Other·March 17, 2026

F684 42 CFR § 483.25 Quality of care. Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices… 22 CCR 72311 (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 72301 (f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated. 22 CCR 72543 (f) Patients' health records shall be current and kept in detail consistent with good medical and professional practice based on the service provided to each patient. Such records shall be filed and maintained in accordance with these requirements and shall be available for review by the Department. All entries in the health record shall be authenticated with the date, name, and title of the persons making the entry. Based on interview, medical record review and facility P&P (Policy and Procedure) review, the facility failed to provide the necessary skilled nursing care and services for Patient 7, who was found pulseless and apneic (temporary cessation of breathing) by facility staff and later expired following transport to an ED (Emergency Department). The facility failed to ensure Patient 7, whose resuscitation status was “Full Code,” received treatment and care in accordance with professional standards of practice by failing to provide continuous cardiopulmonary resuscitation, as evidenced by the statements and documentation of emergency responders that upon their arrival, facility staff were not performing chest compressions. The facility also failed to accurately document their CPR (Cardio Pulmonary Resuscitation) practices, as evidenced by absence of documentation of measurable vitals supporting RN 3 and LVN5’s report that they stopped performing chest compressions because they achieved a carotid pulse. These failures to appropriately perform and document CPR for a “full code” status of the patient reflect one or more practices, means, methods, or operations that present substantial probability that death or serious physical harm to the patient of the facility would result. Patient 7 was an 84-year-old male, with the following diagnoses but not limited to Cerebral Infarction (a medical condition caused by blockage reducing blood flow to the brain), Hemiplegia (paralysis to one vertical half of the body) and Hemiparesis (weakness to one side of the body) following Cerebral Infarction affecting the right dominant side and Essential Hypertension (high blood pressure). Findings: 1. Review of the facility’s P&P titled Emergency Procedure - Cardiopulmonary Resuscitation and Basic Life Support dated 2001 showed the personnel are certified in CPR (Cardiopulmonary resuscitation for healthcare providers and BLS (basic life support), including defibrillation for victims of sudden cardiac arrest. If an individual is found unresponsive and not breathing normally, a staff member who is certified in CPR for health care providers or BLS will administer CPR unless: a. it is known that a do not resuscitate (DNR) order that specifically prohibits CPR and/ or external defibrillation exist for that individual; or b. there are obvious signs or irreversible death. Medical record review for Patient 7 was initiated on 2/4/26.  Patient 7 was admitted to the facility on 1/27/26. Review of Patient 7’s H&P (History and Physical) examination dated 1/29/26, showed the patient had the capacity to understand and make decisions.    Review of Patient 7’s Order Summary Report dated 2/4/26, showed a physician’s order dated 1/27/26, for full code.    Review of Patient 7’s POLST Physician’s Orders for Life-Sustaining Treatment) dated 1/27/26, the CPR section indicated to “Attempt Resuscitation/CPR” and the Medical Interventions section indicated “Full Treatment” (primary goal of prolonging life by all medically effective means).    Review of Patient 7’s eInteract SBAR (Situation/Background/Assessment/Recommendation) Communication Form and Progress Notes dated 2/2/26, showed Patient 7 was found on the floor next to the bed, with no response to verbal and tactile stimuli, the assessment revealed asystole and absence of respiration, CPR was initiated and 911 was called.  After approximately 20 minutes of CPR, return of spontaneous circulation was achieved and assumed care. The note further showed the fire department arrived, continued CPR and lifesaving measured for another 20 minutes.  Further review of Patient 7’s medical record failed to show a documentation and/or the vital signs reading when the staff achieved spontaneous circulation.   Review of Patient 7’s Electronic Patient Care Report from the Fire Department dated 2/2/26 at 0236 hours, showed the fire department arrived on scene to find the patient on the ground surrounded by care staff pulseless, apneic and without compressions being performed.  The manual compressions was initiated.  BVM (Bag-Valve-Mask) with high flow oxygen was administered.  Defibrillation pads were applied at 0239 hours, resident was PEA (Pulseless Electrical Activity).   Review of Patient 7’s Emergency Department H&P examination dated 2/2/26, the Disposition section showed unfortunately the patient passed away in the Emergency Department. On 2/4/26 at 1435 hours, a telephone interview was conducted with the Fire Captain.  The Fire Captain stated he arrived at the facility and found Patient 7 on the ground surrounded by care staff, pulseless and not breathing, and without compressions being performed.  The Fire Captain further stated the staff informed him of the CPR provided to the patient for twenty minutes and believed the heart rate was back and stopped the compressions.    On 2/4/26 at 1611 hours, a telephone interview was conducted with RN 3.  RN 3 stated she walked in Patient 7’s room with LVN 5 on the scene.  RN 3 stated Patient 7 was unresponsive and had no pulse, then LVN 5 and RN 3 initiated CPR immediately.  RN 3 stated LVN 5 provided compressions while RN 3 provided breathing with the use of Ambu bag (is a handheld, portable device used by medical professionals to provide manual, positive-pressure ventilation to patients who are not breathing or struggling to breathe). RN 3 further stated the pulse was achieved prior to the fire department’s arrival at the scene.  However, RN 3 further stated Patient 7 had no blood pressure and remained unconscious.   On 2/4/26 at 1536 hours, a telephone interview was conducted with LVN 4.  LVN 4 stated Patient 7 was unresponsive and had no pulse, and CPR was initiated immediately.  LVN 5 provided compressions while RN 3 provided breathing with the use of Ambu bag.  LVN 4 further stated they provided CPR for twenty minutes then the patient’s pulse came back, and RN 3 stated to stop the CPR while waiting for the paramedics.    On 2/5/26 at 0617 hours, an interview was conducted with LVN 5.  LVN 5 stated he found Patient 7 lying on the floor on the left side halfway on prone position.  LVN 5 stated Patient 7 had no pulse oximeter reading and RN 3 verified the patient had no pulse and respiration.  LVN 5 stated he provided the compressions while RN 3 provided the breathing with the use of Ambu bag.  LVN 5 further stated they had performed CPR for 18-20 minutes then obtained carotid pulse as confirmed by RN 3.  LVN 5 stated they stopped the compressions with the presence of carotid pulse.  LVN 5 further stated Resident 7 remained unconscious, barely breathing and did not have any blood pressure reading for approximately 5-7 minutes while waiting for the paramedics to arrive. On 2/5/26 at 0850 hours, an interview was conducted with the DON.  The DON stated the expectation for the licensed nurses was to continue with the CPR until the fire department arrives and takes over the resuscitation.

F726 42 CFR § 483.35 Nursing services. The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at § 483.71. (a) Sufficient Staff (3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. (c) Proficiency of nurse aides. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. 22 CCR 72311 (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 72301 (f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated. 22 CCR 72543 (f) Patients' health records shall be current and kept in detail consistent with good medical and professional practice based on the service provided to each patient. Such records shall be filed and maintained in accordance with these requirements and shall be available for review by the Department. All entries in the health record shall be authenticated with the date, name, and title of the persons making the entry. Based on interview, medical record review, and facility document review, the facility failed to ensure the facility staff provided the necessary emergency care and services to Patient 7. * LVNs 4 and 5 and RN 3 failed to provide continued CPR to Patient 7 when the patient remained unconscious, barely breathing and did not have any blood pressure reading. These failures had the potential to put the patient at risk for care not provided in a safe and competent manner. Findings:   Review of the facility’s P&P titled Competency of Nursing Staff dated 2001 showed all nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by State law.  The staff development and training program is created by the nursing leadership, with input from the medical director, and is designed to train nursing staff to deliver individualized, safe, quality care and services for the patients.  Competency demonstrations will be evaluated based on the staff member's ability to use and integrate knowledge and skills obtained in training, which will be evaluated by staff already deemed competent in that skill or knowledge.   Review of the facility’s P&P titled Emergency Procedure - Cardiopulmonary Resuscitation and Basic Life Support dated 2001 showed personnel are certified in CPR (Cardiopulmonary resuscitation for healthcare providers and BLS (Basic Life Support), including defibrillation for victims of sudden cardiac arrest.  If an individual is found unresponsive and not breathing normally, a staff member who is certified in CPR for health care providers or BLS will administer CPR unless: a. it is known that a do not resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exist for that individual; or b. there are obvious signs or irreversible death.  Review of Patient 7’s medical record was initiated on 2/4/26.  Patient 7 was admitted to the facility on 1/27/26.   Review of Patient 7’s Order Summary Report dated 2/4/26, showed a physician’s order dated 1/27/26, for full code.   Review of Patient 7’s POLST dated 1/27/26, the CPR section indicated to “Attempt Resuscitation/CPR” and the Medical Interventions section indicated “Full Treatment” (primary goal of prolonging life by all medically effective means).     Review of Patient 7’s eInteract SBAR Communication Form and Progress Note dated 2/2/26, showed Patient 7 was found on the floor next to the bed, with no response to verbal and tactile stimuli, the assessment revealed asystole and absence of respiration, CPR was initiated and 911 was called.  After approximately 20 minutes of CPR, return of spontaneous circulation was achieved and assumed care. The note further showed the fire department arrived, continued CPR and lifesaving measured for another 20 minutes.   Further review of Patient 7’s medical record failed to show a documentation and/or the vital signs reading when the staff achieved spontaneous circulation.   Review of Patient 7’s Electronic Patient Care Report from the Fire Department dated 2/2/26 at 0236 hours, showed the fire department arrived on scene to find the patient on the ground surrounded by care staff pulseless, apneic and without compressions being performed.  The manual compressions was initiated.  BVM (Bag-Valve-Mask) with high flow oxygen was administered.  Defibrillation pads were applied at 0239 hours, the patient was PEA (Pulseless Electrical Activity).   Review of Patient 7’s Emergency Department History and Physical examination dated 2/2/26, the Disposition section showed unfortunately the patient passed away in the Emergency Department.   On 2/4/26 at 1435 hours, a telephone interview was conducted with the Fire Captain.  The Fire Captain stated he arrived at the facility and found the patient on the ground surrounded by care staff pulseless and not breathing without compressions being performed.  The Fire Captain further stated the staff informed him of the CPR provided to the patient for twenty minutes and had believed heart rate was back and stopped the compression.   On 2/4/26 at 1536 hours, a telephone interview was conducted with LVN 4.  LVN 4 stated Patient 7 was unresponsive and had no pulse, and CPR was initiated immediately.  LVN 5 provided compressions while RN 3 provided breathing with the use of Ambu bag.  LVN 4 further stated they provided CPR for twenty minutes then the patient’s pulse came back, and RN 3 stated to stop the CPR while waiting for the paramedics.   On 2/4/26 at 1611 hours, a telephone interview was conducted with RN 3.  RN 3 stated she walked in Patient 7’s room with LVN 5 on the scene.  RN 3 stated Patient 7 was unresponsive and had no pulse, then LVN 5 and RN 3 initiated CPR immediately.  RN 3 stated LVN 5 provided compressions while RN 3 provided breathing with the use of Ambu bag.  RN 3 further stated the pulse was achieved prior to the fire department’s arrival at the scene.  However, RN 3 further stated Patient 7 had no blood pressure and remained unconscious.   On 2/5/26 at 0617 hours, an interview was conducted with LVN 5.  LVN 5 stated he found Patient 7 lying on the floor on the left side halfway on prone position.  LVN 5 stated Resident 7 had no pulse oximeter reading and RN 3 verified  the patient had no pulse and respiration.  LVN 5 stated he provided the compressions while RN 3 provided the breathing with the use of Ambu bag.  LVN 5 further stated they had performed CPR for 18-20 minutes then obtained a carotid pulse as confirmed by RN 3.  LVN 5 stated they stopped the compressions with the presence of carotid pulse.  LVN 5 further stated Patient 7 remained unconscious, barely breathing and did not have any blood pressure reading for approximately 5-7 minutes while waiting for the paramedics