Skytop View Rehabilitation Center

Based on interview and record review, the facility failed to ensure physician ordered medication parameters were followed for adequate indications for use, resulting in the administration of unnecessary medications for 1 of 3 residents, Resident #1, reviewed for unnecessary pain medications. Findings include: Review of Resident #1's admission record documented diagnosis of atherosclerotic heart disease of native coronary artery(heart disease) without angina pectoris (chest pain), fibromyalgia (a disorder of pain processing causing chronic widespread pain), essential (primary) hypertension (high blood pressure), major depressive disorder, recurrent, unspecified, anxiety disorder unspecified, personal history of pulmonary embolism (a blood clot in the lung), personal history of malignant neoplasm breast (breast cancer), muscle weakness generalized, and difficulty in walking not elsewhere classified. Review of Resident #1's physician order dated 10/22/2025 read, Oxycodone-Acetaminophen tablet 10-325 mg (milligram) give one tablet by mouth every six hours as needed for severe pain 7-10,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to ensure respiratory care services were provided for oxygen administration for 1 of 3 Residents, Resident #5, reviewed for respiratory services. Findings include: Record review of Resident #5's clinical record documented the resident was admitted with diagnosis that included: anemia, atherosclerosis heart disease, pulmonary hypertension, and chronic obstructive pulmonary disease. Review of Resident #5's physician orders dated 3/3/2025 read, Oxygen at 4LPM [liters per minute] via NC [nasal cannula] every shift. Review of Resident #5's care plan dated 2/6/2025 read, Focus: The resident has oxygen therapy r/t [related to] COPD [chronic obstructive pulmonary disease]. Interventions/Tasks: Give medications as ordered by physician. During an observation on 3/3/2025 at 10:08 AM of Resident #5, the resident was sitting at bedside. Oxygen was being administered at 3 liters per minute via nasal cannula. (Photograph evidence obtained). During an interview on 3/3/2025 at 1:16 PM Resident #5 stated, I do not change the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure a rationale was in the medical record for psychotropic PRN (pro re nata/as needed) medications being prescribed for greater than 14 days for 1 of 5 residents, Resident #84, reviewed for unnecessary medications. Findings include: Review of the pharmacist's consultation report, dated 2/17/2025, read [Resident #84's Name] has a PRN order for a sedative/hypnotic, without a stop date: Zolpidem 10mg [milligrams] q [every] HS [hour of sleep] PRN for insomnia. Recommendation: Please discontinue PRN Zolpidem, or a stop date that is less than 14 days from initiation. If the medication cannot be discontinued at this time, document the indication for use, the intended duration of therapy, and the rationale for the extended time period. Review of Resident #84's physician's orders dated 2/17/25 read Zolpidem Tartrate Oral Tablet 10MG [milligrams] (Zolpidem Tartrate) *Controlled Drug* Give 1 tablet by mouth every 24 hours as needed for Difficulty Sleeping for 30 days. The physician's order did not contain documented rationale for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to secure medications for 1 of 3 wings, the south. Findings included: During an observation on 3/3/2025 at 10:08 AM of Resident #5's room there was one bottle of Saline Nasal Mist and one bottle of normal saline eye solution on the bedside table unsecured. (Photograph evidence obtained). During an observation on 3/3/2025 at 12:18 PM of Resident #5's room there was one bottle of Saline Nasal Mist and one bottle of normal saline eye solution on the bedside table unsecured. During an interview on 3/3/2025 at 12:22 PM Resident #5 stated, My wife brought them to me and I use them as needed at least daily. During an interview on 3/3/2025 at 12:30 PM Staff A, Registered Nurse (RN) verified the Saline Nasal Mist and bottle of normal saline eye solution medications unsecured at Resident #5's bedside. Staff A, RN stated, Medication cannot be kept at the bedside, all medications have to be secured. During an interview on 3/3/2025 at 1:16 PM the Director of Nursing stated, Medications cannot be at the bedside unsecured.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure transmission-based precautions were implemented for 1 of 3 residents reviewed, Resident #5, to prevent the possible spread of infections and communicable diseases. Findings include: Review of Resident #5's progress note, dated 7/12/24 at 8:51 PM, revealed the resident was noted with congested cough. The progress note documented Resident #5's physician ordered COVID-19 PCR [polymerase chain reaction] test. Review of Resident #5's COVID-19 test result, received by the facility on 7/15/2024 at 2:20 PM, revealed the resident had been tested for COVID-19 on 7/13/2024 at 8:27 AM and had been positive for COVID-19 on 7/13/2024 at 10:08 AM. Review of Resident #5's physician orders revealed no order for transmission-based precautions on 7/12/2024 after the resident was symptomatic with congested cough. Review of Resident #5's physician orders revealed orders for Zinc Sulfate oral capsule 50 milligrams one capsule by mouth one time a day for COVID-19 prophylaxis for 10 days (start date 7/15/2024 at 2:24 PM); Zyrtec Allergy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care consistent with professional standards of practice by not dating the oxygen tubing for 1 of 3 residents reviewed for oxygen administration, Resident #184 (photographic evidence obtained). Findings include: During an observation on 11/19/2023 at 10:50 AM, Resident #184 was sitting in her bedside chair with oxygen being administered at 2 liters per minute from the oxygen concentrator. There was no date labeled on the tubing. During an observation on 11/19/2023 at 1:18 PM, Resident #184 was sitting in her bedside chair with oxygen being administered at 2 liters per minute from the oxygen concentrator. There was no date labeled on the tubing. Review of Resident #184's admission record showed the resident was admitted to the facility on [DATE] with a diagnosis of, but not limited to, acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease with acute exacerbation.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the clinical records was accurate for 1 of 3 sampled residents, Resident #82. Findings include: Review of Resident #82's admission record showed the resident was most recently admitted to the facility on [DATE]. Review of Resident #82's progress note dated 11/18/2023 showed the progress note reads, 97 y/o [year old] female arrived on 9/18/2023 . During an interview on 11/20/2023 beginning at 11:49 AM, the Director of Nursing confirmed Resident #82 was admitted on [DATE]. She confirmed the progress note entry related to Resident #82's admission date was inaccurate. Review of Resident #82's wandering risk assessment dated [DATE] showed the assessment reads Medications 1. Taking antipsychotics. Review of Resident #82's current, discontinued and completed physician orders with the Director of Nursing did not show any documentation indicating Resident #82 was or had been prescribed with an antipsychotic medication. During an interview on 11/20/2023…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the facility failed to label and store all medications available for use in accordance with professional standards in 2 out of 2 medications carts reviewed. Findings: During an observation conducted on 6/14/22 at 8:22 AM with Staff A, Licensed Practical Nurse (LPN) medication cart #1 contained one opened Aspart insulin pen with no date opened or expiration date, and two Aspart insulin pens unopened with a label from the pharmacy to refrigerate until opened. During an interview conducted on 6/14/2022 at 8:28 AM Staff A, LPN stated, I haven't gotten to check these yet and all insulin if it is on the cart should have the date opened on them or be kept in the refrigerator until they are opened During an observation conducted on 6/14/22 at 8:36 AM with Staff B, Registered Nurse (RN) medication cart #2 contained one opened Toujeo insulin pen with no date opened or expiration date, and two unopened Aspart insulin pens with a label from the pharmacy to refrigerate until opened During an interview conducted on 6/14/2022 at 8:40 AM Staff B,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide respiratory care services in accordance with professional standards of practice for 4 of 7 residents, Residents #12, #68, #118, and #119, reviewed for oxygen administration and respiratory equipment. Findings: 1. During an observation on 6/14/2022 at 9:44 AM Resident #119 was observed sitting at the bedside with oxygen being administered at 2 liters per minute by nasal cannula. Review of the medical record for Resident #119 documented the resident was admitted to the facility on [DATE] with the following diagnoses: type 2 diabetes mellitus without complications, chronic obstructive pulmonary disease, chronic kidney disease stage 4, hypertensive chronic kidney disease, hyperlipidemia (high cholesterol}, history of falling, fracture of third thoracic vertebra, pulmonary embolism (a blood clot) without acute cor pulmonale (a form of sudden right sided heart failure), traumatic subarachnoid hemorrhage (bleeding in the brain). Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide care in accordance with professional standards of practice for 2 of 6 residents, Residents #14 and #114, reviewed for unnecessary medications. Findings: Review of the medical record for Resident #14 documented the resident was admitted to the facility on [DATE] with the following diagnoses: spondylosis, history of falling, atherosclerotic heart disease of native coronary artery without angina pectoris (chest pain), chronic obstructive pulmonary disease, benign prostatic hyperplasia without lower urinary tract symptoms, type 2 diabetes mellitus without complications. Review of the medical record documented vital signs dated 4/21/2022 at 10:53 PM oxygen saturation of 94% on room air. Review of the nursing progress note dated 4/22/22 at 12:20 AM authored by the Director of Nursing (DON) reads: O2 [oxygen] at 2 liters applied secondary to patient requested CPAP [continuous positive airway pressure] to be turned off. Review of the medical record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to ensure a qualified director of food and nutritional services was provided for oversight of the daily operations of the facility dietary services. Findings: During an interview on 06/15/22 at 10:00 AM the Dietary Manager stated he is not certified or licensed as a Dietary Manager. During an interview on 06/15/22 at 10:00 AM the dietitian stated she works for the hospital and does not work at the facility full time as a dietitian; she stated she works part time. During an interview on 06/15/22 at 02:12 PM the Administrator stated that the Dietary Manager does not have his Certified Dietary Manager certification. He does not have an associate degree in food service management or hospitality. The dietitian works at the hospital full time and comes to the Skilled Nursing Unit part time. Review of the Dietary Manager's application documented a high school diploma; there was no associates degree contained in the file. Review of the Learner Records for [Dietary Manager's name] did not document training in Certified Dietary Manager…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to have a designated Infection Preventionist who completed specialized training in infection prevention and control. Findings: During an interview conducted on 6/16/2022 at 11:30 AM the Director of Nursing stated, I am the designated infection control nurse I complete all the tracking and trending of infections throughout the facility. I have not taken any special course on infection control. I am not certified in Infection control, and I did not know that I needed anything special to be the infection control nurse. During a review of the education and training for the Director of Nursing there was no specialized certifications for infection control. During an interview conducted on 6/16/2022 at 12:00 PM the Facility Administrator stated, I should have known that she needed to have the Infection control training, she is new, and our previous Director of Nursing had the training.