Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brookdale Skyline during CMS and state inspections, most recent first.
A resident with multiple medical conditions and high fall risk was transferred from the toilet to a wheelchair by two CNAs using a gait belt instead of the required mechanical lift, as specified in the care plan. The resident lost the ability to bear weight during the transfer and fell, sustaining a right femur fracture. The staff did not consult with nursing or follow the care plan instructions before changing the transfer method.
Staff failed to use required assistive devices and proper techniques during transfers and incontinence care for three residents with severe cognitive impairment and mobility needs. This included not using a gait belt or Hoyer lift sling correctly, delaying incontinence care for nearly four hours, and not following perineal care and hand hygiene protocols.
The facility did not complete required annual performance reviews or provide regular in-service education for two CNAs, as confirmed by record review and staff interviews. The DON acknowledged that the reviews and education, which are mandated by facility policy, had not been conducted.
A resident on enhanced barrier precautions for an abdominal wound did not consistently receive care in accordance with infection control protocols, as a nurse was observed providing wound care while wearing only gloves and not a gown. Facility policy and CDC guidelines require both gloves and a gown for high-contact care activities, but interviews and observations confirmed that this practice was not always followed, despite clear signage and staff awareness of the requirements.
A resident with chronic respiratory failure and severe cognitive impairment did not consistently receive supplemental oxygen as ordered by the physician. Observations showed the resident was left without a nasal cannula and with an empty portable oxygen tank on multiple occasions, and staff interviews confirmed lapses in monitoring and administration of oxygen therapy.
Two residents with dementia did not receive person-centered care, as staff failed to address repeated requests for assistance and did not implement or document individualized interventions for behaviors such as repetitive motions and wandering. Care plans lacked specific strategies to manage these behaviors, and staff interviews revealed gaps in knowledge and documentation regarding effective dementia care.
A resident with dementia and Parkinson's disease did not receive meals according to her preferences because her meal ticket was left blank, despite assistance from her son and nursing staff. The issue was ongoing, and staff interviews revealed a lack of clear process for ensuring meal tickets were completed and reviewed, resulting in the resident receiving food she did not order.
Failure to Follow Care Plan for Mechanical Lift Transfer Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when staff failed to follow the care plan for a resident who required a mechanical lift for transfers. The resident, who was admitted for rehabilitation and had diagnoses including COPD, cirrhosis, duodenal ulcer, chronic respiratory failure, and low back pain, was assessed as dependent on staff for activities of daily living and at high risk for falls. The care plan and Kardex specified the use of a sit-to-stand mechanical lift for all transfers due to the resident's inability to reliably bear weight. On the night of the incident, two CNAs transferred the resident from the toilet to her wheelchair using a gait belt instead of the required mechanical lift. The decision to use the gait belt was influenced by the resident's previous complaints of discomfort with the mechanical lift and perceived difficulty maneuvering the lift in the bathroom. During the transfer, the resident lost the ability to bear weight in one leg and fell to the floor, resulting in a right femur fracture. The CNAs did not consult with a nurse or follow the care plan instructions prior to changing the transfer method. Interviews and documentation confirmed that the CNAs had received prior training on mechanical lifts and resident transfers, and that the resident's care plan had not been updated to allow for a less supportive transfer method. The incident was reported to nursing staff, and the resident was subsequently evaluated and sent to the hospital, where the fracture was confirmed. The failure to use the mechanical lift as directed in the care plan directly led to the resident's fall and injury.
Failure to Provide Proper ADL Assistance and Timely Incontinence Care
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living (ADLs) received the necessary services to maintain proper personal hygiene. Specifically, staff did not use a gait belt when transferring a resident with dementia, a history of falls, and abnormal gait from a recliner to a wheelchair, despite the resident requiring assistance for transfers and being at risk for falls. During a subsequent transfer, although a gait belt was applied, staff did not use it correctly and instead lifted the resident by the shoulders, contrary to facility policy and professional guidance. For another resident with severe cognitive impairment and total dependence on staff for ADLs, staff failed to use a Hoyer lift sling according to manufacturer guidelines during a transfer from wheelchair to bed. The lower straps of the sling were not crossed as required, and incontinence care was delayed for nearly four hours, resulting in the resident remaining in a heavily saturated brief. Additionally, staff did not follow proper perineal care technique, using the same disposable cloth for multiple wipes and failing to perform hand hygiene before repositioning the resident. A third resident, also with severe cognitive impairment and total incontinence, was not offered or provided incontinence care for almost four hours while in common areas. Staff repositioned this resident in her wheelchair by hooking their arms under her armpits, which is not in accordance with safe transfer practices. The care plans for both residents required regular incontinence checks and assistance, but these interventions were not consistently implemented as observed during the survey.
Failure to Complete Annual CNA Performance Reviews and In-Service Education
Penalty
Summary
The facility failed to complete annual performance reviews for two certified nurse aides (CNAs) and did not provide regular in-service education based on the outcomes of these reviews. Record review showed that both CNAs, one hired in 2020 and the other in 2008, did not have documented annual performance evaluations. The facility was unable to provide these records when requested, indicating that the required reviews had not been conducted. Interviews with the director of nursing (DON) confirmed that the facility's policy requires annual performance reviews and regular in-service education for CNAs, but these had not been completed for the two CNAs in question. The DON acknowledged the absence of the reviews and stated that the purpose of the evaluations is to assess job performance, identify areas needing improvement, and provide feedback. The lack of completed reviews and corresponding in-service education constituted the deficiency identified during the survey.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to maintain and follow its infection prevention and control program (IPCP) as required, specifically in relation to the use of personal protective equipment (PPE) during wound care for a resident on enhanced barrier precautions (EBP) due to an abdominal wound. According to CDC guidelines and the facility's own policies, staff are required to wear both gloves and a gown during high-contact care activities, such as wound care, for residents with wounds or indwelling medical devices. Observations revealed that a registered nurse (RN) provided wound care to the resident while only wearing gloves and failed to don a gown, despite clear signage on the resident's door and established protocols indicating the necessity of both gloves and a gown for such care activities. Interviews with the resident confirmed that nurses consistently did not wear gowns during dressing changes or when managing the wound vacuum device, only using gloves. Staff interviews further corroborated this, with a certified nurse aide (CNA) stating she wore both gloves and a gown for high-contact care, while the RN admitted to forgetting to wear a gown during the observed wound care. The director of nursing (DON) and the infection preventionist (IP) both acknowledged the requirement for staff to use gloves and gowns for residents on EBP during high-contact care, and the DON described the facility's procedures for signage, PPE availability, and staff education regarding precautions. Despite these policies and procedures, the failure to consistently implement the required PPE protocols during wound care for the resident on EBP was observed and confirmed through interviews. The infection preventionist also indicated some uncertainty regarding the need for gowns during certain activities, which may have contributed to inconsistent adherence to the established infection control measures.
Failure to Consistently Administer Oxygen per Physician's Orders
Penalty
Summary
The facility failed to ensure that a resident requiring continuous supplemental oxygen received care consistent with physician's orders and professional standards of practice. The resident, a 65-year-old with chronic respiratory failure, COPD, severe cognitive impairment, and other significant medical conditions, had a physician's order for continuous oxygen via nasal cannula at 2 to 4 liters per minute. Observations revealed that the resident was found without her nasal cannula in place and with an empty portable oxygen tank on more than one occasion. Staff interviews confirmed that the resident was dependent on staff for care and did not resist or decline oxygen use. Staff acknowledged that monitoring of portable oxygen tanks was inconsistent, with tanks sometimes running empty without being noticed. The facility's policy required nurses to monitor oxygen administration and document the resident's response, as well as to verify and follow physician's orders. Despite this, the resident was left without oxygen for periods of time, and staff did not consistently ensure the resident's oxygen was administered as prescribed.
Failure to Provide Person-Centered Dementia Care and Services
Penalty
Summary
The facility failed to provide appropriate, person-centered care and services to two residents diagnosed with dementia, resulting in deficiencies related to the residents' physical, mental, and psychosocial well-being. For one resident with severe cognitive impairment and multiple comorbidities, including diabetes and hearing loss, staff did not respond to repeated requests to go to bed, instead redirecting him to the dining area for lunch without offering individualized interventions. Observations showed the resident repeatedly returning to his room, engaging in repetitive rolling motions in his wheelchair, and calling for help, but staff did not address these behaviors with person-centered care or update the care plan to reflect his needs and preferences prior to the survey. The care plan for this resident lacked interventions addressing his repetitive behaviors, requests for help, and desire to go to bed, focusing instead on general communication and medication encouragement. Although the activities care plan noted some preferences, it did not include the resident's request to go to bed until after the survey began. Staff interviews confirmed a lack of knowledge about effective interventions for redirecting the resident to meaningful activities and acknowledged insufficient documentation of observed behaviors and attempted interventions. For another resident with moderate cognitive impairment, Parkinson's disease, and a history of stroke, the facility did not adequately address wandering behaviors, particularly the resident's tendency to enter other residents' rooms. The care plan failed to specify interventions to prevent this behavior or document the resident's preferences. Progress notes and behavior monitoring records showed inconsistent documentation of interventions used and their effectiveness. Interviews with staff and other residents revealed ongoing issues with wandering and a lack of clear strategies to manage or redirect the behavior.
Failure to Provide Meals According to Resident Preferences Due to Incomplete Meal Ticket Process
Penalty
Summary
A deficiency occurred when a resident with dementia, depression, and Parkinson's disease did not receive meal items according to her stated preferences. The resident's meal ticket for lunch was found to be blank, despite her son assisting her in completing it with the help of nursing staff over the phone. The resident reported that this issue had been ongoing since her admission, resulting in her receiving and not eating food she did not order. Observations confirmed that the resident's son questioned the registered dietitian about the blank meal ticket, and the dietitian was unable to explain why the completed ticket was missing. Staff interviews revealed that both nursing and dietary staff were involved in the meal ticket process, but there was a lack of clarity and follow-through regarding the completion and verification of meal tickets. The dietary staff would serve the main dish when tickets were blank, and there was no consistent process to ensure that incomplete tickets were identified and addressed. The nutrition care plan for the resident indicated she was at nutritional risk and required monitoring of meal intake, but the failure to ensure her meal preferences were honored led to the deficiency.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Colorado Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bear Creek Senior Living | 0.7 mi | ★★★★★ | 1 | 0 |
| Sundance Skilled Nursing And Rehabilitation | 1.1 mi | ★★★★★ | 22 | 1 |
| Kiowa Hills Rehabilitation And Nursing, Llc | 1.7 mi | ★★★★★ | 8 | 0 |
| Gardens, The | 2 mi | ★★★★★ | 12 | 0 |
| The Healthcare Resort Of Colorado Springs | 3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.