Inspection·June 29, 2023

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow the physician's order for one of three sampled residents (Resident 1) when the licensed nurses gave three pain medications at the same time and not according to the pain scale. This failure had the potential to compromise safety and well-being. Residents Affected - Few Findings: Review of Resident 1's clinical record indicated Resident 1 was admitted on [DATE] with diagnoses including malignant neoplasm of the breast (a cancerous tumor) and chronic obstructive pulmonary disease (a group of lung diseases that block airflow that can cause difficulty of breathing). Review of Resident 1's physician order dated 5/20/22 indicated morphine sulfate solution (pain medication used for chronic pain) give 1 ml as needed for pain scale of 7 to 10 (severe pain). Further review of Resident 1 physician order dated 5/5/22 indicated the following: 1. Tramadol 50 milligrams (mg, unit of measurement) tablet, give one tablet every eight hours as needed for moderate pain. 2. Tylenol 325 mg two tablets every four hours as needed for pain scale of 1 to 3 (mild pain) for 90 days. During a concurrent interview and record review with Licensed Vocational Nurse C (LVN C) on 3/30/23 at 2:26 p.m., LVN C reviewed Resident 1's August 2022 medication administration record (MAR) and acknowledged on 8/2/22 and 8/13/22 she administered morphine sulfate 1 ml, tramadol 50 mg, and Tylenol 650 mg at the same time. LVN C further stated, she should follow the pain scale assessment before administering the pain medications. During a phone interview with Registered Nurse B (RN B) on 4/20/23 at 8:18 a.m., RN B acknowledged on 8/3/22 and 8/24/22, she administered morphine solution 1 ml and tramadol 50 mg at the same time to Resident 1. RN B further stated Resident 1 wanted all her pain medications at the same time. RN B verified there were no notes indicating the physician was made aware that Resident 1 wanted all her medication at the same time. Review of Resident 1's November 2022 MAR, indicated an order of Tylenol 650 mg every four hours as needed for mild pain. During a concurrent interview and record review with Registered Nurse D (RN D) on 6/29/23 at 3:02 p.m., RN D reviewed Resident 1's November 2022 MAR and acknowledged on 11/17/22 and 11/20/22 both morphine solution 1 ml and tramadol 50 mg were administered together for severe pain. RN D stated on 11/22/22 he administered morphine 1ml, tramadol 50 mg, and Tylenol 650 mg all at the same time for severe pain. RN D acknowledged he should have followed the physician's order in administering the above medications. During a concurrent interview and record review with the Director of Nursing (DON) on 6/29/23 at 4:18 p.m., the DON reviewed Resident 1's August and November 2023 MAR. The DON stated licensed nurses should follow the physician's order. The pain scale should be followed when administering pain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055017 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Redwood Grove Post Acute 2990 Soquel Avenue Santa Cruz, CA 95062 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete medications. The DON further stated administering tramadol and morphine together could increase the risk of respiratory depression. A review of the facility's policy titled, Administering Medications, revised April 2019 indicated, Medications are administered in accordance with prescriber orders, including any required time frame. The policy further indicated the physician, interdisciplinary team in collaboration with the consultant pharmacist as needed should reevaluate residents who uses frequent PRN (as needed) medications. Event ID: Facility ID: 055017 If continuation sheet Page 3 of 3