Skyline Healthcare Center: Resident Attack Triggers PTSD - CA
The incident happened at Skyline Healthcare Center, a nursing facility at 3032 Rowena Avenue in Los Angeles, at around 6:45 a.m. on March 21, 2025. Federal inspectors arrived eleven days later and documented what happened, citing the facility for allowing physical abuse that caused actual harm to a resident.
The woman, identified in inspection records only as Resident 1, told inspectors the scratch was 10 centimeters long. She said it brought back her PTSD from a previous incident. "It shook her," the report noted, "and made her scared."
That fear, according to the Director of Nursing, was exactly the kind of harm the facility was supposed to prevent.
The morning had started with an argument. Resident 2, who shared a room with Resident 1, woke up upset. A housekeeper was cleaning the room around 6:45 a.m. when Resident 2 sat up in bed, began shouting and yelling at the housekeeper, then stood up, grabbed the detachable remote control from her own bed, and started swinging it at CNA 1, the nursing assistant assigned to care for both women that shift.
CNA 1 had been working since 11 p.m. the night before. Her shift was almost over.
Two licensed vocational nurses, LVN 2 and LVN 3, came to the room. Now there were three staff members surrounding Resident 2, a woman holding a bed remote control in her left hand, walking toward the door. The CNA told inspectors that she and the two nurses were moving around Resident 2, trying to support her so she wouldn't fall, while also trying not to get hit.
Resident 1's bed was the one nearest the door.
Resident 2 walked all the way to it. She scratched Resident 1's right lower foot. Resident 1, lying in bed, said aloud: "She scratched my foot."
Resident 1 told inspectors she couldn't remember the exact date but recalled it was early morning, around 6 a.m. She watched her roommate swing the remote control at the CNA before turning toward her. She said she was lying in bed and could not defend herself.
The Director of Nursing told inspectors she learned about the incident at around 9 a.m. that same morning, when she encountered Resident 1 in the hallway. Resident 1 told her what had happened. The DON said she considered Resident 2 scratching Resident 1's foot to be physical abuse. She said the facility does not allow abuse because a resident can feel psychosocially unsafe in her own environment, and because of the potential for further harm.
The DON used the word "psychosocially" and then explained what she meant: how both psychological and social factors contribute to a person's overall well-being, development, and functioning. The report captured her definition in full.
What the report did not capture was any account of what was done in the moment, when three staff members stood in that room and watched Resident 2 cross the floor to Resident 1's bed.
The facility's own abuse prevention policy, revised in May 2024 and in effect since June of that year, states the facility does not condone any form of resident abuse. A separate reporting policy, last reviewed in April 2024, affirms that residents have the right to be free from physical abuse.
Those policies existed on March 21. Resident 1 still has a 10-centimeter scratch on her right foot, and a fear that, by her own account, she had not felt since something bad happened to her before.
What that previous incident was, the inspection report does not say. What it does say is that being scratched by her roommate, in her own bed, while three people stood close enough to intervene, was enough to bring it back.
The inspection was completed on April 1, 2025. The deficiency was cited under the federal standard requiring facilities to protect residents from abuse, with a finding of actual harm affecting a small number of residents.
Resident 1 is still at Skyline Healthcare Center. So, as of the inspection date, was Resident 2.
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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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 10, 2026 · Our methodology
SKYLINE HEALTHCARE CENTER - LA in LOS ANGELES, CA was cited for violations during a health inspection on April 1, 2025.
The incident happened at Skyline Healthcare Center, a nursing facility at 3032 Rowena Avenue in Los Angeles, at 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.