Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Skylake Post Acute during CMS and state inspections, most recent first.
A cognitively intact resident with multiple medical conditions required assistance with bathing but did not have bathing preferences or specific shower days incorporated into the ADL care plan, and no shower preference assessment was completed on admission. The resident’s representative reported that staff were not providing requested showers, observed the resident in the same clothing with a personal odor, and the facility could not produce documentation of completed showers. CNA and LPN interviews described a routine shower schedule, processes for offering and documenting showers and refusals, and communication between shifts, while the DON stated that preference evaluations and post-admission showers were expected but acknowledged staff reported forgetting to document offers or refusals. Record review showed no documented showers during the resident’s stay, demonstrating a failure to provide and document showers consistent with the resident’s preferences.
A resident with sepsis, pneumonia, weakness, and high fall risk required substantial assistance with ADLs and had a care plan that included two-person assistance for incontinence care. During incontinence care, a CNA assisted the resident alone, during which the resident rolled out of bed and sustained right shoulder pain, multiple toe skin tears, and a knee abrasion. The resident later reported that the CNA repeatedly pushed her to roll and that she was pulled up from the floor by her painful arm. The ADL care plan did not clearly specify bed mobility assistance needs, staff understanding of required assistance was inconsistent with the care plan, and there were no nursing progress notes documenting the fall in the EMR on the day of the incident.
A resident with multiple medical conditions and a documented pineapple allergy was served a dinner tray containing pineapple, which the resident ate before the error was recognized, despite the allergy being clearly listed and highlighted on the meal ticket and in the care plan. Facility policy required identification of food allergies at admission, documentation in the care plan, and provision of appropriate substitutions, with meal tickets used by dietary and nursing staff to verify diets and allergies. In this case, a dietary aide did not properly review the meal ticket and placed pineapple on the tray, and a CNA noticed the error only after the resident had already consumed some of it. Resident council feedback later described broader concerns that CNAs were not consistently following meal tickets or correcting meal errors, indicating ongoing issues with adherence to established meal verification processes.
Staff failed to follow infection control protocols by not wearing required gowns during high-contact care for a resident on enhanced barrier precautions and by not sanitizing wound care equipment or maintaining a clean work surface during wound care. These actions were inconsistent with facility policy and were confirmed through staff interviews.
The facility failed to protect residents from abuse in the memory care-secured unit, where a resident with a known history of aggression was admitted without a comprehensive assessment or behavioral management plan. This led to an incident where the resident physically assaulted another resident, causing severe injuries. The facility's inadequate screening and admission process, along with the lack of communication about the resident's history, contributed to the incident.
The facility did not have a written transfer agreement with a local hospital certified by Medicare or Medicaid. During a review, the DON and corporate nurse consultants could not provide the agreement. The INHA stated that hospitals accepted residents based on availability, making a formal agreement unnecessary.
A facility failed to inform a resident's legal representative about care plan meetings, medical appointments, and changes in the resident's condition. The resident, with severe cognitive impairment, had a representative to make decisions on their behalf. Despite daily visits, the representative was not notified of care conferences or medical appointments, learning about them only through a voicemail. Staff interviews revealed inconsistencies in the notification process, impacting the representative's ability to participate in care planning.
A resident in a long-term care facility was found with a bite wound of unknown origin, which was not reported to the State oversight agency within the required 24-hour timeframe. Despite the facility's policy requiring immediate reporting, staff, including the DON and an LPN, failed to investigate or document the incident. The resident's representative and hospice nurse were the first to notice the wound, but the facility did not take appropriate action, leading to a deficiency in compliance with reporting regulations.
A resident with severe cognitive impairments was found with a bite wound of unknown origin, but the LTC facility failed to investigate the incident thoroughly. Despite concerns raised by the resident's representative and hospice nurse, the staff did not document or report the injury, and the Director of Nursing admitted no investigation was conducted. This resulted in a failure to address potential abuse and ensure the resident's safety.
Failure to Honor Resident Bathing Preferences and Document Shower Provision
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to self-determination and choice regarding bathing, specifically by not ensuring showers were provided consistent with the resident’s preferences. The resident, an older adult with diagnoses including severe sepsis with septic shock, pneumonia, major depressive disorder, and weakness, was cognitively intact with a BIMS score of 15 and required assistance with several activities of daily living. The MDS documented bathing as not applicable for assistance, while the ADL care plan initiated shortly after admission indicated the resident needed partial to substantial assistance for bathing or showering but did not include the resident’s bathing preferences or specific shower days. The resident’s representative reported that the resident stated staff were busy and not providing showers, and that the resident requested a shower during the week after admission but did not receive one. The representative observed the resident wearing the same clothing on multiple occasions and noted a personal female odor, and the resident expressed a desire to be clean. When the representative requested documentation of completed showers from the DON, the facility was unable to provide it. Review of the CNA bathing task documentation from admission through discharge showed no documented showers during the resident’s stay, and the electronic medical record revealed that the shower preference assessment was not completed upon admission. Staff interviews indicated that residents were scheduled for showers multiple times per week and could choose morning or evening showers, with refusals to be documented and communicated between shifts. A CNA stated that this resident was scheduled for showers three times weekly and sometimes refused due to fatigue after therapy, with refusals to be documented and missed showers potentially made up on subsequent days. An LPN described a process of repeated offers, documentation of refusals, and family notification if a resident refused showers. The DON stated residents were to be offered showers at least twice weekly, that a preference evaluation was part of the admission packet, and that new admissions were to be offered a shower the day after admission, but acknowledged staff reported they forgot to document offers or refusals and that she was unaware of any bathing concerns until after the resident had discharged. These findings collectively show that the facility did not ensure the resident’s shower preferences were assessed, care planned, and carried out in practice, nor consistently documented.
Failure to Provide Safe Assistance During Incontinence Care Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe assistance and adequate supervision during incontinence care, resulting in a fall with minor injuries. The facility’s Falls – Clinical Protocol policy required identification of residents at risk for falls and assessment and documentation of falls and related factors. Resident #1, an older adult with severe sepsis with septic shock, pneumonia, major depressive disorder, and weakness, was cognitively intact and required substantial to maximal assistance with toileting and other ADLs. A fall risk assessment identified her as a high fall risk, and her fall care plan cited risk factors including respiratory failure, COPD, and chronic pain. The resident’s ADL care plan noted a self-care performance deficit and need for staff assistance, but the bed mobility intervention did not specify the level of assistance or number of staff required. The fall care plan, however, included an intervention that two staff members were to provide incontinence care. On the date of the incident, a CNA was providing incontinence care when the resident rolled out of bed, landing on her lower extremities. The resident reported right shoulder pain, and the nurse observed multiple skin tears on the toes and a right knee abrasion. An IDT note later described that the resident lifted her right leg, her weight shifted, and she rolled left and slid out of bed onto her knees during incontinence care. The resident’s representative reported that the resident stated an unknown CNA kept pushing her to roll over during incontinence care, leading to her falling off the bed, and that a nurse entered and saw the CNA pulling the resident up from the floor by her right arm despite the resident’s complaints of pain. The representative also reported abrasions or bruising on every toe of the resident’s right foot, with bandages applied, and that the facility notified her later that the resident had a fall and was fine, without informing her of injuries. Staff interviews showed inconsistency between the care plan requirement for two-person assistance during incontinence care and staff understanding of the needed level of assistance, with the DON stating the resident required one-person assistance for turning in bed prior to the fall. Review of the electronic medical record revealed no nursing progress notes documenting the fall event on the date it occurred.
Failure to Prevent Serving Allergen-Containing Food Despite Documented Allergy
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food served accommodated a resident’s documented allergy, resulting in the resident being served and ingesting pineapple despite a known pineapple allergy. Facility policy on Food Allergies and Intolerances, revised August 2017, states that residents with food allergies are to be identified upon admission, have allergies documented in the care plan, and be offered appropriate substitutions, with steps taken to prevent exposure to allergens. For the resident involved, the comprehensive care plan initiated in mid-January identified allergies to pineapple and wool, and the care plan report listed pineapple as an allergy and included an intervention for staff to honor food preferences, although it did not document specific food likes and dislikes. The resident, an older adult with diagnoses including severe sepsis with septic shock, pneumonia, major depressive disorder, and weakness, was cognitively intact with a BIMS score of 15 and required set-up or clean-up assistance with eating. On an evening in January, nursing documentation shows that pineapple was present on the resident’s dinner tray even though the resident had a documented pineapple allergy. The progress note states the resident ate two pieces of pineapple before the error was recognized and the pineapple was removed. The resident’s representative reported that the allergy was documented in the medical record and on the meal ticket, yet pineapple was still served, and that the resident became upset and did not understand how this occurred. According to the facility’s own root cause analysis, the dietary aide responsible for serving food did not correctly review the resident’s meal card and failed to note the highlighted pineapple allergy, placing pineapple on the tray as dessert. The CNA delivering the tray identified the pineapple only after the resident had already eaten two pieces. Interviews with the dietary manager, dietary aide, cook, RD, CNA, RN, and DON consistently described a system in which resident allergies are entered into an electronic system, printed on meal tickets, and highlighted so that kitchen and nursing staff can verify trays before service. However, in this incident, staff did not adequately review or follow the meal ticket information, and subsequent resident council notes documented ongoing resident concerns that CNAs were not following meal tickets correctly and were not consistently asking residents for their meal choices. Resident council meeting notes from late January and late February further describe meal service concerns, including reports that CNAs blamed the kitchen for meal mistakes and did not correct issues when errors occurred, and that meal tickets were not being followed correctly by CNAs on a specific unit. These resident reports indicate that, beyond the single documented pineapple incident, residents perceived ongoing problems with adherence to meal tickets and proper verification of meals against documented diets and allergies. The deficiency is thus centered on the facility’s failure, in at least one case, to prevent exposure to a known food allergen despite clear documentation and an established process intended to identify and avoid such allergens.
Failure to Adhere to Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not adhering to established protocols for personal protective equipment (PPE) and wound care. Specifically, staff did not wear gowns when providing direct care to a resident on enhanced barrier precautions (EBP), despite facility policy requiring both gloves and gowns for high-contact care activities involving residents at risk for or colonized with multi-drug resistant organisms (MDROs). Observations showed that a certified nurse aide and two LPNs provided care to a resident on EBP while only wearing gloves, omitting the required gown. Additionally, infection control measures were not followed during wound care procedures. One LPN used scissors from her pocket to cut wound dressing without sanitizing them before use, and another LPN used a retractable tape measure to measure an open wound, then retracted and stored it without sanitization. Wound care supplies were also placed directly on a resident's nightstand among personal items, rather than on a clean surface. Staff interviews confirmed that these actions were inconsistent with facility policy and best practices for infection control.
Failure to Protect Residents from Abuse in Memory Care Unit
Penalty
Summary
The facility failed to protect residents from abuse and neglect, specifically in the memory care-secured unit, where two residents were involved in incidents of resident-to-resident abuse. Resident #6, who had a known history of aggressive behavior, was admitted without a comprehensive assessment or a behavioral management care plan. The facility did not inform staff about Resident #6's history of aggression, which led to an incident where Resident #6 physically assaulted Resident #2, causing severe injuries. The staff did not closely monitor Resident #6's activities, despite observing changes in his behavior, which resulted in the assault on Resident #2. Resident #2, an 89-year-old with severe cognitive impairment and dementia, was unable to protect herself from the assault. She suffered significant injuries, including facial trauma and fractures, requiring hospitalization. The facility's failure to assess and manage Resident #6's behavior and to communicate his history to staff contributed to the incident. Additionally, the facility did not implement effective interventions to prevent resident-to-resident abuse, as evidenced by another incident where Resident #5 physically abused Resident #11. The facility's screening and admission process was inadequate, as it did not ensure the safety and appropriateness of admissions for residents with behavioral needs. The facility did not obtain or communicate sufficient information about Resident #6's history, which could have prevented the incident. The lack of a behavior-focused care plan and interventions for Resident #6, along with the failure to reassess his care needs, created a situation of immediate jeopardy for other residents in the memory care-secured unit.
Removal Plan
- Resident was discharged from the facility.
- Resident was placed on one-to-one monitoring and will continue one-to-one support with a review by the interdisciplinary team.
- The facility will hold admissions until it can review the pre-admission screening tool for residents with known behaviors.
- An ad hoc quality assurance performance improvement (QAPI) meeting will be held after the review of the pre-admission screening tool.
- The abuse policy was reviewed.
- The nurse practice educator/designee educated all staff on the facility abuse policy.
- Facility management staff reviewed the facility assessment on staffing and skills to care for residents with behaviors.
- The facility revised its pre-admission screening intake form to include a history of behaviors and supervision needs by the admissions director.
- The director of nursing educated the admissions team on the pre-admission screening tool and process.
- Residents in the memory support unit will be reviewed by social services and/or nursing/designee for behaviors, wandering, current interventions, and their care plan related to behaviors.
- Staff assigned to the memory support unit will be trained in specific resident care needs upon completion of the review, with training completed prior to their next assigned shift.
- Any admission to the memory support unit will be reviewed by social services and nursing to enter behavior tracking and a baseline care plan to meet the resident's needs.
- The facility assessment was reviewed and revised to include staffing levels for all departments in the memory support unit.
- New hires will receive education on abuse prevention and de-escalating behaviors during onboarding by the nurse practice educator.
- The nursing home administrator will implement a review with the quality assurance performance improvement (QAPI) committee to review and interpret all abuse findings, with all audit findings reviewed at the monthly meeting for at least three months or until the compliance pattern is maintained.
Lack of Hospital Transfer Agreement
Penalty
Summary
The facility failed to maintain a written transfer agreement with at least one local hospital certified by Medicare or Medicaid. This deficiency was identified during a record review and staff interviews. On a specific date, a request was made to the Director of Nursing (DON) and a corporate nurse consultant for the facility's hospital transfer agreement, but they were unable to provide such a document for the area hospital. During an interview, the interim nursing home administrator (INHA) and two corporate nurse consultants confirmed that the facility did not have a hospital transfer agreement. The INHA explained that local hospitals accepted residents based on their availability, and therefore, a formal transfer agreement was deemed unnecessary by the facility.
Failure to Inform and Involve Resident's Representative in Care Planning
Penalty
Summary
The facility failed to ensure that a resident's legal representative was informed and involved in the care planning process. The resident, who had severe cognitive impairment and was unable to participate in care planning, had a legal representative appointed to make decisions on their behalf. However, the facility did not notify the representative in advance of care plan meetings, nor did they inform her of the resident's podiatry and dental appointments or changes in the resident's condition, such as falls. The legal representative reported that she was not informed of a care conference meeting held on a different date than initially scheduled. She only learned about the resident's frequent falls and medical appointments through a voicemail left by the facility after the meeting. Despite being present at the facility daily, the representative was not kept informed of the resident's care and treatment changes, which hindered her ability to participate actively in the resident's care. Interviews with facility staff revealed inconsistencies in the notification process for care conferences and medical appointments. The social services assistant admitted to not notifying representatives of routine medical appointments and only contacting them by phone when there was insufficient time to send a letter. The director of nursing acknowledged issues with scheduling care conferences and emphasized the need for notifying representatives of all scheduled visits and changes in the resident's condition.
Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report an allegation of an injury of unknown origin, specifically a bite wound, to the State oversight agency within the required 24-hour timeframe. The incident involved a resident who was discovered to have a bite wound on the top of his left hand, which was suspected to have been caused by someone other than the resident himself. The facility's policy mandates that such incidents be reported immediately, defined as within two hours for serious bodily injury or within 24 hours for other allegations. However, the facility did not adhere to this policy, as the incident was not reported to the appropriate authorities. Interviews and record reviews revealed that the resident's representative and hospice nurse were the first to notice and report the bite wound. The hospice nurse informed the resident's representative and attempted to contact the facility, leaving a voicemail when unable to reach the memory care unit manager. Despite these efforts, the facility staff, including the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #3, were either unaware of the bite wound or did not take appropriate action to investigate or report the incident. The DON acknowledged hearing about the allegation but did not ensure an investigation was conducted or that the incident was reported. The lack of documentation and follow-up by the facility staff further compounded the issue. The DON could not provide evidence of an investigation or assessment of the resident's injury, and there was no documentation of any nurse's assessment of the bite wound. This failure to investigate and report the injury of unknown origin represents a significant deficiency in the facility's adherence to its policies and regulatory requirements.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an allegation of physical abuse involving a resident who was found with a bite wound of unknown origin. The resident, who had severe cognitive impairments and was known to wander, was discovered with a bite mark on the top of his wrist. Despite the resident's representative and hospice nurse raising concerns about the injury, the facility staff did not document or investigate the incident as required by their policies. Interviews with staff revealed inconsistencies and a lack of awareness regarding the resident's injury. The resident's representative reported the bite mark to the facility staff, but no one could provide an explanation for how the injury occurred. The hospice nurse also noted the injury and attempted to communicate with the facility, but the staff did not follow up with an investigation or report the incident to the appropriate authorities. The facility's Director of Nursing (DON) acknowledged that no investigation was conducted and that the incident was not reported as an injury of unknown origin. The DON admitted to hearing about the allegation but did not personally assess the resident or ensure that the staff documented the incident. This lack of action and documentation led to a failure in addressing the potential abuse and ensuring the resident's safety.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Thornton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Malley Transitional Care Center | 2.3 mi | — | 0 | 0 |
| Villas At Sunny Acres, The | 2.4 mi | — | 1 | 0 |
| Center At Northridge, Llc, The | 3.2 mi | — | 0 | 0 |
| Thornton Care Center | 3.8 mi | — | 0 | 0 |
| Adara Living | 5.9 mi | — | 2 | 0 |
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