Skyland Terrace and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Skyland Terrace and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF745Dec 6, 2024

  Based on record review, observations, and resident, staff, Physician, Nurse Practitioner (NP), Physician Assistant (PA) and neurology office Scheduler interviews the facility failed to ensure a neurology appointment was scheduled for a resident (Resident #14). The Physician ordered a neurology referral for Resident #14 first on 8/23/24 for evaluation of her tremors. A second neurology consult was ordered by the NP on 11/5/24 again for evaluation of her tremors. Resident #14 had tremors to her upper and lower extremities, including her hands and feet. Resident #14 reported her tremors had worsened, were unmanageable, made her feel awful, and like she could not do anything. […]

• Actual harm, isolatedF689Dec 16, 2021

  Based on medical record review, resident and staff interviews, the facility failed to provide 2 staff members when using a sit-to-stand mechanical lift for 1 of 2 residents (Resident #21) as per the care plan which resulted in a fall with fractures of the distal tibia (shin bone) and fibula (calf bone) with displacement. The findings included: Resident #21 was admitted to the facility on [DATE] with diagnoses that included muscle weakness, charcot's joint of the right ankle and foot (a complication which affects the bones, joints, and soft tissues of the foot and ankle causing the bones to become weak and break, or the joints to dislocate), type 2 diabetes, and lumbago with sciatica (pain that radiates along the sciatic nerve which runs down one or both legs from the lower back). […]

• No harm, potential for more than minimal, widespreadF880Dec 16, 2021

  Based on observations and staff interviews the facility failed to implement a Legionella prevention program that could have affected 55 of 55 residents. The facility also failed to have hand sanitizer or a functioning hand washing station available in 1 of 2 laundry rooms that could have affected 43 of 55 residents reviewed for infection control. 1. Review of the Emergency Preparedness workbook with the Administrator on 12/16/21 at 11:27 AM revealed no information on water safety management for Legionella. He explained he would speak with the Director of Maintenance to acquire about the information. The water safety plan workbook for Legionella dated 09/23/2018 was reviewed. There were no updated facility risk assessments or monitoring logs since 2018. […]

• No harm, potential for more than minimal, patternF756Jul 14, 2023

  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. […]

• No harm, potential for more than minimal, patternF760Jul 14, 2023

  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. […]