LOS ANGELES, CA - Federal inspectors documented serious safety violations at Skyline Healthcare Center on Rowena Avenue, including a resident smoking in their room that created potential fire and burn hazards, according to a June 2024 inspection report.
The Centers for Medicare & Medicaid Services investigation found the 117-bed facility failed to develop proper care plans for multiple safety concerns, with the smoking violation representing the most immediate danger to residents and staff.
Smoking Violation Creates Fire Risk
Inspectors discovered that Resident 41, a smoker since his original admission in 2021, had been found smoking inside his room in February 2024 despite facility policies prohibiting indoor smoking. The facility failed to develop an appropriate smoking safety care plan, which should have included supervision protocols, designated smoking times, and safety equipment like protective aprons.
The resident's initial smoking safety evaluation from 2022 incorrectly indicated he did not use tobacco, leading to the absence of necessary safety protocols. Staff confirmed the resident had been smoking since his original admission but lacked proper documentation and care planning for this activity.
"Without a care plan, there was a potential safety risk that could have resulted in a fire or self-harm from burns," the Director of Nursing told inspectors during interviews.
Care Plan Failures Across Multiple Areas
The inspection revealed systematic failures in developing comprehensive care plans required by federal regulations. Beyond smoking safety, inspectors documented missing care plans for:
Anticoagulant Medication Monitoring: Resident 7, who was prescribed Eliquis (apixaban) for deep vein thrombosis management, lacked a care plan for anticoagulant monitoring. This medication requires careful observation for bleeding complications, as anticoagulants reduce the blood's ability to clot.
Nursing staff acknowledged the importance of having monitoring protocols in place. "It was important to have a care plan on the use of anticoagulant-Eliquis to ensure the healthcare team is providing consistent interventions on monitoring for and avoiding complications on the use of an anticoagulant such as bleeding," a registered nurse told inspectors.
Bed Rail Safety: Three residents (15, 74, and 64) were observed using bed rails without corresponding care plans to ensure appropriate and safe usage. Bed rails, while helpful for some residents, can pose entrapment risks and require careful assessment and monitoring.
Pressure Ulcer Prevention Equipment: Resident 74, who had an unstageable pressure injury, was using a low air loss mattress by physician order but without a care plan detailing proper use and monitoring protocols.
Assessment Accuracy Problems
Inspectors also found significant inaccuracies in resident assessments that form the foundation of care planning. The Minimum Data Set (MDS) assessments, which determine care needs and federal reimbursement, contained multiple errors:
- Resident 64's MDS incorrectly indicated no bed rail use despite being observed with bilateral bed rails - Resident 12's hospice status was not reflected in assessment documents - Resident 7's range of motion limitations were understated in later assessments
The MDS Coordinator acknowledged that "incorrect information for Resident 7 was sent to the Federal database," highlighting how assessment errors can impact both individual care and broader healthcare data systems.
Medical Significance of Care Plan Failures
Care plans serve as roadmaps for nursing staff, ensuring consistent, safe care delivery across shifts and departments. Each violation identified creates specific medical risks:
Anticoagulant medications like Eliquis require monitoring for signs of bleeding, drug interactions, and dose adjustments. Without proper protocols, residents face increased risk of hemorrhage or treatment failure.
Bed rails, while sometimes necessary for positioning or safety, can cause injury if improperly used. Care plans should specify when rails are appropriate, alternatives considered, and monitoring requirements.
Pressure ulcer prevention equipment must be used correctly to prevent skin breakdown. Low air loss mattresses require specific protocols for inflation levels, skin checks, and turning schedules.
Smoking safety plans are essential in residential care settings where oxygen therapy, medications, and mobility limitations create heightened fire risks. Proper protocols include designated smoking areas, supervision levels, timing restrictions, and safety equipment.
Regulatory Requirements and Standards
Federal regulations require nursing homes to develop comprehensive, person-centered care plans within seven days of completing resident assessments. These plans must be reviewed regularly and updated based on changing needs or conditions.
The facility's own policies, last updated in April 2024, require care plans that "reflect best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents." The policies specifically mandate safety evaluations for activities like smoking, with corresponding care plans to "mitigate safety risk factors."
Industry standards emphasize that care plans serve as communication tools between healthcare team members, ensuring all staff understand each resident's specific needs and safety considerations.
Facility Response and Oversight
The inspection resulted in citations for "minimal harm or potential for actual harm" violations, requiring the facility to submit correction plans to state and federal authorities. The facility must demonstrate how it will prevent similar violations and ensure proper care plan development going forward.
The Director of Nursing acknowledged to inspectors that care plans "serve as a communication tool to all healthcare providers to provide standardized services in order to achieve the resident's targeted goals."
Skyline Healthcare Center has 117 beds and serves residents requiring various levels of long-term and rehabilitative care. The facility is located at 3032 Rowena Avenue in Los Angeles.
The complete inspection report contains additional details about assessment procedures, staff interviews, and policy reviews conducted during the June 2024 survey.
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.
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