Health inspection·July 16, 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 to ensure one of three sampled residents (Resident 2) received care and services in accordance with professional standards of practice by failing to administer Resident 2's Norco (a medication used to relieve severe pain) as prescribed by the physician. This deficient practice had the potential for Resident 2 to experience untreated pain.Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted Resident 2 on 6/2/2022 and readmitted on [DATE] with diagnoses that included metabolic encephalopathy (a brain disorder caused by a chemical imbalance in the body due to an underlying illness or organ dysfunction), sepsis (a serious condition in which the body responds improperly to an infection), paraplegia (loss of movement and/or sensation, to some degree, of the legs), and chronic pain syndrome (a condition where pain persists for more than three to six months, beyond the expected healing time for an injury or illness). During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool) dated 6/19/2025, the MDS indicated Resident 2 had intact cognition (the process of acquiring knowledge and understanding through thought, experience, and senses). The MDS further indicated that Resident 2 required set-up or clean up assistance with eating, and oral hygiene, partial or moderate assistance with personal hygiene, and was dependent on staff with toileting hygiene. During a review of Resident 2's Order Summary Report dated 2/26/2025, the Order Summary Report indicated an order for Norco Oral Tablet 5-325 milligrams (mg- unit of measurement), give one (1) tablet orally every six (6) hours as needed for severe pain (pain rated at seven to 10 on a pain scale from zero [0] to 10, where 10 is the worst possible pain). During a review of Resident 2's Situation, Background, Assessment and Recommendation (SBAR- a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form dated 6/21/2025, the SBAR indicated Resident 2 had nine (9) out of 10 pain in the perineal area (the area between the anus and genitals). During a review of Resident 2's Care Plan for pain dated 7/7/2025, the Care Plan indicated under interventions to administer medications as ordered by the physician. During a review of Resident 2's Medication Administration Record (MAR - a legal record of all medications and treatments administered to a resident) for 6/2025, the MAR indicated to give Norco 5-325 mg one tablet orally every six hours as needed for severe pain (seven to 10 out of 10 pain). There was no entry or documented evidence in Resident 2's MAR indicating Norco 5-325 mg one tablet was given on 6/21/2025. During a concurrent interview and record review on 7/16/2025 at 2:00 p.m., with the Case Manager (CM), the CM reviewed Resident 2's SBAR Communication Form dated 6/21/2025 and MAR for 6/2025. The CM stated that Resident 2 had a change in condition (significant alteration in a person's physical, mental, or functional state) on 6/21/2025 for tachycardia (a medical condition characterized by an abnormally fast heart rate) and fever. The CM stated that Resident 2's pain level was evaluated and stated that Resident 2's pain level was documented to be nine out of 10 in the perineal area. The CM further stated that Resident 2 was not Residents Affected - Few Page 1 of 2 056363 056363 07/16/2025 Grand Valley Health Care Center 13524 Sherman Way Van Nuys, CA 91405

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few administered PRN (as needed) pain medication on 6/21/2025. During an interview on 7/16/2025 at 2:39 p.m., with Registered Nurse 2 (RN 2), RN 2 stated that on 6/21/2025 the charge nurse (Licensed Vocational Nurse 1 [LVN 1] assigned to Resident 2 reported to RN 2 on 6/21/2025 that Resident 2 had tachycardia and fever. RN 2 stated that she (RN 2) then went to Resident 2's room to assess Resident 2. RN 2 stated that during the assessment, Resident 2 complained of nine out of 10 pain in her perineal pain. When asked if Resident 2 was offered pain medication as prescribed by the physician or if pain medication was administered to address Resident 2's nine out of 10 pain, RN 2 stated that pain medication was not administered to Resident 2. RN 2 stated that Resident 2 should have been administered pain medication because of Resident 2's complaint of pain. When asked why Resident 2 was not administered pain medication, RN 2 did not answer. RN 2 further stated that Resident 2 should have been administered pain medication for her nine out of 10 pain because Resident 2 had PRN pain medication ordered and by administering Resident 2's PRN pain medication it would have helped address and relieve the pain. During a review of the facility's policy and procedure (P&P) titled, Pain Management Protocol, last reviewed by the facility on 8/15/2024, the policy indicated pain management may consist of continuous narcotic infusing, routine medication, PRN medication or a combination of both medication and PRN medication for breakthrough pain. During a review of the facility's P&P titled, Medication Administration-General Guidelines, last reviewed by the facility on 8/15/2024, the policy indicated medications are administered as prescribed in accordance with good nursing principles and practices and only persons legally authored to do so. Medications are administered in accordance with written orders of the attending physician. During a review of the facility's P&P titled, Quality of Care, Routine Resident Monitoring and Scope of Services, last reviewed by the facility on 8/15/2024, the policy indicated it is the policy of the facility that each resident receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical mental and psychosocial well-being consistent with the residents comprehensive assessment and plan of care. 056363 Page 2 of 2