Health inspection·October 23, 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 interview, and record review, the facility failed to ensure appropriate dialysis (the process of removing excess water and cleaning the blood) treatment was acquired for one of three residents (Resident 1) for 2 days.This failure resulted in a clinically compromised resident Resident 1 not receiving dialysis as ordered by the physician and was sent out to acute hospital for treatment and placing health and safety at risk. Findings:During review of Residents 1's admission Record (general demographics information), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which include End Stage Renal Disease (kidneys have severe damage) dependent on Renal Dialysis, acute respiratory failure (fluid prevents lungs filling with air), hypertension (high blood pressure).During a record review on October 23, 2025, at 11:30AM, Resident 1's medical records, reviewed and verified the following:1. History and Physical dated October 22, 2025: Patient is not able to make own decisions.2. Order: June 04, 2025, 18:48: Dialysis Care Center, Dialysis IV access Right chest IJ one time a day every Monday, Tuesday, Wednesday, Thursday, Friday for Dialysis.3. admission Summary Note October 21, 2025, 1548: Dialysis resident and dialysis on Mondays, Wednesdays, and Fridays. Hemodialysis port at right upper chest.4. Order October 21, 2025: Dialysis Care center Dialysis IV Access right chest IJ every shift for Monday, Wednesday and Friday.Start 10/24/25. (Resident 1 was readmitted [DATE], missed dialysis October 22, 2025, and October 24, 2025)5. Spectrum Dialysis: Consent to home hemodialysis treatment dated/signed by resident son 10.22.25.During an interview on October 23, 2025, at 11:20 AM, with the Assistant Director of Nursing (ADON), ADON stated, our admissions, consent needs to be done first before the resident gets here for Dialysis. Prior to residents being transferred back from the acute hospital, so for the residents at [acute hospital], there are labs to be drawn up and family consents before admitting the resident back. The dialysis does have an office here in our facility.During an interview on October 23, 2025, at 12:36 PM, with the admission Coordinator Marketing Director (ACMD), ACMD stated, I submitted to [dialysis company] the documents for this resident. I was not made aware that [dialysis company] had discharged (D/C) him off their dialysis schedule. He was D/C completely from the facility, he was at acute over 30 days, there was no bed hold. It should have been my responsibility to get consent from family for his Dialysis. The Dialysis coordinator told me we need to be all paperwork because he was no longer in their system. I did not know we had to do all the paperwork over again. He should have been a new admission. It was my responsibility to follow up and I dropped the ball; I take full responsibility.During an interview on October 23, 2025, at 12:40 PM, with the Director of Nursing (DON), DON stated, It is a third-party Dialysis, they usually get the consents. I do understand that he is our responsibility, and it should have been our responsibility to make sure the authorization and documents were done. He missed Wednesday because we still did not have consent from the son, we called the doctor he ordered labs and Friday we sent him out because we did not have consent.During a review of the facility's policy and procedure Residents Affected - Few Page 1 of 2 555435 555435 10/23/2025 The Canyons Post-Acute 1350 Reche Canyon Rd Colton, CA 92324

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few titled, Change in a Resident Condition or Status revised on May 2017, the policy and procedure indicated, Our facility shall promptly notify the resident his or her attending physician and representative of changes in the resident medical/ mental condition and or statusDuring a review of the facility's policy and procedure titled, Hemodialysis Access Care revised on September 2010, the policy and procedure indicated, Hemodialysis devices may only be accessed by medical personnel who have received training and demonstrated clinical competency regarding use of these devices. 555435 Page 2 of 2