Brookdale Skyline

Inspectors wroteBased on record review and interviews, the facility failed to ensure supervision and monitor assistive devices to prevent accidents for one (#2) of five residents reviewed for accidents out of seven sample residents. The facility failed to ensure staff transferred Resident #2 appropriately with a mechanical lift which resulted in a fall with major injury for the resident. Resident #2 was admitted to the facility for rehabilitation services on 10/7/25. The resident's care plan directed staff to utilize a mechanical lift (a sit to stand lift) for transfers. On 10/11/25 certified nurse aide (CNA) #1 and CNA #2 used a gait belt (a belt that fastens around the waist, used for someone with mobility issues) to transfer Resident #2 from the toilet to her wheelchair. Resident #2 stood, and then lost the ability to bear weight in one of her legs and fell to the floor. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain proper personal hygiene for three (#6, #8 and #9) of seven residents reviewed for ADLs out of 13 sample residents. Specifically, the facility failed to: -Ensure staff used a gait belt when transferring Resident #6 from a recliner to the wheelchair while taking the resident to his room to provide incontinence care; -Ensure staff properly used a Hoyer lift (mechanical lift) when transferring Resident #8 to her bed to provide incontinence care; and, -Ensure Resident #8 and Resident #9 were provided with timely incontinence care.

Inspectors wroteBased on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12-months and provide regular in-service education based on the outcome of these reviews for two of two certified nurse aides (CNA). Specifically, the facility failed to complete annual performance reviews and provide regular in-service education based on the outcome of the reviews for CNA #2 and CNA #3.

Inspectors wroteBased on observations and interviews, the facility failed to ensure an infection prevention and control programs (IPCP) was maintained and followed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on one of three units. Specifically, the facility failed to ensure staff wore the appropriate PPE when providing wound care for Resident #50 who was on enhanced barrier precautions (EBP) related to an abdominal wound.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents who needed respiratory care was provided such care, consistent with professional standards of practice for one (#1) of two residents reviewed for the use of supplemental oxygen of 27 sample residents. Specifically, the facility failed to ensure Resident #1's oxygen was consistently administered according to physician's orders.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure a resident who displayed or was diagnosed with dementia received the appropriate treatment and services to attain or maintain his or her highest practical physical, mental, and psychosocial well-being for two (#29 and 42) of three residents reviewed for dementia care out of 27 sample residents. Specifically, the facility failed to effectively identify person-centered approaches for dementia care for Resident #29 and Resident #42 to provide the resident with their highest practicable quality of life and care.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure meals were served according to the resident's preferences for one (#103) of three residents out of 27 sample residents. Specifically, the facility failed to ensure Resident #103 received the meal items she ordered.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to protect the residents' privacy by using video monitoring for eight (#15, #27, #36, #37, #41, #43, #80 and #203) of eight residents reviewed out of 30 sample residents. Specifically, the facility failed to obtain resident and/or family consent for resident video monitoring, failed to consistently observe the video displays for resident behaviors, failed to protect the video display from others not involved in direct resident care, failed to post signage that indicated video cameras were in use and failed to obtain consent from roommates when cameras were in use.

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 and transmission of diseases and infection for two out of three units at the facility. Specifically, the facility failed to: -Ensure housekeeping staff were following the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touched areas (call lights, door handles and hand rails); and -Ensure surface disinfectant times were followed.

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents received notices orally and in writing which included a written description of their legal rights. Specifically, the facility failed to: -Include the email address of the State Survey Agency so a resident may file a care complaint; and, -Post the information in a manner accessible and understandable to all residents.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure two (#16 and #34) of four out of 30 sample residents received the highest practicable treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility failed to: -Ensure Resident #16 was wearing her geri gloves (to help her skin from bruising and skin tears) at all times when out of bed; and, -Ensure Resident #34 was wearing her prevalon boots (which help reduce the risk of pressure injuries to the heel/foot).

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide care and treatment for the resident's hearing aid that was required to maintain hearing ability for one (#21) of one resident out of 30 sample residents. Specifically, the facility failed to develop a resident centered care plan for the care and treatment to maintain ability to hear, failed to ensure the resident's hearing aid was maintained in working condition, failed to identify communication needs and preferences for the resident with hearing impairment when the device did not work, and failed to ensure hearing impairment was included as a current diagnosis for treatment.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure one (#7) of three residents who required respiratory care received the care consistent with professional standards of practice, out of 30 sample residents. Specifically, for Resident #7 the facility failed to: -Ensure a physician's order was in place to include the appropriate care of a continuous positive airway pressure (CPAP) machine; -Follow manufacturer recommendations to maintain, clean, sanitize, and store Resident #7's CPAP; -Accurately complete section O in the comprehensive minimum data set (MDS) assessment under respiratory treatments; -Ensure a care plan was in place to include settings, cleaning, disinfecting, and storage of the CPAP; -Ensure a physician's order was in place for oxygen therapy for Resident #7; [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain emergency response carts and equipment in safe operating condition for two of three emergency carts. Specifically, the facility failed to ensure emergency oxygen canisters on the emergency response carts were maintained and ready for use.

Inspectors wroteBased on interviews and record review, the facility failed to take the necessary steps to ensure one (#8) of one resident was free from abuse out of 16 sample residents. Resident #8 was admitted to the facility for long term care on 12/18/19 with diagnoses of vascular dementia without behavioral disturbance, hemiplegia (paralysis) and hemiparesis (partial paralysis, weakness) following nontraumatic intracerebral hemorrhage (stroke) affecting left non-dominant side, and pain. The resident was dependent on staff for activities of daily living which included toileting and upper and lower body dressing. The resident had both physical and verbal behavior symptoms directed towards others and had rejections related to care. The facility failed to address the behaviors to ensure resident safety (cross-reference F744 for dementia care). [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible, and adequate supervision was provided to prevent accidents, for two (#14 and #34) for elopement out of 16 sample residents. Specifically the facility: -Failed to complete an elopement assessment at the time of wander guard placement for Resident #14 and #34, and, -Failed to attempt an alternate intervention prior to the implementation of a wander guard for Resident #14. I. Facility policy The Elopement Risk policy, revised October 2020, provided by the nursing home administrator (NHA) on 6/21/22 at 3:16 p.m., included: Skilled nursing elopement: Any incident where a resident leaves the interior of the skilled nursing portion of the community; [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure one (#8) of three residents reviewed for dementia care of 16 sample residents, received the appropriate treatment and services to maintain their highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to address Resident #8's behaviors that were directed towards staff and the resident was involved in an altercation with a caregiver.