Skyline Healthcare Center: Medication Safety Failures - CA
The resident, identified in inspection records only as Resident 295, takes Metoprolol Succinate Extended Release to manage high blood pressure and Duloxetine Delayed Release to treat depression. Both are formulated specifically to dissolve slowly inside the body. Both, inspectors found, were not administered according to manufacturer recommendations.
Extended release and delayed release medications are engineered to deliver a controlled amount of a drug into the bloodstream over a period of hours. When that delivery mechanism is disrupted — by crushing a tablet, splitting it, or administering it in a way that breaks down its coating — the drug can release all at once instead of gradually. That means a patient may receive too much of the medication too quickly, or too little over the period when it is supposed to be working.
For a blood pressure drug like Metoprolol Succinate ER, that kind of disruption can cause a sudden drop in heart rate or blood pressure. For Duloxetine DR, improper administration can strip away the protective coating that keeps the drug from dissolving in the stomach rather than the intestine, where it is meant to be absorbed. The result can be gastrointestinal irritation, nausea, or reduced effectiveness of an antidepressant that a resident depends on.
Inspectors noted both failures during observation of medication administration, meaning they watched it happen.
Skyline Healthcare Center is a skilled nursing facility in Los Angeles. Inspectors reviewed five residents' medication administration during this inspection. Resident 295 was the only one flagged for this type of violation. That is not a reassuring ratio. One in five observed residents receiving medications incorrectly is a significant failure rate for a basic nursing task.
The inspection report classified the deficiency under F658, which covers the requirement that nursing homes provide services that meet professional standards of quality. Inspectors wrote that the failures had the potential to result in Resident 295 receiving suboptimal care and experiencing adverse medication effects that would negatively impact their health and well-being.
"Potential" is the word regulators use when harm has not yet been documented. It does not mean the harm did not occur. Gastrointestinal irritation from improperly administered Duloxetine can be painful and disorienting, particularly for an elderly resident already managing depression. A blood pressure medication that does not work as intended can leave a resident's cardiovascular system inadequately protected for hours.
What the inspection report does not say is how long this had been happening. It does not say whether Resident 295 reported feeling unwell. It does not say whether anyone at the facility had caught the error before inspectors arrived and watched it unfold in real time.
Medication administration is among the most routine tasks in a nursing home. Nurses and certified medication aides perform it multiple times a day, for every resident, across every shift. The protocols for extended release and delayed release drugs are not obscure. Pharmaceutical manufacturers print instructions on the label. Pharmacy dispensing systems flag medications that cannot be altered. The question inspectors did not answer in this report is why those safeguards did not work for Resident 295.
Metoprolol Succinate is one of the most commonly prescribed heart medications in the United States. Duloxetine is prescribed to millions of people for depression and anxiety. Neither is an unusual or complicated drug. Administering them correctly is not an advanced clinical skill. It is a baseline one.
Resident 295 came to Skyline Healthcare Center trusting that the staff there knew how to give them their medications. On at least one occasion that inspectors directly observed, that trust was not honored.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 13, 2026 · Our methodology
SKYLINE HEALTHCARE CENTER - LA in LOS ANGELES, CA was cited for violations during a health inspection on June 13, 2024.
Both are formulated specifically to dissolve slowly inside the body.
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.