Skyline Transitional Care Center

Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to ensure residents were provided respiratory services consistent with professional standards of practice. This was true for 4 of 5 residents (#9, #23, #26, and #28) whose respiratory devices were not stored properly and 1 of 5 residents (#89) reviewed for physician orders for oxygen therapy. This deficient practice created the potential for residents to develop infection and to receive too little or too much oxygen.

Inspectors wroteBased on observation, policy review, and staff interviews, it was determined the facility failed to ensure adherence to infection control and prevention practices, consistent with professional standards of practice. This was true for 3 of 3 residents (#6, #48, and #64) when staff did not follow hand hygiene protocols when going from a dirty to a clean environment during wound care and activities of daily living (ADL's), and 1 of 3 residents (Resident #6) observed for not following enhanced barrier precautions (EBP) during wound care. This deficient practice created the potential for harm to the residents due to cross-contamination and increased risk for infection.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure residents were transferred to the hospital with all required documentation. This was true for 1 of 5 residents (Resident #64) whose hospital transfers were reviewed. This failure placed Residents #64 at risk for harm when the receiving healthcare institution were not provided the residents' care plan goals. [...]

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure the required Preadmission Screening and Resident Review (PASRR) process was completed accurately for a resident with mental health diagnoses. This was true for 1 of 2 residents (Resident #6) reviewed for PASRRs. This failure created the potential for the residents' mental health needs or need for specialized services to go undectected if PASRRs were inaccurate. Findings Include:Resident #6 was admitted to the facility on [DATE], with multiple diagnoses including a primary diagnosis of severe protein-calorie malnutrition, major depressive disorder, anxiety disorder, and dementia. Resident #6's PASRR level 1 dated 5/19/26, documented she had an anxiety disorder, mood disorder and a primary diagnosis of dementia. [...]

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure a comprehensive, person centered care plan was developed to reflect the resident's diagnosed needs. This was true for 1 of 19 residents (Resident #27) reviewed for person-centered care plans. The failure to include Resident #27's Post Traumatic Stress Disorder (PTSD) diagnosis and related triggers in the care plan created the potential for unaddressed psychosocial needs and triggering of traumatic stress responses.

Inspectors wroteBased on observation, policy review, record review, and staff interview, it was determined the facility failed to ensure necessary pressure relieving boots were consistently applied as ordered to prevent development of pressure injuries and promote skin integrity. This was true for 1 of 5 residents (Resident #1) reviewed for pressure-injury prevention. This failure placed Resident #1 at increased risk for harm related to pressure-related skin breakdown.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to follow up on the dialysis centers recommendations for a resident receiving dialysis services. This was true for 1 of 1 resident (Resident #28) reviewed for dialysis services. The failure to act on dialysis recommendations created the potential for adverse outcomes related to fluid management, a critical component of care for residents with end stage renal disease.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure trauma informed care services were provided in accordance with professional standards of practice and in a manner that accounted for the resident's experiences and preferences. This was true for 1 of 1 resident (Resident #27) reviewed for trauma informed care. The facility's failure to identify and address trauma related needs created the potential for exposure to triggers and re traumatization.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure residents were receiving medication with adequate monitoring. This was true for 3 of 6 residents (#19, #24, and #27) whose records were reviewed for unnecessary medications. This deficiency placed Residents #19 and #27 at risk for overmedication when their pain medication orders did not include parameters for administration and placed Resident #19, #24, and #27, at risk to suffer from side effects due to the lack of opioid side effect monitors.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure the cleaning and sanitation of kitchen cookware. This deficiency had the potential to affect the 64 residents who consumed food prepared by the facility. This placed residents at risk for potential foodborne illnesses and adverse health outcomes due to contaminated food services equipment.

Inspectors wroteBased on review of the Resident Assessment Instrument (RAI) Manual, record review, and staff interview, it was determined the facility failed to ensure residents' Minimum Data Set (MDS) Assessments included correct assessment information. This was true for 4 of 16 residents (#1, #8, #25, and #27) whose records were reviewed for accuracy. This deficient practice had the potential for negative outcomes if residents were not assessed and/or monitored due to inaccurate assessments.

Inspectors wroteBased on record review, resident and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 1 of 2 residents (Resident #12) reviewed for bowel and bladder incontinence. This failed practice created the potential for Resident #12 to experience bowel obstruction when her medications were not administered according to the physician's order.

Inspectors wroteBased on observation, policy and record review, it was determined the facility failed to ensure that prior to placement of bed rails, residents were thoroughly assessed for the risk of entrapment. This was true for 1 of 1 resident (Resident #115) reviewed for bed rails. This deficient practice created the potential for harm from entrapment or injury related to use of bed rails. The facility's Bed Rails policy and procedure, revised 12/2023 documented the following: - The facility would attempt to use appropriate alternatives prior to installing a side or bed rail. - If it was determined that these alternatives failed to meet the resident's assessed needs, the interdisciplinary team would assess the resident for risk of entrapment. - The risks and benefits regarding the use of bed rails would be considered for each resident. [...]

Inspectors wroteBased on record review, review of facility's policy and procedure, review of Incidents and Accidents (I&As) reports, and staff interview, it was determined the facility failed to ensure residents were free from significant medication errors. This was true for 2 of 2 residents (#116 and #117) reviewed for medication errors. The facility's Six Rights of Medication Administration, revised May 2024, documented the following in order to ensure safety and accuracy of medication administration. - Right resident - Right time - Right medication - Right dose - Right route - Right documentation The facility's Medication Errors and Adverse Reactions policy and procedure, revised January 2025 documented resident's condition must be monitored for 72 hours or as may be directed and detailed account of the incident must be recorded on an incident report. [...]

Inspectors wroteBased on policy review, resident and staff interview, review of Incident and Accident reports (I&As), and record review, it was determined the facility failed to ensure residents were free from abuse and neglect. This was true for 3 of 15 Residents (#4, #23, and #36) reviewed for potential abuse and/or neglect. Resident #4 experienced neglect resulting in emotional distress and mental anguish when the facility failed to ensure he was provided with an alternative communication system to enable him to effectively express himself. Resident #23 also experienced neglect resulting emotional distress and mental anguish when the facility failed to ensure she had an augmentative or alternative communication system to enable her to file grievances and clearly communicate with staff and others following a stroke. [...]

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure a resident received appropriate care to prevent and treat pressure ulcers. This was true for 1 of 3 residents (Resident #12) reviewed for pressure ulcer care. This deficient practice resulted in harm to Resident #12 when she developed new Stage 3 and Stage 4 pressure ulcers, and the pressure ulcer she was admitted with, worsened.

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure residents, their representatives, and families were updated regarding the number of new COVID-19 positive cases for residents and staff, the cumulative number of COVID-19 cases for residents and staff, and the mitigating factors the facility was used to help control/stop the spread of the virus by 5:00 PM the next day. This was true for all 58 residents who resided in the facility. This systemic failure had the potential to deprive the resident representatives and families of each of the residents in the facility of the extent of COVID-19 cases in the facility and the opportunity to advocate for the resident and assist the resident in choosing whether to remain in the facility.

Inspectors wroteBased on resident and staff interview, policy review, review of grievances, and record review, it was determined the facility failed to ensure: * Residents were notified individually or through postings in the facility of how to file a grievance * A functional process for filing a grievance anonymously was in place * Residents received written responses to grievances which included the date the grievance was received, steps taken to investigate the grievance, and corrective action taken to resolve the grievance. This was true for 4 of 13 residents interviewed regarding grievances (Residents #8, #9, #23, and #51) and had the potential to impact all of the other 53 residents in the facility, or their representatives, who may want to file a grievance. These failures impeded the ability of residents and their representative to file grievances and to receive resolution.

Inspectors wroteBased on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to ensure residents' care plans were revised and updated as needs changed and included residents' representative in the development of the care plan. This was true for 4 of 15 residents (#3, #12, #24, and #35) whose care plans were reviewed. This deficient practice placed residents at risk for adverse outcomes if care and services were not provided appropriately due to a lack of information in the care plans.

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 5 of 15 residents (#3, #10, #17, #33, and #35) reviewed for standards of practice. Specifically: *Resident #3 was at risk for ongoing constipation or fecal impaction when physician orders for bowel care were not followed. Resident #3 was also at risk for side effects of a narcotic given contrary to parameters ordered by the physician. [...]

Inspectors wroteBased on observation, policy review, and staff interviews, it was determined the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility failed to properly date food items when they were received and stored and failed to monitor and discard outdated food items. This had the potential to affect the 58 residents residing in the facility who consumed food prepared by the facility and placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses.

Inspectors wroteBased on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to promote and facilitate a resident's ability to make food choices. This was true for 1 of 3 residents (Resident #4) reviewed for accommodation of food choices. This deficient practice placed Resident #4 at risk of continued weight loss, a decreased sense of well-being and self-worth, and frustration when he was not asked what foods he would like to eat and was not provided with menu choices.

Inspectors wrote2. Resident #35 was admitted to the facility on [DATE], with multiple diagnoses including cerebral infarction (stroke) and diabetes. Resident #35's quarterly MDS assessment, dated 12/8/21, documented he was moderately cognitively impaired. He did not walk, depended on a wheelchair, was totally dependent, and required the assistance of two people for bed mobility and transfers, and extensive assistance from one person for dressing, toileting, and hygiene. Resident #35 had a Foley catheter (indwelling urinary catheter) and was always incontinent with bowel function. On 1/18/22 at 10:01 AM, Resident #35 said CNA #4 acted like a doctor. Resident #35 said CNA #4 was rough during peri care and grabbed his testicles and told him it was for his own good. Resident #35 said CNA #4 told him he needed to get his leg amputated. [...]

Inspectors wroteBased on policy review, record review, review of grievances, and resident and staff interview, it was determined the facility failed to ensure allegations of abuse, neglect, and misappropriation of resident's property were investigated for 2 of 15 residents (#8 and #35) reviewed for abuse, neglect and/or misappropriation of personal property. This failure created the potential for residents to be subjected to ongoing abuse and misappropriation of resident property without detection.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure the MDS assessment accurately reflected a resident's status. This was true for 1 of 15 residents (Resident #12) whose MDS assessments were reviewed. This deficient practice had the potential for negative outcomes if the resident was not assessed and/or monitored due to inaccurate assessments.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure a resident's care plan included individualized, resident-centered interventions and goals related to treatment of his insomnia and related medication. This was true for 1 of 15 residents (Resident #35) whose care plans were reviewed. This placed the resident at risk of adverse outcomes if cares and/or services were not provided appropriately due to a lack of information in the care plan.

Inspectors wroteBased on record review, and resident and staff interview, it was determined the facility failed to ensure a resident was given the appropriate treatment and services to maintain or improve communication ability to carry out the activities of daily living. This was true for 1 of 15 residents (Resident #23) reviewed for activities of daily living. This failure placed Resident #23 at risk for decreased quality of life and psychosocial distress, depression, and negative behavior related to the inability to communicate her needs and choices.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure there was an ongoing activity program designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. This was true for 3 of 3 residents (Resident #4, #23, and #24) reviewed for activities. This failure created the potential for harm if residents experienced boredom and lacked meaningful activities throughout the day.

Inspectors wroteBased on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to ensure residents were provided a therapeutic diet that took into account the resident's clinical condition and preferences. This was true for 1 of 15 residents (#4) reviewed for nutrition concerns. This failure created the potential for harm if Resident #4 failed to eat because his nutritional preferences were not considered.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure actions were taken in a timely manner to address drug regimen review irregularities identified by the consultant pharmacist for 1 of 15 residents (Resident #35) reviewed for medication administration. This failure put Resident #35 at risk to experience adverse effects from medications that were not compatible or administered as recommended.

Inspectors wroteBased on record review, policy review, review of facility menus, and resident and staff interview, it was determined the facility failed to follow a resident's gluten-free meal preference or provide appropriate meal alternatives. This was true for 1 of 15 residents (Resident #8) reviewed for food preferences. This failure put Resident #8 at risk if she experienced hunger or weight loss for not having meals provided according to her needs or preference.

Inspectors wroteBased on observation, resident and staff interviews, and policy review, it was determined the facility failed to ensure a safe environment was provided for residents, staff and the public. This was true for 1 of 45 residents (Resident #39) observed using an extension cord with a power strip. This failure placed a resident at risk of physical harm if his extension cord power strip caught on fire due to being covered with pillows.