Skyline Ridge Nursing & Rehabilitation Center

In the surveyor’s words

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

• Actual harm, isolatedF689Sep 19, 2024

  Based on observations, record review and interviews, the facility failed to ensure the residents' environment remained as free of accidents or hazards as possible to prevent falls for one (#59) of five residents reviewed for falls out of 48 sample residents. Resident #59, who had a history of falling, required the use of a sit-to-stand mechanical lift for transfers. Per staff interviews (see interviews below), the use of the sit-to stand mechanical lift required that two staff members were present during resident transfers. On the night of 7/31/24, Resident #59 was being transferred to bed by a certified nurse aide (CNA). The CNA did not have another staff member present during the transfer and the resident sustained a fall. […]

• Actual harm, isolatedF692Sep 19, 2024

  Based on observations, record review and interviews, the facility failed to ensure one (#34) of three residents out of 50 sample residents received the care and services necessary to meet their nutrition needs and to maintain their highest level of physical well-being. Resident #34 was admitted to the facility for long-term care on 6/30/24 with diagnoses of age-related osteoporosis, hypokalemia (low potassium levels in the blood), hypocalcemia (low calcium levels in the blood), hypomagnesemia (low magnesium levels in the blood), cognitive communication deficit and cerebral infarction (stroke). Upon admission, on 6/30/24, the resident weighed 103.4 pounds (lbs). The 7/2/24 nutritional evaluation determined the resident was malnourished. […]

• Actual harm, isolatedF689Mar 17, 2022

  Based on record review, observations and interviews, the facility failed to ensure four (#15, #16, #49, and #2) of five residents received adequate supervision to prevent accidents out of 40 sample residents reviewed. Specifically, the facility failed to develop and implement a person-centered care plan that identified the resident's fall risk and put effective interventions into place to reduce falls and prevent injury for Resident #15, #16 and #49. Resident #15 was identified as a fall risk within the comprehensive care plan. The facility failed to identify the resident's patterns throughout the day and put personalized and effective interventions into place to prevent falls. […]

• No harm, potential for more than minimal, widespreadF882Jan 16, 2025

  Based on interviews and record review, the facility failed to employ an infection preventionist (IP) who had completed specialized training in IP and control which had the potential to affect all residents residing in the facility at the time of the survey. Specifically, the facility failed to have a qualified IP involved with the facility's IP and control program. Findings include: I. Facility policy and procedure The Infection Preventionist policy, revised September 2022, was received from the director of nursing (DON) on 1/15/25 at 3:33 p.m. […]

• No harm, potential for more than minimal, patternF880Jan 16, 2025

  Based on records review and interviews the facility failed to maintain an effective infection prevention and control program to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease for seven (#2, #5, #6, #7, #8, #12 and #13) of 14 residents out of 14 sample residents. Specifically, the facility failed to ensure the tracking, offering and administration of the COVID-19 vaccination for Resident #2, Resident #5, Resident #6, Resident #7, Resident #8, Resident #12 and Resident #13. Findings include: I. […]