Skyline Healthcare Center: Abuse Cover-Up Failure - CA
The admission came during a complaint inspection on September 2, 2025, at the facility on Rowena Avenue in Los Angeles. What inspectors documented was not a case of a violation slipping through bureaucratic cracks. It was a case of a facility administrator who understood exactly what was required of him, said so out loud, and then acknowledged he had done none of it.
The resident at the center of the allegation is identified in inspection records only as Resident 2. On August 24, 2025, she sent a text message to the administrator saying that a registered nurse and a certified nursing assistant, identified as RN 2 and CNA 2, had "started fighting physical" with her. The administrator reviewed those text messages with inspectors during the September 2 visit.
He did not dispute what the messages said. He confirmed he received them. He confirmed he understood, at the time he received them, that what Resident 2 was describing was abuse. "Abuse would be any physical, verbal, or wrongdoing against someone," he told inspectors. "I would consider this abuse."
Then he said this: "I should have told the nurse at that time to report to OMB, SSA, police and start the investigation."
He had not done that.
The administrator also serves as the facility's designated abuse coordinator, a role that carries specific responsibilities under the facility's own written policy. That policy, last reviewed on April 4, 2025, less than five months before Resident 2's allegation, requires that suspected abuse be reported to law enforcement within two hours of the initial report. It requires a written report to the ombudsman, law enforcement, and the California Department of Public Health within 24 hours. It requires that any employee accused of resident abuse be immediately suspended pending investigation. It requires that the resident be informed of the investigation's outcome and any corrective action within five working days.
None of those things happened.
The administrator told inspectors he had not opened any investigation into Resident 2's allegation. He acknowledged the consequence of that failure directly: "Potential for not investigating can be a resident continues to be at risk for further abuse."
That was his own assessment. He said it to inspectors. The two staff members Resident 2 accused were still working at the facility.
The Director of Staff Development, interviewed separately earlier that afternoon, described speaking with Resident 2 on August 28, four days after the initial text message to the administrator. During that conversation, Resident 2 said RN 2 and CNA 2 had scratched her. The Director of Staff Development told inspectors that when a resident alleges she has been scratched, that constitutes physical abuse. The director also confirmed the mandatory reporting timeline: two hours, three agencies, the ombudsman, police, and the state Social Services Agency.
When inspectors asked whether any of that reporting had been done, the Director of Staff Development said she wasn't sure. She said she would have to check with the administrator.
The inspection record also contains a brief account of what Resident 2 and the staff members have each said about the underlying incident. According to the records, when RN 2 and CNA 2 placed Resident 2 back into bed, the resident became upset and wanted things done a certain way. The staff members, in their account, said Resident 2 grabbed CNA 2 by the hair and scratched RN 2. Resident 2, in her account, said it was the staff who scratched her.
That is precisely the kind of disputed account that an abuse investigation exists to resolve. Investigators interview witnesses. They review records. They determine what happened. They make a decision about whether the accused employees should continue working with the resident who says she was harmed by them.
None of that happened at Skyline Healthcare Center. No investigation was opened. No witnesses were interviewed. No determination was made. Resident 2's allegation sat in the administrator's text messages for nine days while the people she accused continued working in the facility.
The facility's own policy is explicit about what should happen when an employee is accused. The accused employee is to be removed from the resident's care immediately and suspended pending the outcome of the investigation. The policy uses the word "immediately" twice in a single sentence. There is no ambiguity in the language. The administrator, who reviewed and is responsible for that policy, told inspectors he had not followed it.
Inspectors rated the level of harm in this deficiency as minimal harm or potential for actual harm, and noted that few residents were affected. The citation is a serious one nonetheless. Abuse reporting requirements exist because the alternative is what happened here: a resident makes an allegation, the allegation goes nowhere, and she remains in the care of the people she says hurt her.
What the inspection record does not contain is any account of what Resident 2 experienced during those nine days. Whether she saw RN 2 or CNA 2 again. Whether she said anything more to anyone. Whether she felt safe. The inspection record ends where the administrator's accountability ended, which was the moment he read her text message and decided not to act on it.
The administrator told inspectors what he should have done. He laid it out in sequence: tell the nurse, report to the ombudsman, report to the state agency, report to police, start the investigation. He knew the steps. He had reviewed the policy that required them four months earlier. He is the designated abuse coordinator. He is the person the policy names as responsible for every one of those notifications.
He made none of them.
Skyline Healthcare Center is located at 3032 Rowena Avenue in Los Angeles.
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.
Download the official CMS inspection PDF from Medicare.gov
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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 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 admission came during a complaint inspection on September 2, 2025, at the facility on Rowena Avenue in Los Angeles.
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.