Apostolic Christian Skylines

In the surveyor’s words

From the most serious findings on record at Apostolic Christian Skylines, in the surveyor’s own words.

• Actual harm, isolatedF689Dec 21, 2023

  Based on observation, interview, and record review, the facility failed to provide safe transfer during a bath for one (R1) of three residents reviewed for transfers in a sample of three. This failure resulted in R1 being hospitalized and suffering from fractures to his right proximal humerus and C2 (cervical vertebrae). Findings include: The facility's Fall Occurrence Policy, dated 2/2/2022, documents, Policy: (Named facility) wants to create an environment that is free from accident hazards as much as possible for residents, provide supervision when needed, and assist with detecting and preventing hazardous situations. The facility's undated (Named) Transfers and Stretcher Safe Operation & Maintenance Manual documents, System Preparation (Before Transferring or Lifting): 9. […]

• No harm, potential for more than minimal, patternF656Oct 10, 2024

  Based on observation, interview, and record review, the facility failed to develop a careplan to include oxygen and edema with compression hose for four (R5, R6, R11, R43) of 15 residents reviewed for care plan development in a sample of 24. Findings include: Facility Care Plan Process, dated 3/4/24, documents, (Facility) will create a resident-centered plan of care for each skilled resident residing at the facility. 1. R6's current physician orders for October 2024 documents, Oxygen 2-4 L (liters) per NC (nasal cannula) as needed with an initial order date of 5/14/24. R6's online medical record documents R6 has Chronic Pulmonary Edema. On 10/8/24 at 1:18 PM, R6 had oxygen and an oxygen concentrator in her room. […]

• No harm, potential for more than minimal, patternF558Apr 8, 2021

  Based on observation, interview and record review, the facility failed to answer call lights in a timely manner for four of five residents (R234, R137, R136, R16) reviewed for call light wait times in a sample of 27. Findings include: A Dignity policy dated 12/20/10 states, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. This policy further states that staff should assist residents by, Promptly responding to the resident's request for toileting assistance. 1. R234's Minimum Data Set (MDS) assessment dated [DATE] documents R234 is cognitively intact and requires assistance of one person for toileting. R234's current Care Plan documents for R234 is to have staff assistance to the bathroom. On 4/5/21 at 11:18 a.m. […]

• No harm, potential for more than minimal, isolatedF559Apr 12, 2025

  Based on observation, interview, and record review, the facility failed to issue a written notice of room moves for two of three residents (R1 and R2) reviewed for room moves in a sample of 3. Findings include: The facility's Room Change Policy, undated, documents, It is the policy of (the facility) to promote a resident's right to make choices and to promptly receive written notice of a room change or change in an assigned roommate. The facility supports the resident's right to refuse a room change made for the purpose solely for the staff's convenience. B. Room Change (Transfer Room to Room). f. If the facility requests the resident to move to a different room, within the provisions of Federal and State Regulations, the facility will give prompt notice to the resident and representative. […]

• No harm, potential for more than minimal, isolatedF623Oct 10, 2024

  Based on interview and record review, the facility failed to notify resident/resident representative in writing of hospital transfers for two (R14 and R36) of two residents reviewed for hospitalization in a sample of 24. Findings include: The facility's undated Transfer to Hospital Checklist documents, A resident must have the below listed items prior to transferring to the hospital. Please check off and sign at the bottom indicating these were given. Place this form in Medical Records to be scanned into resident chart. […]