Health inspection·June 18, 2025

§483.25(1) 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. § 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 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, drug. § 72313. Nursing Service--Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. §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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. (c) Each facility shall establish and implement policies and procedures, including but not limited to: (D) Notification of the licensed healthcare practitioner acting within the scope of his or her professional licensure regarding sudden or marked adverse change in a patient's condition. On 5/6/2025 the California Department of Public Health (CDPH) conducted an unannounced recertification survey at the facility. The facility failed to: 1. Ensure Resident 1, who had a Stage 4 pressure ulcer (wound that penetrate all layers of skin exposing muscles, tendons [tissue that unites a muscle with a bone] cartilage {tissue that lines a joints}, and bones caused by prolonged pressure on the skin) to left buttock (the back of a hip that forms one of the fleshy parts on which a person sits), did not experience unnecessary pain and suffering during pressure ulcer treatment and repositioning. 2. Ensure the Treatment Nurse (TN) 1 stopped providing Resident 1 with left buttock pressure ulcer treatment when Resident 1 had facial grimacing (a facial expression where the mouth and face are twisted, often to indicate disgust, disapproval, or pain) and was moaning during treatment. 3. Ensure Licensed Vocational Nurse (LVN) 4 medicated Resident 1 with Tylenol (pain medication) 500 milligrams (mg-unit of measurement) one hour before the treatment to a left buttock pressure ulcer as ordered by the physician. 4. Ensure TN 1 and TN 2 checked if Resident 1 received Tylenol one hour before providing the resident with a pressure ulcer treatment to the left buttock. 5. Ensure TN 1, TN 2 and LVN 4 followed Resident 1's care plan titled, "Care Plan Report" dated 10/2024, that indicated the goal for Resident 1 was not to experience facial grimacing if pain existed. 6. Ensure Resident 1 received treatment for a left buttock pressure ulcer within one hour after Tylenol administration to lessen possible experience of pain and/or discomfort. 7. Ensure staff followed the facility's policy and procedures (P&P) titled, "Pain Assessment and Management," dated 2022, which indicated "Observe the resident during rest and movement for physiologic (functions of the body) and behavioral (non-verbal) signs of pain such as groaning, crying, screaming, facial grimacing, frowning, behavior such as resisting care, irritability, or depression (loss of interest in activities, causing significant impairment in daily life). Review resident's treatment record to identify any situations or interventions where an increase in the resident's pain may be anticipated such as treatment like wound care or dressing changes." As a result, Resident 1 experienced unrelieved, and uncontrolled pain manifested by facial grimacing and moaning during pressure ulcer treatment on 5/8/2025. A review of Resident 1's Admission Record, indicated Resident 1 was originally admitted to the facility on 7/25/2003 and was readmitted on 10/16/2024 with diagnoses including anoxic brain injury (occurs when the brain receives no oxygen at all and causes brain damage), functional quadriplegia (a severe medical condition characterized by the partial or total loss of function in all four limbs [extremities] and the torso {upper part of the body}), and a Stage 4 pressure ulcer to the left buttock. A review of Resident 1's History and Physical (H& P) dated 3/25/2021, indicated Resident 1 was not able to express needs, communicate, and could not follow commands. A review of Resident 1's Minimum Data Set ([MDS] resident assessment tool ) dated 4/1/2025, indicated Resident 1 was dependent (helper does all the effort, resident does none of the effort to complete the activity) on staff for bed mobility, moving from sitting on side of bed to lying flat on bed, toileting hygiene, bathing, dressing, personal hygiene, and oral hygiene. The MDS indicated Resident 1 had a Stage 4 pressure ulcer on the left buttock. During an observation on 5/7/2025 at 8:21 a.m. in Resident 1's room, the resident was observed in bed lying on her back with her eyes open. Resident 1 was nonverbal (doesn't use spoken words) and responsive to tactile stimuli (any form of touch or physical contact that is perceived by the skin). During an interview on 5/7/2025 at 4:00 p.m. Certified Nurse Assistant (CNA ) 2 stated Resident 1 was nonverbal and dependent with care (refers to the care and support provided for individuals who are unable to care for themselves) for activities of daily living ([ADL's]- basic tasks everyone performs daily to care for themselves, like eating, dressing, bathing, and moving around). CNA 2 stated Resident 1 had a pressure ulcer to her left buttock. CNA 2 stated that he observed Resident 1 had facial grimacing and moaning during personal care and pressure ulcer treatments to her left buttock. CNA 2 stated the Treatment Nurse (TN 1) continues to perform the pressure ulcer wound treatment despite Resident 1 having facial grimacing and moaning. CNA 2 stated when Resident 1 makes facial grimacing and moaning that indicates that Resident 1 was in pain. CNA 2 stated that TN 1 should have given Resident 1 pain medication prior to each pressure ulcer treatment. CNA 2 stated he had not reported Resident 1 facial grimacing and moaning during pressure ulcer treatment to the charge nurse because Resident 1 always had facial grimacing and moaning during pressure ulcer treatment. CNA 2 stated that he should have reported Resident 1's facial grimacing during pressure ulcer treatment to a charge nurse. During an observation on 5/8/2025 at 8:18 a.m., in the presence of TN 1 and CNA 1, in Resident 1's room, Resident 1 was observed with facial redness, moaning and facial grimacing when Resident 1 was repositioned. After being repositioned observed TN 1 started wound treatment to Resident 1's left buttock pressure ulcer. Resident 1 was observed moaning louder when TN 1 started vigorously cleaning the surrounding skin area of the left buttock pressure ulcer and applying Santyl ointment (a smooth thick substance that is put on sore skin or a wound to help it heal). TN 1 was observed continuing with Resident 1's left buttock pressure ulcer treatment even after Resident 1 continued to moan and grimacing. Resident 1 was observed to stop having facial grimacing and moaning only after when TN 1 finished the pressure ulcer treatment. During an interview on 5/8/2025 at 8:20 a.m. TN 1 stated Resident 1 was nonverbal, responsive to tactile stimulation, and was dependent on ADL. TN 1 stated Resident 1 had a Stage 4 pressure ulcer to her left buttock and was receiving pressure ulcer treatment daily. TN 1 stated Resident 1 appeared to be in pain because she had facial grimacing and moaning during pressure ulcer treatment. TN 1 stated facial grimacing and moaning were the indicators that Resident 1, who was nonverbal, was experiencing pain and was uncomfortable. TN 1 stated she should have stopped the pressure ulcer treatment, assessed Resident 1's pain level, including the non-verbal cues, like facial grimacing, notified the physician, and medicated Resident 1 with pain medication. TN 1 stated she did not know why she continued with the pressure ulcer treatment in spite Resident 1's moaning and facial grimacing. TN 1 stated Resident 1 should be assessed for pain before, during, and after treatment, because Resident 1 could be experiencing pain during pressure ulcer treatment. TN 1 stated Resident 1 should have been pre medicated with Tylenol (medication to relieve pain) one hour prior to pressure ulcer treatment per physician order. TN 1 stated she failed to verify with Licensed Vocational Nurse (LVN) 4, if Resident 1 had been pre medicated with Tylenol prior to pressure ulcer treatment. During an interview on 5/8/2025 at 9:27 a.m. LVN 4 stated Resident 1 was nonverbal, and dependent with ADLs and had nonverbal cues of pain (moaning and facial grimacing) during provision of personal care and pressure ulcer treatment. LVN 4 stated Resident 1 should have received Tylenol 500 milligram (mg-unit of weight measurement) one hour before left buttock pressure ulcer treatment, for pain management. LVN 4 stated when nonverbal residents begin to moan and have facial grimacing during personal care or pressure ulcer treatment, that would be an indication that a resident was in pain. LVN 4 stated TN 1 should have stopped the pressure ulcer treatment immediately and reassess Resident 1's pain. LVN 4 stated Resident 1's doctor should also be notified because the intervention/medication may not be effective. LVN 4 stated Resident 1 should be assessed before, during and after wound treatment to manage her pain, because pain can negatively impact Resident 1's wellbeing. LVN 4 stated she forgot to give Resident 1 pain medication on 5/8/2025 prior to Resident 1's pressure ulcer wound treatment. During a concurrent interview and record review on 5/9/2025 at 11:35 a.m. with TN 2, Resident 1's Treatment Administration Record (TAR), dated 5/2025 was reviewed. The TAR indicated, on 5/7/2025, at 3:39 p.m., TN 2 performed wound treatment to Resident 1's left buttock pressure ulcer. TN 2 validated that she provided wound treatment without Resident 1 receiving Tylenol prior to pressure ulcer treatment. TN 2 stated Resident 1 had a Stage 4 pressure ulcer to her left buttock, and she should have received Tylenol one hour prior to pressure ulcer treatment to the left buttock. TN 2 stated Resident 1 was non-verbal, and during the wound treatment on 5/7/2025 Resident 1 had facial grimacing and moaning, which indicated Resident 1 was in pain. TN 2 stated the pressure ulcer treatment should have been stopped, and the charge nurse should have been notified. TN 2 stated she continued with the pressure ulcer treatment in spite Resident 1's moaning and facial grimacing because it was going to be done quickly. TN 2 stated that after the treatment Resident 1 stopped grimacing and moaning, which indicated that she was no longer in pain. TN 2 stated Resident 1 should have been assessed for pain before, during and after treatment to ensure she was not in pain because that could affect her quality of life. During an interview on 5/9/2025 at 4:44 p.m. the Director of Nursing (DON), stated that when residents receive pressure ulcer treatment the nurse should assess resident pain before, during and after treatment. The DON stated for nonverbal residents the staff should observe behaviors such as facial grimacing, frowning, moaning, and crying. The DON stated if a resident exhibits those types of behaviors during pressure ulcer treatment the nurse should stop treatment immediately and contact the doctor. The DON stated unmanaged pain could negatively affect the residents' blood pressure, leading to a high risk of hypertension (high blood pressure) which can ultimately cause a heart attack (supply of blood to the heart is suddenly blocked), stroke (lack of adequate blood supply to the brain), or even death. A review of Resident 1's Order Summary Report, dated 5/7/ 2024, indicated, to monitor for pain before, during, after wound treatment, every day shift for pain management. A review of Resident 1's Order Summary Report, dated 1/17/2025, indicated, Tylenol 500 mg one tablet every day shift for pain management one hour prior to wound treatment. A review of Resident 1's Care Plan titled, "Resident 1 totally dependent with all ADLs, at risk for pain during turning, facial grimaces if pain existed" dated 10/17/2024, indicated the goal for Resident 1 was not to experience pain during turning and facial grimaces if pain existed. The care plan interventions included to monitor resident for inability to express needs, pain during turning and facial grimaces if pain existed. A review of Resident 1's Care Plan titled, "Resident 1 has slow wound healing on left buttock" dated 10/17/2024, indicated the interventions indicated to assess Resident 1 for pain every shift and provide interventions for pain. A review of Resident 1's Medication Administration Record (MAR) and Treatment Administration Record (TAR), indicated that pressure ulcer treatment was not provided in one hour after Tylenol administration to ensure Resident 1would have the most effective pain relief and it was as follows: 1. On 4/24/2025 Tylenol 500 mg was given at 9:16 a.m., but left buttock pressure ulcer treatment was done at 1:36 p.m. 2. On 4/25/2025 Tylenol 500 mg administered at 9:47 a.m., but left buttock pressure ulcer treatment was done at 2:41 p.m. 3. On 4/27/2025 Tylenol 500 mg administered at 9:56 a.m., but left buttock pressure ulcer treatment was done at 2:54 p.m. p.m. 4. On 4/28/2025 Tylenol 500 mg administered at 9:51 a.m., but left buttock pressure ulcer treatment was done at 12:42 p.m. 5. On 4/29/2025 Tylenol 500 mg administered at 8:35 a.m., but left buttock pressure ulcer treatment was done at 12:53 p.m. 6. On 4/30/2025 Tylenol 500 mg administered at 9:38 a.m., but left buttock pressure ulcer treatment was done at 11:39 a.m. 7. On 5/01/2025 Tylenol 500 mg administered at 8:55 a.m., but left buttock pressure ulcer treatment was done at 2:35 p.m. 8. On 5/2/2025 Tylenol 500 mg administered at 8:34 a.m., but left buttock pressure ulcer treatment done at 1:50 p.m. 9. On 5/4/2025 Tylenol 500 mg was administered at 8:41 a.m., but left buttock pressure ulcer treatment was done at 1:40 p.m. 10. On 5/5/2025 Tylenol 500 mg administered at 9:32 a.m., but left buttock pressure ulcer treatment was done at 1:40 p.m. 11. On 5/6/2025 Tylenol 500 mg administered at 8:49 a.m., but left buttock pressure ulcer treatment done at 2:22 p.m. 12. On 5/7/2025 Tylenol 500 mg administered at 10:40 a.m., but left buttock pressure ulcer treatment was d