Skylake Post Acute

In the surveyor’s words

From the most serious findings on record at Skylake Post Acute, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684May 11, 2026

  Based on record review, observations and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for two (#4 and #16) of seven sample residents reviewed for change of condition assessments out of 14 sample residents. Resident #4 was admitted on [DATE] with diagnoses of dementia, severe, with other behavioral disturbance, pancytopenia (lower than normal count of all three types of blood cells), and protein-calorie malnutrition.On 12/10/25 the facility documented that Resident #4 had decreased oral and fluid intake. On 12/11/25 Resident #4 sustained an unwitnessed fall, where his mattress was found partially off the bed frame. […]

• Immediate jeopardy, isolatedF600Jun 14, 2024

  Based on interviews and record review, the facility failed to protect and keep residents safe from abuse and neglect for two (#2 and #11) of three residents reviewed for abuse out of 16 sample residents. A review of resident records and interviews with staff revealed the facility failed to take steps to develop and implement effective interventions to create an environment in the memory care-secure unit that protected residents from resident-to-resident abuse. RESIDENTS #6 AND #2 On 4/8/24, Resident #6 was admitted to the facility's memory care-secured unit. It was known to the facility, before the resident's admission, that he was displaying an increase in unsafe wandering and physical and verbal aggression toward other residents at the facility where he had previously resided. […]

• Immediate jeopardy, isolatedF689Sep 16, 2022

  Based on interviews, record review, and facility policy review, the facility failed to supervise residents that required supervision while smoking, ensure residents assessed to wear a smoking apron were provided one, and failed to ensure independent and supervised residents had a safe place to discard cigarette butts after smoking for 3 of 3 residents reviewed for smoking (R #110, R #74, and R #21). Failed to ensure Resident #74 smoked in designated area, and used the trash can It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. […]

• Actual harm, isolatedF600Apr 27, 2022

  Based on interviews and record review, the facility failed to take the necessary steps to ensure two (#4 and #5) of two residents were free from resident to resident abuse out of nine sample residents. Resident #4 was admitted to the facility for long term care on 2/18/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required limited assistance with locomotion on the unit and utilized a walker and wheelchair for mobility. Since admission to the facility on [DATE], the resident wandered around the unit, including into other resident rooms that put him at risk of a resident to resident altercation. The facility failed to address the wandering and provide appropriate person-centered interventions (cross-reference F744 for dementia care). […]

• Actual harm, isolatedF744Apr 27, 2022

  Based on interviews and record review, the facility failed to ensure one (#4) of one resident reviewed for dementia care of nine sample residents, received the appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being. Resident #4 was admitted to the facility for long term care on 2/18/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required limited assistance with locomotion on the unit and utilized a walker and wheelchair for mobility. Since admission on 2/18/22, the resident wandered around the unit. The facility failed to address the wandering and provide appropriate personalized-centered interventions. […]