Health inspection·April 18, 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. Code of Federal Regulations, Title 42, Section 483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident’s physician; and notify, consistent with his or her authority, the resident representative(s) when there is— (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident’s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) Code of Federal Regulations, Title 42, Section 483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are— (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized California Code of Regulations, Title 22, Section 72311. Nursing Service--General. (a) Nursing service shall include, but not be limited to, the following: (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 72311. Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (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. 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 3/5/2025, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint regarding quality of care and resident rights of Resident 3. As a result of the investigation, the facility failed to recognize, assess, and provide effective pain management to Resident 3, according to Resident 3’s untitled care plan (CP) and the facility's policies and procedures (P&P) titled, "Pain- Clinical Protocol," "Changes in Resident Condition," and “Charting and Documentation.” The facility failed to: 1. Ensure Licensed Vocational Nurse (LVN) 4 accurately assessed and documented Resident 3's pain score (pain score indicating level of pain with zero being no pain and 10 being the worst pain) on 3/6/2025 at 1:50 pm when LVN 4 gave Resident 3 Tylenol (medication used to treat minor aches and pain). 2. Ensure LVN 4 gave the appropriate pain medication to treat Resident 3's pain level of nine (9) out of 10 (severe pain- rated as seven [7] to 10 out of 10 pain) on 3/6/2025 at 1:50 pm, instead of Tylenol. 3. Ensure LVN 4 notified Resident 3’s primary care physician (PCP) of Resident 3’s pain level of 9 out of 10 and obtained appropriate pain medication order. These failures resulted in Resident 3 experiencing severe pain on 3/6/25. Resident 3 hid under Resident 3's blankets, shaking, crying, and stated, "I want to die I'm in so much pain." These failures had the potential to cause Resident 3 psychosocial (mental, emotional, social, and spiritual effects) harm and cause a decline in health. A review of Resident 3's Admission Record, indicated the facility initially admitted Resident 3, a 68-year-old female on 4/16/2024, and was readmitted on 10/18/2024 with diagnoses that included type II diabetes mellitus (DM2- a condition that happens because of a problem in the way the body regulates and uses sugar as fuel) with chronic kidney disease (damage to the kidneys so they cannot filter blood the way they should), and hydronephrosis (a condition where urine backs up into the kidneys, causing them to swell, generally caused by infection or obstruction). A review of Resident 3's untitled CP, initiated 4/17/2024, indicated Resident 3 was at risk for pain related to disease process. The CP goals indicated Resident 3 would verbalize adequate relief of pain or ability to cope with incompletely relieved pain. The CP interventions included for staff to administer analgesia (pain medication) as ordered and to give a half hour before treatment or care, and to monitor/record pain characteristics and as needed: quality, severity, anatomical location, onset, duration, aggravating factors, and relieving factors. A review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 1/13/2025, indicated Resident 3 had severely impaired cognition. The MDS indicated Resident 3 frequently experienced pain or hurting over the last five days of the MDS assessment. The MDS indicated Resident 3 experienced seven (7) out of 10 pain over the last five days of the MDS assessment. A review of Resident 3's Order Summary Report (OSR), active as of 3/6/2025, indicated Resident 3 had the following physician orders: 1. Tylenol oral tablet 325 mg (acetaminophen), give two tablets via gastrostomy tube (GT- tube inserted through the belly that brings nutrition directly to the stomach) every six hours as needed for mild pain (one [1] to three [3] out of 10), ordered on 10/18/2024. 2. Norco Oral Tablet 10-325 milligrams (mg) (hydrocodone-acetaminophen), give one tablet via GT every eight hours as needed for breakthrough pain (sudden increase in pain that may occur in patients who already have chronic pain from infection, disease, or other conditions), ordered on 2/10/2025. A review of Resident 3's Medication Administration Record (MAR) dated 3/6/2025, indicated Resident 3 received Norco oral table 10-325 mg, one tablet via GT on 3/6/2025 at 10:07 am for 7 out of 10 pain. The MAR indicated LVN 4 administered the Norco at 10:07 am. The MAR indicated Resident 3 received Tylenol oral tablet 325 mg, two tablets via GT at 1:50 pm for 3 out of 10 pain. The MAR indicated LVN 4 administered the Tylenol at 1:50 pm. During a concurrent observation and interview on 3/6/2025 at 2:12 pm, with Resident 3, inside Resident 3's room, Resident 3's pain was observed. Resident 3 had blankets covering Resident 3's head. Resident 3 stated Resident 3 was cold, dizzy, and "In so much pain." Resident 3 was observed shaking. Resident 3 stated Resident 3's feet hurt, "so bad," and was in 9 out of 10 pain. Resident 3 stated Resident 3 received pain medication not long before the interview (1:50 pm on 3/6/2025) but could not remember what Resident 3 received. Resident 3 stated LVN 4 did not ask how much pain Resident 3 was having before giving Resident 3 pain medication not long ago. Resident 3 stated, "I want to die I'm in so much pain." During an observation on 3/6/2025 at 2:20 pm, in Resident 3's room, Resident 3 told LVN 4 Resident 3 was in 9 out of 10 pain. LVN 4 informed Resident 3 that Resident 3 received Tylenol at 1:50 pm. LVN 4 stated LVN 4 could not give Resident 3 Norco until 6 pm because it was last given at 10 am and could only be given every eight hours. Resident 3 began crying again. During a concurrent interview and record review on 3/6/2025 at 4:37 pm, LVN 4 reviewed Resident 3's MAR for 3/2025. LVN 4 stated LVN 4 gave Resident 3 Tylenol at 1:50 pm, without asking Resident 3 how much pain Resident 3 had because Resident 3 could not receive more Norco until 6 pm. LVN 4 stated, "Giving something was better than giving nothing." LVN 4 stated LVN 4 should have asked Resident 3's pain score so Resident 3’s pain could be treated appropriately instead of documenting Resident 3's pain score of 3 out of 10. LVN 4 stated Resident 3's pain score was 9 out of 10. LVN 4 stated LVN 4 should have asked what Resident 3's pain score was and notified Resident 3's primary care provider (PCP). LVN 4 stated Tylenol was not used to treat severe pain, but mild pain. LVN 4 stated not asking Resident 3 what Resident 3's pain score was and documenting a pain score of 3 out of 10 was incorrect. LVN 4 stated inaccurate documentation of Resident 3’s pain score put Resident 3 in more pain than Resident 3 needed to be, resulting in Resident 3's pain not being managed properly. LVN 4 stated 9 out of 10 pain could be considered uncontrolled pain. During an interview on 3/6/2025 at 7:13 pm, the DON stated licensed nurses were supposed to assess the residents' pain score before giving pain medication because licensed nurses had to give the appropriate medication based on the residents’ pain score. The DON stated Tylenol generally treated mild pain rated 1 to 3 out of 10. The DON stated it was not appropriate to give Tylenol to treat a pain score of 9 out of 10. The DON stated LVN 4 needed to document that Resident 3's pain was not controlled and call Resident 3’s physician to get an appropriate order if there was nothing appropriate to give. The DON stated it was not okay to document a pain score if the resident's pain level was not assessed because the resident could be given inappropriate medication to treat the resident’s pain and could end up with more or uncontrolled pain. A review of the facility's P&P titled, "Pain- Clinical Protocol," revised 10/2022, indicated, “The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, and whenever there was a significant change of condition, and when there is new onset of new pain or worsening of existing pain.” The P&P indicated, “The staff and physician will identify the characteristics of pain such as location, intensity, frequency, pattern, and severity… Staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident’s cognitive level.” The P&P indicated, “Pain medications should be selected based on pertinent treatment guidelines.” The P&P indicated, “If the resident's pain is complex or not responding to standard interventions, the attending physician may consider additional consultative support.” A review of the facility's P&P titled, "Changes in Resident Condition," dated 11/3/2023, indicated, “The resident, attending physician and legal representative … are notified when changes in condition or certain events occur.” The P&P indicated, “Changes of condition are communicated from shift to shift through the 24-hour report management system. Examples of clinical condition changes are… any change in resident from resident’s baseline/onset of new concern/incident…” The P&P indicated, “Document in the resident's medical record … Date and time of the change of condition – Who … was notified regarding the condition change, information communicated, response and/or orders received, assessment of resident condition and ongoing monitoring of resident condition, care provided ...” A review of the facility’s P&P titled, “Charting and Documentation,” revised 7/2017, the P&P indicated, “All services provided to the resident, progress toward the care plan goals, or any changes to the resident’s medical, physical, functional, or psychosocial condition, shall be documented in the resident’s medical record. The medical should facilitate communication between the IDT regarding the resident’s condition and response to care.” The P&P indicated, “Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.” The facility failed to recognize, assess, and provide effective pain management to Resident 3, according to Resident 3’s untitled CP and the facility's P&P titled, "Pain- Clinical Protocol," "Changes in Resident Condition," and “Charting and Documentation.” The facility failed to: 1. Ensure LVN 4 accurately assessed and documented Resident 3's pain score on 3/6/2025 at 1:50 pm when LVN 4 gave Resident 3 Tylenol. 2. Ensure LVN 4 gave the appropriate pain medication to treat Resident 3's pain level of 9 out of 10 on 3/6/2025 at 1:50 pm, instead of Tylenol. 3. Ensure LVN 4 notified Resident 3’s primary care physician (PCP) of Resident 3’s pain level of 9 out of 10 and obtained appropriate pain medication order. These failures resulted in Resident 3 experiencing severe pain on 3/6/25. Resident 3 hid under Resident 3's blankets, shaking, crying, and stated, "I want to die I'm in so much pain." These failures had the potential to cause Resident 3 psychosocial harm and cause a decline in health. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 3.