West Hills Health and Rehabilitation Center failed to provide appropriate pain management for a resident who had been readmitted in April with multiple serious conditions including brain hemorrhage, spinal curvature, arthritis, and chronic ear infection.
The resident's physician had ordered Tylenol Extra Strength 500 milligrams every six hours as needed for mild pain, specifically defined as levels 1-3 on the standard 10-point pain scale. Moderate pain registers 4-6, while severe pain spans 7-10.
On November 1 at 11:14 p.m., Licensed Vocational Nurse 2 administered the Tylenol to the resident who reported pain level 5 out of 10. Nine days later, the same scenario repeated when another nurse gave the mild pain medication for the same moderate pain level of 5/10.
Licensed Vocational Nurse 1 told inspectors that nurses should assess residents' pain before administering medication and give treatment based on the actual pain level reported. She confirmed that based on the physician's orders limiting Tylenol to mild pain, the other nurse "should not have administered Tylenol 500 mg and should have called Resident 1's physician to obtain an order for a stronger pain medication."
The facility's own policy requires nurses to contact the prescribing physician, attending physician, or medical director when "the dosage is believed to be inappropriate or excessive for a resident." The policy specifically states medications must be administered "in accordance with prescriber orders."
Director of Nursing confirmed the violation during the November inspection, stating that the nurse "should have called the physician to obtain an order that is appropriate for Resident 1's pain level of 5/10." She emphasized that "it is important to administer the appropriate medication so that residents do not suffer in pain."
The resident's complex medical history made proper pain management particularly crucial. Originally admitted to West Hills in July 2018, the resident returned in April 2025 with multiple painful conditions. Nontraumatic intracerebral hemorrhage refers to bleeding within the skull. Scoliosis creates painful side-to-side spinal curvature, while kyphosis causes excessive forward rounding of the upper back. Osteoarthritis progressively destroys joint cartilage, and chronic mastoiditis involves persistent infection of the mastoid bone behind the ear.
The facility had established a care plan for the resident's acute and chronic pain on September 11, with an intervention specifically calling for administering "pain medications per order." However, nurses failed to follow through when the existing orders proved insufficient for the resident's reported pain level.
Registered Nurse 1 confirmed during the inspection that the facility had administered Tylenol Extra Strength to the resident on both November dates when pain level reached 5/10, acknowledging the medication was designed only for mild pain up to level 3.
The facility's pain assessment and management policy, reviewed in January, states its purpose is "to help the staff identify pain in a resident, and to develop interventions that are consistent with the resident's goals and needs that address the underlying cause of pain."
Federal inspectors classified the violation as having minimal harm or potential for actual harm, noting the deficient practice "had the potential to result in inadequate management of Resident 1's pain."
The inspection occurred following a complaint and found that one of three residents sampled for pain management review had received inadequate treatment. The facility's medication administration records documented both instances when nurses gave inappropriate medication for the resident's moderate pain level.
Staff interviews revealed nurses understood the proper protocol but failed to implement it. The gap between policy and practice left the resident experiencing moderate pain while receiving medication intended only for mild discomfort, potentially prolonging unnecessary suffering that could have been addressed with a simple phone call to the physician.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for West Hills Health and Rehabilitation Center from 2025-11-24 including all violations, facility responses, and corrective action plans.
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