F 0726
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way
that maximizes each resident's well being.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to follow professional standards of practice when a Licensed
Nurse did not ensure pain medication for 1 of 3 residents (Resident 1), was administered completely before
leaving the resident's room. This failure had the potential to result in the patient not taking the medication
correctly, unrelieved pain, danger of other residents taking the medication, patient dissatisfaction, and loss
of patient trust and confidence in the nursing staff of the facility.
Findings:
A review of Resident 1's admission record, indicated she was admitted to the facility on [DATE] for dizziness
and giddiness, localized swelling, mass, and lump on both her lower extremities, generalized muscle
weakness, pressure ulcer (wound caused by pressure on an area of the skin) of the sacral region (base of
the spine) and adult failure to thrive among other conditions. A review of Resident 1's Minimal Data Set
(MDS -providing information of each resident's functional capabilities and helps nursing home staff identify
health problems) dated 4/5/23, indicated Resident 1 was receiving pain medication as needed (as the
situation demands).
During an interview on 4/12/23, at 3:32 p.m., Resident 1 stated, on the Monday following Easter Sunday
(4/10/23), she waited for Licensed Nurse P (LN P) to see her. When the LN P came, LN P left Resident 1's
pain medication in a cup and left without seeing Resident 1 take the medication. Resident 1 stated LN P
was supposed to make sure she took the medication.
During interview on 4/20/23, at 1:49 p.m., LN P stated she was informed Resident 1 was waiting for LN P
for an hour. LN P stated she immediately prepared Resident 1's pain medication and went to the resident's
room to administer the medication. At the resident's room, LN P stated she gave the medication to the
resident but could not recall if the pain medication was in a small dispensing cup or she handed the
medication into the resident's hand. LN P stated when she saw the resident move forward, she assumed
Resident 1 was thanking her and left the room. LN P acknowledged she did not see the resident take her
medication before she turned and headed back to the nurse's station.
During a subsequent interview on 4/24/23 at 3:40 p.m., LN P stated she had not asked the pain level of
Resident 1 before and after she gave the pain medication. LN P stated Resident 1's pain level was
monitored every shift and before and after administration of pain medication.
During a review of Resident 1's Controlled drug record documenting the date and time Percocet, a brand
name for a narcotic (medication that dulls the senses and relieves pain) containing 5 milligrams (mg - unit
of measure) of oxycodone, and 325 mg acetaminophen (pain reliever), indicated 1 tablet
(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:
055222
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
055222
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/25/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Springs Road Healthcare
1527 Springs Road
Vallejo, CA 94591
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 0726
of Percocet was given to Resident 1 on 4/10/23 at 3:00 p.m.
Level of Harm - Minimal harm
or potential for actual harm
A review of the policy titled, Administering medications revised 4/2019, indicated medications are
administered in a safe manner, and as prescribed. Resident may self-administer their own medications only
if the attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that
they have the decision-making capacity to do so safely.
Residents Affected - Few
During an interview on 4/15/23, at 11:26 a.m., the Director of Nursing (DON) stated the facility performs
assessments of residents who prefer to self-administer their own medication. A physician's order is
obtained when a resident is assessed safe to self-administer his/her own medication. The DON stated a
Licensed Nurse reminds the resident of the schedule and supervises the self-administration of the
medication. The DON stated that the licensed nurse must be physically present and witness the resident
take and swallow the medication before documenting the medication administration. The DON confirmed
Resident 1 did not have an order to self-administer her own medication.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055222
If continuation sheet
Page 2 of 2
