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
interview, and record review, the facility failed to ensure that residents received the treatment and care in
accordance with professional standards of practice related to pain management for one out of three
sampled residents (Resident 1) when
Residents Affected - Some
1. The licensed nurses did not follow physician's order to administer the pain medications as needed (PRN)
based on the pain assessment documented;
2. The licensed nurses did not update Resident 1's care plan for pain management;
3. The licensed nurses did not follow the physician's order to administer the PRN medication for severe
pain; and
4. The pain scale did not include the pain levels 1, 3, 5, and 7.
These failures had the potential for Resident 1's pain not being properly managed and could negatively
affect Resident 1's comfort and well-being.
Findings:
1. A review of Resident 1's clinical record indicated Resident 1 was admitted to the facility on [DATE] with
diagnoses including generalized muscle weakness and cervical region spinal stenosis (the space inside the
backbone is too small), Major depressive disorder (a mental health disorder characterized by persistently
depressed mood or loss of interest in activities, causing significant impairment in daily life), schizoaffective
disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as
hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression).
A review of Resident 1's physician order summary indicated:
a. Morphine ( a controlled pain medication) immediate release 15 mg 1 tablet oral special instruction: for
spinal stenosis as a breakthrough for moderate to severe pain every 6 hours PRN, started on 2/10/23.
b. Tylenol extra strength tablet 500 mg, two oral tablets for moderate pain every 8 hours PRN, started on
4/7/23.
During a concurrent interview and record review with the ADON on 2/14/24 at 11:20 a.m., the ADON
(continued on next page)
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
Page 1 of 2
Event ID:
055318
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055318
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/08/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Skyline Healthcare Center - San Jose
2065 Forest Avenue
San Jose, CA 95128
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0697
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
reviewed Resident 1's December 2023 MAR. The pain assessment indicated that the pain level was 4 on
12/13, 5 on 12/15, 8 on 12/17, 6 on 12/18, 4 on 12/20, and 7 on 12/30. The ADON confirmed that there was
no documented evidence Resident 1 had refused or declined the PRN pain medication and the licensed
nurses did not administer the prescribed PRN pain medication as indicated in the physician's order based
on the assessed pain levels. The ADON stated the licensed nurses should have followed the physician's
order to administer PRN Tylenol and PRN Morphine to relieve the pain after pain assessment.
2. A review of Resident 1 's care plan initiated on 8/23/19 indicated administer Morphine 15 mg 1 or 2 tabs
in the morning and at night, three tabs limited to 24 hours.
During a concurrent interview and record review with the ADON on 2/14/24 at 11:25 a.m., the ADON
reviewed Resident 1's care plan for pain and stated the licensed nurse should have updated the care plan
to include the PRN medication to manage Resident 1's pain.
3. During a concurrent interview and record review with the ADON on 2/14/24 at 11:35 a.m., the ADON
reviewed Resident 1's January MAR of 2024. The ADON confirmed that the licensed nurse administered
Tylenol 1000 mg to Resident 1 for severe pain 8 out of 10 on 1/1/24 and 1/ 2/24. The ADON stated the
physician prescribed Tylenol 1000 mg for moderate pain and the licensed nurses should have administered
Morphine 15 mg instead of Tylenol for severe pain 8/10 according to the physician's order.
4. A review of Resident 1's pain monitoring records with pain scale, started on 6/27/20, indicated 0: no pain,
2: mild pain,4-6: moderate pain, and 8-10: severe pain.
During a concurrent interview and record review with the ADON on 2/14/24 at 11:45 a.m., the ADON
reviewed the pain scale and stated the scale should reflect pain levels ranging from 1 to 10, including 1, 3,
5, 7, categorized as mild pain, moderate pain, or severe pain.
A review of the facility's undated policy and procedure titled oral medication administration indicated, To
administer oral medications in an accurate, safe, timely and sanitary manner .verify physician's order .
A review of the facility's undated policy and procedure titled Pain Management indicated, administer a
therapeutic intervention for pain if ordered .update the patient's care plan to include pain management. The
care plan shall include both pharmacological and non-pharmacological interventions and review the
patient's response to treatment daily. Adjust the care plan as needed to manage pain .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055318
If continuation sheet
Page 2 of 2
