The woman, identified as Resident 3 in inspection records, told federal inspectors in December that her left ribs were fractured and she was "in too much pain." When nurses moved and turned her, she said, "she would scream."
Valley Palms Care Center admitted the resident in August with multiple rib fractures, a fall, and heart disease. Her doctor ordered hydrocodone-acetaminophen tablets every four hours as needed for moderate to severe pain rated four to ten on the standard pain scale.
On December 5, Licensed Vocational Nurse 3 documented that the resident's pain level was eight out of ten. The medication administration record showed no hydrocodone was given that day.
The facility's Assistant Director of Nursing reviewed the records with inspectors and confirmed the violation. "LVN 3 should have administered hydrocodone to Resident 3's pain as ordered by the physician," the ADON said. She acknowledged the resident "could have suffered in pain that could have resulted in uncontrollable pain."
The resident told inspectors that when she does receive pain medication, "it helps but only for a short time." Her most recent assessment in December showed she had occasional pain at level six, and her cognitive skills were intact, meaning she could clearly communicate her needs.
Progress notes contained no documentation that pain medication was administered on December 5, despite the nurse's notation of severe pain.
The Director of Nursing confirmed to inspectors that "nurse should medicate Resident 3 for pain as ordered by the physician." The DON said the resident "could have unresolved pain that could affect Resident 3's mood and could cause Resident 3's distress."
Federal inspectors cited Valley Palms for failing to provide safe, appropriate pain management. The facility's own policies require medications to be administered according to prescriber orders, including required time frames, and specify that physicians will order appropriate interventions to address individual pain.
The violation affected few residents but created potential for actual harm, according to the inspection report completed December 19.
The resident remains at Valley Palms, where she continues to experience pain from her fractured ribs while depending on staff who have already demonstrated they may not follow doctor's orders for her relief.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Valley Palms Care Center from 2025-12-19 including all violations, facility responses, and corrective action plans.