Health inspection·October 2, 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received his pain medication as ordered by the physician. Residents Affected - Few This failure resulted in Resident 1 to feel mad and had the potential for Resident 1 to experience unrelieved pain. Cross Reference F755 Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including respiratory failure (when the lungs cannot get enough oxygen into the blood), difficulty in walking, and dysphagia (difficulty swallowing foods or liquids). During a review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 7/1/2024, the MDS indicated Resident 1 had no impairment in cognitive skills (ability to make daily decisions). Resident 1 was dependent (helper does all the effort) on staff for toileting and bathing. The MDS indicated Resident 1 did not have pain in the last five days. During a review of Resident 1's untitled care plan (CP), initiated 8/5/2024, the CP indicated Resident 1 was at risk for pain and discomfort. The CP interventions included for staff to assess characteristics of pain: location, duration, quality, aggravating/alleviating factors, radiation, intensity, and notify the physician as needed and administer medication as ordered. During a review of Resident 1's Order Summary Report, dated 9/26/2024, the Order Summary Report indicated Resident 1 had a physician order dated 8/1/2024, for Norco (a medication used to treat moderate to severe pain) Oral Tablet 5-325 milligram (MG, a unit of measurement), give one (1) tablet by mouth every four (4) hours as needed (PRN) for severe pain. During a concurrent interview and record review on 10/2/2024 at 10:07 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's Medication Administration Record (MAR), dated September 2024, was reviewed. The MAR indicated Resident 1 did not receive Norco PRN for severe pain on 9/25/2024. The MAR indicated Resident 1 received Norco PRN for severe pain on 9/26/2024 at 5 p.m. LVN 1 stated Resident 1 was able to notify the nursing staff when Resident 1 was experiencing pain. LVN 1 stated in the morning of 9/26/2024 (around 9:30 a.m.), Resident 1 requested to have Norco due to Resident 1 experiencing pain. LVN 1 stated LVN 1 was not able to give Resident 1 Norco because the facility had run out (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 4 Event ID: 055449 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 055449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Covina Rehabilitation Center 261 W. Badillo Street Covina, CA 91723 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)