Health inspection·December 12, 2023

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 observation, interview and record review, the facility failed to manage two of three resident's (Resident 1 and Resident 2) pain according to professional standards of practice and resident's preferences when residents were not properly educated about their pain medication management. This failure resulted in increased pain levels and had the potential to cause a delay in recovery, impair mobility, impair mood, disturb sleep, and diminish quality of life and wellbeing. Residents Affected - Some Findings: During an interview on 10/31/23, at 3:03 p.m., Resident 1 stated she had pain on the lower back, neck, and her whole body. Resident 1 stated her scheduled pain medication was not given on time. The longest she had to wait was half hour, depending on the nurse on duty. Resident 1 stated she did not like to wait because it messed up her schedule and made her pain worse. Resident 1 stated, about two weeks ago, a night shift nurse refused to give her pain medication, because the previous nurse supposedly already gave her 11 p.m. pain medication. The night shift nurse told her she would give the medication at 3 a.m. but did not come back. Resident 1 stated she missed her 11 p.m., and 3 a.m. pain medication and finally received medication at 7a.m. Resident 1 stated she did not receive medication from the nurse who was supposed to give her pain medication at 11 p.m. Resident 1 stated her pain level was always 10 (numerical pain rating scale 0-10: where 0 is no pain and 10 is the worst pain imaginable), and it took twice as long to relieve the pain. The Nurse argued with her like she was crazy, or not stable, and did not know about her medication. Resident 1 stated she did not feel respected by that nurse. A review of Resident 1's admission Minimum Data Set (MDS - a federally mandated clinical assessment tool) dated 9/6/23 indicated she was admitted [DATE] with a Brief interview for Mental Status (BIMS – a tool to assess cognitive function) score of 13 indicating Resident 1 was cognitively intact. Resident 1's facesheet (resident demographics) indicated she was admitted with a diagnosis of cancer of the breast, pressure ulcer of the sacrum, diabetes, and depression among other medical conditions. A review of Resident 1's Medication Administration Record (MAR) for 9/23 and 10/23 indicated she was prescribed Morphine (narcotic pain medication) 30 milligram (mg - unit of measure equal to a thousandth of a gram) to be given one (1) tablet twice a day routinely and Oxycodone (another type of narcotic pain medication) 10 mg to be given one (1) tablet every four (4) hours as needed (PRN – to be administered when it is requested by, or as needed by, the patient; is not scheduled and not required on a regular basis) for moderate (level 4-6) and severe (level 7-10) pain. During a follow-up interview on 10/31/23, at 4:15 p.m., Resident 1 stated she expected the (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: 055919 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 055919 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472 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)