Skyline Heights Nursing and Rehabilitation

Inspectors wroteBased on interview and record review, the facility staff failed to prevent, identify, assess, measure, document, and implement necessary interventions for the prevention of avoidable pressure ulcers that developed shortly after a resident's admission, for 1 (#1) of 18 sampled residents. The resident had one Stage lll on his heel and one Stage lll on the gluteal area, which were both avoidable. The deficient practice placed the resident at risk of having a deterioration of the pressure ulcer.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's medication regimen was thoroughly assessed and free from unnecessary medications that may cause sedation, for 1 (#1) of 9 sampled residents. Resident #1 was on hospice and had multiple medications for pain or agitation/behavior contributing to sedation. This was not addressed by the facility. The resident was sent to the hospital for further evaluation.

Inspectors wroteBased on interview and record review, the facility failed to ensure the dietary manager completed a certification program approved by a national certifying body or had higher education in a related field when the dietitian was not scheduled and working at the facility full-time (35 hours). The staff in the dietary department were not following sanitary practices or storing food properly, and this increased the ongoing risk of cross-contamination for anyone receiving food or products from the kitchen, and for deficient practices to continue.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained throughout the kitchen; failed to ensure food located in the coolers was labeled and dated; and failed to ensure cooler temperatures were maintained in the food storage safe zone. This deficient practice increased the risk for the development of foodborne illnesses and unsanitary conditions for all residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the the nurses failed to ensure enhanced barrier precautions were followed when performing wound care for 1 (#24) of 27 sampled residents and failed to ensure weekly documentation related to the monitoring and prevention of legionellosis was completed as part of the facility's water management plan. This deficient practice increased the risk for exposure to infectious diseases, including drug resistant organisms and legionellosis.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident received treatment and care in accordance with professional standards related to wound care, and failed to follow physicians' orders for the wound care for the resident's numerous wounds, for 1 (#2) of 27 sampled residents. This deficient practice placed the resident at risk for a deterioration in wounds or infections, and the concerns continued over several months.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication carts remained locked when a staff member was not in attendance; and failed to ensure monitoring was completed as needed for the unit refrigerator temperatures that stored medications. This failure put the security of resident medications located in an unlocked and unattended medication cart at risk of theft or misuse, and placed residents who had refrigerated medications at risk for experiencing negative effects from improperly stored medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure as needed psychotropic medications were limited to 14 days, unless the rationale for continuing the medication was documented by a medical provider, for 1 (#5) of 27 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised to accurately reflect individual resident-centered care needs for 2 (#s 2 and 5), and identify a resident's preference for 1 (#5) of 27 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to publicly post the total number and the actual hours worked for each required nursing staff category. This deficient practice limited resident and public access to required nurse staffing information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to inform and educate residents when there was a change in incontinence treatment/products, for 2 (#s 4 and 7) of 8 sampled residents. The lack of facility communication and explanation caused resident #4 and #7 to be upset and frustrated.

Inspectors wroteBased on interview and record review, the facility failed to submit the findings of a Facility Reported Incident to the State Survey Agency prior to the five-day deadline for 1 (#5) of 8 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to update a resident's comprehensive care plan with new interventions for incontinence care for 2 (#s 4 and 7) of 8 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to document the wound identified by the physician, to properly assess during skin checks, treat, and monitor a facility acquired diabetic ulcer for a resident with a history of diabetes, neuropathy, and sores on the feet, for 1 (#1) of 13 sampled residents. The deficient practice contributed to the deterioration of the wound, which resulted in the resident's right great toe being amputated.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's comprehensive care plan contained information related to the diagnosis, care, and monitoring of a diabetic ulcer on a resident with a history of diabetes and neuropathy for 1 (#1) of 13 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff had the competencies and skills to identify, assess, document, and monitor a diabetic ulcer for 1 (#1) of 13 sampled residents. This increased the residents' risk of infection and resulted in hospitalization and amputation of the resident's great toe.

Inspectors wroteBased on interviews and record review, the facility neglected to ensure newly admitted residents were provided antibiotic and pain medications in a timely manner, to ensure the treatment of infections and pain was provided as necessary, for 3 (#s 73, 81 and 109) of 4 recently admitted residents. Resident #73 did not receive medications during his stay and resident #73 discharged home against medical advice. Resident #81 did not receive two doses of IV antibiotics which necessitated his re-admission to the hospital. Resident #109 was returned to the emergency room for further treatment. The neglect of care directly pertained to the facility pharmacy delivery program, oversight, and management of the system, and the medication system was not corrected in a timely manner to ensure negative resident outcomes, and neglect, were prevented.

Inspectors wroteBased on interviews and record review, the facility failed to ensure necessary medications were available for use when residents were admitted , or prior to the first dose being administered, for newly admitted residents, which resulted in the residents not receiving the medications (pain and antibiotics) at all, or not timely, and this caused negative outcomes due to the significant medication errors, for 3 (#s 73, 81, and 109) of 4 sampled residents for medication errors. Resident #73 received no medications from admission to discharge; resident #81 did not receive IV antibiotics and needed to be sent back to the hospital for treatment; and #109 did not receive pain or antibiotic medications, as needed.

Inspectors wroteBased on interview, and record review, the facility failed to provide physician-ordered medications at the prescribed dose and frequency, for 3 (#s 73, 81, and 109); and failed to ensure the availability of prescribed medications resulting in re-hospitalization for one 1 (#81) resident, resulted in 1 (#73) resident discharging against medical advice, and 1 (#109) resident experienced opioid withdrawal, of 4 sampled residents for medication concerns.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide palatable food; cooks were not following the facility menu; and the dietary department failed to provide foods specified on the resident's meal tickets, for 5 (#s 1, 37, 46, 69 and 92) of 24 sampled residents. These deficient practices had the potential to affect the quality of life and nutritional status of the residents.

Inspectors wroteBased on interview and record review, the facility nursing staff failed to ensure treatment was provided, according to acceptable standards of practice, for PICC lines, for 1 (#109) one sampled resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure wound dressings were changed as ordered by the physician, and failed to ensure sufficient wound documentation was completed, for 2 (#11 and #13) of 40 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were answered in a timely manner for 11 (#s 7, 10, 11, 15, 27, 31, 41, 56, 58, 66, and 69), and failed to provide regular bathing and personal cares for 3 (#s 346, 347, and 348) of 40 sampled residents. This left some residents feeling afraid they would not receive care, felt unsafe due to the provision of improper care, felt dirty due to lack of hygiene/bathing assistance, were angry for lack of care and services, and had a feeling of being forgotten when services were not provided as necessary.

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were properly labeled and failed to properly dispose of expired medications and medical supplies, allowing them to remain available for use. These failures could negatively affect a resident receiving expired medications and or medical supplies.

Inspectors wroteBased on interview and record review, the facility failed to utilize and maintain a QAPI system to identify performance improvement issues related to staffing concerns, resident showers, and infection control, and failed to show how the QAPI committee was involved in addressing these quality of care issues which could negatively affect many, or all, of the residents residing at the facility. Refer to F725 Sufficient Staffing, F677 ADL care for Dependent Residents, and F880 - Infection Control, for findings related to the concern areas identified.

Inspectors wroteBased on observation, interview, and record review, the facility and staff failed to follow a resident's care plan by not placing a gel cushion on a resident's recliner for pressure ulcer prevention, and the resident had a pressure ulcer, for 1 (#13); and failed to update the care plan for a resident requiring enhanced barrier precautions for 1 (#14) of 40 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 3 (#s 11, 36, and 66) of 40 residents received dental services, and resident #36 was embarrassed and had discomfort due to her dental needs, and #11 gave up wearing dentures because they did not fit correctly.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure meals were served timely and were served at a palatable temperature, for 5 (#s 5, 11, 12, 13 and 22) of 18 sampled residents. This deficient practice caused cold food and late delivery of meals for residents who received room trays.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician ordered therapeutic diets were followed, for 7 (#s 7, 10, 11, 15, 36, 39, 66) of 40 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure consistent enhanced barrier precautions were provided for 4 (#s 5, 6, 63, and 346) of 40 sampled residents; and the facility failed to provide staff education on proper donning and doffing of PPE, and the expectations of enhanced barrier precautions, which had an increased risk of a negative outcome to the facility population due to those staff working with or around other residents not on precautions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to address medications appropriately for a resident who self administered medications, and ensure medications and narcotics were properly supervised during medication administration, for 1 (#15) of 40 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a baseline care plan was developed and implemented to reflect the resident's care needs after admission, for 1 (#339) of 40 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to provide showers for 2 (#s 346 and 347); residents who felt personal cleanliness was important due to skin concerns and comfort, and repositioning for a dependent resident, for 1 (#346) of 40 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility nursing staff failed to ensure treatment was provided, utilizing the physician orders, for changing a dressing for a PICC line for 1 (#346) of 40 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow a physician's order and provide nebulizer treatment supplies for 1 (#347) of 1 sampled resident for respiratory concerns.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that a licensed pharmacist adequately addressed and documented the monthly medication regimen review for 1 (#63) of 40 residents who received four psychotropic medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure a gradual dose reduction (GDR) was implemented or documented by a provider as clinically contraindicated for residents receiving psychotropic medications, for 3 (#s 5, 18, and 63) of 40 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident immunizations were up to date with the CDC recommendations for 3 (#s 10, 32, and 336) of 40 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff transcribed and initiated physician orders of prescribed medications, and failed to ensure the completion of the full course of medication treatment for a resident who returned from a hospital for 1 (#5) of 5 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary ADL assistance for dependent residents for bathing and showering, at least every seven days, and residents were not assisted with grooming, per observations, and this caused the residents to feel unkempt, for 3 (#s 4, 5, and 7) of 8 sampled residents for bathing and hygiene services.

Inspectors wroteBased on interview and record review, the facility failed to provide supervision for a resident who had a dementia diagnosis and was left at a clinic unattended which placed the resident at risk of elopement, for 1 (#8) of 3 sampled residents with a diagnosis of dementia.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have necessary catheter supplies available, and therefore supplies were used which caused an allergic reaction, and failed to notify the medical provider in a timely manner, for 1 resident (#6) of 3 sampled residents with catheters.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was served in a sanitary manner; and failed to practice hand hygiene while serving meals between residents. This deficient practice had the potential to affect all residents receiving meals provided by the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with meals for a resident identified with weight loss for 1 (#8) of 8 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to address an indwelling urinary catheter on admission, by not obtaining a valid indication for the catheter use, and failed to provide and document ongoing daily care and monitoring for the catheter, which resulted in a urinary tract infection, for 1 (#134) of 46 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve food that was palatable and at a safe and appetizing temperature for 5 (#s 11, 21, 43, 63, and 134) of 46 sampled residents. This deficient practice had the potential to effect all residents in the facility by exposing them to potentially hazardous foods.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label and date food items, and clean and maintain sanitary conditions in the food service areas of the kitchen. These deficient practices had the potential to affect any resident consuming or receiving food from, or prepared by, the kitchen, and 83 residents resided at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect residents from actual or potential physical and psychosocial harm for 3 (#s 7, 25, 29, and 49); and failed to adequately address residents who displayed verbal and physical abuse behaviors for 2 (#s 64 and 68) of 12 sampled residents investigated for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide physician-ordered medications at the prescribed dose and frequency for 3 (#s 11, 51 and 79); and failed to ensure the availability of prescribed medications resulting in the misappropriation of a resident's medication for 1 (#27) for residents sampled for medication reviews.

Inspectors wroteBased on interview and record review, the facility failed to maintain evidence of the resolution of a resident's grievance for 1 (#134) of 46 sampled residents and failed to ensure the facility's policy met regulatory guidelines with regard to the identity and contact information for the grievance official.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report the findings of an allegation of resident-to-resident verbal abuse to the State Survey Agency for 1 (#61) of 46 sampled residents.

Inspectors wroteBased on interview and record review, facility staff failed to provide pertinent medical information to the receiving facility at the time of transfer for 1 (#44) of 46 sampled residents.

Inspectors wroteBased on interview and record review, the facility staff failed to complete the resident assessment portion for the Annual MDS assessment for 1 (#36) of 46 sampled residents.

Inspectors wroteBased on interview and record review, facility staff failed to complete the resident assessment portion for the Quarterly MDS assessments for 2 (#s 2 and 34) of 46 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure an updated PASARR was submitted for a resident diagnosed as having a serious mental health diagnosis with escalating and dangerous behaviors, including homicidal threats, violent attacks on staff, and hypersexual behaviors for 1 (#64) of 16 residents sampled for PASARR screenings.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission for 1 (#134) of 46 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for 2 (#s 64 and #134) of 46 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to update resident care plans as resident care needs changed for 1 (#11) of 46 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor and consistently document a resident's wound status and any dressing changes performed for the resident's wound, for 1 (#27) of 46 sampled residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure all medication carts were securely locked when not being attended by an authorized staff member. The deficient practice had the potential to affect all residents whose medications were stored in the medication cart.

Inspectors wroteBased on interview and record review, facility staff failed to provide a Notice of Transfer/Discharge to the resident or resident's representative, for 3 (#s 17, 44, and 64) of 46 sampled residents, and it was identified the facility had not been completing the notices for any resident who discharged or transferred (refer to interview held 1/18/24 at 10:02 a.m.).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff utilized therapeutic communication and adequate personal hygiene care to meet residents care needs, while providing assistance to dependent residents, which resulted in feelings of intimidation, reluctance to ask for assistance, and tearfulness for 2 (#s 8 and 10); and failed to provide timely services necessary to meet dependent residents' individual care needs for 2 (#s 9 and 11) of 8 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed follow the prescribed treatment for the management of pressure ulcers for 1 (#7) of 1 sampled resident.

Inspectors wroteBased on interview and record review, the dietary department failed to provide a gluten free diet, per providers orders for 1 (#5) of 3 sampled residents.