Medication mix-up results in fine for Skyline
The medication error occurred in June 2025 but wasn't publicly disclosed. State inspectors discovered it during an unannounced inspection in December and later fined the facility $10,358.
Regulators have fined Skyline Nursing and Rehabilitation more than $10,000 in connection with a resident at the Floyd nursing home being given another resident’s drugs.
The resident recovered in an emergency room from taking the wrong medication, while administrators tracked down what happened. It turned out that a nurse mixed up two men who looked alike and often sat in the same area of the dining room.
The medication error occurred in June 2025 but wasn't publicly disclosed. State inspectors discovered it and other issues during an unannounced inspection in December and later fined the for-profit facility $10,358. As an additional sanction, regulators temporarily prohibited the home from accepting new residents. The restriction has been lifted.
The episode placed a negative finding on the home’s performance scorecard with the Centers for Medicare and Medicaid Services. It came to light during a routine check of public records by the Floyd Times.
602 East Main Street
Floyd Virginia
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Jason Schumann, the nursing home’s administrator, released a statement: “The incident referenced in the December 2025 survey has been addressed through the regulatory process and is a matter of public record. Throughout that process, Skyline cooperated fully with the Virginia Department of Health and the Centers for Medicare & Medicaid Services and implemented the corrective actions required to ensure continued compliance with federal regulations.” The fine has been paid, he said.
Surveyors from the Virginia Department of Health went to the 90-bed home at 237 Franklin Pike Road SE on behalf of Medicare to review its operations on Dec. 2. Several aspects of the home checked out fine, including its emergency operations plan. But during a check of 28 randomly picked resident files, they learned that one person had been taken to an emergency room five months earlier.
Inspectors routinely review resident records from previous months during annual inspections. It was the home’s first Medicare inspection in more than three years, according to online records.
A written report gave this account: A licensed practical nurse working on C-wing on June 29, 2025, prepared medications for a resident identified as No. 29 but mistakenly administered the drugs to resident No. 6. Resident No. 6, who suffered from dementia, received the anti-seizure drug Klonopin, the anti-depressant sertraline and benztropine, a Parkinson's disease treatment. A short time later, staff noticed the individual was leaning to one side in his chair with his eyes closed and called an ambulance. Hospital staff monitored him for four and a half hours before declaring him stable.
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The nurse told inspectors “both residents were similar in appearance, both had beards and sat at the same place in the dining room,” the report said. “LPN No. 7 stated after administering the medications to who she thought was Resident No. 29, she heard staff telling Resident No. 29 to come to the dining room and realized she had administered the medications to Resident No. 6.”
It was the home’s practice for nurses to confirm a resident’s identity using their name and a photograph before administering drugs. Skyline cleared up the situation with a plan of correction that included refresher training for licensed staff and bigger pictures of residents on medication carts, according to the report.
Authorities classified the incident as one causing “actual harm.” Under federal nursing-home regulations, "actual harm" means a resident was injured but not placed in immediate jeopardy of death or serious permanent injury.
In the report available on a state website, regulators identified a handful of less-serious deficiencies, including:
- Resident No. 6’s file contained a do-not-resuscitate order that belonged to another resident.
- A doctor ordered dosages of medicine from an inhaler for a resident with lung disease but it took staff four days to give it.
- Staff failed to strictly follow a doctor’s order to give a diabetic resident insulin.
- Staff failed to place a knee brace to a resident for at least four hours a day as ordered by a doctor.
- The home lacked proof that it had provided regular education to staff about the COVID-19 vaccine.
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Inspectors returned in February and found more issues. Staff failed on two occasions to give antibiotic ointment to a resident with a swollen eyelid and failed to give a prescribed heart medicine on time.
The nurses involved in each of those omissions were fired, the report said. There was no indication in any of the reports whether disciplinary action was taken against the nurse who mixed up the residents. Schumann declined to discuss the employee, explaining that Skyline does not discuss personnel.
Medicare rates nursing homes on their staffing, care and performance on inspections to help consumers compare nursing homes, issuing from one to five stars, with five stars being the best rating. Skyline has two stars currently, a below-average rating.
Owned by Avardis Health in Atlanta, Skyline is Floyd’s only nursing home. Schumann said leaders of the home “continually evaluate our clinical practices, strengthen our systems, and invest in education to support safe, high-quality care for our residents.” Skyline received a silver Achievement in Quality Award from the American Health Care Association and National Center for Assisted Living, he said.
There are a total of eight other homes within 25 miles. The next-closest home to Floyd, Heritage Hall Laurel Meadows in Carroll County, scores five stars currently on Medicare’s scale.
