Skyline Nursing & Rehabilitation

In the surveyor’s words

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

• Actual harm, isolatedF760Dec 4, 2025

  Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure one (1) of 24 sampled residents were free of significant medication errors, Resident #6. This failure resulted in harm to Resident #6 requiring emergency care at the hospital. The findings included: Resident #6's clinical record listed diagnoses which included but not limited to other encephalopathy, Alzheimer's disease, vascular dementia, and malignant neoplasm of sigmoid colon.Resident #6's most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 09/08/25 assigned the resident a Brief Interview for Mental Status (BIMS) score of 3 out of 15 in section C, cognitive patterns. […]

• No harm, potential for more than minimal, isolatedF580Dec 4, 2025

  Based on staff interview, clinical record review, and facility document review, the facility staff failed to notify a medical provider of a change in condition for (3) three of (24) twenty-four sampled residents. Resident #5, Resident #39, and Resident #51. The findings included:1.For Resident #5 the facility staff failed to notify a medical provider of the resident's transfer to a higher level of care on 4/22/25. Resident #5's diagnosis list indicated diagnoses, which included, but not limited to Chronic Kidney Disease-Stage 4, Hypertension, Chronic Obstructive Pulmonary Disease, Atherosclerotic Heart Disease, Chronic Respiratory Failure with Hypoxia, and Diabetes Mellitus Type 2. […]

• No harm, potential for more than minimal, isolatedF628Dec 4, 2025

  Based on staff interview, clinical record review, and facility document review, facility staff failed to provide notification to the representative of the office of the local state long-term care ombudsman of a resident transfer to a higher level of care for (1) one of (24) twenty-four sampled residents. Resident #9. The findings included:For Resident #9, the facility staff failed to notify the office of the state long-term care ombudsman of a transfer/discharge to a higher level of care on 10/22/25. Resident #9's diagnosis list indicated diagnoses that included, but were not limited to, History of Falling, Age-Related Cognitive Decline, Osteoarthritis, Restlessness and Agitation, and Unspecified Fracture of Upper End of Left Humerus. […]

• No harm, potential for more than minimal, isolatedF684Dec 4, 2025

  Based on staff interview, clinical record review and facility document review, facility staff failed to process a medical provider order for (1) one of (20) twenty sampled residents, Resident #4 and the facility staff failed to follow physician orders for (1) one of (24) twenty-four sampled residents Resident #39. The findings included: 1. For Resident #4, the facility nursing staff failed to process a provider order for the medication Fluticasone Propionate inhaler. This provider ordered this medication on 11/26/25 and the order was not processed until 12/01/25. […]

• No harm, potential for more than minimal, isolatedF688Dec 4, 2025

  Based on observations, staff interview, clinical record review, and facility document review, the facility staff failed to provide services and/or treatment to prevent further decrease in range of motion, including the provision of equipment for limited range of motion for (1) one of (24) twenty-four sampled residents. Resident #10. The findings included:For Resident #10, the facility staff failed to provide a right knee brace as ordered by a medical provider to prevent abduction and external rotation of the right hip for contracture management. […]