Skyline Healthcare: Resident Left Bedridden for Years - CA
Resident 7, admitted in July 2022 with right-side paralysis following a brain injury, was supposed to receive daily range-of-motion exercises and wear protective hand and arm splints to prevent muscle shortening. Instead, federal inspectors found the resident lying in hospital gowns day after day, never getting out of bed, while contractures gradually locked joints into permanently bent positions.
The resident's family member called the facility in June 2024, concerned about developing contractures in hands and legs.
Staff admitted they had abandoned the therapy program entirely for two months in 2022, with no documentation of any restorative nursing sessions in August or September. When services resumed in October, nursing aides skipped the critical hand splints that occupational therapists had specifically ordered to prevent the right hand from contracting into a fist.
"The resident's decline in ROM in the right hand was preventable since the right resting hand splint was not applied for six months," the Director of Nursing told inspectors.
By December 2023, the resident was screaming when staff tried to apply the left hand roll. An occupational therapy evaluation in February 2024 revealed devastating deterioration. The resident's right shoulder could only move 45 degrees instead of the normal 180. The left shoulder was nearly frozen at just 10 degrees of movement.
Both knees had locked into permanent flexion. The facility didn't even obtain the knee splints that physical therapists recommended until March 2024 — 19 months after discharge orders called for them.
During the inspection, a restorative nursing aide attempted to apply splints to the resident's legs. The resident "winced, moaned, and cried" as the aide worked, according to federal observers. The aide had to notify nurses about the resident's pain.
"PROM to both shoulders were not performed because Resident 7 could not tolerate the pain," the aide explained.
The resident now requires pain medication before any therapy attempts. On June 11, 2024, the aide tried multiple times to work with the resident but ultimately provided no range-of-motion exercises or splint applications because the resident "screamed" and "refused due to pain."
A physical therapist who examined the resident during the inspection described both arms as "contracted at both shoulders and elbows" and was unable to fully extend the right hand fingers despite the resident wincing from pain.
The facility's Director of Rehabilitation acknowledged the quarterly screening system had failed completely. The screening forms "did not indicate any ROM assessment" in the resident's arms and legs and "did not indicate Resident 7's RNA program was reviewed."
"The quarterly Rehabilitation Screening should have caught that Resident 7's right resting hand splint and left-hand roll were not being applied from 8/2022 to 2/2023," the director admitted.
Staff also ignored the resident's basic dignity. During four separate observations over three days, inspectors found the resident wearing only hospital gowns while lying in bed. A certified nursing assistant explained the resident wore gowns "because Resident 7 was usually in bed" and was only dressed in regular clothes when family visited.
The Director of Nursing told inspectors the resident "was alert and should not be in bed" and that "the facility was not maintaining Resident 7's mobility and quality of life while Resident 7 remained in bed."
The resident's care plan called for activities to enhance mobility and getting out of bed to a chair "if tolerated." But activity records show only "room visits" from January through June 2024. The Activity Assistant admitted she couldn't "imagine lying in bed all day" but didn't know why the resident wasn't brought to the activity room.
Shower records reveal another consequence of the neglected therapy. The resident was supposed to receive showers on Mondays and Thursdays but only got bed baths because staff said it was "difficult and caused Resident 7 pain to position Resident 7 in the shower chair."
The deterioration extended beyond mobility. Speech therapy had recommended small amounts of pureed applesauce for "oral gratification" — the simple pleasure of tasting food — when the resident was discharged from therapy in August 2022. That order was discontinued during a hospitalization in September and never resumed, despite a rehabilitation screening form recommending speech therapy evaluation.
The resident remained on continuous tube feeding through a gastrostomy tube, never receiving another swallowing evaluation until February 2024. By then, the speech therapist found the resident "unable to swallow" and recommended "nothing by mouth."
Federal inspectors also documented systematic failures in pressure ulcer prevention. Staff were supposed to turn the resident every two hours following a posted schedule, but observers found the resident in the wrong position for hours at a time.
On June 11, the resident was supposed to be on their back at 1 p.m. but was found lying on their right side. A certified nursing assistant admitted the resident was "supposed to be on her back per the turning clock schedule" and that turning every two hours was important "to prevent pressure ulcers."
The pattern continued the next day. At 10:30 a.m., a licensed vocational nurse found the resident in the wrong position and acknowledged they "should be turning the resident every two hours and follow the turning clock schedule to prevent pressure injury."
Another resident faced different but equally serious risks from improper equipment management. Resident 74, who weighed 161 pounds, had their low air loss mattress set at 300 — far above their body weight. A registered nurse explained this "could cause further skin issues such as worsening of the pressure injury."
The facility's problems extended to basic safety protocols. Inspectors found topical medication packets left unattended on a resident's bedside table, accessible to other confused residents who might ingest them. A treatment nurse warned that swallowing the ointment "could have poisonous effects."
Staff training failures emerged in critical areas. One licensed vocational nurse had completed CPR training online rather than the required hands-on certification. The Director of Nursing explained that nurses without proper CPR certification "may not to be competent enough to provide the necessary resuscitative efforts which could lead to potential loss of life."
Equipment maintenance problems affected respiratory care. The facility had no system for tracking or servicing nebulizer machines used by residents with chronic lung disease. The Central Supply Staff admitted he "had no way of tracking which nebulizer machine he had tested because he does not know how many nebulizer machines there are in the facility."
Medication administration errors put another resident at risk when a nurse failed to check feeding tube placement and patency before giving medications through a gastrostomy tube. The nurse acknowledged that without these safety checks, "medications could be delivered outside the stomach causing Resident 295 to develop toxicity and stomach ulcers."
Two residents who smoked lacked proper safety assessments despite facility policies requiring comprehensive evaluations and care plans. One resident had been found smoking in his room in February 2024, but his admission evaluation incorrectly indicated he didn't use tobacco, preventing appropriate safety planning.
The inspection revealed a facility where basic care protocols routinely failed, leaving vulnerable residents like Resident 7 to deteriorate in ways that could have been prevented with consistent, competent care. The resident who once had functional shoulder and elbow movement now faces permanent disability from contractures that developed under the facility's watch.
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.
The resident's family member called the facility in June 2024, concerned about developing contractures in hands and legs.
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.