Health inspection·February 11, 2026

F698 §483.25(l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. 22 CCR §72311. Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 22 CCR §72523. Patient Care Policies and Procedures. (a)Written patient care policies and procedures shall be established and implemented to ensure that patient-related goals and facility objectives are achieved. On 12/19/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding resident death in the facility. The facility failed to ensure 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) treatment on 10/30/2025, 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 to the body) and was receiving Eliquis (a medication used to prevent and treat blood clots by slowing down the body's clotting process, which increases the risk of 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 left upper arm arteriovenous fistula (AV fistula or shunt – a surgically created connection between an artery and a vein to provide hemodialysis access) 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 10/30/2025, at approximately 7:10 p.m.   2. Implement Resident 1’s care plan (a plan that includes measurable objectives and timetables to meet the resident’s physical, psychosocial and functional needs) which included interventions that required monitoring of Resident 1’s left upper arm AV fistula site for bleeding and other complications upon return to the facility following hemodialysis treatment.   3. Ensure a clearly documented communication process was in place and followed when Resident 1 returned to the facility from a hemodialysis treatment on 10/30/2025, at approximately 7:10 p.m.   4. Follow the facility’s policy and procedure (P&P) titled, “Dialysis Care,” last reviewed on 6/19/2025, 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), Care of a Resident with,” last reviewed on 6/19/2025, indicating, “Residents with ESRD will be cared for according to currently recognized standards of care.” 6. Ensure facility P&P for “Dialysis Care” clearly defined pre- and post-dialysis responsibilities of licensed nurses, including the required monitoring of the residents before and after dialysis treatment and the care and monitoring of dialysis access sites. 7. Ensure facility P&P adequately covered implementation of care plan interventions. As a result, on 10/30/2025, 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 10/30/2025 at 8:15 p.m., paramedics (persons trained to give emergency medical care to people who are injured or ill) pronounced Resident 1 deceased in the facility. A review of Resident 1’s Admission Record indicated the facility originally admitted Resident 1, a 72-year-old female, on 7/2/2021, and readmitted on 8/10/2025 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). A review of Resident 1’s Order Summary Report indicated the following physician’s order: - 8/10/2025: Hemodialysis every Tuesday, Thursday, and Saturday. - 8/10/2025: Monitor left arm AV shunt dialysis access for bruit (sound of turbulent blood flow heard with a stethoscope) and thrill (the palpable vibration felt by hand over a turbulent blood flow), swelling, bleeding, and signs of infection every shift. - 8/17/2025: Eliquis oral tablet 2.5 milligram to give one tablet by mouth two times a day for a-fib. A review of Resident 1’s History and Physical (H&P – a comprehensive assessment of a resident’s medical condition), dated 8/11/2025, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1’s Minimum Data Set (MDS – a resident assessment tool), dated 9/12/2025, 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. 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 9/16/2025, timed at 11:21 p.m., indicated that on 9/16/2025, 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. A review of Resident 1’s Care Plan regarding hemodialysis, initiated on 9/16/2025, indicated Resident 1 was a hemodialysis resident with AV fistula in her left arm. The Care Plan indicated Resident 1 had episodes of prematurely 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 dialysis for bleeding, redness, swelling, pain, and notify the physician as needed. A review of Resident 1’s Progress Note, dated 10/30/2025, indicated that on 10/30/2025, at approximately 7:50 p.m., CNA 1 informed Registered Nurse 1 (RN 1) that Resident 1 was bleeding from her AV fistula site. The Progress Note indicated Resident 1 was found in a “sitting position” (at the edge of the bed) with her “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 10/30/2025 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 (measurements of your body's most basic functions, including temperature, heart rate, respiratory rate, and blood pressure) were unobtainable. The Progress Note indicated the paramedics pronounced Resident 1 deceased on 10/30/2025 at 8:15 p.m. A review of Resident 1’s “Nursing Facility Pre-Dialysis Assessment (to be completed by the facility staff)” form, dated 10/30/2025, indicated that Licensed Vocational Nurse 5 (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 10/30/2025. A review of Resident 1’s Certificate of Death, dated 11/12/2025, the Certificate of Death indicated Resident 1 died at the facility on 10/30/2025 at 8:18 p.m. During an interview on 12/19/2025 at 3:44 p.m. with CNA 1, CNA 1 stated that on 10/30/2025 during the 3 p.m. to 11 p.m. shift, she was the assigned CNA for Resident 1. CNA 1 stated that on 10/30/2025, at the start of her 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 lunch break. CNA 1 further stated that on 10/30/2025, at approximately 7:50 p.m., upon returning from her lunch break, she entered Resident 1’s room and found Resident 1 sitting on the side of the bed with her feet on the floor and her 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 12/19/2025 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 10/30/2025. LVN 1 stated that at the start of her shift, Resident 1 had already left the facility for outpatient (non-overnight) hemodialysis treatment. 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. On 10/30/2025 at approximately 7:30 p.m., she (LVN 1) went on her lunch break. LVN 1 stated that prior to leaving for her lunch break, she could not recall checking Resident 1’s room to determine whether Resident 1 had returned to the facility. 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 LVN 1 to follow her to Resident 1’s room. LVN 1 stated that when she entered Resident 1’s room, at approximately 8 p.m., Resident 1 was lying on her back, in bed with her eyes open and fixed upward. Resident 1’s AV fistula dressing was no longer in place and was located on the bed next to Resident 1’s left arm. There was blood on the AV fistula dressing, on the bed, and “everywhere.” 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. She (LVN 1) felt Resident 1’s thready (very weak) 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 entered Resident 1’s room (cannot recall the exact time), paramedics arrived, at which point she stepped out of the room. During a concurrent interview and record review on 12/24/2025 at 11:19 p.m. with Registered Nurse 2 (RN 2), Resident 1’s Progress Notes dated 10/30/2025 and “Nursing Facility Post-Dialysis Assessment” form dated 10/30/2025, and Resident 1’s Care Plan regarding hemodialysis, initiated on 9/16/2025, charged facility staff to monitor the dialysis access site upon return from the dialysis for bleeding. RN 2 stated there was no record in Resident 1’s progress notes indicating the time Resident left the facility for hemodialysis or the time Resident 1 returned to the facility on 10/30/2025. 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 10/30/2025. 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. On 10/30/2025, 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 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. There was no documentation showing that the AV fistula dressing was assessed or indicating when the dressing was removed. 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 harmful or undesired outcomes, including bleeding. 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 12/24/2025 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 10/30/2025. RN 1 stated that on 10/30/2025, at approximately 7:10 p.m., she observed transportation staff with Resident 1 seated in a wheelchair outside the facility near the locked emergency exit door. 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 room. 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. Resident 1 sat on the edge of the bed. She (RN 1) connected Resident 1 to oxygen at two liters 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. She (RN 1) did not check Resident 1’s vital signs and did not visually inspect Resident 1’s left uppe