Skyline Healthcare: Blood Pressure Drug Given Unsafely - CA
The medication errors at Skyline Healthcare Center involved a resident with severe cognitive impairment who couldn't make daily decisions and required total assistance with eating and showering. The patient had been admitted in May following a stroke that left one side of their body paralyzed.
On June 3, the physician ordered midodrine hydrochloride to treat the resident's low blood pressure. But the doctor included a critical safety instruction: hold the medication if blood pressure rises above 110 systolic.
Nurses ignored that order repeatedly.
On August 2 at 10 p.m., they administered the drug when the patient's blood pressure measured 132/80. Two days later at 6 a.m., they gave it again with a reading of 124/87. On August 7, they administered a third dose at 6 a.m. despite a blood pressure of 124/76.
Each administration violated the physician's safety parameters by significant margins.
The Director of Nursing acknowledged the failures during an August 9 interview with federal inspectors. She stated that nurses "failed to follow the physician's order to hold the midodrine for blood pressure above 110 mmHg."
More concerning, she explained the potential consequences. The resident "could have elevated blood pressure and experienced adverse effects from the medication."
Midodrine works by tightening blood vessels to raise blood pressure in patients with hypotension. But giving it to someone whose pressure is already elevated can push readings dangerously high, particularly in stroke patients whose cardiovascular systems are already compromised.
The resident's medical history made the medication errors especially risky. Admitted with diagnoses including stroke-related paralysis and essential hypertension, the patient had fluctuating capacity to understand medical decisions according to a May 16 examination.
By June, a comprehensive assessment rated the resident's cognitive skills for daily decisions as severely impaired. The patient depended entirely on staff for basic functions like eating and bathing.
Federal inspectors found that facility policy required medications to be "administered directed by a Licensed nurse and upon the order of a physician." The policy, last reviewed in April, made no exceptions for conditional orders like the hold parameters.
The violations occurred during routine medication administration rounds. Licensed nurses are responsible for checking physician orders against current vital signs before dispensing drugs, particularly those with conditional parameters.
Each of the three administrations represented a separate failure to follow medical orders designed to protect patient safety. The systolic readings ranged from 14 to 22 points above the hold threshold.
The August 2 administration was the most egregious, with a systolic pressure of 132 - more than 20% higher than the safety cutoff. Even the lowest violation on August 7 exceeded the limit by 14 points.
Federal regulations require nursing homes to provide pharmaceutical services that ensure accurate dispensing and administration of all medications. The rule specifically mandates following physician orders precisely.
Skyline Healthcare Center operates at 3032 Rowena Avenue in Los Angeles. The facility's medication administration policy, dating to 2012, emphasizes that drugs must be given according to physician orders and under licensed nurse supervision.
The inspection occurred following a complaint about the facility's medication practices. Federal investigators reviewed medication administration records, physician orders, and resident assessments to document the violations.
The Director of Nursing's admission that the errors could have caused adverse effects highlighted the serious nature of the violations. Elevated blood pressure in stroke patients can trigger additional cardiovascular events or worsen existing conditions.
The resident's vulnerability made the medication errors particularly concerning. With severe cognitive impairment and total dependence on staff, the patient had no ability to recognize or report symptoms of medication-related complications.
The violations demonstrate systematic failures in medication safety protocols. Three separate nurses on different shifts made identical errors over a five-day period, suggesting inadequate training or oversight rather than isolated mistakes.
Each administration required the nurse to check the resident's blood pressure, review the physician's conditional order, and make a decision about whether to proceed. All three nurses failed this basic safety check.
The facility's acknowledgment of the violations through its Director of Nursing confirmed that staff understood the physician's orders but failed to implement them properly during routine medication administration.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Skyline Healthcare Center - La from 2025-08-09 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 August 9, 2025.
The patient had been admitted in May following a stroke that left one side of their body paralyzed.
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.