Skyline Heights Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Skyline Heights Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Nov 19, 2025

  Based on interview and record review, the facility failed to document the wound identified by the physician, to properly assess during skin checks, treat, and monitor a facility acquired diabetic ulcer for a resident with a history of diabetes, neuropathy, and sores on the feet, for 1 (#1) of 13 sampled residents. The deficient practice contributed to the deterioration of the wound, which resulted in the resident's right great toe being amputated. Findings include: On 11/4/25 at 11:45 a.m., the Administrator, Chief Nursing Officer, and Corporate Resource Nurse, were notified that an Immediate Jeopardy existed in the area of F684, Quality of Care, related to the failure to identify, monitor, and treat a diabetic ulcer for a resident with a history of neuropathy, diabetes, and sores on the… […]

• Actual harm, patternF689Feb 2, 2023

  Based on interview and record review, the facility failed to prevent falls with significant injuries requiring residents to go to the emergency department, for 3 (#s 47, 229, and 279), of 5 sampled residents; and, #47 had a significant skin tear; #279 had multiple falls and injury to her head; #229 broke open a knee incision and had surgery to clean and repair the incision, and resident #47 was transferring himself to the bathroom independently, due to a lack of staff assistance at the time of the fall. The facility also failed to prevent a fall with fracture to a resident's patella, for 1 (#55), and failed to protect a resident from significant burns, for 1 (#24), of 8 sampled residents. Findings include: 1. […]

• Actual harm, patternF725Feb 2, 2023

  Based on observation, interview, and record review, the facility failed to provide an adequate number of staff to provide timely responses to requests for care for 14 (#s 3, 15, 20, 21, 26, 27, 29, 36, 37, 56, 229, 230, 235, and 429) of 15 sampled residents, which included several residents dependent on nursing staff for care. This failure caused a decrease in bathing for resident #21, resident #229 and #26 to have episodes of incontinence, resident #230 to have a decrease in bathing and to receive her pain medications late, resident #235 to have a decrease in bathing and had the potential to negatively affect care for all residents of the facility. It was identified some residents were waiting over an hour to receive assistance from staff. […]

• Actual harm, isolatedF686Jul 16, 2026

  Based on interview and record review, the facility staff failed to prevent, identify, assess, measure, document, and implement necessary interventions for the prevention of avoidable pressure ulcers that developed shortly after a resident's admission, for 1 (#1) of 18 sampled residents. The resident had one Stage lll on his heel and one Stage lll on the gluteal area, which were both avoidable. The deficient practice placed the resident at risk of having a deterioration of the pressure ulcer. […]

• Actual harm, isolatedF656Nov 19, 2025

  Based on interview and record review, the facility failed to ensure a resident's comprehensive care plan contained information related to the diagnosis, care, and monitoring of a diabetic ulcer on a resident with a history of diabetes and neuropathy for 1 (#1) of 13 sampled residents. Findings include:Review of a facility document titled Nurse/Provider Communication Form, dated 1/23/24, showed the resident presented with an open friction area to the right great toe and a scabbed area to the right middle toe.Review of a document titled, Wound Tracker Form, dated 6/29/24, showed Resident #1 was seen by wound care that day, and notes showed the resident had wounds on the Right distal 4th and 5th toe, both due to being cut while clipping his nails. […]