Skyline Healthcare Center: Abuse Report Delayed - CA
The incident happened on the morning of March 21, 2025, sometime between 7 and 7:30 a.m. By the time the Director of Nursing filed a report with the state, it was 11:30 a.m. The two-hour reporting window the facility's own policy requires had closed long before anyone picked up the phone.
The scratch itself reopened something deeper. The resident, identified in inspection records only as Resident 1, told an inspector on April 1 that the attack brought back her PTSD from a previous incident. "It shook her," the report notes, "and made her scared." She described lying in bed, unable to defend herself, while her roommate walked toward her.
What the staff who witnessed it did next, and what they didn't do, is what brought federal inspectors to document the failure.
The sequence leading to the scratch began around 6:45 a.m., when Resident 2, the roommate, sat up in bed upset and started shouting and yelling at a housekeeper who was cleaning their shared room. A certified nursing assistant, identified as CNA 1, was assigned to care for both residents that shift. CNA 1 had been working since 11 p.m. the night before.
Resident 2 stood up, grabbed the detachable remote control from the bed, and began swinging it at CNA 1. Two licensed vocational nurses, LVN 2 and LVN 3, came to the room. Now there were three staff members present, circling Resident 2, trying to prevent a fall and avoid being struck by the swinging remote control. Resident 2 was still holding the remote in her left hand when she walked all the way across the room to where Resident 1 lay in the bed nearest the door.
CNA 1 watched Resident 2 scratch Resident 1's right lower foot. CNA 1 heard Resident 1 say, "She scratched my foot."
Staff knew about the incident by approximately 7:45 a.m. The Director of Nursing did not learn about it until she encountered Resident 1 in the hallway at around 9 a.m., when Resident 1 told her directly what had happened. The DON filed the required report to the California Department of Public Health's Social Services Agency at approximately 11:30 a.m., more than three and a half hours after staff first became aware.
During the April 1 inspection, the DON was asked to produce documentation verifying the report had been sent. The facility provided a Transmission Verification Report, a document that confirms a fax was successfully sent. The date on it read October 1, 2013, at 9:15 p.m.
The DON acknowledged the date was wrong. She said the fax machine's timestamp was incorrect and that the transmission was actually sent on March 21, 2025, at around 11:40 a.m. Inspectors recorded the discrepancy without resolving it in the report.
The DON was direct about what the timeline meant. She told inspectors that her staff should have reported the incident to the administrator or to her immediately, that they knew about it around 7:45 a.m., and that the report didn't go out until 11:30 a.m. She called it a delay. She said the potential for not reporting within the two-hour window can place residents at further risk for abuse.
She also said, without qualification, that what Resident 2 did to Resident 1 was physical abuse.
The facility's own written policy, last reviewed in April 2024, requires a telephone report to local law enforcement and a written report to the California Department of Public Health within two hours of any observation, knowledge, or suspicion of physical abuse. Three staff members had direct knowledge of the incident by 7:45 a.m. The report went out at 11:30 a.m.
What the inspection report does not explain is why none of the three staff present, CNA 1, LVN 2, or LVN 3, reported the incident in the two hours after it happened. The DON told inspectors her staff should have reported it. The inspection record does not include any account from LVN 2 or LVN 3 about what they did or didn't do after leaving the room. It does not say whether any of them were disciplined or counseled after the fact.
The inspection record also does not explain how Resident 1 came to be roomed with Resident 2 given Resident 2's apparent behavioral history, or whether the facility had any plan in place to manage the risk Resident 2 posed to a roommate. The morning of March 21 was not described in the report as the first time Resident 2 had become agitated or physically threatening. The report does not say it was.
What it does say is that Resident 1 was lying in bed when her roommate crossed the room and hurt her, that three staff members were present and did nothing to stop it, and that the same three staff members then failed to report it in time for the state to respond within the window designed to protect residents from further harm.
Resident 1 told inspectors the scratch brought back her PTSD. She said it made her scared. She said she could not defend herself.
The DON told inspectors the facility does not allow abuse because a resident can feel psychosocially unsafe in her own environment. She used the word "psychosocially" and the inspector recorded its definition in parentheses: how both the psychological and social factors contribute to a person's overall well-being, development, and functioning.
Resident 1 was in her bed, in her room, in the facility where she lives. Her roommate walked over and scratched her foot while staff watched. Then the people who saw it happen waited nearly four hours to tell anyone with the authority to do something about it.
Resident 1 was still living at Skyline Healthcare Center when inspectors arrived eleven days later to document what had occurred.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Skyline Healthcare Center - La from 2025-04-01 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.
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Last verified: November 4, 2026 · Our methodology
SKYLINE HEALTHCARE CENTER - LA in LOS ANGELES, CA was cited for abuse-related violations during a health inspection on April 1, 2025.
The incident happened on the morning of March 21, 2025, sometime between 7 and 7:30 a.m.
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.