Other·March 23, 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 Patients. Based on the comprehensive assessment of a Patient, the facility must ensure that Patients receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the Patient's choices...

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 Patient safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each Patient, as determined by Patient assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's Patient 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 Patients' needs, as identified through Patient 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 Patients' needs, as identified through Patient 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 72527 (a)(8) (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (8) To be free from discrimination based on sex, race, color, religion, ancestry, national origin, sexual orientation disability, medical condition, marital status, or registered domestic partner status.

F684 Based on observation, interview, medical record review, facility document review, facility P&P (Policy & Procedure) review, and hospital Encounter Summary review, the facility failed to provide the necessary services and interventions to maintain the highest practicable well-being for one of three sampled Patients (Patient 103) reviewed for closed record. Additionally, the facility failed to ensure the licensed nursing staff possessed and demonstrated the competencies and standard-of-practice skills required to provide safe and effective care. Patient 103, who had a history of dementia, COPD (Chronic Obstructive Pulmonary Disease), aspiration pneumonia, and acute hypoxic (a state of low oxygen levels in the bodily tissues) respiratory failure, was found in respiratory distress as evidenced by thickened secretions, inability to clear the airway, desaturation to 83-85%, hypotension (low blood pressure) following deterioration, hypothermia (medical emergency when the body loses heat faster that it can produce it), and altered mentation. Despite these indicators of respiratory compromise, discomfort, and medical instability, the staff did not implement required emergency interventions or reassessment. Additionally, the facility's actions resulted in differential treatment of Patient 103 based on the patient's medical condition (COPD, dementia, respiratory failure) and DNR (Do Not Resuscitate) status. Staff repeatedly stated they did not call 911 "because he was DNR" and waited for physician or family guidance while the resident remained alive, breathing, and in distress. This resulted in denial of standard emergency care, and of conform-focused interventions, that would otherwise have been provided to similarly situated patients. The facility: 1. Failed to call emergency medical services in response to a significant and documented change in condition, including respiratory distress, oxygen saturation of 83-85% despite supplemental oxygen. The staff delayed activation of EMS (Emergency Medical Services) based on the patient's DNR status, resulting in denial of standard emergency care and palliative care. 2. Failed to initiate or escalate oxygen therapy per facility policy, including failure to place the resident on a non-rebreather mask at 10-15 L/min (liters per minute) when severe desaturation and respiratory distress were identified. 3. Failed to document the resident's condition after suctioning despite abnormal vitals requiring reassessment and monitoring. 4. Failed to ensure timely, complete, and clinically accurate notification of the physician and responsible party, including failure to report vital signs that demonstrated medical instability and need for immediate escalation of care. 5. Failed to ensure licensed nursing staff demonstrated required competencies, including recognition of a change in condition, implementation of emergency oxygen therapy, appropriate activation of EMS, and understanding the scope of a DNR order to apply only in the event of cardiopulmonary arrest. 6. Failed to ensure that the care and emergency response decisions were free from discrimination based on disability or medical condition, in violation of 22 CCR 72527 (a)(8). This was evidenced by their explanation of justification of the decision not to call 911 "because he was DNR," even though the DNR was not applicable, because the patient was still breathing and had a pulse. The withholding of standard emergency and comfort-focused care constituted disparate treatment based on the patient's medical condition and DNR code status. These failures contributed to delayed treatment, unmanaged respiratory distress and discomfort, and the patient's subsequent death. Findings: Review of the facility's P&P titled Admission, Transfer and Discharge revised 11/2016 showed when the Facility transfers or discharges a patient, the Facility shall ensure that the transfer or discharge is documented in the patient's medical record and appropriate information is communicated to the receiving health care institution or provider. The Facility shall permit each patient to remain in the Facility and not transfer or discharge the patient from the Facility unless the transfer or discharge is necessary for the patient's welfare and the patient's needs cannot be met in the facility; and the health of individuals in the Facility would otherwise be endangered. Review of the facility's Job Description for Licensed Vocational Nurse/Licensed Practical Nurse dated 12/17/21, showed the purpose of the job position is to provide primary care to specific patients under the medical direction and supervision of the patients' attending physicians or the Medical Director of the facility with emphasis on assessment, illness prevention and health care management. Further review of the Job Description showed essential duties and responsibilities which included to chart nurses' notes in professional and appropriate manner that timely, accurately, and thoroughly reflects the care provided to the Patient, as well as the patient's response to the care; chart all changes in patient condition and the response to those changes; chart all communication with the patient's attending physician regarding the patient, the patient's treatment, or the response to that treatment. Review of the facility's P&P titled Oxygen Administration Per Partial Non-Rebreathing Mask revised 4/2025 showed the purpose was to deliver high-concentration oxygen quickly to a patient with acute hypoxia (a rapid, sudden drop in tissue oxygenation causing immediate symptoms like shortness of breath, rapid breathing, confusion, and cyanosis (bluish skin)) or respiratory distress until further medical evaluation or transfer occurs. In an emergency situation, such as Code (an alert status to inform staff of the emergency services needed which may include, but not limited to, Code Blue- for cardiac/respiratory arrest, Code Red- for fire, Code Silver for active shooter or armed intruder, etc.) or life-threatening decrease in patient's oxygen level, partial non-rebreathing mask may be used without an immediate physician order. Documentation to include the date and time, oxygen liter flow (dictates the amount of supplemental oxygen delivered, usually ranging from 1 to 10 LPM (Liters Per Minute) for home use, with 2 LPM being a common starting point) patient's response to partial rebreathing mask, and oxygen saturation via pulse oximeter (a noninvasive, usually finger-clipped device that measures blood oxygen saturation and pulse rate). Review of the facility's P&P titled Change in Condition revised 4/2025 showed it is the policy of this facility to ensure each patient receives quality of care and services to attain and maintain the highest practicable physical mental and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care. The P&P included the following: - If, at any time, it is recognized by any one of the team members that the condition or care needs of the patient have changed, the Licensed Nurse or Nurse Supervisor should be made aware. Examples would be the following (but not limited to): change or a trending change in vital signs, to include temperature, pulse, blood pressure, heart rate, and oxygen saturation. - The nurse will perform and document an assessment of the patient and identify need for additional interventions, considering implementation of existing orders or nursing intervention or through communication with the patient's provider using SBAR (Situation, Background, Assessment, Recommendation-a structured, four-step communication framework used primarily in healthcare to ensure concise, accurate, and rapid exchange of information) or similar process to obtain new orders or interventions). - The patient will then be placed on the 24-Hour Report and Nursing will provide no less than three (3) days of observation, documentation, and response to any interventions. An attempt to identify the cause of decline, when it occurs, needed to assist and patient behavior/acceptance of increased need of assistance will be monitored. - The nurse will communicate the change to other departments as appropriate and updated communications will be available during morning report. - There will be certain circumstances where immediate attention will be warranted, and nursing will be responsible for notifying the appropriate department for evaluation. The nurse shall use his/her clinical judgment and shall contact the physician based on the urgency of the situation. The Medical Director shall be notified in the event that the Attending Physician or on-call Physician cannot be reached. The patient/patient representative will be notified of the change of condition and any changes in the patient's medical or nursing care. Review of the facility's P&P titled Nursing Staff Competency revised 4/2025 showed it is the policy of this facility to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure patient safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each patient, as determined by patient assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's patient population in accordance with the facility assessment required at §483.70(e) (a regulatory number assigned under Code of Federal Regulations (codification of the general and permanent rules published in the Federal Register by the departments and agencies of the Federal Government). Further review of the P&P showed the definition of competency (per CMS -Center for Medicare and Medicaid Services) as measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. Closed medical record review for Patient 103 was initiated on 1/30/26. Patient 103 was readmitted to the facility on 11/29/25, with diagnoses including aspiration pneumonia (a serious lung infection caused by inhaling foreign materials such as food, liquid, vomit, or saliva into the airways, often due to impaired swallowing or decreased consciousness) and respiratory failure (a condition in which the lungs cannot properly transfer oxygen to the blood or remove carbon dioxide). Review of Patient 103's POLST (Physician Orders for Life-sustaining Treatment) dated 11/29/25, showed do not attempt resuscitation allowing natural death with selective treatment and no artificial means of nutrition, including feeding tubes signed and dated 11/29/25, by Family Member 1 who was the patient's legal recognized decisionmaker. Review of Patient 103's H&P (History and Physical) examination dated 11/30/25, showed Patient 103 cannot make own medical decisions due to dementia (a progressive decline in memory, thinking, and behavior, often caused by damaged brain cells from diseases like Alzheimer's (a progressive neurodegenerative disorder, most common in people over 65, that destroys memory, thinking, and behavior) or vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, depriving brain cells of oxygen and nutrients). Review of Patient 103's Plan of Care showed a care plan problem initiated on 11/30/25, addressing the patient's altered respiratory status, difficulty breathing related to COPD (Chronic Obstructive Pulmonary Disease - a progressive, incurable lung disease- primarily caused by smoking that restricts airflow and makes breathing difficult), acute hypoxic respiratory failure (a critical condition defined by a low blood oxygen level), aspiration pneumonia (a serious lung infection caused by inhaling foreign materials such as food, liquid, vomit, or saliva into the airways, often due to impaired swallowing or decreased consciousness), Congestive Heart Failure- (CHF-a chronic condition where the heart pumps inefficiently, causing fluid buildup in the lungs and body) , and chronic atelectasis (partial or complete collapse of the lung). Interventions included to monitor signs and symptoms of respiratory distress and report to the MD (Doctor of Medicine) as needed for increased respirations, decreased pulse oximetry, increased heart rate, cough, pleuritic pain (sharp, stabbing chest pain that intensifies with breathing, coughing, or sneezing, caused by inflammation of the pleural lining of the lungs), accessory muscle usage, skin color changes to blue/grey. Review of Patient 103's MDS (Minimum Data Set-an assessment tool) assessment dated 12/3/25, showed Patient 103 had moderate cognitive (refers to the mental processes involved in gaining knowledge and comprehension, including thinking, knowing, remembering, judging, and problem-solving) impairment. Review of Patient 103's Change in Condition (COC) dated12/13/25 at 0530 hours, showed the facility initiated a COC for Patient 103 for thick, white phlegm in the patient's mouth. The COC documentation showed Patient 103 was observed with thick, white phlegm in the mouth and unable to spit out. Oral suction performed, obtained 200 ml (milliliters). Patient 103's blood pressure was 174/102 mmHg (normal range: top number less than 120 and lower number less than 80), heart rate was 74 (normal range: between 60 to 100 beats per minute), respiratory rate was 22 (normal range: from 12 to 20 breaths per minute) and oxygen saturation was ranging from 83% to 85% (normal range: between 95 to 100%), and Temperature 95 degrees F (Fahrenheit) (Normal range: 97-99 degrees F). MD notified. Awaiting call back. Called and left message for Emergency Contact 1, Family Member 1. Her pho