Based on interview, record review, and facility policy review, the facility failed to ensure Resident #1 received care and services following a hemodialysis treatment consistent with professional standards of practice including ongoing assessment of the resident's condition and monitoring for complications after dialysis treatments for one (1) of four (4) residents reviewed, Resident #1 as evidenced by the facility failed to remove the resident from the facility van on 9/15/23 following their transportation from the dialysis facility, leaving the resident strapped in a wheelchair restrained by the seatbelts in the facility van for sixteen (16) hours and fifteen (15) minutes without the staff's monitoring. …
Based on observations, interviews, record review, facility document review, and facility policy review, the facility failed to ensure a physician-ordered fluid restriction was implemented and monitored for three (3) of five (5) dialysis residents. Resident #12, #43, and #58. Findings Include:
Record review revealed that the facility does not have a policy and presented a statement on facility letterhead dated 06/17/26, that stated, (Proper name) nursing home does not have a policy specific to fluid restrictions on dialysis residents, signed by the Administrator.
Resident #12An observation and interview with Resident #12 on 6/16/26 at 8:30 AM revealed she was lying in bed. A 32-ounce water pitcher full of ice water was located on the bedside table. …
D · No harm, potential for more than minimal, isolatedJuly 15, 2026
Based on record review, interviews, and facility policy review, the facility failed to ensure a resident received physician-ordered dialysis treatment by failing to arrange alternate transportation after becoming aware the scheduled transportation provider was unavailable due to a holiday, for one (1) of three (3) residents reviewed for dialysis services (Resident #1).Findings include:A review of the facility's policy titled, Non-Emergency Transportation for Residents Policy, review date 7/25, revealed, 1. Nursing facilities may ask family members, Resident Representative or friends of residents to transport residents who require non-emergency transportation. …
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