitoring, communication, and documentation. 2. Effective [DATE], at 2 p.m., all residents returning from hemodialysis treatment or any off-site procedure will be assessed upon return at the soonest practicable time by the Charge Nurse (an LVN coordinating care for the assigned residents) and/or RN. The assessment will include direct inspection of the hemodialysis access site, vital signs (measurements of your body's most basic functions, including temperature, heart rate, respiratory rate, and blood pressure), bleeding assessment, condition of the resident, documentation of findings in the nursing progress notes, and the Nursing Facility Post Dialysis Assessment form. The CNA will immediately notify any licensed nurse of any observed signs of bleeding or distress and will endorse findings to the LVN Charge Nurse and/or RN. 3. On [DATE] at 2 p.m., the RN Supervisor and Charge Nurse reviewed and updated the person-centered care plans for residents receiving hemodialysis (Residents 2, 3, 4, 5, 6, 7, 8, and 9) to reflect each resident's individual needs and the required care of their (Residents 2, 3, 4, 5, 6, 7, 8, and 9) dialysis access sites.4. On [DATE] at 2:05 p.m., the DON and Medical Records staff conducted an audit (review of records, processes, or systems to assess accuracy, compliance) on the Nursing Facility Pre and Post Dialysis Assessment forms for eight residents (Residents 2, 3, 4, 5, 6, 7, 8, 9) receiving hemodialysis treatment. There were no other residents identified with deficiencies similar to those found for Resident 1. 5. On [DATE], at 2:05 p.m., the DON and RN Supervisor conducted an audit of care plans related to dialysis care and the Nursing Facility Post Dialysis Assessment form for eight residents (Resident 2, 3, 4, 5, 6, 7, 8, and 9) receiving hemodialysis. The audit showed that all applicable care plan interventions were present and up to date for Residents 2, 3, 4, 5, 6, 7, 8, and 9. 6. On [DATE] at 2:10 p.m. and 5:25 p.m., and on [DATE] at 12 p.m., the DON and DSD provided in-service (refers to individualized, one-on-one education provided to a single individual by a staff member or professional) training to nursing staff regarding care planning, with emphasis on the following: a. Implementation of residents' individualized hemodialysis care plans. b. Completion of the Nursing Facility Post-Dialysis Assessment form, the Dialysis Flow Sheet-Return Assessment and nursing progress notes documenting the date and time residents returned to the facility, to be completed by LVNs or RNs following hemodialysis treatment. c. Comprehensive assessment and monitoring of residents by LVNs or RNs following 056084 Page 3 of 21 056084 12/26/2025 Astoria Healthcare Center 14040 Astoria Street Sylmar, CA 91342

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few dialysis treatment. 7. On [DATE] at 4 p.m., the DON provided a one on one (1:1) in-service to RN 1 and LVN 1, who were assigned to Resident 1 on [DATE] during the 3 p.m. to 11 p.m. shift regarding P&P on Dialysis Care. The in-service addressed conducting pre and post dialysis assessments with focus on assessing the dialysis access site for signs of bleeding, resident's medical condition and other complications. The in-service addressed documentation on the nurse's progress notes and the Nursing Facility Pre and Post Dialysis Assessment form. Licensed nurse will document in the nurse's progress notes resident's return to the facility from the hemodialysis treatment, including the date and time of the return and the care provided to the resident. Cross reference with F698. Findings: 1. During a review of Resident 1's admission Record, undated, the admission Record indicated the facility originally admitted Resident 1 on [DATE], and readmitted on [DATE] with diagnoses including End-Stage Renal Disease (ESRD - the final stage of chronic kidney disease [CKD] where kidneys fail permanently, requiring hemodialysis or a kidney transplant for survival), anemia, unspecified atrial fibrillation (a-fib - an irregular and often very rapid heart rhythm), and acute on chronic combined systolic and diastolic heart failure (a long-standing heart problem affecting both the heart's ability to pump [systolic] and relax/fill [diastolic], leading to fluid buildup and inefficient blood flow). During a review of Resident 1's Order Summary Report, the Order Summary Report indicated the following physician's order: - [DATE]: Hemodialysis every Tuesday, Thursday, and Saturday. - [DATE]: Monitor left arm AV shunt dialysis access for bruit (sound of turbulent blood flow heard with a stethoscope [a medical instrument for listening to the action of someone's heart or breathing]) and thrill (the palpable vibration felt by hand over a turbulent blood flow), swelling, bleeding, and signs of infection every shift. [DATE]: Eliquis oral tablet 2.5 milligram (mg - unit of measurement) to give one tablet by mouth two times a day for a-fib. During a review of Resident 1's History and Physical (H&P - a comprehensive assessment of a resident's medical condition), dated [DATE], the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated [DATE], the MDS indicated Resident 1's cognitive functioning (the ability to think, learn, remember, use judgment, and make decisions) was intact. The MDS indicated Resident 1 needed setup or clean-up assistance (helper sets up or cleans up; resident completes activity and helper assists only prior to or following the activity) with eating, oral hygiene, toileting hygiene, personal hygiene, upper body dressing, and lower body dressing. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) from the facility staff to propel (move) a wheelchair (a chair with wheels used in order to move around) at least 150 feet (ft - unit of length). During a review of Resident 1's Change in Condition (COC - major decline or improvement in a resident's status that will not resolve without intervention) Evaluation form, dated [DATE], timed at 11:21 p.m., the COC form indicated on [DATE], during the afternoon hours (time not specified), Resident 1 removed the AV shunt pressure dressing prior to the allotted time (not specified) and bled for over one hour. During a review of Resident 1's Care Plan regarding hemodialysis, initiated on [DATE], the Care Plan indicated Resident 1 was a hemodialysis resident with AV fistula in her (Resident 1) left arm. The Care Plan indicated Resident 1 had episodes of prematurely (before the recommended time) removing the pressure dressing, resulting in bleeding from the fistula site. The Care Plan interventions indicated to check bandage and leave in place for at least 4 hours after hemodialysis treatment or longer if the needle site continued to ooze. The Care Plan interventions also indicated to monitor the dialysis access site upon return from the dialysis for bleeding, redness, swelling, pain, and notify the physician as needed. During a review of Resident 1's Progress Note, dated [DATE], the Progress Notes indicated that on [DATE], at 056084 Page 4 of 21 056084 12/26/2025 Astoria Healthcare Center 14040 Astoria Street Sylmar, CA 91342

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few approximately 7:50 p.m., CNA 1 informed RN 1 that Resident 1 was bleeding from her (Resident 1) AV fistula site. The Progress Note indicated Resident 1 was found in a sitting position (at the edge of the bed) with her (Resident 1) upper body lying in bed without the pressure dressing on the fistula site and with blood all over the bed and floor. The Progress Note indicated RN 1 applied pressure to the AV fistula site and placed Resident 1 in bed. The Progress Note further indicated that paramedics arrived at the facility on [DATE] at 8:15 p.m. The Progress Note indicated Resident 1 was noted with cardiac (relating to the heart) activity, however respirations (action of breathing) were not observed, and vital signs were unobtainable. The Progress Note indicated the paramedics pronounced Resident 1 deceased on [DATE] at 8:15 p.m. (The Certificate of Death indicated Resident 1's time of death as 8:18 p.m. on [DATE].) During a review of Resident 1's Nursing Facility Pre-Dialysis Assessment (to be completed by the facility staff) form, dated [DATE], the pre-dialysis assessment form indicated LVN 5 completed Resident 1's pre-dialysis assessment. However, the lower portion of the form titled, Nursing Facility Post-Dialysis Assessment (to be completed by the facility staff) was blank and not completed indicating that a post-dialysis assessment was not conducted by the facility staff after Resident 1 returned from the hemodialysis treatment on [DATE]. During a review of Resident 1's Certificate of Death, dated [DATE], the Certificate of Death indicated Resident 1 died at the facility on [DATE] at 8:18 p.m. The Certificate of Death indicated ESRD as the immediate cause of death and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide [colorless, odorless gas] from the body, making it hard to breathe and function) as a significant condition contributing to death but not resulting in the underlying cause. During an interview on [DATE] at 3:44 p.m. with CNA 1, CNA 1 stated that on [DATE] during the 3 p.m. to 11 p.m. shift, she (CNA 1) was the assigned CNA for Resident 1. CNA 1 stated that on [DATE], at the start of her (CNA 1) shift, Resident 1 was outside the facility receiving hemodialysis treatment. CNA 1 stated that she did not observe Resident 1's return to the facility prior to going on her lunch break at approximately 7:20 p.m. and did not check Resident 1's room before leaving for her (CNA 1) lunch break. CNA 1 further stated that on [DATE], at approximately 7:50 p.m., upon returning from her (CNA 1) lunch break, she (CNA 1) entered Resident 1's room and found Resident 1 sitting on the side of the bed with her (Resident 1) feet on the floor and her (Resident 1) upper body leaning onto the bed. CNA 1 stated there was a puddle of blood on the floor and Resident 1's hemodialysis access site was actively bleeding, like a running faucet, like if you cut yourself with a kitchen knife. CNA 1 stated that she (CNA 1) immediately exited the room and notified RN 1 of Resident 1's condition. During an interview on [DATE] at 5:01 p.m. with LVN 1, LVN 1 stated that she was the LVN assigned to Resident 1 during the 3 p.m. to 11 p.m. shift on [DATE]. LVN 1 stated that at the start of her (LVN 1) shift, Resident 1 had already left the facility for outpatient hemodialysis treatment. LVN 1 stated that Resident 1 would usually return from the hemodialysis treatment between 7 p.m. and 7:30 p.m., depending on the duration of the treatment. LVN 1 stated that on [DATE] at approximately 7:30 p.m., she (LVN 1) went on her (LVN 1) lunch break. LVN 1 stated that prior to leaving for her (LVN 1) lunch break, she (LVN 1) could not recall checking Resident 1's room to determine whether Resident 1 had returned to the facility. LVN 1 stated she (LVN 1) was not informed by another facility staff when Resident 1 returned from hemodialysis treatment. LVN 1 further stated that upon returning from her (LVN 1) lunch break, RN 1 gestured for her (LVN 1) to follow her (RN 1) to Resident 1's room. LVN 1 stated that when she (LVN 1) entered Resident 1's room, at approximately 8 p.m., Resident 1 was lying on her (Resident 1) back, in bed with her (Resident 1's) eyes open and fixed upward. LVN 1 stated that Resident 1's AV fistula dressing was no longer in place and was 056084 Page 5 of 21 056084 12/26/2025 Astoria Healthcare Center 14040 Astoria Street Sylmar, CA 91342

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few located on the bed next to Resident 1's left arm. LVN 1 stated there was blood on the AV fistula dressing, on the bed, and everywhere. LVN 1 stated there was a pool of blood near Resident 1's left arm. LVN 1 stated CNA 1 and RN 1 were present in Resident 1's room. LVN 1 stated that facility staff attempted to arouse Resident 1 and assess Resident 1's pulse to determine if Resident 1 was responsive, however, Resident 1 did not respond. LVN 1 stated she (LVN 1) felt Resident 1's thready (very weak, barely perceptible, often fading in and out) pulse, but since Resident 1 was not responding, she (LVN 1) was unsure whether Resident 1 had a pulse. LVN 1 stated a few minutes after she (LVN 1) entered Resident 1's room (cannot recall the exact time), paramedics arrived, at which point she (LVN 1) stepped out of the room. During a concurrent interview and record review on [DATE] at 11:19 a.m. with RN 2, Resident 1's Care Plan regarding hemodialysis, initiated on [DATE], indicating to monitor the dialysis access site upon return from the dialysis for bleeding, was reviewed. RN 2 stated there was no documented evidence in Resident 1's medical record to indicate that Resident 1 was assessed and monitored upon return to the facility following hemodialysis treatment. RN 2 further stated there was no documentation showing that the AV fistula dressing was assessed or indicating when the dressing was removed. RN 2 stated the facility staff failed to implement Resident 1's Care Plan interventions related to monitoring and managing Resident 1's AV fistula site and failed to complete post-dialysis assessments upon Resident 1's return to the facility. RN 2 stated that the facility's failure to conduct post-dialysis assessments could potentially result in adverse (harmful or undesired) outcomes, including bleeding. RN 2 stated prompt assessment and monitoring of Resident 1 after returning from hemodialysis could have prevented Resident 1 from removing the AV fistula dressing and experiencing subsequent bleeding, potentially altering the outcome of the incident. During an interview on [DATE] at 2:28 p.m. with RN 1, RN 1 stated that she was the RN assigned to Resident 1 during the 3 p.m. to 11 p.m. shift on [DATE]. RN 1 stated that on [DATE], at approximately 7:10 p.m., she (RN 1) observed transportation staff with Resident 1 seated in a wheelchair outside the facility near the locked emergency exit door. RN 1 stated that she (RN 1) was the only staff member present near the nursing station at that time. RN 1 stated she (RN 1) opened the door and wheeled Resident 1 to her (Resident 1) room. RN 1 stated Resident 1 remained seated in the wheelchair, and she (RN 1) assisted Resident 1 back into bed by holding Resident 1's left arm and guiding Resident 1 to the bed. RN 1 stated Resident 1 sat on the edge of the bed. RN 1 stated she (RN 1) connected Resident 1 to oxygen at two liters (L - unit of measurement) per minute via nasal cannula (clear tube with two prongs that sit in the nostrils to deliver supplemental oxygen). RN 1 stated Resident 1 did not complain of pain. RN 1 stated Resident 1 was wearing a cardigan and that she (RN 1) did not see the left upper arm AV fistula dressing. RN 1 stated that because Resident 1's cardigan near the left upper arm was not wet, she (RN 1) assumed Resident 1's left upper arm AV fistula site was not bleeding. RN 1 stated she (RN 1) did not check Resident 1's vital signs and did not visually inspect Resident 1's left upper arm AV fistula site. RN 1 stated Resident 1 looked stable and that when she (RN 1) was paged to answer a phone call (cannot recall the details of the phone call), she (RN 1) left Resident 1's room after spending approximately 10 minutes in Resident 1's room. RN 1 further stated she did not inform LVN 1, CNA 1, or any other facility staff that Resident 1 had returned to the facility. RN 1 stated she (RN 1) assumed that both LVN 1 and CNA 1 were on their lunch breaks but did not confirm with them (LVN 1 and CNA 1). RN 1 stated after answering the phone call, she (RN 1) returned to the nursing station. RN 1 stated that at 7:50 p.m. (approximately 30 minutes after RN 1 left Resident 1's room), CNA 1 informed her (RN 1) that Resident 1 was bleeding. RN 1 stated she (RN 1) immediately went to Resident 1's room. RN 1 stated there was blood all over Resident 1's bed and on the floor. RN 1 056084 Page 6 of 21 056084 12/26/2025 Astoria Healthcare Center 14040 Astoria Street Sylmar, CA 91342

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few stated Resident 1's legs were near the edge of the bed with her (Resident 1) feet touching the floor, while her (Resident 1) upper body was leaning back towards the right side with her (Resident 1) eyes closed. RN 1 stated that Resident 1 opened her eyes when her (Resident 1) name was called but did not verbally respond. RN 1 stated Resident 1's cardigan was off, and that the left upper arm AV fistula dressing made of gauze and tape, was off and no longer in place and was next to the left arm. RN 1 stated blood was actively squirting from Resident 1's left upper arm AV fistula site. RN 1 stated blood was all over Resident 1's clothing and bed. RN 1 stated Resident 1's abdominal area, pants and the left side of the bed linens were saturated with blood. RN 1 stated that there was blood on the floor, approximately equal to the size of a bedside table. RN 1 stated she (RN 1) immediately used gauze to put pressure on Resident 1's left upper arm AV fistula site to stop the bleeding. RN 1 stated Resident 1 had a weak pulse, and she (RN 1) was unable to obtain a blood pressure reading. RN 1 stated that paramedics arrived at approximately 8:05 p.m. and that Resident 1 was pronounced deceased at approximately 8:15 p.m. (The Certificate of Death indicated the time of death as 8:18 p.m. on [DATE].). RN 1 stated she (RN 1) should have assessed Resident 1's vital signs and inspected the AV fistula site for bleeding upon Resident 1's return from hemodialysis treatment. RN 1 stated that she (RN 1) should have documented Resident 1's return and notified other facility staff. RN 1 further stated Resident 1's Care Plan interventions (such as checking the bandage and monitoring the access site upon return from hemodialysis for bleeding) were not implemented, and that Resident 1 was not assessed and monitored upon return from hemodialysis. RN 1 stated Resident 1's incident on [DATE] could have been avoided if Resident 1 had been assessed and monitored following her (Resident 1) return to the facility from hemodialysis treatment. During a concurrent interview and record review on [DATE] at 12:14 p.m. with the DON, Resident 1's Care Plan regarding ESRD - hemodialysis, initiated on [DATE], and Care Plan regarding hemodialysis, initiated on [DATE] were reviewed. The Care Plan initiated on [DATE] indicated Resident 1 needed hemodialysis. The Care Plan interventions included checking the dressing on Resident 1's left upper arm AV fistula, changing the dressing daily, and documenting the care provided. The Care Plan interventions further indicated to monitor and document, as needed, for signs and symptoms of bleeding or hemorrhage (loss of blood from a damaged blood vessel). The DON stated there was no documented monitoring system in place beyond assessing Resident 1's AV fistula site every shift for bleeding or other complications. The DON stated monitoring was primarily based on visual observation by facility staff. The DON further stated that the Nursing Facility Pre and Post Assessment form did not include documentation of the time the hemodialysis access site dressing was removed and Resident 1's response to the removal. The DON stated facility staff should document when the dressing is removed and how the resident tolerates the process. The DON stated there was no record indicating that Resident 1 was assessed and monitored following hemodialysis treatment on [DATE]. The DON further stated that Resident 1's dialysis-related Care Plan interventions were not implemented by the facility staff. The DON stated that the Care Plan serves as a guiding process for providing appropriate and accurate care to residents. The DON stated that prior to the incident on [DATE] when Resident 1 removed her (Resident 1) AV fistula dressing and experienced bleeding, Resident 1's Care Plan did not adequately address care of the left upper arm AV fistula. The DON stated that a specific Care Plan addressing AV fistula site care was necessary to ensure staff understood how to appropriately monitor and manage the fistula site. The DON stated it is the responsibility of LVNs and RNs to ensure that a resident's care plan is complete, accurate, and that all interventions are implemented. The DON stated facility staff failed to implement Resident 1's Care Plan interventions related to hemodialysis and AV fistula assessment and monitoring following Resident 1's 056084 Page 7 of 21 056084 12/26/2025 Astoria Healthcare Center 14040 Astoria Street Sylmar, CA 91342

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few return from hemodialysis treatment on [DATE]. During an interview on [DATE] at 2:31 p.m. with the DON, the DON stated Resident 1's death could have been avoided had Resident 1's Care Plan addressing hemodialysis and AV fistula site care been fully developed and Care Plan interventions implemented. The DON further stated the facility did not have a policy addressing Care Plan intervention implementations. During a review of the current facility-provided P&P titled, Care Planning, last reviewed on [DATE], the P&P indicated, To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. II. The Care Plan serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and Interdisciplinary Team (IDT - a group of various skilled healthcare professionals who collaborate to create a comprehensive, person-centered care plan for a resident, coordinating services, setting goals, and addressing complex needs) work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental, and psychosocial needs. IX. Each resident's Comprehensive Care Plan will describe the following: A. Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. During a review of the current facility-provided P&P titled, End-Stage Renal Disease, Care of a Resident with, last reviewed on [DATE], the P&P indicated, Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. 5. The resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care. 2. During a review of Resident 5's admission Record, the admission Record indicated the facility admitted Resident 5 on [DATE], with diagnoses that included unspecified (unconfirmed) encephalopathy (any disease, disorder, or damage that changes the way your brain works), late onset Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), and history of falling. During a review of Resident 5's H&P, dated [DATE], the H&P indicated Resident 5 did not have the capacity to understand and make decisions. During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 5 was dependent on staff for all activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily). The MDS indicated Resident 5 was always incontinent (unable to control) of bowel and bladder functions. During a review of Resident 5's Physician Order, dated [DATE], the Physician Order indicated admitting Resident 5 to hospice with routine level of care. During a review of Resident 5's Care Plan, dated [DATE], the Care Plan indicated Resident 5's admission to hospice. During a concurrent interview, and record review on [DATE], at 10:30 a.m., with the MDS Nurse Coordinator (MDSC), Resident 5's Care Plan, dated [DATE] was reviewed. The MDSC stated Resident 5 was admitted to hospice on [DATE]. The MDSC stated Care Plan on hospice should have been created on [DATE] when Resident 5 was admitted to hospice and not on [DATE]. The MDSC stated the nurse who received the order on [DATE], for admission to hospice should have created a care plan on [DATE]. The MDSC stated delays in care plan can cause a delay in care. During an interview on [DATE], at 1:40 p.m., with the Director of Nursing (DON), the DON stated care plan should have been created on [DATE] when Resident 5 was admitted to hospice to prevent delay in care. During a review of facility's P&P titled, Care Planning, dated [DATE], and last reviewed on [DATE], the P&P indicated, To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. The Care Plan serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and Interdisciplinary Team work to help the resident move toward resident-specific goals that address the resident's 056084 Page 8 of 21 056084 12/26/2025 Astoria Healthcare Center 14040 Astoria Street Sylmar, CA 91342

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few medical, nursing, mental and psychosocial. A Licensed Nurse will initiate the Care Plan . and updated as indicated for change in condition, onset of new problems, resolution of current problems, and as deemed appropriate by clinical assessment and judgment on an as needed basis. VIII. A Comprehensive Care Plan will be developed for each resident. The Care Plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs. IX. Each resident's Comprehensive Care Plan will describe the following: A. Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. 056084 Page 9 of 21 056084 12/26/2025 Astoria Healthcare Center 14040 Astoria Street Sylmar, CA 91342

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) who returned to the facility after a hemodialysis (a medical treatment that acts as an artificial kidney, filtering waste products and extra fluid from the blood when kidneys are not working well) treatment on [DATE], at approximately 7:10 p.m., received necessary care and monitoring in accordance with professional standards of practice. Resident 1, who had anemia (a condition where blood lacks enough healthy red blood cells to carry adequate oxygen [a colorless, odorless reactive gas and the life-supporting component of the air] to the body) and was receiving Eliquis (a medication used to prevent and treat blood clots [gel-like clumps of blood that forms inside the body when blood vessels [a tube through which the blood circulates in the body] are injured or damaged] by slowing down the body's clotting process and increase the risk for bleeding), had a history of removing the pressure dressing (specialized bandage applied to access site to provide firm, consistent pressure after dialysis to stop bleeding) from her (Resident 1) left upper arm arteriovenous fistula (AV fistula or shunt - a surgically created connection between an artery and a vein to provide hemodialysis access where a needle is inserted allowing blood to be drawn, cleaned, and returned to the body) after a hemodialysis treatment, which had previously resulted in bleeding. The facility failed to: 1. Conduct a post-dialysis assessment (a crucial clinical evaluation after a hemodialysis treatment to check for complications and access site issues like bleeding) and ensure Resident 1 was not bleeding from the left upper arm AV fistula site when Resident 1 returned to the facility after a hemodialysis treatment on [DATE], at approximately 7:10 p.m. 2. Monitor Resident 1's left upper arm AV fistula site for bleeding and other complications upon return from a hemodialysis treatment on [DATE], at approximately 7:10 p.m. 3. Ensure a clearly documented communication process was in place and followed when Resident 1 returned to the facility from a hemodialysis treatment on [DATE], at approximately 7:10 p.m. 4. Follow the facility's policy and procedure (P&P) titled, Dialysis Care, last reviewed on [DATE], indicating, The Facility will be responsible for the overall care delivered to the resident, monitoring of the resident . after the completion of each dialysis treatment. 5. Follow the facility's P&P titled, End-Stage Renal Disease (ESRD - the final stage of chronic kidney disease [CKD] where kidneys fail permanently, requiring hemodialysis or a kidney transplant for survival), Care of a Resident with, last reviewed on [DATE], indicating, Residents with ESRD will be cared for according to currently recognized standards of care. As a result, on [DATE], at approximately 7:50 p.m., Certified Nurse Assistant 1 (CNA 1) found Resident 1 bleeding from the AV fistula site. Resident 1 was found, unresponsive, in a sitting position at the edge of the bed, with upper body leaning on the bed, without the pressure dressing in place at the AV fistula site, and with blood all over the bed and floor in Resident 1's room. On [DATE] at 8:15 p.m., the paramedics (persons trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) pronounced Resident 1 deceased in the facility. On [DATE] at 1:31 p.m., while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's non-compliance with one or more requirements of participations has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) in the presence of the Director of Staffing Department (DSD), the Infection Preventionist (IP), and the Administrator (through telephone), due to the facility's failure to ensure a resident who required hemodialysis treatment received care and services consistent with professional standards of practice under S483.25(l) Dialysis, by not providing the necessary care and monitoring to Resident 1, which resulted in Resident 1's death on [DATE] at 8:18 p.m. (the Certificate Residents Affected - Few 056084 Page 10 of 21 056084 12/26/2025 Astoria Healthcare Center 14040 Astoria Street Sylmar, CA 91342

F 0698 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few of Death dated [DATE] indicated a time of death of 8:18 p.m., while the facility's Progress Note dated [DATE] indicated the time of death as 8:15 p.m.). On [DATE] at 5:08 p.m., the Administrator provided an acceptable IJ removal plan (a detailed plan that identifies all actions the facility will take to immediately address the non-compliance that has resulted to the IJ situation) for the facility's failure to provide necessary care and monitoring to Resident 1, resulting in Resident 1's death on [DATE] at 8:15 p.m. On [DATE] at 6:27 p.m., while onsite at the facility, the SSA verified and confirmed the facility's full implementation of the IJ Removal Plan through observations, interviews, and record reviews, and determined the IJ situation regarding the facility's failure to provide necessary care and monitoring to Resident 1, resulting in Resident 1's death on [DATE] at 8:15 p.m., was no longer present. The SSA removed the IJ situation, while onsite, on [DATE] at 6:27 p.m. in the presence of the Administrator and the DON. The acceptable IJ Removal Plan included the following summarized actions: 1. On [DATE] at 4 p.m., the DON conducted a comprehensive review of Resident 1's hemodialysis-related care upon Resident 1's return from the hemodialysis treatment on [DATE]. The DON conducted interviews with Registered Nurse 1 (RN 1), and Licensed Vocational Nurse 1 (LVN 1), who were assigned to Resident 1 on [DATE] during the 3 p.m. to 11 p.m. shift (scheduled work period). The DON reviewed the facility's P&P on Dialysis Care,, forms used for dialysis care (Nursing Facility Pre and Post Dialysis Assessment forms), nurses progress notes, and communication related to Resident 1's return from the dialysis treatment. The DON identified failures related to post-dialysis assessment, monitoring, communication, and documentation. 2. Effective [DATE], at 2 p.m., all residents returning from hemodialysis treatment or any off-site procedure will be assessed upon return at the soonest practicable time by the Charge Nurse (an LVN coordinating care for the assigned residents) and/or RN. The assessment will include direct inspection of the hemodialysis access site, vital signs (measurements of your body's most basic functions, including temperature, heart rate, respiratory rate, and blood pressure), bleeding assessment, condition of the resident, documentation of findings in the nursing progress notes, and the Nursing Facility Post Dialysis Assessment form. The CNA will immediately notify any licensed nurse of any observed signs of bleeding or distress and will endorse findings to the LVN Charge Nurse and/or RN. 3. On [DATE] at 2:05 p.m., the DON and Medical Records staff conducted an audit (review of records, processes, or systems to assess accuracy and compliance) on the Nursing Facility Pre and Post Dialysis Assessment forms for eight residents (Residents 2, 3, 4, 5, 6, 7, 8, 9) receiving hemodialysis treatment. There were no other residents identified with deficiencies similar to those found for Resident 1. 4. On [DATE] at 3 p.m., the Administrator and the DON reviewed and updated the P&P on Dialysis Care. The Dialysis Flow Sheet-Return Assessment form was updated to include signature columns for the Charge Nurse and RN Supervisor, as well as the inclusion of the Nursing Facility Pre and Post Dialysis Assessment form. On [DATE] at 10 a.m., the Administrator notified the Medical Director regarding the details of the IJ issued by the SSA and the updated policy on Dialysis Care. The updated policy became effective [DATE] at 3 p.m. and will be presented to the Quality Assurance Committee at the next monthly meeting in 1/2026. 5. On [DATE] at 4 p.m., the DON provided one-on-one (1:1) in-service (refers to individualized, one-on-one education provided to a single individual by a staff member or professional) to RN 1 and LVN 1, who were assigned to Resident 1 on [DATE] during the 3 p.m. to 11 p.m. shift regarding P&P on Dialysis Care. The in-service addressed conducting pre and post dialysis assessments with focus on assessing the dialysis access site for signs of bleeding, resident's medical condition and other complications. The in-service addressed documentation on the nurse's progress notes and the Nursing Facility Pre and Post Dialysis Assessment form. Licensed nurse will document in the nurse's progress notes resident's return to 056084 Page 11 of 21 056084 12/26/2025 Astoria Healthcare Center 14040 Astoria Street Sylmar, CA 91342

F 0698 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the facility from the hemodialysis treatment, including the date and time of the return and the care provided to the resident. 6. The facility will ensure that residents who require hemodialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan (a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial [relating to the interrelation of social factors and individual thought and behavior] and functional needs), and the residents' goals and preferences. 7. On [DATE] at 2:10 p.m. and 5:25 p.m., and [DATE] at 12 p.m., the DON and DSD provided in-service education to nursing staff regarding the updated policy on Dialysis Care, with emphasis on the following: a. Comprehensive assessment and monitoring of residents by LVNs or RNs post dialysis treatment. b. Completion of the Nursing Facility Post-Dialysis Assessment form, the Dialysis Flow Sheet-Return Assessment, and nursing progress notes documenting the date and time residents return to the facility. 8. On [DATE] at 3:30 p.m., the DON performed a competency check (an evaluation of the necessary skills, knowledge, and behaviors for a specific task) of RN 1 regarding dialysis care, including monitoring, documentation, and communication. 9. On [DATE] at 3:30 p.m., the DON performed competency checks of licensed nurses regarding post dialysis observation, reporting, monitoring, interventions, and proper documentation. 10. On [DATE] at 3:30 p.m., the DSD performed competency checks of CNAs regarding observation and reporting on resident's return post-dialysis and post procedure, monitoring, safety, and communication of observations. 11. On [DATE] at 4 pm., the DON conducted an audit on residents who returned from hemodialysis on [DATE] (Residents 2, 4, 7, and 8). Audit findings showed all requirements were completed and in place for each of the reviewed residents. The review showed that a process is in place to ensure appropriate assessment, monitoring, documentation, and clinical oversight for residents returning to the facility following outpatient (a resident who receives care and treatment at a hospital or clinic but does not stay overnight) hemodialysis. Cross reference F656.Findings: During a review of Resident 1's admission Record, undated, the admission Record indicated the facility originally admitted Resident 1 on [DATE], and readmitted on [DATE] with diagnoses including ESRD, anemia, unspecified atrial fibrillation (a-fib - an irregular and often very rapid heart rhythm), and acute on chronic combined systolic and diastolic heart failure (a long-standing heart problem affecting both the heart's ability to pump [systolic] and relax/fill [diastolic], leading to fluid buildup and inefficient blood flow). During a review of Resident 1's Order Summary Report, the Order Summary Report indicated the following physician's order: - [DATE]: Hemodialysis every Tuesday, Thursday, and Saturday. - [DATE]: Monitor left arm AV shunt dialysis access for bruit (sound of turbulent blood flow heard with a stethoscope [a medical instrument for listening to the action of someone's heart or breathing]) and thrill (the palpable vibration felt by hand over a turbulent blood flow), swelling, bleeding, and signs of infection every shift. - [DATE]: Eliquis oral tablet 2.5 milligram (mg - unit of measurement) to give one tablet by mouth two times a day for a-fib. During a review of Resident 1's History and Physical (H&P - a comprehensive assessment of a resident's medical condition), dated [DATE], the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated [DATE], the MDS indicated Resident 1's cognitive functioning (the ability to think, learn, remember, use judgment, and make decisions) was intact. The MDS indicated Resident 1 needed setup or clean-up assistance (helper sets up or cleans up; resident completes activity and helper assists only prior to or following the activity) with eating, oral hygiene, toileting hygiene, personal hygiene, upper body dressing, and lower body dressing. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) from the facility staff to propel (move) a wheelchair (a chair with wheels used 056084 Page 12 of 21 056084 12/26/2025 Astoria Healthcare Center 14040 Astoria Street Sylmar, CA 91342

F 0698 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few in order to move around) at least 150 feet (ft - unit of length). During a review of Resident 1's Change in Condition (COC - major decline or improvement in a resident's status that will not resolve without intervention) Evaluation form, dated [DATE], timed at 11:21 p.m., the COC form indicated that on [DATE], in the afternoon (time not specified), Resident 1 removed the AV shunt pressure dressing prior to the allotted time (not specified) and bled for over one hour. During a review of Resident 1's Care Plan regarding hemodialysis, initiated on [DATE], the Care Plan indicated Resident 1 was a hemodialysis resident with AV fistula in her (Resident 1) left arm. The Care Plan indicated Resident 1 had episodes of prematurely (before the recommended time) removing the pressure dressing, resulting in bleeding from the fistula site. The Care Plan interventions indicated to check bandage and leave in place for at least 4 hours after hemodialysis treatment or longer if the needle site continued to ooze. The Care Plan interventions also indicated to monitor the dialysis access site upon return from the dialysis for bleeding, redness, swelling, pain, and notify the physician as needed. During a review of Resident 1's Progress Note, dated [DATE], the Progress Notes indicated that on [DATE], at approximately 7:50 p.m., CNA 1 informed RN 1 that Resident 1 was bleeding from her (Resident 1) AV fistula site. The Progress Note indicated Resident 1 was found in a sitting position (at the edge of the bed) with her (Resident 1) upper body lying in bed without the pressure dressing on the fistula site and with blood all over the bed and floor. The Progress Note indicated RN 1 applied pressure to the AV fistula site and placed Resident 1 in bed. The Progress Note further indicated that paramedics arrived at the facility on [DATE] at 8:15 p.m. The Progress Note indicated Resident 1 was noted with cardiac (relating to the heart) activity, however respirations (action of breathing) were not observed, and vital signs were unobtainable. The Progress Note indicated the paramedics pronounced Resident 1 deceased on [DATE] at 8:15 p.m. (The Certificate of Death indicated Resident 1's time of death as 8:18 p.m. on [DATE]). During a review of Resident 1's Nursing Facility Pre-Dialysis Assessment (to be completed by the facility staff) form, dated [DATE], the Pre-Dialysis Assessment form indicated that LVN 5 completed Resident 1's pre-dialysis assessment. However, the lower portion of the form titled, Nursing Facility Post-Dialysis Assessment (to be completed by the facility staff) was blank and not completed, indicating that a post-dialysis assessment was not conducted by the facility staff after Resident 1 returned from hemodialysis treatment on [DATE]. During a review of Resident 1's Certificate of Death, dated [DATE], the Certificate of Death indicated Resident 1 died at the facility on [DATE] at 8:18 p.m. During an interview on [DATE] at 3:44 p.m. with CNA 1, CNA 1 stated that on [DATE] during the 3 p.m. to 11 p.m. shift, she (CNA 1) was the assigned CNA for Resident 1. CNA 1 stated that on [DATE], at the start of her (CNA 1) shift, Resident 1 was outside the facility receiving hemodialysis treatment. CNA 1 stated that she did not observe Resident 1's return to the facility prior to going on her lunch break at approximately 7:20 p.m. and did not check Resident 1's room before leaving for her (CNA 1) lunch break. CNA 1 further stated that on [DATE], at approximately 7:50 p.m., upon returning from her (CNA 1) lunch break, she (CNA 1) entered Resident 1's room and found Resident 1 sitting on the side of the bed with her (Resident 1) feet on the floor and her (Resident 1) upper body leaning onto the bed. CNA 1 stated there was a puddle of blood on the floor and Resident 1's hemodialysis access site was actively bleeding, like a running faucet, like if you cut yourself with a kitchen knife. CNA 1 stated that she (CNA 1) immediately exited the room and notified RN 1 of Resident 1's condition. During an interview on [DATE] at 5:01 p.m. with LVN 1, LVN 1 stated that she was the LVN assigned to Resident 1 during the 3 p.m. to 11 p.m. shift on [DATE]. LVN 1 stated that at the start of her (LVN 1) shift, Resident 1 had already left the facility for outpatient hemodialysis treatment. LVN 1 stated that Resident 1 would usually return from the hemodialysis 056084 Page 13 of 21 056084 12/26/2025 Astoria Healthcare Center 14040 Astoria Street Sylmar, CA 91342

F 0698 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few treatment between 7 p.m. and 7:30 p.m., depending on the duration of the treatment. LVN 1 stated that on [DATE] at approximately 7:30 p.m., she (LVN 1) went on her (LVN 1) lunch break. LVN 1 stated that prior to leaving for her (LVN 1) lunch break, she (LVN 1) could not recall checking Resident 1's room to determine whether Resident 1 had returned to the facility. LVN 1 stated she (LVN 1) was not informed by another facility staff when Resident 1 returned from hemodialysis treatment. LVN 1 further stated that upon returning from her (LVN 1) lunch break, RN 1 gestured for her (LVN 1) to follow her (RN 1) to Resident 1's room. LVN 1 stated that when she (LVN 1) entered Resident 1's room, at approximately 8 p.m., Resident 1 was lying on her (Resident 1) back, in bed with her (Resident 1's) eyes open and fixed upward. LVN 1 stated that Resident 1's AV fistula dressing was no longer in place and was located on the bed next to Resident 1's left arm. LVN 1 stated there was blood on the AV fistula dressing, on the bed, and everywhere. LVN 1 stated there was a pool of blood near Resident 1's left arm. LVN 1 stated CNA 1 and RN 1 were present in Resident 1's room. LVN 1 stated that facility staff attempted to arouse Resident 1 and assess Resident 1's pulse to determine if Resident 1 was responsive, however, Resident 1 did not respond. LVN 1 stated she (LVN 1) felt Resident 1's thready (very weak, barely perceptible, often fading in and out) pulse, but since Resident 1 was not responding, she (LVN 1) was unsure whether Resident 1 had a pulse. LVN 1 stated a few minutes after she (LVN 1) entered Resident 1's room (cannot recall the exact time), paramedics arrived, at which point she (LVN 1) stepped out of the room. During a concurrent interview and record review on [DATE] at 11:19 p.m. with Registered Nurse 2 (RN 2), Resident 1's Progress Notes dated [DATE] and Nursing Facility Post-Dialysis Assessment form dated [DATE], were reviewed. RN 2 stated there was no record in Resident 1's progress notes indicating the time Resident left the facility for hemodialysis and the time she (Resident 1) returned to the facility on [DATE]. RN 2 further stated Resident 1's Nursing Facility Post-Dialysis Assessment portion of Resident 1's post-dialysis assessment form was not completed, indicating that facility staff did not perform and document Resident 1's post hemodialysis assessment when Resident 1 returned to the facility on [DATE]. RN 2 stated per facility policy and protocol when residents return to the facility after a hemodialysis treatment, an LVN or the RN is required to complete a post-hemodialysis assessment and document the resident's return in the progress notes. RN 2 stated that on [DATE], facility staff did not follow the facility's policies and protocols for the care of dialysis residents and failed to assess Resident 1 upon her (Resident 1) return from hemodialysis treatment. RN 2 further stated that there was no record or documentation identifying which facility staff member received Resident 1 upon return from hemodialysis treatment and there was no documentation indicating that Resident 1's AV fistula site was assessed or monitored following Resident 1's return. RN 2 stated that a prompt post-hemodialysis assessment upon Resident 1's return could have identified potential issues, including the status of the AV fistula dressing, and could have prevented Resident 1 from removing the AV fistula dressing and experiencing subsequent bleeding, which could have potentially altered the outcome of the incident. During an interview on [DATE] at 2:28 p.m. with RN 1, RN 1 stated that she was the RN assigned to Resident 1 during the 3 p.m. to 11 p.m. shift on [DATE]. RN 1 stated that on [DATE], at approximately 7:10 p.m., she (RN 1) observed transportation staff with Resident 1 seated in a wheelchair outside the facility near the locked emergency exit door. RN 1 stated that she (RN 1) was the only staff member present near the nursing station at that time. RN 1 stated she (RN 1) opened the door and wheeled Resident 1 to her (Resident 1) room. RN 1 stated Resident 1 remained seated in the wheelchair, and she (RN 1) assisted Resident 1 back into bed by holding Resident 1's left arm and guiding Resident 1 to the bed. RN 1 stated Resident 1 sat on the edge of the bed. RN 1 stated she (RN 1) connected Resident 1 to oxygen at two liters (L 056084 Page 14 of 21 056084 12/26/2025 Astoria Healthcare Center 14040 Astoria Street Sylmar, CA 91342

F 0698 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few - unit of measurement) per minute via nasal cannula (clear tube with two prongs that sit in the nostrils to deliver supplemental oxygen). RN 1 stated Resident 1 did not complain of pain. RN 1 stated Resident 1 was wearing a cardigan and that she (RN 1) did not see the left upper arm AV fistula dressing. RN 1 stated that because Resident 1's cardigan near the left upper arm was not wet, she (RN 1) assumed Resident 1's left upper arm AV fistula site was not bleeding. RN 1 stated she (RN 1) did not check Resident 1's vital signs and did not visually inspect Resident 1's left upper arm AV fistula site. RN 1 stated Resident 1 looked stable and that when she (RN 1) was paged to answer a phone call (cannot recall the details of the phone call), she (RN 1) left Resident 1's room after spending approximately 10 minutes in Resident 1's room. RN 1 further stated she did not inform LVN 1, CNA 1, or any other facility staff that Resident 1 had returned to the facility. RN 1 stated she (RN 1) assumed that both LVN 1 and CNA 1 were on their lunch breaks but did not confirm with them (LVN 1 and CNA 1). RN 1 stated after answering the phone call, she (RN 1) returned to the nursing station. RN 1 stated that at 7:50 p.m. (approximately 30 minutes after RN 1 left Resident 1's room), CNA 1 informed her (RN 1) that Resident 1 was bleeding. RN 1 stated she (RN 1) immediately went to Resident 1's room. RN 1 stated there was blood all over Resident 1's bed and on the floor. RN 1 stated Resident 1's legs were near the edge of the bed with her (Resident 1) feet touching the floor, while her (Resident 1) upper body was leaning back towards the right side with her (Resident 1) eyes closed. RN 1 stated that Resident 1 opened her eyes when her (Resident 1) name was called but did not verbally respond. RN 1 stated Resident 1's cardigan was off, and that the left upper arm AV fistula dressing made of gauze and tape, was off and no longer in place and was next to the left arm. RN 1 stated blood was actively squirting from Resident 1's left upper arm AV fistula site. RN 1 stated blood was all over Resident 1's clothing and bed. RN 1 stated Resident 1's abdominal area, pants and the left side of the bed linens were saturated with blood. RN 1 stated that there was blood on the floor, approximately equal to the size of a bedside table. RN 1 stated she (RN 1) immediately used gauze to put pressure on Resident 1's left upper arm AV fistula site to stop the bleeding. RN 1 stated Resident 1 had a weak pulse, and she (RN 1) was unable to obtain a blood pressure reading. RN 1 stated that paramedics arrived at approximately 8:05 p.m. and that Resident 1 was pronounced deceased at approximately 8:15 p.m. (The Certificate of Death indicated the time of death as 8:18 p.m. on [DATE].). RN 1 stated she (RN 1) should have assessed Resident 1's vital signs and inspected the AV fistula site for bleeding upon Resident 1's return from hemodialysis treatment. RN 1 stated that she (RN 1) should have documented Resident 1's return and notified other facility staff. RN 1 further stated Resident 1's Care Plan interventions (such as monitoring access site upon return from hemodialysis for bleeding) were not implemented, and that Resident 1 was not assessed and monitored upon return from hemodialysis. RN 1 stated Resident 1's incident on [DATE] could have been avoided if Resident 1 had been assessed and monitored following her (Resident 1) return to the facility from hemodialysis treatment. During an interview on [DATE] at 4:13 p.m. with the DON, the DON stated residents who receive hemodialysis should be assessed prior to leaving the facility and upon return following hemodialysis treatment. The DON stated the Nursing Facility Pre and Post Dialysis Assessment form must be completed by the Charge Nurse (LVN), RN, or another licensed nurse on the floor who accepts the resident upon return from the outpatient hemodialysis center. The DON further stated that facility staff should document in the progress notes the time residents leave the facility and the time they return from outpatient treatments such as hemodialysis. The DON stated Resident 1, who had anemia, heart failure, was receiving Eliquis, and had a documented history of prematurely removing her (Resident 1) AV fistula dressing, was not assessed and monitored on [DATE] after returning to the facility from the 056084 Page 15 of 21 056084 12/26/2025 Astoria Healthcare Center 14040 Astoria Street Sylmar, CA 91342

F 0698 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few hemodialysis treatment. The DON stated facility staff failed to document when Resident 1 left and returned to the facility, failed to obtain vital signs, and failed to assess Resident 1's AV fistula site for bleeding upon her (Resident 1) return. The DON stated there was no documented evidence to indicate that Resident 1 was monitored after returning to the facility on [DATE]. The DON stated facility staff did not follow the facility's policies and protocol related to the care and monitoring of a resident receiving hemodialysis and failed to implement Resident 1's Care Plan interventions for AV fistula care and monitoring following her (Resident 1) return from hemodialysis treatment. The DON stated, as a result, on [DATE], Resident 1 experienced a hemorrhage (excessive bleeding) from the AV fistula site and passed away at 8:15 p.m. The DON stated the incident on [DATE] could have been avoided if facility staff followed the facility's P&P for the care and monitoring of hemodialysis residents and implemented Resident 1's Care Plan (initiated on [DATE]) interventions. During a concurrent interview and record review on [DATE] at 3:08 p.m. with the DON, the facility's P&P tiled, Dialysis Care, dated [DATE] was reviewed. The P&P indicated, The Facility will be responsible for the overall care delivered to the resident, monitoring of the resident prior to and after the completion of each dialysis treatment and providing for all non-dialysis needs of the resident including during the time period when the resident is receiving dialysis. V. Documentation: A. All documentation concerning dialysis services and care of the dialysis resident will be maintained in the resident's medical record. B. Documentation may include NP-225-Form A-Pre/Post Dialysis Assessment, Form-225-Form-B-Dialysis Flow Sheet-Return Assessment. The DON stated the facility's P&P for Dialysis Care did not clearly define the pre- and post-dialysis responsibilities of licensed nurses, the required monitoring of the residents before and after dialysis treatment, and the care and monitoring of dialysis access sites. The DON stated that this lack of clarity resulted in confusion among facility staff regarding preand post-dialysis assessments, the care of residents receiving hemodialysis, and the proper implementation of care plan interventions. The DON further stated there was a systemic failure in the facility's processes for providing care to residents before and after hemodialysis treatment. During a review of the current facility-provided P&P titled, End-Stage Renal Disease, Care of a Resident with, last reviewed on [DATE], the P&P indicated, Residents with (ESRD) will be cared for according to currently recognized standards of care. 1. Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. 2. Education and training of staff includes, specifically: . b. the type of assessment data that is to be gathered about the residents' condition on a daily or per shift basis; . g. the care of grafts (is a surgically implanted, soft, synthetic tube used to connect an artery and a vein, typically in the arm) and fistulas. 5. The resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care. During a review of the current facility-provided P&P titled, Documentation-Nursing, last reviewed on [DATE], the P&P indicated, To provide documentation of resident status and care given by nursing staff. Nursing documentation will be concise, clear, pertinent, and accurate. G. Nurse's notes addressing the resident leaving the facility will document when and with whom, and time of return, along with any medications sent. 056084 Page 16 of 21 056084 12/26/2025 Astoria Healthcare Center 14040 Astoria Street Sylmar, CA 91342

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on interview and record review, the facility failed to ensure two of five sampled staff (Registered Nurse [RN] 1 and Licensed Vocational Nurse [LVN] 1) were competent (a combination of knowledge, skills, abilities, and behaviors that enable an individual to perform a task or role successfully) on dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney or kidneys have failed) care and assessment by:Failing to ensure newly hired staff had orientation (the process of introducing new employees to a company's culture, policies, colleagues, and their specific job role, typically in the first few days or weeks, to help them feel welcome, understand expectations, and integrate effectively into the organization) on dialysis care.Failing to ensure staff were in serviced on dialysis care before providing dialysis care.Failing to ensure staff were aware of dialysis site assessment.These failures had the potential to affect the care necessary to provide nursing care and related services to meet residents' needs safely.Findings:During a review of Registered Nurse 1's (RN 1) Initial Annual Skills Checklist, signed and dated on 2/17/2025, the Skill Checklist did not indicate anything on dialysis care, assessment and training.During a record review of Licensed Vocational Nurse 3 (LVN 3)'s Initial Annual Skills Checklist, signed and dated 5/29/2025, the Skills Checklist did not indicate anything on dialysis care, assessment and training.During a record review of RN 1's Job Description, signed and dated on 6/12/2025, the Job Description indicated, The Supervisor is an RN who is responsible for the overall supervision of nursing care in the facility during their shift. Responsible and accountable (responsible) for the provision (supplying something needed) of direct, age specific, resident care to those assigned to his/her care for each established shift. The RN provides resident care according to the nursing processes of the facility and is responsible for the coordination of the team approach to meet each resident's individual needs.Position and Responsibilities/Duties.2. Completes initial and ongoing assessments in a timely manner, incorporating functional/development age factors into the assessment process.During a record review of RN 4's Initial Annual Skills Checklist, signed and dated 6/14/2025, the Skill Checklist did not indicate anything on dialysis care, assessment and training.During a record review of LVN 1's Job Description, signed and dated on 6/17/2025, the Job Description indicated, b. Completes initial and ongoing assessments by gathering data in a timely manner, incorporating functional/development age factors into the assessment process.Maintains knowledge of, and implements resident care activities to promote, maintain and/or restore health for assigned residents.During a review of LVN 1's Initial Annual Skills Checklist, signed and dated 11/18/2025, the Skill Checklist did not indicate anything on dialysis care, assessment and training.During an interview on 12/25/2025, at 11:11 a.m., with the Director of Staff Development (DSD), the DSD stated dialysis care, assessment and training was not part of the orientation process. The DSD stated dialysis care, assessment and training should be part of the nursing orientation since the facility had admitted residents who go out for dialysis services. The DSD stated there was no dialysis care, assessment and training provided by the facility to the nursing staff. The DSD stated she (DSD) had never provided in-services for dialysis for Certified nursing Assistants (CNAs) until 12/24/2025.During an interview on 12/26/2025, at 11:26 a.m., with RN 1, RN 1 stated she (RN 1) had been with the facility for five years and did not receive any orientation on dialysis care and assessment. RN 1 stated there was no in-service on how to check the dialysis site for thrill (the palpable [able to be touched or felt] vibration felt with the hand over that same turbulent flow) and bruit (a noisy, whooshing sound heard with a stethoscope [medical instrument used to listen to internal body sounds] from turbulent blood flow in a vessel). RN 1 stated there was no in-service 056084 Page 17 of 21 056084 12/26/2025 Astoria Healthcare Center 14040 Astoria Street Sylmar, CA 91342

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some provided on what to do to a resident going out for dialysis and what to do when resident return from dialysis. RN 1 stated it would help a lot if she (RN 1) was provided orientation and training on dialysis care and assessment. RN 1 stated the facility did not provide instruction that we (staff) had to inform assigned nurses of the residents return from dialysis. RN 1 stated RNs responsibility when resident return from dialysis was to assess the dialysis site for any complication (a new or worsening medical problem that arises during a disease, treatment, or procedure) like bleeding or absence of thrill and bruit.During an interview on 12/26/2025, at 12:06 p.m., with LVN 1, LVN 1 stated the facility did not provide training on dialysis care. LVN 1 stated they had in-services on what supply should be available at resident bedside. LVN 1 stated she (LVN 1) does check the dialysis site for thrill and bruit. LVN 1 stated she (LVN 1) does feel the bruit and listen with the stethoscope to check for the thrill.During an interview on 12/26/2025, at 12:44 p.m. with RN 1, RN 1 stated when assessing dialysis site, she (RN 1) would feel the bruit and listen with a stethoscope for the thrill.During an interview on 12/26/2025, at 1:40 p.m., with the Director of Nursing (DON), the DON stated the facility provided an in-service on dialysis care a year ago (2024) and again on 11/19/2025. The DON stated they do not have a copy of the dialysis in-service from last year (2024). The DON stated dialysis assessment site includes feeling for the thrill and listening for the bruit. The DON stated there was no formal class or in-service on how to check for the thrill and bruit of dialysis access site. The DON stated the dialysis care and access site assessment was not part of the new staff orientation. The DON stated the facility had competency issues on dialysis care and assessment. The DON stated it is important to check staff competency for dialysis care and assessment to ensure staff are providing the proper care and assessment to residents who were on dialysis to prevent dialysis complication like bleeding. The DON stated competency, checks the nurse's knowledge and skills to find out if they (nurses) need training and to know the nurse's strength and weakness to ensure quality of care is provided to residents. The DON stated nurses who did not receive orientation on dialysis care might not be able to provide and take care of dialysis residents. The DON stated nurses who were not competent on dialysis care will not be skilled enough to provide care especially to residents who just returned from dialysis, and it could lead to complications like bleeding. The DON stated nurses who were not trained on dialysis site assessment would not be able to know how to assess the dialysis site for thrill and bruit and could possibly lead to incorrect assessment and incorrect information relayed to the physician.During a concurrent interview and record review on 12/26/2025, at 3:01 p.m., with the DON, facility's policy and procedure (P&P), titled, Staffing, Sufficient and Competent Nursing, dated 8/2022, and last reviewed on 6/19/2025, the P&P indicated, Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment.6. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care, the resident assessments and the facility assessment.7. Factors considered in determining appropriate staffing ratios and skills include an evaluation of the diseases, conditions, physical or cognitive limitations of the resident population, and acuity.Competent Staff:I. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully.2. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law.3. Staff must demonstrate the skills and techniques necessary to care for resident needs including (but not limited to) the following areas: .c. Person centered care; .4. Licensed nurses and nursing 056084 Page 18 of 21 056084 12/26/2025 Astoria Healthcare Center 14040 Astoria Street Sylmar, CA 91342

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some assistants are trained and must demonstrate competence in identifying, documenting and reporting resident changes of condition consistent with their scope of practice and responsibilities.5. Competency requirements and training for nursing staff are established and monitored by nursing leadership with input from the medical director to ensure that: a. programming for staff training results in nursing competency; b. gaps in education are identified and addressed; c. education topics and skills needed are determined based on the resident population; d. tracking or other mechanisms are in place to evaluate effectiveness of training; and e. training includes critical thinking skills and managing care in a complex environment with multiple interruptions. The DON stated the P&P for Staffing, Sufficient and Competent Nursing, was not followed. 056084 Page 19 of 21 056084 12/26/2025 Astoria Healthcare Center 14040 Astoria Street Sylmar, CA 91342

F 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on interview and record review, the facility failed to accurately update the Facility Assessment Tool (an evaluation of the physical environment necessary to meet the needs of the residents) by:Failing to ensure the Facility Assessment indicated the approved facility's name of Skilled Nursing Facility 2 (SNF 2) after a change of ownership on 6/2025.Failing to ensure Facility Assessment was followed, on staff dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) care, training and competency (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully).Failing to ensure Facility Assessment indicated the type of electronic health information technology used by the facility.These failures had the potential to delay necessary care and services and misinformation.Findings:During a review of facility's Facility Assessment Tool, dated 6/1/2025, the Facility Assessment Tool indicated, Facility Name: (Skilled Nursing Facility 1 [SNF 1])Services and Care We Offer Based on our Resident's Needs.Part 2: Resident support/care needs2.1 List the types of care that your resident population requires and that you provide for your resident population.General Care: .Other Special Care Needs: Dialysis.Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During EmergenciesStaff training/education and competencies. 3.4. Describe the staff training/education and competencies that are necessary to provide the level and types of support and care needed for your resident population.Consider the following competencies.Specialized care . dialysis care.During a concurrent interview and record review on 12/25/2025, at 10:37 a.m., with the Administrator (ADM), Facility Assessment Tool, dated 6/1/2025 was reviewed. The ADM stated the Facility Assessment Tool indicated the previous facility name SNF 1. The ADM stated the current facility name is SNF 2. The ADM stated the facility name change was already approved. The ADM stated the Facility Assessment Tool dated 6/1/2025 should have been updated when the change of facility name was approved.During a concurrent interview, and record review on 12/25/2025, at 10:41 a.m., with the Director of Nursing (DON), Facility Assessment, dated 6/1/2025 was reviewed. The DON stated the Facility Assessment indicated dialysis care as part of care provided by the facility. The DON stated the Facility Assessment did not indicate dialysis training. The DON stated the Facility Assessment Tool should have been updated to reflect services provided by the facility. The DON stated updating Facility Assessment ensures staff are aware and trained in caring for dialysis residents. The DON stated the facility also transitioned from paper medical record to electronic medical record and it was not indicated in the Facility Assessment. The DON stated the facility started the electronic medical record on 7/2025. The DON stated the Facility Assessment should have been updated on 7/2025. The DON stated the Facility Assessment should be updated yearly and when changes happen within the facility. The DON stated if Facility Assessment was not updated it could misinform the public and contain inaccurate information about the facility.During an interview on 12/26/2025 at 1:40 p.m., the DON stated the ADM should have updated the Facility Assessment Tool.During a review of facility's policy and procedure (P&P), titled, Facility Assessment, dated 10/2018, and last reviewed on 6/19/2025, the P&P indicated, A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. Determining our capacity to meet the needs of and care for our residents during emergencies is included in this assessment.1. Once a year, and as needed, a designated team conducts a facility-wide assessment to ensure that the resources are available to meet the specific needs of our residents.3. The 056084 Page 20 of 21 056084 12/26/2025 Astoria Healthcare Center 14040 Astoria Street Sylmar, CA 91342

F 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility assessment includes a detailed review of the resident population. This part of the assessment includes: a. resident census data from the previous 12 months; b. resident capacity of the facility and its occupancy rate for the past 12 months; c. factors that affect the overall acuity of the residents, such as the number and percentage of residents with: . (5) conditions or diseases that require specialized care (example given dialysis.).4. The facility assessment also includes a detailed review of the resources available to meet the needs of the residents' population. This part of the assessment includes the following: . f. A breakdown of the training, licensure, education, skill level and measures of competency for all personnel; g. The current status of health information technology, including: (1) electronic health records; (2) electronic exchange of information with other organizations; and (3) personnel access to devices and equipment, internet and other tools.6. The facility assessment is intended to help our facility plan for and respond to changes in the needs of our resident population and helps to determine budget, staffing, training, equipment and supplies needed. It is separate from the quality assurance and performance improvement evaluation. 056084 Page 21 of 21