Health inspection·December 23, 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 two (2) of 2 sampled residents (Residents 1 and 2) received proper pain management by failing to have pain scale parameters to pain medications ordered when: Resident 1, who had returned from the general acute care hospital (GACH) after a right hip hemiarthroplasty (a surgical procedure that involves replacing half of the hip joint), had a physician's order for Tramadol Hydrochloride (drug commonly used to treat severe pain) as needed (PRN) for pain without a pain scale parameter (mild, moderate, or severe pain). Resident 2 had a physician's order for Tramadol Hydrochloride and Tylenol Extra Strength (drug which reduces fever and relieves minor aches and pain) PRN for pain without a pain scale parameter.This deficient practice had the potential for Residents 1 and 2's pain not to be managed which could result in negatively affecting the residents' overall well-being. Findings: 1. During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE], with the diagnoses including but not limited to atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), dementia (progressive brain disorder that slowly destroys memory and thinking skills), and age-related osteoporosis (weakening of bones, leading to a decrease in bone density and an increased risk for fractures). During a review of Resident 1's care plan, dated 10/1/2025, the record indicated Resident 1 was at risk for alteration in comfort related to pain. The staff's intervention was to monitor/record/report to nurse when resident complaints of pain or requests for pain treatment. During a review of Resident 1's Minimum Data Set (MDS, a resident's assessment tool), dated 10/6/2025, the record indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making were severely impaired. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steading and/or contact guard assistance as resident completes activity) for sitting to lying, toilet transfer, and walking 50 feet. During a review of Resident 1's Radiology Results Report, dated 12/12/2025, the report indicated Resident 1 had an acute nondisplaced subcapital femoral fracture (a type of fracture that occurs below the femur's [bone of the thigh] head). During a review of Resident 1's GACH record, dated 12/13/2025, the record indicated Resident 1 had a surgical procedure for right hip hemiarthroplasty. During a review of Resident 1's Order Summary Report, dated 12/19/2025, the order indicated as follows:Tramadol Hydrochloride (HCl) oral tablet 50 milligrams (mg, unit of measurement): Give one (1) tablet by mouth every eight (8) hours as needed for pain; Hold for respiratory rate (RR) less than 12.Tramadol HCl oral tablet 50 mg: Give 1 tablet by mouth two times a day for pain management; Hold for RR less than 12. Tylenol Extra Strength (pain reliever medication) oral tablet 500 mg: Give 1 tablet by mouth two times a day for pain management; not to exceed (NTE) three (3) grams (gm, unit of measurement)/24 hours.During an interview on 12/22/2025 at 1:19 PM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 1 returned from GACH on 12/19/2025 after her right hip arthroplasty Residents Affected - Some Page 1 of 3 555272 555272 12/23/2025 Atherton Baptist Home 214 South Atlantic Blvd. Alhambra, CA 91801

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 555272 Page 2 of 3 555272 12/23/2025 Atherton Baptist Home 214 South Atlantic Blvd. Alhambra, CA 91801

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. 555272 Page 3 of 3