Skyline Healthcare: Delayed Abuse Reporting - CA
The March 21 incident began around 6:45 a.m. when the roommate with severely impaired cognition became agitated while a housekeeper cleaned their shared room. The resident with dementia stood up, grabbed a detachable bed remote control, and began swinging it at a certified nursing assistant who had come to help.
Two licensed vocational nurses rushed to the room as the agitated resident walked toward the door, still holding the remote control. Staff surrounded her to prevent falls while trying to avoid being struck.
But the resident with dementia turned toward her roommate's bed and scratched the quadriplegic woman's right foot before staff could intervene.
"She scratched my foot," the injured resident told staff immediately after the attack.
The victim, admitted to Skyline in February with parkinsonism and quadriplegia, was completely dependent on staff for toileting and showering. She had intact cognition and understood exactly what had happened to her.
Staff knew about the incident by 7:45 a.m. The Director of Nursing didn't report it to the State Survey Agency until 11:30 a.m. — a nearly four-hour delay that violated federal requirements for immediate abuse reporting.
"Staff should have reported to the Administrator and/or the DON and should have reported the incident immediately," the Director of Nursing acknowledged to inspectors. "The potential for not reporting within the two-hour timeframe can place the residents at further risk for abuse."
The injured resident's wound measured 10 centimeters long by 0.3 centimeters wide. Her physician ordered daily cleaning with saline solution, antibiotic ointment, and air drying for 21 days.
During interviews with inspectors, the victim described the psychological trauma alongside her physical injury. The incident "brought back her PTSD from a previous incident," she said. "It shook her and made her scared."
She recalled lying defenseless in bed around 6 a.m. when she saw her roommate swing the bed remote at the nursing assistant. As staff tried to escort the agitated resident from the room, "Resident 2 turned towards Resident 1 and scratched Resident 1's right foot."
The nursing assistant who witnessed the attack confirmed the sequence of events. She had been caring for both residents during her 11 p.m. to 7 a.m. shift when the roommate "sat up in Resident 2's bed upset and began to shout and yell at the Housekeeper who was cleaning Resident 1 and Resident 2's room."
The resident with dementia had been admitted to Skyline in April 2024 and readmitted the following month with diagnoses including major depressive disorder and general anxiety disorder alongside her dementia. Her assessment showed she needed substantial assistance just to stand from a sitting position.
On the morning of the incident, records show the resident with dementia experienced "increased aggression through striking out for no apparent reason" and was "combative" while "yelling and screaming" at staff.
The facility's own policy, last reviewed in April 2024, requires reporting suspected physical abuse "immediately and no later than two (2) hours" to both local law enforcement and the California Department of Public Health.
The Director of Nursing told inspectors that resident-to-resident scratching constitutes physical abuse because the victim "can psychosocially feel unsafe in Resident 1's environment and the potential for further harm."
Federal inspectors found the facility's transmission verification report for the abuse notification was dated October 1, 2013 — more than 11 years before the incident occurred. The Director of Nursing acknowledged the date was "incorrect" and confirmed she had actually sent the report on March 21, 2025.
The injured resident's psychiatric follow-up note documented her visible distress after the attack. She "did not answer questions when prompted as she was visibly upset," according to the mental health professional who evaluated her. The resident had a pre-existing diagnosis of depression.
Staff cleaned and treated the scratch wound the same day, applying antibiotic ointment and leaving it open to air as ordered by the physician. But the delay in reporting meant state authorities couldn't immediately investigate the incident or take steps to prevent similar attacks.
The resident with dementia's change-in-condition evaluation noted her episode of increased aggression occurred "for no apparent reason," highlighting the unpredictable nature of her behavioral outbursts that put her vulnerable roommate at risk.
Both residents remained at the facility as of the April inspection, with the quadriplegic woman still recovering from her physical wound and psychological trauma while sharing living space with other residents who might pose similar risks.
The four-hour reporting delay violated not just federal regulations but the facility's own written policies designed to protect residents from abuse. As the Director of Nursing admitted, the delay "can place the residents at further risk for abuse" — a risk that proved prophetic for a woman who couldn't defend herself when her roommate's dementia turned violent.
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: 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 abuse-related violations during a health inspection on April 1, 2025.
The March 21 incident began around 6:45 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.