Inspection Reports for
Skyline Ridge Skilled Nursing & Rehab in Cañon City, CO
515 Fairview Ave, Cañon City, CO 81212, CO, 81212
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
20 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
285% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 9, 2025
Visit Reason
The inspection was conducted following a complaint investigation of an incident involving physical abuse between two residents at Skyline Ridge Nursing & Rehabilitation Center on 8/13/2025.
Complaint Details
The complaint investigation involved an incident on 8/13/25 where Resident #1 was physically abused by Resident #2, resulting in facial injuries. The facility's investigation included interviews, record reviews, and observations. CNA #1 failed to report the incident and was terminated. Resident #1 was sent to the ER for evaluation. The facility did not substantiate the abuse formally but acknowledged the incident based on resident statements and observations.
Findings
The facility failed to ensure adequate supervision and intervention to prevent physical abuse between residents. Resident #1 sustained a black eye and nosebleed after an altercation with Resident #2. The investigation revealed failures in staff reporting, monitoring, and implementation of safety measures such as room separation and use of stop signs.
Deficiencies (1)
F 0600: The facility failed to protect residents from physical abuse, specifically failing to prevent Resident #1 from being physically abused by Resident #2 on 8/13/25. Staff failed to report the incident timely and did not implement adequate safety measures to prevent further incidents.
Report Facts
Residents affected: 2
BIMS score Resident #1: 1
BIMS score Resident #2: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Failed to report the abuse incident on 8/13/25 and was terminated |
| RN #1 | Registered Nurse | Interviewed regarding reporting procedures and resident behaviors |
| DON | Director of Nursing | Interviewed about staff education and incident response |
| NHA | Nursing Home Administrator and Abuse Coordinator | Interviewed about investigation process and staff notification |
| SSD | Social Services Director | Interviewed about investigation procedures and care planning |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 9, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident of physical abuse between two residents (#1 and #2) at Skyline Ridge Nursing & Rehabilitation Center on 8/13/2025.
Complaint Details
The complaint investigation was triggered by an incident on 8/13/25 where Resident #1 was physically abused by Resident #2, resulting in facial injuries. The facility investigation included interviews with staff and residents, review of medical records, and observations. CNA #1 failed to report the incident and was subsequently suspended and terminated. The abuse was substantiated based on Resident #1's statement and physical evidence. Safety measures were inadequately implemented post-incident.
Findings
The facility failed to ensure adequate supervision and intervention to prevent physical abuse between residents. Resident #1 was physically abused by Resident #2, resulting in facial injuries including a black eye and bloody nose. The investigation revealed staff failures in reporting and implementing safety measures such as room separation and use of stop signs. Staff interviews indicated inconsistent monitoring and communication regarding resident behaviors and incidents.
Deficiencies (3)
Failure to protect residents from physical abuse, specifically Resident #1 from abuse by Resident #2.
Failure of CNA #1 to report the incident of abuse at the time it occurred.
Failure to implement and maintain safety measures such as stop signs on Resident #2's door and adequate room separation.
Report Facts
Residents affected: 2
BIMS score Resident #1: 1
BIMS score Resident #2: 6
Observation period: 104
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Failed to report the abuse incident on 8/13/25; subsequently suspended and terminated. |
| CNA #2 | Certified Nurse Aide | Notified LPN #1 of Resident #1's injuries and interviewed during investigation. |
| RN #1 | Registered Nurse | Interviewed regarding reporting procedures and resident behaviors. |
| DON | Director of Nursing | Interviewed about staff education, incident response, and monitoring procedures. |
| NHA | Nursing Home Administrator | Provided facility policies, coordinated abuse investigation, and confirmed CNA #1 termination. |
| SSD | Social Services Director | Interviewed about investigation process and care planning related to resident safety. |
Inspection Report
Routine
Deficiencies: 2
Date: Jan 16, 2025
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically focusing on COVID-19 vaccination tracking, offering, and administration, as well as the qualifications of the infection preventionist.
Findings
The facility failed to maintain an effective infection prevention and control program by not ensuring proper documentation and administration of the 2024-2025 COVID-19 vaccine for several residents. Additionally, the facility lacked a qualified infection preventionist with completed specialized training from 10/25/24 until 1/15/25.
Deficiencies (2)
F 0880: The facility failed to ensure tracking, offering, and administration of the 2024-2025 COVID-19 vaccination for seven residents. Documentation was incomplete or missing for residents #2, #5, #6, #7, #8, #12, and #13.
F 0882: The facility failed to employ a qualified infection preventionist with completed specialized training from 10/25/24 until 1/15/25. The new infection preventionist lacked certification during this period.
Report Facts
Residents affected: 7
Residents affected: Many
Inspection Report
Routine
Deficiencies: 2
Date: Jan 16, 2025
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically focusing on the tracking, offering, and administration of the 2024-2025 COVID-19 vaccination to residents.
Findings
The facility failed to maintain an effective infection prevention and control program by not ensuring proper documentation and administration of the COVID-19 vaccine for seven of fourteen sampled residents. Additionally, the facility lacked a qualified infection preventionist with completed specialized training from 10/25/24 until 1/15/25.
Deficiencies (2)
Failed to ensure the tracking, offering, and administration of the COVID-19 vaccination for seven residents.
Failed to employ a qualified infection preventionist who had completed specialized training in infection prevention and control.
Report Facts
Residents affected: 7
Date of previous infection preventionist resignation: Oct 25, 2024
Date new infection preventionist certificate provided: Jan 15, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Provided facility policies, interviewed about infection prevention program and vaccination documentation | |
| Corporate Resource Nurse (CRN) | Interviewed regarding infection prevention program management and vaccination documentation; provided IP certificate during survey |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 2
Date: Sep 19, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to maintain accurate medical records for residents' CPR status and to ensure the environment was free from accident hazards to prevent falls.
Complaint Details
The complaint investigation substantiated that the facility failed to maintain accurate CPR status documentation for four residents (#72, #34, #33, and #237) and failed to prevent a fall resulting in a fracture for one resident (#59).
Findings
The facility failed to maintain accurate CPR status documentation for four residents, resulting in discrepancies between residents' wishes and the CPR list used by nursing staff. Additionally, the facility failed to prevent a fall resulting in a fracture for one resident due to improper use of a mechanical lift and inconsistent fall prevention interventions.
Deficiencies (2)
F 0678: The facility failed to maintain accurate medical records for residents' CPR status, resulting in discrepancies between residents' advance directives and the CPR list used by nursing staff.
F 0689: The facility failed to ensure a safe environment and adequate supervision to prevent falls, resulting in a resident sustaining a fractured wrist after a fall during a mechanical lift transfer without two staff present.
Report Facts
Sample residents reviewed: 50
Residents reviewed for falls: 48
Residents affected by CPR documentation deficiency: 4
Residents affected by fall deficiency: 1
BIMS score: 15
BIMS score: 15
BIMS score: 8
Medication dosage: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Interviewed regarding use of CPR list in narcotics book | |
| Registered Nurse (RN) #2 | Interviewed regarding CPR list and electronic medical records | |
| Interim Director of Nursing (IDON) | Interviewed regarding CPR list usage and staff training | |
| Certified Nurse Aide (CNA) #2 | Interviewed regarding fall incident and fall mat placement | |
| Corporate Consultant (CC) #2 | Interviewed regarding fall investigation and staff suspensions |
Inspection Report
Complaint Investigation
Deficiencies: 11
Date: Sep 19, 2024
Visit Reason
The inspection was conducted due to complaints related to resident abuse, failure to report abuse timely, use of physical restraints, medication errors, nutritional care, fall prevention, infection control, and documentation of residents' CPR status.
Complaint Details
The complaint investigation focused on allegations of resident abuse, failure to report abuse timely, improper use of physical restraints, medication errors, nutritional neglect, fall prevention failures, inaccurate CPR documentation, medication storage issues, and infection control deficiencies.
Findings
The facility failed to prevent physical abuse between residents, timely report abuse allegations, ensure proper use of physical restraints, maintain accurate CPR status documentation, provide adequate nutritional care, prevent falls, ensure medication administration within prescribed times, maintain secure medication storage, and provide proper infection control including hand hygiene and laundry handling.
Deficiencies (11)
F0600: The facility failed to prevent physical altercations between residents #239 and #38, and residents #74 and #70, resulting in minimal harm.
F0604: The facility failed to ensure a physician's order, safety risk assessment, and alternative interventions for Resident #62's bed alarm, a physical restraint.
F0609: The facility failed to timely report an allegation of resident-to-resident physical abuse involving Residents #74 and #70 to state and local authorities within 24 hours.
F0661: The facility failed to complete discharge summaries for Residents #236, #84, #85, and #238, omitting key information including recapitulation of stay and functional status.
F0676: The facility failed to provide Resident #4 with adequate assistance and encouragement during meals, resulting in inadequate nutritional intake.
F0678: The facility failed to maintain accurate and accessible documentation of residents' CPR status for Residents #72, #34, #33, and #237, causing confusion among staff.
F0689: The facility failed to ensure a safe environment and adequate supervision to prevent falls for Resident #59, resulting in a fall with fracture due to improper mechanical lift use and inconsistent fall interventions.
F0692: The facility failed to provide adequate nutritional care to Resident #34, resulting in severe weight loss and failure to monitor nutritional interventions and meal assistance.
F0759: The facility's medication error rate was 7.69%, exceeding the acceptable rate of 5%, including late administration of medications to Resident #49.
F0761: The facility failed to ensure medication refrigerators were locked when unattended and controlled medications were double locked inside the refrigerator.
F0880: The facility failed to provide hand hygiene assistance to residents before meals and failed to handle clean laundry in a sanitary manner, risking infection transmission.
Report Facts
Medication error rate: 7.69
Resident #34 weight loss: 15.9
Resident #34 weight loss: 7.8
Resident #4 meal supervision: 37
Resident #4 limited assistance: 17
Resident #4 extensive assistance: 4
Medication administration delay: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Administered medications late to Resident #49 |
| RN #2 | Registered Nurse | Interviewed regarding medication refrigerator lock and CPR list usage |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding CPR list usage |
| CNA #1 | Certified Nurse Aide | Failed to provide meal assistance and encouragement to Resident #4 |
| CNA #2 | Certified Nurse Aide | Failed to place fall mat back for Resident #59 and failed to offer hand hygiene assistance |
| CNA #3 | Certified Nurse Aide | Described use of bed alarm for Resident #62 |
| CNA #4 | Certified Nurse Aide | Removed Resident #34's meal tray without offering alternative |
| CNA #5 | Certified Nurse Aide | Observed Resident #34 spilling shake and needing assistance |
| IDON | Interim Director of Nursing | Interviewed regarding multiple findings including medication administration, fall prevention, CPR documentation, and nutritional care |
| NHA | Nursing Home Administrator | Interviewed regarding multiple findings including medication administration, fall prevention, CPR documentation, and infection control |
| RD | Registered Dietitian | Interviewed regarding nutritional care of Resident #34 and Resident #4 |
| CC #1 | Corporate Consultant | Interviewed regarding discharge summaries and infection control |
| CC #2 | Corporate Consultant | Interviewed regarding fall investigation for Resident #59 |
| IP | Infection Preventionist | Interviewed regarding hand hygiene and laundry handling |
| LA | Laundry Aide | Interviewed regarding improper handling of clean laundry |
Inspection Report
Complaint Investigation
Deficiencies: 12
Date: Sep 19, 2024
Visit Reason
The inspection was conducted due to complaints regarding physical abuse between residents and failure to report alleged abuse timely, as well as concerns about restraint use, discharge summaries, assistance with activities of daily living, CPR status documentation, fall prevention, nutrition care, medication errors, medication storage, and infection control.
Complaint Details
The complaint investigation focused on allegations of physical abuse between residents, failure to report abuse timely, and other care concerns including restraint use, discharge summaries, assistance with activities of daily living, CPR status documentation, fall prevention, nutrition care, medication errors, medication storage, and infection control.
Findings
The facility failed to prevent physical altercations between residents, failed to timely report abuse allegations, failed to ensure proper use of restraints, failed to complete discharge summaries, failed to provide adequate assistance with meals, failed to maintain accurate CPR status documentation, failed to prevent a fall resulting in fracture due to improper use of mechanical lift, failed to provide adequate nutrition monitoring and assistance, had medication administration errors, failed to secure medication refrigerators properly, and failed to ensure proper hand hygiene and sanitary handling of clean laundry.
Deficiencies (12)
Failed to prevent physical altercations between residents #239 and #38, and #74 and #70.
Failed to timely report an allegation of resident to resident physical abuse to local police or State Agency within 24 hours.
Failed to ensure a physician's order was obtained, a safety risk assessment was completed, and alternative interventions attempted for use of Resident #62's bed alarm.
Failed to ensure discharge summaries were completed and included a recapitulation of the resident's stay for four residents (#236, #84, #85, #238).
Failed to provide Resident #4 with encouragement and cueing at meals to ensure adequate nutritional intake.
Failed to maintain accurate and consistent documentation of residents' CPR status; discrepancies found between MOST forms, physician orders, and CPR list.
Failed to ensure Resident #59's environment was free from accident hazards and provide adequate supervision to prevent falls; improper use of mechanical lift resulted in fall and fracture.
Failed to provide adequate nutrition care to Resident #34, resulting in severe weight loss and failure to monitor nutritional supplement intake and meal assistance.
Medication error rate was 7.69%, exceeding the 5% threshold; example includes late administration of medications to Resident #49.
Failed to ensure medication refrigerator was locked when unattended and controlled medications were double locked inside the refrigerator.
Failed to ensure facility staff offered appropriate hand hygiene to residents before meals, especially those not independent in self-care.
Failed to ensure laundry staff handled clean laundry in a sanitary manner; clean laundry was held against staff uniform.
Report Facts
Residents reviewed for abuse: 50
Residents affected by abuse: 10
Residents affected by physical abuse: 2
Residents reviewed for restraint use: 50
Residents reviewed for discharge summaries: 50
Residents reviewed for ADL assistance: 50
Residents reviewed for CPR documentation: 13
Residents reviewed for falls: 48
Medication error rate: 7.69
Weight loss: 15.9
Weight loss: 7.9
Medication administration delay: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Administered medications late to Resident #49 |
| RN #2 | Registered Nurse | Locked medication refrigerator; interviewed about CPR list and medication storage |
| CNA #1 | Certified Nurse Aide | Failed to provide cueing and encouragement to Resident #4 during meals |
| CNA #2 | Certified Nurse Aide | Failed to keep fall mat in place for Resident #59; failed to offer siesta meal to Resident #34 initially |
| CNA #3 | Certified Nurse Aide | Described use of bed alarm for Resident #62 |
| CNA #4 | Certified Nurse Aide | Removed Resident #34's dinner tray without offering alternative |
| CNA #5 | Certified Nurse Aide | Observed Resident #34 spilling shake and needing assistance |
| CNA #6 | Certified Nurse Aide | Described Resident #4's need for cueing and encouragement during meals |
| IDON | Interim Director of Nursing | Interviewed about multiple deficiencies including CPR documentation, fall prevention, nutrition care, and medication administration |
| NHA | Nursing Home Administrator | Interviewed about abuse investigations, medication storage, and other deficiencies |
| RD | Registered Dietitian | Interviewed about Resident #34's nutrition care and weight loss |
| CC #1 | Corporate Consultant | Interviewed about discharge summaries and infection control |
| CC #2 | Corporate Consultant | Interviewed about Resident #59's fall and investigation |
| IP | Infection Preventionist | Interviewed about hand hygiene and laundry handling |
| LA | Laundry Aide | Interviewed about improper handling of clean laundry |
Inspection Report
Annual Inspection
Census: 48
Deficiencies: 2
Date: Sep 19, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including accurate documentation of residents' cardiopulmonary resuscitation (CPR) directives and ensuring a safe environment to prevent falls.
Findings
The facility failed to maintain accurate CPR status documentation for four residents, resulting in discrepancies between residents' wishes and the CPR list used by nursing staff. Additionally, the facility failed to prevent a fall resulting in a fracture for one resident due to improper use of a mechanical lift and inconsistent implementation of fall prevention interventions.
Deficiencies (2)
Failed to maintain accurate CPR status documentation and ensure nursing staff awareness of residents' CPR directives.
Failed to ensure a safe environment and adequate supervision to prevent falls, resulting in a resident fall with fracture.
Report Facts
Residents reviewed for CPR documentation: 50
Residents with inaccurate CPR documentation: 4
Residents reviewed for falls: 48
Residents reviewed for falls with detailed observation: 5
Residents affected by fall deficiency: 1
BIMS score for Resident #72: 15
BIMS score for Resident #34: 15
BIMS score for Resident #59: 8
Date of fall for Resident #59: Jul 31, 2024
Date of compliance: Aug 9, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Interviewed regarding CPR list usage and fall incident |
| Registered Nurse #2 | RN | Interviewed regarding CPR list usage |
| Interim Director of Nursing | IDON | Provided information on CPR list usage, training, and fall prevention |
| Certified Nurse Aide #2 | CNA | Involved in Resident #59 fall and interviewed about fall mat placement |
| Corporate Consultant #2 | CC | Interviewed regarding fall investigation and staff suspensions |
Inspection Report
Routine
Census: 44
Deficiencies: 10
Date: May 18, 2023
Visit Reason
Routine inspection to assess compliance with regulatory requirements including resident abuse prevention, restraint use, PASRR coordination, fall prevention, catheter care, medication management, staff competencies, psychotropic medication use, medication administration, and infection control.
Findings
The facility failed to prevent and report resident-to-resident abuse, failed to ensure proper use of physical restraints, failed to coordinate PASRR assessments, failed to provide adequate supervision to prevent accidents, failed to provide appropriate catheter care, failed to ensure nursing staff competencies, failed to monitor and reduce unnecessary psychotropic medications, had a medication administration error rate above 5%, and failed to maintain adequate hand hygiene among staff.
Deficiencies (10)
F0600: The facility failed to prevent two resident-to-resident altercations involving Residents #64, #65, and #77 and failed to substantiate and report the abuse as required.
F0604: The facility failed to provide rationale, justification, and consent for placing a wander guard on Resident #48 to restrict movements.
F0609: The facility failed to timely report three resident-to-resident altercations involving Residents #64, #65, and #77 to the State Agency as required.
F0644: The facility failed to coordinate assessments with the PASRR program for Resident #29 after new diagnosis of psychosis and initiation of antipsychotic medication.
F0689: The facility failed to document and investigate a fall reported by Resident #233, including lack of RN assessment and updated fall risk assessment.
F0690: The facility failed to obtain physician orders and document catheter care and maintenance for Resident #63 with an indwelling catheter.
F0726: The facility failed to ensure nursing staff had completed required competencies in catheter care and ADLs for several nurses and aides.
F0758: The facility failed to monitor targeted behaviors, side effects, and non-pharmacological interventions for psychotropic medications and failed to complete risk/benefit statements or gradual dose reductions for Residents #33, #22, and #29.
F0759: The facility had a medication administration error rate of 7.4% due to crushing medications contraindicated for crushing and administering them to Resident #21.
F0880: The facility failed to ensure nursing staff performed adequate hand hygiene before and after resident contact and other required times.
Report Facts
Residents in sample: 44
Medication administration opportunities: 27
Medication administration errors: 2
Medication administration error rate: 7.4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding abuse prevention, reporting, catheter care, medication administration, hand hygiene, and staff competencies | |
| Social Services Director | Interviewed regarding abuse reporting, PASRR coordination, psychotropic medication monitoring, and resident behaviors | |
| Registered Nurse #1 | Observed and interviewed regarding medication administration errors and hand hygiene | |
| Registered Nurse #2 | Interviewed regarding medication administration, psychotropic medication monitoring, and hand hygiene | |
| Certified Nurse Aide #2 | Observed and interviewed regarding hand hygiene | |
| Infection Preventionist | Interviewed regarding hand hygiene policy and staff compliance |
Inspection Report
Routine
Deficiencies: 10
Date: May 18, 2023
Visit Reason
The inspection was conducted to evaluate compliance with federal regulations regarding resident abuse prevention, physical restraint use, abuse reporting, PASRR coordination, fall prevention, catheter care, nursing staff competencies, psychotropic medication use, medication administration, and infection control.
Findings
The facility failed to prevent and properly report resident-to-resident abuse incidents, failed to ensure appropriate use and documentation of physical restraints, failed to coordinate PASRR assessments for residents with new psychosis diagnoses and antipsychotic medication starts, failed to document and investigate a resident fall, failed to obtain physician orders and document catheter care, failed to ensure nursing staff competencies were current, failed to monitor and document psychotropic medication use including behaviors and side effects, had a medication administration error involving crushing medications that should not be crushed, and failed to ensure proper hand hygiene among staff.
Deficiencies (10)
Failed to prevent resident-to-resident abuse involving Residents #64, #65, and #77.
Failed to ensure one resident (#48) was free from physical restraints without proper consent and justification.
Failed to timely report resident-to-resident altercations involving Residents #64, #65, and #77 to the State Agency.
Failed to coordinate PASRR assessments and notify PASRR program of new psychosis diagnosis and antipsychotic medication for Resident #29.
Failed to document and investigate a fall reported by Resident #233, including lack of RN assessment and fall risk reassessment.
Failed to obtain physician orders and document catheter care and maintenance for Resident #63 with an indwelling catheter.
Failed to ensure nursing staff had completed required competencies in catheter care and ADLs for selected RNs and CNAs.
Failed to monitor targeted behaviors, side effects, and provide non-pharmacological interventions for psychotropic medications for Residents #33, #22, and #29; and failed to complete risk/benefit statements or gradual dose reductions for Residents #33 and #22.
Medication administration error: crushed medications (Amlodipine and Memantine) that should not be crushed, resulting in a 7.4% error rate.
Failed to ensure adequate hand hygiene by nursing staff before and after resident contact and other key moments.
Report Facts
Medication administration error rate: 7.4
Residents reviewed for abuse: 44
Residents reviewed for catheter care: 44
Residents reviewed for psychotropic medication: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed medication administration error and interviewed about medication crushing policies |
| DON | Director of Nursing | Provided policies, interviewed regarding multiple deficiencies including abuse prevention, catheter care, medication errors, hand hygiene, and staff competencies |
| SSD | Social Services Director | Interviewed regarding abuse reporting, PASRR coordination, psychotropic medication monitoring |
| RN #2 | Registered Nurse | Interviewed regarding medication administration, psychotropic medication monitoring, catheter care |
| CNA #1 | Certified Nurse Aide | Interviewed regarding resident behaviors and abuse incidents |
| IP | Infection Preventionist | Interviewed regarding hand hygiene policies and staff compliance |
Inspection Report
Routine
Deficiencies: 12
Date: Mar 17, 2022
Visit Reason
Routine state inspection survey of Skyline Ridge Nursing & Rehabilitation Center to assess compliance with regulatory requirements including resident rights, care, safety, medication administration, activities, and food service.
Findings
The facility was found deficient in multiple areas including failure to honor resident rights related to meal choices and dignified care, failure to provide assistance for resident smoking preferences, incomplete advanced directive documentation, improper use and assessment of physical restraints, inadequate provision of meaningful activities, failure to follow physician orders for medication administration including insulin and antihypertensives, unsafe bed positioning, inadequate fall prevention interventions, incomplete oxygen therapy orders, insufficient pain management documentation and parameters, failure to ensure residents were free from unnecessary psychotropic medications, failure to provide adequate hydration with thickened liquids as ordered, and improper food temperature control and sanitation during meal service.
Deficiencies (12)
F 0550: Facility failed to ensure Resident #2 was offered regular meal choices and nursing staff did not stand while assisting the resident to eat.
F 0561: Facility failed to ensure Resident #30 was provided assistance to go outside to smoke at her request.
F 0578: Facility failed to ensure Residents #64 and #62 had legally signed advanced directive orders and documentation of legally designated medical power of attorney.
F 0604: Facility failed to identify recliner as a restraint for Resident #51 and failed to comprehensively assess and care plan self releasing seat belt as a restraint for Resident #57.
F 0679: Facility failed to provide ongoing program to support residents' choice of activities and meaningful engagement for Residents #30, #51, #55, and #66.
F 0684: Facility failed to ensure medication administration followed physician orders for insulin and antihypertensives for Residents #8, #27, #37, and #56.
F 0689: Facility failed to provide adequate supervision and fall prevention interventions for Residents #15, #16, #49, and #2, including unsafe elevated bed position for Resident #2.
F 0695: Facility failed to have complete and comprehensive oxygen orders for Resident #66 and failed to provide consistent oxygen therapy.
F 0697: Facility failed to ensure pain medication orders included pain level parameters and failed to document non-pharmacological pain interventions for Residents #2, #19, and #33.
F 0758: Facility failed to ensure residents were free of unnecessary psychotropic medications and failed to provide informed consent with required information for Residents #47, #2, and #55.
F 0807: Facility failed to consistently provide Resident #64 with thickened liquids as ordered and failed to provide drinks of choice between meals.
F 0812: Facility failed to ensure proper food holding temperatures during meal service and failed to properly clean and sanitize dining room tables after meals.
Report Facts
Deficiencies cited: 12
Fall incidents: 6
Blood sugar levels: 450
Medication doses: 3
Medication doses: 25
Medication doses: 0.5
Medication doses: 0.25
Medication doses: 30
Medication doses: 60
Medication doses: 15
Medication doses: 10
Medication doses: 50
Medication doses: 325
Medication doses: 650
Food temperatures: 134
Food temperatures: 50.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed assisting Resident #2 with eating and interviewed regarding meal assistance and medication administration. |
| RN #3 | Registered Nurse | Observed administering Metoprolol to Resident #8 without obtaining current blood pressure. |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding medication administration and fall prevention for Residents #15, #16, #19. |
| CNA #2 | Certified Nurse Aide | Interviewed regarding Resident #2's bed height and fall risk. |
| Director of Nursing | Director of Nursing | Interviewed multiple times regarding facility policies, medication administration, fall prevention, and informed consent. |
| Dietary Manager | Dietary Manager | Interviewed regarding food temperature control and thickened liquids preparation. |
| Social Services Director | Social Services Director | Interviewed regarding informed consent process and fall prevention. |
Inspection Report
Routine
Deficiencies: 13
Date: Mar 17, 2022
Visit Reason
Routine inspection of Skyline Ridge Nursing & Rehabilitation Center to assess compliance with regulatory requirements including resident rights, care, medication administration, fall prevention, activities, and food safety.
Findings
The facility had multiple deficiencies including failure to honor resident rights related to meal choices and dignified care, inadequate assistance for smoking preferences, incomplete advanced directive documentation, improper use and assessment of restraints, insufficient activity programming, medication administration errors including insulin and antihypertensives, inadequate pain management documentation, failure to ensure safe bed positioning and fall prevention, incomplete oxygen therapy orders, and food safety violations including improper food temperature control and inadequate dining room sanitation.
Deficiencies (13)
Failed to ensure Resident #2 was offered regular meal choices and nursing staff did not stand while assisting the resident to eat.
Failed to ensure Resident #30 was provided assistance to go outside to smoke at her request.
Failed to obtain legally signed advanced directive orders for Residents #64 and #62 and ensure physician and legally designated representatives signed orders.
Failed to ensure residents were free from physical restraints; recliner identified as restraint for Resident #51 and inadequate assessment and care planning for self releasing seat belt restraint for Resident #57.
Failed to provide meaningful activities consistent with resident preferences and needs for Residents #30, #51, #55, and #66.
Failed to follow physician orders during insulin administration for Residents #56 and #37, including administering insulin when blood sugar was below ordered threshold and not administering insulin as ordered.
Failed to ensure vital signs were obtained prior to administration of antihypertensive medications for Residents #8 and #27.
Failed to ensure Resident #2's bed was in a safe position and failed to provide adequate supervision to prevent accidents for Residents #15, #16, #49, and #2.
Failed to provide safe and appropriate respiratory care with complete oxygen orders for Resident #66.
Failed to provide safe, appropriate pain management including lack of pain level parameters on orders and failure to document non-pharmacological interventions for Residents #2, #19, and #33.
Failed to implement gradual dose reductions and provide sufficient informed consent including black box warnings for psychotropic medications for Residents #47, #2, and #55.
Failed to ensure drinks and fluids were provided consistent with care plan and preferences for Resident #64, including failure to provide thickened liquids as ordered and failure to provide drinks of choice between meals.
Failed to ensure dietary department followed safe practices to prevent food contamination and food-borne illness including improper holding temperatures during meal service and inadequate cleaning and sanitizing of dining room tables.
Report Facts
Pain level: 3
Pain level: 5
Pain level: 6
Blood sugar: 163
Blood sugar: 79
Blood sugar: 401
Blood pressure: 90
Blood pressure: 110
Blood pressure: 135
Blood pressure: 41
Food temperature: 50.6
Food temperature: 107
Food temperature: 122.1
Food temperature: 134
Food temperature: 134.5
Food temperature: 127
Food temperature: 133
Food temperature: 138
Food temperature: 114.8
Food temperature: 127
Food temperature: 192
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in findings related to meal assistance and medication administration |
| RN #2 | Registered Nurse | Named in findings related to medication administration and hydration |
| RN #3 | Registered Nurse | Named in findings related to medication administration |
| RN #4 | Registered Nurse | Named in findings related to medication administration |
| LPN #1 | Licensed Practical Nurse | Named in findings related to medication administration and fall prevention |
| LPN #2 | Licensed Practical Nurse | Named in findings related to medication administration and hydration |
| CNA #1 | Certified Nurse Aide | Named in findings related to smoking assistance and fall prevention |
| CNA #2 | Certified Nurse Aide | Named in findings related to restraint and fall prevention |
| CNA #3 | Certified Nurse Aide | Named in findings related to fall prevention |
| CNA #6 | Certified Nurse Aide | Named in findings related to hydration |
| CNA #7 | Certified Nurse Aide | Named in findings related to meal service |
| DON | Director of Nursing | Named in multiple findings related to policy, medication, fall prevention, hydration, and informed consent |
| SSD | Social Service Director | Named in findings related to advanced directives, psychotropic medications, and fall prevention |
| DM | Dietary Manager | Named in findings related to food service and hydration |
| HRN | Hospice Registered Nurse | Named in findings related to bed safety |
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