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 pain management was provided according to the
physician's order and plan of care, for one of ten (Resident A).
Residents Affected - Some
This failure had the potential to result in Residents A's pain to not be managed.
Findings:
On May 9, 2025, at 10:45 a.m., an unannounced visit was made to the facility for the investigation of a
complaint regarding quality of care.
On May 9, 2025, a review of Resident A ' s medical record was conducted. Resident A was admitted to the
facility on [DATE], with diagnoses which included morbid obesity (a body mass index [BMI] of 40 or higher,
or a BMI of 35 or higher with obesity-related health problems).
Resident A's Order Summary Report, included the following orders for pain medication and management:
- .MONITOR PAIN EVERY SHIFT: DOCUMENT PAIN LEVEL: 0= no pain, 1-3=mild pain, 4-5= moderate
pain, 6-9= severe pain 10=excruciating pain ., date ordered January 3, 2022;
- .Percocet (a pain medication) 10-325mg (milligram-a type of measurement) .give one tablet every eight
hours as needed for severe pain level of 7-10 ., date ordered January 3, 2024;
- .Hydrocodone (a pain medication used to treat moderate to severe pain) 10-325 mg .give one tablet every
six hours as needed for pain for 30 days ., date ordered on April 29, 2025, and re-ordered on May 29, 2025;
Resident A ' s care plan, dated January 3, 2022, indicated, .Alteration in comfort related to pain .Administer
pain medication as ordered .
Resident A ' s IDT (Interdisciplinary team) Conference Summary, dated April 16, 2025, at 2:53 p.m.,
indicated, .pain medication management reviewed .
Resident A's Medication Administration Record (MAR), for the month of March 2025, indicated
Hydrocodone-Acetaminophen 10-325 mg one table every six hours as needed for moderate pain (4-6) was
given for pain scale of 7 and above multiple times on the following months:
(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:
055581
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
055581
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Jurupa Hills Post Acute
6401 33rd Street.
Riverside, CA 92509
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
- March 2025; four (4) times;
Level of Harm - Minimal harm
or potential for actual harm
- April 2025; 29 times; and
- May 2025; 25 times.
Residents Affected - Some
On May14, 2025, at 12:10 p.m., an interview was conducted with Resident A. Resident A stated he gets
pain medications for his knees and back, he gets Norco (Hydrocodone) in the morning and the afternoon,
and the Percocet about 6 a.m. and 10 p.m. Resident A stated he was getting pain medication about four
times a day and the medication would help.
On May 14, 2025, at 4:45 p.m., an interview and concurrent record review was conducted with the Director
of Nursing (DON). The DON stated the physician ' s orders were not being followed as written, the pain
scale number should match with the medication to be given. The DON stated Resident A was taking PRN
pain medications multiple times each day, and the nurses should have called the physician and asked for
one of his pain medications to be changed from as needed to scheduled and the other pain medication to
be used as needed for breakthrough pain.
A review of the facility ' s procedure titled Pain Assessment and Management, dated October 2022 ,
indicated, .help the staff identify pain in the resident, and to develop interventions that are consistent with
the resident ' s goals and needs and that address the underlying causes of pain .pain management
program .appropriate assessment and treatment of pain, based on professional standards of practice, the
comprehensive care plan, and the resident ' s choices .chronic pain the resident ' s pain and consequences
of pain are assessed at least weekly .review the medication administration record to determine how often
the individual requests and receives PRN (as needed) pain medication, and to what extent the
administered medications relieve the resident ' s pain .when opioids are used for pain management, the
resident is monitored for medication effectiveness, adverse effects, and potential overdose .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055581
If continuation sheet
Page 2 of 2
