Inspection Reports for
Skylake Post Acute
12080 BELLAIRE WAY, THORNTON, CO, 80241-3600
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
11.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
117% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Routine
Deficiencies: 10
Date: Dec 1, 2025
Visit Reason
Routine state inspection survey of a nursing home facility to assess compliance with regulatory requirements including resident care, medication management, food safety, infection control, and hospice services.
Findings
The facility was found deficient in multiple areas including resident dignity and privacy, personal funds management, fall prevention interventions, trauma-informed care, behavioral health care, medication storage and labeling, food safety practices, hospice communication and documentation, and infection control program implementation.
Deficiencies (10)
F 0550: The facility failed to ensure resident privacy and staff announcing themselves before entering rooms, causing distress to residents.
F 0569: The facility failed to notify Medicaid residents or their representatives when personal funds accounts approached eligibility limits.
F 0689: The facility failed to consistently implement fall prevention interventions for a high-risk resident, leading to multiple falls with injury.
F 0699: The facility failed to provide trauma-informed, culturally competent care for a resident with a history of sexual abuse and trauma.
F 0740: The facility failed to document person-centered behavioral health interventions and non-pharmacological approaches prior to administering PRN anti-anxiety medication.
F 0761: The facility failed to properly label, date, and remove expired medications and vaccines in medication rooms, carts, and refrigerators.
F 0812: The facility failed to ensure food service staff wore beard nets, performed proper hand hygiene, and labeled and dated food items in refrigerators and freezers.
F 0813: The facility failed to implement safe storage and monitoring of foods brought in by visitors in residents' personal refrigerators, including temperature monitoring and removal of outdated food.
F 0849: The facility failed to establish and maintain a communication process documenting hospice care and services provided, with incomplete hospice documentation in resident records.
F 0880: The facility failed to maintain an effective infection prevention and control program, including an outdated and non-specific water management plan for legionella control.
Report Facts
Residents reviewed for personal funds accounts: 71
Residents reviewed for accidents/hazards: 71
Residents reviewed for trauma-informed care: 71
Residents reviewed for behavioral health care: 71
Residents reviewed for hospice care: 71
Expired COVID-19 vaccine vials: 8
Expired influenza vaccine vials: 9
Missing refrigerator temperature logs: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | LPN | Interviewed regarding fall interventions and medication storage |
| Director of Nursing | DON | Interviewed regarding multiple findings including fall prevention, trauma-informed care, medication management, hospice communication, and infection control |
| Nursing Home Administrator | NHA | Interviewed regarding personal funds management, food safety, and hospice services |
| Dietary Supervisor | DS | Interviewed regarding food safety and hygiene practices |
| Maintenance Director | MTD | Interviewed regarding water management and legionella control |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Dec 1, 2025
Visit Reason
The inspection was conducted to assess compliance with regulations regarding the management of residents' personal funds accounts, specifically notification requirements when account balances approach Medicaid eligibility limits.
Findings
The facility failed to notify two Medicaid-funded residents or their legal representatives when their personal funds accounts reached $200 less than the eligibility resource limit. This issue was identified through record review and staff interviews.
Deficiencies (2)
F 0569: The facility failed to notify Resident #175 or her legal representative when the personal funds account balance reached $200 less than the Medicaid eligibility resource limit. The account balance was $1,915.07 with no documentation of notification.
F 0569: The facility failed to notify Resident #45 or her legal representative when the personal funds account balance reached $200 less than the Medicaid eligibility resource limit. The account balance was $1,892.06 with no documentation of notification.
Report Facts
Residents reviewed for personal funds accounts: 5
Residents affected: 2
Sample residents: 71
Account balance Resident #175: 1915.07
Account balance Resident #45: 1892.06
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | Interviewed regarding confusion about Medicaid fund limits and notification procedures |
Inspection Report
Routine
Deficiencies: 2
Date: May 7, 2025
Visit Reason
The inspection was conducted to assess the facility's infection prevention and control program compliance, focusing on staff adherence to personal protective equipment (PPE) use and wound care procedures.
Findings
The facility failed to ensure staff wore appropriate PPE when providing direct care to a resident on enhanced barrier precautions and did not follow proper infection control measures during wound care, including failure to sanitize equipment and maintain a clean working surface.
Deficiencies (2)
F 0880: The facility failed to ensure staff wore appropriate PPE when providing direct care to a resident on enhanced barrier precautions, including failure to wear gowns during care.
F 0880: Staff failed to follow infection control measures during wound care, including not sanitizing scissors and tape measure and placing wound care supplies on an unclean surface.
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jun 14, 2024
Visit Reason
The inspection was conducted due to complaints and allegations of failure to inform residents' representatives, failure to protect residents from abuse and neglect, failure to timely report suspected abuse, and failure to have a hospital transfer agreement.
Complaint Details
The complaint investigation revealed failures in informing resident representatives, protecting residents from abuse, timely reporting and investigating injuries of unknown origin, and lacking hospital transfer agreements.
Findings
The facility failed to ensure Resident #1's legal representative was informed of care plan meetings and changes in condition. The facility failed to protect residents from resident-to-resident abuse resulting in serious injury to Resident #2. The facility failed to timely report an injury of unknown origin (bite wound) and failed to investigate the allegation thoroughly. The facility also lacked a hospital transfer agreement with a local hospital.
Deficiencies (5)
F 0552: The facility failed to inform Resident #1's legal representative in advance of care plan meetings, upcoming podiatry and dental services, and changes in the resident's condition including falls.
F 0600: The facility failed to protect residents from abuse and neglect, resulting in immediate jeopardy due to resident-to-resident physical abuse causing severe injuries to Resident #2.
F 0609: The facility failed to timely report an allegation of an injury of unknown origin (bite wound) to the State oversight agency within 24 hours and failed to investigate the allegation thoroughly.
F 0610: The facility failed to thoroughly investigate an allegation of physical abuse related to a bite wound and failed to monitor the resident to prevent repeated injury.
F 0843: The facility failed to have a written hospital transfer agreement with one local area hospital to ensure timely admission when transfer was medically appropriate.
Report Facts
Residents reviewed: 16
Residents affected: 3
Date survey completed: Jun 14, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Witnessed Resident #6 assaulting Resident #2 and reported incident |
| LPN #2 | Licensed Practical Nurse | Nurse who was asked to assess Resident #1's bite wound |
| LPN #3 | Memory Care Unit Manager | Interviewed regarding Resident #1's bite wound and care conference notification |
| DON | Director of Nursing | Interviewed regarding care conference scheduling, abuse incidents, and bite wound investigation |
| HRN | Hospice Registered Nurse | Reported and assessed Resident #1's bite wound |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jan 9, 2024
Visit Reason
The inspection was conducted to investigate multiple complaints and grievances filed by residents and their representatives regarding unresolved grievances, unsafe mechanical lift transfers, long call light response times, and failure to prevent elopement.
Complaint Details
The investigation was complaint-driven based on multiple grievances filed by residents and their representatives regarding unresolved complaints about call light response times, unsafe mechanical lift transfers, missing property, medication issues, and failure to follow up on grievances. The complaints were substantiated with evidence of inadequate grievance documentation, unsafe transfer practices, and failure to prevent elopement.
Findings
The facility failed to properly document and resolve resident grievances, ensure timely call light responses, safely transfer residents using mechanical lifts with adequate staffing, prevent elopement risks, maintain staff competencies, and provide menus that met residents' dietary needs. Several grievances lacked documented resolution and follow-up, and staff were inadequately trained on grievance processes and mechanical lift use.
Deficiencies (5)
F585: The facility failed to file and resolve grievances, inform residents of outcomes, and ensure staff were trained on grievance procedures. Call lights were not answered timely.
F689: The facility failed to ensure staff were trained and competent in safe mechanical lift transfers and failed to implement effective interventions to prevent elopement of a cognitively impaired resident.
F726: The facility failed to ensure nursing staff demonstrated competencies necessary to care for residents, including safe transfers, respiratory equipment use, and hand hygiene.
F730: The facility failed to complete annual performance reviews and provide in-service education for several certified nurse aides.
F803: The facility failed to ensure menus met residents' nutritional needs and failed to serve prescribed soaked dinner rolls to residents on modified diets.
Report Facts
Residents affected by grievance deficiencies: 7
Residents on dysphagia diets without prescribed soaked dinner rolls: 16
Number of grievances reviewed: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse manager #1 | Nurse Manager | Named in findings related to failure to document grievances and instruct staff on grievance process; instructed CNA #5 to perform one-person mechanical lift transfers. |
| CNA #5 | Certified Nurse Aide | Performed unsafe one-person mechanical lift transfers; agency staff without orientation; resigned due to poor staffing and unsafe conditions. |
| Resident #19's representative | Certified Nurse Aide (not employed by facility) | Reported unsafe one-person mechanical lift transfers and filed grievances on behalf of Resident #19. |
| Nursing Home Administrator | NHA | Acknowledged gaps in staff competency checks and grievance documentation; provided performance improvement plan. |
| Director of Nursing | DON | Discussed importance of two-person mechanical lifts and staff competency; confirmed unsafe one-person transfers. |
| Cook #1 | Cook | Reported changes in diet orders affecting residents on dysphagia diets. |
| Nutrition Services Director | NSD | Provided dietary staff education on modified textures and diet extensions. |
Inspection Report
Routine
Deficiencies: 17
Date: Jan 9, 2024
Visit Reason
Routine state inspection survey of the nursing home facility to assess compliance with regulatory requirements including resident care, safety, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to properly handle and resolve resident grievances, failure to report abuse allegations timely, unsafe use of mechanical lifts for resident transfers, inadequate respiratory care for a resident using CPAP, lack of staff competency and training in key areas, failure to provide appropriate dementia care and meaningful activities, failure to serve food at proper temperatures and according to prescribed diets, failure to maintain infection control practices including PPE use and housekeeping, failure to provide required immunizations, failure to maintain laundry equipment safely, and failure to provide required staff training on abuse prevention and dementia care.
Deficiencies (17)
F585: The facility failed to ensure grievances were filed, documented, resolved, and communicated to residents and representatives in a timely and satisfactory manner.
F609: The facility failed to report an allegation of abuse within 24 hours to the State Survey Agency for one resident.
F689: The facility failed to ensure safe use of mechanical lifts, allowing one-person transfers that risk resident injury.
F695: The facility failed to provide appropriate respiratory care for a resident using CPAP, including lack of physician orders and failure to use distilled water.
F726: The facility failed to ensure nursing staff demonstrated competency in resident care skills including transfers, respiratory care, and hand hygiene.
F730: The facility failed to complete annual performance reviews and provide in-service education for certified nurse aides.
F744: The facility failed to provide appropriate dementia care and meaningful activities for residents with dementia in the secure unit.
F803: The facility failed to ensure menus met residents' nutritional needs and failed to serve prescribed diet items such as soaked dinner rolls for texture modified diets.
F804: The facility failed to serve food at palatable temperatures and failed to monitor food temperatures after service.
F806: The facility failed to provide food and beverages that accommodated resident preferences and failed to provide snacks and beverages between meals as requested.
F812: The facility failed to maintain sanitary food handling practices including hand hygiene and glove use, and failed to discard expired food items in kitchen and resident unit refrigerators.
F880: The facility failed to maintain an effective infection control program including proper PPE use for COVID-19 positive residents and proper housekeeping cleaning and disinfectant contact times.
F883: The facility failed to offer recommended pneumococcal vaccinations to a resident as per CDC guidelines.
F908: The facility failed to keep laundry dryer lint traps and compartments clean, creating a fire hazard.
F943: The facility failed to ensure nurse aides received required annual abuse prevention, identification, and reporting training.
F947: The facility failed to ensure nurse aides received required education in dementia care and abuse prevention.
F949: The facility failed to ensure clinical staff received training on behavioral health and dementia management consistent with facility assessment.
Report Facts
Residents affected by grievance deficiencies: 7
Residents sample size: 54
Expired yogurt containers: 9
Staff trained in abuse prevention: 25
Staff trained in dementia care: 21
Certified nurse aides without annual performance review: 4
Certified nurse aides without 12 hours annual training: 4
Residents with dementia reviewed: 10
Residents with food preferences not met: 2
Residents with pneumonia vaccine deficiency: 1
Facility dryers with lint buildup: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse manager #1 | Nurse Manager | Named in grievance and mechanical lift transfer deficiencies |
| CNA #5 | Certified Nurse Aide | Named in mechanical lift transfer deficiency and staff interview |
| Nurse manager #2 | Nurse Manager | Named in dementia care observations and interviews |
| CNA #4 | Certified Nurse Aide | Named in grievance, dementia care, and infection control observations |
| CNA #6 | Certified Nurse Aide | Named in dementia care and staff training deficiencies |
| CNA #1 | Certified Nurse Aide | Named in mechanical lift transfer deficiency and staff interview |
| Nursing Home Administrator | Administrator | Named in multiple interviews and follow-up plans |
| Director of Nursing | Director of Nursing | Named in multiple interviews and follow-up plans |
| Infection Preventionist | Infection Preventionist | Named in infection control observations and follow-up |
| Nutritional Services Director | Nutrition Services Director | Named in food service deficiencies and interviews |
| Housekeeping Assistant Manager | Housekeeping Assistant Manager | Named in infection control and housekeeping deficiencies |
| Housekeeping Supervisor | Housekeeping Supervisor | Named in infection control and housekeeping deficiencies |
| Maintenance Director | Maintenance Director | Named in laundry equipment deficiencies |
| Corporate Nurse Consultant | Corporate Nurse Consultant | Named in multiple interviews and follow-up plans |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 9, 2023
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at Skylake Post Acute facility.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Sep 16, 2022
Visit Reason
The inspection was conducted to investigate complaints related to resident privacy during care, failure to complete required mental health screenings, unsafe smoking practices, and food safety violations.
Complaint Details
The complaint investigation included issues of privacy violation during care, failure to complete required mental health screenings, unsafe smoking practices leading to immediate jeopardy, and food safety violations including improper storage and contamination risks.
Findings
The facility failed to ensure resident privacy during incontinence care, did not complete a required Level II PASRR screening after a new mental illness diagnosis, failed to supervise residents requiring supervision while smoking leading to immediate jeopardy, and failed to maintain food safety standards including proper food storage, labeling, and sanitation.
Deficiencies (4)
F 0583: The facility failed to provide full privacy for Resident #117 during incontinence care due to a privacy curtain that did not fully enclose the resident's area.
F 0644: The facility failed to complete a Level II PASRR screening for Resident #17 after a new diagnosis of PTSD in 2019, affecting the ability to meet the resident's mental health needs.
F 0689: The facility failed to supervise residents requiring supervision while smoking, failed to ensure smoking aprons were used, and allowed unsafe smoking practices that posed immediate jeopardy to resident health or safety for Residents #110, #74, and #21.
F 0812: The facility failed to store, label, and date food properly, allowed spoiled food to remain in stock, maintained a malfunctioning refrigerator on Arbor Unit with unsafe food storage, failed to clean an ice chest after contamination, and failed to cover food during transport to residents.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 174
Residents affected: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in smoking supervision deficiency and resident #110 smoking incident |
| CNA #4 | Certified Nursing Assistant | Named in privacy curtain and smoking supervision deficiencies |
| RN #4 | Registered Nurse Unit Manager | Named in smoking supervision deficiency |
| Assistant Dietary Manager | Named in smoking supervision and food safety deficiencies | |
| Director of Nursing | DON | Named in privacy curtain, PASRR, and smoking supervision deficiencies |
| Administrator | Named in privacy curtain, smoking supervision, and food safety deficiencies | |
| Director of Social Services | DSS | Named in PASRR screening deficiency |
| Registered Nurse-Infection Preventionist | RN-IP | Named in food safety deficiencies |
| Registered Dietitian | Named in food safety deficiencies | |
| Registered Nurse Consultant | RNC | Named in food safety deficiencies |
| NCNA #1 | Non-Certified Nursing Aide | Named in smoking supervision deficiency |
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