Skyline Healthcare: Abuse Allegations Not Reported - CA
The incident at Skyline Healthcare Center unfolded on August 24, 2025, when Resident 2 complained she wasn't comfortable with CNA 2 providing her care. Registry nurse RN 2 volunteered to help the resident around 9 a.m., providing perineal care, changing her depend, and giving her water.
Around 1 p.m., RN 2 returned to the resident's room with CNA 2. The resident was upset and didn't want CNA 2 to help her. RN 2 explained there was limited assistance available.
The resident yelled at RN 2 and called her derogatory names. She was sitting in her wheelchair, soaked in urine.
When staff moved the resident back to bed, she became more agitated and wanted things done a specific way. During the transfer, the resident grabbed CNA 2 by the hair and scratched RN 2.
But that's not how the resident described what happened.
Four days later, on August 28, the Director of Staff Development spoke with Resident 2. The resident claimed RN 2 and CNA 2 had scratched her.
"When a resident alleges they have been scratched, that would be considered abuse," the Director of Staff Development told inspectors. "This would have been physical abuse."
The administrator had known about the incident since August 24, when RN 2 told him what happened. The resident also texted him directly with her version of events.
During the inspection, the administrator reviewed the text messages between himself and Resident 2. The resident alleged staff "started fighting physical" on August 24.
The administrator serves as the facility's abuse coordinator. He told inspectors that abuse "would be any physical, verbal, or wrongdoing against someone."
When asked if he considered the resident's allegations to be abuse, he was direct: "I would consider this abuse."
He acknowledged what should have happened next: "I should have told the nurse at that time to report to OMB, SSA, police and start the investigation."
He didn't.
The administrator admitted he "did not do any investigation for Resident 2 allegation of abuse."
When inspectors asked about the potential consequences of not investigating, the administrator recognized the risk: "A resident continues to be at risk for further abuse."
The facility's own policy, last reviewed on April 4, 2025, requires immediate action when abuse allegations surface. Any "allegation of abuse, neglect, mistreatment, exploitation, or reasonable suspicion of a crime" must be reported to the administrator or designated representative immediately.
If the suspected perpetrator is an employee, the policy states the facility must "remove the employee immediately from the care of the resident and immediately suspend the employee pending the outcome of the investigation."
The policy also mandates notification of outside agencies. The administrator must notify law enforcement by telephone "immediately, or as soon as practicable possible, but no longer than two hours of the initial report."
Written reports must go to the ombudsman, law enforcement, and the California Department of Public Health Licensing and Certification within 24 hours.
None of this happened.
The Director of Staff Development wasn't sure if the administrator had reported the incident to the required agencies. "Not sure if we did anything," she told inspectors. "Would have to check with Adm not sure if it was reported."
The policy requires suspended employees to remain off duty "until the results of the investigation have been reviewed by the Adm." It also mandates that residents be informed of investigation results and corrective actions within five working days.
The administrator must provide written reports on investigation results to state agencies and others required by law within five working days of the reported allegation.
The facility's policy acknowledges the seriousness of abuse allegations and the need for swift action. But when faced with a resident's claims that staff had physically fought and scratched her, the abuse coordinator took no investigative steps and made no required reports.
The resident's text message alleging staff "started fighting physical" sat unaddressed. Her claims that RN 2 and CNA 2 had scratched her went uninvestigated.
Registry nurse RN 2, who worked at the facility only on August 24 from 7 a.m. to 3 p.m., described a different sequence of events. She said the resident grabbed CNA 2's hair and scratched her, not the other way around.
But under federal regulations, the resident's allegations alone triggered mandatory reporting and investigation requirements, regardless of staff's version of events.
The administrator's admission was unequivocal: he considered the resident's claims to be abuse, knew he should have initiated reports and investigation, and failed to do either.
The Director of Staff Development confirmed that any allegation of scratching "would be considered abuse" and constituted "physical abuse."
Yet nearly two weeks passed between the incident and the federal inspection before anyone began examining what the resident claimed had happened to her.
The facility's detailed policies outlined exactly what should occur when abuse allegations arise, but those procedures weren't followed when a resident texted her administrator claiming staff had physically fought and injured her during care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Skyline Healthcare Center - La from 2025-09-02 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 September 2, 2025.
The incident at Skyline Healthcare Center unfolded on August 24, 2025, when Resident 2 complained she wasn't comfortable with CNA 2 providing her care.
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.