Skyline Nursing Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had a right to a dignified existence and self-determination that promoted enhancement of his or her quality of life, recognizing each resident's individuality for 4 (Residents #14, #21, #178 and #184) of 6 residents reviewed for resident rights. The facility failed to ensure Resident #178's Care Plan was followed. Resident #178's mattress was placed directly on the floor which could be seen by anyone who entered the men's behavioral unit due to the location of Resident #178's room. The facility failed to ensure residents' information was not loudly discussed in the dining room and/or down the hallway for anyone to hear as evidenced by the following: [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure the resident had a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 4 of 18 resident beds (Resident bed #1, Resident bed #2, Resident bed #3, Resident bed #4) reviewed for bed linens. 1. The facility failed to ensure residents had linen that was clean and in good repair on Resident bed #1, Resident bed #2, Resident bed #3, and Resident bed #4 on 4/12/26 and 4/13/26.3. The facility failed to maintain enough linen on the downstairs secured unit. These failures could place residents at risk of exposure to infectious diseases, unsanitary environment and a decline in quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 4 of 12 residents (Resident#10, Resident#15, Resident#50,and Resident #169) reviewed for ADL care. The facility failed to provide Resident #169 assistance with timely incontinence care for at least 4 hours. The facility failed to ensure Resident #10 had his fingernails cleaned and trimmed on 04/12/26. The facility failed to ensure Resident #15 had his face cleaned and his eye free of buildup on 04/13/26. The facility failed to ensure Resident #50 had her fingernails cleaned and trimmed on 04/12/2026. These failures could place residents at risk for loss of dignity, risk for infections and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that each resident received, and the facility provided at least three meals daily, at regular times comparable to normal mealtimes in the community for two (lunch on 04/12/26 and 04/13/26) of two meals observed for dietary services. The facility failed to serve the 04/12/26 and 04/13/26 lunch meals on time at the scheduled time based on the meal postings. This failure could place residents at risk for decreased meal satisfaction, decreased intake, loss of appetite, side effects from medications given without food, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 5 residents (Resident #164, # 21, 157, 184, and #105) of 10 residents observed for infection control. The facility failed to ensure:CNA B changed gloves and completed hand hygiene during incontinent care for Resident #164 on 4/12/26. CNA K did not utilize her bare hands when assisting Residents #21, #157 and #184 during lunch on 04/12/2026. CNA N wore appropriate PPE and completed hand hygiene during incontinent care for Resident #105, who was on Enhanced Barrier Precaution, on 4/13/26. These failures could place residents at risk for infection and cross contamination of pathogens and illness. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the responsible party regarding changes in condition for 1 (Resident #178) of 6 sampled residents reviewed for changes in condition and resident rights. The facility failed to notify Resident #178's responsible party when he had a fall and when he had a newly acquired pressure wound. This failure could place residents at risk of not having their responsible party notified of changes resulting in a delay in medical intervention. Review of Resident #178's admission Record dated 04/14/2026 revealed Resident #178 was a [AGE] year-old male who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident had the right to personal privacy for personal care for one of five (Resident #105) residents observed for personal care. CNA N failed to provide privacy during incontinent care of Resident #105 on 04/13/26. The failure could affect residents, by placing them at risk for loss of privacy and dignity.

Inspectors wroteBased on observation, interview and record review the facility failed to assist residents in obtaining routine dental care for one of 8 residents (Resident #117) reviewed for dental services. The facility failed to ensure Resident #117 received routine dental services since admission on [DATE]. This failure could place residents at risk of difficulty with eating, decline in eating and a delay in treatment for dental services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from misappropriation of property for one (Resident #1) of 10 residents reviewed for misappropriation of property. The facility failed to protect Resident #1 from misappropriation of property by one of their employees, Housekeeper A. On 12/18/2025 the Social Worker came to know that Housekeeper A used Resident #1's bank account for unauthorized transactions. As a result, Resident #1 lost approximately $300.00 from his personal bank account. This failure could place residents at risk of loss of lifelong earnings.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 residents (Resident#1 and #Resident #2) of 6 residents reviewed for ADLs. The facility failed to ensure: 1. Resident #1 had his fingernails cleaned and trimmed on 08/06/25.2. Resident #2 had her fingernails cleaned and trimmed on 08/06/25. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life.1. Record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to establish and 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 for 1 of 6 residents (Resident #3) reviewed for infection control. The facility failed to ensure CNA A performed hand hygiene while providing incontinence care to Resident #3 on 08/06/25. These failures could place residents at risk of cross-contamination and development of infections. Record review of Resident #3's annual MDS assessment dated [DATE] reflected Resident #3 was an [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source. were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 of 4 residents (Resident #1 and #2) reviewed for neglect reporting. The facility failed to report an allegation of neglect to the State Agency when Resident #1 was physically abused by Resident #2, sustaining an injury, on 05/02/25. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for Food and Nutrition Services. 1. The facility failed to ensure 6 tomatoes in the walk-in refrigerator were not bruised. 2. The facility failed to ensure three of six dietary staff (Dietary [NAME] O, Dietary Aide P and Dietary [NAME] T) used proper hand hygiene while handling and serving food during the lunch meal preparation and service on 01/28/25. 3. The facility failed to ensure five of six dietary staff (Dietary Aide P, Dietary Aide Q, Dietary Aide R, Dietary [NAME] T and Dietary Supervisor) used effective hair restraints while in the kitchen on 01/28/25 during the lunch meal preparation and service. 4. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident had a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for seven of eight hallways (shower rooms on 100, 200, 300, 400, 500, 700, and 800 hallways) reviewed for environment and 1 of 34 residents ( Resident # 109) reviewed for clean linens. 1. The facility failed to ensure the shower rooms were cleaned throughout the day, kept orderly, and maintained in a sanitary and comfortable condition for resident use. 2. The facility failed to ensure Resident #109 had clean linens on 01/28/2024 from 9:27 AM until 11:00 AM. This failure could place residents at risk of exposure to infectious diseases and other unsanitary health hazards.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for one of 7 residents (Resident#23) reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system was within reach of Resident #23 when the resident was lying in bed . This failure could place residents at risk of being unable to have a means of directly contacting caregivers.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 2 of 4 residents (Resident #14 and Resident #31) reviewed for ADLs. 1. The facility failed to ensure Resident #14 had her fingernails trimmed on 01/27/25. 2. The facility failed to ensure Resident #31 had his fingernails cleaned and trimmed on 01/29/25. These failures could place residents at risk for loss of dignity, risk for infections and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, administering of drugs and biologicals, to meet the needs of each resident for of 3 medication carts 1 (nurses cart hall 100) reviewed for pharmacy services. 1. The facility failed to ensure RN C, who was responsible for Nurses Cart Hall 100, removed medications in unsecure containers from the Nurses Cart. 2. The facility failed to ensure the Nurses Cart Hall 100 did not have an expired insulin pen for Resident #55 These failures could place residents at risk of not having the medication available due to possible drug diversion, diminished effectiveness, and not receiving the therapeutic benefits of the medications. Findings Include: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to establish and 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 for 2 of 8 residents (Resident #9 and Resident #109) reviewed for infection control. The facility failed to ensure CAN J changed her gloves and performed hand hygiene while providing incontinence care to Resident #9 on 01/28/25 . These failures could place residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from Misappropriation of property for one (Resident #1) of 8 residents reviewed for misappropriation of property. The facility failed to protect Resident #1 from misappropriation of property by one of their employees AA. On 06/24/2024 the facility Business Office Manager and Administrator came to know that AA was using Resident#1's bank debit card for unauthorized transactions for the past several months. As a result, Resident #1 lost approximately $25,000.00 from his personal bank account. This failure could place residents at risk of Exploitation/Misappropriation of Property and loss of lifelong earnings.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for three (Resident #1, Resident #2, and Resident #3) of ten residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #1, Resident #2, and Resident #3's rooms was in a position that was accessible to the resident. This failure could place the residents at risk of being unable to obtain assistance when needed and not get help in the event of an emergency.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three (Resident #4, Resident #5, and Resident #6) of five residents reviewed for respiratory care. The facility failed to ensure Resident #4 and Resident #5's mask for breathing treatment were dated and bagged when not in use. The facility failed to ensure Resident #6's nasal cannula (a device used to deliver supplemental oxygen to an individual. It consists of a lightweight tube on which one is connected to the oxygen source and the other end splits into two prongs and are placed in the nostrils) was dated and bagged when not in use. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents in 5 of (701, 706, 708, 709, and 711) of twelve resident bedrooms reviewed for resident rights. The facility failed to maintain 5 (701, 706, 708, 709, and 711) bedrooms in a safe, sanitary, and comfortable condition. This deficient practice could place residents at risk of a diminished quality of life due to an unsafe and unmaintained environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 3 (Resident #22, Resident 162, and Resident #173) of 8 residents reviewed for ADLs. The facility failed to ensure: 1- Resident #22 had his fingernails trimmed. 2- Resident #162 had his fingernails trimmed and cleaned. 3- Resident #173 had his fingernails trimmed and cleaned. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of medications for 1 (Resident #138) of 4 residents observed for medication administration and 3 medication cart (Nurses Cart 100/200 halls, Medication Aide Cart 400 hall, and Medication Aide Cart 600/800 halls) of 5 medication carts reviewed for pharmacy services in that: 1. The facility failed to ensure MA F administered medications for Resident #138 on time as ordered. 2. The facility failed to ensure medications in unsecure containers were immediately removed from stock. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation in that: 1. Facility failed to ensure missing tile floor was repaired in the dish room of kitchen. 2. Dietary Aide N and Dietary Aide O failed to practice appropriate hand hygiene when putting up clean dishes. These failures could place residents at risk for food contamination and food-borne illness.

Inspectors wroteBased observation, interview, and record review, 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 for one (Resident #86) of ten residents, six (200, 400, 500, 600, 700, and 800 Halls) of eight clean linen closets, and 2 of 4 medication carts reviewed for infection control. 1. LVN H failed to change gloves and perform hand hygiene during wound care to Resident #86. 2. The facility failed to ensure clean linen closets were kept sanitary and free of personal care and clothing items. 3. The facility failed to ensure the Silent Night pill crushers were clean for 2 of 4 medication carts. These failures could place residents at risk of infection, slow wound healing, and or a decline in health.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan that included measurable goals and objectives, and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #38) of 3 residents reviewed for comprehensive care plans. The facility failed to ensure Resident #38 had a person-centered care plan to include significant weight loss interventions. This failure could place resident at risk of not having needs identified and addressed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles on 1 medication cart (Nurses Cart Hall 900) of 5 medication carts observed for medication storage in that: Facility failed to ensure medication cart (Nurses Cart Hall 900) did not contain a bag of snack mixed with medication in the second drawer of the medication cart. This failure could place residents at risk of receiving contaminated medication.

Inspectors wroteBased on interview and record review, the facility failed to consult the resident's physician and resident representative when there was a significant change in the resident's physical, mental or psychosocial status for one (Resident #1) of five residents reviewed for resident rights. 1. The facility failed to ensure Resident #1's physician and psychiatrist was notified when she refused her prescribed psychotropic and blood pressure medications consistently for over a week from 09/01/23 through 09/09/23 . 2. The facility failed to ensure Resident #1's RP/family member(s) were notified when she refused her prescribed psychotropic and blood pressure medications consistently for over a week from 09/01/23 through 09/09/23. An Immediate Jeopardy was identified on 09/14/23. The IJ Template was provided to the facility on [DATE] at 1:45 PM. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the resident has the right to be free from neglect for one (Resident #1) of five residents reviewed for neglect. 1. The facility failed to provide prescribed psychotropic medications to Resident #1, who lived with dementia and mental illness, and moved her to several different rooms in a week's time which resulted in her having increased behaviors resulting in two separate unwitnessed resident to resident altercations. 2. The facility failed to notify the MD when Resident #1 refused her psychotropic medications prior to the two resident to resident altercations. An Immediate Jeopardy was identified on 09/14/23. The IJ Template was provided to the facility on [DATE] at 1:45 PM. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to develop and implement written policies and procedures that prohibit and prevent neglect for one (Resident #1) of five residents reviewed for neglect policies. The facility failed to provide prescribed psychotropic medications to Resident #1, who lived with dementia and mental illness, and moved her to several different rooms in a week's time which resulted in her having increased behaviors resulting in two separate unwitnessed resident to resident altercations. The facility failed to notify the MD when Resident #1 refused her psychotropic medications prior to the two resident to resident altercations. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who displayed or is diagnosed with a mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for two (Residents #1 and #4) of five residents reviewed for psychosocial concerns. 1) The facility management and staff did not observe and intervene for manifestations related to mental and psychosocial adjustment difficulties when Resident #1, who lived with dementia with behavioral disturbance and mental illness was changed to three different rooms in a week, after she had been living in a room alone for most of 2023. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for one (Resident #1) of three residents reviewed for transfer and discharge rights. The facility failed to provide or document sufficient preparation for an orderly transfer when Resident #1 allegedly got into an unwitnessed physical altercation with her new roommate. An Immediate Jeopardy was identified on 09/14/23. The IJ Template was provided to the facility on [DATE] at 1:45 PM. While the Immediate Jeopardy was removed on 09/18/23, the facility remained out of compliance at the severity level of Actual harm that is not Immediate Jeopardy and at a scope of pattern due to the facility's need to implement and monitor the effectiveness of its corrective systems. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter or alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner or clinical nurse specialist for four (Residents #1, #2, #4 and #5) of four residents reviewed for physician services. The facility failed to ensure Residents #1, #2, #4 and #5 were seen by their attending physician at least once every 60 days. The attending physician's extenders were completing all visits for the residents, not alternating visits with the physician. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide mandatory effective behavioral health training for six (ADON B, RN F, CNA Q, CNA R, LVN I, CNA U) of six facility staff hired since October 2022 for required training. The facility failed to ensure newly hired staff in the past year (since October 2022)- ADON B, RN F, CNA Q, CNA R, LVN I and CNA U completed behavioral health training upon hire as was listed as a training requirement in the facility's annual assessment. The facility failure could place residents at risk of not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being due to lack of staff training and knowledge in working with residents who have mental health issues.

Inspectors wroteBased on interviews and record review, the facility failed to ensure in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must have evidence that all alleged violations are thoroughly investigated and prevent further abuse, neglect, exploitation, or mistreatment while the investigation is in process for two (Residents #1 and #2) of five residents reviewed for abuse and neglect. The facility failed to thoroughly investigate an unwitnessed resident to resident allegation with Residents #1 and #2,. The facility failed placed residents at risk of being sent out for unnecessary psychiatric and psychological evaluations, unnecessary increases in psychotropic medications, lack of knowledge of the events which could cause the wrong interventions, and lack of due diligence in investigating resident to resident altercations.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for one (Resident #5) of ten residents reviewed for care plans. Resident #5's care plan was not individualized and did not address her wounds. This failure could place residents at risk of not receiving individualized care and services to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure that in accordance with accepted professional standard and practices, medical records were accurately documented for one (Resident #5) of five residents reviewed for clinical records accuracy. The facility failed to document wound care orders on Resident #5's TAR. The facility failure could place residents at risk of inaccurate clinical records.