Brookdale Skyline

In the surveyor’s words

From the most serious findings on record at Brookdale Skyline, in the surveyor’s own words.

• Actual harm, isolatedF689Dec 10, 2025

  Based on record review and interviews, the facility failed to ensure supervision and monitor assistive devices to prevent accidents for one (#2) of five residents reviewed for accidents out of seven sample residents. The facility failed to ensure staff transferred Resident #2 appropriately with a mechanical lift which resulted in a fall with major injury for the resident.Resident #2 was admitted to the facility for rehabilitation services on 10/7/25. The resident's care plan directed staff to utilize a mechanical lift (a sit to stand lift) for transfers. On 10/11/25 certified nurse aide (CNA) #1 and CNA #2 used a gait belt (a belt that fastens around the waist, used for someone with mobility issues) to transfer Resident #2 from the toilet to her wheelchair. […]

• Actual harm, isolatedF689May 25, 2023

  Based on record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for accidents out of eight sampled residents received adequate assistance and supervision to prevent an accident while toileting. Record review and interview revealed Resident #1 had multiple risk factors for falls, including impulsivity, lack of coordinator, impaired balance, and unassisted transfers, among others, and fell without injury on 4/14/23 when he attempted a transfer from his wheelchair to bed without assistance. His care plan read not to leave the resident alone in the restroom. However, on 4/22/23, the certified nurse aide (CNA) left the resident unattended on the toilet to get a clean gown. […]

• Actual harm, isolatedF600Jun 22, 2022

  Based on interviews and record review, the facility failed to take the necessary steps to ensure one (#8) of one resident was free from abuse out of 16 sample residents. Resident #8 was admitted to the facility for long term care on 12/18/19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was dependent on staff for activities of daily living which included toileting and upper and lower body dressing. The resident had both physical and verbal behavior symptoms directed towards others and had rejections related to care. The facility failed to address the behaviors to ensure resident safety (cross-reference F744 for dementia care). […]

• Actual harm, isolatedF689Mar 25, 2021

  Based on observations, record review and interviews, the facility failed ensure each resident received adequate supervision and assistance devices to prevent accidents for one (#133) of six out of 19 sample residents. Resident #133 admitted to the facility on [DATE] with a known history of falling and weakness before being admitted to the facility. The resident was identified as being high risk based on the facility fall risk assessment. The resident was not assessed for a wheelchair to be utilized for her mobility in the room. A transport chair was in her room for mobility which was utilized at the time of her fall instead of a wheelchair, which caused the resident to fall backwards due to not being able to utilize the brakes on the transport chair. […]

• No harm, potential for more than minimal, widespreadF730Apr 17, 2025

  Based 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 two of two certified nurse aides (CNA). Specifically, the facility failed to complete annual performance reviews and provide regular in-service education based on the outcome of the reviews for CNA #2 and CNA #3. Findings include: I. Facility policy and procedure The Annual Performance Planning Guide, undated, was provided by the nursing home administrator (NHA) on 4/17/25 at 4:47 p.m. It read in pertinent part, Performance planning is a critical part of the performance management process. While annual reviews are a look back, performance plans are a look forward. […]