Health inspection·June 18, 2025

F697 42 CFR §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. 42 CFR §483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility’s resident population in accordance with the facility assessment required at §483.70(e). 22 CCR § 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. 22 CCR § 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. 22 CCR § 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. 22 CCR § 72547. Content of Health Records. (a) A facility shall maintain for each patient a health record which shall include: (5) Nurses' notes which shall be signed and dated. Nurses' notes shall include: (F) Medications and treatments administered and recorded as prescribed. An unannounced visit was conducted by California Department of Public Health on 5/6/2025 at 12 PM to investigate a complaint regarding an allegation that the facility nursing staff did not assess Resident 1 or take any action when the resident was complaining of pain on the left side of hip down to the knee, which was found out that Resident 1 sustained a left hip fracture (break in the bone) after Resident 1 was discharged from the facility. The facility failed to assess and manage reported pain for Resident 1 as indicated in Resident 1’s care plan and the facility’s policies and procedures titled, “Pain Recognition and Management,” and “Pain Management,” by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 1 assessed and documented Resident 1’s pain location. 2. Ensure Resident 1 received pain medication when Resident 1 complained of persistent pain to Resident 1’s right lower extremity (RLE- right leg, including hip, thigh, knee, calf, and foot) on 4/7/2025. As a result, Resident 1 experienced unrelieved/uncontrolled pain and had the potential to result in physical, mental, and emotional distress. A review of Resident 1’s Admission Record (AR), the AR indicated Resident 1, a 88-year-old-male, was admitted to the facility on 3/28/2025, with diagnoses of history of falling, right femur (thigh bone) fracture , and encounter for orthopedic after care, dementia , osteoarthritis abnormalities of gait and mobility, and generalized muscle weakness. A review of Resident 1’s Care Plan (CP) titled “Care Plan Report,” dated 3/28/2025, the CP indicated Resident 1 had pain of the right femur due to a recent right femur fracture and surgical intervention following a fall. The CP interventions indicated for staff to administer analgesia (absence of pain) medication as per physician orders and give one-half (½) hour before treatments or care, anticipate need for pain relief, and respond immediately to any complaint of pain. A review of Resident 1’s Physician Order (PO), dated 3/28/2025, the PO indicated Resident 1 had an order for licensed staff to monitor Resident 1’s pain level using zero (0) to 10 pain scale (0 = no pain, 1 to 3 = mild pain, 4 to 6 = moderate pain, and 7 to 10 = severe pain) every shift. A review of Resident 1’s PO, dated 3/31/2025, the PO indicated Resident 1 had an order for Hydrocodone-Acetaminophen (medication to treat moderate to severe pain) oral tablet 5-325 milligram (mg) give one (1) tablet by mouth every six hours as needed (PRN) for moderate to severe pain from all sources. A review of Resident 1’s Minimum Data Set (MDS- resident assessment tool), dated 4/1/2025, the MDS indicated Resident 1 had moderately impaired for daily decision making. The MDS indicated Resident 1 required supervision for oral and personal hygiene, partial/moderate assistance for upper body dressing, and substantial/maximal assistance for showering/bathing, rolling left and right, sitting to lying on the bed, lying to sitting on side of the bed, and toilet transfer. The MDS indicated Resident 1 had not attempted to transfer to and from a bed to a wheelchair, sit to stand, or walk ten feet due to medical condition or safety concerns. The MDS indicated Resident 1 had a fall in the last month prior to admission, surgical repair of the hip, required pain assessment interview, and had not had any pain in the last five days of the assessment. A review of Resident 1’s CP titled, “Care Plan Report,” dated 4/4/2025, the CP indicated Resident 1 was at risk for hip fracture complications due to impaired mobility. The CP interventions indicated for staff to monitor/document/report to the doctor for signs and symptoms (s/sx) of hip fracture complications such as unrelieved pain, impaired mobility, and pain after exercise or weight bearing. A review of Resident 1’s Physical Therapy (PT) Treatment Encounter Notes (PT TEN) dated 4/7/2025, timed at 2:38 PM, completed by Physical Therapist 1 (PT 1), the PT TEN indicated Resident 1 complained of discomfort on Resident 1’s left lower extremity despite being pre-medicated. The PT TEN indicated PT 1 informed LVN 4 and agreed to monitor Resident 1. A review of Resident 1’s Medication Administration Record (MAR) for April 2025, the MAR indicated no documented evidence Resident 1 received Hydrocodone-Acetaminophen before or after the therapy session on 4/7/2025. The MAR indicated no documentation the licensed nurse assessed Resident 1 having any pain on 4/7/2025. The MAR indicated Resident 1 was administered Hydrocodone-Acetaminophen 5-325 mg for complaints of pain (pain location was not indicated) on the following dates and times: a. On 4/9/2025 at 10:32 AM for pain level of 8 out of 10. b. On 4/14/2025 at 8:56 AM for pain level of 8 out of 10. c. On 4/14/2025 at 8:09 PM for pain level of 7 out of 10. d. On 4/16/2025 at 8:20 AM for pain level of 7 out of 10. e. On 4/17/2025 at 8:18 AM for pain level of 7 out of 10. During a concurrent interview and record review on 5/6/2025 at 12:40 PM with the MDS Nurse, Resident 1’s MAR for April 2025 was reviewed. The MDS Nurse stated the MAR did not indicate Resident 1’s pain location when the licensed nurse (LVN 1) administered pain medication to treat Resident 1’s complaint of moderate to severe pain on 4/9/2025, 4/14/2025, 4/16/2025, and 4/17/2025. The MDS Nurse stated it was important for licensed nurses to document thoroughly such as the location of resident’s pain to provide appropriate care, treatment, and notify the doctor if necessary. During a concurrent interview and record review on 5/6/2025 at 3:19 PM with LVN 4, Resident 1’s medical record and MAR for April 2025 were reviewed. LVN 4 stated LVN 4 was Resident 1’s licensed nurse on 4/7/2025 during the 7 am to 3 pm shift. LVN 4 stated LVN 4 could not remember being informed by PT 1 about Resident 1 having pain and giving Resident 1 pain medication. LVN 4 stated there were no documented interventions, assessments, nor pain relief provided to Resident 1 on 4/7/2025. LVN 4 stated the MAR indicated the licensed nurse (LVN 1) administered Hydrocodone to Resident 1 on 4/9/2025 at 10:32 AM, 4/14/2025 at 8:56 AM and 8:09 PM, 4/16/2025 at 8:20 AM, and 4/17/2025 at 8:18 AM but there was no documentation of Resident 1’s pain location therefore the location of the pain was unknown. During an interview on 5/7/2025 at 10:09 AM with LVN 1, LVN 1 stated when a resident (in general) reported pain, LVN 1 should ask the location, intensity, and onset of the pain, and what triggered the resident’s pain. LVN 1 stated when LVN 1 administered Hydrocodone to Resident 1 on 4/9/2025, 4/14/2025, 4/16/2025, and 4/17/2025, LVN 1 failed to document the location of Resident 1’s pain which put Resident 1 at risk for missed or delayed diagnosis, inappropriate treatment, ineffective pain relief, and delay in timely interventions which can further worsen any injury residents may have. LVN 1 stated she could not recall by memory where Resident 1’s pain was located. During an interview on 5/7/2025 at 11:59 AM with PT 1, PT 1 stated that she provided therapy to Resident 1 on 4/7/2025 which consisted of the right leg range of motion, as well as the left leg range of motion while Resident 1 laid down on Resident 1’s bed. PT 1 stated PT 1 provided hip and knee flexion, with hip abduction (the movement of a limb away from the midline of the body) and adduction (the movement of a limb towards the midline) to the left leg/left hip. PT 1 stated PT 1 only took care of Resident 1 that day, and her memory was blurry regarding actual events which was why she relied heavily on her thorough documentation to recall events that day. PT 1 stated based on her assessment and documentation, Resident 1 was able to roll to his right side while lying in bed, and partially roll to his left side, progressing to sitting on edge of bed with assistance. PT 1 stated during the session, Resident 1 refused to attempt standing or getting out of bed and began to exhibit agitation. PT 1 stated Resident 1 wanted to go back to bed as Resident 1 complained of discomfort on his left lower extremity despite being pre-medicated prior to therapy and was guarding his left leg due to complaints of persistent pain. PT 1 stated Resident 1 was unable to describe or quantify Resident 1’s pain level at that time. PT 1 stated PT 1 walked over to the nurse’s station to inform the licensed nurse (LVN 4) of Resident 1’s discomfort to Resident 1’s left lower extremity and LVN 4 agreed to monitor Resident 1. PT 1 stated PT 1 could not recall how Resident 1 was showing agitation other than refusing to continue the therapy session. PT 1 stated there was a possibility PT 1 may have written the wrong laterality (preference for using one side of the body over the other) of Resident 1’s pain location. During an interview on 5/7/2025 at 12:45 PM with LVN 2, LVN 2 stated when residents (in general) report pain, licensed nurses should assess origin of pain, when the pain started, and depending on the pain level should give pain medication as needed, reassess the resident for effectiveness of pain medication, and document findings on the MAR. LVN 2 stated if the interventions were not effective, licensed nurses should document the reason, notify the doctor and family, and ask for X-rays or any type of diagnostic testing to rule out any unknown injuries. During an interview on 5/7/2025 at 2:04 PM with the Assistant Director of Nursing (ADON), the ADON stated licensed nurses were to communicate with staff and respond to any complaints of pain by assessing the resident’s pain level, location of pain, pain intensity, new onset of pain, determining if pain was long-term, and check the resident’s physician orders for any medication and/or treatment available to treat the resident’s pain. The ADON stated it was important to follow up on the resident’s pain levels and reassess the pain to determine if the treatment was effective and to ensure the facility was meeting the resident’s needs. The ADON stated failure to properly assess the resident’s complaint of pain can result in untreated pain, delayed or missed interventions, decline in physical function, and complications from over or under medication. A review of an electronic mail (e-mail) titled, “Documentation Clarification,” dated 5/7/2025, timed at 3:01 PM, emailed by PT 1, the e-mail indicated PT 1 provided a written statement to clarify Resident 1’s PT TEN dated 4/7/2025. The e-mail indicated per PT 1; PT 1 made an incorrect entry when PT 1 incorrectly documented Resident 1 complained of persistent pain on Resident 1’s left lower extremity (LLE) instead of RLE. The email indicated per PT 1, Resident 1’s pain location on 4/7/2025 was on the RLE. A review of the facility’s P&P titled, “Pain Recognition and Management,” revised 1/2022, the P&P indicated, “It is the policy of this facility to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan ...” The P&P indicated the care plan “will reflect the location and type of pain, pharmacological, and non-pharmacological interventions, with evaluation and revision as indicated.” A review of the facility’s P&P titled “Pain Management,” the P&P dated 10/2024, the P&P indicated, “The resident will be assessed for pain ... On admission with a pain-related diagnosis, or if pain in indicated through the Nursing Admission Assessment ... Upon development of new symptoms of acute pain... Complete the Pain Management Review assessment ... Complete appropriate physical assessment to determine any physical changes or manifestations as needed.” The P&P indicated, “Monitor pain status and treatment effects on a regular basis, e.g., during routine medication pass ... Consult physician for additional interventions if pain is not relieved by currently ordered treatment modalities and comfort measures. The Care Plan will include pharmacological and non-pharmacological interventions, with evaluation and revision as needed.” The facility failed to assess and manage reported pain for Resident 1 as indicated in Resident 1’s care plan and the facility’s policies and procedures titled, “Pain Recognition and Management,” and “Pain Management,” by failing to: 1. Ensure LVN 1 assessed and documented Resident 1’s pain location. 2. Ensure Resident 1 received pain medication when Resident 1 complained of persistent pain to Resident 1’s right lower extremity on 4/7/2025. As a result, Resident 1 experienced unrelieved/uncontrolled pain and had the potential to result in physical, mental, and emotional distress. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.