The Terraces at Skyline

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a shower chair was securely latched during bath assistance causing an avoidable fall for 1 of 3 residents (Resident 1), reviewed for accident hazard. This failure placed residents at risk for injury, adverse outcomes, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to establish a grievance policy that designated a Grievance Official (an individual responsible for overseeing the grievance process) for 2 of 2 floors (Seventh & Eighth Floor), reviewed for grievances. This failure placed residents and their representatives at risk of not having access to the required information regarding the Grievance Official, potentially hindering the facility's ability to investigate and resolve concerns effectively.

Inspectors wroteBased on interview and record review, the facility failed to provide the required Registered Nurse (RN) coverage for 1 out of 30 days (08/03/2025), reviewed for staffing. This failure placed the residents at risk for inadequate assessments, delay in care services by an RN, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitizing solution test strips were not used after expiration date and failed to keep records of the sanitizing solution test log forms for 1 of 1 kitchen (Fourth Floor Main Kitchen), and failed to ensure food items were discarded after the use-by-date in accordance with professional standards for food safety for 1 of 3 storage rooms (Seventh Floor Storage Area), reviewed for food services. These failures placed the residents at risk for food borne illness [caused by the ingestion of contaminated food or beverages] and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure infections related to initiation of antibiotic (medicine that prevents or treats infections) practices were based on the Center for Disease Control and Prevention (CDC) approved criteria for 6 of 6 months (February 2025, March 2025, April 2025, May 2025, June 2025 & July 2025), reviewed for antibiotic stewardship program. This failure placed the residents at risk of receiving or not receiving necessary antibiotics, and a diminished quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper storage, dating and labeling of respiratory equipment for 3 of 4 residents (Residents 1, 2 & 3), reviewed for respiratory care. These failures placed the residents at risk for respiratory infection, related complications, and a diminished quality of life. Findings Included . Review of the facility's policy titled, Oxygen Administration,” revised on 02/07/2024 showed, it is the policy of the facility to administer oxygen to the residents when insufficient oxygen is being carried by the blood to the tissues. Place nasal cannula (a flexible tubing that delivers oxygen through the nose) or mask in place with date written on label attached to tubing. The oxygen tubing should be changed every week with a new cannula or mask. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose expired medication in accordance with current accepted professional standards for 1 of 1 medication refrigerator (8th Floor Medication Room Refrigerator), reviewed for medication storage and labeling. This failure placed the residents at risk for receiving compromised or ineffective medications, potential unsafe medication administration, and potential adverse side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a detailed written description of the facility's water system was included in their water management program and/or appropriate personnel were included in the water management team that assessed the potential growth of Legionella (a family of micro-organisms which are naturally found in water bodies), failed to ensure an outbreak (a sudden rise in the incidence of a disease or infection) was reported for 4 of 4 residents (Residents 6, 3, 1 & 22), and failed to ensure appropriate Personal Protective Equipment (PPE- equipment wore to minimize exposure to hazards that can cause serious illnesses) was used for 2 of 7 residents (Residents 7 & 3), reviewed for infection control. These failures placed the residents, visitors, and staff at an increased risk for infection and related complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure a copy of the advance directive (a written document describing a resident's wishes for care if they became incapacitated such as a living will or Durable Power of Attorney [DPOA- a document delegating to an agent the authority to make health care decisions in case the individual delegating the authority subsequently becomes incapable to do so]) for health care was obtained from the resident/representatives who had an advance directive for 1 of 1 resident (Resident 11), reviewed for advance directive. This failure placed the resident and/or their representative at risk for losing their right to have their preferences honored regarding care

Inspectors wroteBased on interview and record review, the facility failed to ensure non-pharmacological (treating a health problem without using medications) interventions were in place for an antidepressant (medication used to treat depression -feeling loneliness and sadness) for 1 of 5 residents (Resident 3), reviewed for unnecessary medications. This failure placed the resident at risk for unidentified non-pharmacological interventions, unmet care needs, adverse side effects, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS - an assessment tool) was completed for 1 of 2 residents (Resident 2), reviewed for significant change of condition. The failure to complete an SCSA within 14 days of a significant change of condition placed the resident at risk for delayed care planning, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess 1 of 15 residents (Resident 28), reviewed for resident assessment. The failure to ensure resident assessment was completed accurately on the Minimum Data Set (MDS-an assessment tool) regarding discharge status placed the resident at risk for unidentified and/or unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop and/or implement a discharge care plan for 1 of 12 residents (Resident 15), reviewed for comprehensive care plan. This failure placed the resident at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Activities of Daily Living (ADL) assistance were consistently provided for 1 of 2 residents (Resident 2), reviewed for ADLs. The failure to provide a resident who was dependent on staff for assistance with personal hygiene and nourishment placed the resident at risk for aspiration (food and/or liquid enters the lungs instead of the stomach) and associated complications, poor hygiene, decreased self-esteem, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow a therapeutic diet and to provide education to the resident's representative regarding the risks of not following the therapeutic diet for 1 of 1 resident (Resident 2), reviewed for nutrition. This failure placed the resident at risk of unmet care needs, medical complications, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure disinfectants (cleaning products containing chemicals that kill germs) were stored properly for 1 of 1 room (room [ROOM NUMBER]), reviewed for accident hazards. This failure placed the residents at risk for potential ingestion and/or exposure to cleaning chemicals and potential negative outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Medication Regimen Review (MRR - a comprehensive assessment of resident's medications, performed by a pharmacist [a qualified professional to provide expert advice on medication management, safety, and regulatory compliance] to identify and address potential problems) was completed for 1 of 5 residents (Resident 20), reviewed for unnecessary medications. This failure placed the resident at risk of receiving unnecessary medications and a diminished quality of life. Review of the facility's policy titled, Medication Regimen Review, revised on 07/01/2024, showed, Recommendations are acted upon and documented by the facility staff and or the prescriber. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff was provided education about COVID-19 (a viral illness that causes fever, difficulty breathing or possibly death) vaccination, including risks, benefits, potential side effects, document if the vaccine was accepted and/or refused in employee record for 1 of 1 staff (Staff O), reviewed for COVID-19 immunizations. This failure placed staff and residents at risk of and exposure to illness from COVID-19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure bed rails (bed enablers) were properly secured and maintained for safety for 2 of 2 residents (Residents 9 & 29), reviewed for accident hazards. This failure placed the residents at risk for injury and/or entrapment.

Inspectors wroteBased on interview and record review, the facility failed to ensure incident of unexpected death was investigated timely for 1 of 2 residents (Resident 1), reviewed for abuse/neglect investigations. This failure placed the residents at risk for repeated incidents, unidentified abuse/neglect, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure that direct care staffing information was submitted timely to the Centers for Medicare and Medicaid Services (CMS), for 1 of 1 quarter (Quarter 4) for the fiscal year 2023 (which included October 2023 through December 2023), reviewed for Payroll Based Journal (PBJ- mandatory reporting of staffing information based on payroll data) submission. This failure caused the CMS to have inaccurate data related to nursing home staffing levels and had the potential to impact resident care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a homelike dining environment was provided during 2 of 3 dining observations to 6 of 8 residents (Residents 3, 8, 235, 19, 14 & 13). The failure to ensure licensed nurses refrained from administration of medications during resident meals placed the residents at risk for diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide the required Registered Nurse (RN) coverage for 6 of 92 days (10/07/2023, 10/08/2023, 10/15/2023, 10/21/2023, 10/22/2023 & 11/04/2023), reviewed for sufficient and competent nurse staffing. This failure placed the residents at risk for inadequate assessments, delay in care services by an RN, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately label/store medications/biologicals (diverse group of medicines made from natural sources) and/or medical supplies for 2 of 2 medication rooms (Seventh Floor and Eighth Floor Medication Rooms), reviewed for medication storage. This failure placed the residents at risk for receiving compromised and ineffective medications and medical supplies.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired food items were discarded after the expiration date or use by date and failed to have a working thermometer in accordance with professional standards for food safety for 1 of 5 refrigerators (Kitchen Walk-In Refrigerator). These failures placed the residents at risk for foodborne illness (caused by the ingestion of contaminated food or beverages).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hand hygiene practices were followed during meal tray pass for 1 of 4 staff (Staff L), reviewed for infection control. In addition, the facility failed to follow infection control practices for 3 of 10 residents (Residents 6, 235 & 18), reviewed for medication administration. These failures placed the residents, visitors, and staff at an increased risk for infection and related complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure informed consent for an antidepressant (medication used to treat depression) was completed before administration for 1 of 5 residents (Resident 4), reviewed for unnecessary medications. This failure placed the resident and/or their representative at risk of not being fully informed of the risks and benefits before making decisions about medications before administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents were evaluated and assessed, and/or a physician order was obtained for safe administration of medication for 2 of 2 residents (Residents 235 & 20), reviewed for self-medication administration. This failure placed the residents at risk for inaccurate and unsafe medication administration, adverse side effects, medical complications, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide a written transfer/discharge notice to the resident and/or their representative for 1 of 1 resident (Resident 12), reviewed for hospitalization. This failure placed the resident and/or their representative at risk for not having an opportunity to make informed decisions about transfers/discharges.

Inspectors wroteBased on interview and record review, the facility failed to ensure bed hold (the opportunity to reserve a resident's current occupied bed while out of the facility to ensure their room was available when ready to return) notice was offered for 1 of 1 resident (Resident 12), reviewed for hospitalization. This failure placed the resident or their representative at risk for lack of knowledge regarding the right to hold their bed while in the hospital.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS- an assessment tool) was completed timely for 1 of 1 resident (Resident 9), reviewed for significant change in condition. The failure to complete a SCSA within 14 days placed the resident at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident-centered care and treatment were provided in accordance with professional standards of practice when the facility failed to ensure consistent communication and collaboration of care occurred between the facility and hospice care for 1 of 1 resident (Resident 9), reviewed for hospice services. This failure placed the resident at risk of not receiving necessary comfort care services, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to thoroughly assess and stage a pressure ulcer (localized damage to the skin and underlying tissue from prolonged pressure, friction, or shear, causing pain) at onset and weekly and maintain clear and accurate wound documentation for a pressure ulcer for 1 of 1 resident (Resident 9), reviewed for pressure ulcer. This failure placed the resident at risk for deterioration of their pressure ulcer and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain, label/date, and properly store oxygen tubing/supplies and nasal cannula (flexible tubing that sits inside the nose and delivers oxygen) for 2 of 2 residents (Residents 23 & 20), reviewed for respiratory care. This failure placed the residents at risk for unmet care needs, respiratory infections, and related complications.

Inspectors wroteBased on interview and record review, the facility failed to initiate and/or thoroughly investigate incidents for 3 of 3 residents (Residents 1, 2 & 3), reviewed for incident investigations. The failure to initiate and conduct thorough investigations placed the residents at risk for unidentified abuse/neglect, repeated incidents, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the daily nurse staffing form was accurately posted and updated with actual hours worked for each shift for 30 out of 30 days reviewed for sufficient and competent staffing. This failure placed the residents, the residents' representatives, and visitors at risk of not being fully informed of the current staffing levels and census information.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess 4 of 6 residents (Residents 18, 11, 12 and 22) reviewed for Minimum Data Set (MDS) assessment. The failure to ensure accurate assessments regarding hospice, antipsychotic medication, pressure ulcers, dental and injections placed the residents at risk for unidentified or unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure baseline care plans were developed within 48 hours of admission to ensure continuity of care and/or to ensure a summary/copy of the baseline care plan was provided to the residents and/or their representatives for 7 of 9 residents (Residents 12, 79, 378, 379, 128, 329 & 330) reviewed for baseline care plan. This failure resulted in the residents not being informed of their initial plan for delivery of care services and placed the residents at risk for unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive care plan (CP) for 5 of 8 residents (Residents 11, 18, 3,12 and 22) reviewed for comprehensive CPs. The failure to develop CPs for residents' limited range of motion, medication, siderails, air mattresses, activities of daily Living (ADL) and pain, placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foods stored in the refrigerator and kitchen storage were labeled/dated when opened, and discard food products on or before the use by date in 1 of 3 refrigerators (main kitchen walk-in refrigerator) and 1 of 1 kitchen dry storage. These failures placed the residents at risk for developing food borne illness (caused by ingestion of contaminated food or beverages).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure hand hygiene was performed between glove change for 1 of 1 resident (Resident 12) reviewed for wound care, and 1 of 6 residents (Resident 328) reviewed for medication pass. In addition, the facility failed to ensure components of an effective infection control program to include: [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement an antibiotic stewardship program (ASP) to promote appropriate use of antibiotics, failed to obtain/analyze and make antibiotic resistance patterns based on laboratory data and/or use of an antibiogram (antibiogram-a set of information usually in the form of a table reviewing the proportion of individual bacterial pathogens sensitive to different antimicrobial agents or medicine), failed to provide feedback to prescribing providers on their antibiotic use and compliance with the ASP, and failed to share ongoing analysis of surveillance data with the infection control committee. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a copy of the Advance Directive (AD) was obtained from the residents/representatives who have an AD in place and ensure a copy was readily available in the medical records for 2 of 6 residents (Residents 22 and 6) reviewed for advance directives. This failure placed the residents at risk of losing their right to have their preferences and choices honored regarding emergent and end-of-life care situations.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Notice of Medicare (national health program) Non-Coverage (NOMNC) was issued at least two calendar days before Medicare services ended and/or inform residents of their potential liability for payment for 1 of 6 sampled residents (Resident 178) reviewed for liability notice and coverage. This failure placed the resident and/or their representative at risk for not having adequate information to make financial decisions related to continued stay in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of abuse were reported to the State Agency (SA) within the required timeframe for 2 of 3 residents (Residents 11 & 78) reviewed for abuse. This failure placed the residents at risk for further abuse and lack of protection due to unrecognized abuse/neglect.

Inspectors wroteBased on interview and record review, the facility failed to identify allegations of abuse and ensure investigations were initiated and/or thoroughly investigated for 2 of 3 residents (Residents 11 and 78) reviewed for abuse investigation. This failure placed the residents at risk for repeated incidents, unidentified abuse, and inappropriate corrective actions.

Inspectors wroteBased on interview and record review, the facility failed to conduct a timely significant change in status Minimum Data Set (MDS) assessment for 1 out of 2 residents (Resident 18) reviewed for significant change in status assessment. The failure to complete a significant change in status assessment within 14 days placed the resident at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to complete and transmit resident assessment data to the Centers for Medicare & Medicaid Services (CMS) within the required timeframes for 1 of 3 residents (Resident 4) reviewed for timeliness in completing and transmitting discharge tracking records. This failure placed the resident at risk of unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents with limited range of motion (ROM) received appropriate treatment and services to increase ROM and/or to prevent further decrease in ROM for 2 of 3 residents (Residents 6 and 11) reviewed for ROM services. The failure to consistently assess, develop, implement, and/or revise individualized care plan interventions related to ROM placed the residents at risk for decline in functional ability and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure necessary respiratory care and services were provided in accordance with professional standards of practice about the use and proper care of Continuous Positive Airway Pressure (CPAP - a therapy that pumps air into the lungs through the nose and mouth that keeps the airway open) for 1 of 1 resident (Resident 329) reviewed for respiratory care. In addition, the facility failed to ensure a physician's order for use of O2 was accurate and/or followed according to resident's needs. These failures placed the resident at risk for respiratory infections and related complications.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess, obtain physician orders, provide risks/benefits of use, and develop care plans to meet the needs of 2 of 3 residents (Residents 18 and 3) for whom siderails devices were reviewed. This failed practice placed the residents at risk for injury.

Inspectors wroteBased on interview and record review, the facility failed to obtain registry verification to ensure staff met competency evaluation requirements before allowing to serve as a nurse aide for 1 of 3 staff (Staff M) reviewed for nursing aide registry. The facility's failure to receive registry verification that the individual had met competency evaluation requirements placed the residents at risk for abuse and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were labeled and dated for 1 of 2 medication storage rooms (7th floor medication room) reviewed for medication storage. This failure placed the residents at risk for receiving compromised and/or ineffective medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and resident representatives were provided education about COVID-19 vaccination, including risks, benefits, potential side effects, document if the vaccine was accepted and/or refused in the medical record, and document as to why the vaccine was refused for 1 of 5 residents (Resident 330) reviewed for COVID-19 immunizations. This failure denied the resident and/or their representative of the right to make informed decisions.

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nursing Assistants (CNAs) had the required abuse and neglect and/or dementia management training annually for 1 of 3 staff (Staff W). This failure placed residents at risk for potential negative outcomes and unmet care needs.