Inspection Reports for Skyline Heights Nursing and Rehabilitation
1807 24th St W, Billings, MT 59101, MT, 59101
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
30.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
422% worse than Montana average
Montana average: 5.8 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Dec 31, 2025
Visit Reason
The inspection was conducted to investigate complaints related to resident education and communication about changes in incontinence products, timely reporting of a facility incident, and updating residents' comprehensive care plans.
Findings
The facility failed to adequately inform and educate residents about changes in incontinence products, resulting in resident frustration. The facility also failed to timely report a facility incident involving a resident's fall to the State Survey Agency and did not update residents' comprehensive care plans to reflect changes in incontinence care.
Complaint Details
The complaint investigation revealed substantiated issues including lack of resident education on incontinence product changes, late submission of a facility incident report involving resident #5, and failure to update care plans for residents #4 and #7.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to inform and educate residents about changes in incontinence treatment/products, causing frustration for residents #4 and #7. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to submit findings of a Facility Reported Incident to the State Survey Agency within the required five-day deadline for resident #5. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to update residents' comprehensive care plans with new interventions for incontinence care for residents #4 and #7. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 8
Residents affected: 2
Residents affected: 1
Days late: 2
Inspection Report
Annual Inspection
Deficiencies: 3
Nov 19, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to resident care, specifically focusing on the management and treatment of a diabetic foot ulcer for a resident with a history of diabetes and neuropathy.
Findings
The facility failed to ensure a resident's comprehensive care plan included timely diagnosis, monitoring, and treatment of a diabetic foot ulcer, resulting in delayed care and eventual amputation of the resident's right great toe. The facility also failed to ensure staff competency in identifying and managing the wound, and did not administer prescribed treatments as ordered.
Severity Breakdown
Level of Harm - Actual harm: 2
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to develop and implement a complete care plan that meets all the resident's needs, with measurable timetables and actions. | Level of Harm - Actual harm |
| Failed to provide appropriate treatment and care according to orders, resident’s preferences and goals, resulting in immediate jeopardy to resident health or safety. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to ensure nurses and nurse aides had the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Level of Harm - Actual harm |
Report Facts
Residents sampled: 13
Residents affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member C | Stated charge nurses are responsible for care planning and expected nurses to include preventative measures in care plans. | |
| Staff member E | Described adding changes to care plans and stated confidence in skin assessments. | |
| Staff member F | Reported notifying nurses of new skin issues and nurses updating care plans. | |
| Staff member D | Reported notifying nurses of new skin issues and reading care plans for completeness. | |
| Staff member G | Reported reporting skin issues to nurses and completing skin assessment sheets. | |
| Staff member H | Reported nurses completing wound measurements and notifying providers. | |
| Staff member I | Physician | Identified concerns with resident's right great toe and communicated standard of care expectations to facility. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Mar 27, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to provide timely antibiotic and pain medications to newly admitted residents, resulting in negative health outcomes including hospital readmission, discharge against medical advice, and opioid withdrawal.
Findings
The facility neglected to ensure timely administration of antibiotic and pain medications for 3 of 4 recently admitted residents, leading to actual harm. Medication delivery and pharmacy communication systems were deficient, resulting in missed doses, resident distress, and re-hospitalizations. Additionally, nursing staff failed to properly manage PICC lines and medication administration records.
Complaint Details
The investigation was complaint-driven based on allegations that newly admitted residents were not provided timely antibiotic and pain medications, resulting in harm including hospital readmission, discharge against medical advice, and opioid withdrawal.
Severity Breakdown
Level of Harm - Actual harm: 2
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to provide timely antibiotic and pain medications to newly admitted residents resulting in actual harm. | Level of Harm - Actual harm |
| Failure to ensure nursing staff competencies in managing PICC lines, including documentation and treatment. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide pharmaceutical services to meet residents' needs, including failure to provide prescribed medications at the correct dose and frequency. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure residents are free from significant medication errors, including missed doses of antibiotics and pain medications causing negative outcomes. | Level of Harm - Actual harm |
| Failure to provide palatable food and follow the facility menu, resulting in residents not receiving specified vegetables and dissatisfaction with meals. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Missed doses of Tylenol: 3
Missed doses of Duloxetine: 1
Missed doses of Enoxaparin: 1
Missed doses of Gabapentin: 2
Missed doses of Pantoprazole: 2
Missed doses of Tamsulosin: 1
Missed doses of Ibuprofen: 3
Missed doses of Tizanidine: 2
Missed doses of Oxycodone: 2
Missed doses of Cefazolin: 2
Date of resident #81 hospital discharge: 2025
Date of resident #109 transfer to emergency room: 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member B | Mentioned in relation to medication administration record issues and attempts to obtain medications for residents #73 and #109. | |
| NF1 | Interviewed regarding residents #73 and #81 medication administration and outcomes. | |
| NF2 | Interviewed regarding resident #81 and #109 medication administration and PICC line issues. | |
| Staff member D | Interviewed regarding medication administration records and pharmacy communication. | |
| Staff member A | Interviewed regarding resident #109 pain management and medication issues. | |
| Staff member E | Interviewed regarding pharmacy operations and medication delivery system. | |
| NF3 | Attended QAPI meetings and discussed pharmacy issues. | |
| Staff member J | Interviewed regarding dietary services and meal preparation errors. | |
| NF4 | Interviewed regarding pharmacy medication order processing and delivery. |
Inspection Report
Routine
Deficiencies: 16
Jan 30, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including medication management, care planning, pressure ulcer care, activities of daily living assistance, respiratory care, staffing adequacy, medication regimen review, dental services, meal service, therapeutic diets, infection control, and immunization practices.
Findings
The facility was found deficient in multiple areas including improper medication self-administration supervision, incomplete baseline and comprehensive care plans, failure to provide adequate bathing and repositioning, failure to follow wound care orders, failure to provide respiratory treatments, inadequate staffing leading to delayed call light responses and missed cares, insufficient pharmacist medication regimen reviews, failure to implement gradual dose reductions for psychotropic medications, improper medication labeling and expired supplies, failure to provide dental services, late and cold meal service, failure to follow therapeutic diets, inconsistent infection control practices including enhanced barrier precautions, and incomplete immunization tracking.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 15
Level of Harm - Actual harm: 1
Deficiencies (16)
| Description | Severity |
|---|---|
| Failed to address medications appropriately for a resident who self-administered medications and ensure medications and narcotics were properly supervised during medication administration. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a baseline care plan was developed and implemented to reflect the resident's care needs after admission. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow a resident's care plan by not placing a gel cushion on a recliner for pressure ulcer prevention and failed to update care plan for enhanced barrier precautions. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide showers and repositioning for dependent residents who felt personal cleanliness was important. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure treatment was provided according to physician orders for changing a PICC line dressing. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure wound dressings were changed as ordered and sufficient wound documentation was completed. | Level of Harm - Actual harm |
| Failed to provide safe and appropriate respiratory care by not providing nebulizer treatment supplies and treatments as ordered. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide enough nursing staff to meet the needs of every resident, resulting in missed baths, delayed call light responses, and unmet care needs. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a licensed pharmacist performed adequate monthly drug regimen reviews and failed to implement gradual dose reductions for psychotropic medications. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure drugs and biologicals were labeled properly and failed to dispose of expired medications and medical supplies. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide or obtain dental services for residents with dental needs, causing embarrassment and discomfort. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure meals were served timely and at a palatable temperature. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure physician ordered therapeutic diets were followed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to utilize and maintain a QAPI system to identify and address quality deficiencies related to staffing, resident showers, and infection control. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure consistent enhanced barrier precautions and staff education on proper PPE use. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure resident immunizations were up to date with CDC recommendations. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 40
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 11
Residents affected: 1
Residents affected: 3
Expired vacutainers: 45
Expired needles: 6
Expired COVID test kits: 7
Residents affected: 3
Residents affected: 5
Residents affected: 7
Residents affected: 4
Residents affected: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Mentioned in relation to lack of staff education on medication self-administration, pharmacy medication review issues, staffing shortages, and QAPI committee involvement | |
| Staff member B | Mentioned in relation to medication self-administration, care plan deficiencies, infection control education needs | |
| Staff member C | Mentioned in relation to baseline care plan development, enhanced barrier precautions, and immunization tracking | |
| Staff member D | Mentioned in relation to wound care and pressure ulcer dressing changes | |
| Staff member E | Mentioned in relation to staffing shortages, PICC line dressing care, and medication supply monitoring | |
| Staff member F | Mentioned in relation to medication supply monitoring | |
| Staff member H | Mentioned in relation to medication labeling and wound care PPE use | |
| Staff member I | Mentioned in relation to bathing care and enhanced barrier precautions | |
| Staff member J | Mentioned in relation to nebulizer treatments and enhanced barrier precautions | |
| Staff member K | Mentioned in relation to medication self-administration, call light response, therapeutic diets, and infection control education | |
| Staff member L | Mentioned in relation to medication self-administration, wound care, and pharmacist medication review | |
| Staff member M | Mentioned in relation to meal service and therapeutic diet knowledge | |
| Staff member N | Mentioned in relation to infection control education and immunization tracking | |
| Staff member O | Mentioned in relation to immunization tracking | |
| Staff member P | Mentioned in relation to call light response | |
| Staff member Q | Mentioned in relation to call light response | |
| Staff member R | Mentioned in relation to staffing shortages and missed baths |
Inspection Report
Complaint Investigation
Deficiencies: 2
Nov 20, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to ensure nursing staff transcribed and initiated physician orders of prescribed medications and to complete the full course of medication treatment for a resident who returned from a hospital.
Findings
The facility failed to timely start prescribed medications for resident #5 after hospital discharge, resulting in a five-day delay. Staff interviews revealed systemic issues with order transcription and communication between nursing staff and pharmacy, compounded by inconsistent nurse staffing and management turnover.
Complaint Details
The complaint investigation found substantiated delays in medication initiation for resident #5 after hospital discharge, with a documented five-day delay in starting prescribed antibiotics and steroids. Staff interviews indicated systemic issues with order transcription and communication.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure nursing staff transcribed and initiated physician orders of prescribed medications and complete the full course of medication treatment for a resident returning from hospital. | Level of Harm - Minimal harm or potential for actual harm |
| Nursing staff did not always communicate prescriber orders to the pharmacy and were responsible for contacting the pharmacy if a resident's medication was not available for administration. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Delay in medication start: 5
Residents sampled: 5
Residents affected: 1
Medication administration days: 5
Medication administration days: 7
Inspection Report
Complaint Investigation
Deficiencies: 3
Oct 3, 2024
Visit Reason
The inspection was conducted based on complaints regarding inadequate assistance with activities of daily living (ADLs) such as bathing and grooming, lack of supervision for a resident with dementia, and issues related to catheter care.
Findings
The facility failed to provide necessary ADL assistance for dependent residents, resulting in missed showers and hygiene care for several residents. Additionally, a resident with dementia was left unattended at a medical appointment, posing a risk of elopement. The facility also failed to have appropriate catheter supplies, leading to an allergic reaction and delayed medical notification for one resident.
Complaint Details
The visit was complaint-related, triggered by allegations of inadequate ADL assistance, lack of supervision for a resident with dementia, and improper catheter care. Substantiation status is not explicitly stated.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to provide necessary ADL assistance for dependent residents for bathing and grooming, causing residents to feel unkempt. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide supervision for a resident with dementia who was left unattended at a medical appointment, placing the resident at risk of elopement. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to have necessary catheter supplies available, causing an allergic reaction and failure to notify the medical provider in a timely manner. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Days without shower: 47
Days without shower: 29
Days without shower: 25
Days without shower: 44
Days without shower: 34
Residents per staff: 15
Assessment Reference Date: Jul 7, 2024
Assessment Reference Date: Aug 15, 2024
Assessment Reference Date: Aug 21, 2024
Catheter change dates: 2
Date of catheter clogging note: Aug 28, 2024
Date of allergic reaction note: Aug 29, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member E | Responsible for 15 residents during shift; stated showers were mostly completed but occasionally missed. | |
| Staff member B | Stated a staff member should have stayed with resident #8 at medical appointment due to severe cognitive impairment. | |
| Staff member D | Stated she was not supposed to stay with residents at medical appointments. | |
| Staff member F | Replaced resident #6's catheter; was unaware of allergy to silicone; did not notify medical provider immediately. | |
| NF1 | Stated resident #8 was left unsupervised at medical appointment. |
Inspection Report
Routine
Deficiencies: 2
May 20, 2024
Visit Reason
The inspection was conducted to assess compliance with care and assistance for residents, food safety and hygiene practices, and adherence to facility policies related to meal assistance and hand hygiene.
Findings
The facility failed to provide necessary meal assistance to a resident with weight loss, resulting in minimal harm. Additionally, the facility did not ensure food was served in a sanitary manner and staff failed to perform hand hygiene between serving meals, potentially affecting all residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide assistance with meals for a resident identified with weight loss. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food was served in a sanitary manner and failed to practice hand hygiene while serving meals between residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: Few residents affected by meal assistance deficiency
Residents affected: Many residents affected by food sanitation and hand hygiene deficiency
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member J observed not assisting resident #8 with meals | ||
| Staff member F stated resident #8 required meal assistance and that CNA was agency staff unaware of needs | ||
| Staff member I, agency nurse, unaware of resident #8's meal assistance needs | ||
| Staff member C described location of resident care plan information | ||
| Staff member G observed with personal sandwich in tray line area | ||
| Staff member H observed drinking personal drink in tray line area | ||
| Staff member K observed serving meals without hand hygiene between residents | ||
| Staff member E stated staff had training on hand hygiene and tray line conduct | ||
| Staff member A stated staff had received training on hand hygiene when assisting residents with meals |
Inspection Report
Complaint Investigation
Deficiencies: 6
Jan 18, 2024
Visit Reason
The inspection was conducted based on complaints and allegations regarding resident grievances, abuse, care deficiencies, and food service issues at Skyline Heights Nursing and Rehabilitation.
Findings
The facility failed to maintain grievance documentation, protect residents from abuse, develop baseline care plans timely, provide appropriate catheter care, and serve food at safe temperatures. Multiple residents were affected by these deficiencies, with some resulting in actual harm such as urinary tract infections and psychosocial distress.
Complaint Details
The complaint investigation included allegations of failure to resolve resident grievances, failure to protect residents from abuse including resident-to-resident verbal and physical abuse, failure to report abuse findings to the State Survey Agency, failure to develop timely care plans, failure to provide appropriate catheter care leading to urinary tract infection, and failure to serve food at safe temperatures. Multiple interviews, observations, and record reviews were conducted to substantiate these findings.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Level of Harm - Actual harm: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to maintain evidence of resolution of a resident's grievance and ensure grievance policy met regulatory guidelines. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to protect residents from physical and psychosocial harm due to resident-to-resident abuse and inadequate response to aggressive behaviors. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to report findings of resident-to-resident verbal abuse to the State Survey Agency. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement a baseline care plan within 48 hours of admission for a resident with a urinary catheter and colostomy. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate catheter care and monitoring, resulting in a urinary tract infection. | Level of Harm - Actual harm |
| Failed to serve food that was palatable and at a safe and appetizing temperature for multiple residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 46
Residents affected by grievance deficiency: 1
Residents affected by abuse deficiency: 5
Residents affected by verbal abuse reporting deficiency: 1
Residents affected by baseline care plan deficiency: 1
Residents affected by catheter care deficiency: 1
Residents affected by food temperature deficiency: 5
Dates of food temperature chart documentation: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member K | Discussed grievance documentation, food complaints, and food temperature issues; signed document denying resident #134 filed grievance | |
| NF7 | Interviewed regarding resident #134's complaints and grievance process | |
| Staff member H | Discussed grievance conversations, catheter care, and food complaints | |
| Staff member S | Provided information about resident #64's mental health and safety concerns | |
| Staff member T | Notified about resident #7's concerns about roommate | |
| Staff member E | Commented on roommate conflicts involving resident #68 | |
| Staff member M | Discussed reporting procedures for resident altercations and roommate conflicts | |
| Staff member N | Observed preparing residents for smoking and reheating meal trays | |
| Staff member R | Discussed conflict management during smoking times | |
| Staff member L | Discussed reheating food trays due to cold food | |
| Staff member P | Observed ice on waffles and discussed reheating meals | |
| Staff member O | Reported meal tray delivery times |
Inspection Report
Routine
Deficiencies: 16
Jan 18, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident grievances, abuse prevention, resident transfers, assessments, care planning, medication management, food service, and kitchen sanitation at Skyline Heights Nursing and Rehabilitation.
Findings
The facility was found deficient in multiple areas including failure to maintain grievance documentation, protect residents from abuse, provide timely and complete resident assessments and care plans, ensure proper medication administration and availability, maintain food at safe temperatures, and uphold sanitary conditions in the kitchen. Several residents experienced inadequate care, medication issues, and poor food quality.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 14
Level of Harm - Potential for minimal harm: 1
Level of Harm - Actual harm: 1
Deficiencies (16)
| Description | Severity |
|---|---|
| Failed to maintain evidence of resolution of a resident's grievance and ensure grievance policy met regulatory guidelines. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to protect residents from actual or potential physical and psychosocial harm and address verbal and physical abuse behaviors. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to report findings of an allegation of resident-to-resident verbal abuse to the State Survey Agency. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide pertinent medical information to receiving facility at time of transfer. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide Notice of Transfer/Discharge to residents or representatives before transfer or discharge. | Level of Harm - Potential for minimal harm |
| Failed to complete Annual MDS assessment in a timely manner. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete Quarterly MDS assessments in a timely manner. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure updated PASARR for resident with serious mental health diagnosis and escalating behaviors. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement comprehensive, person-centered care plans for residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to update resident care plans as resident care needs changed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to monitor and consistently document wound status and dressing changes for a resident's wound. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to address indwelling urinary catheter care, resulting in urinary tract infection. | Level of Harm - Actual harm |
| Failed to provide physician-ordered medications at prescribed dose and frequency and ensure availability of medications, resulting in medication borrowing and missed doses. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medication carts were securely locked when unattended. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to serve food that was palatable and at a safe and appetizing temperature. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to label and date food items and maintain sanitary conditions in the kitchen and food service areas. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 46
Residents affected by grievance deficiency: 1
Residents affected by abuse deficiency: 5
Residents affected by medication deficiency: 4
Residents affected by food temperature deficiency: 5
Residents affected by kitchen sanitation deficiency: 83
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| NF7 | Interviewed regarding resident #134's grievances | |
| Staff member H | Discussed resident #134's complaints and catheter care | |
| Staff member K | Handled food-related grievances and food temperature checks | |
| Staff member S | Interviewed about resident #64's behavior and safety concerns | |
| Staff member T | Notified about resident #7's concerns | |
| Staff member E | Discussed roommate issues and medication ordering process | |
| Staff member M | Discussed resident altercations and medication incident reporting | |
| Staff member B | Interviewed about transfer documentation, care plans, and medication availability | |
| Staff member J | Interviewed about late MDS assessments | |
| Staff member F | Interviewed about resident #64's care plan and medication availability | |
| Staff member D | Administered medication and dressing changes; involved in medication borrowing incident | |
| Staff member L | Observed reheating food trays | |
| Staff member N | Observed smoking area and food tray delivery | |
| Staff member R | Discussed resident conflicts during smoking times | |
| Staff member O | Discussed meal tray delivery times | |
| Staff member P | Observed cold food and meal tray delivery | |
| Staff member Q | Agreed meals were cold | |
| Staff member NF2 | Notified about methocarbamol medication unavailability | |
| Staff member NF3 | Notified about Jardiance medication unavailability | |
| Staff member NF4 | Discussed pharmacy and medication ordering process |
Inspection Report
Complaint Investigation
Deficiencies: 4
Oct 12, 2023
Visit Reason
The inspection was conducted following multiple facility-reported incidents and complaints regarding staff performance, resident care, and dietary issues at Skyline Heights Nursing and Rehabilitation.
Findings
The facility was found to have failed in ensuring therapeutic communication and adequate personal hygiene care, timely assistance to dependent residents, proper pressure ulcer care, and provision of a gluten-free diet as ordered. Several staff performance concerns were substantiated, and corrective actions were taken, but documentation of staff education was lacking.
Complaint Details
The visit was complaint-related, triggered by multiple facility-reported incidents involving allegations of staff rudeness, inadequate personal care, delayed assistance, improper wound care, and failure to provide a prescribed gluten-free diet. All allegations were substantiated by the facility's investigations.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure staff utilized therapeutic communication and adequate personal hygiene care, resulting in feelings of intimidation and reluctance to ask for assistance for residents #8 and #10. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide timely services necessary to meet dependent residents' individual care needs for residents #9 and #11. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to follow prescribed treatment for pressure ulcers for resident #7, including delayed dressing changes by six days. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide a gluten-free diet per provider's orders for resident #5, resulting in exposure to gluten-containing foods and unsatisfactory care. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 8
Delay in wound dressing changes: 6
Duration of delayed assistance: 3
Duration resident #11 left on toilet: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member H | Named in findings related to rude behavior and inadequate personal care for residents #8 and #10. | |
| Staff member I | Named in findings related to delay of care for resident #9. | |
| Staff member J | Named in findings related to delayed assistance for resident #11. | |
| Staff member A | Provided statements about staff education and QAPI program focus. | |
| Staff member E | Cook | Provided statements regarding gluten-free diet preparation and dietary department practices. |
| Staff member F | Provided statements regarding lack of preparation for gluten-free diet for resident #5. | |
| Staff member G | Provided statements regarding notification and handling of gluten-free diet for resident #5. | |
| Staff member B | Provided statements regarding admission referral process and eligibility. |
Inspection Report
Deficiencies: 1
Mar 21, 2023
Visit Reason
The inspection was conducted to respond appropriately to all alleged violations at Skyline Heights Nursing and Rehabilitation.
Findings
The report notes a deficiency with minimal harm or potential for actual harm affecting some residents, but the specific deficiency text is not available.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Respond appropriately to all alleged violations. | Level of Harm - Minimal harm or potential for actual harm |
Inspection Report
Complaint Investigation
Deficiencies: 9
Feb 2, 2023
Visit Reason
The inspection was conducted based on multiple complaints and facility reported incidents involving abuse, neglect, medication errors, infection control, staffing inadequacies, and failure to provide appropriate care to residents.
Findings
The facility was found to have substantiated abuse and neglect allegations, failed to investigate incidents timely, did not provide adequate assistance with activities of daily living including bathing and eating, failed to prevent falls and injuries, had medication errors causing harm, failed to maintain proper infection control practices, and had inadequate staffing leading to delayed care and unmet resident needs.
Complaint Details
The visit was complaint-related, triggered by multiple allegations including abuse, neglect, medication errors, infection control breaches, and staffing concerns. Some allegations were substantiated, such as verbal abuse, neglect, medication errors, and infection control violations.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Level of Harm - Actual harm: 4
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to protect residents from verbal and emotional abuse by staff. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to investigate facility reported incidents timely and thoroughly, including neglect and misappropriation of medications. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide adequate assistance with bathing and eating for multiple residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to change wound vacuum dressing as ordered, causing increased skin breakdown. | Level of Harm - Actual harm |
| Failed to prevent falls resulting in significant injuries including fractures and skin tears. | Level of Harm - Actual harm |
| Failed to provide adequate staffing resulting in delayed responses to call lights and unmet resident care needs. | Level of Harm - Actual harm |
| Failed to ensure residents were free from significant medication errors resulting in seizure. | Level of Harm - Actual harm |
| Failed to provide food with correct and safe diet texture as ordered, placing resident at risk for choking. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain proper infection control practices including failure of staff to wear masks during COVID-19 outbreak. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 2
Residents affected: 6
Residents affected: 1
Falls: 5
Call light wait times >15 minutes: 87
Late medication doses: 24
Late medication doses: 36
Showers received: 8
Showers received: 2
Showers received: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member B | Interviewed regarding abuse investigations and medication error incident | |
| Staff member E | Observed not wearing mask properly during COVID-19 outbreak | |
| Staff member F | Entered incorrect medication order leading to medication error | |
| Staff member Q | Interviewed about staffing and care plan issues | |
| Staff member M | Interviewed about staffing shortages and care delays | |
| Staff member A | Interviewed about incident investigations and staffing |
Inspection Report
Routine
Deficiencies: 21
Feb 2, 2023
Visit Reason
The inspection was a routine survey of Skyline Heights Nursing and Rehabilitation to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including medication administration, resident abuse prevention, care planning, infection control, staffing adequacy, dietary services, fall prevention, wound care, restorative services, and resident rights. Several residents experienced harm or potential harm due to these deficiencies.
Severity Breakdown
Level of Harm - Actual harm: 9
Level of Harm - Minimal harm or potential for actual harm: 12
Level of Harm - Potential for minimal harm: 1
Deficiencies (21)
| Description | Severity |
|---|---|
| Failed to assess resident #230 for self-administration of medication, leading to potential medication errors. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to notify a physician of severe weight loss for resident #39. | Level of Harm - Actual harm |
| Failed to ensure residents were free from abuse for residents #26 and #430. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to investigate facility reported incidents timely and thoroughly for residents #400, #433, #3, and #22. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement a baseline care plan with minimum healthcare information for resident #430. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement a complete care plan meeting all resident needs for residents #12, #39, #47, #70, and #74. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide assistance with activities of daily living including bathing and eating for residents #2, #12, #26, #60, #72, #254, and #23. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to update resident #77's Physician Order for Life-Sustaining Treatment (POLST) to Do Not Resuscitate (DNR), resulting in failure to administer CPR. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate treatment and care according to orders for resident #54, including failure to change wound vacuum dressing timely. | Level of Harm - Actual harm |
| Failed to prevent development of a Stage 4 pressure ulcer for resident #4. | Level of Harm - Actual harm |
| Failed to provide appropriate care to maintain or improve range of motion and mobility for residents #12 and #74. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a nursing home area was free from accident hazards and provide adequate supervision to prevent accidents, resulting in falls with injuries for residents #24, #55, #47, #229, and #279. | Level of Harm - Actual harm |
| Failed to provide appropriate care for residents who are continent or incontinent of bowel/bladder, including failure to assess indwelling catheter removal and provide bladder retraining for residents #12 and #430. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide enough food and fluids to maintain resident #39's health, resulting in severe weight loss. | Level of Harm - Actual harm |
| Failed to provide enough nursing staff to meet resident needs and have a licensed nurse in charge on each shift, resulting in delayed care and unmet needs for multiple residents. | Level of Harm - Actual harm |
| Failed to ensure a licensed pharmacist performed monthly drug regimen review with appropriate follow-up for medication irregularities for resident #48. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide sufficient support personnel to safely and effectively carry out dietary functions, resulting in delayed meal service and unsanitary kitchen conditions. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure therapeutic diets were prescribed and provided as ordered, placing resident #33 at risk for choking and inadequate intake. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to safeguard resident-identifiable information and maintain medical records, including timely receipt and scanning of physician progress notes for resident #48. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide and implement an infection prevention and control program, including failure of nursing staff to wear masks during COVID-19 outbreak, risking spread of infection. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain an arbitration agreement that explicitly granted residents or representatives the right to rescind within 30 days. | Level of Harm - Potential for minimal harm |
Report Facts
Weight loss percentage: 22.67
Medication late times: 24
Medication late times: 36
Shower opportunities: 27
Showers received: 8
Shower opportunities: 23
Showers received: 11
Shower opportunities: 19
Showers received: 8
Shower opportunities: 7
Showers received: 2
Longest call light wait: 88
Longest call light wait: 85
Longest call light wait: 78
Longest call light wait: 70
Longest call light wait: 69
Longest call light wait: 52
Longest call light wait: 49
Longest call light wait: 44
Longest call light wait: 38
Residents requiring 1-2 staff for dressing: 67
Residents fully dependent for dressing: 22
Residents requiring 1-2 staff for toilet use: 74
Residents fully dependent for toilet use: 15
Residents in chair most/all the time: 69
Residents bedfast: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member Q | Involved in medication self-administration observation and interview with resident #230 | |
| Staff member V | Interviewed regarding weight loss notification for resident #39 | |
| Staff member B | Interviewed regarding abuse investigations and staffing concerns | |
| Staff member A | Interviewed regarding incident investigations and staffing | |
| Staff member C | Interviewed regarding investigations and medication regimen review | |
| Staff member G | Interviewed regarding care plan updates and baseline care plan | |
| Staff member M | Interviewed regarding oxygen tubing, wound care, restorative therapy, and infection control | |
| Staff member E | Observed and interviewed regarding mask wearing and infection control | |
| Staff member I | Interviewed regarding care plan creation and resident #47 care plan | |
| Staff member J | Interviewed regarding bathing assistance and staffing | |
| Staff member T | Interviewed regarding rounds and resident #430 incontinence | |
| Staff member U | Interviewed regarding tearful resident #430 and social worker notification | |
| Staff member H | Interviewed regarding mental health services availability | |
| Staff member W | Interviewed regarding staffing and call light response | |
| Staff member Z | Interviewed and observed in dietary department regarding kitchen conditions | |
| Staff member Y | Interviewed regarding dietary staffing and kitchen sanitation | |
| Staff member F | Interviewed regarding medication order entry error and wound care | |
| Staff member R | Interviewed regarding POLST processing |
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