Health inspection·August 29, 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 provide care and services needed for one of three sampled residents (Resident 2), who required dialysis (treatment to clean one's blood by removing waste and extra fluid when the kidneys are unable to) by failing to ensure Resident 2 was provided with a means of transportation to and from dialysis treatments three times a week between 7/25/2025 and 8/13/2025. As a result of this failure, Resident 2 did not receive nine (7/25/2025, 7/28/2025, 7/30/2025, 8/1/2025, 8/4/2025, 8/6/2025, 8/8/2025, 8/11/2025, 8/13/2025) dialysis treatments. Resident 2 was transferred to General Acute Care Hospital (GACH) 1 on 8/13/2025 at 9:30 pm. Resident 1 was diagnosed with metabolic acidosis (condition where the body produces too many acids or cannot eliminate them effectively, leading to a decrease in blood pH [acidity], uremia (the build-up of urea [an organic chemical waste product that is produced in the liver and filtered from the blood by the kidneys to be excreted in urine] and other waste products in the blood due to kidney failure), and abdominal pain. Resident 2 was admitted to GACH 1 for dialysis. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 7/15/2025 and was readmitted on [DATE] with diagnoses that included dependence on renal (kidney) dialysis, unspecified chronic kidney disease (CKD- damage to the kidneys so they cannot filter blood the way they should), and type II diabetes mellitus (DM2- A condition that happens because of a problem in the way the body regulates and uses sugar as a source of energy). During a review of Resident 2's Order Summary Report (OSR), dated 8/13/2025, the OSR indicated Resident 2 had a physician's order to have dialysis Mondays, Wednesdays, Fridays at 1:15 pm. For transportation to dialysis, the OSR indicated Resident 2's husband would pick up Resident 2. The OSR indicated Resident 2's primary care provider/Medical Doctor (MD) 1 reviewed and approved the plan of care and certified that Resident 2 continued to need this level of care unless otherwise specified and to continue orders for 45 days. During a review of Resident 2's History and Physical (H&P), dated 7/16/2025 and timed at 1:36 pm, the H&P indicated Resident 2 had end stage renal disease (ESRD- Condition in which the kidneys cease functioning on a permanent basis leading to the need for regular course of long-term dialysis or kidney transplant to maintain life). The H&P indicated Resident 2 was receiving hemodialysis (dialysis) three times per week and to continue current schedule. During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool) dated 7/22/2025, the MDS indicated Resident 2 had intact cognition (ability to think, remember, and function). The MDS indicated Resident 2 required dialysis and had renal insufficiency (improperly functioning kidneys), renal failure, or ESRD. The MDS indicated Resident 1 was dependent (helper does ALL the effort) on others for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) with chair/bed-to-chair transfers. The MDS indicated the activity was not attempted due to medical condition or safety concerns for sitting to standing, car transfers and walking 10 feet. During a review of Resident 2's SBAR (situation, background, assessment, Residents Affected - Few Page 1 of 2 555737 555737 08/29/2025 Bayshire San Dimas Post-Acute 1740 S San Dimas Ave San Dimas, CA 91773

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form, dated 7/19/2025, the SBAR indicated Resident 2 missed dialysis. The SBAR indicated Medical Doctor (MD) 1 (primary physician for Resident 2) was informed that Resident 2 missed dialysis. The SBAR indicated Registered Nurse (RN) 2, was unable to reschedule Resident 2's dialysis due to insurance. The SBAR indicated MD 1 was informed with no new orders. During a review of Resident 2's SBAR, dated 7/28/2025, the SBAR indicated Resident 2 missed dialysis due to transportation issues. The SBAR indicated MD 1 was informed that Resident 2 missed dialysis and MD 1 ordered to continue monitoring Resident 2 for fluid overload or fluid retention, for fatigue, muscle cramps, loss of appetite, and mental changes. During a review of Resident 2's PN, dated 8/7/2025 and timed at 8:21 pm, the PN indicated Resident 2 was monitored for fluid retention due to not going to dialysis. During a review of Resident 2's PN, dated 8/8/2025 and timed at 11:50 pm, the PN indicated Resident 2 was monitored for fluid retention and for elevated BUN and creatinine due to missing dialysis. During a review of Resident 2's PN, dated 8/9/2025 and timed at 7:18 am, the PN indicated Resident 2 was being monitored for fluid retention due to missing dialysis. During a review of Resident 2's PN, dated 8/10/2025 and timed at 9:36 am, the PN indicated Resident 2 was being monitored for fluid retention due to missing dialysis. During a review of Resident 2's SBAR, dated 8/11/2025, the SBAR indicated Registered Nurse (RN) 1 received a call from the laboratory regarding Resident 2's abnormal BUN of 79 and creatinine of 8.4. The SBAR indicated RN 1 informed MD 1 regarding Resident 2's abnormal BUN and creatinine levels and MD 1 ordered for Resident 2 to see a nephrologist (a medical doctor who specializes in diagnosing and treating kidney diseases). The SBAR also indicated the last time Resident 2 had dialysis was on 7/23/2025. During a review of Resident 2's laboratory results, dated 8/11/2025, the laboratory results indicated Resident 2's BUN level was 79 mg/dl and creatinine level was 8.4 mg/dl. During a review of Resident 2's Progress Note (PN), dated 8/13/2025 and time at 7:58 pm, the PN indicated Resident 2 was being monitored for fluid retention or any change of condition due to not going to dialysis and for elevated blood urea nitrogen (BUN - medical test that measures the amount of urea in the blood. Normal level range is 6 to 24 milligrams per deciliter [mg/dl]) of 79 mg/dl and creatinine (waste product from muscle and protein breakdown that healthy kidneys filter from the blood and remove through urine. Normal level range for women is 0.6 to 1.1 mg/dl) and creatinine of 8.4 mg/dl. During a review of Resident 2's PN, dated 8/13/2025 and timed at 9:30 pm, the PN indicated Resident 2 was transferred to GACH 1 via ambulance due to missed dialysis. During a review of Resident 2's PN, dated 8/12/2025 and timed at 3:59 am, the PN indicated Resident 2 was being monitored for fluid retention and for elevated BUN and creatinine. During a review of Resident 2's GACH 1 H&P, dated 8/14/2025, the H&P indicated Resident 2 had left-sided flank (on the side of the body between the ribs and the hip) pain with nausea for 1 week and was found to have metabolic likely due to missed hemodialysis (dialysis). During an interview on 8/29/2025 at 11:06 am with the Director of Nursing (DON), the DON stated when Resident 2 was admitted to the facility, the facility assumed responsibility for Resident 2's care and was responsible for providing Resident 2's transportation to dialysis. During an interview on 8/29/2025 at 11:11 am with MD 1, MD 1 stated a BUN level of 79 and a creatinine level of 8.4 indicated Resident 2 needed dialysis. MD 1 stated MD 1 was not sure if MD 1 recommended for Resident 2 to be dialyzed with a BUN of 79 and a creatinine of 8.4. 555737 Page 2 of 2