Skyline Heights: Six Nursing Directors in One Year - MT

The January incident at Skyline Heights Nursing and Rehabilitation illustrates how management chaos has undermined basic infection control at the 24th Street facility. Federal inspectors found the nursing home had cycled through six directors of nursing in a single year while staff routinely ignored requirements to wear protective equipment during wound care and catheter procedures.

"We are working on getting our sixth DON hired in the one year I've been here, so we haven't had consistent management of nurse staffing issues," an administrator told inspectors on January 29.

The administrator was juggling his regular duties plus three other administrative positions due to vacancies. He had been filling in as the facility's infection prevention coordinator when no one else was available, a role that rotated through departing assistant directors of nursing and nursing directors.

"Infection control issues were not up to date due to the new ADON just getting started in her role," the administrator said.

Resident 63, who had a below-the-knee amputation, told inspectors that nurses changing her leg dressing "only wear gloves" because "the facility is not in Covid outbreak, so the nurses don't have to wear gowns."

When inspectors observed her wound care on January 28, they watched nurse H don gloves, remove the old dressing, spray the wound with cleanser, and pack calcium alginate into four open holes along the incision. The nurse then removed his gloves without sanitizing his hands and left the room to retrieve tape. He returned immediately and placed an abdominal dressing pad on the wound and taped it in place with his bare hands.

"He should have worn a gown and gloves for the whole treatment," the nurse admitted afterward.

The facility's own policy required gown and glove use for "wound care for any skin opening requiring a dressing." Enhanced barrier precautions were supposed to remain in place for residents' entire stays or until wounds healed.

Resident 346, who had recent double amputations on both legs, pointed to personal protective equipment hanging unused on his bathroom door. "The staff just put that in here. It's never been in here before. They don't even use the gowns and stuff in there. I don't know why it is in here," he said.

Two family members confirmed staff weren't following protocols. One said staff "have never used gowns or gloves when getting him up." Another observed that staff "do use gloves when doing personal care, but not a gown."

A nursing assistant told inspectors that transfers wouldn't be considered direct care requiring protective equipment, despite the facility policy indicating otherwise for residents with wounds or medical devices.

"EBP signs are on the doors of those residents that require the use of PPE while performing cares. I can't say staff follow them though," another staff member said.

The confusion extended beyond wound care. Resident 5, who had a catheter, said staff "sometimes wear gowns when they perform catheter care, they usually just wear gloves." Resident 6, who had both wound dressings and catheter care, said staff "wear gloves and sanitize hands but don't wear a gown when doing catheter care."

One staff member admitted being unsure when enhanced barrier precautions were needed. The facility had provided education on the topic the day before the interview, but staff weren't required to physically practice putting on and removing protective equipment.

"Education was needed for all of their staff concerning enhanced barrier precautions," two administrators acknowledged.

The management turnover had derailed the facility's quality improvement efforts. The administrator said the quality committee had worked on a skin care action plan related to shower violations, "and they started it, some of it fell apart, and they restarted it due to staff turnover."

When inspectors requested the facility's quality assurance plan on January 27, they initially received only a list of committee members. A second request that evening yielded two undated PowerPoint slides showing quarterly and yearly goals, including reducing employee turnover by 10 percent and agency usage by 35 percent.

The slides lacked any documented process for maintaining performance standards or timeframes for tracking improvements. They didn't describe how the facility would identify and correct deficient practices.

The facility had a formal policy from February 2020 outlining quality assurance requirements, including tracking performance, establishing goals, identifying deficiencies, analyzing root causes, and monitoring corrective actions. But the actual implementation had collapsed under the weight of constant administrative changes.

The former director of nursing had taken staffing documents when she left, according to the administrator, leaving gaps in essential records. "There was frequent turnover in nursing management positions, which affected the ability of the facility to keep up with regular staffing needs and training."

Immunization tracking had also broken down. Three residents were missing recommended pneumococcal vaccines, with staff member O admitting to taking residents' word during admission about whether they were up to date on immunizations.

"I did not have any clinical background and did not track the residents immunizations," staff member O said. "I thought this process could be better and stated there was a potential for some immunizations to be missed with their current process."

Two residents had signed declination forms claiming they were "up to date" on pneumococcal vaccines, but their medical records showed no documented vaccinations. A third resident had received older vaccine formulations but was missing the newer vaccines recommended by the CDC.

The administrator acknowledged the facility "could do better" with immunization tracking, while different staff members gave conflicting accounts of who was responsible for entering vaccine information into the computer system.

Skyline Heights' struggles illustrate how leadership instability can cascade through basic safety protocols. Six nursing directors in twelve months left the facility unable to maintain consistent infection control practices, even for procedures as fundamental as wound care and catheter management.

The facility's yearly goals included improving nursing documentation to 95 percent completion and ensuring residents receive timely showers. But with protective equipment hanging unused on bathroom doors and nurses performing wound care with bare hands, the more immediate challenge was preventing the spread of infection among vulnerable residents recovering from amputations and managing chronic conditions.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Skyline Heights Nursing and Rehabilitation from 2025-01-30 including all violations, facility responses, and corrective action plans.

Additional Resources

• View all inspection reports for Skyline Heights Nursing and Rehabilitation
• Browse all MT nursing home inspections