Skyland Care Center

In the surveyor’s words

From the most serious findings on record at Skyland Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Jun 30, 2023

  Based on record review, review of surveillance video, and interviews with staff, 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 and wheeled her into the facility without being assessed by a licensed professional. The Resident complained of mid back pain at 7 out of 10 (10 being the worst pain) and bruising was noted on her right forearm. […]

• Immediate jeopardy, isolatedF689Jun 30, 2023

  Based on observations, record reviews, video surveillance review, and staff and Nurse Practitioner interviews the facility contracted van driver failed to ensure the lift gate was in the elevated position before unloading a resident from the back of a facility contracted 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 Resident complained of mid back pain at 7 out of 10 (10 being the worst pain) and bruising was noted on her right forearm. Resident #287 was sent to the emergency department for evaluation and diagnosed with a compression fracture of the L1 vertebrae. This occurred for 1 of 3 residents sampled for accidents (Resident #287). […]

• No harm, potential for more than minimal, widespreadF880Nov 21, 2024

  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. […]

• No harm, potential for more than minimal, isolatedF602Nov 21, 2024

  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. […]

• No harm, potential for more than minimal, isolatedF644Nov 21, 2024

  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. […]