Tracy Nursing And Rehabilitation Center
Inspection Findings
F-Tag F0678
F 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
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 REDACTED], at 4:20 PM, with the Director of Nursing (DON), Resident 1's POLST dated [DATE REDACTED], Resident 1's Nurses Note dated [DATE REDACTED], at 6:28 AM, and the facility's policy and procedure (P&P) titled, Cardiopulmonary Resuscitation (CPR), dated [DATE REDACTED], 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.
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TRACY NURSING AND REHABILITATION CENTER in TRACY, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in TRACY, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from TRACY NURSING AND REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.