Inspection·August 22, 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 Resident 1 was adequately assessed for pain during the evening and night shifts on July 12, 2025, and provide appropriate pain medication to manage pain. This failure resulted to Resident 1 calling emergency services to be transferred out of the facility on July 13, 2025, due to worsening pain.Findings:On August 12, 2025, at 1:43 p.m., an unannounced visit was made at the facility to conduct an investigation of a complaint regarding quality of care.A review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE], around 4:31 p.m., with diagnoses which included left femur fracture (a break in the long bone of the left leg), presence of left artificial hip joint, low back pain, multiple sclerosis (body's immune system attacks the protective covering of the nerve cells in the brain, optic nerve and spinal cord), and fibromyalgia (persisting condition characterized by widespread muscle pain and tenderness).A review of Resident 1's Minimum Data Set (MDS- a clinical assessment tool), dated July 13, 2025, indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact).A review of Resident 1's Order Summary Report, included physician's orders for:- Pain monitor every shift., order date July 12, 2025; and- Hydrocodone (narcotic pain medication)-Acetaminophen (used to relieve mild pain or fever) Oral (by mouth) tablet 5-325 MG (milligram- unit of measurement).Give 1 tablet by mouth every 6hours as needed for pain., order date July 12, 2025.A review of Resident 1's Medication Administration Record (MAR) for July 1 to 31, 2025, indicated the following:- Pain Monitor every shift.Start Date 7/12/2025 1500 (3 pm)., there was no pain level documented for the Evening (PM) shift and Night (NOC) shits and there were no licensed nurses' (LN) initials on the document to signify the task was performed;- The MAR did not include the order for Hydrodocone-Acetaminophen, therefore there was no indication that the medication was given to Resident 1 for pain.A review of Resident 1's care plans indicated there was no care plan initiated for pain or pain management.A review of the SBAR (Situation, Background, Appearance, Review and Notify) Communication Form, dated July 13, 2025, indicated the following:- .Situation.The change in condition.is/are.Pain (uncontrolled), Shortness of Breath (SOB).- .Background.Pain Evaluation.Does the resident have pain.Yes.Worsening of chronic pain.hip pain from hip surgery.Intensity of pain rate on scale of 1-10, with 10 being the worst): 8.- .Appearance.Resident sent self out per 911 (emergency medical services). complaints of pain and SOB. No signs of SOB noted.A review of Resident 1's progress notes indicated no documentation pertaining to pain assessment for the PM or NOC shifts for July 12, 2025, to July 13, 2025, prior to Resident 1 calling 911 to be transferred out of the facility. The progress notes indicated Resident 1 left the facility at 8:09 a.m. on July 13, 2025.On August 28, 2025, at 10:57 a.m., Registered Nurse (RN) 1 was interviewed. RN 1 stated she was working on July 13, 2025, when Resident 1 was sent out via 911. RN 1 recalled the endorsement from the previous shift's RN that Resident 1 was frequently asking for pain medication throughout the previous night, and no medications were delivered for Resident 1 that Residents Affected - Few (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: 056095 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 056095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Devonshire Care Center 1350 East Devonshire Avenue Hemet, CA 92544 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)