**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, hospital record review, review of data found at www.kidneyfoundation.org, policy review and interviews, the facility failed to prevent an incident of neglect when Resident #51 did not receive hemodialysis treatments as ordered due to a lack of facility provided transportation. This resulted in Immediate Jeopardy and actual harm with risk of death beginning on 07/21/25 when Resident #51, who was dependent on hemodialysis due to end stage renal disease, was not transported to a scheduled dialysis treatment. The resident subsequently missed hemodialysis on 07/23/25 again due to a lack of facility provided/arranged transportation. As a result, Resident #51 developed symptoms of fluid volume overload, shortness of breath, fatigue and weakness. The facility failed to timely identify the resident's condition change and did not transfer the resident to the emergency room (ER) until the evening of 07/23/25 at which time she was diagnosed with hyperkalemia (elevated potassium level of 7.7 (critical)) due to missed hemodialysis treatments and required admission to the intensive care unit (ICU) to receive continuous renal replacement therapy (CRRT) to restore the resident's blood potassium level and prevent imminent deterioration of the resident's condition. This affected one resident (Resident #51) of one resident identified by the facility to receive hemodialysis treatments. The facility census was 52. On 08/04/25 at 4:47 P.M. the Director of Nursing #7, Assistant Director of Nursing #6, Administrator #128 , Regional Director of Operations (RDO) #614, and Regional Director of Clinical Services 615 were notified Immediate Jeopardy began on 07/21/25 when the facility failed to secure transportation for Resident #51 to receive life sustaining hemodialysis treatments required due to the resident's end stage renal disease. Due to the missed appointments, the resident was hospitalized in the intensive care unit requiring continuous renal replacement. The resident was assessed to have hyperkalemia, was hyponatremic and her electrocardiogram revealed cardiac changes, including heart block, due to the changes in condition associated with the missed hemodialysis treatments. The Immediate Jeopardy was removed on 08/04/2025 when the facility implemented the following corrective actions: On 08/04/2025 from 5:07 P.M. until 5:17 P.M. Regional Director of Operations (RDO) #614 Regional Director of Clinical Services #615, Administrator #128, Director of Nursing (DON) #7 and Assistant Director of Nursing (ADON) #6 were educated via Teams call by VP of Clinical Operations #613 and VPO #612 regarding: Abuse and Neglect Policy, Resident examination and assessment, Change in Resident's Condition or Status with Notification, Transportation and interventions, and Charting and Documentation. On 08/04/2025 at 5:20 P.M. all department heads were educated via in-person meeting by RDO #614 and Regional Director of Clinical Services #615 on Abuse and Neglect Policy, Resident examination and assessment, Change in Resident's Condition or Status with Notification, Transportation and interventions, and Charting and Documentation. Department heads educated included Administrator #128, DON #7, Business Office Manager (BOM) #129, ADON #6, admission Coordinator/Marketing #218, Dietary Manager #65, Social Services #106, Minimal Data Set (MDS) Registered Nurse (RN) #2, Regional Director of Clinical Services #615, RDO #614, and Central Supply/Medical Records #5. On 08/04/2025 from 5:30 P.M. until 6:00 P.M. an audit of the facility appointment calendar was completed for all 52 residents for missed appointments due to transportation concerns the week of 07/21/2025 to 07/28/2025 when the facility was without a wheelchair accessible van. Two additional residents were identified as having missed appointments and were clinically assessed for a decline in condition. The audit completed by ADON #6 identified Resident #15 had a chemotherapy appointment scheduled for 07/21/2025 but arranged transportation did not arrive to transport the resident on 7/21/2025. Resident #15's appointment was rescheduled for 07/31/2025 and transportation was provided by the facility. Resident #17 had a non-life sustaining dermatology appointment scheduled for 07/21/2025. Transportation was canceled by Valley Logistics transportation company; the Activity Director was notified on 7/18/2025 when the Activity Director called to confirm transportation arrangements. This appointment and transportation were rescheduled to 08/18/2025, with the facility to transport. On 08/04/2025 from 6:04 P.M. until 6:40 P.M. resident interviews were conducted to identify possible situations of neglect. Thirty-one (31) residents with a Brief Interview for Mental Status (BIMS) score of 13 or higher were interviewed by the BOM. Residents interviewed included Resident #4, # 5, #10, #11, #12, #13, #14, #15, #17, #18, #19, #20, #21, # 22, #23, #26, #28, #29, # 32, #34, #35, #37, #38, #42, #43, #47, # 48, #50, #51, #53, and #55. Questions included, Has staff, a resident or anyone else here neglected you? and Have you seen any resident here being neglected?. On 08/04/2025 from 6:05 P.M. until 6:40 P.M. resident skin assessments were completed for (21) residents with a BIMS score of 12 or lower by facility ADON #6 and DON #7. Residents assessed included Resident #1, #2, #3, #6, # 7, #8, #9, #16, #27, #30, #31, #33, #36, #39, #40, #41, #45, #46, #49 and#54. On 08/04/2025 from 6:40 P.M. until 7:00 P.M. a Quality Assurance Performance Improvement (QAPI) meeting was held meeting held with facility staff members including Administrator #128, Director of Nursing #7, BOM #129, Assistant Director of Nursing #6 , admission Coordinator/Marketing #218, Dietary Manager #65, Social Services #106 (by phone), MDS RN #2, Regional Director of Clinical Services #615, Regional Director Operations #614, Central Supply/Medical Records #5, and Medical Director #606 (by phone). The QAPI agenda consisted of the review of the facility IJ abatement plan, a root cause analysis, staff education topics, and weekly audits to be completed. The root cause was identified as transportation concerns arose, staff did not complete appropriate notifications, assessments, and interventions to ensure Resident #51 had no adverse effects. Education topics include pertinent facility policies, including the policies titled, Abuse and Neglect Policy, Resident examination and assessment, Change in Resident's Condition or Status with Notification, Transportation and interventions, and Charting and Documentation. On 08/04/2025 from 6:59 P.M. until 8:44 P.M. an audit of the facility EHR report titled 72 Hour Report, which included weights and vitals, progress notes, the completion of assessments, etc. for the previous 72 hours, was completed for all 52 residents by MDS RN #2, to confirm appropriate notifications and interventions for residents with a change in condition. On 08/04/2025 from 7:05 P.M. until 7:17 P.M. All Staff Education was completed remotely by RDO #614 via facility communication system on the topics of Abuse/ Neglect, Resident examination and assessment, Change in Resident's Condition or Status with notification, Transportation and interventions, and Charting and Documentation. All 80 staff members were educated, including re-education to facility administration. (Education was provided to 20 licensed practical nurses (LPN) and registered nurses (RN), 34 Certified Nursing Assistants (CNAs), eight dietary staff members, six housekeeping staff members, one laundry staff member, two activity staff members, one central supply/medical records staff member, and eight administrative staff members. The facility communication system allowed facility administration to send information to staff via Short Message Service (SMS), with confirmation of receipt of the message being received by the facility for each staff member. In addition to the remote education, facility staff were to sign an in-service sheet in acknowledgement of receipt of this education, at the arrival of the facility for their next scheduled shift. This was being audited daily by facility Administrator or Designee, until completion. The facility's new hire orientation was updated by the facility Administrator to include the policies outlined in the completed education. On 08/04/2025 from 8:00 P.M. until 8:19 P.M. all appointments scheduled for 07/27/25 through 08/02/25 were audited for missed appointments due to lack of transportation by DON #7. Residents who had appointments included Resident #51, Resident #43, Resident #50, Resident #15. On 08/04/25 from 8:13 P.M. until 8:28 P.M. all appointments scheduled for Sunday 08/03/25 through 08/09/25 were audited to ensure transportation was scheduled. The audit was completed by BOM #129. Residents who have scheduled appointments included Resident #51, Resident #3, Resident #36, Resident #37, Resident #20. Transportation would be completed by the facility or Valley Logistics transportation company for all appointments. On 08/04/25 at 10:39 P.M. Resident #51's care plan was updated to add appropriate steps for any missed dialysis appointments per facility policies by MDS RN #2. Resident #51's care plan would be accessible to nursing staff via facility Electronic Health Record (EHR), including transportation interventions and notification, in accordance with facility policies titled, Transportation, Charting and Documentation, and Change in a Resident's Condition or Status, Resident Examination and Assessment, and a handout titled Education Highlights. The facility implemented a plan for the following audits to be initiated on or by 08/06/2025: o Appointment calendar will be audited for accuracy, completion and transportation five times per week for four weeks and then weekly for four weeks by DON or designee. The facility appointment calendar is managed by Activity Director, including the verification of scheduled appointments and transportation. All transportation is completed by the facility and/or Valley Logistics transportation company. o Interventions for missed appointments would be audited by DON or designee five times per week for four weeks then weekly for four weeks, including documentation in the medical record of interventions and notifications to facility DON and primary care provider team. Facility EHR bulletin board notice posted on 08/04/2025 at 10:46 P.M. by RDO #614 for nurses to notify DON of any missed appointments. o 24/72hr report to be reviewed for resident changes in condition would be audited daily Monday through Friday; Monday to capture Friday through Sunday five times per week for four weeks to ensure proper documentation is included such as assessments, adverse reactions, unusual occurrences, refusals, declines, notifications. Audit to be completed by DON or Designee. o Resident interviews for residents with a BIMS of 13 or higher or head to toe assessments for residents with a BIMS of 12 or lower to assess for concerns of neglect would be completed for three random residents five times per week for four weeks and then three random residents weekly for four weeks by DON or Designee. o Results of all audits would be reviewed weekly, at minimum, by the facility's QAPI committee for the duration of the audits. Although the Immediate Jeopardy was removed on 08/04/2025 the deficiency remains at Severity Level II (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include:Record review revealed Resident #51 was admitted to the facility on [DATE] with diagnoses including respiratory failure, type two diabetes, chronic obstructive respiratory disease, anemia, atherosclerotic heart disease, schizophrenia, borderline personality disorder, hypothyroidism, hypertension, chronic kidney disease, kidney failure and renal (hemo)dialysis dependence. Review of Resident #51's physician orders revealed an order for hemodialysis every Monday, Wednesday, and Friday at an outside dialysis center due to renal failure. Review of Resident #51's care plan dated 04/11/25 revealed the resident needed hemodialysis related to renal failure. Goals included the resident would have immediate intervention should any signs or symptoms of complications from dialysis exist. The care plan reflected the resident received (hemo)dialysis at (name and location of dialysis center) on Monday, Wednesday, and Friday at 10:30 A.M. Interventions included encouraging the resident to go for their scheduled dialysis appointments. Monitor vital signs and notify the medical doctor (MD) of significant abnormalities. Monitor, document, report as needed (PRN) for signs and symptoms of renal insufficiency such as changes in level of consciousness, changes in skin turgor, oral mucosa, and changes in heart and lung sounds. Check arteriovenous (AV) fistula (a connection between an artery and vein surgically created to receive dialysis) site thrill (a palpable vibration or tremor felt over an AV fistula that indicates turbulent blood flow)/bruit (an abnormal sound, often described as a swishing or blowing that can be heard with a stethoscope over a blood vessel and indicates turbulent blood flow); palpate/feel to assess for thrill and auscultate for bruit as ordered. Review of Resident #51 quarterly Minimum Data Set (MDS) assessment completed 06/04/25 revealed the resident had a BIMS score of 15 (out of a total score of 15), indicating Resident #51 was cognitively intact. The assessment also reflected the resident received dialysis. Review of Resident #51's dialysis communication binder, taken to and from each dialysis appointment for communication between the facility and the dialysis provider, revealed Resident #51 did not receive dialysis treatments on 07/21/25, or 07/23/25. Resident #51 last attended a dialysis appointment was on 07/18/25 which resulted in Resident #51 going a total of five days without being dialyzed before she was transferred to the hospital (on 07/23/25) for emergent medical intervention/treatment. Further reviews of Resident #51's medical record revealed no documentation, including vital signs, were available on 07/21/25 or 07/23/25 until the resident was transported to the hospital for evaluation (on 07/23/25). Further review revealed no additional nursing progress notes or documentation the resident missed the hemodialysis treatments on this date. There was no documentation the resident's physician or nephrologist were notified of the missed hemodialysis treatments. Review of Resident #51's progress note dated 07/23/25 at 6:49 P.M. authored by Registered Nurse (RN) #120 revealed Resident #51 was feeling very weak and having a change in condition, sending to emergency department for evaluation. An additional note dated 07/23/25 authored by LPN #38 at 10:48 P.M. revealed the resident was admitted to the hospital. Review of Resident #51's emergency room documentation dated 07/23/25 and authored by Doctor of Medicine (MD) #608 revealed Resident #51 presented to the emergency department (ED) on 07/23/25 from a skilled nursing facility (SNF) with shortness of breath. Resident #51 had a past medical history (PMH) of end stage renal disease (ESRD) and missed dialysis on Monday 07/21/25 due to lack of transportation from the SNF. Lab work revealing hyperkalemia, potassium 7.7 milliequivalents per liter (mEq/L) (normal range 3.5-5.0 mEq/L), mixed metabolic and respiratory acidosis (a serious life-threatening situation when the lungs and the body's metabolism are making the blood too acidic at the same time, caused by an increase in carbon dioxide and an excessive amount of acid build up). Electrocardiogram (EKG) showing Intraventricular conduction delay (IVCD) (the electrical signals from the lower heart chambers are moving slower than usual, causing the heart to beat out of sync or rhythm therefore not pumping blood to the body efficiently). Resident #51 was admitted to the ICU to facilitate continuous renal replacement therapy (CRRT). CRRT is a type of dialysis that provides a continuous, 24-hour treatment with acute kidney injury who are too unstable for traditional, intermittent dialysis methods offering life-saving support to critically ill patients. Primary hospital diagnoses for Resident #51 hospital admission from 07/23/25 through 07/25/25 included acute hyperkalemia, encounter for CRRT for end-stage renal disease (ESRD) and admitted to intensive care unit (ICU) for CRRT. Resident #51 required CRRT, transitioning to hemodialysis (HD), hyperkalemia treatment, strict intake and outputs, serial basic metabolic panel (BMP) lab work, and hyponatremia improving with CRRT. Hyponatremia (lab work revealing sodium of 128) was likely due to volume overload with two missed hemodialysis (HD) sessions. EKG on admission with sinus bradycardia (a slower than normal heart rate, less than 60 beats per minute) , second degree atrioventricular (AV) block (a heart rhythm where electrical signals from the upper chambers of the heart are not conducted to the hearts lower chambers causing the heart to miss a beat) , Mobitz type 2 right bundle branch block (the right side of the heart has a delay in receiving electrical signals causing signals to come late or be completely missed), repeat EKG showing sinus bradycardia with sinus arrhythmia and right bundle branch block, likely metabolic in nature secondary to missed HD and hyperkalemia. Patient was treated with medications without significant improvement and was admitted to ICU for dialysis.Review of Resident #51's hospital record revealed an EKG reading from 07/23/25 authored by Cardiologist #609 that stated Resident #51 had junctional bradycardia with intermittent heart block, widening of the QRS complex, this was a change when compared to prior EKGs Review of Resident #51's hospital record revealed an admission note authored by MD #606 which included Resident #51 was dialysis dependent (for renal failure) and she missed (HD treatments) due to transportation issues. EKG showed junctional bradycardia with intermittent heart block, widening of the QRS complex. Resident #51 showed hyperkalemic changes on her EKG, changes that were not there on the previous. Resident #51 would be admitted to the ICU for dialysis. Review of Resident #51's hospital record revealed a hospital admission note dated 07/23/25 and authored by the emergency department physician Doctor of Osteopathic Medicine (DO) #610, which documented Resident #51 had a high probability of imminent life or limb threatening deterioration due to severe hyperkalemia with EKG changes. Review of Resident #51 hospital record revealed a note dated 07/24/25 and authored by Nephrologist #611 which included Resident #51 was known to their practice due to her dialytic needs. Resident #51 was typically compliant with her treatments for dialysis. Resident #51 missed dialysis on Monday 07/21/25 and Wednesday 07/23/25 due to the nursing facility not having transportation because of issues with their van. Lab work revealed hyperkalemia, acidemia, and cardiac involvement secondary to hyperkalemia. The note included will touch base with our team regarding further management from her facility so these transportation issues are resolved. Review of Resident #51's progress note dated 07/25/25 at 7:42 P.M. and authored by LPN #304 revealed Resident #51 returned from the hospital after admission for continuous dialysis. Interview on 07/30/25 at 10:34 A.M. with offsite Dialysis Registered Nurse (RN) #604 revealed it was not recommended for any patient who required dialysis to miss an appointment for dialysis. Missing even just one appointment could lead to hospitalization and possible death. Someone who may be presenting with adverse reactions from missing dialysis could include confusion and diarrhea; the resident's potassium level could rise causing hyperkalemia; a dangerous excess amount of potassium leading to cardiac changes. Interview on 07/30/25 at 10:59 A.M. with offsite dialysis social worker, Licenses Social Worker (LSW) #603 revealed on Monday 07/21/25 the facility called the dialysis center to cancel Resident #51's dialysis appointment due to transportation issues. LSW #603 also shared the facility canceled dialysis on 07/23/25, without reason. At that time (on 07/23/25) dialysis staff recommended the resident be sent to the ER. Further interview revealed Nephrologist #611 shared, later on 07/23/25, that Resident #51 was in the hospital requiring continuous renal replacement therapy (CRRT). Nephrologist #611 wanted to discharge Resident #51 from the hospital on [DATE] back to the facility; however, the facility advised against this stating they felt it was safer for the resident to remain in the hospital for dialysis. Resident #51 was scheduled for dialysis on 07/25/25 at the offsite dialysis center but remained in the hospital at that time. LSW #603 stated missing a dialysis appointment could lead to toxin build up and fluid overload, some symptoms may include shortness of breath, nausea and vomiting, and swelling. Interview with Via [NAME] Therapeutic Behavior support (TBS) #605 on 07/30/21 at 1:20 P.M. revealed she saw Resident #51 a few days a week. TBS #605 revealed Resident #51 missed a few dialysis appointments and was in the hospital the week of 07/21/25 to 07/25/25. TBS stated she was told Resident #51 missed dialysis due to transportation issues; transportation was down. TBS #605 stated she was told this on Wednesday 07/23/25. TBS #605 stated she went in to see Resident #51on 07/23/25 around 2:30 P.M. and Resident #51 said she didn't feel good and that she had thrown up. TBS #605 shared Resident #51 was not her usual self that day. TBS #605 stated she notified the nurse but could not remember which nurse. TBS #605 shared the nurse said they were aware and told her Resident #51 hadn't been feeling well. Interview with Registered Nurse (RN) #11 on 07/30/25 at 2:51 P.M. confirmed Resident #51 did not receive hemodialysis on 07/21/25 and 07/23/25 on her usual appointment days due to the facility not having transportation to get Resident #51 to the dialysis facility. Interview on 07/30/25 at 3:10 P.M. with LPN #60 verified Resident #51 missed two hemodialysis appointments, on Monday 07/21/25 and Wednesday 07/23/25. The LPN revealed Resident #51 missed her dialysis appointments due to not having transportation to the dialysis center and back. LPN #60 stated Resident #51 was ready for dialysis and as time passed and it got closer to when she would usually leave, someone then told them there was no transportation and dialysis was cancelled. LPN #60 stated Resident #51 was eventually transferred to the hospital due to a status change, not feeling well and not acting like her usual self. The nurse stated the resident was in the ICU for a few days due to missing two dialysis appointments. During that time Resident #51 required an ICU admission for CRRT. Interview on 07/30/25 at 3:23 P.M. with Licensed Practical Nurse (LPN) #200 confirmed on 07/21/25 Resident #51 missed her dialysis appointment. LPN #200 stated Resident #51's dialysis appointment was missed due to the facility not having a van to transfer the resident to and from dialysis on 07/21/25. Interview on 07/30/25 at 3:54 P.M. with Anonymous Staff Member (ASM) #484 revealed Resident #51 was not acting herself on Wednesday 07/23/25. The ASM stated Resident #51 had missed two dialysis appointments due to transportation issues and was not acting herself, she would answer appropriately but was acting off. Before Resident #51 was transferred to the hospital, she had vomited. ASM #484 revealed at times when Resident #51 didn't feel good she could be more agitated than usual, maybe a little crabby at times when she was unwell but Resident #51 wasn't even doing this, it was as if the lights were on but no one was there. ASM #484 confirmed Resident #51 was transferred to the emergency room on [DATE] because of her change in status. Interview on 07/30/25 at 4:07 P.M. with Certified Nursing Assistant (CNA) #377 revealed the week of 07/20/25 through 07/26/25 the facility's transportation van was down and out of order. CNA #377 confirmed Resident #51 missed two dialysis appointments due to having no transportation to get there. CNA #377 revealed the days leading up to Resident #51 being transferred to the hospital Resident #51 was not herself, she was acting different than she usually did and even stated several times she was feeling sick. Interview on 07/30/25 at 4:24 P.M. with LPN #61 revealed transportation had been down since last week (week of 07/20/25). LPN #61 revealed residents were missing appointments due to this. LPN #61 stated Resident #51 did not go to dialysis on 07/21/25 due to having no transportation and the resident appeared more tired than usual the days following up to her being admitted to the ICU (on 07/23/25). The LPN was unsure if Resident #51's physician or nephrologist were notified of the resident missing her dialysis appointments. LPN #61 denied any knowledge of anyone trying to set up alternative transportation for Resident #51 for the dialysis on Monday or Wednesday; the transportation vehicle was down so her appointments got canceled. Interview on 07/30/25 at 4:54 P.M. with Resident #51 confirmed she missed dialysis on Monday 07/21/25 because there was no van but stated she could not recall if she missed dialysis on Wednesday 07/23/25 due to her not being able to remember anything from those days. Resident #51 stated she didn't remember if she had dialysis or not, she didn't remember if she was sick, she did not remember if she felt unwell, she couldn't recall anything from those days. Resident #51 shared she missed dialysis on Monday and then she woke up and was in the hospital, in the ICU with a lot of stuff going on around her. Resident #51 stated anything between the two events she didn't recall. Resident #51 stated to her knowledge the dialysis center called the facility to see where she was and that was when the facility told dialysis that she wouldn't be making it to dialysis because the van wasn't working. Resident #51 stated she does not believe her doctor knew she wasn't going to dialysis. Resident #51 stated she knows what goes on, she doesn't forget things, however she stated she could not remember anything after missing dialysis on 07/21/25 until she woke up in the ICU. Interview on 07/30/25 at 6:02 P.M. with ASM #455 revealed Resident #51 missed two dialysis appointments on 07/21/25 and 07/23/25. ASM #455 stated these appointments were missed due to the facility transportation van being out of order. The ASM stated to their knowledge no one attempted to get alternative transportation for Resident #51 to get to her dialysis appointments for either of the two appointments missed. ASM #455 revealed on the days leading up to Resident #51 hospital admission (on 07/23/25) the resident was not right at all, she was acting different, complaints of not feeling well, and even her body color was not what it usually was. ASM #455 revealed something should have been done sooner, transport was down Monday, but the resident still missed Wednesday; and it seemed like her status was worsening and nothing was being done about it. Interview on 07/31/25 at 7:14 A.M. with CNA #74 revealed Resident #51 missed two dialysis appointments on 07/21/25 and 07/23/25. CNA #74 confirmed that these two dialysis appointments were missed due to the facility transportation van being broke down. An interview on 07/31/25 at 7:30 A.M. with CNA #301 revealed on 07/21/25 Resident #51 was up and ready for her dialysis appointment like she was every Monday. Around 9:30 A.M. they were notified that there was no transportation for Resident #51 to go to dialysis. Resident #51 then missed another dialysis appointment on 07/23/25 again due to having no transportation. This resulted in Resident #51 being admitted to the hospital in the intensive care unit requiring continuous dialysis. Interview on 07/31/25 at 7:55 A.M. with CNA #64 confirmed Resident #51 missed two dialysis appointments on Monday 07/21/25 and Wednesday 07/23/25. CNA #64 stated these dialysis appointments were missed due to the facility transportation vehicle not working. CNA #51 confirmed Resident #51 ended up in the intensive care unit requiring continuous dialysis due to missing the two appointments. Interview on 07/31/25 at 8:31 A.M. with CNA #21 confirmed Resident #51 missed dialysis appointments due to not having transportation to get there. CNA #21 revealed awareness of Resident #51 missing dialysis on 07/21/25 and stated she was unsure of how many more days she missed. CNA #21 revealed Resident #51 in the days leading up to her hospitalization after missing dialysis complained of being short of breath, but she was unsure if that was correlated. Interview on 07/31/25 at 12:59 P.M. with facility medical director (MD) #606 revealed the MD was not notified of Resident #51 missing dialysis on 07/21/25 or 07/23/25. MD #606 stated when Resident #51 was admitted to the hospital (on 07/23/25) he was notified she was being admitted , but it wasn't until after that that he was told she had missed two dialysis days. MD #606 revealed missing a dialysis day could result in fluid overload, hyperkalemia, hospitalization, myocardial infarction (MI), and even death. Some symptoms you would experience with fluid overload or hyperkalemia included shortness of breath, cardiac changes, and vomiting. Interview on 07/31/25 at 11:27 A.M. with ASM #450 revealed Resident #51 missed two dialysis appointments, one on 07/21/25 and the other on 07/23/25. The ASM voiced they felt the facility was negligent with Resident #51 missing her dialysis appointments and facility's lack of reaction to Resident #51 decline leading up to her hospitalization. ASM #450 revealed the facility transport van had been down for a while and they (the facility) had ample time to get transportation set up, the facility rented a van to take residents to a wrestling event but didn't attempt to get transportation of any form for Resident #51 to receive medically necessary dialysis. ASM #450 stated in the days leading up to Resident #51's admission to the hospital after missing dialysis she looked pale, she was sleeping a lot and typically she was a very active person, always awake and utilized her call light often which she hadn't been doing, and hadn't voided. Interview on 08/04/25 at 8:40 A.M. with ASM #451 revealed for about a week (the week of 07/20/25) the facility did not have a transportation van. This resulted in several residents missing appointments. The ASM voiced administration did not attempt to get transportation for the residents, it didn't seem like they cared. Resident #51 missed her dialysis appointments, for two days, she hadn't been to dialysis since 07/18/25 so she hadn't been to dialysis in five days leading up to her discharge to the hospital. The ASM stated administration didn't seem to care. Interview on 08/04/25 at 9:30 A.M. with Dialysis RN #607 confirmed Resident #51 missed her dialysis appointment on 07/21/25 and 07/23/25. RN #607 stated Resident #51 had not been to dialysis for two appointments totaling five days without being dialyzed, and Resident #51 was very compliant with dialysis, she didn't miss. The two days that were missed were due to the facility not having transportation to get Resident #51 to dialysis. RN #607 stated on Monday they asked the facility if the resident could attend dialysis Tuesday 07/22/35 and the facility reported the earliest they could get Resident #51 to dialysis was on Wednesday 07/23/25. RN #607 stated Resident #51's dialysis appointments typically began around 10:30 A.M. On 07/23/25 when it became apparent Resident #51 was not going to make it to her dialysis appointment the dialysis facility called the facility to recommended Resident #51 be transferred to the hospital fairly immediately; however, the resident was not sent until later that evening. Dialysis RN #607 stated it was not safe for someone to miss a dialysis appointment; this could cause fluid overload putting a burden on the resident's heart. Missing dialysis could also cause your potassium to rise causing hyperkalemia and anomalies with heart rhythm all the way up to cardiac arrest. Interview on 08/04/25 at 10:15 A.M. with DON #7