F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure that all alleged violations involving
abuse, neglect, exploitation, or mistreatment, including injuries of unknown source. were reported
immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation
involve abuse or result in serious bodily injury to the administrator of the facility and to other officials
(including to the State Survey Agency and adult protective services where state law provides for jurisdiction
in long-term care facilities) in accordance with State law through established procedures for 2 of 4 residents
(Resident #1 and #2) reviewed for neglect reporting.
The facility failed to report an allegation of neglect to the State Agency when Resident #1 was physically
abused by Resident #2, sustaining an injury, on 05/02/25.
This failure could place residents at risk for not having allegations of neglect reported which could lead to
injury or worsening of condition and ongoing abuse/neglect.
Findings included:
Review of Resident #1 MDS assessment, dated April 12, 2025, reflected he was a [AGE] year-old male
admitted to the facility on [DATE]. The resident's cognitive status was moderately impaired. His diagnoses
included Alzheimer's Disease and Dementia.
Review of Resident #1's Care Plan, dated 03/13/2025, reflected:
o
Resident has an ADL self-care performance deficit related to dementia.
o
Resident is at a high risk for falls related to gait/balance problems, confusion
o
Resident is a risk for falls, has had an actual fall with no injury related to poor balance
o
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
455653
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455653
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/04/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Skyline Nursing Center
3326 Burgoyne
Dallas, TX 75233
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 0609
Resident is at risk for harm related to physical aggression from another resident
Level of Harm - Minimal harm
or potential for actual harm
Review of Resident #1's Nurse Note, dated 05/02/2025 at 11:04 AM, reflected:
Residents Affected - Few
The nurse received a call about the resident's injury. The nurse arrived to work and went to assess the
resident he was noted in his wheelchair in the dining room sleeping. Resident's head and ears appeared to
be swollen and face was red. MD called to get orders. A stat skull series was ordered, and DON was made
aware. Awaiting arrival of the x-ray, MD was called again, and new orders were given to send resident out
911 for evaluation and treatment.
Review of Resident #1's Nurse Note, dated 05/02/2025 at 12:46 PM, reflected:
Resident was seen coming to the dinning/nurse's station with a raised and red area to right side of
forehead. Resident was assessed and asked what happened, but resident could not give a description as to
what happened to him. Resident was then given Tylenol for pain. Cold compress was applied to the raised
area. Skull series ordered. Physician notified of incident.
Review of the facility's Physical Agression Recieved for Resident #1 dated 05/02/25 at 05:30 reflected
Incident Description: Resident ws seen coming to the dining/nurses station wiht a raised red area to the
right side of forehead. Resident was assessed and asked what happened, but resident could not give a
description as to what happend to him. Resident was then given tylenol for pain. Cold compress were
applied to the raised area. Skull serious ordered. NP, DON and Family have been notified . Immediate
Action Taken: Head to toe assessment, skull series ordered [Confirmation Number], NP, DON and Family
have been notified .Injury Observed at Time of Incident: Skin tear to right elbow, unable to deteremine to
face .Level of Pain: Numerical: 5, Level of Consciousness: Alert Mobility: Wheelchair bound . Mental Status:
Oriented to person, impulsiveness, forgetful, lack of safety awareness
During an observation on 05/04/25 at 9:45 AM revealed Resident #2's right hand was swollen and bruised.
Resident #2 was observed sleeping.
An interview on 05/04/2025 at 11:40 AM with the DON revealed she was informed that Resident #1 had a
facial injury by staff but could not state who. The DON said that there were no witnesses to the incident,
where Resident #1 had sustained a facial injury. The DON said it was determined Resident #1 was hit in the
head by roommate.
An interview on 05/04/2025 at 12:00 PM with the Administrator revealed the incident involving Resident #1
was not self-reported. Administrator stated Resident #2 had abused Resident #1. Administrator stated he
did not report the incident to Texas Health and Human Services Commissions because it was resident on
resident altercation without intent to harm, since both residents BIMS score are 3 and they resided on the
memory care unit.
Review of the facility policy Abuse Prevention and Prohibition reflected: The Facility will report allegations of
abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of resident
property, or other incidents immediately, but no later than 2 hours after if the alleged violation involves
abuse or results in serious bodily injury to the state survey agency, adult protective services, law
enforcement, and the Ombudsman.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455653
If continuation sheet
Page 2 of 2
