Balboa Nursing & Rehabilitation Center
Inspection Findings
F-Tag F0697
F 0697
Provide safe, appropriate pain management for a resident who requires such services.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to administer pain medication for one of two residents (Resident 1) in a timely manner. This failure placed Resident 1 at risk of unnecessary pain.
Findings
Resident 1 was admitted to the facility on [DATE REDACTED]and 8/21/25 with diagnoses to include right trochanteric bursitis (inflammation of the hip joint), type 2 diabetes, chronic pain syndrome according to the facility's admission Record. According to the physician History and Physical Examination (H&P) dated 8/22/25, indicated Resident 1 has the capacity to understand and make decisions. On 9/9/25 at 2:22 P.M., concurrent observation and interview was conducted with Resident 1. Resident 1 stated on 9/5/25 around 2 A. M., she was in severe pain and asked for pain pill multiple times. Resident 1 stated she was not given pain medication at that time. Resident 1 stated there was a lack of communication between the employees.
On 9/9/25 at 3:08 P.M., a concurrent interview and record review was conducted with Licensed Nurse (LN)
- 1. According to the physician orders, Resident 1 received Hydrocodone-acetaminophen 10-325 milligrams
(mg), give two tablets by mouth every 8 hours as needed for moderate pain (pain scale 4 to 6 out of a possible 10 as the worst pain) and Oxycodone 10 mg, give 1 tablet by mouth every 4 hours as needed for sever pain ( pain scale 7 to10 and 10 as the worst pain). According to the electronic Medication Administration Record (eMAR), Hydrocodone-acetaminophen 10-325 mg was last administered on 9/4/25 at 6:01 P.M. and 9/5/25 at 4:40 A.M. According to the electronic Medication Administration Record (eMAR), Oxycodone 10 mg was last administered on 9/4/25 at 8:50 P.M. and 9/5/25 at 8:27 A.M. During this
interview and record review, LN 2 acknowledged there was an opportunity to provide pain medication around 9/5/25 12AM to 2 AM window. There was no pain medication at around 2 A.M. On 9/9/25 at 4:26 P.M. an interview with LN 2 was conducted with the Quality Assurance Nurse (QA) present. LN 2 stated around 2 AM, Resident 1 was asking for pain medications, but the medication nurse assigned to Resident 1 was on break and did not endorse her medication cart keys. LN 2 stated there was no pain medication given to Resident 1 at that time. LN 2 stated around 3 A.M., the medication nurse assigned to Resident 1 returned, but LN 2 forgot to inform the medication nurse assigned to Resident 1 that Resident 1 was asking for pain medications. LN 2 stated there was no pain medication given to Resident 1 at that time. LN 2 stated around 4 A.M., Resident 1 awakened and was asking for pain medication. The medication nurse assigned to Resident 1 was not available for interview. On 9/9/25 at 4:45 P.M., a concurrent interview and record
review was conducted with QA Nurse.The QA Nurse stated 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 to Resident 1. QA Nurse stated the expectation when Resident 1 complained of pain and requested a pain medication, LNs should check the physician orders and offer what was available in the emergency kit. The QA nurse stated Resident 1's pain should be addressed in a timely manner for patient comfort.During this interview and
record review, QA Nurse acknowledged there was an opportunity to provide pain medication around 9/5/25 12AM to 2 AM window.
Residents Affected - Few
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
BALBOA NURSING & REHABILITATION CENTER in SAN DIEGO, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SAN DIEGO, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from BALBOA NURSING & REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.