Health inspection·December 23, 2025

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some surgery. LVN 1 stated the physician had ordered routine Tramadol and Tylenol and PRN Tramadol for pain. LVN 1 stated there was a scale for mild, moderate, or severe pain, so pain medications were administered from lower to higher ratings depending on how the resident categorized their pain level. LVN 1 stated based on Resident 1's pain level, LVN 1 would need to clarify the Tramadol order with the physician and get an alternative. During a concurrent interview and record review of Resident 1's Order Summary Report on 12/22/2025 at 1:56 PM with LVN 1, LVN 1 stated the PRN Tramadol order did not have a scale and only indicated as needed for pain. LVN 1 stated since there was no pain scale noted on the physician's order for the PRN Tramadol, the pain medication could be administered if the resident complained of any pain from level 1 through 10. During a concurrent interview and record review of Resident 1's Order Summary Report on 12/22/2025 at 3:11 pm with LVN 2, LVN 2 stated PRN Tramadol should specify moderate to severe pain. LVN 2 stated Resident 1 should not receive Tramadol for mild pain. LVN 2 stated the licensed nurse would over medicate Resident 1 if Resident 1 complained of mild pain and Tramadol 50 mg was administered. LVN 2 stated that over medicating a resident could cause the respiratory rate to slow down which could result in vital organs to shut down. During a concurrent interview and record review of Resident 1's Order Summary Report on 12/22/2025 at 3:48 PM with the Director of Nursing (DON), the DON stated pain medications orders should include the dose, frequency, routine, and parameter for the pain rate. The DON stated Tramadol was usually used for breakthrough pain and given for moderate pain. The DON stated there should always be parameters for pain medication and there was no parameter for Resident 1's pain medication Tramadol. The DON stated pain scale parameters were included to ensure the licensed nurses administered the right medication for the right rate of pain. The DON stated residents could have side effects such as drowsiness if they were over medicated with pain medication. The DON stated residents could experience ineffective pain relief if they were undermedicated with pain medication. 2. During a review of Resident 2's admission Record, the admission record indicated Resident 2 was admitted to the facility on [DATE], with the diagnoses including but not limited to dementia, muscle weakness, and pain in right hip. During a review of Resident 2's care plan, dated 3/20/2025, the care plan indicated Resident 2 had an alteration in comfort related to chronic pain. The staff interventions were to administer Tylenol Extra Strength tablet 500 mg by mouth every six (6) hours as needed for pain, administer analgesia (relief or absence of pain) Tylenol, Lidocaine (topical anesthetic to provide localized pain relief), Tramadol as per orders, and monitor/record/report to nurse resident complaints of pain or requests for pain treatment. During a review of Resident 2's Order Summary Report, dated 3/27/2025, indicated as follows:Tylenol Extra Strength tablet 500 mg: Give one tablet by mouth every 6 hours as needed for pain not to exceed 3 grams/24 hours. Tylenol Extra Strength tablet 500 mg: Give one tablet by mouth two times a day for pain management NTE 3 gm/24 hrs.Tramadol HCl oral tablet 50 mg: Give one tablet by mouth every eight hours as needed for pain management (hold if RR is less than 12 and call physician). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 2 required substantial/maximal assistance (helper does more than half the effort) for toileting hygiene, shower/bathing self, upper and lower body dressing, and sitting to standing. During a concurrent interview and record review of Resident 2's Order Summary Report on 12/22/2025 at 4:50 PM with the DON, the DON stated Resident 2 had two PRN pain medications, Tylenol and Tramadol. The DON stated both of Resident 2's PRN pain medications should have and did not have pain scale parameters. The DON stated the pain medication parameters were important to ensure the licensed nurses knew which pain medication to administer based on the resident's pain level. During a record review of the facility's policy and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555272 If continuation sheet Page 2 of 3 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 555272 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atherton Baptist Home 214 South Atlantic Blvd. Alhambra, CA 91801 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete procedure (P&P) titled, Medication Orders, revised 11/2014, the policy indicated PRN Medication Orders When recording PRN medication orders, specify the type, route, dosage, frequency, strength and the reason for administration. During a record review of the facility P&P titled Pain assessment and Management, reviewed October 2022. The policy indicated the purposes of this procedure are to help the staff identify pain in the residents and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. In general guidelines number 3. Pain management is a multidisciplinary care process that includes the following: a. Assessing the potential for pain; b. Recognizing the presence of pain; c. Identifying the characteristics of pain; d. Addressing the underlying causes of the pain; e. Developing and implementing approaches to pain management; f. Identifying and using specific strategies for different levels and sources of pain; g. Monitoring for the effectiveness of interventions; and h. Modifying approaches as necessary. Event ID: Facility ID: 555272 If continuation sheet Page 3 of 3