Skyline Nursing Center

In the surveyor’s words

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

• Immediate jeopardy, patternF580Sep 27, 2023

  Based on interview and record review, the facility failed to consult the resident's physician and resident representative when there was a significant change in the resident's physical, mental or psychosocial status for one (Resident #1) of five residents reviewed for resident rights. 1. The facility failed to ensure Resident #1's physician and psychiatrist was notified when she refused her prescribed psychotropic and blood pressure medications consistently for over a week from 09/01/23 through 09/09/23 . 2. The facility failed to ensure Resident #1's RP/family member(s) were notified when she refused her prescribed psychotropic and blood pressure medications consistently for over a week from 09/01/23 through 09/09/23. An Immediate Jeopardy was identified on 09/14/23. […]

• Immediate jeopardy, patternF600Sep 27, 2023

  Based on observations, interviews, and record reviews, the facility failed to ensure the resident has the right to be free from neglect for one (Resident #1) of five residents reviewed for neglect. 1. The facility failed to provide prescribed psychotropic medications to Resident #1, who lived with dementia and mental illness, and moved her to several different rooms in a week's time which resulted in her having increased behaviors resulting in two separate unwitnessed resident to resident altercations. 2. The facility failed to notify the MD when Resident #1 refused her psychotropic medications prior to the two resident to resident altercations. An Immediate Jeopardy was identified on 09/14/23. The IJ Template was provided to the facility on [DATE] at 1:45 PM. […]

• Immediate jeopardy, patternF607Sep 27, 2023

  Based on observations, interviews, and record reviews, the facility failed to develop and implement written policies and procedures that prohibit and prevent neglect for one (Resident #1) of five residents reviewed for neglect policies. The facility failed to provide prescribed psychotropic medications to Resident #1, who lived with dementia and mental illness, and moved her to several different rooms in a week's time which resulted in her having increased behaviors resulting in two separate unwitnessed resident to resident altercations. The facility failed to notify the MD when Resident #1 refused her psychotropic medications prior to the two resident to resident altercations. […]

• Immediate jeopardy, patternF742Sep 27, 2023

  Based on observation, interview, and record review, the facility failed to ensure a resident who displayed or is diagnosed with a mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for two (Residents #1 and #4) of five residents reviewed for psychosocial concerns. […]

• Immediate jeopardy, patternF744Sep 27, 2023

  Based on observation, interview, and record review, the facility failed to ensure a resident who displayed or was diagnosed with dementia received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental and psychosocial well-being for one (Resident #1) of five residents reviewed for dementia care. 1) The facility failed to comprehensively assess the physical, mental, and psychosocial needs of Resident #1, who had dementia, and identify the risks and/or to determine underlying causes after she had two resident-to-resident altercations where she was alleged to be the aggressor. Resident #1 was taken by the police to a behavioral health center that did not accept her because they had no knowledge she was being admitted . […]