Health inspection·November 7, 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 that pain management was provided to one of three sampled residents (Resident 1), consistent with professional standards of practice and in accordance with its policy and procedure titled Pain Management. The facility failed to: 1. 1. Ensure Resident 1's pain was accurately assessed for the type, frequency, intensity, and duration of the pain, re-evaluate the effectiveness of the intervention to determine what increase or decrease in the frequency, intensity, duration of pain after the resident's fall on 7/28/2025. 2. 2. Ensure that Resident 1 was accurately assessed and evaluated for continued complaints of right leg pain and refusal to ambulate due to pain during Physical Therapy (exercise to promote, maintain, and restore physical movement and function) from 8/2025 to 9/2025. 3. 3. Inform the Nurse Practioner (NP)1 or the Physician (MD)1 that Resident 1 had persistent right leg pain during ambulation and refused to participate in physical therapy exercises due to right leg pain on 8/5/2025, 8/11/2025, 8/29/2025, 8/30/2025, 9/8/2025 and 9/14/2025. These failures resulted in Resident 1's pain being poorly controlled that led to Resident 1's refusal to ambulate after the fall on 7/28/2025 and had the potential for complication due to pain and lack of mobility. Findings: A review of the facility's P&P titled, Pain Management, dated 8/25/2021, the P&P indicated the facility must maintain the highest possible level of comfort for residents by providing a system to identify, assess, treat, and evaluate pain. The P&P indicated Residents who receive pain interventions will be monitored for effectiveness and ineffectiveness of routine or PRN (as needed) medications including interventions, follow-up, and physician or advance practice provider (APP) notification. A review of the facility's P&P titled, Change in Condition: Notification of, dated 8/25/2021, the P&P indicated the facility must immediately inform the resident, the resident's primary care physician (PCP) or nurse practitioner (NP), and notify the resident representative, if the resident experienced a significant change in physical, mental, or psychosocial status. A review of Resident 1's admission Record (AR), the facility admitted Resident 1 on 7/31/2020 and readmitted on [DATE] with diagnoses that included a nondisplaced fracture (broken bone) of lateral malleolus of right fibula (right ankle), initial encounter for closed fracture, and other specified disorder of bone density and structure, right lower leg. A review of Resident 1's History and Physical (H&P), dated 1/21/2025, the HP indicated Resident 1 had fluctuating capacity to understand and make decisions. A review of Resident 1's Change in Condition Evaluation (CoC), dated 7/28/2025 timed at 6:31 PM, the CoC indicated Resident 1 was found on the floor with her head on the pillow. The CoC indicated Resident 1 stated, she pulled herself to the side and rolled off the bed. A review of Resident 1's clinical record indicated an Xray of the hips and knees was completed on 7/28/2025 which did not show any fracture on the first X-ray performed (the first Xray performed). A review of Resident 1's PT evaluation, dated 7/30/2025 timed at 4:24 PM, the evaluation indicated Resident 1 required encouragement to participate in gait (a person's pattern of walking) training due to fear of fall. A review of Residents Affected - Some Page 1 of 5 056487 056487 11/07/2025 Rio Hondo Subacute & Nursing Center 273 E Beverly Boulevard Montebello, CA 90640

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 1's PT Encounter Note, date of service 8/5/2025, the Encounter Note indicated Resident 1 complained of slight right ankle pain after standing for too long with bruising and minimal swelling from a previous fall (fall on 7/28/2025). The Encounter Note indicated Resident 1 PT was deferred ambulation due to Resident 1's pain and safety. A review of the MAR and the PN indicated Resident 1 had zero pain level and did not receive any pain medication 8/5/2025. There was no documented evidence PT informed the licensed nurse about Resident 1's bruising and swelling on the ankle and that ambulation was deferred. A review of Resident 1's Radiology report, examination dated 8/7/2025 timed at 6:45 AM and a reported date of 8/8/2025 timed at 1:46 PM, the report indicated Resident 1 had a right ankle fracture of an uncertain age. A review of Resident 1's PT Encounter Notes, date of service 8/7/2025, the Encounter Note indicated Resident 1 continued to complain of pain. A review of the MAR indicated Resident 1 had zero pain level and did not receive any pain medication. A review of the NPN indicated 8/7/2025 at 11 AM, PT reported while attempting to get up to walk resident complained of right ankle pain when standing. A review of Resident 1's NPN, dated 8/8/2025 timed at 8:13 AM, indicated the Primary Care Physician (PCP) 1 was notified Resident 1's right ankle radiology reports and ordered for Resident 1 not to walk or put weight on the right ankle. The PN indicated PCP 1 will be visiting [Resident 1] within the next week. A review of the MAR indicated on 8/9/2025 at 9:20 AM, Resident 1 received Tylenol 500 milligrams (mg) one tablet for right foot pain at 5/10 pain level (0 no pain and 10-severe pain scale). A review of the NPN dated 8/9/2025 timed at 1:38 PM indicated Resident 1 was medicated for pain as ordered with effect. The NPN further indicated the licensed nurse left a message to PCP for stronger pain medication. A review of the MAR and physician's order on 8/9/2025, indicated Resident 1 had no physician order and did not receive stronger pain medication on 8/9/2025. A review of the NPN dated 8/11/2025 timed at 3:59 AM, indicated Resident 1 was on monitoring for ankle pain and discoloration. PNP indicated Resident 1 was medicated for pain as ordered with effect. The PNP had no documentation of the intensity and level of pain recorded in NPN. A review of the NPN dated 8/11/2025 timed at 11:17AM, indicated Resident 1 was on monitoring for ankle pain and discoloration. PNP indicated Resident 1 was medicated for pain as ordered with effect. The PNP had no documentation of the intensity and level of pain recorded in NPN. A review of Resident 1's NPN, dated 8/11/2025, timed at 7:11PM, indicated Resident 1's inner and outer ankle were bruised, and complained of pain especially if asked to put weight on her foot. MD (physician) aware and will do rounds this week. A review of the MAR indicated on 8/11/2025 Resident 1 had zero pain level and no documented evidence that the resident received any pain medication on 8/11/2025. A review of Resident 1's Physician's Progress Notes, dated 8/14/2025 timed at 9:55 AM, indicated Resident 1 was instructed not to put weight on her right leg and with bruising and tenderness noted to the inner and outer side of the right ankle. The Physician's Progress Notes indicated that Resident 1's pain was controlled with analgesic( pain medication) and require orthopedic ( physician specialized in bone disorder) clearance for progression of mobility. The PN indicated Resident 1's cognitive status remains fluctuating, but her recent behavior indicates decrease recall and processing. A review of Resident 1's PT Encounter Note, service date 8/17/2025, the Encounter Note indicated Resident 1 reported minimal pain during her bilateral lower leg strengthening in bed. A review of Statement of Medical Necessity dated 8/26/2025 indicated Doctor of Podiatry Medicine (DPM-specialized in foot care) recommended for Resident 1 to use a walking boot (a medical device to protect the foot and ankle after injury) for Resident 1's right ankle fracture. A review of Resident 1's PT Encounter Note, service date 8/29/2025, the Encounter Note indicated Resident 1 refused to walk because she complained of right ankle pain. A review of Resident 1's PT Encounter Note, service date 8/30/2025, the Encounter Note indicated 056487 Page 2 of 5 056487 11/07/2025 Rio Hondo Subacute & Nursing Center 273 E Beverly Boulevard Montebello, CA 90640

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some there were multiple attempts to encourage Resident 1 to walk, however, Resident 1 insisted on saying she can't because of the right ankle pain. A review of the MAR indicated Resident 1 had zero level pain and received Tylenol 500mg tablet for pain every shift (three times a day) on 8/29/2025 to 8/31/2025 every shift. There was no documented evidence Resident 1's ankle pain was assessed and evaluated for what increases or decreases the pain frequency, intensity, duration of pain on 8/29/2025 and 8/31/2025. A review of Resident 1's PT Encounter Note, service date 9/8/2025, the Encounter Note indicated Resident 1 had an unsteady balance when transferring from sitting to standing with a front wheeled walker and had difficulty moving her right leg forward during ambulation and stated [Resident 1's] legs feel heavy. A review of Resident 1's PT Encounter Note, service date 9/14/2025, the Encounter Note indicated Resident 1 received manual stretches of the right leg but refused to ambulate due to right foot pain. A review of the MAR and NPN dated 9/14/2025 indicated Resident 1 was not administered pain medication for the complaint of right foot pain on 9/14/2025. A review of Resident 1's Physician 1's PN, dated 9/23/2025 timed at 9:30 AM, the PN indicated Resident 1 was able to put weight on her right lower leg in the CAM boot (a walking boot to immobilize the foot and ankle after injury) with PT. A review of Nursing Progress Notes dated 9/25/2025 at 12:04 PM, indicated at 11:45 AM today during physical therapy session, Resident 1 was reported feeling weak. During the same interview on 11/6/2025 at 10:25 AM, CNA 1 stated he had taken care of Resident 1 on 9/22/2025 and Resident 1 had complained of right leg pain after the therapist helped her to walk the resident complained that her leg pain was getting worse but he does not know if he reported the resident's complained of pain. During the same interview on 11/6/2025 at 10:40 AM with CNA 1, CNA 1 started on one of Resident 1's shower days last month (October 2025) Resident 1 mentioned to him/her that her right leg was hurting more than usual. CNA 1 stated, it slipped my mind to mention Resident 1's complaint of leg pain on 9/22/2025 to a licensed nurse because he got busy with another resident. During the same interview on 11/6/2025 at 10:45 AM with CNA 1, CNA 1 stated, Resident 1 told him that the pain was more severe when walking with the therapist during the week of 9/14/2025 or the week of 9/21/2025, and Resident 1 needed more assistance with transferring and walking with the PT. CNA 1 stated, he noticed a progressive decline in the way Resident 1 transfers from the shower chair to the bed and noticed Resident 1 did not want to sit in the wheelchair during the weeks of 9/14/2025 to 9/25/2025 due to leg pain. During the same interview on 11/6/2025 at 10:50 AM with CNA 1, CNA 1 stated, it was around the end of August and beginning of September that Resident 1 would complain about pain of her right leg. CNA 1 stated, the last time Resident 1 was okay to be transferred was in mid-August. CNA 1 stated he noticed a decline in Resident 1's chair to chair or chair to bed transfer from mid-August to September because she would complain her leg would hurt. CNA 1 stated when he would roll Resident 1 to her left side and attempt to bend her right leg to change her adult briefs, Resident 1 told him to be careful, I do feel pain in that leg. During an interview on 11/6/2025 at 1:07 PM with LVN 2, LVN 2 stated Resident 1 had fallen 1 to 2 months before she was transferred to the GACH in September 2025. LVN 2 stated, Resident 1 had a greenish and purplish discoloration on her right ankle, LVN 1 stated that Resident 1's right ankle was tender to touch, and Resident 1 was not allowed to put weight on her right leg. LVN 2 stated, Resident 1 had generalized body pain and right foot pain. During an interview on 11/6/2025 at 1:13 PM with LVN 3, LVN 3 stated that Resident 1 was not walking. LVN 3 stated, she would ask Resident 1 if she wanted to walk to the restroom, and Resident 1 said, I cannot get up, I get my [adult briefs] changed. LVN 3 stated, she was not aware of Resident 1's physical restrictions. LVN 3 stated, she never saw Resident 1 walk because she was always lying in bed. During an interview on 11/6/2025 at 1:37 PM with CNA 2, CNA 2 stated that Resident 1 was mostly 056487 Page 3 of 5 056487 11/07/2025 Rio Hondo Subacute & Nursing Center 273 E Beverly Boulevard Montebello, CA 90640

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some independent for someone staying in bed. CNA 2 stated, Resident 1 needed assistance getting out of bed, but she was usually in bed when I took care of her. During an interview on 11/7/2025 at 1:47 PM with FM 1, FM 1 stated Resident 1 reported to her that her foot was hurting and that the resident often stayed in bed. FM 1 stated, on 9/25/2025, the GACH physician explained to her that Resident 1 had a blood clot in her leg for not being mobile. During the same concurrent interview and record review on 11/7/2025 at 2:50 PM with ADON 1, Resident 1's Nursing PN dated 8/14/2025 at 9:20 AM was reviewed. ADON 1 stated that before Resident 1's fall on 7/28/2025, Resident 1 was able to walk with the Restorative Nurse Aide (RNA) and walk to the bathroom with assistance from the nurses and her walker. The ADON stated, after Resident 1's fall on 7/28/2025, there was a decline in Resident 1's function, and Resident 1 was not mobile and needed more assistance. During the same current interview and record review on11/7/2025 at 2:55 PM with ADON 1, Resident 1's Assessment PN dated 8/26/2025 timed at 4:56 PM and MAR for August 2025 were reviewed. ADON 1 stated, she saw Resident 1 on 8/26/2025 Resident 1 complained of 3/10 mild right ankle pain with movement and tenderness to touch and she told the Charge Nurse (unknown) to provide pain management. ADON 1 stated, there was no documented evidence of pain assessment and reassessment and no documented evidence of Resident 1 receiving any pain management on 8/26/2025. During a concurrent interview and record review on 11/7/2025 at 3:50 PM with ADON 2, stated that the Evaluation indicated Resident 1 complained of right foot pain on 8/6/2025 during PT. ADON 2 stated that there was no documented evidence Resident 1 received pain management from 8/5/2025, 8/7/2025. The ADON 2 stated on 8/9/2025 Resident 1 did not received a stronger medication, and no record the physician responded to the message from the licensed nurse on 8/9/2025. ADON 2 stated there was no documented evidence of Resident 1's pain was accurately assessed for pain intensity, quality, frequency, and location. During an interview on 11/7/2025 at 4:20 PM with the ADON, the ADON stated, if a resident did not want to move, it could have been a sign of pain. The ADON stated, if Resident 1 was in pain, it made sense why Resident 1 never wanted to move or walk and preferred to stay in bed. During an interview on 11/7/2025 at 4:45 PM with the Director of Nursing (DON), the DON stated, pain assessment included documentation of the location, type, frequency, intensity, and duration of the pain. The DON stated, the pain reassessment should be completed after any pharmacological or non-pharmacological pain intervention to re-evaluate the effectiveness of the intervention. The DON stated, the pain reassessment should demonstrate and increase or decrease in the frequency, intensity, duration, location, and type of pain. A review of the PNP dated 8/26/2025 timed at 4:56 PM, indicated Resident 1 complained of right ankle pain level of 3, acute pain described as aching occurs with light touch or pressure, movement makes the pain worst and medication makes the pain better NP was made aware was ordered Resident 1 to receive Tylenol for one week. A review of the MAR indicated on 8/26/2025 Resident 1 was not administered pain medication. A review of the MAR for August 2025 and September 2025 indicated the Resident 1 received Tylenol 500 milligrams by mouth for the complaint of pain on the right malleolus three times a day every shift on 8/27/2025 to 9/5/2025.1. 8/27/2025 pain level 4/102. 8/28/2025-pain level 0/103. 8/29/2025-pain level 0/104. 8/30/2025-pain level 0/105. 8/31/2025-pain level 0/106. 9/1/2025-pain level 2/107. 9/2/2025-pain level 2/108. 9/3/2025-pain level 2/109. 9/4/2025-pain level 3/1010. 9/5/2025-pain level 0/10 A review of the MAR and the Nursing Progress Notes indicated no documented evidence that Resident 1 was assessed for type, frequency, intensity, and duration of the pain, provide pharmacological or non-pharmacological pain intervention and re-evaluate the effectiveness of the intervention. A review of the MAR and the Nursing Progress Notes on the following dates 8/29/2025, 8/30/2025, 9/8/2025 and 9/14/2025, Resident 1 had zero level of pain and no complaint of pain. However, the PT encounter notes reported Resident 1 056487 Page 4 of 5 056487 11/07/2025 Rio Hondo Subacute & Nursing Center 273 E Beverly Boulevard Montebello, CA 90640

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some had pain on the right foot and refused to ambulate due to pain. During an interview on 11/21/2025 at 9:40 AM with the DON, the DON stated that according to Resident 1's nursing progress notes and the MAR, Resident 1 had zero level of pain and had no complaints of pain during assessment on 8/29/2025, 8/30/2025, 9/8/2025 and 9/14/2025. The DON stated he was not aware that Resident 1 had complaint of pain with ambulation according to the PT's PN. DON explained as documented, at the time the licensed staff assessed Resident 1 for pain on 8/29/2025, 8/30/2025, 9/8/2025 and 9/14/2025, Resident 1 did not report having pain. During an interview with the Physical Therapy Assistant (PTA) on 11/21/2025 at 10:40 AM, stated Resident 1 complained of right leg pain during Physical therapy on 9/8/2025, ambulation which she reported to the nurse in charge of the resident on 9/8/25. During an interview on 11/21/2025 at 11:30 AM with the NP, stated the licensed nurses did not inform him about Resident 1's continued complaint of right leg pain during ambulation with the physical therapy on 8/5/2025, 8/29/2025, 8/30/2025, 9/8/2025 and 9/14/2025. NP stated if Resident 1 had continued right leg pain the resident should be evaluated for pain or sent to the hospital. NP started on 9/19/2025 during his visit, Resident 1 denied acute pain and he observed the right leg and ankle with a little bruise and was healing. 056487 Page 5 of 5