The 83-year-old patient, identified as Resident 1 in inspection records, had been admitted to Claremont Care Center following a fall that fractured his right femur. He required surgical repair and had moderately impaired cognition, along with generalized muscle weakness that left him needing substantial assistance with basic activities.
His care plan specifically instructed staff to "respond immediately to any complaint of pain" and monitor for hip fracture complications including unrelieved pain. Physician orders required licensed nurses to assess his pain level every shift using a 0-to-10 scale.
But when the resident reported pain levels of 7 and 8 out of 10 on multiple occasions in April, nurses administered hydrocodone without documenting where he hurt.
On April 7, during a physical therapy session, the resident complained of discomfort in his lower extremity despite being pre-medicated for the session. Physical Therapist 1 noted the resident "refused to attempt standing or getting out of bed and began to exhibit agitation," wanting to return to bed due to "complaints of persistent pain."
The therapist walked to the nurses' station to inform LVN 4 about the resident's discomfort. LVN 4 agreed to monitor the patient.
No pain medication was given that day. No assessment was documented.
Two days later, on April 9 at 10:32 AM, a nurse administered hydrocodone for a pain level of 8 out of 10. The medication record showed no indication of where the resident hurt.
The pattern continued. On April 14, the resident received hydrocodone twice — once at 8:56 AM for pain level 8, again at 8:09 PM for pain level 7. On April 16 at 8:20 AM, another dose for pain level 7. On April 17 at 8:18 AM, another dose for pain level 7.
Each time, nurses failed to document the location of his pain.
"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," the facility's MDS Nurse told inspectors during a May 6 interview.
LVN 1, who administered the pain medication on four of those occasions, acknowledged the failures during a May 7 interview. She told inspectors that when residents report pain, she should ask about location, intensity, onset, and triggers.
"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," according to the inspection report.
The nurse said she could not recall where the resident's pain was located.
Adding to the documentation problems, Physical Therapist 1 had initially recorded the wrong location of the resident's pain in her April 7 notes. She documented pain in the left lower extremity, but later sent an email correction stating the pain was actually in the right lower extremity — the side of his hip fracture.
"There was a possibility PT 1 may have written the wrong laterality of Resident 1's pain location," the therapist told inspectors.
LVN 4, who was supposed to monitor the resident after the therapist's report on April 7, told inspectors she could not remember being informed about the resident's pain or providing any interventions that day.
The facility's Assistant Director of Nursing explained that nurses should assess pain level, location, intensity, and determine if pain is new or chronic. "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."
The facility's own pain management policy, revised in January 2022, requires care plans to "reflect the location and type of pain" and mandates that staff "monitor pain status and treatment effects on a regular basis."
Another policy from October 2024 instructs nurses to "complete appropriate physical assessment to determine any physical changes or manifestations as needed" and "consult physician for additional interventions if pain is not relieved."
None of this happened for the hip fracture patient whose pain complaints went undocumented through April, leaving a medical record that inspectors found contained "inaccurate and incomplete information" with the potential to affect his care.
The resident required substantial assistance for basic movements including rolling in bed, sitting up, and toilet transfers. He had not attempted to walk ten feet due to medical conditions and safety concerns.
His wife had reduced her work hours to help care for him after his amputation following a previous nursing home stay, according to his medical history.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Claremont Care Center from 2025-05-07 including all violations, facility responses, and corrective action plans.