Health inspection·December 2, 2025

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 ensure one out of three sampled residents (Resident 1) was provided with adequate pain management when Resident 1's new pain medication order was not carried out by the facility for 35 days. This failure contributed to Resident 1 experiencing pain and had the potential to cause unnecessary psychosocial distress.A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses including palliative care (If an illness that cannot be cured, palliative care makes the person comfortable as possible by managing pain and other distressing symptoms), dementia (affecting a person's ability to remember, think, and make decision), mild neurocognitive disorder (a condition where a person's memory or thinking skills have slightly declined), history of falling, and legal blindnessDuring a phone interview on 9/23/25, at 12:37 PM, with Family Member (FM) 1, FM 1 stated she went to the facility on September 17 to visit Resident 1, she saw Resident 1 crying, gasping for breath, and looked uncomfortable and in pain. FM 1 stated the nurse told her that Resident 1 missed her pain medication. FM 1 stated Resident 1 was still in bed and in pain when the Assistant Director of Nursing (ADON), the administrator (ADM) and Social Worker (SW) came to the room and explained that the pain medication, morphine sulfate, was PRN (as needed) and if Resident 1 was showing signs of pain like moaning or groaning they could provide her the pain medication. FM 1 stated she called the hospice agency (palliative care agency), and she was told by the hospice nurse that Resident 1 actually had morphine sulfate ordered to be given every six hours routinely since August 12. FM 1 stated the facility told her that hospice needed to reevaluate Resident 1 before they changed the order to routine. FM 1 stated she came back the next day and asked the nurse if Resident 1 had been given morphine sulfate, and the nurse told her that Resident 1 had not been given any morphine sulfate since September 15.A review of the Resident 1's medical record titled, [company name] Hospice Physician's order dated 6/24/25, indicated .Morphine Sulfate 100mg/5ml [100 milligrams per 5 milliliters, units of measure] give 0.25ml q4hrs [every 4 hours] PRN [as needed].A review of the Resident 1's medical record titled, [company name] Hospice, Inc POC/IDG [Plan of Care/Interdisciplinary Group] Review, dated 8/20/25, indicated, Order Date 8/12/2025 Start Date 8/12/2025 Type New Medication Morphine Sulfate 20mg/mL Concentrated Solution.Dosage 10mg (0.5ml) EVERY 6hrs [6 hours] around the clock.Indication PainDuring an interview on 9/24/25, at 10:11 AM, with Licensed Nurse (LN) 1, LN 1 stated it was important to address a resident's pain because the resident needed to be comfortable. LN 1 stated if the resident's pain was not addressed, it would be considered neglect to the resident and the resident's condition could get worse and they wanted to avoid that. LN 1 stated if the pain medication was PRN and the resident does not verbalize that they are in pain, the nurses use a pain scale for non-verbal residents called the PAINAD scale (Pain Assessment in Advanced Dementia, with scores ranging from 0 to 10 to indicate mild to severe pain). LN 1 stated this scale uses breathing and facial expressions of the resident to assess their pain instead of relying Residents Affected - Few Page 1 of 3 055201 055201 12/02/2025 Oak Grove Post Acute 4545 Shelley Court Stockton, CA 95207

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on the resident to say if they were in pain.During an interview on 9/24/25, at 11:06 AM, with LN 2, LN 2 stated when providing residents with pain medication, he could tell if the resident was in pain by the resident's facial expressions, like facial grimacing. LN 2 stated it was important to address the resident's pain because the pain could increase in severity and it could cause more problems, and the resident could be distressed and experience restlessness. LN 2 stated it was change of shift when Resident 1 started crying on September 17, but he did not give her pain medication during his shift because she was not in pain at that time. LN 2 stated Resident 1's pain medication, morphine sulfate was ordered as PRN.During a concurrent interview and record review of Resident 1's medical record on 9/24/25, at 11:12 AM, with the Assistant Director of Nursing (ADON), the ADON stated it was important to address a resident's pain and if it was not addressed, there would be continuation of pain. The ADON stated that when the hospice provider orders a pain medication for a resident on hospice, the hospice provider will fax the order to the facility, and the hospice staff will also call to verify if the fax was received. The ADON stated the nurses notify the facility's doctor, and the doctor normally follows what the hospice doctor ordered. Resident 1's medical record was reviewed with the ADON, Resident 1 was admitted to hospice on 6/24/25, with an order for PRN morphine sulfate 0.25 ml dated 6/24/25. The ADON stated the routine morphine sulfate 0.5 ml every 6 hours was ordered on 9/17/25 and she still had the PRN morphine sulfate 0.25 ml. Resident 1's medical records from the hospice agency indicated Resident 1 had an order for Morphine Sulfate 0.5 ml every 6 hours around the clock for pain dated 8/12/25 when the hospice changed the order to routine. The ADON stated the order from the hospice agency should have been carried out when it was faxed to the facility on 8/12/25, but it was not. The ADON stated the risk of the medication order not being carried out was a possibility that Resident 1's condition could worsen, and Resident 1 could experience pain.During an interview on 9/24/25, at 1:40 PM, with the ADON, the ADON stated she does not know what happened with Resident 1's routine pain medication order, it was a miscommunication between hospice and the facility. The ADON confirmed that it had been 35 days since hospice changed Resident 1's order for morphine sulfate from PRN to routine, and it was originally ordered on [DATE]. During a concurrent phone interview and record review of Resident 1's medical record on 9/24/25, at 2:10, with the Hospice Director of care patient services (HDCPS), the HDCPS stated that when there was a new order or changes in an order for a resident, the hospice agency faxes it to the facility, or it can also be a verbal order to the facility nurse when the hospice nurse was at the facility. HDCPS reviewed Resident 1's document, and stated Resident 1 had an order for PRN morphine sulfate but on 8/12/25 morphine sulfate 0.5ml every 6hrs was ordered. The HDCPS stated that when the hospice gives a new order over the phone, the nurse at the facility carries it out (adding it to the resident's medical record. The HDCPS stated the hospice liaison officer then brings the resident's documents like progress notes, orders, and the care conference notes to the facility. The HDCPS stated the hospice nurse visited the facility on 8/12/25 at 12:45 PM and that was the time they changed Resident 1's morphine order from PRN to routine. The HDCPS stated the hospice nurse wrote a note that same day that read Resident 1 was restless, moaning, grimacing and reporting pain and appears to be uncomfortable. The HDCPS stated the hospice nurse documented that Resident 1's nurse was informed.During an interview on 9/24/25, at 2:30 PM, with LN 3, LN 3 stated he does not remember getting a verbal order from the hospice nurse for Resident 1. LN 3 stated usually the hospice nurse has a paper document and would just ask the nurses if they would enter the order in the resident's EHR (electronic health record).A review of Resident 1's medical record from [company name] Hospice, titled, VISIT NOTE SHORT FORM dated 8/12/25, indicated, .pt [patient] did complain of pain and was moaning and grimacing/tense during visit. Sitter 055201 Page 2 of 3 055201 12/02/2025 Oak Grove Post Acute 4545 Shelley Court Stockton, CA 95207

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reports that patient was getting up and down from wc [wheelchair] and trying to stand most of the day and appeared to be very uncomfortable. New orders to start routine pain med [medication] and increase anxiety med, staff nurse [name of Resident 1's nurse] updated, and staff nurse was going to give pain med when due at 230pm.A review of the facility's policy and procedure (P&P) titled, Pain Management, dated 8/25/2021, the P&P indicated, .Residents will be evaluated as part of the nursing assessment process for the presence of pain upon admission/re-admission, quarterly, with change in condition or change in pain status.Pain management that is consistent with professional standards of practice, the comprehensive person-centered care plan, and the Resident's goals and preferences is provided to Residents who require such services.A review of the facility's undated policy and procedure titled, Hospice Program, the P&P indicated, .In general, it is the responsibility of the hospice to manage the resident's care as it relates to the terminal illness and related conditions, including.Providing medical direction, nursing and clinical management of the terminal illness.In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs. These include.Administering prescribed therapies, including those therapies determined appropriate by the hospice and.in the hospice plan of care. 055201 Page 3 of 3