Northern Colorado Rehabilitation Hospital, Inc.

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 52287 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.13 Patient’s Rights was out of compliance. A-0144 The patient has the right to receive care in a safe setting. Based on interviews and document reviews, the facility failed to ensure patients received care in a safe setting. Specifically, the facility failed to ensure staff identified and addressed patients’ changes in condition in three of five medical records reviewed for patients who experienced changes in condition (Patient #1, #2, and #5). Additionally, the facility failed to ensure the rapid response team was notified when changes in condition occurred in three of five medical records reviewed for patients who experienced changes in condition. (Patient #1, #3, and #5)”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 52287 Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.21 Quality Assessment and Performance Improvement Program, was out of compliance. A-0283 The hospital must use the data collected to (ii) identify opportunities for improvement and changes will lead to improvement. (1) The hospital must set priorities for its performance improvement activities-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success and track performance to ensure improvements are sustained. Based on interviews and document reviews, the quality assurance and performance improvement (QAPI) program failed to identify opportunities for improvement in high-risk, problem-prone areas, and failed to ensure interventions were implemented and monitored for effectiveness to ensure the safety of services and quality of care. (Cross-reference A-0144)”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 52287 Based on interviews and document reviews, the facility failed to ensure patients received care in a safe setting. Specifically, the facility failed to ensure staff identified and addressed patients’ changes in condition in three of five medical records reviewed for patients who experienced changes in condition (Patient #1, #2, and #5). Additionally, the facility failed to ensure the rapid response team was notified when changes in condition occurred in three of five medical records reviewed for patients who experienced changes in condition. (Patient #1, #3, and #5) Findings include: Facility policies: The Reassessment policy read, patients at the hospital receive care based upon a documented assessment of patient care needs and problem identification. In order to achieve this goal, data is collected to identify problems and assess the needs of the patient. The data is analyzed to establish the plan of care. Decisions are made regarding patient care or treatment based on analysis of the data. A patient’s need for care related to his/her admission is assessed by a nurse. Patient needs, response to treatments/interventions, and change in condition or diagnosis are evaluated as necessary. The registered nurse (RN) will perform reassessment and will direct patient care through a variety of mechanisms, including notification of the change to the physician, changes to the plan of care, and other interventions based on the patient’s needs. The inpatient is reassessed periodically by members of the treatment team routinely. Nursing patients presenting with emergent conditions. Emergent conditions are reassessed every fifteen minutes until transfer to the appropriate level of care is complete. Patients will also have reassessments when changes occur in condition and/or diagnosis. The Rapid Response Team (RRT) policy read, the purpose is to ensure the RRT is available to efficiently assess and implement clinical care to patients and/or visitors who are in need of clinical care assistance, by providing basic life support, additional staffing, and operational resources to clinical staff. Any member of the hospital staff who has witnessed or determined a patient in need of clinical care assistance may initiate the request for a RRT. If the patient’s situation is critical, initiate the Code Blue Team. Procedure: Initiation of a RRT, immediate assessment by a registered nurse and interventions may be initiated based on nurse assessment, if indicated, while calling the physician. Patient indicators and criteria may include, however, are not limited to, change in mental status or level of consciousness, respiratory rate of less than 8 breaths/minute, oxygen saturation less than 90% while resting on oxygen, acute change in heart rate to less than 50 beats per minute (bpm) or more than 130 bpm, acute change in systolic (pressure in the arteries when the heart is beating) blood pressure to less than 90 mmHg (millimeters of mercury) or greater than 190 mmHg, with inadequate response to previous interventions or treatment. Any member of the hospital staff who finds an individual in need of immediate assistance will overhead page the request for the RRT to the location. Reference: The Medical Staff Rules and Regulations read, all members of the health care team have a duty to advocate for the patient through the organizational chain of command when they have concerns about the patient’s condition they believe are not being adequately addressed or they have concerns about decisions being made in the care of the patient. 1. The facility failed to ensure staff identified and addressed patients’ changes in condition. a. A review of Patient #5’s medical record revealed Patient #5 had been admitted on 4/29/25 for rehabilitation after septic shock (a life-threatening, advanced stage of sepsis where a body-wide infection causes extremely low blood pressure (hypotension) and dangerous, widespread organ dysfunction) and bacteremia cholangitis (severe infection of the bile duct). Review of Patient #5’s vital signs revealed, on 4/30/25 at 2:55 p.m., Patient #5 had a shock index of 1.1 (a clinical tool used to detect early shock, calculated by dividing the heart rate by the top number of the blood pressure). The shock index flow sheet revealed a normal shock index was 0.5 to 0.7 and read, if the shock index was above 1.0, staff should have initiated an RRT and called the physician. The medical record failed to reveal a nursing assessment performed until 5:04 p.m., approximately two hours later. The medical record also failed to reveal a provider had been notified for Patient #5’s shock index of 1.1. This was in contrast to the shock index flow sheet, which revealed the physician should have been notified for a shock index above 1.0. This was also in contrast to the Reassessment policy, which read, patients received care based upon a documented assessment of patient care needs and problem identification. Decisions were made regarding patient care or treatment based on analysis of the data. Patients were to be reassessed when changes in condition occurred. The RN performed reassessment and directed patient care through a variety of mechanisms, including notification of the change to the physician. On 5/5/25 at 11:11 a.m., an occupational therapy (OT) note revealed Patient #5’s heart rate, measured on the pulse oximeter (measures the level of oxygen in the blood) during the therapy session, read between 36 bpm and 250 bpm (normal is 60-100). The OT note indicated Patient #5 was pale with increased tremors. Patient #5’s heart rate remained at 238 bpm for the next two minutes, and then decreased to 111 bpm. There was no evidence a nurse or provider had been notified of Patient #5’s change in condition. This was in contrast to the Reassessment policy, which read, patients at the hospital received care based upon a documented assessment of patient care needs and problem identification. Patients were to be reassessed when changes in condition occurred. Review of a nursing note from 5/9/25 at 1:30 p.m. revealed Patient #5 was lethargic (sluggish), complained of pain, and their blood pressure had dropped to the 80s. Between 1:30 p.m. and 11:30 p.m., sodium chloride 1,000 ml, and an additional 500 ml sodium chloride bolus, was administered intravenously (IV) for low blood pressure. Review of Patient #5’s vital signs at 4:00 p.m. revealed Patient #5 had a shock index of 1.3, and at 7:28 p.m., had a shock index of 1.1. The medical record failed to reveal a provider had been notified of the abnormal shock index results. This was in contrast to the shock index flow sheet, which revealed the physician should have been notified for a shock index above 1.0. The medical record failed to reveal a nursing assessment was performed until 7:08 p.m., approximately three hours later. This was in contrast to the Reassessment policy, which read, patients at the hospital received care based upon a documented assessment of patient care needs and problem identification. Decisions were made regarding patient care or treatment based on analysis of the data. Patients were to be reassessed when changes in condition occurred. The RN performed reassessment and directed patient care through a variety of mechanisms, including notification of the change to the physician. Review of transfer documentation revealed, on 5/10/25 at 4:00 a.m., Patient #5 had experienced altered mental status, a low blood glucose (sugar), and staff were unable to measure Patient #5’s blood pressure. Patient #5 was transferred to the hospital and died. b. A review of Patient #2’s medical record revealed Patient #2 had been admitted to the facility on 11/15/25 for postoperative care after a right tibia/fibula (lower leg bones) open reduction and internal fixation (ORIF) surgery (surgery to repair broken bones). Patient #2 had a history of pulmonary embolism (PE- a blood clot in the lung) and Factor V Leiden (an inherited genetic mutation which increases blood clotting risk). Patient #2 had been treated with an anticoagulant medication (decreases blood clotting) for these conditions. The RN admission assessment completed on 11/15/25 revealed Patient #2 scored a six on the deep vein thrombosis (DVT-blood clot formed in a deep vein in the body) risk assessment. According to the medical record, a DVT score greater than three required nursing staff to notify the provider. The medical record further revealed on 11/16/25, Patient #2 had been assessed by a provider. The provider’s progress note revealed there had been a concern from nursing staff for DVT and Patient #2’s right calf discomfort. The provider’s assessment revealed Patient #2 had swelling and tenderness on the side of the calf. Although nursing, provider, and pain assessments revealed Patient #2 continued to have pain and swelling to the right calf, knee, and leg daily, there was no evidence in the medical record Patient #2’s concern had been escalated to the provider by nursing staff or addressed by the provider over the next 4 days. This was in contrast to the Medical Staff Rules and Regulations, which read, all members of the health care team had a duty to advocate for the patient when they had concerns about the patient’s condition they believed had not been adequately addressed, or they had concerns about decisions made in the care of the patient. This was also in contrast to the Reassessment policy, which read, the RN performed reassessment and directed patient care through a variety of mechanisms, including notification of the change to the physician, changes to the plan of care, and other interventions based on the patient’s needs. On 11/21/25, provider documentation revealed Patient #2’s swelling to the right leg had not improved, and an ultrasound (imaging used to detect blood flow in the veins) was ordered, which revealed a DVT in the right popliteal (behind the knee) vein. c. A review of Patient #1’s medical record revealed Patient #1 had been admitted to the facility on 11/26/25 for oxygen therapy and postoperative care after mitral valve (a critical piece of the heart located on the left side, ensuring one-way blood flow to the body) surgery. Nursing documentation revealed, on 11/30/25 at 10:41 p.m., Patient #1 experienced slurred speech, had a crooked smile, and left-sided facial drooping. Patient #1 was assisted to the bedside and assessed by a nurse. Patient #1’s oxygen saturation (the amount of oxygen in the blood) was 84% (normal is 95% - 100%), staff then removed the oxygen tubing from the wheelchair tank and connected the tubing to the wall connection. Patient #1’s oxygen saturation then improved to 93%, their speech became clear, and their smile returned to normal. Nursing staff documented Patient #1 would be monitored and assessed throughout the night. There was no evidence in the medical record a provider had been notified of Patient #1’s change in condition. The medical record also failed to reveal a focused assessment to rule out stroke (when the blood supply to part of the brain is blocked, reduced, and/or the brain has less oxygen available) had been performed for Patient #1. In addition, there was no evidence Patient #1 had been monitored and assessed throughout the night. This lack of assessment was in contrast to the Reassessment policy, which read, patients received care based upon a documented assessment of patient care needs and problem identification. The RN reassessed and directed patient care through a variety of mechanisms, including notification of the change to the physician. This was also in contrast to an interview with Patient #1’s physician, Provider #6, conducted on 2/19/26 at 2:00 p.m., who stated a provider should have been notified immediately to assess for neurological deficits. The provider’s discharge summary revealed, on 12/2/25, Patient #1 had a surgical follow-up appointment outside of the facility. At the appointment, Patient #1 had a left-sided facial droop and was sent emergently to the emergency department. d. An interview was conducted on 2/18/26 at 6:37 p.m. with RN #2. RN #2 stated it was important to reassess patients to ensure interventions were effective. RN #2 also stated it was important to assess patients with complaints of facial drooping and slurred speech to ensure they received immediate treatment. RN #2 stated nurses were trained to know the signs and symptoms of a stroke, and were unaware of education provided by the facility for stroke recognition. RN #2 further stated the RN needed to notify the provider after assessing a patient who had experienced changes in condition in case the patient required transfer to the hospital. e. An interview was conducted on 2/18/26 at 7:12 p.m. with RN #3. RN #3 stated abnormal changes in condition included changes in a patient’s breathing pattern, difficulty breathing, mental status changes, and stroke symptoms. RN #3 further stated a provider needed to be notified of any abnormal change in a patient’s condition. f. An interview was conducted on 2/23/26 at 12:57 p.m. with RN #4. RN #4 stated patients at the facility were at increased risk for changes in condition due to their current stage of illness, post-surgical risk, and decreased mobility. RN #4 stated it was important to identify any symptoms early and to notify the provider so interventions could be initiated to decrease any harm to the patient. These interviews were in contrast to the medical reviews for Patients #1, #2, and #3, which revealed changes in condition had occurred, and their providers had not been notified. g. An interview was conducted on 2/23/26 at 2:08 p.m. with charge RN #5. RN #5 stated a score of six on the DVT risk assessment signified the patient had a high risk for DVT. RN #5 stated an untreated DVT could have resulted in a loss of limb or PE. RN #5 stated a patient with a previous diagnosis of PE was at increased risk for further blood clots. This was in contrast to the medical record review, which revealed Patient #2 had a history of PE, scored six on DVT scale, and was not diagnosed with a DVT until five days after their symptoms were first reported. h. An interview was conducted on 2/19/26 at 2:00 p.m. with medical provider (Provider) #6. Provider #6 stated the provider should have been notified anytime a patient had a change in condition. Provider #6 stated staff should have immediately notified a provider to assess for neurological deficits when Patient #1 experienced a change in condition. 2. The facility failed to ensure the rapid response team was notified when changes in condition occurred. a. A review of Patient #5’s medical record revealed Patient #5 had been admitted on 4/29/25 for rehabilitation after septic shock and bacteremia cholangitis. Review of Patient #5’s medical record revealed, on 4/30/25 at 2:55 p.m., Patient #5 had a shock index of 1.1. The shock index flow sheet revealed a normal shock index was 0.5 to 0.7 and read, if the shock index was above 1.0, staff should have initiated an RRT. There was no evidence an RRT had been initiated for the shock index of 1.1. On 5/5/25 at 11:11 a.m., an OT note revealed Patient #5’s heart rate, measured on the pulse oximeter during the therapy session, read between 36 bpm and 250 bpm. The OT note indicated Patient #5 was pale with increased tremors. Patient #5’s heart rate remained at 238 bpm for the next two minutes, and then decreased to 111 bpm. There was no evidence an RRT had been initiated. This was in contrast to the RRT policy, which read, any staff member who witnessed or determined a patient in need of clinical care assistance could initiate the request for an RRT. Patient indicators included an acute change in heart rate, less than 50 bpm, or more than 130 bpm. Review of Patient #5’s vital signs revealed, on 5/9/25 at 8:26 a.m., Patient #5 had a blood pressure of 73/53, and at 2:27 p.m., had a blood pressure of 86/64. A nursing note from 5/9/25 at 1:30 p.m. revealed Patient #5 was lethargic and their blood pressure had dropped to the 80s. Further review of Patient #5’s vital signs at 4:00 p.m. revealed Patient #5 had a shock index of 1.3, and at 7:28 p.m., had a shock index of 1.1. There was no evidence an RRT had been initiated. This was in contrast to the shock index flow sheet, which revealed an RRT should have been initiated for a shock index above 1.0. This was also in contrast to the RRT policy which read, an RRT should have been initiated for a blood pressure less than 90 mmHg with inadequate response to previous interventions. Review of transfer documentation revealed, on 5/10/25 at 4:00 a.m., Patient #5 had experienced altered mental status, a low blood glucose, and staff were unable to measure Patient #5’s blood pressure. Patient #5 was transferred to the hospital and died. b. A review of Patient #3’s medical record revealed Patient #3 had been admitted to the facility on 12/9/25 for postoperative care after a lumbar spine compression fracture (a break in one of the lower back bones). Patient #3 required the use of high-flow oxygen and used a wheelchair for mobility. Nursing documentation revealed, on 12/17/25 before 10:00 p.m., a patient care technician (PCT) assisted Patient #3 to the bathroom. When the PCT returned to the bathroom, Patient #3 was weak and unable to stand or transfer into the wheelchair. The PCT transferred Patient #3 into the wheelchair, but was unable to transfer Patient #3 back into the bed. The PCT left the room, and informed an RN Patient #3 appeared weaker, heavier, and had blue lips and fingers. Staff were unable to obtain an oxygen saturation for Patient #3. With the help of another PCT and RN, staff transferred Patient #3 into the bed. Patient #3 experienced decreased responsiveness, a blue nose, blue lips, blue hands, and agonal respirations (irregular, gasping breaths). Staff determined Patient #3 did not have a pulse, activated the emergency response button, and began cardio-pulmonary resuscitation (CPR). Staff found Patient #3 had a do-not-resuscitate (DNR) order, and rescue efforts were then stopped. Patient #3 died at 10:15 p.m. This was in contrast to the RRT policy, which read, any member of the hospital staff who found an individual in need of immediate assistance would overhead page the request for the RRT to the location. A change in mental status or level of consciousness indicated initiation of an RRT. c. A review of Patient #1’s medical record revealed Patient #1 had been admitted to the facility on 11/26/25 for oxygen therapy and postoperative care after mitral valve surgery. Nursing documentation revealed, on 11/30/25 at 10:41 p.m., Patient #1 experienced slurred speech, had a crooked smile, and left-sided facial drooping. There was no evidence an RRT had been initiated for Patient #1’s change in condition. This was in contrast to the interview with charge RN #5 on 2/23/26 at 2:08 p.m., who stated although Patient #1’s symptoms had resolved, they were still at risk for a transient ischemic attack (TIA- a temporary blockage of blood flow to the brain, a medical emergency which indicates a high risk for a major stroke). RN #5 further stated patients could suffer permanent neurological damage if staff did not initiate an RRT and further evaluate the patient. The provider’s discharge summary revealed, on 12/2/25, Patient #1 had a surgical follow-up appointment outside of the facility. At the appointment, Patient #1 had a left-sided facial droop and was sent emergently to the emergency department. d. An interview was conducted on 2/18/26 at 5:50 p.m. with PCT #1. PCT #1 stated they were unsure of what a rapid response was, and it was standard practice to leave the patient to notify a nurse if a change in status occurred. This was in contrast to the RRT policy, which read, any staff member who witnessed a patient in need of clinical care assistance could initiate an RRT. PCT #1 further stated the emergency response button was only activated when a patient was in danger, or experienced a fall, bleeding, or death. PCT #1 stated the call light was activated if staff could not leave the room and required assistance. PCT #1 stated, although they had received computer-based training on RRTs, they did not know how to initiate an RRT. e. An interview was conducted on 2/18/26 at 6:37 p.m. with RN #2. RN #2 stated rapid responses were only initiated when patients were unconscious and pulseless. RN #2 stated rapid responses were not initiated at night. RN #2 further stated treatment could be delayed and patients’ lives were at risk if RRTs were not initiated when patients’ symptoms began. f. An interview was conducted on 2/18/26 at 7:12 p.m. with RN #3. RN #3 stated rapid responses were initiated to get staff, support, and needed equipment into the room to assist the patient. RN #3 stated rapid response training was important and cemented staffs’ reactions for what needed to be done during an emergency. g. An interview was conducted on 2/23/26 at 2:08 p.m. with charge RN #5. RN #5 stated RRTs were initiated for all patients with stroke symptoms. RN #5 further stated Patient #1 was at risk for a TIA even though their symptoms had resolved. RN #5 stated a patient could suffer permanent neurological damage if staff did not initiate an RRT and further evaluate the patient. h. An interview was conducted on 2/24/26 at 9:35 a.m. with clinical nurse educator (Educator) #7. Educator #7 stated rapid response training was conducted during orientation, annually, and monthly drills were performed. Educator #7 further stated rapid response and code blue drills were conducted to ensure staff knew their roles and responsibilities when actual events occurred. Educator #7 stated patients could die if staff were not trained to initiate rapid responses and code blues. This was in contrast to the interview with PCT #1, who stated they did not know how to initiate an RRT. This was also in contrast to the interview with RN #2, who stated RRTs were not initiated at night, and were only initiated when patients were unconscious and pulseless.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 52287 Based on interviews and document reviews, the quality assurance and performance improvement (QAPI) program failed to identify opportunities for improvement in high-risk, problem-prone areas, and failed to ensure interventions were implemented and monitored for effectiveness to ensure the safety of services and quality of care. (Cross-reference A-0144) Findings include: Facility policies: The Rapid Response Team (RRT) policy read, the purpose is to ensure the RRT is available to efficiently assess and implement clinical care to patients and/or visitors who are in need of clinical care assistance, by providing basic life support, additional staffing, and operational resources to clinical staff. The Performance Improvement Plan (PIP) policy read, this PIP promotes the mission of the hospital by establishing a formal, organization-wide system to monitor and continuously improve patient outcomes, patient safety, and hospital services. This plan will be used by each employee of the hospital to continually monitor and improve the processes they perform, with the goal to improve the quality of care, provide for a safe environment for patients, visitors, and staff while satisfying our patients. Guiding principles of the plan: Data is to be collected including patient care data and other relevant data to monitor the effectiveness and safety of services and quality of care while identifying opportunities for improvement and changes which will lead to improvement. Objectives: To improve the quality of patient care using a robust comprehensive systems approach to assess and evaluate the functions, processes and outcomes affecting patient care while minimizing individual blame or retribution for involvement in unanticipated adverse events; to communicate performance improvement activities, findings, actions and the effectiveness through a system of communication that reaches all aspects of the hospital; to prioritize performance improvement activities that focus on high-risk, high-volume, or problem prone areas, consider the incidence, prevalence, and severity of problems in those areas, and those that affect health outcomes, patient safety, and quality of care; to identify safety/risk areas and potential safety/risk processes prior to any unanticipated adverse outcome or data. The Sentinel Event (SE)/Root Cause Analysis (RCA)/Colorado Department of Public Health and Environment (CDPHE) reporting policy read, the RCA process is part of QAPI. While the investigation and data collection is performed in any unusual occurrence, further analysis of processes and systems may reveal issues which may cause further injury or future medical errors. RCA is a process for identifying the basic or causal factors which identify underlying variations in performance, including the occurrence or possible occurrence of a sentinel event. An RCA identifies potential improvements in processes or systems which would tend to decrease the likelihood of such events in the future. An action plan that identifies the strategies which will be implemented in order to reduce the risk of similar events occurring in the future will be developed at the conclusion of the analysis. The plan will address the responsibility for implementation, oversight, pilot testing as appropriate, time frames for implementation, and strategies for ensuring the effectiveness of actions. 1. The QAPI program failed to identify opportunities for improvement in high-risk, problem-prone areas, and failed to ensure interventions were implemented and monitored for effectiveness to ensure the safety of services and quality of care. A. Document Review i. A review of Patient #4’s medical record revealed Patient #4 had been admitted on 4/18/25 for rehabilitation post revascularization (a procedure to restore blood flow) of the right lower leg. On 4/25/25 at 8:00 a.m., Patient #4 experienced acute hypoxia (sudden, low oxygen levels) and was emergently transferred to the hospital. An RCA review for Patient #4 revealed rapid response team (RRT) activation was delayed for 12 minutes after Patient #4 experienced a change in condition. RCA review further revealed clinical staff caring for Patient #4 had been educated on initiating RRTs without delay; however, there was no evidence of the education provided to staff or a further action plan in the RCA. ii. A review of Patient #5’s medical record revealed Patient #5 had been admitted on 4/29/25 for rehabilitation after septic shock (a life-threatening, advanced stage of sepsis where a body-wide infection causes extremely low blood pressure (hypotension) and dangerous, widespread organ dysfunction) and bacteremia cholangitis (severe infection of the bile duct). On 5/10/25 at 4:00 a.m., Patient #5 experienced altered mental status, a low blood glucose (sugar), and staff were unable to measure Patient #5’s blood pressure. Patient #5 was transferred to the hospital and died. An RCA review revealed the facility identified Patient #5 had experienced a change in condition on 5/5/25 and 5/9/25. The review revealed staff had not called an RRT either time. There was no evidence of an action plan developed in response to the event. iii. A review of Patient #3’s medical record revealed Patient #3 had been admitted to the facility on 12/9/25 for postoperative care after a lumbar spine compression fracture (a break in one of the lower back bones). On 12/17/25, Patient #3 experienced Patient #3 experienced decreased responsiveness, a blue nose, blue lips, blue hands, agonal respirations (irregular, gasping breaths), and died. An RCA review revealed the facility identified staff had not initiated an RRT for Patient #3. There was no evidence of an action plan developed in response to the event. iv. On 2/24/26 at 1:22 p.m., upon request, the facility was unable to provide evidence of RRT education provided to staff, or action plans developed in response to the events for Patient #4, Patient #5, or Patient #3. The failure to identify opportunities for improvement or implementation of PI projects to ensure patient safety and quality of care was in contrast to the SE/RCA/CDPHE reporting policy, which read, an RCA identified potential improvements in processes or systems which tended to decrease the likelihood of such events in the future. An action plan, which identified the strategies to be implemented in order to reduce the risk of similar events occurring in the future, would be developed at the conclusion of the analysis. The plan would address the responsibility for implementation, oversight, time frames for implementation, and strategies to ensure the effectiveness of actions. This was also in contrast to the PIP policy which read, the plan would be used to continually monitor and improve the processes they performed, with the goal to improve the quality of care and provide for a safe environment for patients. Data was to be collected, including patient care data and other relevant data to monitor the effectiveness and safety of services and quality of care, while opportunities were identified for improvement and changes which led to improvement. Additionally, the PIP policy read, the objectives were to improve the quality of patient care using a robust comprehensive systems approach to assess and evaluate the functions, processes and outcomes affecting patient care; to communicate performance improvement activities, findings, actions and the effectiveness through a system of communication; to prioritize performance improvement activities which focused on high-risk, or problem prone areas, considered the incidence, prevalence, and severity of problems in those areas, and those that affected health outcomes, patient safety, and quality of care; to identify safety/risk areas and potential safety/risk processes prior to any unanticipated adverse outcome or data. B. Interviews i. An interview was conducted on 2/18/26 at 5:50 p.m. with patient care technician (PCT) #1. PCT #1 stated they were unsure of what a rapid response was. PCT #1 further stated the emergency response button was only activated when a patient was in danger, or experienced a fall, bleeding, or death. PCT #1 stated, although they had received computer-based training on RRTs, they did not know how to initiate an RRT. ii. An interview was conducted on 2/18/26 at 6:37 p.m. with registered nurse (RN) #2. RN #2 stated rapid responses were only initiated when patients were unconscious and pulseless. RN #2 stated rapid responses were not initiated at night. RN #2 further stated treatment could be delayed and patients’ lives were at risk if RRTs were not initiated when patients’ symptoms began. iii. On 2/24/26 at 4:37 p.m., an interview was conducted with the chief nursing officer (CNO) #8. CNO #8 stated the purpose of an RCA was to identify processes, causes, and performance issues that occurred during events, and to identify opportunities for improvement. CNO #8 stated their role during an RCA was to focus on what educational opportunities could be provided to staff. CNO #8 stated education was provided to staff after the RCA for Patient #4, although the education and who had received the education was not documented. CNO #8 stated the RCAs for Patients #3 and #5 had also identified the need for RRT training for all staff. CNO #8 stated they had educated staff, however they had not tracked which staff received the education, nor monitored the effectiveness of the education provided. CNO #8 stated it was important for all staff to be educated on safety concerns identified during RCAs to improve patient outcomes. CNO #8’s statement they had educated was in contrast to the interview with PCT #1, who stated they did not know how to initiate an RRT, and in contrast to the interview with RN #2, who stated RRTs were not initiated at night and were only initiated when patients were unconscious and pulseless. iv. On 2/25/26 at 10:55 a.m., an interview was conducted with the director of compliance (DOC) #9. DOC #9 stated the purpose of quality was to ensure patients were cared for in a safe environment. DOC #9 stated the purpose of performance improvement was to improve patient outcomes by monitoring processes, collecting data, and implementing a plan when changes were needed. DOC #9 stated RRT training opportunities had been identified at the conclusion of the RCAs, and confirmed they had not tracked which staff had participated or completed the training. DOC #9 also confirmed action plans were not developed in response to the RCAs. DOC #9 stated RCAs without action plans led to poor patient outcomes and missed opportunities for improvement. This was in contrast to the PIP policy which read, the plan would be used to continually monitor and improve the processes performed, with the goal to improve the quality of care and provide for a safe environment for patients. Data was to be collected, including patient care data and other relevant data to monitor the effectiveness and safety of services and quality of care, while opportunities were identified for improvement and changes which led to improvement. Additionally, the objectives were to improve the quality of patient care using a robust comprehensive systems approach to assess and evaluate the functions, processes and outcomes affecting patient care; to communicate performance improvement activities, findings, actions and the effectiveness through a system of communication, which reached all aspects of the hospital; to prioritize performance improvement activities which focused on high-risk, high-volume, or problem prone areas, considered the incidence, prevalence, and severity of problems in those areas, and those that affected health outcomes, patient safety, and quality of care; to identify safety/risk areas and potential safety/risk processes prior to any unanticipated adverse outcome or data.”