Skyland Care Center

Based on record review, and Physician and staff interviews, the facility failed to implement an infection surveillance plan for monitoring and tracking infections in the facility. This practice had the potential to affect 89 of 89 residents in the facility. Findings included: The Surveillance Plan for Infections) policy (Revised May 2022) read in part: The Infection Preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcomes and that may require transmission-based precautions and other preventative interventions. -The Purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and HAIs, to guide appropriate interventions, and to prevent future infections. -The Criteria for such infections are based on the current standard CDC definitions of infections. -Infections that will be included in routine surveillance include those with: evidence of transmissibility in a health…

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 staff interviews, the facility failed to protect residents' rights to be free from misappropriation of controlled medications for 2 of 2 residents (Resident # 348 & Resident #147) reviewed for misappropriation of residents' property. Findings included: The facility has a policy against abuse, neglect, exploitation and misappropriation with a revised date of 3/3/2017. The policy states that any suspected incident of abuse, neglect, exploitation, or misappropriation of resident property is to be reported immediately to a supervisor or a member of administration. The facility will subsequently report any and all suspected incidences of abuse, neglect, exploitation, and/or misappropriation of resident property to the required State and Federal agencies. Any staff member who witnesses abuse, neglect, exploitation, or misappropriation should immediately intervene to protest the resident involved. The witnessing staff member should then report the abuse to their immediate supervisor and/or…

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 staff interviews, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) Level II was completed for 1 of 2 residents (Resident #74) reviewed for PASRR. The findings included: Resident #74 was admitted to the facility on [DATE]. A review of Resident #74's medical record indicated post-traumatic stress disorder (PTSD) was added to his diagnoses list effective 4/22/24. Resident #74's medical record indicated he currently had a PASRR Level I. An interview with the Social Services Director (SSD) on 11/20/24 at 1:29 PM revealed she was responsible for PASRR, and she confirmed that Resident #74 currently had a PASRR Level I. The SSD stated she did not know about Resident #74's PTSD diagnosis and if she had, she would have applied for a PASRR Level II. The SSD further stated that she wasn't sure when Resident #74 was diagnosed with PTSD, but the nurses would need to notify her if the residents had a new mental health diagnosis. An interview with the Minimum Data Set…

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 observations, record review, resident and staff interviews, the facility failed to assess the ability of a resident to self-administer medications for 1 of 1 sampled resident observed with medications at bedside (Resident #53). Findings included: Resident #53 was admitted to the facility on [DATE]. Her diagnoses included heart failure, hypertension, and chronic obstructive pulmonary disease (difficulty breathing). The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #53 had intact cognition and required limited to extensive staff assistance with most activities of daily living. Review of the medical record revealed no documentation in 2022 or 2023 that Resident #53 was assessed for self-administration of medications. Review of the physician's orders for Resident #53 revealed no order for self-administration of medications. During an observation and interview on 06/26/23 at 12:06 PM, Resident #53 was sitting up on the side of her bed with the overbed table pulled directly in front of her…

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 staff interviews the facility failed to develop a baseline care plan within 48 hours of admission that addressed a resident's immediate needs for 1 of 4 sampled residents reviewed for baseline care plans (Resident #82). The findings included: Resident #82 was admitted to the facility on [DATE] with diagnoses including diabetes, pneumonia, and respiratory failure. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #82 had moderate impairment in cognition. He required limited assistance with activities of daily living and used a walker and wheelchair for mobility. Further review revealed Resident #82 received insulin injections 7 of 7 days, anticoagulant (blood thinner) medication 7 of 7 days and antibiotic medication 5 of 7 days during the MDS 7-day look-back period. Review of Resident #82's medical record on 06/28/23 at 2:27 PM revealed no evidence a baseline care plan was completed. During an interview on 06/28/23 at 4:00 PM, Nurse #3 revealed the admitting…

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 observations, record review, and interviews with staff the facility failed to assure a nurse assessed a new skin tear and determined treatment for 1 of 4 residents reviewed for skin conditions (Resident #13). The findings included: Resident #13 was admitted to the facility on [DATE]. Resident #13's diagnoses included Alzheimer's disease, dementia, and anxiety disorder. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #13 as having severely impaired cognition and extensive assistance was required for bed mobility and transfers and total assistance with toilet use. Review of the physician's standing orders for the treatment of skin tears read in part, The nurse was responsible for documentation in the nurse notes, writing the order for treatment and filling out an incident report and notifying the Medical Doctor (MD) or Nurse Practitioner (NP). Review of the medical records for Resident #13 revealed no documentation of an incident for a skin tear to the right forearm dated 06/24/23,…

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 observations, record review, and interviews with the Speech/Language Pathologist and staff the facility failed to provide a therapeutic diet as ordered by the physician for 1 of 3 residents reviewed for nutrition (Resident #38). The findings included: Resident #38 was admitted to the facility on [DATE]. Resident #38's diagnoses included Alzheimer's disease, abnormal weight loss, and severe dementia. Review of the current physician's diet order dated 11/08/21 revealed Resident #38 was to receive a mechanical soft diet with instructions for ground meats with extra gravy or sauce on the side for the meat. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #38 was rarely understood or understands and was unable to complete the cognitive assessment, therefore a staff assessment was completed and indicated severe impairment. The MDS revealed the amount of assistance Resident #38 required for eating from staff was supervision with setup help and indicated there had been no known…

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 observations, record review, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions the committee put into place following a recertification survey completed on 08/26/21. This failure was for a deficiency originally cited in the area of Quality of Care (F684) on 08/26/21. This continued failure during two federal surveys of record showed a pattern of the facility's inability to sustain an effective QAA Program. The findings included: This tag is cross referenced to: F684: Based on record review, review of surveillance video, and interviews with staff, the Nurse Practitioner (NP) and Medical Director (MD), the facility failed to assess Resident #287 immediately after a fall from the contracted transportation van. On 12/12/22 Resident #287 was rolled out of the back of the contracted transportation van in her wheelchair and fell to the ground landing on her left side and hitting the back of her head. The Contracted Transporter lifted Resident #287 back into her wheelchair…

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.