Health inspection·October 15, 2025

F698 42 CFR §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 §72301. Required Services. (d)Written arrangements shall be made for obtaining all necessary diagnostic and therapeutic services prescribed by the attending physician, podiatrist, dentist, or clinical psychologist subject to the scope of licensure and the policies of the facility. If the service cannot be brought into the facility, the facility shall assist the patient in arranging for transportation to and from the service location. 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. On 8/28/2025, an unannounced visit was made to the facility to conduct a complaint investigation regarding quality of care and resident’s rights for Resident 2. The facility failed to provide care and services needed for Resident 2 who required dialysis 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 and abdominal pain. Resident 2 was admitted to GACH 1 for dialysis. A review of Resident 2’s Admission Record (AR) indicated the facility admitted Resident 2, a 44-year-old female on 7/15/2025 and was readmitted on 7/19/2025 with diagnoses that included dependence on renal dialysis, unspecified chronic kidney disease (CKD) and type II diabetes mellitus. A review of Resident 2’s History and Physical (H&P) dated 7/16/2025 and timed at 1:36 pm indicated Resident 2 had end stage renal disease. The H&P indicated Resident 2 was receiving hemodialysis three times per week and to continue current schedule. A review of Resident 2’s Order Summary Report (OSR) dated 7/16/2025 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.   A review of Resident 2’s SBAR Communication Form dated 7/19/2025 indicated Resident 2 missed dialysis. The SBAR indicated MD1 (primary physician for Resident 2) and was informed that Resident 2 missed dialysis. The SBAR indicated Registered Nurse 2 (RN 2), was unable to reschedule Resident 2’s dialysis due to insurance. The SBAR indicated MD 1 was informed with no new orders.   A review of Resident 2’s Minimum Data Set (MDS) dated 7/22/2025 indicated Resident 2 had intact cognition. The MDS indicated Resident 2 required dialysis and had renal insufficiency, renal failure, or ESRD. The MDS indicated Resident 1 was dependent on others for all activities of daily living and 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.   A review of Resident 2’s SBAR dated 7/28/2025 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.   A review of Resident 2’s Progress Note (PN) dated 8/7/2025 and timed at 8:21 pm indicated Resident 2 was monitored for fluid retention due to not going to dialysis.   A review of Resident 2’s PN dated 8/8/2025 and timed at 11:50 pm indicated Resident 2 was monitored for fluid retention and for elevated Blood Urea Nitrogen (BUN) and creatinine due to missing dialysis.   A review of Resident 2’s PN dated 8/9/2025 and timed at 7:18 am indicated Resident 2 was being monitored for fluid retention due to missing dialysis.   A review of Resident 2’s PN dated 8/10/2025 and timed at 9:36 am indicated Resident 2 was being monitored for fluid retention due to missing dialysis. A review of Resident 2’s laboratory results dated 8/11/2025 indicated Resident 2’s BUN level was 79 milligram/deciliter (mg/dl, normal level range is 6 to 24 [mg/dl]) and creatinine level was 8.4 mg/dl (normal level range for women is 0.6 to 1.1 mg/dl).   A review of Resident 2’s SBAR dated 8/11/2025 indicated Registered Nurse 1 (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 Resident 2 to see a nephrologist. The SBAR also indicated the last time Resident 2 had dialysis was on 7/23/2025.     A review of Resident 2’s PN dated 8/12/2025 and timed at 3:59 am indicated Resident 2 was being monitored for fluid retention and for elevated BUN and creatinine. A review of Resident 2’s PN dated 8/13/2025 and time at 7:58 pm indicated Resident 2 was being monitored for fluid retention or any change of condition due to not going to dialysis and for elevated BUN of 79 mg/dl and creatinine of 8.4 mg/dl. A review of Resident 2’s PN dated 8/13/2025 and timed at 9:30 pm indicated Resident 2 was transferred to GACH 1 via ambulance due to missed dialysis. A review of Resident 2’s GACH 1 H&P dated 8/14/2025 indicated Resident 2 had left-sided flank pain with nausea for 1 week and was found to have metabolic acidosis likely due to missed hemodialysis.   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 mg/dl and a creatinine of 8.4 mg/dl. The facility failed to provide care and services needed for Resident 2 who required dialysis 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 dialysis treatments on 7/25/2025, 7/28/2025, 7/30/2025, 8/1/2025, 8/4/2025, 8/6/2025, 8/8/2025, 8/11/2025 and 8/13/2025. Resident 2 was transferred to GACH 1 on 8/13/2025 at 9:30 pm. Resident 1 was diagnosed with metabolic acidosis and abdominal pain. Resident 2 was admitted to GACH 1 for dialysis. This violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 2.