Health inspection·April 22, 2025

Code of Federal Regulations, Title 42, Section 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. California Code of Regulations, Title 22, Section 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: (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. California Code of Regulations, Title 22, Section 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. California Code of Regulations, Title 22, Section 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. On 3/25/2025, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint regarding resident rights, quality of care, and nursing services for Resident 2. As a result of the investigation, the facility failed to manage Resident 2’s pain as indicated in Resident 2’s care plan and the facility’s policy and procedure (P&P) titled, “Pain Assessment and Management.” The facility failed to: 1. Ensure licensed nurses (LNs) assessed and documented Resident 2’s pain level before and after administration of oxycodone (medication used to treat moderate to severe pain) for pain management. 2. Ensure LNs assessed and documented Resident 2’s abdominal pain level and characteristic and administered pain medication as needed as ordered by the physician on 1/13/25 and 1/14/25. These failures had the potential for Resident 2 to experience unrelieved/uncontrolled pain that could result in physical, mental, and emotional distress. A review of Resident 2’s Admission Record, indicated the facility admitted Resident 2, a 65-year-old female, on 12/13/2024, with diagnoses that included fracture (break in a bone) of the right femur (thigh bone), subsequent encounter for closed fracture (broken bone without puncture or open wound) with routine healing, other abnormalities of gait and mobility, and other muscle spasm. A review of Resident 2’s History and Physical Examination (H&P) dated 12/14/2024, indicated Resident 2 did not have the capacity to understand and make decisions. A review of Resident 2’s Care Plan (CP) titled, “Care Plan Report,” initiated on 12/14/2024, indicated Resident 2 was at risk for unrelieved pain due to right hip fracture status post (s/p- condition after) open reduction and internal fixation (ORIF- surgical procedure to treat bone fractures). The CP interventions included for staff to monitor/document pain on a scale of zero (0) to 10 (0 = no pain and 10 = the worst pain) before and after implementing measures to reduce pain. A review of Resident 2’s Minimum Data Set (MDS- a resident assessment tool) dated 12/18/2024, indicated Resident 2 was able to understand others and express ideas and wants. The MDS indicated Resident 2 had severely impaired cognition (ability to think, learn, and remember), required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, showering/bathing self, lower body dressing, putting on/taking off footwear, and rolling left and right on the bed, and was dependent on staff for chair/bed-to-chair transfer. The MDS indicated Resident 2 received scheduled pain medication regimen and had no pain in the last five days of assessment. A review of Resident 2’s Physician Order (PO) dated 12/20/2024, indicated Resident 2 had an order for licensed staff to administer oxycodone hydrochloride (HCl) oral tablet 5 milligrams (mg- unit of measurement), one (1) tablet by mouth two times a day for pain management. A review of Resident 2’s Medication Administration Records (MAR) for 12/2024 and 1/2025, indicated Resident 2 received oxycodone HCl two times a day at 9 am and 5 pm from 12/20/2024 to 12/31/2024 and 1/1/2025 to 1/13/2025. A review Resident 2’s Progress Notes (PN) dated 1/13/2025, timed at 11:53 am, indicated Nurse Practitioner (NP) 1 visited Resident 2 at the bedside and ordered abdominal ultrasound (US- imaging test that uses sound waves to take pictures of the inside of the body) due to Resident 2’s complaint of right upper abdominal pain. The PN indicated no documentation of Resident 2’s pain level and characteristic and what interventions were provided to address Resident 2’s pain on 1/13/2025. A review of Resident 2’s PO dated 1/13/2025, indicated Resident 2 had an order for licensed staff to administer oxycodone HCl oral tablet 5 mg, one tablet by mouth every 12 hours as needed for moderate to severe pain (pain level of 4 to 10 out of 10). A review of Resident 2’s Change in Condition Evaluation (CICE) dated 1/14/2025, timed at 3:30 pm, indicated Resident 2 complained of abdominal pain and was requesting to be transferred to the hospital for further evaluation and treatment. The CICE indicated no documentation of Resident 2’s pain level and pain characteristic. During an interview on 3/26/2025 at 8:01 am, Licensed Vocational Nurse 2 (LVN) 2 stated Resident 2 complained of frequent back and hip pain and received routine oxycodone at 9 am and 5 pm. LVN 2 stated any resident who complained of pain needed to be assessed for facial grimacing (expression of pain/strong dislike) and pain level from a scale of 0 to 10. LVN 2 stated depending on the resident’s pain level, LVN 2 would provide non-pharmacological (treatment or strategies that do not involve medications) interventions first and if ineffective, would follow with pain medication as ordered. LVN 2 stated, LNs needed to assess and document the resident’s (in general) pain level on the electronic MAR (eMAR) and/or progress notes before giving routine and/or as needed (PRN) pain medication. LVN 2 stated LNs needed to reassess and document the resident’s pain level an hour after giving the pain medication to evaluate if the pain medication was effective in relieving the resident’s pain. During a concurrent interview and record review on 3/26/2025 at 8:58 am, Registered Nurse Supervisor (RNS) 1 reviewed Resident 2’s MAR for 12/2024 and 1/2025 and Resident 2’s PN from 12/2024 to 1/2025. The MAR for 12/2024 and 1/2025 indicated Resident 2 received oxycodone HCl every day at 9 am and 5 pm routinely (regularly) for pain management as ordered by the physician. RNS 1 stated Resident 2’s MAR and PN indicated no documented evidence LNs assessed and documented Resident 2’s pain level before and after administering oxycodone. RNS 1 stated LNs needed to assess and document the residents’ (in general) pain level before and after giving routine and/or PRN pain medication. During the same concurrent interview and record review on 3/26/2025 at 8:58 am, RNS 1 reviewed Resident 2’s PN dated 1/13/2025 and 1/14/2025, CICE dated 1/14/2025, and MAR for 1/2025. RNS 1 stated RNS 1 was the RNS on duty on 1/13/2025 and 1/14/2025, and RNS 1 completed Resident 2’s CICE dated 1/14/2025. RNS 1 stated Resident 2 complained of abdominal pain on 1/14/2025 and told RNS 1 her pain (Resident 2’s) was “bad.” RNS 1 stated Resident 2 was crying at that time and requested to be transferred to the hospital. RNS 1 stated RNS 1 notified NP 2 and NP 2 ordered to transfer Resident 2 to the hospital per Resident 2’s request. RNS 1 stated Resident 2's PN and CICE indicated no documentation of Resident 2’s abdominal pain level and characteristic. RNS 1 stated LNs needed to assess and document residents’ (in general) pain level and characteristic, provide non-pharmacological and pharmacological interventions to address the pain, and evaluate effectiveness of the interventions. RNS 1 stated Resident 2’s MAR for 1/2025 indicated no documentation staff administered any pain medication to Resident 2 for Resident 2’s complaints of abdominal pain on 1/13/2025 at 11:53 am and 1/14/2025 at 3:30 pm. RNS 1 stated LNs needed to give Resident 2 pain medication for Resident 2’s abdominal pain and document the medication administration in the MAR. During a telephone interview on 3/26/2025 at 11:32 am, the Director of Nursing (DON) stated LNs should assess and document the resident’s (in general) pain level before and after administering routine and prn pain medications. The DON stated a resident’s new onset of pain was considered a change of condition and LNs needed to address it. The DON stated LNs needed to notify the resident’s physician of the change of condition, obtain physician orders, and carry out the orders. The DON stated LNs needed to document the change of condition in the CICE form on the date and time the change of condition first started and LNs needed to monitor the resident. The DON stated LNs should administer pain medications as needed for pain and as ordered by the physician. A review of the facility’s P&P titled, “Pain Assessment and Management,” revised 10/2022, the P&P indicated, “Acute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained. The P&P indicated, “Monitor the resident for the presence of pain and the need for further assessment when there is a change of condition.” The P&P indicated, “During the pain assessment gather the following information as indicated from the resident… Characteristics of pain: (1) Location of pain; (2) Intensity of pain (as measured on a standardized pain scale); (3) Characteristics of pain (e.g. aching, burning, crushing, numbing, burning, etc.); (4) pattern of pain (e.g., constant or intermittent); and (5) frequency, timing and duration of pain)…” The P&P indicated, “Document the resident’s reported level of pain with adequate detail (i.e., enough information to gauge the status of pain and the effectiveness of interventions for pain) as necessary and in accordance with the pain management program. Upon completion of the pain assessment, the person conducting the assessment shall record the information obtained from the assessment in the resident’s medical record.” The facility failed to manage Resident 2’s pain as indicated in Resident 2’s care plan and the facility’s P&P titled, “Pain Assessment and Management.” The facility failed to: 1. Ensure LNs assessed and documented Resident 2’s pain level before and after administration of oxycodone for pain management. 2. Ensure LNs assessed and documented Resident 2’s abdominal pain level and characteristic and administered pain medication as needed and ordered by the physician on 1/13/25 and 1/14/25. These failures had the potential for Resident 2 to experience unrelieved/uncontrolled pain that could 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 2.