Health inspection·July 11, 2025

The following reflects the finding of the California department of Public Health during Investigation of a complaint number: CA00964124. A Class A citation was issued. REGULATORY VIOLATIONS: Title 42 Code of Federal Regulations §483.25(k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Title 22, California Code of Regulations § 72311. Nursing Service-General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of the admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. (G) The facility's inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies or services as prescribed under conditions which present a risk to the health, safety or security of the patient. (b) All attempts to notify licensed healthcare practitioners acting within the scope of his or her professional licensure shall be noted in the patient's health record including the time and method of communication and the name of the person acknowledging contact, if any. If the attending licensed healthcare practitioner acting within the scope of his or her professional licensure or his or her designee is not readily available, emergency medical care shall be provided as outlined in Section 72301(g). § 72313. Nursing Service-Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (1) No medication or treatment shall be administered except on the order of a person lawfully authorized to give such order. (2) Medications and treatments shall be administered as prescribed. (3) Tests and taking of vital signs, upon which administration of medications or treatments are conditioned, shall be performed as required and the results recorded. (c) The time and dose of the drug or treatment administered to the patient shall be recorded in the patient's individual medication record by the person who administers the drug or treatment. Recording shall include the date, the time and the dosage of the medication or type of the treatment. Initials may be used, provided that the signature of the person administering the medication or treatment is also recorded on the medication or treatment record. § 72523. Patient Care Policies and Procedures. (a). Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. § 72353. Pharmaceutical Service-General. (a) Arrangements shall be made to assure that pharmaceutical services are available to provide patients with prescribed drugs and biologicals. § 72355. Pharmaceutical Service--Requirements. (a) Pharmaceutical service shall include, but is not limited to, the following: (1) Obtaining necessary drugs including the availability of 24-hour prescription service on a prompt and timely basis as follows: (B) Anti-infectives and drugs used to treat severe pain, nausea, agitation, diarrhea or other severe discomfort shall be available and administered within four hours of the time ordered. (C) Except as indicated above, all new drug orders shall be available on the same day ordered unless the drug would not normally be started until the next day. (D) Refill of prescription drugs shall be available when needed. On 5/27/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint allegation regarding neglect of a resident and medication not administered as ordered by the resident's physician. As a result of the investigation, CDPH determined the facility failed to provide effective pain management for Resident 2, who had a left shoulder fracture (broken bone), left hip fracture, and had undergone bladder surgery after a motorcycle accident. The facility failed to: 1. Administer the pain medication, Hydromorphone (also known as Dilaudid, a strong pain reliever to treat moderate to severe pain) as needed when Resident 2 complaint of "a lot of pain" on 5/24/2025 in the morning in the morning. Resident 2 received a dose of Hydromorphone 2 milligrams (mg) on 5/24/25 at 4 PM. 2. Administer the Hydromorphone as needed when Resident 2 complained of pain on 5/27/2025 at 1:15 PM. 3. Accurately assess and document Resident's 1 pain level. 4. Evaluate the effectiveness of analgesic medication (medications that relieve pain) in relieving pain within two hours of administration based on the facility Policy and Procedures (P&P) titled "Pain Assessment & Management" revised 7/12/2024. As a result, Resident 2 suffered uncontrolled and continuous pain for two days (5/24/25 to 5/26/2025). On 5/26/2025 at approximately 9:15 PM, Resident 2 was transferred to a General Acute Care Hospital (GACH) emergency room (ER) for blood in the urine and 9/10 (0 representing no pain and 10 representing the worst possible pain) lower abdomen pain. During a record review, Resident 2's Admission Record indicated Resident 2, a 27-year-old male, was initially admitted to the Skilled Nursing Facility (SNF) on 3/14/2025 and readmitted on 4/2/2025 with diagnoses that included nondisplaced fracture of lower end of right and left humerus (upper arm bone), injury of the bladder, lack of coordination, fracture of left shoulder, essential primary hypertension (HTN-high blood pressure). During a record review, Resident 2's Minimum Data Set (MDS-a resident assessment tool) dated 3/20/2025, indicated Resident 2's cognitive skills (ability to acquire and understand knowledge) for daily decision making were intact. The MDS indicated Resident 2 experienced pain occasionally, had difficulty sleeping, and had limited participation in rehabilitation therapy sessions due to occasional pain. The MDS indicated that occasionally, Resident 2 experienced pain, that pain made it hard for the resident to sleep at night, limited the resident's participation in rehabilitation sessions, and limited the resident's day-to-day activities excluding rehabilitation therapy sessions. During a record review, Resident 2's Care Plan (CP) dated 4/2/2025, indicated Resident 2 is at risk for alteration in comfort due to pain related to multiple fractures, recent surgery. The CP goal indicated that Resident 2, "Will remain free of signs and symptoms of pain such as grimacing, crying, moaning, guarding, verbal expression of pain daily x 90 days. Will report pain is relieved or controlled 30 minutes to 1 hour after pain medication is administered x 90 days. Will verbalize sense of control and enhanced enjoyment of life x 90 days." The CP interventions included assessing location, characteristics, onset, duration, frequency, and intensity of pain, determining acceptable level of pain and pain control goals, and providing comfort measures with touch, repositioning, use of heat and or cold packs. The CP indicated to administer Hydromorphone 2 milligrams (mg) q [every] 4 hours (hrs.) PRN (as needed). The CP also indicated to administer Hydromorphone 4 mg q 4 hrs. PRN. During a record review, Resident 2's Skilled Nursing Facility History and Physical (H&P) Examination dated 4/4/2025, indicated, Resident 2 was readmitted to GACH on 3/27/2025 and had closed left proximal humerus (upper arm bone) fracture, bladder rapture repair, and discharged to skilled nursing facility for rehabilitation. The H&P indicated Resident 2 had left hip incision (staple (small, metallic clips used to close wounds or incisions) from prior operation, had persistent bladder pain/pressure consistent with spasms (sudden involuntary and painful tightening of a muscle/s) that limited discharge. The H&P indicated on day of discharge; Resident 2's pain was well controlled with an oral regimen. During a record review, Resident 2's Physician History and Physical (H&P) dated 4/5/2025, indicated, Resident 2 had persistent bladder pain/pressure consistent with spasms improved with oral (by mouth) pain medications. During a record review, Resident 2's Pain Flow Sheet for the month of 5/2025, indicated the following: - On 5/20/2025 at 8:15 AM., Resident 2 was experiencing upper arm pain, aggravated by movement. The interventions included to administer Hydromorphone 4 mg for pain intensity 8/10. - No documented pain level and intervention on 5/21, 5/22, 5/23, 5/24, and 5/26/2025. - On 5/26/2025 at 2 PM., Resident 2 was experiencing upper arm pain, aggravated by movement. The interventions included to administer Hydromorphone 4 mg for pain intensity 8/10. During a record review, Resident 2's Medication Administration Record for 5/2025, indicated the following: - Hydromorphone 2 mg tablet, give one tablet by mouth every 4 hours as needed for moderate pain scale 5-7. Diagnosis multiple fractures. - Hydromorphone 4 mg tablet, give 1 tablet by mouth every 4 hours as needed for moderate pain scale 8-10. Diagnosis multiple fractures. The same Resident 2's MAR Record for 5/2025 indicated the following entries: - On 5/24/2025 at 4 PM, Resident 2 received a dose of Hydromorphone 4 mg. The MAR document did not indicate the pain level and reassessment of the pain after two hours of the pain medication administration. - On 5/24/2025 at 8:30 PM, Resident 2 received a dose of Hydromorphone 4 mg. The document did not indicate the pain level and reassessment of the pain after two hours of the pain medication administration. During a record review of Resident 2's MAR for 5/2025 Pain Assessment Every Shift for the 5/2025, indicated that on 5/24/2025 for 11PM to 7 AM shift, 7 AM-3 PM shift, and 3 PM to 11 PM shift, Resident 2's pain scale was documented as 0/10. During a record review, Resident 2's Physician and Telephone Order dated 5/26/2025 at 5:08 PM indicated, to transfer Resident 2 to GACH emergency room via regular ambulance related to blood in the urine and 9/10 (severe) lower abdomen pain. During a record review, Resident 2's GACH Emergency Department Service Report dated 5/26/2025 at 9:47 PM, indicated Resident 2 presented with hematuria (blood in the urine) that began in the morning, 5/26/2025 and with an 8/10 pain level. The GACH Emergency Department Service Report indicated that on 5/27/2025 at 8:48 AM, Resident 2 was discharged back to SNF. During an interview with Resident 2 on 5/27/2025 at 1 PM, Resident 2 stated he was involved in a motorcycle accident and is on Hydromorphone which helps him with severe pain. Resident 2 stated he returned to the facility (SNF) on 5/27/2025 in the morning. Resident 2 stated that the weekend (5/24/2025-5/26/2025) he was in a lot of pain, was asking for pain medication, but was told that he had to wait because they (facility) did not have the pain medication (Hydromorphone). Resident 2 stated, "They (nurses) bring all the medication except Hydromorphone." Resident 2 stated that on Saturday (5/24/2025), "I went to the nursing station to ask for the Hydromorphone. I asked twice for the medication and they told me to wait. I used the walker and went to the nurse station to ask for the Hydromorphone few times and I didn't get it until late evening. I was in a lot of pain throughout the weekend. I had to go to hospital because the pain has not been controlled. I have pain in a lot of places, shoulder, hip, and bladder." Resident 2 stated he is happy with the medication orders for pain management, "I just want to get them on time. When they have the medication (Hydromorphone), they give it me every 4 hours. They (nurses) have been telling me they don't have them (Hydromorphone) even to give me every 4 hours." During a telephone interview and concurrent record review with Registered Nurse (RN) 2 on 5/27/2025 at 11:12 AM, Resident 2's MAR and Pain Assessment Sheet for 5/2025 were reviewed. The MAR indicated that on 5/24/2025, there was no documented evidence that Resident 2 received Hydromorphone for pain and the pain level assessed after 2 hours of receiving Hydromorphone. RN 2 stated that resident pain assessment should be done before and after medicating a resident with pain medication. RN 2 was unable to provide post pain medication administration assessment logs and stated, the facility uses the two pain assessment sheets (MAR and pain assessment sheet). During a concurrent observation in Resident 2s room, interview, and concurrent record review on 5/27/2025 at 1:15 PM with Licensed Vocational Nurse (LVN) 1, Resident 2's MAR for 5/2025 was reviewed. LVN 1 entered Resident 2's room to administer pain medications to Resident 2. Resident 2 was in bed and was complaining of pain. The MAR indicated for Resident 2 was also on Robaxin (muscle relaxing medication), gabapentin (medication for nerve pain)., Tylenol (mediation for mild pain and to relieve fevers), and Hydromorphone. LVN 1 stated, "Hydromorphone is not available, I am about to call pharmacy to authorize to access the emergency medication kit. LVN 1 stated and acknowledged it was not according to the standard of nursing care to ignore a resident's pain leading to hospitalization. LVN 1 stated LVN 1 was waiting for the pharmacist to give authorization to remove Hydromorphone from the emergency medication kit. LVN 1 further stated, "Not managing pain can lead to decline in rehabilitation progress." During an interview on 5/27/2025 at 1:48 PM, Certified Nursing Assistant (CNA) 1 stated, I have been assigned to Resident 2. I have heard him (Resident 2) today complaining about pain medication. I have seen him come out of his room to ask for pain medications and I do not have the details of the conversations" with the nurses. CNA 1 stated Resident 2 "is not happy when he does not get his medications on time." During an interview on 5/27/2025 at 2:58 PM, the Director of Staff Development (DSD) stated licensed staff are trained to manage residents' pain, contact a medical doctor (MD) about a resident's pain, and communicate with facility leadership to address unmet resident's needs. DSD stated, "It is not the facility policy and standard of care to ignore pain. It is the practice and policy for licensed staff to call the pharmacy and get preauthorization to access emergency medication kits for narcotic medications. During an interview on 5/27/2025 at 3:50 PM, LVN 1 stated, "I have called pharmacy three times, they have not responded to me yet. LVN 1 further stated the pharmacy has to preauthorize the facility to access the emergency medication kit." LVN 1 stated LVN 1 administered scheduled Robaxin 1000 mg, Tylenol 1000 mg, and gabapentin 900 mg to Resident 2 on 5/27/2025 at 1:15 PM. LVN 1 also stated Hydromorphone was missing from the medication cart, not delivered by pharmacy. During an interview on 5/27/2025 at 4:38 PM, the facility administrator (ADM) stated, pain complaints should be addressed immediately and a MD notified of any change of condition or uncontrolled pain. ADM stated, "I believe staff shoul