Skyline Ridge Nursing & Rehabilitation Center

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents received adequate supervision and intervention to prevent physical abuse for two (#1 and #2) of three residents reviewed for abuse out of three sample residents. Specifically the facility failed to protect Resident #1 from physical abuse by Resident #2.

Inspectors wroteBased on interviews and record review, the facility failed to employ an infection preventionist (IP) who had completed specialized training in IP and control which had the potential to affect all residents residing in the facility at the time of the survey. Specifically, the facility failed to have a qualified IP involved with the facility's IP and control program.

Inspectors wroteBased on records review and interviews the facility failed to maintain an effective infection prevention and control program to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease for seven (#2, #5, #6, #7, #8, #12 and #13) of 14 residents out of 14 sample residents. Specifically, the facility failed to ensure the tracking, offering and administration of the COVID-19 vaccination for Resident #2, Resident #5, Resident #6, Resident #7, Resident #8, Resident #12 and Resident #13.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the residents' environment remained as free of accidents or hazards as possible to prevent falls for one (#59) of five residents reviewed for falls out of 48 sample residents. Resident #59, who had a history of falling, required the use of a sit-to-stand mechanical lift for transfers. Per staff interviews (see interviews below), the use of the sit-to stand mechanical lift required that two staff members were present during resident transfers. On the night of 7/31/24, Resident #59 was being transferred to bed by a certified nurse aide (CNA). The CNA did not have another staff member present during the transfer and the resident sustained a fall. The CNA alerted the licensed practical nurse (LPN) to the resident's fall and the CNA and the LPN assisted Resident #59 back to her bed. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#34) of three residents out of 50 sample residents received the care and services necessary to meet their nutrition needs and to maintain their highest level of physical well-being. Resident #34 was admitted to the facility for long-term care on 6/30/24 with diagnoses of age-related osteoporosis, hypokalemia (low potassium levels in the blood), hypocalcemia (low calcium levels in the blood), hypomagnesemia (low magnesium levels in the blood), cognitive communication deficit and cerebral infarction (stroke). Upon admission, on 6/30/24, the resident weighed 103.4 pounds (lbs). The 7/2/24 nutritional evaluation determined the resident was malnourished. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure a discharge summary was in place for four (#236, #84, #85 and #238) of four residents reviewed for discharge out of 50 sample residents. Specifically, the facility failed to ensure discharge summaries were completed and included a recapitulation of the resident's stay.

Inspectors wroteBased on record review and interviews, the facility failed to maintain medical records on each resident that were accurately documented for four (#72, #34, #33 and #237) of 13 residents out of 50 sample residents. Specifically, the facility failed to have an effective process in place to ensure residents' directives for cardiopulmonary resuscitation status (CPR) were maintained accurately and nursing staff was aware of where to find the information in the event of a medical emergency.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development of infection and transmission of diseases. Specifically, the facility failed to: -Ensure facility staff offered appropriate hand hygiene to residents before meals; and, -Ensure laundry staff handled clean laundry in a sanitary manner.

Inspectors wroteBased on interviews and record review, the facility failed to ensure two (#38 and #74) of 10 residents reviewed for abuse out of 50 sample residents were kept free from physical abuse. Specifically, the facility failed to: -Prevent a physical altercation between Resident #239 and Resident #38; and, -Prevent a physical altercation between Resident #74 and Resident #70.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents were free from physical restraints for one (#62) of one resident reviewed out of 50 sample residents. Specifically, the facility failed to ensure a physician's order was obtained, a safety risk assessment was completed and alternative interventions were attempted for the use of Resident #62's bed alarm.

Inspectors wroteBased on record review and interviews, the facility failed to report alleged violations of potential abuse to the State Survey and Certification Agency in accordance with state law for one (#74) of ten residents reviewed for abuse out of 50 sample residents. Specifically, the facility failed to report an allegation of resident to resident physical abuse to the local police or the State Agency within 24 hours of the altercation.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide assistance with activities of daily living (ADL) for one (#4) of four residents reviewed out of 50 sample residents. Specifically, the facility failed to provide Resident #4 with encouragement and cueing at meals to ensure the resident received adequate nutritional intake.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the medication error rate was not greater than five percent (%). Specifically, the facility's medication error rate was 7.69% or two errors out of 26 opportunities for error.

Inspectors wroteBased on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored in one of two medication refrigerators. Specifically, the facility failed to: -Ensure the medication refrigerator was locked when left unattended; and, -Ensure controlled medications were locked in a double locked area inside the medication refrigerator.

Inspectors wroteBased on interviews and record review, the facility failed to ensure two (#65 and #77) out of 44 sample residents were kept free from abuse. Specifically, the facility: -Failed to prevent two resident-to-resident altercations between Resident #65 and #64; and, -Failed to prevent a resident-to-resident altercation between Resident #65 and #77.

Inspectors wroteBased on interviews and record review, the facility failed to report resident to resident altercations for three (#65, #64 and #77) out of 44 sample residents. Specifically, the facility: -Failed to report two resident-to-resident altercations between Resident #65 and #64; and, -Failed to report a resident-to-resident altercation between Resident #65 and #77.

Inspectors wroteBased on record review and interviews, the facility failed to ensure licensed nurses were able to demonstrate competencies in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. Specifically, the facility failed to ensure nursing staff had completed competencies in the past 12 months prior to providing skilled services as described in the plan of care for two out of three registered nurses (RN) and two of six certified nurse aides (CNA) reviewed for competencies.

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure three (#33, #22 and #29) of five residents were free from unnecessary psychotropic medications out of 44 sample residents. Specifically, the facility failed to: -Monitor targeted behaviors, side effects, and provide non-pharmacological interventions for psychotropic medications for Resident #33, #22 and #29; and, -Ensure a risk/benefit statement or a gradual dose reduction was completed for psychotropic medications for Resident #33 and Resident #22.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to ensure one (#48) of four residents reviewed were free from physical restraints out of 44 sample residents. Specifically, the facility failed to provide rationale, justification, and a consent for placing a wander guard on Resident #48 to restrict her movements in and around her environment.

Inspectors wroteBased on record review and staff interviews, the facility failed to coordinate assessments with the pre-admission screening resident review (PASRR) program for one (#29) of 44 sample residents. Specifically, the facility failed to notify the PASRR program that the resident had started on an antipsychotic medication and had a new diagnosis of psychosis.

Inspectors wroteBased on record review and interviews, the facility failed to provide adequate supervision and an environment as free from accidents hazards as possible for one (#233) out of 44 sample residents. Specifically, the facility failed to document a fall reported by Resident #233 in the resident's record and complete appropriate assessments including a registered nurse (RN) assessment, a fall risk assessment and an investigation.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents with indwelling catheters received the appropriate care and services according to professional standards for one (#63) of three residents reviewed for catheters of 44 sample residents. Specifically, the facility failed to obtain physician orders and documentation for catheter care and maintenance for Resident #63.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater. Specifically, the medication administration observation error rate was 7.4% or two errors out of 27 opportunities for error.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to ensure nursing staff had adequate hand hygiene when making contact with residents.

Inspectors wroteV. Resident #2 A. Resident status Resident #2, age [AGE], was admitted on [DATE]. According to the March 2022 computerized physician orders (CPO), the diagnoses included dementia with behavioral disturbance, depressive disorder, type 2 diabetes, hypertension and COVID-19. The 12/25/21 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of four out of 15. She required extensive assistance of two people with bed mobility, dressing, toilet use, personal hygiene, limited assistance of two people with transfer, and extensive assistance of one person with eating. The resident resided in the memory care unit. B. Observation On 3/14/22 at 12:47 p.m., Resident #2's bed position was very high. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents were free from physical restraints imposed for purposes of convenience and the least restrictive alternatives were used for two (#51 and #57) of two residents reviewed out of 40 sample residents. Specifically, the facility: -Failed to identify recliner as a restraint for Resident #51; -Failed to comprehensively assess and re-evaluate Resident #57 ability to use self releasing seat belt; and, -Failed to identify and care plan self releasing seat belt as a restraint for Resident #57.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide an ongoing program to support residents in their choice of activities designed to meet the interests of the resident and support the physical, mental, and psychosocial well-being of each resident for four (#30, #51, #55 and #66) of ten out of 40 sample residents. Specifically, the facility failed to offer and provide meaningful activities to Residents #30, #51, #55, and #66.

Inspectors wroteBased on record review, observations and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for four (#8, #27, #37, and #56) of eight out of 40 sample residents. Specifically, the facility failed to: -Ensure vital signs were obtained prior to the administration of hypertension medications for Resident #8 and #27; and, -Ensure insulin was administered and in accordance with physician orders for Resident #37 and #56.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure pain management program was in a manner consistent with professional standards of practice for three (#2, #19 and #33) out five out of 40 sample residents. Specifically, the facility failed to: - Follow pain medication parameter order, and ensure all pain medications have a pain level parameter ordered for Resident #2, #19 and #33; and, - Follow resident's care plan and attempt non pharmacological interventions prior to providing as needed pain medication for Resident #2.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that residents were free of unnecessary psychotropic medications for three (#47, #2, and #55) of five residents reviewed for psychotropic medications out of 40 sample residents. Specifically, the facility failed to: -Provide the resident and/or the resident's family/representative sufficient information for their understanding of the intended/actual benefit and potential risk(s) or adverse consequences associated with the prescribed medication, dose, and duration, before starting the resident on an antidepressant and/or antipsychotic medication(s) for Residents #47 and #2. [...]

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure the dietary department followed safe practices to prevent the potential contamination of food and spread of food-borne illness through proper kitchen sanitation procedures. Specifically the facility failed to: -Ensure holding temperatures were at appropriate levels during meal service; and, -Ensure the dining room tables were cleaned and sanitized properly after meal services.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure for one (#2) out of 40 sample residents had the right to a dignified existence. Specifically, the facility failed to ensure: -Resident #2 was offered regular meal choices during meal times and the nursing staff did not stand while assisting the resident to eat.

Inspectors wroteBased on observations, interviews and record review, the facility failed to honor preferences of one (#30) of two residents reviewed out of 40 sample residents. Specifically, the facility failed to ensure Resident #30 was provided assistance to go outside to smoke at her request.

Inspectors wroteBased on record review and interviews, the facility failed to ensure each resident had the right to formulate an advanced directive for two (#64 and #62) of five residents reviewed out of the 40 sample residents. Specifically, the facility failed to: -Obtain a legally signed advanced directive order designating the residents choice for end of life/life saving treatment measures for Resident #64 and #62; -Ensure the Resident #64 and #62 had completed and signed advanced directive orders in the resident record; -Ensure the Resident #64's physician and a confirmed legally designated medical power of attorney (MDPOA) signed Resident #64's medical orders for scope of treatment (MOST)/advanced directive orders for do not resuscitate with selective treatment, when the resident was assessed to lack the capacity to make a decision for the order; [...]

Inspectors wroteBased on observations, record review and interview, the facility failed to ensure residents who needed respiratory care was provided such care, consistent with professional standards of practice, for one (#66) of four residents reviewed for oxygen therapy out of 40 sample residents. Specifically, the facility failed to have complete and comprehensive oxygen orders for Residents #66.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure drinks and other fluids were provided and consistent with the care plan, preferences and choices for one (#64) of two residents investigated for hydration of 40 sample residents. Specifically the facility to consistently provide Resident #64 with thickened liquids with meals, as ordered; and failed to provide the resident with drinks of choice in between meals.