Health inspection·January 21, 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 pain medications were administered as ordered by the physician, for one of three residents (Resident A). Residents Affected - Few This failure had the potential for Resident A's pain not be managed and affect overall health condition. Findings: On January 2, 2025, at 11:30 a.m., an unannounced visit to the facility was conducted to investigate an allegation of abuse. On January 2, 2025, a review of Resident A's medical record was conducted. Resident A was admitted to the facility on [DATE], with diagnoses which included atherosclerotic (a buildup of fats, cholesterol, and other substances in and on the artery walls) heart disease and polyneuropathy (a condition where multiple peripheral nerves throughout the body become damaged or malfunction). A review of Resident A's care plan, dated June 26, 2023, indicated, .Resident is at risk for pain r/t (related to) risk factors .Interventions .Administer medications as ordered . A review of Resident A's Order Summary Report, included the following physician's order: - Monitor level of pain (0-10 scale): Document pain level as follows: 0 = none, 1-3 = mild pain, 4-6 = moderate pain, 7-10 = severe pain, every shift, date order May 24, 2023; - Tramadol (a drug used for pain) tablet 50 mg every 6 (six) hours as needed for pain management Moderate pain (4-6 pain scale), date order February 27, 2024; and - Morphine Sulfate .100 MG/5ML .Give 0.50 ml by mouth every 4 (four) hours as needed for Severe pain (7-10), date order July 31, 2024, discontinued December 6, 2024; - Morphine Sulfate (a drug used to treat pain) 100 mg (milligram - a unit of measure)/5 ml (milliliter-a unit of measure), give 1 (one) ml as needed for wound treatment, may medicate prior to wound treatment, date order December 19, 2024; A review of Resident A's Medication Administration Record (MAR), for Morphine Sulfate 0.50 ml every 4 hours as needed for severe pain, for December 1 to 6, 2024, indicated morphine sulfate was administered to Resident A on December 4, 2024, at 12:20 a.m., with a pain scale of 5 (moderate pain). Page 1 of 3 555915 555915 01/21/2025 The Springs Health and Rehabilitation Center 25924 Jackson Ave Murrieta, CA 92563

F 0697 Level of Harm - Minimal harm or potential for actual harm A review of Resident A's Medication Administration Record (MAR), for December 2024, indicated the morphine sulfate 1 ml was administered to Resident A with a pain scale of 4-6 (moderate pain) on the following dates: - December 8, 2024, at 9:09 p.m.; pain level of 4; Residents Affected - Few - December 9, 2024, at 1:38 a.m.; pain level of 6; - December 9, 2024, at 10:02 a.m.; pain level of 3; - December 9, 2024, at 2:02 p.m.; pain level of 5; - December 9, 2024, at 6:30 p.m.; pain level of 3; - December 10, 2024, at 3:11 a.m., pain level of 6; - December 14, 2024, at 3:29 a.m., pain level of 5; - December 15, 2024, at 10:13 p.m.; pain level of 4; - December 18, 2024, at 9:40 p.m.; pain level of 6; and - December 19,2024, at 5:31a.m.; pain level of 4. A review of Resident A's Medication Administration Record (MAR), for December 2024, indicated the tramadol (ordered for moderate pain) was administered to Resident A with a pain scale of mild or severe pain on the following dates: - December 1, 2024, at 11:58 a.m.; pain level of 3; - December 2, 2024, at 12:05 p.m.; pain level of 3; - December 6, 2024, at 12:41 p.m.; pain level of 8; - December 8, 2024, at 11:05 a.m.; pain level of 7; - December 11, 2024, at 9:53 a.m.; pain level of 9; and - December 13, 2024, at 10:50 a.m.; pain level of 8. A review of Resident A's Hospice Nurse Progress Note Routine Visit, dated December 18, 2024, indicated, .always c/o (complain of) pain BLE (bilateral lower extremities-both legs) .pain not controlled with current medication .patient is not compliant to medication regimen .Hospice aide to provide care according to assignment .confused; sad; tearful-pt (patient) refused wound care . On January 10, 2025, at 3:30 p.m., an interview and concurrent record review was conducted with the Director of Nursing (DON). The DON reviewed Resident A's MAR for December 2024, regarding Resident A's orders for morphine sulfate and tramadol. The DON stated the morphine sulfate should have been given for severe pain, and the tramadol was to be given for moderate pain. The DON stated morphine 555915 Page 2 of 3 555915 01/21/2025 The Springs Health and Rehabilitation Center 25924 Jackson Ave Murrieta, CA 92563

F 0697 sulfate and tramadol were not administered as ordered by the physician. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure titled Pain Assessment and Management, dated March 2023, indicated, .to help the staff identify pain in the resident and to develop interventions that are consistent with the resident's goals and needs .ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management .Pain management is an interdisciplinary care process that includes .identifying and using specific strategies for different levels and sources of pain .conduct a comprehensive pain assessment upon admission to the facility .whenever there is a significant change in condition .assess the resident's pain and consequences of pain at least each shift .behavioral signs of pain .verbal expressions such as groaning, crying, screaming .resisting care, irritability, depression, decreased participation .guarding, rubbing or favoring a particular part of the body evidence of depression, anxiety .assess pain using a consistent approach and a standardized pain assessment instrument .pain management interventions shall reflect the sources, type and severity of pain .non-pharmacological interventions may be appropriate alone or in conjunction with medications .pharmacological interventions .may be prescribed to manage pain .implement the medication regimen as ordered .relevant criteria for measuring pain management .document the resident's reported level of pain with adequate detail as necessary and in accordance with the pain management program . Residents Affected - Few 555915 Page 3 of 3