Health inspection·November 12, 2025

F 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure quality of care and services were provided to one of three sampled residents (Resident 1) when cardiopulmonary resuscitation (CPR- an emergency lifesaving procedure performed when the heart stops beating) was not attempted by licensed staff when Resident 1 was found unresponsive on [DATE].This failure resulted in the wishes for Resident 1's Representative/ Decisionmaker (RR) not being honored and also potentially contributed to the death of Resident 1.A review of Resident 1's admission RECORD, dated [DATE], indicated Resident 1 was admitted to the facility on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (COPD- a group of lung diseases that cause persistent airflow obstruction and breathing problems that can significantly impact quality of life and life expectancy), encounter for palliative care (medical services where a patient receives care and support related to a serious or life-limiting illness), dementia (a group of conditions that cause a decline in cognitive abilities, such as memory, thinking, reasoning, and problem solving), hypertensive heart disease with heart failure (a condition where prolonged high blood pressure damages the heart muscle leading to the heart not pumping blood as well as it should).A review of Resident 1's medical record titled, [Hospice Company Name] [City Name] PHYSICIANS'S ORDER SHEET, dated [DATE], indicated, .admitted to [Hospice Company Name] under routine level of care.Code status: Full code [if a patient's heart and/or breathing stops, medical staff will perform all possible life-saving interventions, including CPR].A review of Resident 1's medical record document provided by the Hospice Company titled, Narrative Note, dated [DATE], indicated, .Code status: Full code .Primary Hospice [specialized care that provides physical comfort and emotional, social and spiritual support for people nearing the end of life] Diagnosis: Chronic Obstructive Pulmonary Disease.Reviewed Hospice philosophy, care and goals, coverage, medications. and.plan of care with family and facility staff. They Verbalized understanding of all instructions given. Consents were signed and reviewed with [RR/Decisionmaker's Name].in person. Provided [NAME] of Rights, patient's handbook with the review of emergency preparedness.to [RR/Decisionmaker's Name].A review of Resident 1's Physician Orders for Life Sustaining Treatment (POLST- portable medical orders communicating a patient's end-of-life wishes, ensuring they are known and honored by providers) dated [DATE], indicated, .First follow these orders, then contact Physician/NP [nurse practitioner]/PA [physician assistant]. A copy of the signed POLST form is a legally valid physician order .A .CARDIOPULMONARY RESUSCITATION (CPR): If patient has no pulse and is not breathing .Attempt Resuscitation/CPR .B .MEDICAL INTERVENTIONS .Full Treatment - primary goal of prolonging life by all medically effective means . Further review of Resident 1's POLST indicated that it was signed by the Resident 1's representative/decision maker (RR); the POLST form did not contain a physician's signature.A Review of Resident 1's Progress Notes titled, Nurses Note, dated [DATE], at 6:28 AM, indicated, .Resident was found unresponsive, unable to obtain v/s [vital Page 1 of 3 555080 555080 11/12/2025 Tracy Nursing and Rehabilitation Center 545 West Beverly Place Tracy, CA 95376

F 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few signs: body temperature, pulse rate, respiration rate, blood pressure, and oxygen saturation], writer and another nurse assess resident @ [at] 0545 [5:45 AM]. [Hospice Company Name] notified and arrived @ 06:15 [6:15 AM]. Resident pronounced time of death 0618 [6:18 AM]. Further review of the Nurses Note failed to show CPR was attempted for Resident 1 when he was found unresponsive.During an interview on [DATE], at 11:12 AM, with the Director of Staff Development, the DSD confirmed Resident 1's POLST indicated he was Full Code. The DSD further confirmed that CPR was not performed on Resident 1 when he was found unresponsive on [DATE]. The DSD stated that she was assigned to Resident 1 and worked the night shift on [DATE] from 11 PM through [DATE] 11 AM. The DSD explained she was working alongside LN 1 during that shift and was training her on the floor. The DSD stated LN 1 notified her upon finding Resident 1 unresponsive in Resident 1's room. The DSD further stated that she accompanied LN 1 to Resident 1's room to assess him and acknowledged that nursing staff failed to initiate CPR. The DSD stated that in her mind, Resident 1 was unresponsive, had no heartbeat, she was unable to obtain vital signs, and was a hospice patient. The DSD further stated that she should have considered Resident 1 as Full Code; regardless of the POLST not being signed by the physician. The DSD stated LN 1 should have initiated CPR when she found Resident 1 unresponsive and not breathing to honor the RR's wishes and possibly save Resident 1's life. During a phone interview on [DATE], at 12:51 PM, with LN 1, LN 1 stated she worked alongside the DSD on the night shift for [DATE] through the morning of [DATE], and she was shadowing (involves observing a professional's work, interactions, and procedures) the DSD during the shift. LN 1 further stated that Resident 1 was found unresponsive and she was unable to obtain vital signs; stating she was .Unable to find respirations, heartbeat, not breathing . LN 1 stated she left Resident 1 unattended and left the room to locate the DSD for assistance. LN 1 confirmed she did not initiate CPR when she found Resident 1 unresponsive. LN 1 stated she did not know the facility's protocol and added that she had .Concerns to revive him . LN 1 further stated that CPR should have been initiated immediately when a resident with a Full code status was found not breathing and unresponsive. LN 1 stated Resident 1's POLST specified that Resident 1's RR wished for Resident 1 to be Full Code and that those wishes should have been followed by the nursing staff. LN 1 further stated nursing staff failed to honor the RR's wishes regarding CPR for Resident 1. During a phone interview on [DATE], at 1:18 PM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated he worked the night shift on [DATE] and Resident 1 was included in his assigned group. CNA 1 further stated that he made rounds in the residents' rooms to ensure safety and that residents' needs were met. CNA 1 stated that between 3 AM and 4 AM, he observed Resident 1 asleep but was breathing. CNA 1 further stated he did not hear or observe that a Code Blue (a call for an immediate medical emergency response for a patient who is in cardiac or respiratory arrest) was called, nor did he observe CPR being performed on Resident 1 during that shift.During a phone interview of [DATE], at 2:21 PM, with CNA 2, CNA 2 stated that she also worked the night shift on [DATE] and assisted CNA 1 with providing post-mortem care (the respectful, hygienic preparation of a deceased person's body for burial, cremation, or viewing by family) for Resident 1. CNA 2 explained that in a Code Blue situation, nursing staff who were CPR-certified were expected to initiate CPR when a Full Code resident was found unresponsive. CNA 2 stated she did not note that a Code Blue was called or that CPR was initiated by licensed staff when Resident 1 was found unresponsive on [DATE].During a phone interview on [DATE], at 3:32 PM, with the (Hospice Company Name) Director of Patient Care Services (DOPCS), the DOPCS stated that the hospice nurse had discussed Resident 1's code status with Resident 1's representative (RR), and that the hospice agency had received the representative's consent for Resident 1 to be Full Code. The DOPCS further stated the RR wanted Resident 1 to be Full Code but preferred to 555080 Page 2 of 3 555080 11/12/2025 Tracy Nursing and Rehabilitation Center 545 West Beverly Place Tracy, CA 95376

F 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few avoid any hospitalization. The DOPCS stated that when a resident was considered Full Code, the facility was responsible for following its own policies and procedures related to the code status. The DOPCS confirmed the facility was aware of Resident 1's code status as it was the wish and direction of Resident 1's representative.During a concurrent interview and record review on [DATE], at 4:20 PM, with the Director of Nursing (DON), Resident 1's POLST dated [DATE], Resident 1's Nurses Note dated [DATE], at 6:28 AM, and the facility's policy and procedure (P&P) titled, Cardiopulmonary Resuscitation (CPR), dated [DATE], were reviewed. The DON confirmed Resident 1 was considered Full Code. The DON further confirmed that CPR had not been initiated for Resident 1. The DON explained the process for initiating a Code Blue, stating it was the nurse's responsibility to call a Code Blue in an emergency situation when Resident 1's code status was not Do Not Resuscitate (DNR- not to perform cardiopulmonary resuscitation if a person's heart stops or they stop breathing. It is a legal document signed by a patient or their representatives). The DON stated the process began with calling Code Blue, taking the crash cart (a wheeled container carrying medicine and equipment for use in emergency resuscitations) immediately to the resident's location, initiating CPR, while additional staff document and called emergency medical services. The DON further stated that upon admission, the nurse would explain the code status and would review the POLST form with the resident or resident representative to provide education, after which the resident or representative would make the decision and sign the POLST form which was a legal document. The DON explained that when a resident was admitted to hospice, the hospice nurse would review the POLST with the resident or representative to inform them about their rights. The DON stated there were risks involved, explaining that CPR was a life-saving intervention and outcomes depended on the down time, which could result in the resident not receiving life-saving care or receiving care that might lead to a condition the resident would not be comfortable with. The DON further stated that the time of discovery and the amount of down time were critical factors. Review of the facility P&P indicated, .Policy.Properly trained personnel will be available to provide basic life support, including cardiopulmonary resuscitation (CPR), to those requiring emergency care, prior to arrival of emergency medical personnel, and subject to accepted professional guidelines, advance directives, and physician orders.facility staff will provide basic life support, including CPR.if.absence of a valid, Do Not Resuscitate/DNR order.In a cardiopulmonary emergency, immediately initiate, code blue emergency response to facilitate additional assistance in obtaining, implementing, and activating emergency services. Facility staff should engage in concurrent/coordinated emergency response activities, to include assessing individual (i,e. quickly evaluating responsiveness, breathlessness, pulselessness, etc.), activating 911, positioning individual for CPR, initiating chest compressions and performing rescue efforts as indicated, retrieving crash cart, verifying code status, and preparing records for emergency transfer as indicated.Initiate chest compression when pulse is absent and continue until EMS arrives, patient begins moving, or consciousness is regained. The DON acknowledged that the facility's P&P was not followed by nursing staff. The DON stated her expectation was that because Resident 1 was Full Code, CPR should have been initiated immediately. The DON further stated that the decision to perform CPR was not up to the nursing staff, as Resident 1's representative had already signed the POLST indicating that Resident 1 was Full Code. 555080 Page 3 of 3