Skyview Springs Rehab and Nursing Center

In the surveyor’s words

From the most serious findings on record at Skyview Springs Rehab and Nursing Center, in the surveyor’s own words.

• Actual harm, isolatedF600Aug 14, 2023

  Based on resident interview, staff interview, facility document review, and clinical record review, the facility failed to protect the resident's right to be free from sexual abuse by a resident, for one of three residents in the survey sample, Resident #2. The facility developed and implemented an acceptable plan of correction, therefore this deficiency is cited at past non-compliance. The findings include: For Resident #2 (R2), the facility staff failed to ensure the resident was free from sexual abuse by another resident (Resident #1) on 7/16/2023. The facility synopsis of the event, dated 7/16/2023, documented, Incident type: Resident to resident sexual abuse. Describe Incident: (Name of R1) noted in (room number) with (Name of R2) with (R2's) penis in mouth performing oral sex. […]

• No harm, potential for more than minimal, patternF656Nov 2, 2023

  Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for eight of 34 residents in the survey sample; Residents #94, #11, #29, #97, #106, #23, #35, and #46. The findings include: 1. For Resident #94, the facility staff failed to follow the comprehensive care plan for the administration of diabetic related medications as ordered. A review of the comprehensive care plan revealed one dated 9/2/23 for The resident has Diabetes Mellitus. This care plan included the intervention dated 9/2/23 for Diabetes medication as ordered by doctor . A review of the clinical record revealed the following orders: 1. […]

• No harm, potential for more than minimal, patternF698Nov 2, 2023

  Based on resident interview, staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide dialysis care and services for one of 34 residents in the survey sample, Resident #29. The findings include: For Resident #29, the facility failed to monitor for fluid restriction and intake, failed to assess for bruit and thrill at the dialysis access site, and failed to maintain a complete communication system with the dialysis center. Resident #29 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ESRD (end stage renal disease) and diabetes. […]

• No harm, potential for more than minimal, patternF580May 3, 2023

  Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to notify the physician and/or responsible party for a change in condition for two of seven residents in the survey sample, Residents #1 and #4. The findings include: 1. For Resident #1 (R1), the facility staff failed to notify the responsible party of a fall in May 2022. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 2/1/2023, the resident scored a one out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely, cognitively impaired for making daily decisions. A nurse's note dated, 5/10/2022 at 3:31 a.m. […]

• No harm, potential for more than minimal, patternF658May 3, 2023

  Based on staff interview, facility policy review, and clinical record review, it was determined the facility staff failed to follow professional standards of practice for following the physician orders, and for the administration of medications for two of seven residents in the survey sample, Residents #2 and #3. The findings include: 1. a. For Resident #2 (R2), the facility staff failed to follow the physician's order for notifying the physician/nurse practitioner when the resident's blood sugar was lower than 70 per the physician's order. […]