Health inspection·December 24, 2025

F656 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following — (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and

F697 §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. T22 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. 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. On 11/1/2025, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a complaint regarding quality of care. As a result of the investigation, the CDPH determined the facility failed implement its professional standard of practice in according with its policy and procedure (P&P) titled “Pain Management,” dated 8/25/2021 by failing to: 1. Ensure Resident 1’s pain was accurately assessed for the type, frequency, intensity, and duration of the pain, re-evaluate the effectiveness of the intervention to determine what increase or decrease in the frequency, intensity, duration of pain after the resident’s fall on 7/28/2025. 2. Ensure that Resident 1 was accurately assessed and evaluated for continued complaints of right leg pain and refusal to ambulate due to pain during Physical Therapy (exercise to promote, maintain, and restore physical movement and function) from 8/2025 to 9/2025. 3. Inform the Nurse Practitioner (NP)1 or the Physician (MD)1 that Resident 1 had persistent right leg pain during ambulation and refused to participate in physical therapy exercises due to right leg pain on 8/5/2025, 8/11/2025, 8/29/2025, 8/30/2025, 9/8/2025 and 9/14/2025. These failures resulted in Resident 1’s pain being poorly controlled, which lead to Resident 1 not wanting to ambulate (walk) during Physical Therapy (PT, a healthcare professional who specializes in movement and exercise to improve a resident’s mobility, reduce pain, and prevent future injuries) or Occupational Therapy (OT, rehabilitation therapy to help residents develop and improve skills needed to live independently). Resident 1’s refusal to ambulate had the potential to result in the development of deep vein thrombosis (DVT, a blood clot in her right femoral vein leg) and ultimately broke off and lodged itself in Resident 1’s right lung leading to her to be transferred to the GACH on 9/25/2025. A review of Resident 1’s Admission Record (AR), the facility admitted Resident 1 on 7/31/2020 and readmitted on 10/13/2020 with diagnoses that included a nondisplaced fracture (broken bone) of lateral malleolus of right fibula (right ankle), initial encounter for closed fracture, and other specified disorder of bone density and structure, right lower leg. A review of Resident 1’s History and Physical (H&P), dated 1/21/2025, indicated Resident 1 had fluctuating capacity to understand and make decisions. A review of Resident 1’s Change in Condition Evaluation (CoC), dated 7/28/2025 timed at 6:31 PM, indicated Resident 1 was found on the floor with her head on the pillow. The CoC indicated Resident 1 stated, “she pulled herself to the side and rolled off the bed.” A review of Resident 1’s Physical Therapy (PT) Encounter Note, dated 8/5/2025, indicated Resident 1 complained of slight right ankle pain after standing for too long and had bruising with minimal swelling from a previous fall (fall on 7/28/2025) and the ambulation exercise was deferred due to Resident 1’s pain and safety. A review of Resident 1’s clinical record had no documented evidence that PT informed the licensed nurses about Resident 1’s bruising and swelling on the ankle and that ambulation was deferred on 8/5/2025. A review of the Medication Administration Record (MAR) and the Nursing Progress Note (PN), dated 8/5/2025, indicated Resident 1 had zero pain level and did not receive any pain medication. A review of Resident 1’s PT Encounter Note, date of service 8/7/2025, indicated Resident 1 continued to complain of pain. A review of the Nursing PN indicated 8/7/2025 at 11 AM, PT reported while attempting to get up to walk Resident 1 complained of right ankle pain when standing. A review of the MAR for August 2025 indicated Resident 1 had zero pain level and did not receive any pain medication on 8/7/2025. A review of Resident 1’s Radiology examination report, dated 8/7/2025 timed at 6:45 AM and a reported date of 8/8/2025 timed at 1:46 PM, indicated Resident 1 had a right ankle fracture “of an uncertain age.” A review of Resident 1’s Nursing PN, dated 8/8/2025, timed at 8:13 AM, indicated the Primary Care Physician (PCP) 1 was notified of Resident 1’s right ankle radiology reports and ordered for Resident 1 not to walk or put weight on the right ankle. The PN indicated PCP 1 “will be visiting [Resident 1] within the next week.” A review of the MAR indicated on 8/9/2025 at 9:20 AM, Resident 1 received Tylenol 325 milligrams (mg) two tablets for right foot pain of 5/10 pain level (0 no pain and 10-severe pain scale). A review of Resident 1’s Care Plan (CP), created on 8/8/2025, indicated Resident 1 was at risk for skin break down due to a “green/purple discoloration to right ankle. The CP’s interventions included observing skin for signs/symptoms of skin breakdown, to observe skin condition daily with activities of daily living (ADLs, activities such as bathing, dressing, and toileting a person performs daily) and report abnormalities, and to complete a weekly skin assessment by the licensed nurses. A review of the Nursing PN, dated 8/9/2025 timed at 1:38 PM indicated Resident 1 was medicated for pain as ordered with “effect.” The Nursing PN further indicated the licensed nurse left a message to PCP for “stronger pain medication.” A review of the MAR and the physician’s order on 8/9/2025, indicated Resident 1 had no physician order and did not receive “stronger pain medication” on 8/9/2025. A review of the Nursing PN, dated 8/11/2025 timed at 3:59 AM, indicated Resident 1 was on monitoring for right ankle pain and discoloration. Nursing PN indicated Resident 1 was “medicated for pain as ordered with effect.” There was no documented evidence in the Nursing PN that the pain was not assessed for what worsened or relieved the pain, the pain level or the condition of the skin discoloration recorded. A review of the Nursing PN dated 8/11/2025 timed at 11:17 AM, indicated Resident 1 was on monitoring for right ankle pain and discoloration and the resident was “medicated for pain as ordered with effect.” There was no documented evidence in the NP of the that the pain was not assessed for what worsened or relieved the pain, the pain level or the condition of the skin discoloration recorded in the Nursing PN. A review of Resident 1’s Nursing PN, dated 8/11/2025, timed at 7:11 PM, indicated Resident 1’s inner and outer right ankle were bruised, and “complained of pain especially if asked to put weight on her foot. MD (physician) aware and will do rounds this week.” A review of the MAR indicated on 8/11/2025 Resident 1 had zero pain level and no documented evidence that the resident received any pain medication on 8/11/2025. A review of Resident 1’s Physician’s PN, dated 8/14/2025 timed at 9:55 AM, documented by NP 1 indicated Resident 1 was instructed not to put weight on her right leg and with bruising and tenderness noted to the inner and outer side of the right ankle. The Physician’s PN indicated that Resident 1’s pain was controlled with analgesic (pain medication) and require orthopedic (physician specialized in bone disorder) clearance for progression of mobility. The PN indicated Resident 1’s “cognitive status remains fluctuating,” but her “recent behavior indicates decrease recall and processing.” A review of Resident 1’s PT Encounter Note, service date 8/17/2025, the Encounter Note indicated Resident 1 “reported minimal pain” during her bilateral lower leg strengthening in bed. A review of “Statement of Medical Necessity” dated 8/26/2025 indicated Doctor of Podiatry Medicine (DPM-specialized in foot care) recommended for Resident 1 to use a walking boot (a medical device to protect the foot and ankle after injury) for Resident 1’s right ankle fracture. A review of the Nursing PN dated 8/26/2025 timed at 4:56 PM, indicated Resident 1 complained of right ankle pain level of 3 out of 10 on the pain scale, “acute pain described as aching occurs with light touch or pressure, movement makes the pain worst and medication makes the pain better NP was made aware was ordered Resident 1 to receive Tylenol for one week.” A review of Resident 1’s clinical record indicated no evidence NP 1 physically assessed and evaluated Resident 1 for acute aching pain that occurs with light touch or pressure, movement makes the pain worse on 8/26/2025. A review of the MAR indicated on 8/26/2025 Resident 1 was not administered pain medication. A review of Resident 1’s PT Encounter Note, service date 8/29/2025, the Encounter Note indicated Resident 1 refused to walk because she complained of right ankle pain. A review of Resident 1’s PT Encounter Note, service date 8/30/2025, the Encounter Note indicated there were multiple attempts to encourage Resident 1 to walk, however, Resident 1 “insisted on saying she can’t” because of the right ankle pain. A review of the MAR indicated Resident 1 had zero level pain and received Tylenol 500mg tablet for pain every shift (three times a day) on 8/29/2025 to 8/31/2025 every shift. There was no documented evidence Resident 1’s ankle pain was assessed and evaluated for what increases or decreases the pain frequency, intensity, duration of pain on 8/29/2025 and 8/31/2025. A review of the MAR for August 2025 and September 2025 indicated the Resident 1 received Tylenol 500 milligrams by mouth for the complaint of pain on the right malleolus three times a day every shift on 8/27/2025 to 9/5/2025. 1. 8/27/2025 pain level 4/10 2. 8/28/2025-pain level 0/10 3. 8/29/2025-pain level 0/10 4. 8/30/2025-pain level 0/10 5. 8/31/2025-pain level 0/10 6. 9/1/2025-pain level 2/10 7. 9/2/2025-pain level 2/10 8. 9/3/2025-pain level 2/10 9. 9/4/2025-pain level 3/10 10. 9/5/2025-pain level 0/10 A review of the MAR and the Nursing Progress Notes indicated no documented evidence that Resident 1 was assessed for type, frequency and duration of the pain, or if resident was provided pharmacological or non-pharmacological pain intervention and re-evaluate the effectiveness of the interventions. A review of Resident 1’s PT Encounter Note, service date 9/8/2025, the Encounter Note indicated Resident 1 had an unsteady balance when transferring from sitting to standing with a front wheeled walker and had difficulty moving her right leg forward during ambulation and “stated [Resident 1’s] legs feel heavy.” A review of Resident 1’s PT Encounter Note, service date 9/14/2025, the Encounter Note indicated Resident 1 received manual stretches of the right leg but “refused to ambulate due to right foot pain.” A review of the MAR and Nursing PN dated 9/14/2025 indicated Resident 1 was not administered pain medication for the complaint of right foot pain on 9/14/2025. A review of the MAR and the Nursing Progress Notes on the following dates 8/29/2025, 8/30/2025, 9/8/2025 and 9/14/2025, Resident 1 had zero level of pain and no complaint of pain. However, the PT encounter notes reported Resident 1 had pain in the right foot and refused to ambulate due to pain. A review of Resident 1’s Physician 1’s PN, dated 9/23/2025 timed at 9:30 AM, the PN indicated Resident 1 was able to put weight on her right lower leg in the CAM boot (a walking boot to immobilize the foot and ankle after injury) with PT. A review of Nursing PN, dated 9/25/2025 at 12:04 PM, indicated at 11:45 AM today during a PT session, Resident 1 was reported feeling weak. A review of Resident 1’s CoC Evaluation, dated 9/25/2025 timed at 11:45 AM, the CoC indicated Resident 1 was noted with altered mental status during PT and 911 was called. A review of Resident 1’s General Acute Care Hospital (GACH) 1 record, dated 9/25/2025 timed at 7:42 PM, the GACH 1 records indicated Resident 1’s radiology results indicated a pulmonary embolism (PE, blood clot in the lung) in the right lung and a dilated right-side of her heart. The GACH 1 records indicated the venous doppler (ultrasound to check the circulation of the veins of the legs) indicated the right DVT. A review of Resident 1’s GACH 1 record, titled “Oncology Consultation” dated 9/26/2025 timed at 7:47 AM, the GACH 1 record indicated Physician 2’s Assessment/Plan that indicated a large PE in the right upper and lower lobes with DVT in the right lower extremity… “possibly due to relative immobility.” The GACH 1 record indicated there was no reported prior history of blood clots to suggest this is an inherited coagulopathy (a genetic blood clotting disorder passed down through families). During an interview on 10/2/2025 at 12:35 PM with Registered Nurse (RN) 1, RN 1 stated on 9/25/2025 she was called into Resident 1’s room while Resident 1 was receiving PT. RN 4 stated, Resident was having a hard time breathing and described it as “agonal breathing” and her oxygen saturation (percentage of oxygen in the body’s red blood cells; normal range 95-100%) was 85%. During the same interview on 11/6/2025 at 10:25 AM with Certified Nurse Assistant (CNA) 1, CNA 1 stated he had taken care of Resident 1 on 9/22/2025, and Resident 1 had complained of right leg pain after the therapist helped her to walk the resident complained that her leg pain was getting worse but he does not know if he reported the resident’s complained of pain. During the same interview on 11/6/2025 at 10:40 AM with CNA 1, CNA 1 stated that on one of Resident 1’s shower days last month (October 2025) Resident 1 mentioned to him/her that her right leg was hurting more than usual. CNA 1 stated, it “slipped my mind” to mention Resident 1’s complaint of leg pain on 9/22/2025 to a licensed nurse because he got busy with another resident. During the same interview on 11/6/2025 at 10:45 AM with CNA 1, CNA 1 stated, Resident 1 to