Skyland Terrace and Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to update a care plan to reflect a change of code status for 1 of 18 residents reviewed for care plans (Resident #40).Findings included:Resident #40 was admitted on [DATE] with diagnoses of dementia and epilepsy.Resident #40's care plan was observed on [DATE] and noted as most recently updated on [DATE]. A death with dignity care plan noted Resident #40's wishes included to attempt cardiopulmonary resuscitation (CPR).A progress note written by the Social Worker on [DATE] at 1:27 PM noted Resident #40's family changed the code status to Do Not Resuscitate (DNR).A physician's order for Do Not Resuscitate (DNR) was written on [DATE].Resident #40's comprehensive Minimum Data Set (MDS) dated [DATE] noted he was rarely or never understood.On [DATE] at 2:28 PM during an interview, the SW stated that any new or updated code status forms which were completed would be placed into the physician's notebook for their review and signature. The physician would…

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 a record review and staff interviews, the facility failed to have a nurse assess a resident who had fallen prior to moving the resident for 1 of 2 residents reviewed for falls (Resident #34). Findings included:Resident #34 was admitted on [DATE] with diagnoses of dementia and heart failure.Resident # 34's annual Minimum Data Set (MDS) dated [DATE] coded her with severe cognitive impairment. She required moderate assistance for transfers. She was coded for having behaviors and falls since her last MDS assessment.Resident #34 was care planned on 1/28/26 for participation in restorative care due to being at risk for falls during transfers and demonstrating poor safety awareness. The care plan included providing moderate assistance during all transfers as an intervention to promote safety. Furthermore, the resident was care planned for a history of physical aggression towards others on 12/1/25. Interventions included to remove the resident from any situation that may be escalating or causing agitation and…

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 administer a pneumococcal vaccine to a resident who had consented to receive the vaccine for 1 of 5 residents reviewed for pneumococcal vaccines (Resident #72).Findings included:Resident #72 was admitted to the facility on [DATE].The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #72 had severe cognitive impairment.Review of Resident #72's medical record revealed no documentation that staff had administered a pneumococcal vaccine. The prior pneumococcal immunization history documented revealed a history of Prevnar 13 (pneumococcal 13-valent conjugate) dated 2/11/16.Review of Resident #72's medical record revealed a form titled 'Vaccine Consent Form 2025'. The pneumonia vaccine was marked under the section titled Individual Requests the Following Vaccination(s). The vaccine consent signature section showed that Resident #72's Responsible Party signed the consent for the pneumococcal vaccine on 9/03/25. An interview on 2/17/26 at…

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 resident, family, and staff interviews, the facility failed to protect a resident's right to be free from abuse when a family member (Family Member #1) hit Resident #1 on the leg, covered her mouth with her hand, and told her to shut up. This affected 1 of 3 residents reviewed for abuse (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE]. Her diagnoses included: hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stoke) affecting left non-dominant side. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact. She was not documented on the MDS as having behaviors or rejection of care. The MDS indicated she used a wheelchair, had function limitations in range of motion to her upper and lower extremities on one side, and was dependent on staff for toileting, dressing, personal hygiene, transfers, and mobility. 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 record review, and resident, staff, and Senior Police Officer interviews, the facility failed to protect the resident's right to be free from misappropriation of resident property. This deficient practice was for 1 of 1 resident reviewed for misappropriation of resident property (Resident #78). The findings included: Resident #78 was admitted to the facility on [DATE] with diagnoses which included gastrointestinal hemorrhage and hypertension. The admission Minimum Data Set, dated [DATE] revealed Resident #78 was cognitively intact. Review of the initial facility report dated 11/30/24 at 10:30 AM documented that Resident #78 reported her wedding rings and mother's ring were missing. An interview with Resident #78 12/05/24 at 9:56 AM revealed that there were 5 rings missing. She stated that her family had taken her out on Wednesday, 11/27/24, to get a manicure for Thanksgiving. At that time, her family had given her 5 rings to wear for Thanksgiving on 11/28/24. She stated that she wore them out with 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 observations, record review, resident, staff, and wound care center Nurse Practitioner (NP) interviews the facility failed to follow physician orders from the wound care center for the treatment of a stage II pressure ulcer (partial thickness open wound) for 1 of 2 residents reviewed for services to prevent and treat pressure ulcers (Resident #233). The findings included: Resident #233 was admitted to the facility on [DATE] with diagnoses that included peripheral vascular disease (narrowing of peripheral blood vessels that can cause a disruption in blood flow) with chronic bilateral lower extremity wounds and eczema (a condition that causes red, dry, itchy skin). Resident #233 was discharged from the facility on 6/14/24. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #233 was cognitively intact. She was not coded on the MDS for an unhealed pressure ulcer. She was documented on the MDS as having venous and arterial ulcers present. Resident #233 had a care plan dated as…

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 and staff interviews the facility failed to remove expired nutritional supplement from 1 of 2 nourishment room refrigerators. This practice had the potential to affect residents who received nutritional supplements. Findings included: On 12/4/24 at 2:12 PM an observation of the north nourishment room refrigerator was conducted with the Dietary Manager. The door shelf of the refrigerator contained one container of nutritional supplement dated with 11/25 received date and an additional date of 11/25 open date. The nutritional supplement container was approximately 25% full. The Dietary Manager stated during the observation that opened and stored refrigerator items should be discarded after 7 days. The Dietary Manager immediately discarded the nutritional supplement. The Dietary Manager stated the nourishment room refrigerator was checked two times daily, once in the morning and once in the evening by the dietary staff for expired items, dated and labeled open items, and items to restock. The Dietary Manager stated the nutritional supplement was placed in 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with the resident, staff, Consultant Pharmacist, and Medical Director (MD), the Consultant Pharmacist failed to identify drug irregularities and provide recommendations for 2 of 7 residents reviewed for unnecessary medications (Residents #24 and Resident #38). The findings included: 1.Resident #24 was admitted to the facility on [DATE] with diagnoses that included hyperlipidemia. Review of the medical record for Resident #24 revealed a lipid panel had not been completed since she was admitted to the facility on [DATE]. Review of the physician orders dated 11/12/21 revealed an order for Resident #24 to receive 1 tablet of atorvastatin 20 milligrams (mg) by mouth once daily at bedtime for hyperlipidemia. A review of medication administration records (MARs) indicated Resident #24 had received atorvastatin as ordered for the past 12 months. Review of Resident #24's vital signs revealed her blood pressure was stable and within the normal limits for the past 6 months. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with the resident, staff, Consultant Pharmacist, and the Medical Director (MD), the facility failed to prevent a significant medication error when nurses failed to follow physician's perimeter setting as ordered during insulin administration. As a result, Resident #24 received 2 doses of unnecessary Novolog insulin within 1 day, and Resident #38 had received 34 doses of unnecessary Novolog insulin in June 2023, 13 doses of unnecessary Novolog insulin in July 2023. This affected 2 of 7 residents reviewed for significant medication errors (Resident #24 and Resident #38). The findings included: 1.Resident #24 was admitted to the facility on [DATE] with diagnoses included diabetes mellitus. The diabetic care plan initiated on 05/24/21 for Resident #24 revealed she was diagnosed with diabetes mellitus. The goal was to remain free of complications related to diabetes through the next review period. Intervention included to administer diabetes medications as ordered by 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 observations and staff interviews the facility failed to maintain a walk-in refrigerator from an accumulation of thick, clumpy grayish matter on the circulatory fan cover and thick, clumpy darkish buildup on the floor of 1 of 2 walk-in refrigerators. In addition, the facility failed to discard 2 opened loaves of expired bread. This practice had the potential to affect foods served to residents. Findings included: 1.On 07/11/23 at 9:32 AM an observation of the kitchen prep table revealed 2 opened loaves of bread sitting next to the toaster and ready to be used. The label on the plastic wrap of the white sandwich bread indicated it was expired on 07/08/23 and the whole wheat bread revealed it was expired on 07/09/23. Further observation revealed half of both loaves of bread had been used. During an interview conducted on 07/11/23 at 9:37 AM, [NAME] #1 stated she had used one slice of bread from both loaves of bread this morning to make toasts for residents. She explained it was her oversight as she did not pay attention to the expiration dates of the breads prior to using it.…

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 accurately code the Minimum Data Set (MDS) regarding smoking for 1 of 1 resident reviewed for smoking (Resident #58). Findings included: Resident #58 was admitted to the facility on [DATE]. The smoking care plan initiated on 01/31/23 for Resident #58 revealed she was an unsafe smoker. The goal was to remain free of injury from unsafe smoking practices through the review date. Interventions included instructing Resident #58 about smoking risks and policy of smoking, monitoring for unsafe smoking with oxygen, and providing supervision when while smoking. Review the smoking assessment for Resident #58 on 04/28/23 revealed she was assessed as an unsafe smoker and required direct supervision during smoking. Review of the admission MDS dated [DATE] revealed Resident #58 was coded as a non-tobacco user under Section J 1300. During an interview conducted on 07/11/23 at 3:03 PM, Resident #58 stated she had smoked cigarettes from the day she had been…

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 reviews and interviews with Resident, staff, Consultant Pharmacist, and Medical Director (MD), the facility failed to monitor cholesterol level for 1 of 7 residents reviewed for unnecessary medications (Resident #24). The findings included: Review of lipid guidelines published in 2019 by American College of Cardiology and American Heart Association indicated a lipid panel should be conducted at baseline, then 4 to 12 weeks after statin therapy was started or when a dosage was adjusted. Afterwards, a lipid panel test should be repeated once every 3 to 12 months or as needed. Resident #24 was admitted to the facility on [DATE] with diagnoses that included hyperlipidemia. Review of medical records for Resident #24 revealed a lipid panel had not been completed since she was admitted to the facility on [DATE]. Review of physician's orders dated 11/12/21 revealed an order for Resident #24 to receive 1 tablet of atorvastatin 20 milligrams (mg) by mouth once daily at bedtime for hyperlipidemia. A review…

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.