Skyline Transitional Care Center

In the surveyor’s words

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

• Actual harm, isolatedF689May 12, 2022

  Based on policy review, record review, review of Incidents and Accidents (I&A) reports and staff interview, it was determined the facility failed to ensure adequate supervision of residents to prevent falls. This was true for 1 of 3 residents (Resident #24) reviewed for falls. This resulted in harm to Resident #24 when, after a fall she sustained a puncture wound and hematoma (bruise) to the back part of her head, which required application of surgical staples to close the wound. Findings include: The facility's Fall Management System policy and procedure, revised 6/2018, documented residents would be provided with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. […]

• Actual harm, isolatedF600Jan 24, 2022

  Based on policy review, resident and staff interview, review of Incident and Accident reports (I&As), and record review, it was determined the facility failed to ensure residents were free from abuse and neglect. This was true for 3 of 15 Residents (#4, #23, and #36) reviewed for potential abuse and/or neglect. Resident #4 experienced neglect resulting in emotional distress and mental anguish when the facility failed to ensure he was provided with an alternative communication system to enable him to effectively express himself. […]

• Actual harm, isolatedF686Jan 24, 2022

  Based on record review and staff interview, it was determined the facility failed to ensure a resident received appropriate care to prevent and treat pressure ulcers. This was true for 1 of 3 residents (Resident #12) reviewed for pressure ulcer care. This deficient practice resulted in harm to Resident #12 when she developed new Stage 3 and Stage 4 pressure ulcers, and the pressure ulcer she was admitted with, worsened. Findings include: The National Pressure Injury Advisory Panel website, accessed on 1/31/22, defined pressure ulcer staging as follows: Stage 2 - Partial-thickness skin loss with exposed dermis (thick layer of living tissue below the epidermis which forms the true skin, containing blood capillaries, nerve endings, sweat glands, hair follicles, and other structures). […]

• Actual harm, isolatedF689Jan 24, 2022

  Based on policy review, record review, review of Incidents and Accidents (I&A) reports and staff interview, it was determined the facility failed to ensure adequate supervision of residents to prevent falls. This was true for 1 of 3 residents (Resident #24) reviewed for falls. This resulted in harm to Resident #24 when, after a fall she sustained a puncture wound and hematoma (bruise) to the back part of her head, which required application of surgical staples to close the wound. Findings include: The facility's Fall Management System policy and procedure, revised 6/2018, documented residents would be provided with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. […]

• No harm, potential for more than minimal, widespreadF812Mar 7, 2025

  Based on observation and staff interview, it was determined the facility failed to ensure the cleaning and sanitation of kitchen cookware. This deficiency had the potential to affect the 64 residents who consumed food prepared by the facility. This placed residents at risk for potential foodborne illnesses and adverse health outcomes due to contaminated food services equipment. Findings include: The Food Drug Administration (FDA) Code Section 4-602.12 Cooking and Baking Equipment documented: Food-contact surfaces of cooking equipment must be cleaned to prevent encrustations that may impede heat transfer necessary to adequately cook food. […]