Skylake Post Acute

F-F600 for failure to prevent resident to resident altercations.

The DON was interviewed on 6/13/24 at 11:05 a.m. The DON said the facility did not have an investigation for the resident's bite wound and it was not reported to the State oversight office as an injury of unknown origin.

The DON said she had heard about the allegation that Resident #1 had a bite mark on his arm so she asked one of the facility nurses to look at his arm. The DON said she did not examine the resident herself and could not remember which nurse she asked to look at the resident's arm but she said remembered the nurse reported the resident did not have a bite wound. The DON said she did not know why there was no documentation of the assessment of Resident #1 done by the nurse but said she would try to find out which nurse assessed the resident and look to see if the facility had any documentation of the allegation and the assessment of the resident.

-The DON did not provide any additional evidence to indicate the allegation that Resident #1 sustained a bite wound of unknown origin was investigated or that the nursing staff assessed and monitored the resident's injury.

Cross-referenced to

F-F609 failure to report a suspicious injury of unknown origin.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 26 065238 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065238 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skylake Post Acute 12080 Bellaire WY Thornton, CO 80241

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 LPN #1 was interviewed on 6/14/24 at p.m. LPN #1 said Resident #1 frequently wandered the unit and needed staff redirection to ensure his safety. She said his wandering did not bother other residents. LPN #1 Level of Harm - Minimal harm or said he was working on the secured unit on 4/9/24 and he did see a circular red mark on Resident #1's arm potential for actual harm but assumed he had bumped into something due to his constant wandering. LPN #1 said he did not assess

the resident's injury because he was not the resident's assigned nurse. He said even though the resident Residents Affected - Few lived on the 500 unit he was assigned to the care of a nurse who worked the 400 unit which was just on the other side of the locked unit doors. LPN #1 said the 400 unit would cross the threshold of the secured doors to administer medication, provide treatments, and other types of nursing care services to Resident #1 and a couple of other residents.

E. Facility follow-up

On 6/14/24 at 2:43 p.m. the DON provided an employee counseling form dated 6/14/24. The counseling form read in pertinent part, Employee name: LPN #3. Verbal warning. Nature of infraction: You failed to complete

a risk management for a bite that occurred on your unit. Corrective action: Review of policy on reporting, and verbal education on the incident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 26 065238 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065238 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skylake Post Acute 12080 Bellaire WY Thornton, CO 80241

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0843 Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. Level of Harm - Minimal harm or potential for actual harm 41032

Residents Affected - Many Based on record review and staff interviews, the facility failed to have a written transfer agreement with one or more hospitals approved for participation under Medicare and Medicaid programs to reasonably ensure residents would be transferred from the facility to a hospital, and assured of timely admission to the hospital when transfer was medically appropriate.

Specifically, the facility failed to ensure a written agreement was in effect with one local area hospital.

Findings include:

I. Record review

A request was made to the director of nursing (DON) and corporate nurse consultant (CNC) #1 on 6/13/24 at 4:27 p.m., for the facility's hospital transfer agreement.

-The facility was unable to provide a written agreement for the one area hospital.

II. Interview

The interim nursing home administrator (INHA) and CNC #1 and CNC #2 were interviewed together on 6/14/24 at 3:55 p.m. The INHA said the facility did not have a hospital transfer agreement. The INHA said no area hospitals would provide the facility with a transfer agreement because the hospitals took residents based on the hospital's availability to accept patients. She said since patients were diverted to the closest available hospital a transfer agreement was not necessary.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 26 065238

F-F610 for failure to investigate an allegation of abuse related to an injury of unknown origin.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 26 065238 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065238 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skylake Post Acute 12080 Bellaire WY Thornton, CO 80241

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41032 potential for actual harm Based on record review and interviews, the facility failed to ensure incidents of potential abuse were Residents Affected - Few thoroughly investigated for one (#1) of three residents out of 16 sample residents.

Specifically, the facility failed to ensure an allegation of physical abuse, reported following the discovery of an injury of unknown origin, a bite wound, was thoroughly investigated and that the resident was monitored to prevent the possibility of a repeated instance.

Findings include:

I. Facility policy and procedure

The Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy, revised September 2022, was received from the director of nursing (DON) on 6/14/24 at 10:30 a.m. The policy documented in pertinent part, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of property are reported to the local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.

If resident abuse, neglect or injury of unknown source is suspected, the suspicion must be reported to the administrator and to other officials according to state law.

-Upon receiving any allegation of abuse, neglect or an injury of unknown source, the administrator is responsible for determining what actions are needed for the protection of residents.

-All allegations are thoroughly investigated.

The Investigation Injuries policy, revised December 2016, was received from the DON on 6/14/24 at 10:30 a. m. The policy documented in pertinent part, The administrator will ensure that all injuries are investigated. Documentation shall include information relevant to risk factors and conditions that could cause or predispose someone to similar signs and symptoms.

Injury of unknown source is defined as an injury that meets both the following conditions:

-The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and,

-The injury is suspicious because of the extent of the injury, the location of the injury, the number of injuries at one particular point in time or the incident of the injuries over time.

If an incident is suspected a nurse or nurse supervisor will complete a facility-approved accident/incident form. The form will be disseminated to the appropriate individuals, for example, the administrator and director of nursing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 26 065238 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065238 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skylake Post Acute 12080 Bellaire WY Thornton, CO 80241

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 The Abuse, Neglect, Exploitation or Misappropriation - prevention program policy, revised April 2021, was received from the DON on 6/14/24 at 10:30 a.m. The policy documented in pertinent part, Residents have Level of Harm - Minimal harm or the right to be free from abuse. potential for actual harm II. Resident #1 Residents Affected - Few A. Resident status

Resident #1, age 76, was admitted on [DATE REDACTED] and discharged to another facility on 5/5/24 According to the May 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease, dementia with behavioral disturbance and chronic kidney disease.

According to the 3/9/24 minimum data set (MDS) assessment, the resident had severe cognitive impairments and was not able to complete the brief interview for mental status (BIMS) exam. Staff assessment of the resident revealed the resident usually understood others but had difficulty communicating some words or finishing thoughts but was able to communicate when prompted or given time; however, the resident missed some parts or intent of conversations. The resident had short and long-term memory problems and had moderately impaired cognitive skills for daily decision making for which the resident required cues and staff supervision.

The resident wandered but did not display aggressive behaviors towards self or others.

B. Resident representative interview

Resident #1's representative was interviewed on 6/13/24 at 6:13 p.m. The representative said she was at the facility every day to visit with Resident #1. She said on the morning of 4/9/24 she received a call from Resident #1's hospice nurse asking if she knew about a bite mark on the top of Resident #1's wrist. The representative said that was the first time she was made aware that there was a bite mark on Resident #1's hand. The representative said she was at the facility the day prior (4/8/24) at lunchtime and the resident did not have the bite mark on his arm at that time so the injury had to have happened sometime after she left the faciity on [DATE REDACTED] and the morning of 4/9/24.

The representative said she went to the facility to find out what happened and observed the bite wound on Resident #1's arm. The representative said she talked to the staff on duty and no one knew that the resident had a bite wound and nobody could reasonably explain how the bite happened. The representative said she took a picture of the resident's wound to show the facility administration.

The representative said the bite wound was on the top side of the resident's forearm, starting at the wrist, in

a vertical straight up and down direction. She said there were several teeth marks that broke the skin on top of his wrist just above the wrist joint on the forearm. She said the reddened open wounds had started to scab over. She said there was bruising on the resident's arm approximately two inches from the crescent-shaped teeth impressions with broken skin and mild bruising. She said the bite wound was vertical, or straight up and down, along the arm and not at an angle along the side of the resident's arm or on the top and bottom of the arm, which would have been more typical if the resident had bitten himself.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 26 065238 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065238 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skylake Post Acute 12080 Bellaire WY Thornton, CO 80241

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 The representative said she spoke to licensed practical nurse (LPN) #2, who was Resident #1's nurse and was familiar with him. She said she asked LPN #2 to look at the resident's arm. She said LPN #2 examined Level of Harm - Minimal harm or the resident and said she thought he bit himself. The representative said she told LPN #2 that she did not potential for actual harm believe the resident could have bitten himself due to the placement of the bite being so straight up and down

on the top of the Resident's arm. The representative said, as far as she was aware, LPN #2 took no other Residents Affected - Few action to address the nature of the bite on Resident #1's arm.

The representative said after speaking to LPN #2 she spoke to LPN #3, who was the memory care unit manager. She said LPN #3 said she was unaware of the bite mark on Resident #1 but would look into the matter. The representative said she never heard anything further from facility staff about how Resident #1 got the bite mark on his hand.

The representative said she was concerned for Resident #1's safety.

C. Record review

-A review of Resident #1's electronic medical record (EMR) revealed no documentation from the facility staff about Resident #1 having a bite mark on the top of his left hand on or around 4/9/24.

-Additionally, there was no documentation to indicate that Resident #1 had a history of self-injurious behaviors or self-biting behaviors.

-A review of the resident's medication administration record (MAR) revealed the only behaviors documented

on 4/8/24 and 4/9/24 were restlessness and pacing.

A review of hospice notes revealed the hospice nurse was notified that the resident had a bite mark on the top of his left hand that was reported by the hospice certified nurse aide (CNA) on 4/9/24. The hospice notes documented the following:

A hospice nurse note, dated 4/9/24, documented the nurse was notified by the hospice CNA that Resident #1 had what appears to be a bite mark on his left hand. The hospice nurse contacted the resident's representative to see if she was at the facility or had already been informed. The resident's representative was unaware of the bite mark and told the hospice nurse she was going to the facility to find out what was going on. Later that day (4/9/24) the memory care unit manager (LPN #3) called the hospice nurse and was upset that the wife knew of the resident's injury prior to the facility staff assessing the new wound.

-However, LPN #3 denied knowing anything about Resident #1 having a bite mark on his person when interviewed (see LPN #3 interview below).

A hospice nurse note dated 4/11/24 documented a facility CNA stated the resident was up all night and very tired. The resident had an injury, a presumed bite, to the left hand with no signs or symptoms of infection noted.

A hospice nurse note dated 4/18//24 documented the resident had scabs to his left hand from an apparent bite which was healing. The hospice nurse collaborated with the facility nurse (LPN #1) and updated the resident's binder.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 26 065238 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065238 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skylake Post Acute 12080 Bellaire WY Thornton, CO 80241

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 -However, LPN #1 denied knowing anything about Resident #1 having a bite mark on his person when interviewed (see LPN #1 interview below). Level of Harm - Minimal harm or potential for actual harm D. Staff interview

Residents Affected - Few LPN #2 was interviewed on 6/12/24 at 1:30 p.m. LPN #2 said she remembered Resident #1 but said she did not work with him a lot. She said the resident's representative did mention that he had a bite wound but she was not his nurse and she did not assess him at that time or see the bite wound. She said he did have scratches on his arm.

-However, a review of Resident #1's MAR revealed LPN #2 was the nurse who was administering medications and documented behavior monitoring for Resident #1 on almost every shift in April 2024, including 4/9/24, the day the bite wound was discovered.

Registered nurse (RN) #1 was interviewed on 6/12/24 at 1:33 p.m. RN #1 said she was new to the unit and was not working in her position when Resident #1 was in the facility. RN #1 said there were a lot of aggressive residents needing monitoring and redirection in order to prevent resident to resident altercations.

LPN #3 was interviewed on 6/12/24 at 1:36 p.m. LPN #3 said she had no knowledge of the resident having a bite mark on his arm. She said she was only aware that he had some scratches on his person which she attributed to his wandering. She said the resident was not aggressive toward others but did wander and needed a lot of redirection to stay in areas where staff could monitor him.

-However, the resident's representative said she spoke directly to LPN #3 (see representative interview above) to report the bite marks and an injury of unknown origin and asked for information on how the bite occurred.

-Additionally, the hospice registered nurse (HRN) documented in the progress notes (see record review above) and confirmed in an interview (see interview below) that she spoke to LPN #3 about the bite wound

on Resident #1's left arm.

The memory care unit social services assistant (SSA) was interviewed on 6/12/24 at 1:38 p.m. The SSA said Resident #1's representative mentioned that Resident #1 had a bite mark on his hand The SSA said she did not see the bite mark and the resident's representative had made no further inquiry about the nature of the bite mark. The SSA said Resident #1 was not aggressive towards other residents but he wandered into other resident's rooms which startled some residents and was bothersome to some of the residents in the unit.

She said, for that reason, staff were required to keep an eye on Resident #1 and provide continuous redirection when he was wandering.

The HRN was interviewed on 6/12/24 at 2:16 p.m. The HRN said the resident's hospice CNA called her on

the morning of 4/9/24 to report that the resident had a wound on the top of his left forearm that looked like a bite mark. The HRN said the hospice CNA reported to her that the facility staff were unaware of how the resident got the wound.

The HRN said she called the facility before calling the resident's representative, but had to leave a voice message when the memory care unit manager (LPN #3) did not answer the phone.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 26 065238 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065238 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skylake Post Acute 12080 Bellaire WY Thornton, CO 80241

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 The HRN said when she called the resident's representative to see if she was at the facility or had knowledge of what happened to Resident #1, the resident's representative did not even know the resident Level of Harm - Minimal harm or had a bite mark wound on his person. potential for actual harm

The HRN said about 30 minutes after talking to the resident's representative, she received a call from LPN Residents Affected - Few #3 scolding her for not calling the facility first.

The HRN said LPN #3 said she had no awareness of a bite wound on Resident #1 and then in the same conversation said the resident bit himself.

The HRN said she assessed the resident's wound on 4/11/24, cleaned the wound and bandaged it. The HRN said the wound on Resident #1's upper forearm at the wrist was definitely teeth impression marks. She said the bite was in a pattern of a full set of upper teeth and partial bottom teeth and it was in a placement pattern that was unlikely that he would have done it himself.

The HRN said she observed the resident to have several bruises, scratches and other injuries of unknown origin over the next several weeks with no explanation of how he was injured. The HRN said she had concerns because Resident #1 was known to wander into other resident's rooms and was often injured as a result of some other residents being upset over his wandering behaviors. The HRN said there were a lot of residents on the unit who were physically aggressive toward other residents

Cross-reference