Other·June 12, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public health during the investigation of a complaint. Intake Number: CA00614451 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Representing the Department: HFEN 40587 and HFES 37568 A complaint, Intake Number: CA00614451, was substantiated. Federal deficiencies were cited at F-689 and F-697.

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review the facility failed to supervise a resident with dysphagia (difficulty swallowing) when eating for 1 out of 3 sampled residents (3). As a result Resident 3 was placed at risk for choking. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8Q3V11 Facility ID: CA080000065 If continuation sheet 1 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056105 (X3) DATE SURVEY COMPLETED 05/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BALBOA NURSING & REHABILITATION CENTER 3520 4th Ave San Diego, CA 92103 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 12/07/18 Resident 3 was admitted to the facility with diagnosis which included dysphagia following a stroke per the Admission Record. On 12/20/18 at 9:15 A.M., an observation of Resident 3 was conducted. Resident 3 was alone in his room trying to feed himself. Resident 3 fed himself 5 consecutive bites of pureed sausage and eggs. On 12/20/18 at 9:25 A.M., an interview was conducted with CNA 1. CNA 1 stated it was her responsibility to feed Resident 3. CNA 1 stated she had left Resident 3's room to assist other residents. CNA 1 stated Resident 3 only needed assistance with eating because he could not use his left arm. CNA 1 stated because Resident 1 did not receive thickened liquids he was not at risk for choking. On 12/20/18 at 10:55 A.M., LN 1 was interviewed. LN 1 stated she cared for Resident 3 often and had completed Resident 3's admission assessment. LN 1 stated Resident 3 had difficulty swallowing due to a recent stroke and was at risk for choking and aspiration. LN 1 stated Resident 3 was supposed to have one staff member assigned to him when eating and drinking. LN 1 stated Resident 3's swallowing difficulties had been assessed by the speech therapist who then provided swallowing instructions to the nursing staff. LN 1 stated Resident 3 was to swallow two times per bite and alternate bites of food with liquids. LN 1 said "Resident 3 should never eat alone." LN 1 stated she was unaware CNA 1 had left Resident 3 alone while assisting Resident 3 with breakfast. LN 1 stated it was her responsibility to supervise nurse assistants who fed residents. On 12/26/18 at 10:20 A.M., an interview was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8Q3V11 Facility ID: CA080000065 If continuation sheet 2 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056105 (X3) DATE SURVEY COMPLETED 05/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BALBOA NURSING & REHABILITATION CENTER 3520 4th Ave San Diego, CA 92103 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE conducted with the speech therapist. The speech therapist stated she had screened Resident 3 when he was admitted to the facility at the beginnning of December 2018. The speech therapist stated Resident 3 had recently had a stroke and participated in speech language therapy for his diagnosis of dysphagia (difficulty swallowing). The speech therapist stated the plan was for CNA's to feed Resident 3 in the dining room which was supervised by nurses. The speech therapist stated the facility had previously identified problems with CNA's leaving resident's in their rooms to eat unsupervised. On 1/2/19 at 9:54 A.M., an interview was conducted with Resident 3's family member (FM). FM stated Resident 3 had difficulty swallowing his food. FM 3 stated he believed the skilled nursing facility knew Resident 3 was at risk for choking because of his stroke diagnosis and ground food diet. FM 1 stated the facility knew his family member was at risk for choking and there was a plan for Resident 3 to have assistance when eating. Resident 3's record was reviewed. Under ADL's Eating: Resident 3 was listed as needing extensive assistance, support provided with one person physical assist. Per the Speech Therapist progress note, dated 12/16/18 "...Impact on Burden of Care/Daily Life...With 1:1 supervision during meals for safety and cuing...Precautions...dysphagia diet puree with thin liquids... per the physician's order dated 12/14/19, "...1:1 supervision ..."

F697 SS=G Pain Management CFR(s): 483.25(k) FORM CMS-2567(02-99) Previous Versions Obsolete

F697 Event ID: 8Q3V11 Facility ID: CA080000065 If continuation sheet 3 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056105 (X3) DATE SURVEY COMPLETED 05/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BALBOA NURSING & REHABILITATION CENTER 3520 4th Ave San Diego, CA 92103 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.25(k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, for 2 of 3 sampled residents (1,2), the facility failed to: 1. Analyze and address reoccurring high levels of pain documented on the Electronic Medication Administration Record (EMAR). 2. Re-evaluate the resident's pain management goals and revise an effective pain management care plan with the resident and members of the healthcare team. 3. Address the consulting pharmacist's recommendations in a timely manner. 4. Report to the physician in a timely manner when pain medication was ineffective. As a result, Resident 1 experienced uncontrolled pain which affected his emotional and mental status and his approach to life. Severe pain affected Resident 1's ability to progress in physical therapy (therapy for the restoration of movement and physical functionPT) which caused the discontinuation of physical therapy services. Resident 2 experienced uncontrolled pain which resulted in his inability to get out of bed, use a bed pan (equipment used for relieving bowels or bladder while in bed) or receive a shower. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8Q3V11 Facility ID: CA080000065 If continuation sheet 4 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056105 (X3) DATE SURVEY COMPLETED 05/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BALBOA NURSING & REHABILITATION CENTER 3520 4th Ave San Diego, CA 92103 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1. Resident 1's medical record was reviewed. Resident 1 was admitted to the facility on 10/5/18, following a hospitalization for an intraspinal abscess (a collection of pus and germs in the spine), granuloma (inflammation), and discitis (infection in the discs between vertebrae), per the facility's Admission Record. A review of the hospital Transfer Summary, dated 10/5/18, indicated Resident 1 had a laminectomy (a surgical operation which removed one or more backbones to relieve pressure on the spinal nerves) and he had been given morphine (a pain medication) and Norco (a pain medication) for back pain. The hospital notes indicated pain medication given to Resident 1 at the hospital had improved his pain. A review of the Minimum Data Set (an assessment tool- MDS), dated 10/12/18, indicated Resident 1 had a BIMS of 15 (a BIMS of 13-15 indicated a person is mentally intact). The MDS pain assessment indicated Resident 1 had a pain scale of 4 (on a pain scale of 0-10 with 0 being no pain and 10 being the worst pain). Per the MDS notes, Resident 1's pain had not limited his activities and the intensity of Resident 1's pain was left blank. Resident 1's care plan interventions for back pain, dated 10/5/18, indicated Resident 1 should have been assessed for the effectiveness of pain medication and licensed nurses (LN's) were to notify the physician if pain was unrelieved. A review of physician orders, dated 10/5/18, indicated Resident 1's physician ordered: 1. Morphine 15 milligrams (mg) every night before bed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8Q3V11 Facility ID: CA080000065 If continuation sheet 5 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056105 (X3) DATE SURVEY COMPLETED 05/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BALBOA NURSING & REHABILITATION CENTER 3520 4th Ave San Diego, CA 92103 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2. Norco 5/325 (5 mg of codeine and 325 mg of acetaminophen) mg every 6 hours as needed for severe pain. 3. Norco 10/325 (10 mg of codeine and 325 mg of acetaminophen) mg every 6 hours as needed for breakthrough pain (pain which had not been relieved with another medication). On 10/6/18, LN's documented in the nursing notes that Resident 1 had pain unrelieved by medication and the physician was contacted. The physician discontinued the morphine, and Norco and ordered: 1. Oxycodone (a pain medication) 5 mg every 4 hours as needed for moderate pain 2. Oxycodone 10 mg every 4 hours as needed for severe pain. Per the facility policy, titled Pain Management, dated January 2018, LNs were to assess Resident 1's pain, document the assessment, administer pain medication per the physician's orders and re-assess pain one to two hours after the pain medication was given. If pain was unrelieved, nurses were to notify the physician. According to the EMAR, dated 10/1-10/31/18, LN's documented Resident 1's pre-medication pain assessment pain scale was never less than 6. No nursing documentation was found indicating the licensed nurses had notified Resident 1's physician when Resident 1's pain medication was ineffective from 10/7/18 through 10/23/18. According to the Weekly Summary, dated 10/23/18, the Assistant Director of Nursing (ADON) documented Resident 1 verbalized his pain medication was not effective. On 10/24/18 LN 4 documented Resident 1's physician ordered a pain consultation (physician who FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8Q3V11 Facility ID: CA080000065 If continuation sheet 6 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056105 (X3) DATE SURVEY COMPLETED 05/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BALBOA NURSING & REHABILITATION CENTER 3520 4th Ave San Diego, CA 92103 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE specializes in treating pain). On 10/29/18, the LNs documented Resident 1 was sent to the hospital. When Resident 1 returned to the facility on 11/2/18, the pain consultation was not re-ordered. On 11/11/18, the LN's documented in the nursing notes that Resident 1's pain increased and the physician was notified. Resident 1's physician ordered oxycodone 20 mg, every 4 hours as needed, and discontinued the previous oxycodone orders. Per the physician's orders, dated 11/15/18, a consultation with a pain specialist (physician who specializes in treating pain) was ordered. According to Resident 1's EMAR, dated 11/16/18 through 11/18/18, LNs documented Resident 1's pain medication was "ineffective" 5 times. There was no documentation indicating the LNs notified Resident 1's physician the pain medication was ineffective during that time. Per the notes of the pain consultant dated 11/19/18, Resident 1 was examined and no changes were made to his medications. According to the EMAR, dated 11/23/18 through 11/28/18, LNs documented Resident 1's pain medication was "ineffective" 7 times. There was no documentation found indicating the LNs notified Resident 1's physician the pain medication was ineffective from 11/23/18 to 11/28/18. On 12/20/18, at 10:42 A.M., an observation and interview was conducted with Resident 1. Resident 1 was lying in bed. Resident 1 stated from the day of admission on 10/5/18, until 12/10/18, his pain was "horrible", the pain FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8Q3V11 Facility ID: CA080000065 If continuation sheet 7 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056105 (X3) DATE SURVEY COMPLETED 05/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BALBOA NURSING & REHABILITATION CENTER 3520 4th Ave San Diego, CA 92103 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE medication did not work "even a little" and he had been "absolutely miserable". Resident 1 stated the pain made him feel irritated, frustrated and he had given up and did not care anymore. Resident 1 stated from 10/5-12/10/18, he had experienced "tremendous pain" in his back every time his brief (an adult diaper) was changed, during transfer from bed to wheelchair and when he had been moved by staff. Resident 1 stated, during physical therapy (therapy for the restoration of movement and physical function), he told the staff he had pain and the staff had not changed his position or provided pain medication. Resident 1 stated when he had complained about severe pain during his physical therapy, his sessions ended. Resident 1 further stated he had experienced so much pain that he could not sleep, could not lay flat and suffered constant burning, stabbing pain in his back and nothing alleviated it. Resident 1 stated "I would have tried anything to get pain relief." Resident 1 stated from 10/5-12/20/18, his pain had never been below a 6. Resident 1 stated he had never reported a pain level of "zero" to the nurses. Resident 1's record was reviewed. Per the physician's order, dated 11/2/18, Resident 1's pain levels were to be assessed each shift. Per Resident 1's EMAR, LN's documented Resident 1's pain levels each shift as follows: 11/1-11/30/18, a "0" was entered 36 times. 12/1-12/10/18, a "0" was entered 43 times. Resident 1's EMARs, dated 10/1/18- 11/30/18, indicated LNs documented Resident 1's premedication pain levels were never less than 6. Resident 1's EMAR, dated 12/1-12/10/18 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8Q3V11 Facility ID: CA080000065 If continuation sheet 8 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056105 (X3) DATE SURVEY COMPLETED 05/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BALBOA NURSING & REHABILITATION CENTER 3520 4th Ave San Diego, CA 92103 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated LNs documented Resident 1's premedication pain assessment pain scale was never less than 5. Per the EMAR, the re-assessment of Resident 1's pain, after pain medication was given, was documented by the LNs as follows: 10/1-10/31/18, a "0" was entered 100 times. 11/1-11/30/18, a "0" was entered 71 times. 12/1-12/10/18, a "0" was entered 37 times. On 12/20/18 at 11:20 A.M., an interview with LN 4 was conducted. LN 4 stated the pain specialist visited the facility weekly and any resident in the facility could have been added to his list to be seen. On 12/26/18, at 11:10 A.M, a joint interview and record review was conducted with LN 1. LN 1 reviewed Resident 1's EMAR premedication pain assessment, dated 12/26/18, at 10 A.M. LN 1 stated she had recently documented a zero for Resident 1's pain scale. LN 1 further stated she documented Resident 1's pain scale as a zero because the pain medication was routine. On 12/26/18, at 3:15 P.M., an interview was conducted with Resident 1. Resident 1 stated, on 12/26/18, he told the medication nurses his pain level was a 7 at 10 A.M., and a 7.5 at 2 P.M. On 12/26/18, at 3:34 P.M., an interview and joint record review was conducted with LN 2. LN 2 reviewed Resident 1's EMAR dated 12/26/18, at 2 P.M., and stated Resident 1 had told him his pain was a 7.5. LN 2 further stated "I documented a zero." On 1/3/19, at 4 P.M., a telephone interview was conducted with FAM 1. FAM 1 stated, following FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8Q3V11 Facility ID: CA080000065 If continuation sheet 9 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056105 (X3) DATE SURVEY COMPLETED 05/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BALBOA NURSING & REHABILITATION CENTER 3520 4th Ave San Diego, CA 92103 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 1's admission to the facility, he had sounded sad, not upbeat like usual. FAM 1 stated Resident 1 said he had given up and "I quit" due to the pain. FAM 1 stated she had observed he had been uncomfortable lying in bed. FAM 1 stated she had observed Resident 1 reporting his pain to direct care staff during care and when transferred out of bed. On 1/11/19, at 8:35 A.M., an interview and joint record review was conducted with the DOR. The DOR reviewed the Occupational Therapy (therapy for self-care skills-OT) and Physical Therapy (PT) notes for Resident 1, dated 10/810/11/18. The DOR stated Resident 1 had experienced severe pain during therapy and prevented Resident 1 from fully participating in therapy. The DOR stated there was no documentation indicating nursing or Resident 1's physician had been notified of Resident 1's pain. The DOR stated he had not reported Resident 1's pain to the physician. The DOR reviewed the OT and PT weekly evaluations for Resident 1, dated 10/1610/24/18. The DOR stated Resident 1 had complained of low back and rib pain during therapy. The DOR stated Resident 1 had been given pain medication prior to therapy and still experienced pain at a level that required modification of exercises or ending therapy sessions. The DOR stated on 11/24/18, due to severe pain limiting Resident 1's progress during therapy sessions, his Physical Therapy and Occupational Therapy was discontinued. On 1/11/19, at 2:20 P.M., an interview was conducted with LN 3. LN 3 stated she had been responsible for administering Resident 1's pain medications and he had usually reported that his pain scale was an 8. LN 3 stated she had FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8Q3V11 Facility ID: CA080000065 If continuation sheet 10 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056105 (X3) DATE SURVEY COMPLETED 05/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BALBOA NURSING & REHABILITATION CENTER 3520 4th Ave San Diego, CA 92103 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE not noticed Resident 1's pain medication was ineffective. LN 3 stated she had not analyzed previous LNs documentation regarding Resident 1's pain medication effectiveness, because it was difficult to retrieve and view the data within the computer system. LN 3 stated if a resident continued to have severe pain, the physician should have been notified. On 1/11/19, at 3:43 P.M., an interview was conducted with the Pharmacist (Pharm 1). Pharm 1 stated Resident 1's pain medications were reviewed on 10/26/18. Pharm 1 stated he notified the DON Resident 1's pain needed to be reassessed, because Resident 1 had taken PRN (as needed) pain medication around the clock and continued to have high levels of pain. Pharm 1 stated he was aware the facility failed to follow up or take action on his recommendations for two months. On 1/17/19, at 10:12 A.M., an interview was conducted with the DON. The DON stated the LNs did not correctly analyze the pain information gathered from each shift for Resident 1. The DON stated the nurses did not consistently report to Resident 1's physician when the pain medication was not effective. The DON further stated the facility did not anticipate the resident's pain management needs and instead waited for the resident's to report high levels of pain. The DON stated the pain management program had not been revised in a timely manner for Resident 1 and as a result, Resident 1 experienced uncontrolled pain. The DON stated the team had discussed Resident 1's pain but failed to follow the facility's policy to provide an effective pain management program. The DON further stated she failed to address the pharmacist's recommendations on 10/26/18, to re-evaluate Resident 1's pain medication and interventions, until December. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8Q3V11 Facility ID: CA080000065 If continuation sheet 11 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056105 (X3) DATE SURVEY COMPLETED 05/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BALBOA NURSING & REHABILITATION CENTER 3520 4th Ave San Diego, CA 92103 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 1/18/19, at 4:10 P.M., an interview was conducted with the Medical Director (MD). The MD stated Resident 1's severe pain had not been resolved quickly. The MD stated the LNs had not performed an analysis of pain assessments for Resident 1. The MD stated the LNs had not consistently communicated with Resident 1's physician when pain medication had been ineffective. The MD stated the facility's pain management program needed to be improved. On 1/18/19, at 4:40 P.M., an interview was conducted with the ADM. The ADM stated members of the healthcare team needed to meet with the MD more frequently to address and evaluate resident's pain management programs in a timely manner. Per the facility's policy, dated January 2018, titled Pain Management, "Purpose, the purpose of this procedure is to assess the resident's pain level and provide optimal comfort through a pain control plan which is mutually established with the resident, family and members of the health care team. General Guidelines ...3. Continuing assessment of the pain management program will occur daily and will focus on the effectiveness of the program and the comfort level of the resident. Procedure ...9. If pain is ... not relieved with current medication, the physician will be notified for review of medication ...10. Acceleration of interventions will be reflected in the resident's care plan ...." 2. Resident 2's medical record was reviewed. Resident 2 was admitted on 5/27/18, with diagnoses which included pain in the right and left hips, and fractures of the right and left hips, per the facility's admission record. Per the hospital ICU Admission H&P (History and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8Q3V11 Facility ID: CA080000065 If continuation sheet 12 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056105 (X3) DATE SURVEY COMPLETED 05/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BALBOA NURSING & REHABILITATION CENTER 3520 4th Ave San Diego, CA 92103 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Physical), Resident 2's pain was managed with Fentanyl (a pain medication) and lidocaine patches (a pain medication delivered through the skin on a patch). According to physical therapy and occupational therapy notes, dated 5/28/18 through 7/4/18, Resident 2 had been evaluated by orthopedic surgeons for surgical repair of the hip fractures and had not received the surgical procedure yet. Resident 2's care plan interventions for hip pain, dated 5/28/18, indicated Resident 2 was to be assessed for pain medication effectiveness, and to notify the physician if pain was unrelieved through nursing interventions or medications. According to the Order Summary Report, signed 11/2/19, Resident 2 had physician's orders for: 1. Lidocaine patches to be applied to both hips daily. 2. Oxycodone (a pain medication) 5 milligrams (mg) every four hours as needed for moderate pain 3. Oxycodone 7.5 mg every 4 hours as needed for severe pain Per the facility policy, titled Pain Management, dated January 2018, LNs were to assess the resident's pain, document the assessment, give pain medication per the physician's orders and re-assess pain one to two hours after pain medication was given. If pain was unrelieved, nurses were to notify the physician. According to the Nursing Weekly Summary, dated 11/5/18, Resident 2 continued to wait for the surgeon to approve and arrange surgical repair of the two hip fractures. The LN documented Resident 1 stated he was "looking forward to the day when he will be able to walk FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8Q3V11 Facility ID: CA080000065 If continuation sheet 13 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056105 (X3) DATE SURVEY COMPLETED 05/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BALBOA NURSING & REHABILITATION CENTER 3520 4th Ave San Diego, CA 92103 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE again without being in pain." According to the Electronic Medication Administration Record (EMAR) notes, dated 11/10/18, the LNs had documented Resident 2's pain medication was "ineffective" at 10:30 A.M., and 2:30 P.M. No documentation was found that LNs notified Resident 2's physician. According to the nursing notes, dated 11/13/18, the LNs documented Resident 2 had been encouraged to get out of bed and he had stated he could not get out of bed due to pain. On 11/15/18, the LNs documented Resident 2 could not shower or be weighed due to pain. No new care plan interventions were documented by the LN's addressing Resident 1's inability to complete self-care due to pain. According to the nursing notes, dated 11/16/18, the LNs documented an attempt had been made to transfer Resident 2 out of his bed and the transfer was unsuccessful due to pain. The LNs documented Resident 2 had been given pain medication prior to the attempted transfer. The LNs documented Resident 2 would be seen by the pain specialist (physician who specializes in treating pain) on 11/16/18. According to a later entry, Resident 2's pain specialist visit did not occur until 11/19/18. On 11/19/18, the Pain Consultant (physician who specializes in treating pain) assessment stated Resident 2 had "Chronic pain due to ...bilateral (both sides) femur (leg bone) fractures, chronic low back pain, chronic neck pain, chronic bilateral hip pain, failed back syndrome, [and] failed neck syndrome (unsuccessful surgical procedure on the back or neck leading to chronic pain)." The pain consultant documented Resident 2's hips were "very tender to touch." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8Q3V11 Facility ID: CA080000065 If continuation sheet 14 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056105 (X3) DATE SURVEY COMPLETED 05/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BALBOA NURSING & REHABILITATION CENTER 3520 4th Ave San Diego, CA 92103 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE According to the Consultant Pharmacist's Medication Regimen Review, dated 11/27/18, the consulting pharmacist recommended Resident 2's physician re-evaluate Resident 2's pain due to frequent use of pain medication. On 11/30/18, LNs documented in the nursing notes that Resident 2's physician was notified of the pharmacist's recommendations and no changes were made. On 12/20/18, at 9:50 A.M., an observation and interview was conducted with Resident 2. Resident 2 was lying in bed. Resident 2 stated he could not get out of bed due to pain. Resident 2 stated staff attempted to get him out of bed with a mechanical lift (an assistive device that allows patients with limited mobility to be transferred out of bed) and despite having taken pain medication ahead of time, he could not tolerate being moved due to the pain. Resident 2 stated the staff tried a second time but he could not tolerate being moved due to pain. On 12/20/18, at 11:05 A.M., an interview was conducted with CNA 5. CNA 5 stated when Resident 2 complained of pain, she reported it to the nurse. CNA 5 further stated after the nurses gave Resident 2 his pain medication, he would call and say he was still in pain. On 12/26/18, at 10:13 A.M, an interview was conducted with The Director of Rehabilitation (DOR). The DOR stated Resident 2 had a lot of pain "all the time" and refused therapy due to pain. The DOR stated Resident 2 would agree to therapy, and when he tried to move Resident 2, he yelled "Lay me back down!" The DOR stated he attempted to transfer Resident 2 on 11/16/18 and Resident 2 screamed in pain. On 12/26/18, at 10:31 A.M., an interview was conducted with CNA 6. CNA 6 stated Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8Q3V11 Facility ID: CA080000065 If continuation sheet 15 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056105 (X3) DATE SURVEY COMPLETED 05/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BALBOA NURSING & REHABILITATION CENTER 3520 4th Ave San Diego, CA 92103 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2 experienced pain when he was moved and had stayed in bed all of the time due to pain. On 1/11/19, at 10:55 A.M., an interview was conducted with CNA 2. CNA 2 stated Resident 2 had asked for a shower. CNA 2 stated while transferring Resident 2 out of bed, Resident 2 had a lot of pain and clenched his teeth due to pain throughout the shower. CNA 2 stated Resident 2 could not tolerate getting up for showers after that, due to pain. On 1/11/19, at 11:30 A.M., an interview was conducted with CNA 3. CNA 3 stated resident 2 was always in pain. CNA 3 stated Resident 2 was continent of bowels (able to control bowel movements) and was unable to use a bed pan because of the pain. CNA 2 further stated Resident 2 had to have bowel movements on a disposable pad while lying in bed. On 1/17/19, at 10:12 A.M., an interview was conducted with the DON. The DON stated the nurses did not consistently report to Resident 2's physician when the pain medication was not effective. The DON further stated the facility did not anticipate the resident's pain management needs and instead waited for the resident's to report high levels of pain. The DON stated the pain management care plan had not been revised in a timely manner for Resident 2 and as a result, Resident 2 experienced episodes of uncontrolled pain. The DON stated the team had discussed Resident 2's pain but failed to follow the facility's policy to provide an effective pain management program for Resident 2. On 1/18/19, at 4:10 P.M., an interview was conducted with the Medical Director (MD). The MD stated Resident 2's severe pain had not been resolved quickly. The MD stated the LN's had not communicated with Resident 2's physician when pain medication had been FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8Q3V11 Facility ID: CA080000065 If continuation sheet 16 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056105 (X3) DATE SURVEY COMPLETED 05/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BALBOA NURSING & REHABILITATION CENTER 3520 4th Ave San Diego, CA 92103 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ineffective. The MD stated the pain management program needed improvement. On 1/18/19, at 4:40 P.M., an interview was conducted with the ADM. The ADM stated members of the healthcare team needed to meet with the MD more frequently to address and evaluate Resident 2's pain management in a timely manner. Per the facility's policy, dated January 2018, titled Pain Management, "Purpose, The purpose of this procedure is to assess the resident's pain level and provide optimal comfort through a pain control plan which is mutually established with the resident, family and members of the health care team. General Guidelines ...3. Continuing assessment of the pain management program will occur daily and will focus on the effectiveness of the program and the comfort level of the resident. Procedure ...9. If pain is ... not relieved with current medication, the physician will be notified for review of medication ...10. Acceleration of interventions will be reflected in the resident's care plan ...." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8Q3V11 Facility ID: CA080000065 If continuation sheet 17 of 17