Skyline Healthcare: Call Light Denied to Dementia Patient - CA
Treatment Nurse 1 told federal inspectors on June 11 that Resident 15's family preferred the call light remain beyond the patient's grasp. The nurse admitted no care plan existed to address this preference or its risks.
Resident 15 had lived at the Rowena Avenue facility since December 2021, diagnosed with dementia, adult failure to thrive, and muscle contractures. The patient sometimes could make themselves understood and understand others, but depended entirely on staff for mobility and daily activities.
During the inspection, the call light hung visibly on the wall where the bedridden resident could not reach it.
Director of Nursing learned of the family's unusual request only when inspectors questioned staff about it on June 13. She told investigators the call light should have been within the patient's reach and expressed surprise at discovering the arrangement.
"The Interdisciplinary Team should have met and discussed the family member's preference of not having the call light within the reach of the resident before it gets implemented," the Director of Nursing stated.
She warned that keeping the call light out of reach "could result to accidents such as falls."
No documentation existed showing staff had evaluated the safety implications of the family's request or created protocols to ensure the patient's needs could still be met. The facility's own policy required care plans to address changes in behavior and care, yet none existed for this significant deviation from standard safety practices.
The violation occurred despite the facility's comprehensive care planning policy, last reviewed April 4, 2024, which mandated care plan reviews and revisions for the onset of new problems, changes in condition, and "other times as appropriate or necessary."
Federal inspectors also cited Skyline Healthcare for failing to meet professional standards in insulin administration. The facility failed to rotate injection sites for Resident 6, a practice that prevents tissue damage from repeated injections in the same location.
Same-site insulin injections can cause lipodystrophy, an abnormal distribution of fat under the skin, and cutaneous amyloidosis, where protein clumps build up in tissue. Both conditions can affect insulin absorption and blood sugar control.
The insulin violation affected multiple residents, though inspectors detailed only one case in their findings.
Skyline Healthcare Center operates as a 99-bed facility in Los Angeles' Silver Lake neighborhood. The June inspection found violations affecting resident safety and professional care standards, with both issues rated as causing minimal harm or potential for actual harm.
The call light violation represented a breakdown in the facility's interdisciplinary team process. Treatment Nurse 1's acknowledgment that no care plan existed for the family's preference showed staff implemented a potentially dangerous arrangement without proper evaluation or safeguards.
Federal nursing home regulations require facilities to ensure residents can summon assistance when needed. Call lights serve as the primary communication tool between residents and staff, particularly crucial for patients with mobility limitations who cannot physically seek help.
The Director of Nursing's statement that she only learned of the arrangement during the inspection suggested a communication failure within the facility's management structure. Her immediate recognition that the situation posed fall risks highlighted the seriousness of the oversight.
For Resident 15, who had already experienced significant health decline leading to the failure to thrive diagnosis, the inability to call for help represented an additional layer of vulnerability. The patient's dementia and complete dependence on staff for mobility made access to emergency communication particularly critical.
The facility's policy clearly outlined when care plans should be updated, including for changes in behavior and care. The family's request to remove the call light from reach constituted exactly the type of significant change requiring formal team review and documentation.
Staff's implementation of the family preference without following established protocols demonstrated a gap between written policies and actual practice. The absence of any care plan modification left the resident without documented safeguards to address the increased risk created by the arrangement.
The insulin administration failures compounded concerns about the facility's adherence to professional standards. Proper injection site rotation represents basic diabetes care, and the failure to follow this protocol affected multiple residents' treatment.
Both violations occurred at a facility that had readmitted Resident 15 in 2021, suggesting ongoing responsibility for the patient's complex care needs. The combination of safety oversights and professional standard failures painted a picture of systemic issues in care delivery and oversight.
The inspection findings revealed how family preferences, when not properly evaluated and planned for, can create unintended safety risks for vulnerable residents who depend entirely on facility staff for their wellbeing and emergency response.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Skyline Healthcare Center - La from 2024-06-13 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
SKYLINE HEALTHCARE CENTER - LA in LOS ANGELES, CA was cited for violations during a health inspection on June 13, 2024.
Treatment Nurse 1 told federal inspectors on June 11 that Resident 15's family preferred the call light remain beyond the patient's grasp.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.