Health inspection·February 9, 2026

F684 § 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 residents’ choices, including but not limited to the following:

F726 § 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. (4) Providing care includes but is not limited to assessing, evaluating, planning, and implementing resident care plans and responding to resident's needs. Title 22 CCR 72311 (a) Nursing service shall include, but not be limited to, the following: (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. Title 22 CCR 72523 (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. Title 22 CCR 72527 (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. On 10/27/25, an unannounced visit was conducted at the facility to investigate a complaint regarding concerns about Resident 7’s quality of care. Resident 1 is a 70-year-old female who was admitted to the facility on 8/5/24 with diagnoses of Atherosclerotic Heart Disease (thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery), Personal History of Transient Ischemic Attack (Stroke), and Cerebral Infarction (a type of stroke where a blocked artery cuts off blood flow to part of the brain). Based on observation, interview, and record review, the facility failed to ensure it had sufficient nursing staff with competency to assess, recognize, escalate and properly respond to an acute neurological emergency (sudden, severe condition affecting the brain, spinal cord, or nerves that threatens life or long-term function, requiring immediate medical care) for one of seven sampled residents (Resident 7) who experienced new focal deficits (specific problem in the nervous system [brain, spinal cord, nerves]), distinct from her baseline, manifested by new right facial droop and right sided weakness. The facility staff demonstrated lack of competency concerning the scope and meaning of a POLST order (Physician Orders for Life-Sustaining Treatment is a written order which outlines the specific treatment the resident wants or does not want during a medical emergency) indicating a Do Not Resuscitate (DNR – a medical order instructing healthcare professionals not to perform cardiopulmonary resuscitation [CPR] or other heroic measures if a person’s heart stops or breathing ceases) status and additionally violated Resident 7’s rights to be free from discrimination based on her medical condition, when the Nurse Practitioner (NP) improperly refused to initiate medically appropriate emergency evaluation and transfer in response to Resident 7’s acute neurological symptoms, based solely on her DNR status. The facility failed to implement its Policy and Procedures, “Do Not Resuscitate (DNR)," dated 7/23/28, and “Change in a Resident’s Condition or Status,” dated 8/24/15, when it failed to clarify and present the decision to seek emergency care to the resident and to adhere to the resident’s wishes, and to notify the attending physician of the resident’s change in condition. These failures resulted in a delay in transferring Resident 7 to the hospital for a higher level of care for suspected acute cerebrovascular event (stroke which is a sudden disruption of blood flow to the brain causing brain cells to die leading to rapid neurological deficits), later diagnosed as a cerebrovascular accident (hemorrhagic stroke). As a result, Resident 7 experienced a delay in timely clinical evaluation and intervention, reducing the opportunity to mitigate further neurologic injury. This delay in care directly contributed to Resident 7’s functional decline in mobility, decline in ability to feed self, decline in ability to provide self with oral care, decline in ability to toilet self, decline in ability to shower and/or bathe self, decline in ability to dress upper and lower body, decline in ability to put on footwear, decline in ability to provide self with personal hygiene, and decline in ability to walk. Findings: During a review of Resident 7’s MDS (Minimum Data Set - a standardized assessment to evaluate a resident’s functional abilities and healthcare needs) Assessment, dated 8/5/25, under the section titled, “Brief Interview for Mental Status (BIMS - an assessment of cognition [how well a person thinks, processes and thinks] with scores ranging from 0 – 15 with the higher the score the more intact their cognition is),” the BIMS score was 15 (cognition intact). During a concurrent observation and interview on 10/27/25 at 1:21 p.m. with Resident 7 in the resident room, Resident 7 was observed in her wheelchair with her right side of face drooping. Resident 7 stated on the evening (no specific time provided) of 10/10/25 she started to experience slurred speech and right sided body weakness (change from her normal baseline status). She informed staff (no specific staff identified) that she was having a stroke. Resident 7 stated staff (no specific staff identified) called the Nurse Practitioner (NP - a registered nurse with a graduate degree who provides advanced healthcare, including diagnosing and treating illnesses, ordering and interpreting tests, and prescribing medication) who instructed the staff to place Resident 7 back in bed and just monitor. Resident 7 stated, “I had cried and yelled for help telling them I’m having a stroke, and they (no specific staff identified) said okay and put me in bed. I don’t think that was right because [NP] said he was not going to do anything about it because I am a DNR (Do not resuscitate - a medical order written by a health care provider which instructs providers not to perform CPR [cardiopulmonary resuscitation- an emergency life-saving procedure that is done when someone's breathing or heartbeat has stopped] if a patient's breathing stops or if the patient's heart stops beating).” During an interview on 11/25/25 at 9:05 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she was assigned to Resident 7 on 10/10/25 during the night shift (10/10/25 7 p.m. to 10/11/25 7 a.m.) when Resident 7 complained of right sided weakness and difficulty speaking. LVN 2 stated Resident 7 was stating she was having a stroke, and the right side of her body was having spasms (painful cramps from the tightening of muscles). LVN 2 stated she observed Resident 7 with difficulty speaking and new onset right sided weakness. LVN 2 stated she called the NP regarding Resident 7’s worsening condition and he instructed her to place Resident 7 back in bed and make her comfortable because Resident 7 had these types of issues (stroke) in the past. LVN 2 stated she was told by NP, there was nothing that could be done about Resident 7’s change in condition because she had a DNR order. LVN 2 stated, “I wish I can [sic] take her [Resident 7] to ED [Emergency Department] but that was his [NP] orders. He [NP] never came to see her after I [LVN 2] called. . . She [Resident 7] is a DNR, but she was not needing resuscitation, she [Resident 7] was needing advanced level of care and assessment.” LVN 2 stated she did not pursue any further action after notifying NP of Resident 7’s physical change of condition including not calling the Medical Doctor (MD). During an interview on 11/25/25 at 2:16 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was assigned to care for Resident 7 on 10/10/25 during the night shift (CNA shift is from 6:30 p.m. to 7 a.m.). CNA 1 stated at the beginning of her shift (6:30 p.m.) Resident 7 was smiling and happy, and able to move about the facility as well as her room using both legs and left arm in her wheelchair. CNA stated at approximately 9:30 p.m. she heard what sounded like a loud cry for help from Resident 7’s room. CNA 1 stated she entered Resident 7’s room and noticed immediately Resident 7’s right side of face and body were noticeably drooping more than her normal. CNA 1 stated, “[Resident 7’s] face looked like it was hanging, her mouth was hanging, and she was drooling (not her normal status),” CNA 1 stated she immediately notified LVN 2 about Resident 7’s condition and LVN 2 called NP. CNA 1 stated she was instructed to place Resident 7 back in bed. CNA 1 stated it took three staff members (not identified) to place Resident 7 back into bed. CNA 1 stated prior to this incident Resident 7 was able to place herself back to bed without assistance. CNA 1 stated LVN 2 had told her the NP would be in later in the night to assess Resident 7. CNA 1 stated NP never came by to assess Resident 7. CNA 1 stated she was upset that the NP never came to see Resident 7 and that nothing was done for Resident 7’s change in condition other than placing her in bed. During an interview on 11/26/25 at 10 p.m. with NP, NP stated he was working in the facility on 10/10/25 (date of Resident 7’s change of condition) in a different department. NP stated LVN 2 called him regarding Resident 7’s change of condition. NP stated from previous discussions he had with Resident 7, Resident 7 did not want any advanced type of care and that she was a DNR, so he instructed LVN 2 to monitor Resident 7. NP stated he was unaware Resident 7 could receive medical treatment without restrictions. NP stated he did not recall if he told LVN 2 he would see Resident 7 on 10/10/25. NP stated he was not aware nor made aware by the facility staff that Resident 7 was willing to go to the ED. NP stated had he been made aware of this, he would have instructed staff to ask Resident 7 if she wanted to be transferred to the ED and proceeded with care based on the resident’s decision. During an interview on 12/1/25 at 1:02 p.m. with Director of Nursing (DON), DON stated a resident with a DNR order does not prohibit the facility from assessing and treating the resident for medical conditions. DON stated a resident with a DNR order does not prevent them from being transferred to the Emergency Department for further care and/or treatment/assessment. During an interview on 12/8/25 at 12:48 p.m. with Medical Doctor (MD), MD stated he did not receive a call regarding Resident 7’s change of condition on the night of 10/10/25. MD stated staff are aware he is available for calls or text messages regarding residents twenty-four hours a day, seven days a week. MD stated if he had received a call concerning Resident 7’s change of condition he would have asked the staff to review her “POLST” and ask Resident 7 what type of further care she would allow to happen, then make decisions based on the resident’s responses. If Resident 7 stated she wanted further care when questioned, then he would have pursued the appropriate treatment per her request. MD stated if staff were concerned about NP’s response to Resident 7’s condition, the staff were aware they could have called him for further instructions/clarification. During a review of Resident 7’s “TRANSFER/DISCHARGE REPORT (TDR),” dated 10/27/25, the TDR indicated, Resident 7 admitted to the facility on 8/5/24 with a diagnosis of personal history of Transient Ischemic attack (TIA – a temporary blockage of blood flow to the brain) and Cerebral Infarction (also known as a stroke, it is when blood flow to the brain is stopped, which can result in slurred speech, movement difficulties to one or both sides of the body, numbness, confusion, headache). The TDR indicated Resident 7 was taking amlodipine (medication for high blood pressure [BP -the pressure of blood as your heart pumps blood through the body. A normal blood pressure is 120/80 millimeter of Mercury [mmHG – a unit of measurement]) 5 milligrams (mg – a unit of measurement) for hypertension (high BP - which can cause a heart attack, stroke and other medical complications), Lasix (medication for high BP) 40 mg, and carvedilol (medication for high BP) 3.125 mg. During a review of Resident 7’s MDS Assessment, dated 8/5/25, under the section titled, “GG (assesses functional abilities and goals),” the GG section indicated Resident 7 required the following: a. Set up or clean up assistance with eating b. Set up or clean up assistance with oral hygiene c. Set up or clean up assistance with toileting d. Independently able to shower and/or bathe herself e. Independently able to dress her upper and lower body f. Independently able to put on/take off footwear g. Set up or clean up assistance with personal hygiene h. Independently able to turn left and right, move from sitting to lying position, move from lying to sitting position in bed, move from a sitting to standing position, move from bed to chair or chair to bed, move herself on and off the toilet, move self in and out of shower and/or tub, walk 50 feet (ft - a unit of measurement) with two turns, and walk 150 feet. During a review of Resident 7’s “Physician Orders for Life-Sustaining Treatment, (POLST)” dated 8/5/24, the POLST indicated, Resident 7 signed the POLST on 8/5/24 and NP signed the POLST on 8/6/24 acknowledging Resident 7 did not want to be resuscitated (the act of reviving someone from unconsciousness or apparent death, typically by restoring breathing or heartbeat) but did want selective treatment with a goal of treating medical conditions while avoiding burdensome measures (not defined or specified). The medical treatments Resident 7 agreed to included: medical treatment, Intravenous (IV – into or within the vein) antibiotics (medication for infections), IV fluids, use of non-invasive airway pressure (delivery of oxygen into the lungs), and artificial nutrition (a method of providing nutrition). During a review of Resident 7’s “Care Plan Report (CP),” dated 8/12/24, the CP indicated, Resident 7 had a history of stroke with right sided weakness. The CP indicated the goal was for Resident 1 to be independent with most ADLs (activities of daily living - Basic routine tasks that most healthy individuals can perform without assistance, these activities include bathing, dressing, walking, eating, using the toilet and transferring positions). Interventions for Resident 7’s stroke with right sided weakness included calling the MD as needed. During a review of Resident 7’s “Progress Notes (PN),"