Balboa Nursing: Patient Denied Pain Meds for Hours - CA
The patient, who had been admitted to Balboa Nursing & Rehabilitation Center in August with right trochanteric bursitis and chronic pain syndrome, told inspectors she was in severe pain that night and "asked for pain pill multiple times." She received nothing.
Licensed Nurse 2, who was covering the unit, acknowledged during interviews that there was "an opportunity to provide pain medication around 9/5/25 12AM to 2 AM window." But the medication nurse assigned to the resident's unit was on break and "did not endorse her medication cart keys," leaving LN 2 unable to access the controlled substances.
The resident had two different pain medications available by doctor's orders. Hydrocodone-acetaminophen for moderate pain, rated 4 to 6 on a 10-point scale. And oxycodone for severe pain, rated 7 to 10. Records show she had received hydrocodone at 6:01 PM on September 4th and again at 4:40 AM on September 5th. Her last oxycodone dose was at 8:50 PM on September 4th.
When the medication nurse returned from break around 3 AM, LN 2 forgot to tell her about the resident's pain complaints. "LN 2 forgot to inform the medication nurse assigned to Resident 1 that Resident 1 was asking for pain medications," the inspection report states. No medication was given then either.
The resident woke up again around 4 AM, still asking for pain medication. By then, the medication nurse was unavailable for reasons the report doesn't specify.
The facility's Quality Assurance Nurse confirmed the breakdown during interviews with inspectors on September 9th. "LN 2 did not have the medication cart keys and LN 2 forgot to endorse Resident 1's request for pain medication to the assigned LN," the QA nurse told inspectors.
The QA nurse explained that when residents complain of pain and request medication, nurses should check physician orders and offer what's available in the emergency kit. "Resident 1's pain should be addressed in a timely manner for patient comfort," she said.
But that didn't happen. The resident told inspectors there was "a lack of communication between the employees" during the incident.
The resident's medical history made the delay particularly concerning. She had been admitted with inflammation of the hip joint and chronic pain syndrome, conditions that federal inspectors noted gave her the capacity to understand and make decisions about her care. Her physician's examination from August 22nd confirmed her mental competency.
Federal inspectors found the facility failed to provide safe, appropriate pain management, placing the resident at risk of unnecessary pain. The violation occurred during a complaint investigation, suggesting someone reported concerns about pain management at the facility.
The medication administration records showed a clear gap in pain relief during the critical overnight hours. The resident's last hydrocodone dose before the incident was at 6:01 PM on September 4th. She didn't receive another dose until 4:40 AM on September 5th, nearly eleven hours later. Her oxycodone gap was even longer, from 8:50 PM on September 4th until 8:27 AM on September 5th.
The QA nurse acknowledged there had been an opportunity to provide pain medication during the midnight to 2 AM window when the resident was asking for help. Instead, a combination of policy failures and human error left her suffering through the night.
The inspection found the facility's pain management protocols broke down at multiple points. The medication nurse took keys during a break without ensuring coverage. The covering nurse couldn't access emergency medications. Communication failed when shifts changed. And a resident in documented pain went hours without relief despite having appropriate medications ordered by her physician.
The resident's experience illustrates how procedural breakdowns in nursing homes can translate directly into patient suffering, even when the medical orders and medications are available to provide relief.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Balboa Nursing & Rehabilitation Center from 2025-09-09 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
BALBOA NURSING & REHABILITATION CENTER in SAN DIEGO, CA was cited for violations during a health inspection on September 9, 2025.
The resident had two different pain medications available by doctor's orders.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.