Health inspection·June 11, 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 manage pain for one out of four sampled residents (Resident 1), when Resident 1 did not received pain medication as desired for 13 hours. Residents Affected - Few This failure resulted in Resident 1 suffering from severe pain and a feeling of neglect. Findings: During a review of Resident 1's admission Record, dated May 2024, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with active diagnosis that included thoracic fusion (an operation in the middle region of the spine) and chronic pain. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated April 2024, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) was 15 out of 15, indicating cognitively intact. During a review of Resident 1's Nursing admission Data Collection and Baseline Care Plan Tool, the Nursing admission Data Collection and Baseline Care Plan Tool indicated Resident 1's date and time of admission was 3/22/24 at 7:00 p.m. Further review of the tool indicated, Resident 1's pain interventions were to monitor for presence of pain every shift and to administer pain medication. During a review of Resident 1's Physician Order (PO) Summary, dated March 2024, the PO indicated the following orders of: Oxycodone 5 mg by mouth every 6 hours as needed for moderate to severe pain and Monitor for Presence of Pain every shift using pain scale 0-10. 0=No pain, 1-2=least pain, 3-4=mild pain, 5-6=Moderate pain, 7-8=severe pain and 9-10=very severe pain. During a review of Resident 1's Progress Notes (PN), dated 3/22/24 through 3/23/24, the PN indicated Resident 1 had pain on a number scale of four on 3/22/24 at 9:31 p.m. Further review of PN did not indicate a pain management was provided and that pain was assessed again that night. During a review of Resident 1's Medication Administration Record (MAR), dated March 2024, the MAR indicated that oxycodone 5 mg was first administered on 3/23/24 at 8:25 a.m. for very severe pain of a nine. Further review of the MAR indicated Resident 1 received the same doses of medication on that same day at 2:00 p.m. and 7:14 p.m. for pain scales of 8 and 7 respectively. There was no indication on the MAR Resident 1 received pain medication on the night of 3/22/24. (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: 056327 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 056327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Walnut Creek Skilled Nursing & Rehabilitation Cent 1224 Rossmoor Parkway Walnut Creek, CA 94595 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)