Health inspection·January 17, 2024

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm Based on interview and record review, this requirement was not met when the facility failed to provide pain medication as ordered to one of five sampled residents (Resident 1). This caused Resident 1 to have significant back pain, interrupted his sleeping patterns, and had the potential to negatively affect his health. Residents Affected - Few Findings A review of Resident 1's admission Record, dated 1/12/24, indicated he was admitted to the facility after being hospitalized for pneumonia (an infection of the lungs), and he had a history of back pain. A review of Resident 1's discharge medication list from an acute care hospital on 1/12/24 indicated that Resident 1 should continue to receive pain medication Norco (a narcotic pain medication) Oral Tablet 5-325 MG (milligrams, a unit of measure), give 1 tablet by mouth every 6 hours as needed for pain 4-10 (a scale from zero to ten, used to measure pain) for 14 days. Begin 1/13/24 11:15 AM. A review of the facility's policy titled Pain Management, Dated 11/24/17, indicated, Pain medication is to be given before pain becomes severe. Response to pain is to be documented on the Medication Administration Record. Review of that record for Resident 1 for 1/13/24 indicated Resident 1 reported a back pain level of 7, or Severe. A review of the facility's medication administration record (MAR) for Resident 1, dated 1/12/24 to 1/16/24, indicated Norco Oral Tablet 5-325 MG, give 1 tablet by mouth every 6 hours as needed for pain 4-10 for 14 days. Begin 1/13/24 11:15 AM. No administrations of this medication were recorded up to and including Resident 1's discharge, on 1/16/23. During an interview on 1/16/24 at 3:30 PM, Resident 1's family member (FAM 1) stated, [Resident 1] didn't get hydrocodone so he was in pain for most of the weekend, Friday to Monday. He was so miserable that I had to bring in his medications from home on Sunday night 1/14/23 so that he would have them. He was so uncomfortable that he couldn't sleep. During a concurrent interview on 1/17/24 at 10:45 AM, with the facility's administrator (ADMIN A) and director of nursing (DON B) on 1/17/23 at 10:45 AM, ADMIN A stated that they were aware of pharmacy issues and were working to resolve them. ADMIN A indicated that earlier that day he had sent a letter to the pharmacy being used, terminating their contract. DON B stated that the facility was aware some medications were not being delivered, and staff had been educated to replace the meds through various means such as checking emergency drug kits. DON B reviewed the MAR and confirmed that the Norco had not been given to Resident 1 as needed, as ordered. (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 4 Event ID: 555625 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 555625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Park Post Acute 2850 Sierra Sunrise Terrace Chico, CA 95928 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)