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
observation, interview, and record review, the facility failed to administer pain medication for the appropriate
pain scale as indicated by the physician ' s orders for one of two residents (Resident 1) reviewed for pain
management.
Residents Affected - Few
This deficient practice had the potential to cause Resident 1 further discomfort and pain.
Findings:
A review of the facility ' s admission Record indicated Resident 1 was admitted on [DATE] with diagnoses
which included a fracture of the right humerus (a broken right upper arm bone), lack of coordination, and
muscle weakness.
A review of the Minimum Data Set (MDS, an assessment tool) dated 9/21/24, indicated Resident 1 was
cognitively intact with a BIMS (assessment of cognition) score of 14.
A review of the physician ' s orders dated 9/20/24 indicated, Oxycodone HCL Oral Tablet 5mg Give 1 tablet
by mouth every 4 hours as needed for moderate pain . and Oxycodone HCl Tablet 10mg Give 1 tablet every
4 hours as needed for Severe Pain Score 7-10 for 7 days .
On 9/24/2024 at 12:37 P.M., an observation was conducted in Resident 1 ' s room. Resident 1 was sitting in
her wheelchair, and her right arm was placed in a sling. Resident 1 was observed with facial grimacing,
quietly moaning, with the left hand placed over the right shoulder. Resident 1 stated she was in pain and
wanted pain medication.
During a medication pass observation on 9/24/24 at 12:47 P.M., Licensed Nurse (LN 1) asked Resident 1 to
rate her pain on a scale of one to ten, with ten being the worst pain. Resident 1 stated she had 8/10 pain to
the right arm. LN 1 was observed reviewing Resident 1 ' s Medication Administration Record. LN 1 took a
medication out of the narcotic drawer and placed one pill into a medication cup, and administered it to
Resident 1. LN 1 stated [Resident 1] can have Oxycodone 5mg for severe pain, but if her pain is less than
7, I give her Tylenol .
On 9/24/24 at 1:10 P.M., a concurrent interview and record review was conducted with LN 1. A review of the
physician ' s orders dated 9/20/24 indicated, Oxycodone HCL Oral Tablet 5mg Give 1 tablet by mouth every
4 hours as needed for moderate pain . and Oxycodone HCl Tablet 10mg Give 1 tablet every 4 hours as
needed for Severe Pain Score 7-10 for 7 days . LN 1 stated .(Resident 1) is allowed to have 10mg for
severe pain .but I didn ' t see it . LN 1 stated since Resident 1 reported severe pain, Oxycodone 10mg
should have been administered. LN 1 stated it was important to manage pain .to make
(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:
555158
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
555158
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/24/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
El Centro Post-Acute Care
1700 S. Imperial Ave
El Centro, CA 92243
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)
F 0697
sure the resident is comfortable, its important for healing also .
Level of Harm - Minimal harm
or potential for actual harm
A review of Resident 1 ' s EMAR (Electronic Medical Administration Record) indicated Resident 1 received
Oxycodone 5mg with a severe pain level instead of Oxycodone 10mg, on the following days:
Residents Affected - Few
-9/21/24 at 3:09 A.M. for a pain level of 9/10
-9/21/24 at 12:24 P.M. for a pain level of 7/10
-9/21/24 at 4:50 P.M. for a pain level of 7/10
-9/22/24 at 5:45 A.M. for a pain level of 9/10
-9/24/24 at 1:13 P.M. for a pain level of 8/10
On 9/24/24 at 2 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated her
expectation was .for the resident to maintain a manageable pain level . The DON stated Resident 1 should
have been given Oxycodone 10mg for a pain level of 7 or above, instead of Oxycodone 5mg. The DON
stated by not administering the appropriate dose to address Resident 1 ' s pain, Resident 1 was at risk for
further discomfort and a delay of healing.
A review of the facility policy titled Pain—Clinical Protocol revised 10/22 indicated, .The staff and
physician will identify the characteristics of pain such as location, intensity, frequency, pattern, and severity
.staff will use a consistent approach and a standardized pain assessment instrument appropriate to the
resident ' s cognitive level .Staff will provide the elements of .appropriate physical .interventions .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555158
If continuation sheet
Page 2 of 2
