Skyline Healthcare: Resident Attack Goes Unreported - CA
The September incident began when Resident 2 complained she wasn't comfortable with a particular nursing assistant. RN 2 volunteered to handle the woman's care that morning around 9 a.m., providing perineal care, changing her diaper, and bringing water.
But when RN 2 returned with the nursing assistant around 1 p.m., the resident became upset again. She didn't want the aide in her room.
RN 2 explained there was limited help available. The resident responded by yelling and calling the nurse derogatory names.
The woman was sitting in her wheelchair, soaked in urine. When RN 2 moved to place her back in bed, the resident wanted things done a specific way. That's when she lashed out physically.
She grabbed CNA 2 by the hair. She scratched RN 2, breaking the skin.
The administrator acknowledged during a September 2 interview that Resident 2 had behavioral issues, but said the physical violence was completely new. "Scratching and drawing blood from staff is a brand-new behavior," the administrator told inspectors.
Despite recognizing this as a significant change, nobody created what's called a change of condition report. Nobody notified the resident's doctor.
"Because this is a new behavior a COC should have been created for Resident 2's behavior," the administrator admitted. The report would have triggered monitoring and required the doctor to issue new orders for managing the resident's care.
The administrator said the doctor was never notified. "There is a potential for a delay of care because no COC was done to address the resident's behavioral change."
Skyline's own policy, last reviewed in April, requires staff to "promptly inform the resident, consult with the resident's Physician and notify the resident's legal representative or an interested family member" when a resident experiences a significant change in condition.
The policy specifically defines a change of condition requiring physician notification as "any sudden and marked adverse change in the resident's condition which is manifested by signs and symptoms different than usual denotes a new problem, complication or permanent change in status and requires medical assessment, coordination and consultation with a Physician and a change in treatment plan."
The violent behavior fit that definition exactly. The resident had behavioral issues before, but physically attacking staff and drawing blood represented something different. Something that required medical evaluation and potentially new medication or care approaches.
Instead, the incident was handled as a staffing problem rather than a medical one. The focus remained on which nursing assistant the resident preferred, not on why someone with existing behavioral issues had escalated to physical violence.
The failure meant the resident's doctor had no opportunity to assess whether the behavioral change indicated an underlying medical issue, medication side effect, or psychiatric condition requiring treatment. Without medical evaluation, staff had no new strategies for preventing future attacks.
The administrator's admission that this created "potential for a delay of care" understated the problem. Every day without proper medical assessment was a day the resident might attack again, potentially injuring herself or other staff members more seriously.
Federal inspectors found the facility violated requirements for physician notification and change of condition reporting. The violation affected few residents but created minimal harm or potential for actual harm, according to the inspection report.
But for the nursing staff who were grabbed and scratched that September afternoon, the harm was real enough. And for Resident 2, sitting in her wheelchair soaked in urine and lashing out at the people trying to help her, the failure to involve her doctor meant missing a chance to understand why her behavior had turned violent.
The inspection occurred as part of a complaint investigation, suggesting someone reported concerns about the facility's handling of the incident. Federal inspectors completed their review on September 2, the same day they interviewed the administrator about the unreported attack.
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 violations during a health inspection on September 2, 2025.
The September incident began when Resident 2 complained she wasn't comfortable with a particular nursing assistant.
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.