Based on review of MD 054, facility investigation documentation and the medical record, and staff interviews, it was determined that the facility staff failed to provide [CONDITION(S)] services for a resident (Resident # 19). This was evident for 1 of 7 residents reviewed for [CONDITION(S)] services during the survey.This incident resulted in actual harm to the resident. The resident was sent to the hospital via 911 for elevated blood pressure and change in mental status, and was admitted .
A review of the facility's plan of correction implemented immediately after the facility gained knowledge of the incident, resulted in the deficiency being cited as an IJ past non-compliance. …
Based on record review and staff interviews, it was determined that the facility failed to: 1) accurately monitor residents for weight loss and to communicate dialysis residents' accurate condition (body weight loss reported as weight gain) with the dialysis center, which resulted in harm for Resident #78 due to an 8-day hospitalization for low blood volume; 2) report the resident's weight to the dialysis center and physician before Resident #76's blood pressure dropped, and 3) ensure an effective communication system between the dialysis center; 4) report and/or document the dialysis residents' conditions with physicians. This was evident in 2 (Resident #76 and #78) of 2 dialysis residents' records reviewed during the survey. …
D · No harm, potential for more than minimal, isolatedJuly 14, 2026
Based on interview and record review, it was determined that the facility failed to ensure residents receiving hemodialysis received care and services consistent with professional standards of practice for 2 (Residents #4 and #26) of 2 residents reviewed for hemodialysis services.The findings include:Administering medications prior to hemodialysis—a treatment where a machine filters waste and fluid from the blood—can remove water-soluble drugs before they achieve a therapeutic effect. Additionally, giving blood pressure medications beforehand increases the risk of dangerous blood pressure drops, as the drug's effects combine with the machine's fluid removal process. …
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