Health inspection·October 10, 2024

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure pain was assessed every shift, as ordered, for one of three sampled residents (Resident 1). Residents Affected - Few This deficient practice had the potential to cause avoidable discomfort and distress due to unidentified and untreated pain for Resident 1. Findings: During a review of Resident 1's admission Record, the admisssion record indicated the facility originally admitted Resident 1 on 1/14/2016, and most recently re-admitted Resident 1 on 10/6/2024. Resident 1's diagnoses included broken left hip bone, abnormalities of gait and mobility, generalized muscle weakness, age-related osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D), contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of the right hip, and unspecified dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/7/2024, the MDS indicated Resident 1 had severely impaired cognitive skills for daily decision making (Problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 1 was dependent on staff for activities of daily living (ADLS, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and mobility while in and out of bed. During a review of Resident 1's physician orders, dated 10/6/2024, the physician orders indicated staff were supposed to assess Resident 1 for pain every shift. During a concurrent interview and record review on 10/10/2024 at 2:40 PM, with Licensed Vocational Nurse (LVN) 1, Resident 1's Medication Administration Record (MAR) dated 10/2024 was reviewed. LVN 1 stated Resident 1's MAR indicated staff did not assess Resident 1's pain on 10/9/2024 during the 3:00 PM to 11:00 PM shift. During a concurrent interview and record review on 10/10/2024 at 4:25 PM, with the Director of Nursing (DON), Resident 1's MAR dated 10/2024 and active physician orders were reviewed. The DON stated the physician orders indicated staff were supposed to assess Resident 1's pain every shift, and the MAR indicated staff did not assess Resident 1's pain on 10/9/2024 during the 3:00 PM to 11:00 PM shift. The DON stated the LVNs were responsible for conducting the pain assessments if ordered by the physician. The DON stated that if staff did not assess for pain, especially in residents who might not be able to express themselves due to cognitive deficits, it put the resident at risk for unidentified pain that could go untreated. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055045 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 055045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riviera Healthcare Center 8203 Telegraph Rd Pico Rivera, CA 90660 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)