Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
SKYLAKE POST ACUTE
THORNTON, CO · 242 certified beds · Last Life Safety survey December 1, 2025
CMS Certification Number 065238 · first certified January 1988
Ownership
Operated by PACS GROUP · For profit - Limited Liability company
- Ownership changed November 3, 2023 (change of ownership)from 12080 BELLAIRE WAY OPERATIONS LLC
Position within CO
12 citations — more than 34% of the 210 certified nursing homes in CO. Compared within CO rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
When is the next survey likely?
The window opens May 2027 — about 7 months from now. This facility’s last Life Safety survey was December 2025. Facilities in CO are typically surveyed 17–24 months after the last one (median 19), measured over 177 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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Emergency preparedness
12 of the 12 citations on file are Emergency Preparedness E-tags — every citation here is about the program, not the building. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
8 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 12 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in CO, and nationally. Surveyors differ markedly between states, so the CO figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 12 |
| Median facility in CO | 16 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| September 16, 2022 | 0 |
| January 9, 2024 | 12 |
| December 1, 2025 | 0 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| E-0032 | Provide primary/alternate means for communication. | 1 | 2024-01-09 |
| E-0034 | Provide a means of sharing information on occupancy/needs. | 1 | 2024-01-09 |
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | 1 | 2024-01-09 |
| E-0037 | Establish staff and initial training requirements. | 1 | 2024-01-09 |
| E-0013 | Develop Emergency Preparedness policies and procedures. | 1 | 2024-01-09 |
| E-0001 | Establish an Emergency Preparedness Program (EP). | 1 | 2024-01-09 |
| E-0025 | Create arrangements with other facilities to receive patients. | 1 | 2024-01-09 |
| E-0039 | Conduct testing and exercise requirements. | 1 | 2024-01-09 |
What the citations cover
- Emergency Preparedness Deficiencies 12
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 12 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
January 9, 2024 — 12 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0001 | Establish an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (February 3, 2024) |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (February 3, 2024) |
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (February 3, 2024) |
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (February 3, 2024) |
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | Deficient, Provider has date of correction (February 3, 2024) |
| E-0025 | Create arrangements with other facilities to receive patients. | Deficient, Provider has date of correction (February 3, 2024) |
| E-0029 | Develop a communication plan. | Deficient, Provider has date of correction (February 3, 2024) |
| E-0032 | Provide primary/alternate means for communication. | Deficient, Provider has date of correction (February 3, 2024) |
| E-0033 | Establish methods for sharing information. | Deficient, Provider has date of correction (February 3, 2024) |
| E-0034 | Provide a means of sharing information on occupancy/needs. | Deficient, Provider has date of correction (February 3, 2024) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (February 3, 2024) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (February 3, 2024) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.