Skylake Post Acute

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for two (#4 and #16) of seven sample residents reviewed for change of condition assessments out of 14 sample residents. Resident #4 was admitted on [DATE] with diagnoses of dementia, severe, with other behavioral disturbance, pancytopenia (lower than normal count of all three types of blood cells), and protein-calorie malnutrition. On 12/10/25 the facility documented that Resident #4 had decreased oral and fluid intake. On 12/11/25 Resident #4 sustained an unwitnessed fall, where his mattress was found partially off the bed frame. The staff documented a decline in the resident's function and he continued to have decreased oral and fluid intake, had increased weakness and confusion, had unsteady balance and was pale. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure four (#17, #6, #7 and #5) of seven residents reviewed for abuse out of 14 sample residents were kept free from abuse. Specifically, the facility failed to:-Prevent an incident of physical abuse between Resident #6 and Resident #17;-Prevent an incident of physical abuse between Resident #6 and Resident #7; and,-Protect Resident #5 from physical abuse by Resident #6.

Inspectors wroteBased on record review and interviews, the facility failed to provide choices for preference of bathing schedule for one (#1) of three residents reviewed for self-determination out of eight sample residents. Specifically, the facility failed to ensure Resident #1 received showers consistent with her preferences.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for accidents out of eight sample residents received adequate supervision to prevent risk for accident hazards. Specifically, the facility failed to ensure safe assistance was provided by staff during incontinence care for Resident #1, which resulted in the resident sustaining a fall with minor injuries when she rolled out of bed during the care.

Inspectors wroteBased on record review and interviews, the facility failed to ensure food served accommodated residents' allergies and intolerances for one (#1) of three residents reviewed out of eight sample residents. Specifically, the facility failed to ensure Resident #1 was not served food the resident was allergic to, despite the resident having a documented food allergy.

Inspectors wroteBased on observations and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen. Specifically, the facility failed to ensure:-Beard nets were worn while preparing food in the main kitchen;-Hand hygiene was conducted during meal service and dishwashing; and,-Food was labeled and dated in the walk-in refrigerator, walk-in freezer and reach-in refrigerators.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to prevent the development and transmission of disease and infection. Specifically, the facility failed to:-Ensure there were monitoring measures maintained for all control measures identified that may contribute to the spread of legionella (a type of bacteria that can cause legionella disease, a severe form of pneumonia): -Ensure the facility water management plan was reviewed annually; and,-Ensure the facility water management plan was personalized and specific to the facility.

Inspectors wroteBased on observations and interviews, the facility failed to ensure care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect for two of four units. Specifically, the facility failed to:-Provide Resident #155 privacy while he used the restroom, and,-Staff announced themselves prior to entering residents' rooms.

Inspectors wroteBased on observations and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly according to professional standards in three of four medications rooms, one of five medication carts and one of one vaccine storage refrigerators. Specifically, the facility failed to:-Ensure expired vaccines were removed from refrigerators;-Ensure Tubersol (used to test for tuberculosis) vials were dated upon opening;-Ensure vaccinations were not stored in dormitory style refrigerator;-Ensure expired insulin pens were removed from the medication cart;-Ensure expired medications were removed from over the counter medications supply; and,-Ensure discarded medications were destroyed timely.

Inspectors wroteBased on record review and interviews, the facility failed to ensure money from personal funds accounts was managed accurately for two (#175 and #45) out of five residents reviewed for personal funds accounts out of 71 sample residents. Specifically, the facility failed to notify Resident #175 and Resident #45, who were Medicaid funded, or their legal representative when the resident's personal funds account reached $200.00 less than the eligibility resource limit.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to provide supervision, assistance, services, and implement effective person centered interventions to prevent falls with injuries for one (#156) of three residents reviewed for accidents/hazards out of 71 sample residents. Specifically, the facility failed to ensure the staff were aware and implemented Resident #156's fall interventions consistently.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents who were trauma survivors, received culturally competent, trauma-informed care in accordance with professional stands or practice and accounting for the residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one (#144) of three residents reviewed out of 71 sample residents. Specifically, the facility failed to ensure individualized care approaches were provided for Resident #144 to prevent re-traumatization.

Inspectors wroteBased on record review and interviews, the facility failed to provide the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental and psychosocial well-being for one (#130) of three residents reviewed out of 71 sample residents. Specifically, the facility failed to:-Document resident specific care approaches, to include medication specific target behaviors and person-centered interventions for Resident #130; and,-Document attempted non-pharmacological interventions prior to the administration of a as needed (PRN) anti anxiety medication.

Inspectors wroteBased on observations, record review and interviews, the facility failed to implement their policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption on two of four hallways. Specifically, the facility failed to ensure safe and appropriate storage of food items in resident's personal refrigerators.

Inspectors wroteBased on record review and interviews, the facility failed to establish a communication process that included how the communication would be documented between the facility and the provider for two (#11 and #9) of four residents reviewed for hospice care out of 71 sample residents. Specifically, the facility failed to establish a communication process according to the hospice agreement that included documentation of care and services provided by hospice filed and maintained for Resident #11 and Resident #99.

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. Specifically, the facility failed to: -Ensure staff wore the appropriate personal protective equipment (PPE) when providing direct care to a resident who was on enhanced barrier precautions (EBP); and, -Follow appropriate infection control measures during wound care.

Inspectors wroteBased on interviews and record review, the facility failed to protect and keep residents safe from abuse and neglect for two (#2 and #11) of three residents reviewed for abuse out of 16 sample residents. A review of resident records and interviews with staff revealed the facility failed to take steps to develop and implement effective interventions to create an environment in the memory care-secure unit that protected residents from resident-to-resident abuse. RESIDENTS #6 AND #2 On 4/8/24, Resident #6 was admitted to the facility's memory care-secured unit. It was known to the facility, before the resident's admission, that he was displaying an increase in unsafe wandering and physical and verbal aggression toward other residents at the facility where he had previously resided. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to have a written transfer agreement with one or more hospitals approved for participation under Medicare and Medicaid programs to reasonably ensure residents would be transferred from the facility to a hospital, and assured of timely admission to the hospital when transfer was medically appropriate. Specifically, the facility failed to ensure a written agreement was in effect with one local area hospital.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#1) of three residents out of 16 sample residents had the right to be informed of and participate in care plan meetings and to develop his or her treatment plan including the right to be informed, in advance, of the care to be furnished and the type of caregiver or professional that would furnish care. Specifically, the facility failed to: -Inform Resident #1's legal representative in advance of the facility's scheduled care plan meetings so the representative could participate in care planning; -Inform Resident #1's legal representative of when upcoming podiatry and dental services were to be provided so the representative could be informed and assist with treatment decisions; and, -Notify and inform Resident #1's legal representative of changes in the resident's condition, including falls.

Inspectors wroteBased on record review and interviews, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin were reported immediately for one (#1) of three residents reviewed out of 16 sample residents. Specifically, the facility failed to report an allegation of an injury of unknown origin (bite wound) to the State oversight agency within 24 hours of the injury being discovered.

Inspectors wroteBased on record review and interviews, the facility failed to ensure incidents of potential abuse were thoroughly investigated for one (#1) of three residents out of 16 sample residents. Specifically, the facility failed to ensure an allegation of physical abuse, reported following the discovery of an injury of unknown origin, a bite wound, was thoroughly investigated and that the resident was monitored to prevent the possibility of a repeated instance.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to store, prepare, distribute and serve food in a sanitary manner. Specifically, the facility failed to: -Ensure staff washed hands and changed single use gloves appropriately while plating and serving resident meals in the main kitchen; -Ensure food in the walk-in refrigerator and the reach-in refrigerators in the main kitchen, and in two of two resident unit snack refrigerators was labeled and dated with an open date and disposed of timely when past the used by date; and, -Ensure that expired foods were not served to residents.

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 accurate transmission based precaution procedures were followed, including use of isolation signage on resident doors and following proper procedures for donning (put on) personal protective equipment (PPE) prior to entering a resident's room who was COVID-19 positive. -Ensure housekeeping staff followed appropriate infection control procedures such as hand hygiene and surface disinfectant time adherence. I. Transmission based precaution and PPE A. [...]

Inspectors wroteBased on observation, record review and staff interviews, the facility failed to ensure essential laundry dryer equipment was in safe working order in the facility laundry room. Specifically, the facility failed to keep the dryer lint filters and compartments cleaned and without lint building up in three of three facility dryers.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents were provided prompt efforts by the facility to follow up on grievances. Specifically, the facility failed to: -Ensure grievances and or complaints were filed and the facility actions and resolutions were documented; -Ensure residents were informed of grievances outcomes and of the facility's actions to resolve grievances; -Ensure residents received a resolution to the residents' satisfaction; -Ensure staff were trained and educated on the facility's grievance process; and, -Ensure call lights were answered timely.

Inspectors wroteBased on record review and interviews, the facility failed to ensure seven of seven nursing staff members were able to demonstrate skills and techniques necessary to care for residents' needs. Specifically, the facility failed to: -Ensure that registered nurse (RN) #3 and licensed practical nurse (LPN) #1 had specific competencies and skill sets necessary to care for residents' needs; and, -Ensure certified nurse aides (CNA) #4, CNA #5, CNA #6, CNA #7 and CNA #8 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. Cross-reference F689: the facility failed to prevent accident hazards utilizing mechanical lift for transfers. Cross-reference F695: the facility failed to maintain a resident's respiratory equipment according to professional standards. [...]

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 four of five certified nurse aides. Specifically, the facility had not completed annual performance reviews for certified nurse aide (CNA) #4, CNA #6, CNA #7 and CNA #8, in order to determine potential training needs. Cross-reference F947 failure to ensure CNAs received adequate training as required. Cross-reference F726 failure to assess nursing staff's competency and skill for quality care.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure a residents diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental and psychosocial well-being for four (#110, #115, #126 and #134) of 10 residents reviewed for dementia care out of 54 sample residents. Specifically, the facility failed to address wandering behavior and provide meaningful activities for Residents #110, #115, #126 and #134, who had a diagnosis of dementia and resided in the secure unit of the facility.

Inspectors wroteBased on observations and interviews, the facility failed to ensure facility menus met the needs of residents and were followed. Specifically, the facility failed to ensure menu items were not omitted from the lunch menu service for 16 of 16 residents with prescribed puree, mechanical soft and bite size diet orders.

Inspectors wroteBased on interviews, observations and record review, the facility failed to consistently serve food that was palatable, attractive and at a safe and appetizing temperature. Specifically, the facility failed to ensure resident food was served at a palatable temperature.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide food and beverages that accommodated resident preferences for two (#46 and #134) of 10 residents reviewed food and beverage preferences out of 54 sample residents. Specifically, the facility failed to offer food choices according to Residents #46 and #134's preferences.

Inspectors wroteBased on record review and interviews, the facility failed to provide training to their staff that at a minimum educates staff on activities that constitute abuse, neglect, exploitation and misappropriation of resident property as set forth, procedures for reporting incidents of abuse, neglect, exploitation or misappropriation of resident property and resident abuse prevention for 71 of 96 nursing staff. Specifically, the facility failed to ensure nursing staff including 71 of the facility's hired certified nurse aides (CNA), registered nurses (RN) and licensed practical nurses (LPN) (#2) received annual abuse identification, prevention and reporting training in the past 12 calendar months.

Inspectors wroteBased on interviews and record review, the facility failed to ensure nurse aides received the required number of annual in-service training hours to ensure continued competence for four of five nurse aides reviewed. Specifically, the facility failed to ensure certified nurse aides (CNA) #4, #6, #7 and #8 received 12 hours of continuing education annually. Cross-reference F943 failure to ensure all staff received training on abuse prevention, identification and reporting. Cross-reference F949 failure to ensure all clinical staff received training on the topic of dementia managed care.

Inspectors wroteBased on interview and record review, the facility failed to develop, implement and maintain an effective training program for all staff, which includes, at a minimum, training on behavioral health based on requirements and as outlined in the facility's assessment for 75 out of 96 nursing staff. Specifically, the facility failed to ensure that all nursing staff including 75 of the facility's hired certified nurse aides (CNAs), registered nurses (RNs) and licensed practical nurses (LPNs) received training on behavioral health issues to include care specific to the individual needs of residents who were diagnosed with dementia and how to promote meaningful activities and dementia specific care that promoted engagement and positive meaningful relationships. Cross-reference F744 failure to provide dementia-focused care.

Inspectors wroteBased on record review and interviews, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin were reported immediately for one (#102) resident reviewed out of 54 sample residents. Specifically, the facility failed to report an allegation of abuse within 24 hours to the State Survey Agency.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the resident environment was as free from accident hazards as possible for two (#19 and #46) of four out of 54 sample residents. Specifically, the facility failed to: -Ensure staff received training on safe operating procedures when using a mechanical lifts for Resident #19; -Ensrure staff transferred Resident #19 between surfaces safely using safe transfer techniques; and; -Implement effective interventions for Resident #46 who had known elopement attempts from eloping the building unbeknown to staff and becoming a missing person. Cross-reference F726 failure to ensure nursing staff had the skills and competencies to provide safe and effective care.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#85) of one resident who required continuous positive airway pressure (CPAP) respiratory therapy received the care consistent with professional standards of practice out of 54 sample residents. Specifically, for Resident #85 the facility failed to: -Ensure a physician's order was in place for the use of CPAP therapy; -Ensure a care plan focus was in place for the residents CPAP therapy, to include the type of equipment and device settings; when to administer CPAP therapy including frequency; methods of monitoring the resident's use in case of complications;and, -Ensure staff set up the resident's CPAP machine with distilled water.

Inspectors wroteBased on record review and staff interviews the facility failed to implement policies and procedures related to pneumococcal immunizations for one (#46) of five residents reviewed for immunizations out of 54 sample residents. Specifically, the facility failed to offer Resident #46 additional recommended doses of the pneumococcal vaccination.

Inspectors wrote3. A review of the admission Record revealed the facility admitted Resident #110 with diagnoses that included quadriplegia and right-hand contracture. A review of Resident #110's care plan, last revised 08/15/2022 revealed a focus area that stated the resident may smoke with supervision per smoking assessment. Patient refuses to wear a smoking apron at times. Patient often insists on going out to smoking (sic) at 3:30 in the morning. Patient refuses to let staff assist with flipping [his/her] ashes. The goal was that the resident would smoke safely for 90 days, and the interventions included encourage the resident to wear a smoking apron, inform and reinforce smoking restrictions, inform and remind the resident of locations of smoking areas and smoking times, supervise patient with smoking in accordance with assessed needs, and monitor the residents compliance with the smoking policy. [...]

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to store, distribute, and serve food in accordance with professional standards of food service safety in 1 of 1 kitchen. Specifically, the facility: - Failed to ensure food items in the walk-in cooler and freezer were properly sealed, labeled, and dated when opened. - Failed to ensure food items that were visibly spoiled were removed from stock / discarded. - Failed to ensure a refrigerator on Arbor Unit, where residents' food was stored, was maintained in proper working order. - Failed to ensure an ice chest used to pass ice/water to residents on Arbor Unit was cleaned/sanitized after becoming contaminated. - Failed to ensure food delivered from the kitchen was covered during transport to a resident. [...]

Inspectors wroteBased on record review, observation, resident and staff interviews the facility failed to promote privacy while providing incontinence care when the resident's privacy curtain did not provide full privacy. This occurred for 1 of 1 resident (Resident #117) reviewed for incontinence care.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to complete a Level II Preadmission Screening and Resident Review (PASRR) when Resident #17 was diagnosed with a new mental illness. This deficient practice affected Resident #17, 1 of 3 sampled residents reviewed for PASRR.