Skyline Healthcare Center: Abuse Unreported for Days - CA
That admission came from the administrator himself, during an interview with inspectors on September 2, 2025.
The resident, identified in inspection records only as Resident 2, was found soaked in urine in her wheelchair before the incident escalated. According to RN 2, she was upset when staff moved her back to bed and wanted things done a certain way. RN 2 said she scratched the resident during the encounter. CNA 2 was also involved. When the Director of Staff Development later spoke with Resident 2 on August 28, the resident said both RN 2 and CNA 2 had scratched her.
The Director of Staff Development told inspectors that a resident alleging she had been scratched by staff "would be considered physical abuse." Then the DSD added: "Not sure if we did anything."
They hadn't.
The administrator told inspectors he had known about Resident 2's allegation since August 24, when RN 2 informed him directly. That same day, Resident 2 texted him. He reviewed those messages with inspectors during the September 2 interview, reading them aloud. The texts described staff "started fighting physical" with her.
He is the facility's designated abuse coordinator.
"Abuse would be any physical, verbal, wrongdoing against someone," the administrator told inspectors. He said he would consider what Resident 2 described to be abuse. He said he "should have told the nurse at that time to report to OMB, SSA, police and start the investigation."
Then he said he did not do any investigation for Resident 2's allegation.
The facility's own written abuse policy, last reviewed just five months earlier in April 2025, is explicit. Allegations of abuse are to be reported to the administrator immediately. If the suspected perpetrator is an employee, that employee is to be removed from the resident's care and suspended immediately, pending investigation. Law enforcement must be notified by telephone within two hours. A written report goes to the ombudsman, law enforcement, and California Department of Public Health Licensing and Certification within 24 hours. The administrator is supposed to inform the resident of the investigation's results and corrective action within five working days.
None of that happened. Not the phone call. Not the suspension. Not the written report. Not the follow-up with Resident 2.
CNA 2 received a one-on-one in-service about customer service. That was it. No disciplinary action. No suspension. The Director of Staff Development confirmed CNA 2 had not been suspended as of the day inspectors arrived. Resident 2, for her part, told staff that CNA 2's response to her concerns "was not good."
The Director of Staff Development told inspectors they would have to check with the administrator to find out whether any outside agencies had been notified. The administrator, when asked, said he should have acted and didn't.
What makes the administrator's inaction harder to explain is that he didn't dispute what happened. He wasn't uncertain about whether the allegation met the definition of abuse. He wasn't waiting for more information. He read the texts, heard from his nurse, and reached the same conclusion inspectors did. He just didn't do anything with it.
The administrator acknowledged the consequence of that choice in plain terms. He told inspectors that the potential for not investigating means "a resident continues to be at risk for further abuse."
Resident 2 remained in the facility. CNA 2 remained on staff, caring for residents, including presumably Resident 2.
The inspection was a complaint survey, meaning someone contacted regulators about what was happening at Skyline Healthcare Center before inspectors arrived. The facility is located on Rowena Avenue in the Silver Lake neighborhood of Los Angeles. The September 2 inspection covered a single deficiency related to the abuse allegation and the facility's failure to investigate and report it.
The harm level was classified as minimal harm or potential for actual harm, with few residents affected. That classification reflects the regulatory framework's assessment of documented injury at the time of inspection. It does not capture what Resident 2 described in those text messages, or what she told the Director of Staff Development four days after the incident, or what she was left to navigate alone while the administrator who received her messages decided not to act.
The Director of Staff Development put it plainly enough: when a resident says staff scratched her, that is physical abuse. The administrator put it plainly enough: he should have acted, and he did not. The facility's own policy put it plainly enough: employees accused of abuse are to be suspended immediately.
Resident 2 sent her administrator a text message. She told him staff had fought with her physically. He read it. He agreed with her. He went back to work.
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: 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 26, 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.
That admission came from the administrator himself, during an interview with inspectors on September 2, 2025.
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.