Health inspection·February 13, 2025

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the daily fluid restriction for one of three sampled residents (Resident 2) was monitored and documented as ordered by the physician. This failurehad the potential to result in Resident 2 having an excess of fluid which could lead to negative health consequences due to impaired kidney function and the potential to negatively affect Resident 2's continuity of care while receiving dialysis at an outpatient dialysis center. Residents Affected - Few Findings: Medical record review for Resident 2 was initiated on 2/13/25. Resident 2 was readmitted to the facility on [DATE], with a diagnosis including ESRD requiring the dialysis treatments at an outpatient dialysis center three times a week. Review of Resident 2's Order Summary Report showed a physician's order dated 1/13/24, for fluid restriction of 1500 ml per 24 hours as follows: - dietary department: 840 ml on meals trays (breakfast: 360 ml, lunch 240 ml, dinner 240 ml); and - nursing department: 660 ml (day shift: 350 ml, PM shift: 200 ml, NOC shift: 110 ml). Review of Resident 2's plan of care showed a care plan dated 12/27/24, addressing Resident 2'shemodialysis with a goal for the resident to be free of fluid overload symptoms. Further review of Resident 2's plan of care showed a care plan revised on 1/29/25, addressing Resident 2's altered nutrition and hydration status related to the resident's fluid restriction. The interventions included for fluid restriction of 1500 ml per 24 hours. Further review of Resident 2's medical record failed to show documented evidence Resident 2's daily fluid intake totals were monitored as ordered and care planed. On 2/13/25 at 1500 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 stated Resident 2 was scheduled to go to the outpatient dialysis center for dialysis treatments three times a week and had a physician'sorder for daily fluid restriction of 1500 ml per day. When asked how the facility staff documented and monitored Resident 2's daily fluid intake totals to ensure the fluid restriction was followed as ordered, LVN 2 was not able to provide the documentation of the fluid intake monitoring. LVN 2 further stated there should be a fluid intake monitoring report and documentation of the resident's daily fluid intake totals. On 2/13/25 at 1545 hours, an interview was conducted with RN 1. RN 1 acknowledged the above (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555093 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Post-Acute 1929 N. Fairview Street Santa Ana, CA 92706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)