Skyline Healthcare Center - La

F-F558

Findings:

A review of Resident 15's Admission Record indicated the facility admitted the resident on 4/13/2018, and readmitted the resident on 12/9/2021, with diagnoses of dementia (the loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), adult failure to thrive (when an older adult has a loss of appetite, eats and drink less than usual, loses weight, and is less active than normal), and contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff).

A review of Resident 15's MDS, dated [DATE REDACTED], indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident was dependent on mobility and activities of daily living (ADLs).

During a concurrent observation and interview on 6/11/2024, at 9:48 a.m., with Treatment Nurse 1 (TN 1), inside Resident 15's room, observed the resident's call light hanging on the wall and not within resident's reach. TN 1 stated it was the preference of the family member to have the call light not within the reach of

the resident. TN 1was asked if there was a care plan addressing the resident's family's preference to not keep the call light within the resident's reach. TN 1 stated there was no care plan created to reflect the family member's preference to keep the call light away from the resident's reach.

During an interview on 6/13/2024, at 6:26 p.m., with the Director of Nursing (DON), the DON stated the call light should be within Resident 15's reach. The DON stated she was only made aware of the family's preference of not keeping the call light within the resident's reach today (6/13/2024). The DON stated the Interdisciplinary Team (IDT, a group of professional and direct care staff that have primary responsibility for

the development of a plan for the care and treatment of a resident) should have met and discussed the family member's preference of not having the call light within the reach of the resident before it gets implemented. The DON stated not keeping the call light within the reach of the resident could result to accidents such as falls.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 A review of the facility's recent policy and procedure titled, Comprehensive Person- Centered Care Planning, last reviewed on 4/4/2024, indicated the comprehensive care plan will be periodically reviewed and revised Level of Harm - Minimal harm or by IDT after each assessment which means after each MDS assessment as required, except discharge potential for actual harm assessments. In, addition, the comprehensive care plan will also be reviewed and revised at the following times: Residents Affected - Few i. Onset of new problems;

ii. Change of condition;

iii. In preparation for discharge;

iv. To address changes in behavior and care; and

v. Other times as appropriate or necessary.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or 44376 potential for actual harm Based on interview and record review, the facility failed to provide care in accordance with professional Residents Affected - Some standards to one out of two sampled residents (Resident 6) investigated during review of insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites.

The deficient practice had the potential for adverse effects (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin).

Cross reference

F-F604

Findings:

1. A review of Resident 15's Admission Record indicated the facility admitted the resident on 4/13/2018, and readmitted the resident on 12/9/2021, with diagnoses including contracture of joint (a permanent tightening of

the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff), osteomyelitis (an inflammation or swelling of bone tissue that is usually the result of an infection), and muscle wasting (thinning or loss of muscle tissue).

A review of Resident 15's History and Physical (H&P), dated 4/29/2024, indicated the resident did not have

the capacity to understand and make decisions.

A review of Resident 15's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/8/2024, indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident was totally dependent on mobility and activities of daily living (ADLs).

A review of Resident 15's Bed Rail Assessment (BRA), dated 5/23/2024, indicated the resident was non-ambulatory and had displayed poor bed mobility or difficulty moving to a sitting position on the side of

the bed. The BRA indicated side rails/assist bar were not indicated at this time.

During an observation on 6/11/2024, at 3:24 p.m., inside Resident 15's room, observed the resident lying down in bed with both upper bed side rails up.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 During a concurrent interview and record review on 6/12/2024, at 11:52 a.m., with Registered Nurse 1 (RN 1), reviewed Resident 15's Order Summary Report, Consents, and Bed Rail Assessment. RN 1 stated there Level of Harm - Minimal harm or was no physician order and no informed consent for SR use. RN 1 stated there was a Bed Rail Assessment potential for actual harm done on 5/23/2024 but the assessment indicated no side rail/assist bar indicated at this time. RN 1 stated the SRs should have not been placed for use if the assessment did not indicate the resident needed SRs. RN 1 Residents Affected - Some stated an informed consent should be obtained from the resident or their representative so they (resident and their representative) will know the risk and benefits of using the bed rails and make an informed decision. RN 1 stated applying both upper side rails without an indication can cause injury to the resident including entrapment.

During an interview on 6/13/2024 at 6:30 p.m., with the Director of Nursing (DON), the DON stated prior to use bed rails, there should be a physician's order and an informed consent from the resident or their representative and an assessment for its use. The DON stated the Bed Rail Assessment done on 5/23/2024 which indicated the resident did not need the bed rails, should have been followed and no bed rails should have been applied. The DON further stated applying both upper side rails up when the assessment indicated

the resident did not require the use of bed rails, predisposes the resident to harm such as entrapment.

A review of the facility's recent policy and procedure titled, Bed Rail, last reviewed on 4/4/2024, indicated to provide guidance to adequately evaluate the use of bed rails and prevent potential entrapment or other safety hazards. Prior to installation, assess the resident's risk of entrapment with bed rails. Review the risk and benefits of bed rails with the resident and resident's representative and obtain informed consent prior to installation. Follow manufacturers' recommendations and specifications for installing and maintaining the bed rails. Bed rails cannot be used for staff convenience or as discipline, such as prevention of falls when less effective methods have not been attempted or ruled out. A detailed order by a healthcare provider (e.g., a physician, nurse practitioner) is required before any restraints can be utilized. Prior to the installation of bed rails, the ordering physician will obtain informed consent from the resident or their representative. The licensed nurse will initiate a care plan around the use of bed rails.

A review of the facility provided manufacturer's guideline Fixed Assist Bar 1 (FAB 1) (Includes One Assist Bar and Hardware Bag), dated 8/2014, indicated when assessing the risk of entrapment, you need to consider your bed, mattress, headboard and footboard, assist devices (i.e. rails and assist bars) and other accessories as an entire system. All bed systems are evaluated for full compliance to the FDA/CDRH Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment guidelines.

A review of the facility provided manufacturer's guideline Bed Frame 1 (BF 1), dated 8/2014, indicated the guidelines set forth by the FDA Guidance layout specific dimensional limitations on potentially injury-threatening gaps and spaces that can occur between bed system components, such as rails, when not properly installed. However, entrapment issues can often arise when a healthcare provider/facility has not correctly assembled the components on a bed. It is essential that the provider/facility fully understand their responsibility in complying to the guidelines set forth by the FDA in order to avoid injury.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 2. A review of Resident 74's Admission Record indicated the facility admitted the resident on 11/14/2023, with diagnoses including abnormalities of gait (a manner of walking or moving on foot) and mobility, muscle Level of Harm - Minimal harm or wasting and atrophy (decrease in size of a body part, cell, organ, or other tissue), and history of falling. potential for actual harm

A review of Resident 74's MDS, dated [DATE REDACTED], indicated the resident had the ability to make self-understood Residents Affected - Some and understand others. The MDS indicated the resident required substantial to maximal assistance with mobility and ADLs.

A review of Resident 15's BRA, dated 5/30/2024, indicated the resident was ambulatory and had not displayed poor bed mobility or difficulty moving to a sitting position on the side of the bed. The BRA indicated side rails/assist bar were not indicated at this time.

During an observation on 6/12/2024, at 8:05 a.m., inside Resident 74's room, observed the resident lying down in bed with the left upper bed rail up.

During an observation on 6/13/2024, at 4:13 p.m., with Certified Nursing Assistant 9 (CNA 9), inside Resident 74's room, observed the left upper bed rail of the resident was still up.

During a concurrent interview and record review on 6/12/2024, at 8:05 a.m., with RN 1, reviewed Resident 74's Order Summary Report, Consents, and Bed Rail Assessment. RN 1 stated there was no physician order and no informed consent use of left upper bed rail. RN 1 stated there was a Bed Rail Assessment done on 5/30/2024 but the assessment indicated no side rail/assist bar indicated at this time. RN 1 stated the bed rails should have not been placed for use if the assessment did not indicate the resident needed bed rails. RN 1 stated placing the left upper bed rail is considered a restraint because the bed rail kept the resident from getting out of bed freely on the left side. RN 1 stated an informed consent should be obtained from the resident or their representative so they (resident and their representative) will know the risk and benefits of using the bed rails and make an informed decision. RN 1 stated applying the left upper side rail without an indication can cause injury to the resident including as entrapment.

During an interview on 6/13/2024 at 6:30 p.m., with the DON, the DON stated prior to use of bed rails, there should be a physician's order and an informed consent from Resident 74 resident or their representative and

an assessment for its use. The DON stated the Bed Rail Assessment done on 5/30/2024 which indicated the resident did not need the bed rails, should have been followed and no bed rails should have been applied.

The DON further stated applying bed rails up when the assessment indicated the resident did not require the use of bed rails, predisposes the resident to harm such as entrapment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 A review of the facility's recent policy and procedure titled, Bed Rail, last reviewed on 4/4/2024, indicated to provide guidance to adequately evaluate the use of bed rails and prevent potential entrapment or other Level of Harm - Minimal harm or safety hazards. Prior to installation, assess the resident's risk of entrapment with bed rails. Review the risk potential for actual harm and benefits of bed rails with the resident and resident's representative and obtain informed consent prior to installation. Follow manufacturers' recommendations and specifications for installing and maintaining the bed Residents Affected - Some rails. Bed rails cannot be used for staff convenience or as discipline, such as prevention of falls when less effective methods have not been attempted or ruled out. A detailed order by a healthcare provider (e.g., a physician, nurse practitioner) is required before any restraints can be utilized. Prior to the installation of bed rails, the ordering physician will obtain informed consent from the resident or their representative. The licensed nurse will initiate a care plan around the use of bed rails.

A review of the facility provided manufacturer's guideline FAB 1 (Includes One Assist Bar and Hardware Bag), dated 8/2014, indicated when assessing the risk of entrapment, you need to consider your bed, mattress, headboard and footboard, assist devices (i.e. rails and assist bars) and other accessories as an entire system. All bed systems are evaluated for full compliance to the FDA/CDRH Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment guidelines.

A review of the facility provided manufacturer's guideline BF 1, dated 8/2014, indicated the guidelines set forth by the FDA Guidance layout specific dimensional limitations on potentially injury-threatening gaps and spaces that can occur between bed system components, such as rails, when not properly installed. However, entrapment issues can often arise when a healthcare provider/facility has not correctly assembled

the components on a bed. It is essential that the provider/facility fully understand their responsibility in complying to the guidelines set forth by the FDA in order to avoid injury.

43418

3. A review of Resident 64's Admission Record indicated the facility admitted Resident 64 on 4/16/2024 with diagnoses including, but not limited to, muscle wasting and atrophy.

A review of Resident 64's MDS, dated [DATE REDACTED], indicated Resident 64 had severe cognitive impairment (difficulty understanding and making decisions), and required moderate to maximal assistance with activities of daily living such as hygiene, toileting, and surface-to-surface transfers, and was not using bed rails.

A review of Resident 64's History and Physical (H&P), dated 5/15/2024, indicated Resident 64 was a poor historian and was confused at times.

A review of Resident 64's Bed Rail Assessment, dated 5/13/2024, indicated side rails or assist bars are not indicated at this time.

During an observation on 6/11/2024, at 9:00 a.m., inside Resident 64's room, Resident 64 was lying down in bed with quarter rails on both sides of the head of the bed.

During a concurrent observation and interview with Certified Nursing Assistant (CNA) 4, on 6/13/2024, at 2:47 a.m., inside Resident 64's room, CNA 4 confirmed Resident 64's bed had bed rails on both sides of the bed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 4, on 6/13/2024, at 4:33 p.m., Resident 64's Order Summary Report was reviewed and LVN 4 confirmed Resident 64 did not Level of Harm - Minimal harm or have an order for use of bed rails. LVN 4 stated Resident 64 currently had bed rails on her bed and the potential for actual harm resident should have orders from the physician for use of bed rails because bed rail use can be considered as a form of restraint or enabler and the physician needs to approve the use for both. LVN 4 stated if there is Residents Affected - Some no order for bed rail use, the resident would not be evaluated, assessed, or care planned for its use. Resident 64's Bed Rail Assessment, dated 5/13/2024, was reviewed and LVN 4 confirmed the assessment recommended no side rail replacement recommended and the use of side rails or an assist bar were not indicated at that time. LVN 4 stated it is important to follow the assessment because it is the basic criteria used to determine if a resident requires bed rails or not. Resident 64's medical record was reviewed and LVN 4 confirmed Resident 64 did not have a consent for bed rail use. LVN 4 stated a consent for bed rail use indicates what the bed rail will be used for and obtains permission for use from the resident's responsible party.

During an interview with the Director of Nursing (DON), on 6/13/2024, at 6:14 a.m., the DON stated when using bed rails, a physician's order is required so that the physician is aware of its use. The DON stated bed rail assessments are used to determine if the resident requires the use of bed rails and determines if the resident will use the bed rails to aid with mobility.

A review of the facility's policy and procedure (P&P) titled, Bed Rails, last reviewed 4/4/2024, indicated prior to installation of bed rails, assess the resident's risk of entrapment with bed rails and the ordering physician will obtain informed consent from the resident or their representative.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 68 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0730 Observe each nurse aide's job performance and give regular training.

Level of Harm - Minimal harm or 43988 potential for actual harm Based on interview and record review, the facility failed to complete a performance review (also known as Residents Affected - Few performance evaluation [PE] - a formal and productive procedure to measure an employee's work and results based on their job responsibilities) at least once every 12 months for one of three sampled Certified Nursing Assistants [CNA] (CNA 5) reviewed under sufficient and competent nurse staffing task.

This deficient practice had the potential to result in missed opportunities to address CNA 5's performance issues that could impact resident safety and satisfaction.

Findings:

During a concurrent interview and record review on 6/13/2023 at 4:41 p.m., with Infection Preventionist (IP), reviewed CNA 5's employee file. The IP stated the last performance evaluation (PE) filed for CNA 5 was dated 4/18/2023. The IP verified CNA 5's PE for the year 2023 was missing.

During an interview on 6/13/2024 at 7:15 p.m., with the Director of Nursing (DON), the DON stated performance evaluations are done annually. The DON stated the Director of Staff Development is responsible for completing the CNA's performance evaluation. The DON stated the purpose of doing PE was to inform the employees of their performance progress and discuss areas in their performance that may need improvement and to evaluate the staff's competency in performing their job responsibilities.

A review of the facility's policy and procedure titled, Staff Competency Assessment, last reviewed 4/4/2024, indicated:

- the purpose of completing competency assessments is to determine knowledge and/or performance or assigned responsibilities based on standard of practice, policy and procedure and regulatory requirement.

- Competency assessment will be performed upon hire during the employee's 90-day employment period, annually or as needed.

- Competency assessments will be through written testing and/or observations, whichever is appropriate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 69 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43455

Residents Affected - Few Based on observation, interview, and record review the facility failed to administer a medication on time for one of five sampled residents (Resident 11.) for medication administration.

As a result, Residents 11 did not receive apixaban (a medication used for Deep Vein Thrombosis [DVT - a condition when a blood clot forms in one or more of the deep veins in the body] by reducing blood clots) in accordance with the physician's orders and standards of practice. This failure had the potential to cause Resident 11 to experience serious health complications due to improper management of DVT, possibly resulting in DVT, stroke or heart attack causing hospitalization and/or death.

Findings:

During an observation on 6/11/2024 at 9:54 AM, in medication cart 2, Licensed Vocational Nurse (LVN) 5 was observed not administering apixaban 5 milligram ([mg] - a unit of measure of mass) tablet to Resident 11. LVN 5 informed Resident 11 the apixaban was not available this morning and will have to wait for pharmacy to deliver the medication.

During an interview on 6/11/2024 at 10 AM, with LVN 5, LVN 5 stated that LVN 5 did not administer the apixaban 5 mg to Resident 11 at the scheduled time on 6/11/2024, because it was not available in the medication cart or in the facility. LVN 5 stated LVN 5 will follow up with the pharmacy to expedite the refill of

the apixaban and call the physician to inform the morning dose on 6/11/2024 was not administered. LVN 5 stated that medications should be ordered from the pharmacy when there are 3 days of doses left, and followed up as needed, to ensure timely availability of medications. LVN 5 stated it is important to receive apixaban as ordered by physician for DVT management, and missing doses can harm Resident 11 by causing another DVT leading to hospitalization .

During an interview, on 6/12/2024 at 11:44 AM, with the Director of Nursing (DON,) the DON stated that medication refills should be ordered from the pharmacy about 3 to 4 days before the last dose to prevent medications from not being available to the residents at their scheduled times. The DON stated that LVN's are expected to re-order medications timely and follow-up on the refills to ensure medications are available to residents. The DON stated that Resident 11 was not administered apixaban 5 mg tablet for the 9 AM dose

on 6/11/2024 due to the medication not being available. The DON stated Resident 11 was prescribed apixaban for DVT management and missing the administration can potentially cause thrombosis (clotting of blood), which is critical because the blood is not properly thinned, and the clot can dislodge and travel to the heart and brain forming an embolism (obstruction caused by clots) and causing a heart attack and stroke.

The DON stated that several licensed nurses failed to submit the apixaban 5 mg refill request timely to the pharmacy, to prevent the unavailability and interruption in the medication therapy and ensure continuity of care for Resident 11. The DON stated there needs to be a more proactive approach and better communication to prevent this failure in the future.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 70 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 During a review of Resident 11's Admission Record (a document containing demographic and diagnostic information,) dated 6/11/2024, the Admission Record indicated Resident 11 was originally admitted to the Level of Harm - Minimal harm or facility on [DATE REDACTED] with diagnoses including acute embolism and thrombosis of unspecified deep veins of potential for actual harm bilateral (relating to both) lower extremity (part of the body that includes the hip, thigh, knee, leg, ankle, and foot.) Residents Affected - Few

During a review of Resident 11's Order Summary Report (a report listing the physician order for the resident), dated 6/1/2024, indicated Resident 11 was prescribed apixaban 5 mg tablet by mouth two times a day for DVT management, starting 5/17/2024.

During a review of the MAR ([MAR] - a document of the medications administered to a resident that is part of

the resident's permanent medical record], on 6/11/2024 at 11:48 AM, the MAR indicated Resident 11's dose of apixaban 5 mg was due every day at 9 AM and 5 PM, and there was no documentation for the apixaban 5 mg administration on 6/11/2024 for the 9 AM dose.

Review of the pharmacy facsimile manifests, the pharmacy received a request to refill Resident 11's apixaban 5 mg tablets from the facility on 6/11/2024 at 9:39 AM.

Review of the facility's policy and procedures (P&P), titled Medication Administration, dated 1/1/2012, the P&P indicated:

B. The Licensed Nurse will prepare medications within one hour of administration.

i. Medications may be administered one hour before or after the scheduled medication administration time.

Review of the facility's P&P, titled Reordering, Changin, and Discontinuing Medication Orders, dated 4/4/2024, the P&P indicated that: The facility will communicate any medication reorders, changes, or discontinuations to the pharmacy in accordance with pharmacy guidelines and state / federal regulations; thus ensuing standardized process of communication.

B. Reorder / Refill orders:

1. Refills can be requested via facilities EMAR system; this is the most preferred method. Facility may also request refills by placing the 'refill strip portion of the medication label on the Refill Order Form and faxing it to the pharmacy.

Review of the facility's P&P titled, Medication Ordering and Prescribing Reorders, dated 4/4/2024, the P&P indicated To ensure resident's received medications in a timely fashion.

1. Nurse will examine supply of medication remaining to ascertain when a reorder/refill is needed for the resident. As a guidance, reorder medications when a four (4) day supply remains.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 71 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43455 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure that its medication error rate Residents Affected - Some was less than five percent (%). Four medication errors out of 32 total opportunities contributed to an overall medication error rate of 12.5 % affecting three of five residents observed for medication administration (Resident 11, 36 and 295.) The medication errors were as follows:

1. Resident 11 did not receive a dose of apixaban (a medication used for Deep Vein Thrombosis [DVT - a condition when a blood clot forms in one or more of the deep veins in the body] by reducing blood clots) as ordered by Resident 11's physician.

2. Resident 36 did not receive a dose of Oyster Shell calcium (a medication used as a dietary supplement to provide support to bones) as ordered by Resident 36's physician.

3. Resident 295 was to be administered Metoprolol Succinate (a medication used to treat high blood pressure) Extended Release ([ER]- a form of medication that is sustained (slowly) release) and Duloxetine (a medication used to treat depression) Delayed Release ([DR] - a form medication that is sustained release) against manufacturer's recommendations.

These failures had the potential to result in Resident 11, 36 and 295 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and the potential to result in Residents 11's, 36's and 295's health and well-being to be negatively impacted.

Cross reference

F-F658

2. One of five sampled residents (Resident 295) observed for medication administration by failing to administer Metoprolol Succinate (a medication used to treat high blood pressure) Extended Release ([ER]- a form of medication that is sustained (slowly) release) and Duloxetine (a medication used to treat depression) Delayed Release ([DR] - a form medication that is sustained release) according to manufacturer's recommendations.

These failures had the potential to result in Resident 295 to receive suboptimal (less than the highest standard or quality) care, experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) such as gastrointestinal ([GI] - relating to the stomach) irritation negatively impacting Resident 295's health and well-being.

Cross reference

F-F688.

Findings:

A review of Resident 7's Admission Record indicated the facility admitted Resident 7 on 7/15/2022 with diagnoses including hemiplegia or hemiparesis (weakness or inability to move one side of the body) following

a cerebral infarction (brain damage due to a loss of oxygen to the area) affecting the right dominant (used more often) side, dysphagia (difficulty swallowing), gastrostomy status (G-tube, tube placed directly into the stomach for long-term feeding), aphasia (loss of ability to understand or express speech as a result of brain damage), and functional quadriplegia (complete immobility due to frailty or severe physical disability).

A review of Resident 7's care plan for limited mobility, initiated on 9/7/2022 and revised on 11/6/2022, indicated interventions included to provide Resident 7 with activities that enhance mobility.

A review of Resident 7's care plan for cerebral vascular accident (CVA, blood flow stops to a part of the brain, brain damage due to blocked blood flow) with right sided weakness, initiated on 2/19/2024, indicated interventions to provide Resident 7 with activity as tolerated and out-of-bed to chair if tolerated.

A review of Resident 7's Activity Attendance Record from 1/2024 to 6/2024 indicated Resident 7 participated

in room visits.

A review of Resident 7's Minimum Data Set (MDS, a comprehensive assessment and care planning tool), dated 4/22/2024, indicated Resident 7 had severely impaired cognition (ability to think, understand, learn, and remember) and dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) with oral hygiene, toileting, showering/bathing oneself, upper and lower body dressing, rolling to both sides and tub/shower transfers. The MDS indicated Resident 7 did not attempt chair/bed-to-chair transfers due to medical condition or safety concerns.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0676 During an observation on 6/11/2024 at 12:38 p.m. in Resident 7's bedroom, Resident 7 wore a hospital gown while lying awake in bed. Resident 7 did not verbally respond to questions. Resident 7 actively moved the left Level of Harm - Minimal harm or arm at the shoulder and elbow joints, but the left hand was positioned in a closed fist. Resident 7 shook the potential for actual harm head, No, when asked if Resident 7 could open the left hand. Resident 7 did not have any active movement

in the right arm. Residents Affected - Some

During an observation on 6/12/2024 at 7:30 a.m. in Resident 7's bedroom, Resident 7 wore a hospital gown while lying awake in bed while Restorative Nursing Aide 1 (RNA 1) stood on the left side of the bed attempting to apply a left knee splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion).

During an observation on 6/12/2024 at 12:11 p.m. in Resident 7's bedroom, Resident 7 wore a hospital gown while lying awake in bed.

During an observation on 6/13/2024 at 8:58 a.m. in Resident 7's bedroom, Resident 7 wore a hospital gown while lying awake in bed.

During an interview on 6/13/2024 at 9:03 a.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 7's shower days were on Monday and Thursday. CNA 1 stated Resident 7 received a bed bath on Monday and will receive a bed bath today. CNA 1 stated Resident 7 did not receive showers because it was difficult and caused Resident 7 pain to position Resident 7 in the shower chair.

During an interview on 6/13/2024 at 10:42 a.m. with CNA 1, CNA 1 stated Resident 7 wore a hospital gown because Resident 7 was usually in bed. CNA 1 stated Resident 7 was dressed in regular clothes when the family came to visit and when Resident 7 was transferred into a special type of chair.

During an interview on 6/13/2024 at 3:42 p.m. with the Director of Nursing (DON), the DON stated Resident 7 did not have any care plans preventing Resident 7 from getting out of the bed. The DON stated Resident 7 was alert and should not be in bed. The DON stated the facility was not maintaining Resident 7's mobility and quality of life while Resident 7 remained in bed.

During a concurrent interview and record review on 6/13/2024 at 5:13 p.m. with the Activity Assistant (AA), AA reviewed Resident 7's activity log from 1/2024 to 6/2024 and stated Resident 7 was seen for activities in

the bedroom. AA stated the purpose of the activity program was to assist the residents (in general) with participation, communication, and cognitive function. AA did not know the reason Resident 7 was not assisted out to the activity room and stated, I can't imagine lying in bed all day.

A review of the facility's policy and procedure (P&P) titled, Resident Rights - Quality of Life, revised 2017, indicated each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, individuality and receives services in a person-centered manner, as well as those that support the resident in attaining or maintaining his/her highest practicable well-being. The P&P also indicated resident were encouraged and assisted to dress in their own clothes rather than in hospital gowns.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0678 Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43988

Residents Affected - Few Based on interview and record review, the facility failed to implement their policy and procedure on cardiopulmonary resuscitation (CPR, an emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped) by failing to maintain American Red Cross (an organization led by volunteers that provide relief to victims of disasters and help people prevent, prepare for and respond to emergencies) or American Heart Association (AHA, a non-profit organization that aims to reduce disability and death from cardiovascular diseases and stroke) CPR certification for one of nine sampled employees (Licensed Vocational Nurse 1 [LVN 1])investigated during review of sufficient and competent nurse staffing task.

This deficient practice had the potential for delayed provisions of emergency care for current residents who wishes to have full treatment in a life-threatening situation.

Findings:

During a concurrent interview and record review on [DATE REDACTED]/2024 at 10:52 a.m. with the Infection Preventionist (IP) reviewed the facility's employee files. The IP stated she was not sure if LVN 1's basic life support/CPR training dated [DATE REDACTED] was completed through the American Red Cross or the American Heart Association.

During an interview on [DATE REDACTED] at 3:50 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated she completed her CPR training dated [DATE REDACTED] through an on-line training. LVN 1 stated the last time she took an in-person CPR training was in 2021. LVN 1 stated she was not aware she is required to maintain CPR certification through a provider that provides hands on or in-person training.

A review of the facility's LVN Staff Nurse Job Description form, undated, indicated valid CPR certification as one of the qualifications.

During an interview on [DATE REDACTED] 6:59 p.m., with the Director of Nursing (DON), the DON stated licensed nursing staff should have CPR training with hands-on or in-person skills assessment. The DON stated one of

the qualifications of an LVN is to maintain a valid CPR certification and CPR training received on-line is not acceptable per the facility policy. The DON stated licensed nurses not having a valid CPR certification may not to be competent enough to provide the necessary resuscitative efforts which could lead to potential loss of life.

A review of the facility's policy and procedure titled, Cardiopulmonary Resuscitation, last reviewed [DATE REDACTED], indicated the following:

- The facility shall ensure that properly trained personnel (certified in CPR for Healthcare Providers (HCP) are available immediately (24 hours per day) to provide BLS, including CPR.

- Licensed nursing staff shall maintain current CPR certification for HCP through a CPR provider whose training includes hands-on practice and in-person skills assessment; online only certification is not acceptable.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0678 - A staff member who is certified in CPR/BLS if an individual is found unresponsive with no pulse and respirations unless a Code Status (means the type of emergent treatment a person would or would not Level of Harm - Minimal harm or receive if their heart or breathing were to stop) prohibits CPR. potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Provide activities to meet all resident's needs.

Level of Harm - Minimal harm or 44376 potential for actual harm Based on observation, interview, and record review, the facility failed to provide residents with an ongoing Residents Affected - Few activity program that is resident centered for one of one resident (Resident 43) investigated under the activities care area.

This deficient practice had the potential to affect the residents' sense of self-worth and psychosocial well-being through a feeling of usefulness, self-respect, and self-satisfaction.

Findings:

A review of Resident 43's Admission Record indicated the facility admitted the resident on 4/15/2024, and readmitted the resident on 9/27/2022, with diagnoses including hemiplegia (paralysis that affects only one side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), and generalized anxiety disorder (a condition where a person worry constantly about everyday issues and situations).

A review of Resident 43's History and Physical (H&P), dated 8/18/2023, indicated the resident had a fluctuating capacity to understand and make decisions.

A review of Resident 43's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/22/2024, indicated the resident had the ability to make self-understood and understand others.

A review of Resident 43's Care Plan titled, The resident is dependent on staff for meeting emotional, intellectual, and social needs. last revised on 8/1/2022, indicated an intervention of the resident prefers the following TV channels: Sunday mass, talk shows, sports, food, movies, and concerts.

During an interview on 6/12/2024, at 8:40 a.m., with Resident 43, Resident 43 stated he spoke to the Administrator (ADM) about his concern of not having access to television (TV) channels in his room that incorporates his cultural preferences. The resident stated it is hard for him to go to the activity room to watch movies and sports due to his condition of being paraplegic (the inability to voluntarily move the lower parts of

the body).

During a concurrent interview and record review on 6/12/2024, at 2:36 p.m., with the Activity Director (ACT D), the ACT D stated the last time she assessed the resident's activity needs was 1/23/2024. The ACT D stated she should have done her quarterly activity needs assessment on 4/2023. The ACT D stated it was important to assess the activity needs of the resident quarterly or as needed to capture their activity preferences such as watching the TV. The ACT D stated her failure to conduct her quarterly activity needs assessment resulted in not capturing the preferences of the resident regarding watching preferred TV programs inside the resident room.

During an interview on 6/13/2024, at 6:30 p.m., with the Director of Nursing (DON), the DON stated the ACT D should have assessed the resident quarterly to accommodate the changing needs and preferences of the resident on a certain period.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 A review of the facility's recent policy and procedure titled, Activity Assessment/Care Plan, last reviewed on 4/4/2024, indicated to assess each resident's preferences for customary routine and activity interests, and to Level of Harm - Minimal harm or develop an individualized Care Plan for each resident. Care Plans will be reviewed and revised, as potential for actual harm necessary, at least quarterly, or more often if change of condition occurs.

Residents Affected - Few A review of the facility's recent policy and procedure titled, Assessment and Reassessment, last reviewed on 4/4/2024, indicated the resident will be reassessed via MDS by the Activity Coordinator per MDS schedule (at least quarterly, upon significant change in condition and annually).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or 36943 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure one of three sampled Residents Affected - Few residents (Resident 7) with limited range of motion [(ROM) full movement potential of a joint (where two bones meet)] and mobility (ability to move) was properly assessed for the provision and application of a left elbow splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) in accordance with professional standards of practice for Occupational Therapy (OT, profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]).

This failure had the potential to damage Resident 7's skin integrity (relating to skin health), including but not limited to causing redness, bruising, swelling, and skin breakdown (tissue damage caused by friction, shear, moisture, or pressure).

Findings:

A review of Resident 7's Admission Record indicated the facility admitted Resident 7 on 7/15/2022 with diagnoses including hemiplegia or hemiparesis (weakness or inability to move one side of the body) following

a cerebral infarction (brain damage due to a loss of oxygen to the area) affecting the right dominant (used more often) side, dysphagia (difficulty swallowing), gastrostomy status (G-tube, tube placed directly into the stomach for long-term feeding), aphasia (loss of ability to understand or express speech as a result of brain damage), and functional quadriplegia (complete immobility due to frailty or severe physical disability).

A review of Resident 7's OT Evaluation and Plan of Care, dated 2/15/2024, indicated Resident 7 hand impaired ROM in both arms, including right shoulder flexion (lifting the arm upward) 0 to 45 degrees (0-45 degrees, normal 0-180 degrees), right elbow flexion (bending the elbow) 90-150 degrees (normal 0-150 degrees), left shoulder flexion 0-10 degrees, left elbow flexion 20-150 degrees, and left wrist flexion (bending

the wrist downward) 0-45 degrees (normal 0-90 degrees).

A review of Resident 7's Minimum Data Set (MDS, a comprehensive assessment and care planning tool), dated 4/22/2024, indicated Resident 7 had severely impaired cognition (ability to think, understand, learn, and remember) and was dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) with oral hygiene, toileting, showering/bathing oneself, upper and lower body dressing, rolling to both sides and tub/shower transfers. The MDS indicated Resident 7 did not attempt chair/bed-to-chair transfers due to medical condition or safety concerns.

A review of Resident 7's OT Discharge Summary, dated 4/24/2024, indicated Resident 7's Restorative Nursing Aide (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) program for ROM exercises was established. The OT Discharge Summary also indicated Resident 7 tolerated wearing both hand rolls (rolled towel placed in the palms) and a right elbow extension splint for five hours. The OT Discharge recommendations included RNA to provide Resident 7 with PROM to both arms, apply both hand rolls, and apply the right elbow extension splint.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 A review of Resident 7's physician orders, dated 4/26/2024, indicated for RNA to apply the right elbow extension splint for four to six hours, five times per week as tolerated. Level of Harm - Minimal harm or potential for actual harm During an observation on 6/12/2024 at 7:30 a.m. in Resident 7's bedroom, Restorative Nursing Aide 1 (RNA 1) stood on the left side of Resident 7's bed. Resident 7 was lying awake in bed and had a right elbow splint Residents Affected - Few already applied. RNA 1 massaged Resident 7's left elbow into extension prior to applying a left elbow splint.

During an observation on 6/12/2024 at 12:11 p.m. in Resident 7's bedroom, RNA 1 removed both elbow splints from Resident 7 arms.

During a concurrent interview and record review on 6/12/2024 at 2:25 p.m. with the Director of Rehabilitation (DOR), Resident 7's OT Evaluation, dated 2/15/2024, and OT Discharge Summary, dated 4/26/2024, were reviewed. The DOR stated Resident 7 received an OT Evaluation, dated 2/15/2024, after Resident 7's hospitalization . The DOR stated the OT Evaluation indicated Resident 7's had limited ROM in both shoulders, both elbows, and both wrists. The DOR stated Resident 7 tolerated wearing both hand rolls and a right elbow splint for five hours. The DOR stated Resident 7's OT Discharge Summary, dated 4/26/2024, included recommendations for RNA to provide PROM to both arms, to apply both hand splints, and to apply

the right elbow splint. The DOR stated there were no OT recommendations for the RNA to apply a left elbow splint. The DOR stated splints provided to a resident (in general) required an assessment to ensure the splint was an appropriate fit for the resident since the splint could cause skin breakdown.

A review of a textbook titled, Occupational Therapy for Physical Dysfunction, fifth edition, published 2002, page 316, indicated the OT's role was to evaluate the need for a splint clinically and functionally; to select the most appropriate splint; to provide or fabricate (make) the splint; to assess the fit of the splint; to teach the patient and caregivers the purpose, care, and use of the splint. The Occupational Therapy for Physical Dysfunction textbook, page 316, further indicated the OT must consider, carefully monitor, and teach the patient and caregiver to report any of these problems related to orthotic use, including impaired skin integrity, pain, and swelling.

A review of the facility's policy and procedure titled, Restorative Nursing Program Guidelines: Nursing Manual - Restorative Nursing Program, revised 9/19/2019, indicated the RNA should carry out the restorative program according to the care plan.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44376 potential for actual harm Based on observation, interview, and record review the facility failed to provide care consistent with Residents Affected - Few professional standards of practice to prevent pressure ulcer/injury (ulcers that happen on areas of the skin that are under pressure from lying in bed, sitting in a wheelchair, or wearing a cast for a long period) to two out of two sampled residents (Residents 7 and 74) investigated during review of pressure ulcers by failing to:

1. Turn Resident 7 every 2 hours in bed and follow the turning clock (an interactive tool placed at resident's bedside that outlines the individual positioning plan including frequency of positioning and time for next position change) schedule posted on the resident's wall.

2. Set Resident 74's low air loss mattress (LALM, designed to distribute the resident's weight over a broad surface area and help prevent skin breakdown) according to the resident's weight.

The deficient practices had the potential for the development and worsening of the resident's pressure ulcers/injuries.

Findings:

1. A review of Resident 7's Admission Record indicated the facility admitted the resident on 7/15/2024, with diagnoses including hemiplegia (paralysis that affects only one side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area).

A review of Resident 7's History and Physical (H&P), dated 10/18/2023, indicated the resident did not have

the capacity to understand and make decisions.

A review of Resident 7's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/22/2024, indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident was dependent on mobility and activities of daily living (ADLs) and was incontinent of urine and stool (feces). The MDS also indicated the resident was at risk for pressure ulcer/ injury development.

A review of Resident 7's Braden Scale (for predicting pressure ulcer risk evaluation), dated 4/22/2024, indicated the resident was at risk for development of pressure ulcer/ injury.

A review of Resident 7's Care Plan titled, High risk for compromised health condition associated to history of cerebrovascular accident (CVA, a loss of blood flow to a part of the brain, which damages brain tissue) with right sided weakness, last revised on 4/28/2024, indicated an intervention to turn and reposition every two (2) hours or as needed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 During an observation on 6/11/2024, at 9:05 a.m., observed Resident 7 facing the window or the resident's right side, with the turning wedge pillow (special triangle-shaped pillows that raise the top half of your body) Level of Harm - Minimal harm or placed on the resident's left side. The turning clock schedule indicated the resident should be facing the door potential for actual harm or to the resident's left side.

Residents Affected - Few During an observation on 6/11/2024, at 10:44 a.m., observed Resident 7 facing the window or the resident's right side, with the turning wedge pillow placed on the resident's left side.

During an observation on 6/11/2024, at 1 p.m., observed Resident 7 facing the window or the resident's right side, with the turning wedge pillow placed on the resident's left side. The turning clock schedule indicated the resident should be on her back.

During a concurrent observation and interview on 6/11/2024, at 1:04 p.m., with Certified Nursing Assistant 1 (CNA 1), inside Resident 7's room, observed Resident 7 facing the window or the resident's right side, with

the turning wedge pillow placed on the resident's left side. CNA 1 stated the resident was last turned at 9 a. m. towards the door or to the resident's left side. CNA 1 stated the resident is supposed to be on her back per the turning clock schedule. CNA 1 stated it is important to turn the resident every 2 hours to prevent pressure ulcers.

During a concurrent observation and interview on 6/11/2024, at 1:08 p.m., with Restorative Nurse Aide 1 (RNA 1), inside Resident 7's room, observed the resident was facing the window or to her right side, with the turning wedge pillow at the left side of the resident. RNA 1 stated she turned the resident last at 10 a.m. towards the window or to her right side. RNA 1 stated the resident should be on her back now per turning clock schedule. RNA 1 stated they should turn the resident every 2 hours to prevent skin breakdown.

During an observation on 6/12/2024, at 7 a.m., observed Resident 7 facing the door or to the resident's left side with the turning wedge pillow on her right side. The turning clock schedule indicated the resident should be on her back.

During an observation on 6/12/2024, at 8:49 a.m., observed Resident 7 facing the door or to the resident's left side with the turning wedge pillow on her right side.

During an observation on 6/12/2024, at 10:02 a.m., observed Resident 7 facing the door or to the resident's left side with the wedge pillow on her right side. The turning clock schedule indicated the resident should be

on her right side.

During a concurrent observation and interview on 6/12/2024, at 10:30 a.m., with Licensed Vocational Nurse 6 (LVN 6), inside Resident 7's room, observed resident facing the door or to the resident's left side with the turning wedge pillow on her right side. The turning clock schedule indicated the resident should be facing the window or to the resident's right side with the turning wedge on her left side. LVN 6 stated they should be turning the resident every two hours and follow the turning clock schedule to prevent pressure injury.

During an interview on 6/13/2024, at 6:30 p.m., with the Director of Nursing (DON), the DON stated the resident should be turned according to the turning calendar placed at the resident's wall to prevent the development of pressure injuries. The DON stated the resident should be turned every 2 hours.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 A review of the facility's recent policy and procedure titled, Pressure Ulcer Management, last reviewed on 4/4/2024, indicated to provide a system for treatment and management of residents with pressure ulcers. Level of Harm - Minimal harm or The facility may utilize the Pressure Ulcer Monitor Tool (SK- O2-Form C- Pressure Ulcer Monitoring Tool) to potential for actual harm audit and assess the success of the Pressure Ulcer Management Program).

Residents Affected - Few A review of the facility's recent policy and procedure titled, Positioning and Body Alignment, last reviewed on 4/4/2024, indicated change the resident's position every 2 hours, or as otherwise indicated or ordered by the attending physician.

2. A review of Resident 74's Admission Record indicated the facility admitted the resident on 11/14/2023, with diagnoses including moderate protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), pressure ulcer of sacral region (at the bottom of the spine and lies between the fifth segment of the lumbar spine [L5] and the coccyx [tailbone]), and abnormalities of gait (manner of walking) and mobility.

A review of Resident 74's MDS, dated [DATE REDACTED], indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident required substantial to maximal assistance in mobility and activities of daily living (ADLs) and was at risk for developing pressure ulcers/injuries. The MDS indicated the resident had an unstageable pressure injury (when the stage is not clear) with intervention for pressure reducing device for bed.

A review of Resident 74's Order Summary Report, dated 4/23/2024, indicated an order for low air loss mattress (LALM) for wound management every shift.

A review of Resident 74's Weights and Vitals Summary, dated 6/3/2024, indicated the resident's weight was 161.8 pounds (lbs., a unit of weight)

A review of Resident 74's Braden Scale (for predicting pressure ulcer risk evaluation), dated 5/30/2024, indicated the resident was at risk for developing pressure ulcer/injury.

During a concurrent observation and interview on 6/12/2024, at 10:26 a.m., with Certified Nursing Assistant 6 (CNA 6), inside Resident 74's room, observed the resident's LALM set at 300. CNA 6 stated the LALM should be set according to resident's weight to prevent pressure ulcer.

During a concurrent interview and record review on 6/12/2024, at 12:22 p.m., with Registered Nurse 1 (RN 1) and Licensed Vocational Nurse 6 (LVN 6), reviewed Resident 74's Order Summary Report and Weights and Vitals Summary. LVN 6 stated there was no physician order for the LALM setting. RN 1 stated if there was no settings ordered for the LALM, the LALM will be set according to the resident's weight. LVN 6 stated the resident's latest weight was 161 lbs. RN 1 stated the resident's LALM should not be set at 300 because the setting was incorrect and could cause further skin issues such as worsening of the pressure injury.

During an interview on 6/13/2024, at 6:30 p.m., with the DON, the DON stated the LALM should be set according to resident's weight to maximize the mattress' therapeutic effect. The DON stated inflating the resident over the resident's weight could cause skin breakdown to the resident.

A review of the facility's recent policy procedure titled, Mattresses, last reviewed on 4/4/2024, indicated the facility will provide mattresses capable of meeting the following needs of residents:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 A. To provide pressure reduction to residents at risk for skin breakdown. To distribute body weight relieving areas of pressure. An air mattress is used under the direction of an attending physician's order when the Level of Harm - Minimal harm or resident's clinical condition warrants pressure reducing devices. potential for actual harm

A review of the facility provided manufacturer's guideline for LALM 1, undated, indicated users can adjust the Residents Affected - Few pressure value of the air mattress to a desired pressure by themselves or according to the suggestion from a healthcare professional. It is recommended that the pressure-selector knob set to Firm or press Auto Firm on

the touch panel each time the mattress is first inflated. Users can then easily adjust the air mattress to a desired firmness according to the patient's weight.

A review of the facility provided manufacturer's guideline for LALM 2, undated, indicated patient entrapment with bed side rails may cause injury or death. The Comfort Control LED displays the patient comfort pressure levels from 0 to 9 and provides a guide to the caregiver to set approximate comfort pressure level depending

on the patient weight.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36943 Residents Affected - Few Based on observation, interview, and record review, the facility failed to provide services to maintain mobility (ability to move) for one of three sampled residents (Resident 7) with limited range of motion [(ROM) full movement potential of a joint (where two bones meet)] and mobility. The facility failed to:

1. Provide Resident 7 with passive range of motion ([PROM] movement of joint through the ROM with no effort from the person) in both arms and both legs from 8/3/2022 to 9/30/2022 in accordance with the Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities) and Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) discharge recommendations dated 8/3/2022, and physician's orders dated 8/3/2022, for the Restorative Nursing Aide ([RNA] a certified nursing aide program that helps residents to maintain their function and joint mobility) to provide PROM to both arms and both legs.

2. Apply the resting hand splint [material secured to the arm with straps which extends from the fingertips to

the forearm to position the wrist and the fingers to maintain ROM and prevent the development of contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness)] to Resident 7's right arm from 8/3/2022 to 2/10/2023 (for six months) in accordance with the OT's discharge recommendations dated 8/3/2022, and physician's orders dated 8/3/2022, for the RNA to apply a right resting hand splint for up to six hours, five times per week.

3. Obtain both knee splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) to Resident 7's knees as indicated in the PT Discharge Summary dated 8/3/2022, for positioning and contracture prevention from 8/3/2022 to 3/26/2024 (for 19 months).

4. Monitor Resident 7's ROM in each joint of both arms and legs quarterly in accordance with Resident 7's care plan for limitation in ROM dated 9/7/2022, which indicated to assess Resident 7's joint mobility quarterly.

5. Apply both hand rolls (rolled towel placed in the palm) to Resident 7's hands on 6/11/2023 in accordance with the physician's orders dated 5/12/2024, for the RNA to apply both hand rolls for four to six hours (4 to 6 hours), five times per week as tolerated.

6. Apply the elbow extension splint (splint which prevents bending at the elbow) on Resident 7's right arm on 6/11/2024 in accordance with the physician order dated 6/3/2024, for the RNA to apply the right elbow extension splint for 4-6 hours, five times per week as tolerated.

7. Ensure the facility's policy and procedure titled, Rehab Rounding and Screening: Rehabilitation Services, included objective assessments to monitor a decline in both arms and both legs for Resident 7.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 These failures resulted in Resident 7's developing further ROM limitations in both arms and both legs, including the development of contractures of the right hand, right elbow, both shoulders, and both legs, which Level of Harm - Actual harm caused Resident 7 to feel pain with movement and ROM, and prevented Resident 7 from getting out of the bed, including receiving a shower. Residents Affected - Few Findings:

A review of Resident 7's Admission Record indicated Resident 7 was admitted to the facility on [DATE REDACTED] with diagnoses including hemiplegia (severe or complete loss of strength or paralysis of one side of the body) or hemiparesis (partial weakness or inability to move one side of the body) following a cerebral infarction (brain damage due to a loss of oxygen to the area) affecting the right dominant (used more often) side, dysphagia (difficulty swallowing), gastrostomy tube status ([G-tube] a tube surgically placed directly into the stomach for administration of medications and nutrition), aphasia (loss of ability to understand or express speech as a result of brain damage), and functional quadriplegia (complete immobility due to frailty or severe physical disability).

A review of Resident 7's Rehabilitation Screening Form, dated 7/15/2022, indicated Resident 7 had contractures present in both arms (unspecified joints and severity) and both legs (unspecified joints and severity). The Rehabilitation Screening Form indicated PT and OT evaluations were requested for Resident 7.

A review of Resident 7's OT Evaluation and Plan of Care, dated 7/15/2022, indicated Resident 7 had ROM in both shoulders and both elbows within functional limits (WFL, sufficient movement without significant limitation). The OT Evaluation indicated Resident 7 had impairment in both wrists and minimal (unspecified) limitation in both hands. The OT Evaluation indicated Resident 7 was dependent (helper does all the effort or

the assistance of two or more helpers is required for the resident to complete the activity) on staff for oral hygiene (ability to clean teeth and mouth), toileting, showering/bathing, upper body dressing, and lower body dressing.

A review of Resident 7's PT Evaluation and Plan of Care, dated 7/15/2022, indicated Resident 7 had severe (unspecified) contractures in both hips, both knees, and both ankles. The PT Evaluation indicated Resident 7 was dependent for rolling to both sides, chair/bed-to-chair transfers, and toilet transfers.

A review of Resident 7's OT Discharge Summary, dated 8/3/2022, indicated Resident 7 had a resting hand splint applied to the right hand for six hours and a hand roll applied to the left hand for six hours. The OT Discharge Summary indicated recommendations for an RNA program to provide PROM to both of Resident 7's arms followed by the application of a hand roll on Resident 7's left hand and a resting hand splint on Resident 7's right hand for up to six hours, five days per week.

A review of Resident 7's PT Discharge Summary, dated 8/3/2022, indicated the RNA (unknown) demonstrated 100 percent (%) competence with PROM exercises in both legs in a comfortable range to decrease Resident 7's risk for further contractures. The PT Discharge Summary also indicated Resident 7 would benefit from both knee splints for positioning and to prevent further contracture, pending health insurance approval.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 A review of Resident 7's physician orders, dated 8/3/2022, indicated an RNA program to provide PROM to both arms and both legs, to apply a left-hand roll for up to 6 hours, and to apply a right resting hand splint for Level of Harm - Actual harm up to six hours, five times per week as tolerated.

Residents Affected - Few A review of Resident 7's Restorative Nursing Flow Sheets (record of RNA session) indicated the Restorative Nursing Flow Sheets did not include RNA sessions for the month of 8/2022.

A review of Resident 7's physician's orders, dated 8/30/2022, indicated an order to discontinue RNA for PROM to both legs.

A review of Resident 7's census (record of hospitalization s, room changes, and payer source changes) indicated Resident 7 was transferred to the general acute hospital (GACH) on 8/31/2022.

A review of Resident 7's physician orders, dated 9/2/2022, indicated to discontinue RNA for PROM to both arms, the application of the left hand roll up to 6 hours, and application of the right resting hand splint for up to six hours due to Resident 7's hospitalization .

A review of Resident 7's census indicated Resident 7 was readmitted to the facility on [DATE REDACTED].

A review of Resident 7's care plan for limitation in ROM related to history of cerebral vascular accident ([CVA] a condition when blood flow stops to a part of the brain, brain damage due to blocked blood flow) with right sided weakness, initiated on 9/7/2022, indicated an intervention to assess Resident 7's joint mobility (ROM at each joint) upon admission and quarterly or as needed.

A review of Resident 7's Rehabilitation Screening Form, dated 9/7/2022, indicated Resident 7 did not have any changes in ROM and positioning. The Rehabilitation Screening Form did not include Resident 7's joint mobility assessment in both arms and both legs. The Rehabilitation Screening Form indicated therapy services were not indicated and Resident 7 was referred to RNA.

A review of Resident 7's physician orders, dated 9/7/2022, indicated for RNA to provide PROM to both arms and both legs, five time per week as tolerated. Resident 7's physician's orders did not include RNA for the application of the left-hand roll and right resting hand splint.

A review of Resident 7's RNA Flow Sheets indicated the Restorative Nursing Flow Sheets did not include RNA sessions for the month of 9/2022.

A review of Resident 7's RNA flow sheet for 10/2022 indicated RNA provided Resident 7 with PROM to both arms and both legs, five times per week as tolerated. The RNA flow sheet for 10/2022 did not include for the RNA to apply Resident 7's left hand roll or right resting hand splint.

A review of Resident 7's Rehabilitation Screening Form, dated 10/21/2022, indicated Resident 7 did not have any changes in ROM and positioning. Resident 7's Rehabilitation Screening Form did not include Resident 7's joint mobility assessment in both arms and both legs. The Rehabilitation Screening Forms indicated to continue with the RNA plan of care.

A review of Resident 7's RNA Flow Sheets from 11/2022 to 1/2023 indicated RNA provided Resident 7 with PROM to both arms and legs, five times per week as tolerated, and did not include for the RNA to apply Resident 7's left hand roll or right resting hand splint.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 A review of Resident 7's Rehabilitation Screening Forms, dated 1/5/2023, indicated Resident 7 did not have any changes in ROM and positioning. The Rehabilitation Screening Form did not include Resident 7's joint Level of Harm - Actual harm mobility assessment in both arms and legs. The Rehabilitation Screening Forms indicated to continue with

the RNA plan of care. Residents Affected - Few

A review of Resident 7's physician's orders, dated 2/10/2023, indicated for RNA program to apply both hand rolls for four to six hours (4 to 6 hours), five times per week as tolerated.

A review of Resident 7's RNA Flow Sheet for 2/2023 indicated the RNA applied both hand rolls for 4 to 6 hours, five times per week as tolerated, starting on 2/10/2023.

A review of Resident 7's RNA Flow Sheets from 3/2023 to 11/2023, indicated the RNA provided Resident 7 with PROM to both arms and legs and applied both hand rolls for 4 to 6 hours, five times per week.

A review of Resident 7's Rehabilitation Screening Form, dated 12/5/2023 (11 months since the last Rehabilitation Screening on 1/5/2023), indicated the RNA (unknown) reported a change of condition, including Resident 7 screaming when attempting to place left hand roll. The Rehabilitation Screening Form indicated a new RNA program included applying a right-hand roll.

A review of Resident 7's physician's orders, dated 12/5/2023, indicated for RNA to apply the right-hand roll for 4 to 6 hours, five times per week.

A review of Resident 7's Rehabilitation Screening Form, dated 12/28/2023, indicated Resident 7 did not have any noted changes in ROM. Resident 7's Rehabilitation Screening Form did not include Resident 7's joint mobility assessment in both arms and legs. The Rehabilitation Screening Form indicated to refer Resident 7 to RNA to maintain ROM in both arms and both legs.

A review of Resident 7's RNA Flow Sheets for 1/2024 and 2/2024 indicated the RNA provided Resident 7 with PROM to both arms and legs and applied both hand rolls for 4 to 6 hours, five times per week, from 1/1/2024 to 2/8/2024.

A review of Resident 7's census indicated Resident 7 was transferred to the GACH on 2/8/2024 and was readmitted back to the facility on [DATE REDACTED].

A review of Resident 7's Rehabilitation Screening Form, dated 2/15/2024, indicated to refer the resident to

the OT and PT evaluations for details.

A review of Resident 7's OT Evaluation and Plan of Care, dated 2/15/2024, indicated Resident 7 had impaired ROM in both arms, including right shoulder flexion (lifting the arm upward) 0 to 45 degrees (0 to 45 degrees, normal 0 to 180 degrees), right elbow flexion (bending the elbow) 90 to 150 degrees (normal 0 to 150 degrees), left shoulder flexion 0 to 10 degrees, left elbow flexion 20 to 150 degrees, and left wrist flexion (bending the wrist downward) 0 to 45 degrees (normal 0 to 90 degrees).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 A review of Resident 7's PT Evaluation and Plan of Care, dated 2/15/2024, indicated Resident 7 had impaired ROM in both legs, including both hips fixed (unable to move) to 130 degrees of hip flexion (bending Level of Harm - Actual harm the leg at the hip joint toward the body, normal 0 to 130 degrees) and both knees fixed to 150 degrees of knee flexion (bending the knee, normal 0 to 135 degrees). Residents Affected - Few

A review of Resident 7's Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 4/22/2024, indicated Resident 7 was dependent on staff with oral hygiene, toileting, showering/bathing oneself, upper and lower body dressing, rolling to both sides and tub/shower transfers. The MDS indicated Resident 7 did not attempt chair/bed-to-chair transfers due to medical condition or safety concerns.

A review of Resident 7's OT Discharge Summary, dated 4/24/2024, indicated the RNA program for ROM exercises was established and Resident 7 tolerated wearing both hand rolls and a right elbow extension splint for five hours. The OT discharge recommendations included RNA to provide Resident 7 with PROM to both arms, apply both hand rolls, and apply the right elbow extension splint.

A review of Resident 7's PT Discharge Summary, dated 4/26/2024, indicated knee splints were applied to both of Resident 7's knees starting on 3/26/2024. The PT Discharge Summary indicated Resident 7 had both knee splints applied for up to four hours and had improved ROM to 95 to 110 degrees. The PT Discharge Summary also indicated the RNA (unknown) provided a 100% return demonstration for PROM to both legs through the available ROM. The PT Discharge recommendations included for RNA to provide Resident 7 with PROM to both legs, five times per week as tolerated, and to apply both knee extension splints.

A review of Resident 7's physician's orders, dated 4/26/2024, indicated for RNA to provide PROM to both legs and apply the right elbow extension splint for 4 to 6 hours, five times per week as tolerated. Another physician order, dated 4/26/2024, indicated for the RNA to apply both of Resident 7's knee extension splints (duration unspecified), seven times per week as tolerated.

A review of Resident 7's physician's orders, dated 5/13/2024, indicated for RNA to apply both hand rolls for 4 to 6 hours, five times per week as tolerated.

A review of Resident 7's RNA Flow Sheet for 5/2024 indicated the RNA provided PROM to both arms and legs, applied both hand rolls for four hours, and applied both knee splints for four hours, five times per week.

During a telephone interview on 6/11/2024 at 11:45 a.m. with Family Member 1 (FM 1), FM 1 wanted to know whether Resident 7 was receiving any intervention since FM 1 was concerned Resident's was developing hands and legs contractures.

During an observation on 6/11/2024 at 12:38 p.m. in Resident 7's bedroom, Resident 7 was lying in bed awake but did not verbally respond to questions. Resident 7 was observed actively moved the left arm at the shoulder and elbow joints, but the left hand was positioned in a closed fist. Resident 7 shook the head, No, when asked if Resident 7 could open the left hand. Resident 7 did not have any active movement in the right arm. Resident 7's right elbow was in a bent position and the right wrist was bent downward. Resident 7's right thumb was positioned immediately next to the index finger while the middle, ring, and small fingers were bent completely into a fist. Resident 7 did not have any splints applied to either arm. Resident 7 had a blanket covering both legs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 During an interview on 6/11/2024 at 1:33 p.m. with the Director of Rehabilitation (DOR), the DOR stated the facility monitored residents' ROM quarterly using the Rehabilitation Screening Form. The DOR stated the Level of Harm - Actual harm Rehabilitation Screening Form (in general) did not include a resident's ROM assessment in each joint.

Residents Affected - Few During an observation on 6/12/2024 at 7:30 a.m. in Resident 7's bedroom, Restorative Nursing Aide 1 (RNA 1) was standing on the left side of Resident 7's bed. Resident 7 was lying awake in bed and had a right elbow splint and a right knee splint already applied. RNA 1 rubbed Resident 7's left knee prior to applying the left knee splint. Resident 7's winced (involuntary grimace or shrinking movement caused by pain or distress), moaned, and cried as RNA 1 proceeded to apply the straps of the knee splint to Resident 7's left leg. Both of Resident 7's knees were observed in a bent position while wearing both knee splints. Both of Resident 7's hands were positioned in closed fists. Hand rolls were not applied to either of Resident 7's hands. RNA 1 left

the room momentarily and then returned, stating the nurse (unknown) was notified of Resident 7's pain. Resident 7 moaned and cried as RNA 1 repositioned Resident 7 higher up in bed.

During an interview on 6/12/2024 at 7:44 a.m. with RNA 1, RNA 1 stated the night shift nurse (unknown) informed RNA 1 that Resident 7 received pain medication at 5:30 a.m. RNA 1 stated Resident 7's RNA session started at approximately 7 a.m. with PROM exercises to both arms and both legs. RNA 1 stated PROM to both shoulders were not performed because Resident 7 could not tolerate the pain. RNA 1 stated

the splints needed to be applied after Resident 7 received pain medication because Resident 7 was sensitive to touch and required slow movement during ROM due to pain. RNA 1 stated both of Resident 7's hand rolls were placed later in the day after Resident 7 received additional pain medication because both hands, especially the left hand, were difficult to open.

During an interview on 6/12/2024 at 8 a.m., RNA 1 stated Resident 7 was not seen for RNA session yesterday (6/11/2024), including application of both arm splints, because Resident 7 screamed when RNA 1 attempted to work with Resident 7.

During a follow-up interview on 6/12/2024 at 8:10 a.m., RNA 1 stated she attempted to see Resident 7 multiple times yesterday (6/11/2024) but Resident 7 refused due to pain and despite receiving pain medication. RNA 1 stated Resident 7's knee splints were applied but no other RNA intervention, including ROM and application of the right elbow splint and both hand rolls, was provided to Resident 7 on 6/11/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 During a concurrent interview and record review on 6/12/2024 at 2:25 p.m. with the DOR, Resident 7's OT Evaluations, dated 7/15/2022 and 2/15/2024, and OT Discharge Summaries, dated 8/3/2022 and 4/26/2024, Level of Harm - Actual harm were reviewed. The DOR stated the OT Evaluation, dated 7/15/2022, indicated Resident 7 had ROM WFL in both shoulder and elbows. The DOR stated Resident 7's ROM in the left hand was impaired in the fingers Residents Affected - Few but not the wrist. The DOR stated the left hand was more severe than the right hand since the recommendation was for a left-hand roll. The DOR stated a hand roll was a rolled-up face towel placed in the palm of the hand for residents with severe contractures. The DOR stated Resident 7's right wrist and hand ROM were impaired and recommended a resting hand splint, to position the right wrist and fingers in extension. The DOR stated the purpose of applying a splint (in general) included contracture prevention. The DOR reviewed the OT Discharge Summary, dated 8/3/2022, and stated Resident 7 tolerated wearing the left-hand roll and right resting hand splint for up to six hours. The DOR stated the OT Discharge Summary recommendations included for the RNA to provide Resident 7 with PROM of both arms, apply the left-hand roll, and apply the right resting hand splint. The DOR stated Resident 7 was recently hospitalized and returned to the facility on [DATE REDACTED]. The DOR stated Resident 7 received an OT Evaluation, dated 2/15/2024, which indicated Resident 7's had limited ROM in both shoulders, both elbows, and both wrists. The DOR stated Resident 7 tolerated wearing both hand rolls and a right elbow splint for five hours. The DOR stated Resident 7's OT Discharge Summary, dated 4/26/2024, included recommendations for RNA to provide PROM to both arms, to apply both hand splints, and to apply the right elbow splint.

During a concurrent interview and record review on 6/12/2024 at 3:23 p.m. with the DOR, Resident 7's PT Evaluations, dated 7/15/2022 and 2/15/2024, and PT Discharge Summaries, dated 8/3/2022 and 4/26/2024, were reviewed. The DOR reviewed Resident 7's PT Evaluation, dated 7/15/2022, indicated Resident 7 had severe contractures in both hips, both knees, and both ankles. The DOR reviewed Resident 7's PT Discharge Summary, dated 8/3/2022, and stated recommendations included RNA for PROM to both legs and recommendations for both knee splints for positioning and to prevent further contractures. The DOR stated the PT who discharged Resident 7 did not work at the facility anymore and did not set any therapy goals for Resident 7 to have both knee splints. The DOR stated Resident 7 did not receive the knee splints and did not know the reason Resident 7 never received both knee splints. The DOR reviewed the PT Evaluation, dated 2/15/2024, and stated Resident 7's knees were fixed into full flexion. The DOR reviewed Resident 7's Discharge Summary, dated 4/26/2024, and stated Resident 7's goals were updated on 3/26/2024 to apply both knee splints. The DOR stated Resident 7's Discharge Summary indicated Resident 7 tolerated wearing both knee splints for four hours and had improved ROM to both knees. The DOR stated

the PT Discharge Summary recommendations included for the RNA to provide PROM to both legs and to apply both knee splints for four hours.

During an interview on 6/13/2024 at 9:03 a.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 7's shower days were on Monday and Thursday. CNA 1 stated Resident 7 received bed baths and did not go to the shower because it was difficult and caused Resident 7 pain to position Resident 7 in the shower chair.

During a concurrent interview and record review on 6/13/2024 at 11:25 a.m. with the DOR and the Director of Nursing (DON), the Rehabilitation Screening Form (in general) was reviewed. The DOR stated the purpose of the Rehabilitation Screening Form was to determine a resident had any changes in function, strength, or ROM which required therapy intervention.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 During a concurrent interview and record review on 6/13/2024 at 1:50 p.m. with the DOR and DON, Resident 7's OT Evaluations, dated 7/15/2022 and 2/15/2024, OT Discharge Summary, dated 8/3/2022, Rehabilitation Level of Harm - Actual harm Screening Forms, dated 9/7/2022, 10/21/2022, and 1/5/2023, and RNA flow sheets from 8/2022 to 2/2023 were reviewed. The DOR stated the OT Evaluation, dated 7/15/2022, indicated Resident 7 had ROM WFL in Residents Affected - Few both shoulders and both elbows. The DOR stated the OT Discharge Summary, dated 2/15/2024, indicated for Resident 7 to receive RNA for PROM to both arms, application of the left-hand roll, and application of the right resting hand splint. The DON reviewed Resident 7's RNA Flow Sheets and stated Resident 7 did not have any RNA Flow Sheets for 8/2022 and 9/2022. The DON stated Resident 7 did not receive any RNA services for PROM to both arms and both legs, including the application of the left-hand roll and the right resting hand splint, for 8/2022 and 9/2022 since there was no documentation. The DOR and DON reviewed Resident 7's RNA flow sheets from 10/2022 to 2/2023. The DON stated the RNAs did not apply the left-hand roll and the right resting hand splint from 8/2022 to 2/2023 (for 6 months). The DOR reviewed the RNA flow sheet for 2/2023 and stated Resident 7 had a decline in ROM in the right hand on 2/10/2023 since Resident 7 started receiving RNA for the application of both hand rolls. The DOR and the DON reviewed Resident 7's Rehabilitation Screening Forms, dated 9/7/2022, 10/21/2022, and 1/5/2023. The DOR stated the Rehabilitation Screening Forms did not indicate any ROM assessment in both of Resident 7's arms and legs, did not indicate Resident 7's RNA program was reviewed, and did not indicate Resident 7's splints were checked. The DOR stated the quarterly Rehabilitation Screening should have caught that Resident 7's right resting hand splint and left-hand roll were not being applied from 8/2022 to 2/2023. The DON stated Resident 7's decline in ROM in the right hand was preventable since the right resting hand splint was not applied for six months. The DOR and DON reviewed Resident 7's OT Evaluation, dated 2/15/2024, which indicated Resident 7 had ROM decline in both shoulders and elbows. The DON stated assessments of both arms and both legs should have been completed on the quarterly Rehabilitation Screening Form to determine whether Resident 7's ROM in both arms and both legs were declining. The DON stated the facility's Rehabilitation Screening Form was not an effective system to monitor ROM since there was no assessment and documentation of Resident 7's ROM at each joint for both arms and both legs. The DOR stated Resident 7's ROM limitations could have been slowed down with proper assessment of both arms and both legs during the quarterly Rehabilitation Screening.

During an observation on 6/13/2024 at 3:13 p.m. in Resident 7's bedroom with Physical Therapist 1 (PT 1), Resident 7 was awake while lying in bed. PT 1 described Resident 7's arms as contracted at both shoulders and elbows. PT 1 attempted but was unable to fully extend Resident 7's right-hand fingers. Resident 7 winced due to pain during PT 1's attempts to extend the right-hand fingers. PT 1 attempted to perform ROM to Resident 7's left arm but Resident 7 resisted PT 1's attempts.

A review of the facility's policy and procedure (P&P) titled, Range of Motion Exercise Guidelines: Nursing Manual - Restorative Nursing Program, revised 1/1/2012, indicated the facility would maintain or increase ROM of the joint and to prevent or decrease contractures.

A review of the facility's P&P titled, Restorative Nursing Program Guidelines, revised 9/19/2019, indicated

the Restorative Nursing Program included nursing interventions that promote a patient's ability to attain, and maintain his/her optimal functional potential. Restorative care implies that the possibility for progress exists, and that improvement can be expected, or there is a risk of imminent decline which can be prevented.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 A review of the facility's P&P titled, Rehab Rounding and Screening: Rehabilitation Services, revised 7/22/2021, indicated the purpose of the P&P included to identify residents with changes and to allow those Level of Harm - Actual harm residents to receive therapy services if functional decline or improved are present. The P&P indicated screening did not require objective data and assessments. Residents Affected - Few

During an interview on 6/13/2024 at 7:05 p.m. with the Administrator (ADM), the ADM stated the facility did not have a general ROM policy which did not include Restorative Nursing since all residents were provided RNA if they were not receiving therapy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44244

Residents Affected - Some Based on observation, interview, and record review the facility failed to provide three of four sampled residents (Resident 71, 41, and 80) reviewed under accidents care area, an environment free from accidents and hazards, ensure residents received adequate supervision, and implement and modify interventions to prevent accidents by failing to:

1. Ensure two single-use DermaSeptin (Trademark) ointment (a topical [on the surface of the body] medication to treat or prevent skin irritation) packets were not left unattended and readily available to Resident 71 in Resident 71's room.

This deficient practice had the potential to result in residents obtaining topical medication without staff knowledge resulting in accidental ingestion causing harm to residents.

2. Ensure Resident 41 and 80, who used tobacco had a smoking safety risk assessment upon admission.

3. Ensure Resident 41, who used tobacco, had quarterly smoking interdisciplinary meetings (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of the resident).

4. Ensure Residents 41 and 80, who used tobacco, had resident centered, comprehensive care plans (CP, a written course of action that helps a patient achieve outcomes that improve their quality of life) regarding smoking.

These deficient practices resulted in Resident 41 smoking in his room and had the potential to result in a facility fire from improper disposal of smoking materials and resident injuries from burns.

Findings:

a. A review of Resident 71's Admission Record indicated the facility admitted the resident on 7/12/2023 with diagnoses that included osteoarthritis (a condition that causes joints to become painful and stiff) of the left shoulder, polyneuropathy (a disorder of the peripheral nervous system that may result in pain, discomfort, and mobility issues), and heart failure (a condition in which the heart cannot pump enough blood to meet the body's needs).

A review of Resident 71's MDS (MDS - a standardized assessment a care screening tool), dated 4/19/2024, indicated the resident was able to understand others and was able to make herself understood. The MDS further indicated the resident required substantial/maximal assistance from staff for eating, oral hygiene, dressing, toileting, and mobility.

A review of Resident 71's History and Physical, dated 7/15/2023, indicated the resident had capacity to understand and make decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 A review of Resident 71's CP titled, Potential for injury due to impaired visual functioning, initiated 7/13/2023, indicated to maintain a safe and hazard free environment. Level of Harm - Minimal harm or potential for actual harm A review of Resident 71's Self-Administration of Medication form, dated 7/12/2023, indicated the resident was not capable of storing medication in a secure location, not capable of administering topical medications, Residents Affected - Some and required assistance with identifying situations requiring the administration of as needed medications.

The form indicated Resident 71 may not keep medications at bedside.

During an observation and interview on 6/11/2024 at 9:33 a.m., Resident 71 was lying in bed with the rolling bedside table placed in front of the resident. Observed one opened and one unopened packet of DermaSeptin (Trademark) ointment on the resident's bedside table. Observed the facility Administrator enter

the resident's room, place a water pitcher on the bedside table, then exit the room. Resident 71 stated she uses the ointment on her skin when it itches. Observed Resident 71 remove a small amount of the ointment from the opened packet and placed the ointment on the right forearm. Observed Licensed Vocational Nurse 7 (LVN 7) enter Resident 71's room and pour water from the pitcher on the bedside table into a glass. LVN 7 exited the room. Observed the DermaSeptin (Trademark) packets remained on the bedside table.

During a concurrent observation and interview on 6/11/2024 at 10 a.m., observed Certified Nursing Assistance 1 (CNA 1) enter Resident 71's room. CNA 1 stated there were packets of ointment on the resident's bedside table. CNA 1 stated he did not think the ointment should be on the bedside table and he did not know why the ointment is on Resident 71's bedside table. Observed CNA 1 removed the two DermaSeptin (Trademark) packets from Resident 71's bedside table.

During a concurrent observation and interview on 6/11/2024 at 10:05 a.m., LVN 7 entered Resident 71's room and stated the resident should not have the DermaSeptin (Trademark) at bedside because other residents could get the ointment and it could cause an allergic reaction resulting in hives. LVN 7 stated other residents as well could ingest the ointment resulting in vomiting.

During an interview on 6/11/2024 at 10:10 a.m., Treatment Nurse 1 (TN 1) stated there are certain residents that can self-administer medication, but Resident 71 was forgetful and she was not one of those residents. TN 1 stated DermaSeptin (Trademark) is a medication for skin irritation and should not be left at the residents' bedside. TN 1 stated she was not sure why the resident needed the ointment. TN 1 stated medications are not left at the residents' bedside because if they are confused, they could swallow the medication or give it to their roommates resulting in an unsafe environment. TN 1 stated swallowing DermaSeptin (Trademark) could have poisonous effects.

During a concurrent interview and record review on 6/12/2024 at 2:47 p.m., the Director of Nursing (DON) reviewed the facility policy regarding self-administration of medication. The DON stated only licensed nurses apply DermaSeptin (Trademark) and it is a topical medication used for skin irritation. The DON stated DermaSeptin (Trademark) should not be left at a resident's bedside because there was a risk of another confused resident putting the ointment in their mouth. The DON stated the facility policy was not followed because the resident did not have an assessment indicating it was safe to self-administer medication and DermaSeptin (Trademark) was left at the resident's bedside.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 A review of the facility policy and procedure titled, Medication - Self Administration, last reviewed 4/4/2024, indicated the purpose of the policy was to provide residents with the opportunity to self-administer Level of Harm - Minimal harm or medications when determined they are capable to do so by the Attending Physician and the IDT. If a resident potential for actual harm wants to self-administer medication, the IDT will assess the resident's cognitive, physical, and visual ability to carry out this responsibility based on a review of an assessment by a licensed nurse. The resident may not Residents Affected - Some begin self-administration of medications prior to the approval of the IDT and Attending physician.

A review of the facility policy and procedure titled, Resident Safety, last reviewed 4/4/2024, indicated the purpose of the policy was to provide a safe and hazard free environment. Any facility staff member who identifies an unsafe situation, practice or environmental risk factors should immediately notify their supervisor or charge nurse.

b. A review of Resident 41's Admission Record indicated the facility admitted the resident on 12/3/2021 and readmitted the resident on 5/7/2022 with diagnoses that included type two diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), hypertension (high blood pressure), and schizophrenia (a mental health condition with symptoms of delusions, hallucinations, and disorganized thinking).

A review of Resident 41's MDS dated [DATE REDACTED], indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated the resident required supervision for bathing, dressing, toileting, personal hygiene, and mobility.

A review of Resident 41's History and Physical, dated 10/21/2023, indicated the resident had fluctuating capacity to understand and make decisions.

A review of Resident 41's Smoking Safety Evaluation, dated 12/3/2021, indicated the resident did not utilize tobacco.

A review of Resident 41's CP titled, Resident smoking inside the room, initiated 2/1/2023, indicated to remind

the resident that smoking inside the room is strongly prohibited, explain the importance of compliance with smoking, to educate the resident of the smoking schedule, and notify the physician any changes in condition.

The CP further indicated a goal that the resident would have no episodes of smoking inside the room.

During an interview on 6/11/2024 at 9:10 a.m., observed Resident 41 sitting in his wheelchair on the facility smoking patio.

During an interview on 6/11/2024 at 11:12 a.m., Resident 41 stated he smokes cigarettes, and his smoking supplies are kept on the smoking patio.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 During a concurrent interview and record review on 6/12/2024 at 12:35 p.m., the Minimum Data Set Coordinator (MDSC) reviewed Resident 41's Smoking Safety Evaluation dated 5/7/2022, Smoking Rules Level of Harm - Minimal harm or agreement form dated 4/9/2024, and Care Plans. The MDSC stated every resident has a smoking evaluation potential for actual harm completed at admission. The MDSC stated Resident 41 had an admission smoking evaluation that indicated

the resident did not smoke and there was no smoking safety risk assessment completed. The MDSC stated Residents Affected - Some residents identified as smokers at admission should have a CP for smoking that includes resident specific smoking interventions for safety. The MDSC stated the CP is made so the staff are aware of their responsibilities. The MDSC reviewed Resident 41's CPs and stated, the resident did not have a smoking CP other than the CP indicating the resident was smoking in his room. The MDSC stated the importance of an accurate smoking evaluation, assessment, and smoking CP is for resident safety because the resident may not be aware and may be in danger of burning himself. The MDSC stated the CP communicates the resident plan to all the staff.

During a concurrent interview and record review on 6/12/2024 at 3:12 p.m., the Director of Nursing (DON) reviewed Resident 41's Smoking Safety Evaluation form dated 5/7/2022, Smoking Rules agreement form dated 4/9/2024, and Care Plans. The DON stated a CP is a plan of care for a resident intended for all the facility staff to know a resident's specific needs. The DON stated a smoking risk assessment and smoking CP includes education provided to the resident, resident specific safety measures like wearing a smoking apron, the resident's need for supervision, the smoking time schedule, and the risks of not complying. The DON stated Resident 41 has been a smoker since his original admission and should have a smoking CP.

The DON stated Resident 41 did not have a smoking assessment or CP completed because at admission

the resident was not identified as a smoker in the smoking evaluation. The DON stated without a CP, there was a potential safety risk that could have resulted in a fire or self-harm from burns when Resident 41 was found smoking in his room in 2/2024. The DON stated the facility policy for comprehensive care plans was not followed.

During a concurrent follow-up interview and record review on 6/13/2024 at 6:17 p.m., the DON reviewed the facility policy and procedure regarding smoking. The DON stated the policy indicates that the smoking assessment is reviewed with the resident during IDT meetings. The DON stated the IDT meetings for smoking should have been completed quarterly, but they were not done, and the policy was not followed.

The DON stated the importance of the smoking assessment, quarterly IDT meetings, and smoking CP was for the safety of the residents and to prevent incidences of the resident smoking in his room.

A review of the facility policy and procedure titled, Resident Safety, last reviewed 4/4/2024, indicated the purpose of the policy was to provide a safe and hazard free environment. Residents will be evaluated on admission, quarterly and whenever there is a change in condition to identify circumstances that pose a risk for the safety and wellbeing of residents. During the comprehensive assessment period the IDT members will assess the Resident's safety risk (e.g. smoking, self-administration of medication) as well as any other Resident specific safety risks. After a risk evaluation is completed, a Resident centered care plan will be developed to mitigate safety risk factors. The IDT will establish a person-centered observation or monitoring system for the resident to address the identified risk factors.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 A review of the facility policy and procedure titled, Smoking by Residents, last reviewed 4/4/2024, indicated

the purpose of the policy was to provide a safe environment for residents, staff, and visitors. It is the policy of Level of Harm - Minimal harm or the facility to accommodate residents who desire to smoke by taking reasonable precautions, providing a potential for actual harm safe environment for them, and protecting the non-smoking residents. Using the Resident Smoking Assessment, the LN will assess residents who express a desire to smoke, upon admission, quarterly, Residents Affected - Some annually and upon significant change of condition identification, and present it to the IDT for review. The IDT, consisting of, but not limited to, a LN, Social Services Designee, Activities Director, MDS Nurse, and a Rehab representative, using the Resident Smoking Assessment will review the resident assessment for safety at minimum at the following intervals: when a resident initially expresses a desire to smoke, upon admission, quarterly, annually and upon significant change of condition identification. As identified by the Smoking Assessment, residents who require assistance and/or monitoring for smoking safety are not allowed to smoke unaccompanied. IDT will develop an individualized plan for safe storage, use of smoking materials, assistance and required supervision. This is documented in the Resident Smoking Assessment,

the resident's Plan of Care, and discussed with the resident at care conference meetings.

43418

c. A review of Resident 80's Admission Record indicated the facility admitted Resident 80 on 2/23/2024 with diagnoses including, but not limited to, nicotine dependence, cigarettes.

A review of Resident 80's MDS, dated [DATE REDACTED], indicated Resident 80 was able to understand and make decisions and was independent or required setup assistance with activities of daily living, such as eating, hygiene, toileting, and surface-to-surface transfers.

A review of Resident 80's History and Physical (H&P), dated 2/26/2024, indicated Resident 80 had the capacity to understand and make decisions and was a chronic (long-term) smoker.

A review of Resident 80's Care Plan, dated 3/11/2024, indicated Resident 80 was a smoker with interventions including the resident's smoking supplies are stored with no indication where the smoking supplies are stored.

During a concurrent observation and interview with Resident 80, on 6/11/2024, at 10:30 a.m., in the outside patio, Resident 80 sat in a wheelchair with a cigarette box on the left side of the resident's wheelchair. Resident 80 stated he smokes and stated he has made arrangements with the facility for him to keep his smoking materials with him.

During an observation on 6/13/2024, at 3:54 p.m., inside Resident 80's room, Resident 80 was lying down in bed with two cigarette boxes on a bedside table adjacent to the resident's bed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 4, on 6/13/2024, at 4:33 p.m., Resident 80's care plans, dated 3/11/2024, was reviewed and LVN 4 confirmed Resident 80's Level of Harm - Minimal harm or care plan does not indicate where Resident 80 can store their smoking supplies. LVN 4 stated Resident 80's potential for actual harm care plan is too broad and not specific and should be specific to determine how to deal with certain situations. LVN 4 stated care plans guide nurses on what to do and if it was not specific, the nursing staff Residents Affected - Some would not be able to determine where to store the resident's smoking supplies. LVN 4 reviewed Resident 80's medical record and confirmed Resident 80 did not have a smoking and safety assessment performed on admission and stated Resident 80 should have had an assessment performed on admission to evaluate if

the resident was safe enough to smoke and to determine what interventions will be used. LVN 4 further stated residents are not allowed to keep cigarettes or lighters with them due to resident safety and because residents can potentially injure themselves or others.

During an interview with the Director of Nursing (DON), on 6/13/2024, at 6:14 p.m., the DON stated Resident 80 is a smoker. The DON stated smoking and safety assessments are conducted on admission, quarterly, and when there is a significant change. The DON stated residents smoking materials should not be kept in

the resident rooms and should be kept in the social services department's office. The DON stated the resident's care plan should indicate the location where smoking material is kept because if residents are allowed to keep their smoking material, the facility should know where it is kept. The DON further stated if the facility is not aware of where a resident stores their smoking material, there is a potential for burn injuries, smoking inside the rooms, or starting a fire from improper disposal.

A review of the facility's policy and procedure (P&P) titled, Smoking by Residents, last reviewed 4/4/2024, indicated residents who express a desire to smoke are assessed for safety when a resident initially expresses a desire to smoke, upon admission, quarterly, upon significant change of condition, and annually.

The P&P indicated smoking paraphernalia will be stored by facility staff. The P&P further indicated the interdisciplinary team will develop and individualized plan for safe storage, use of smoking materials, assistance and required supervision for residents who smoke.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Minimal harm or potential for actual harm 44376

Residents Affected - Few Based on observation, interview, and record review the facility failed to ensure a resident's indwelling urinary catheter (a device inserted into the bladder to drain urine form the body) bag was not touching the floor to one out of one sampled resident (Resident 6) investigated during review of urinary catheter care area.

The deficient practice had the potential Resident 6 to develop catheter associated urinary tract infection (CAUTI, an infection of the urinary tract caused by a tube [urinary catheter] that has been placed to drain urine from the bladder [an organ inside the body that stores urine until it is can be excreted]).

Findings:

A review of Resident 6's Admission Record indicated the facility admitted the resident on 8/2/2016, and readmitted the resident on 7/26/2023, with diagnoses including benign prostatic hyperplasia (a condition in men in which the prostate gland [part of the male reproductive system] is enlarged and not cancerous), and obstructive/reflux uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow and can be either structural or functional).

A review of Resident 6's History and Physical (H&P), dated 12/5/2023, indicated the resident had the capacity to understand and make decisions.

A review of Resident 6's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/19/2024, indicated the resident usually had the ability to make self-understood and understand others.

A review of Resident 6's Order Summary Report, dated 12/4/2023, indicated an order for indwelling/SP catheter (a catheter which is inserted into the bladder, via the urethra and remains in situ to drain urine) size (FR#16/10) with balloon via gravity drainage for (Obstructive Uropathy) every shift.

During a concurrent observation and interview on 6/11/2024, at 9:10 a.m., with Certified Nursing Assistant 2 (CNA 2), inside Resident 6's room, observed the resident's urinary catheter drainage bag touching the floor. CNA 3 stated the urinary catheter drainage bag should be kept off the floor to prevent infection to the resident.

During an interview on 6/13/2024, at 6:30 p.m., with the Director of Nursing (DON), the DON stated the urinary catheter bag should be kept off the floor to prevent ascending infection (the most common route by which bacteria gain access into the urinary tract) to the resident. The DON further stated the bag was touching the floor could also cause accidents such as slips, trips, and falls to the residents and the staff and could result in dislodgement of the urinary catheter.

A review of the facility's recent policy and procedure titled, Catheter- Care of, last reviewed on 4/4/2024, indicated the catheter tubing, bag or spigot will be anchored to not touch the floor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36943

Residents Affected - Some Based on observation, interview, and record review, the facility failed to:

1. Provide one of three sampled residents (Resident 7) with limited range of motion [(ROM) full movement potential of a joint (where two bones meet)] and mobility (ability to move) who was fed through a gastrostomy tube (G-tube, tube placed directly into the stomach for long-term feeding) with services to restore oral (by mouth) eating skills.

2. Check the Percutaneous Endoscopic Gastrostomy ([PEG] - a tube surgically inserted in the stomach to receive nutrition and medications) Tube placement (ensure tube is inside the stomach,) patency (ensure tube is open and unobstructed,) residuals (ensure liquid drained from tube is within normal limit,) and flush the PEG-Tube with water prior to medication administration, for one of five sampled residents (Resident 295) observed for medication administration.

These deficient practices had the potential to result in:

1. Reduce Resident 7's quality of life.

2. Resident 295 to receive suboptimal (less than the highest standard or quality) care and have complications of the GT including aspiration (when food or liquid comes back up from the stomach and enters the lungs [pair of organs situated within the rib cage responsible for breathing]) leading to serious health issues like pneumonia (infection of the lung) and lung scarring (wound).

Findings:

1. A review of Resident 7's Admission Record indicated the facility admitted Resident 7 on 7/15/2022 with diagnoses including hemiplegia or hemiparesis (weakness or inability to move one side of the body) following

a cerebral infarction (brain damage due to a loss of oxygen to the area) affecting the right dominant (used more often) side, dysphagia (difficulty swallowing), gastrostomy status (G-tube, tube placed directly into the stomach for long-term feeding), aphasia (loss of ability to understand or express speech as a result of brain damage), and functional quadriplegia (complete immobility due to frailty or severe physical disability).

A review of Resident 7's Speech Therapy (ST or SLP, profession aimed in the prevention, assessment, and treatment of speech, language, communicative, and swallowing disorders) Discharge Summary, dated 8/3/2022, indicated recommendations for Resident 7 to receive four ounces of puree (food altered into a smooth and creamy texture for people with difficulty chewing or swallowing) apple sauce at lunch time for oral gratification (pleasure or satisfaction derived from activities involving the mouth, including chewing or tasting which are important for developing proper speech and feeding skills).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 A review of Resident 7's physician orders, dated 8/3/2022, included providing oral gratification to Resident 7 with four ounces of puree applesauce at lunch time. Further review of the physician orders, dated 9/2/2022, Level of Harm - Minimal harm or indicated Resident 7's oral gratification of puree applesauce was discontinued due to Resident 7's potential for actual harm hospitalization .

Residents Affected - Some A review of a Rehabilitation Screening Form, dated 9/14/2022, indicated Resident 7 demonstrated decline in cognition (ability to think, understand, learn, and remember) and swallowing function. The Rehabilitation Screening Form indicated a SLP evaluation was recommended.

A review of Resident 7's physician orders, dated 1/24/2024, indicated to provide Jevity 1.5 (specific type of G-tube feeding) through the enteral pump (G-tube feeding machine) at 45 cubic centimeters (measure of volume) per hour for 20 hours.

A review of the SLP Evaluation and Plan of Care, dated 2/16/2024, indicated Resident 7 was non-verbal and did not follow any commands. The SLP Evaluation indicated Resident 7 was unable to swallow. The SLP Plan of Care included treatment of swallowing dysfunction, oral function for feeding, speech, language, and communication, three times per week for four weeks.

A review of Resident 7's Minimum Data Set (MDS, a comprehensive assessment and care planning tool), dated 4/22/2024, indicated Resident 7 had severely impaired cognition and dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) for eating.

A review of the SLP Discharge Summary, dated 5/10/2024, indicated Resident 7 had severe swallowing abilities. The SLP Discharge Summary recommendations indicated for Resident 7 to have nothing by mouth and to continue with G-tube feeding.

During an observation on 6/11/2024 at 12:38 p.m. in Resident 7's bedroom, Resident 7 was lying awake in bed with the G-tube attached to the feeding machine, which was turned off.

During an observation on 6/12/2024 at 12:11 p.m. in Resident 7's bedroom, Resident 7 was lying awake in bed with the G-tube feeding machine turned off.

During a concurrent interview and record review on 6/12/2024 at 3:23 p.m. with the Director of Rehabilitation (DOR), Resident 7's SLP Discharge Summary, dated 8/3/2022, and SLP Evaluation, dated 2/16/2024, was reviewed. The DOR stated the SLP Discharge Summary, dated 8/3/2022, indicated a recommendation to provide Resident 7 with puree apple sauce. The DOR stated Resident 7 did not receive another SLP Evaluation until 2/16/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 During a concurrent interview and record review on 6/13/2024 at 1:50 p.m. with the DOR and the Director of Nursing (DON), Resident 7's SLP Discharge Summary, dated 8/3/2022, physician orders for puree Level of Harm - Minimal harm or applesauce, dated 8/3/2022, and Rehabilitation Screening Form, dated 9/14/2022, were reviewed. The DOR potential for actual harm and DON reviewed Resident 7's SLP Discharge Summary, dated 8/3/2022, which indicated recommendations to provide four ounces of puree applesauce at lunch time for oral gratification. The DOR Residents Affected - Some and DON reviewed Resident 7's physician orders, dated 8/3/2022, to provide Resident 7 with four ounces of puree applesauce at lunch time, which was discontinued on 9/2/2022 due to Resident 7's hospitalization .

The DOR and DON reviewed Resident 7's Rehabilitation Screening Form, dated 9/14/2022, recommending

a SLP evaluation. The DOR stated Resident 7 did not receive the SLP evaluation. The DON stated the facility did not maintain Resident 7's ability to eat puree apple sauce for oral gratification.

A review of the facility's policy and procedure (P&P) titled, Rehab Rounding and Screening: Rehabilitation Services, dated 7/22/2021, indicated the therapist completing the screen will submit the completed Rehabilitation Screening Form to the DOR, who track results and request evaluation orders as needed.

A review of the facility's P&P titled, Eating and Swallowing: Nursing Manual - Restorative Nursing Program, revised 1/1/2012, indicated the facility would improve or maintain the resident's ability to ingest nutrition and hydration by mouth.

43455

2. During a review of Resident 295's Admission Record (a document containing demographic and diagnostic information,) dated 6/11/2024, indicated the resident was originally admitted to the facility on [DATE REDACTED] with diagnoses including gastrostomy status (artificial entrance to the stomach.)

During a review of Resident 295's Order Summary Report (a report listing the physician order for the resident) for June 2024, indicated Resident 295 was prescribed to check for placement, patency and residual of enteral feed (method of feeding that uses the gastrointestinal (GI) tract to deliver nutrition) and to flush the tube with water, starting 6/7/2024.

During an observation on 6/11/24 at 9:24 AM, with Licensed Vocational Nurse (LVN) 1, LVN 1 was observed not checking the Percutaneous Endoscopic Gastrostomy ([PEG] - a tube surgically inserted in the stomach to receive nutrition and medications) Tube placement, patency, residuals, and not flushing the tube with water, and LVN 1 grabbing the medication cup for administration into the PEG-Tube for Resident 295. LVN 1 was stopped by the surveyor before any medication was administered to Resident 295 and advised to discuss the PEG-tube technique and medication preparation with the surveyor in the hallway.

During an interview on 06/11/2024 at 9:25 AM, with LVN 1, LVN 1 stated that LVN 1 failed to check the PEG-tube placement, patency, residuals, and flush tube with water prior to administration of medications. LVN 1 stated without checking the tube placement LVN 1 will not know if the tube is in the stomach, and the medications could be delivered outside the stomach causing Resident 295 to develop toxicity and stomach ulcers (open sores.) LVN 1 stated residuals should also be checked to ensure the tube is not clogged and that the medications will be delivered and not stuck in the tube.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 During an interview, on 6/12/2024 at 11:44 AM, with the DON, the DON stated that LVN 1 failed to check Resident 295's PEG-Tube placement, patency, residuals and failed to flush the tube with water prior to Level of Harm - Minimal harm or medication administration. The DON stated these are important to ensure Resident 295's PEG-Tube is not potential for actual harm clogged and placed in the stomach where the medications will be delivered.

Residents Affected - Some Review of the facility's Policy & Procedures (P&P), titled Feeding Tube - Administration of Medication, dated November 2018, the P&P indicated that Medications are administered appropriately and safely when the resident has a feeding tube in place.

IV. Attach syringe to the end of the tube and insert 20 cc of air.

A. Check placement and patency by auscultation.

B. Check for Residual

V. Flush tube with 30-50 cc (unless a different amount is specified by the physician/prescriber) of water

before administering medication.

Review of the facility's (P&P), titled Medication Administration Errors, dated 4/4/2024, the P&P indicated:

I. A medication administration error occurs when a resident receives a dose of medication that deviates from

the original physician's order and/or established facility policy and procedures. Types of errors include:

8. Incorrect administration technique.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or 44376 potential for actual harm Based on observation, interview, and record review the facility failed to ensure maintenance of equipment Residents Affected - Few (nebulizer, an electrically powered machine that turns liquid medication into a mist so that it can be breathed directly into the lungs through a face mask or mouthpiece) for respiratory care in accordance with the manufacturer specifications and consistent with federal, state, and local laws and regulations for one out of one sampled resident (Resident 15) investigated during review of respiratory care area.

The deficient practice had a potential for Resident 15 to have respiratory infections and shortness of breath that could lead to hypoxemia (a low level of oxygen in the blood) due to ineffective operating condition of the nebulizing machine.

Findings:

A review of Resident 15's Admission Record indicated the facility admitted the resident on 4/13/2018 and readmitted the resident on 12/9/2021, with diagnoses including chronic obstructive pulmonary disease (COPD, a chronic inflammatory disease that causes obstructed airflow from the lungs).

A review of Resident 15's History and Physical (H&P), dated 4/29/2024, indicated the resident did not have

the capacity to understand and make decisions.

A review of Resident 15's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/8/2024, indicated the resident usually make self-understood and understand others.

A review of Resident 15's Order Summary Report, indicated an order for:

-5/25/2024 Budesonide inhalation suspension 0.5% milligrams (mg, a unit of weight)/ 2 milliliters (ml, a unit of volume). 2 ml inhale orally via nebulizer two times a day for chronic obstructive pulmonary disease (COPD) management. Give every 12 hours (hrs.) at 9 a.m. and 9 p.m.

-5/23/2024 Ipratropium bromide inhalation solution 0.02%. 2.5 ml inhale orally via nebulizer every 4 hours for COPD management. Administer via nebulizer for 15 minutes or until dose in complete.

During a concurrent observation and interview on 6/11/2024, at 9:48 a.m., with Treatment Nurse 1 (TN 1), observed a nebulizer on top of the resident's nightstand, without a date of when the machine was last serviced. TN 1 stated that she does not know if the machine was regularly checked. TN 1 stated the Central Supply Staff (CSS) is the one who oversees the nebulizer machines in the facility. TN 1 stated when the resident's nebulizer is not working, they (licensed nurses) inform the CSS.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 During an interview on 6/12/2024, at 1:41 p.m., with the CSS, the CSS stated he tests the machines every fifteenth of the month, but he does not maintain a log of nebulizer machines he had tested . The CSS stated Level of Harm - Minimal harm or he had no way of tracking which nebulizer machine he had tested because he does not know how many potential for actual harm nebulizer machines there are in the facility. The CSS stated he only replaces the nebulizer machine if the staff reported it as broken. The CSS stated he was not trained to service and maintain the nebulizer Residents Affected - Few machines. The CSS further stated he should have a system in place on tracking and servicing the nebulizer machines to ensure the nebulizers were working properly per manufacturer's guidelines.

During an interview on 6/13/2024, at 6:30 p.m., with the Director of Nursing (DON), the DON stated the facility should have a process of ensuring the nebulizer machines are working properly. The DON stated there should be a system in place for accounting for the nebulizers the facility has and maintaining the integrity of the machines to such as changing the filters to keep it safe to use.

A review of the facility provided manufacturer's guideline Neb 1, indicated the air filter lasts up to 500 hours of use before replacement.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services.

Level of Harm - Minimal harm or 43418 potential for actual harm Based on interview and record review, the facility failed to ensure that residents who receive care and Residents Affected - Few services for the provision of dialysis (a type of treatment that helps remove extra fluid and waste products from the blood when the kidneys [organ that removes waste and extra water from the body] are not able to) are consistent with professional standards of practice for one of one sampled resident reviewed under the dialysis care area (Resident 21) when Resident 21's care plan was not revised to include the resident's additional day of dialysis.

This deficient practice had the potential for facility staff to not know when the resident receives dialysis and when to perform pre- and post-dialysis care.

Findings:

A review of Resident 21's Admission Record indicated the facility originally admitted Resident 21 on 8/23/2021, and readmitted the resident on 7/5/2023, with diagnoses including, but not limited to, end stage renal disease (ESRD - when the kidney ceases to function) and dependence on renal (related to the kidneys) dialysis.

A review of Resident 21's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 4/29/2024, indicated Resident 21 was able to understand and make decisions, required maximal assist or was dependent on facility staff for activities of daily living, such as hygiene, toileting, and surface-to-surface transfer, and received dialysis treatments.

A review of Resident 21's History and Physical (H&P), dated 9/3/2023, indicated Resident 21 has the capacity to understand and make decisions and receives dialysis treatments for ESRD.

A review of Resident 21's Order Summary Report, dated 4/3/2024, indicated Resident 21 was ordered the following:

- On 4/3/2024, dialysis every Tuesday, Thursday, and Saturday at 8:30 a.m., and Wednesday at 10:10 a.m.

- On 9/1/2023, monitor site for bruit (audible sound associated with blood flow) and thrill (vibration caused by blood flow) on the left upper arm atrioventricular shunt (AV shunt - a connection that's made between the artery [blood vessel that delivers oxygenated blood from the heart to the rest of the body] and vein [blood vessel that delivers oxygen depleted blood from the body towards the heart] for dialysis access) every shift.

- On 9/1/2023, monitor dialysis access site every shift for redness, swelling, bleeding, pain, or drainage.

- On 9/1/2023, if bleeding occurs at the AV shunt any time after dialysis, apply pressure with clean gauze for five to ten minutes, repeat until bleeding stops, and to notify the physician if the intervention does not control

the bleeding.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 - On 9/1/2023, no blood pressure (the measurement of the pressure or force of blood inside your arteries) taking or blood draws on the left upper arm. Level of Harm - Minimal harm or potential for actual harm A review of Resident 21's Care Plans, last revised 4/29/2024, indicated Resident 21 has dialysis on Tuesdays, Thursdays, and Saturdays. The care plan does not indicate Resident 21's Wednesday dialysis Residents Affected - Few schedule.

During an interview with Licensed Vocational Nurse (LVN) 1, on 6/11/2024, at 9:58 a.m., LVN 1 stated she was assigned to Resident 21 and that Resident 21 went to dialysis every Tuesday, Wednesday, Thursday, and Saturday.

During an interview with Resident 21, on 6/11/2024, at 3:55 p.m., Resident 21 stated he had just returned from dialysis and that he goes to the dialysis clinic every Tuesday, Wednesday, Thursday, and Saturday.

During a concurrent interview and record review with LVN 4, on 6/13/2024, at 4:33 p.m., Resident 21's care plan, last revised 4/29/2024, was reviewed and LVN 4 confirmed the care plan did not indicate Resident 21's scheduled Wednesday dialysis session. LVN 4 stated Resident 21 goes to dialysis every Tuesday, Wednesday, Thursday, and Saturday. LVN 4 stated Resident 21's care plan should be revised to include his Wednesday dialysis sessions so that the facility staff knows what the resident's schedule is in case there is a change of condition, and the right information can be provided to the physician. LVN 4 further stated care plans are revised quarterly and during significant changes.

During an interview with the Director of Nursing (DON), on 6/13/2024, at 6:14 p.m., the DON stated Resident 21 gets dialysis treatments. The DON stated Resident 21's care plan should include the resident's dialysis days so that the staff would know what days the resident receives dialysis, and the resident can receive pre- and post-dialysis treatments on the specified days. The DON further stated if the care plan is not revised, the facility staff would not be aware of the care to provide to the resident.

A review of the facility's policy and procedure (P&P) titled, Dialysis Care, last reviewed 4/4/2024, indicated

the interdisciplinary team will ensure that the resident's care plan includes documentation of the resident's renal condition and necessary precautions (e.g., shunt site, weights, dietary and fluid restrictions, no blood pressure on affected side, lab draws, IV, injection on arm with shunt, observe for signs and symptoms of infection, etc.). The P&P further indicated the resident's care plan will be updated as needed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed Level of Harm - Minimal harm or consent; and (4) Correctly install and maintain the bed rail. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44376 Residents Affected - Some Based on observation, interview, and record review the facility failed to ensure the safe and appropriate use of bed rails to three of three sampled residents (Residents 15, 74, and 64) investigated during review of restraints by:

1. Failing to obtain a physician's order prior to use of bed rails.

2. Failing to conduct an accurate resident assessment including risks of entrapment from bed rails prior to installation.

3. Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.

These deficient practices had the potential to result in the restriction of residents' freedom of movement, a decline in physical functioning, psychosocial harm, physical harm from entrapment (an event in which a patient is caught, trapped, or entangled in the spaces in or about the bed rail, mattress, or hospital bed frame), and death of residents.

Cross reference

F-F700

Findings:

1. A review of Resident 64's Admission Record indicated the facility admitted Resident 64 on 4/16/2024 with diagnoses including, but not limited to, muscle wasting and atrophy.

A review of Resident 64's MDS, dated [DATE REDACTED], indicated Resident 64 had severe cognitive impairment (difficulty understanding and making decisions), and required moderate to maximal assistance with activities of daily living such as hygiene, toileting, and surface-to-surface transfers, and was not using bed rails.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 A review of Resident 64's History and Physical (H&P), dated 5/15/2024, indicated Resident 64 was a poor historian and was confused at times. Level of Harm - Minimal harm or potential for actual harm During an observation on 6/11/2024, at 9:00 a.m., inside Resident 64's room, Resident 64 was lying down in bed with quarter rails on both sides of the head of the bed. Residents Affected - Some

During a concurrent observation and interview with Certified Nursing Assistant (CNA) 4, on 6/13/2024, at 2:47 a.m., inside Resident 64's room, CNA 4 confirmed Resident 64's bed had bed rails on both sides of the bed.

During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 4, on 6/13/2024, at 4:33 p.m., Resident 64's MDS, dated [DATE REDACTED], was reviewed and indicated Resident 64 was not using bed rails. LVN 4 stated Resident 64 had side rails on both sides of the resident's bed. LVN 4 stated the MDS should indicate that Resident 64 used bed rails daily. LVN 4 further stated assessments should always match what is ongoing and the care provided to the resident because residents can be potentially provided

the wrong interventions with an inaccurate assessment.

During an interview with the Director of Nursing (DON), on 6/13/2024, at 6:14 p.m., the DON stated it is important to have an accurate assessment in the MDS for bed rail use because assessments promote care to be used for bed rails.

A review of the facility's policy and procedure (P&P) titled, RAI [Resident Assessment Instrument] Process, last reviewed 4/4/2024, indicated the purpose was to provide resident-assessments that accurately depict and identify resident-specific issues and objectives as required, while meeting state and federal guidelines and data submission requirements.

43988

2. A review of Resident 12's Admission Record indicated the facility admitted the resident on 11/10/2023 with diagnoses including dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and hypertension (a condition in which the force of the blood against the artery walls is too high).

A review of Resident 12's History and Physical, dated 11/30/2023, indicated the resident did not have the capacity to understand and make decisions.

During a concurrent interview and record review on 6/12/2024 at 4:10 p.m. with MDS Coordinator (MDSC), reviewed Resident 12's Order Summary Report dated 11/10/2023 and MDS Assessment, dated 2/22/2024. MDSC verified Resident 12 had physician's order for admission under Hospice Provider 1 (HP 1) on 11/10/2023. The MDSC verified Resident 12's MDS Assessment should have reflected Resident 12 was receiving hospice services while a resident in the facility. The MDSC stated not having an accurate MDS assessment can result in staff not being aware of the resident's plan of care which can lead to a delay in providing the resident hospice care and services.

A review of the facility's policy and procedure titled, RAI Assessment, last reviewed 4/4/2024, indicated the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 - Provide resident assessments that accurately depict and identify resident-specific issues and objectives as required. Level of Harm - Minimal harm or potential for actual harm - The facility will utilize the Resident Assessment Instrument (AI) process as the basis for the accurate assessment of each resident's functional capacity and health status. Residents Affected - Some - The facility must maintain all resident assessments completed within the previous 15 months in easily accessible location and use the results to develop, review, and revise the resident's comprehensive care plans.

36943

3. A review of Resident 7's Admission Record indicated the facility admitted Resident 7 on 7/15/2022 with diagnoses including hemiplegia or hemiparesis (weakness or inability to move one side of the body) following

a cerebral infarction (brain damage due to a loss of oxygen to the area) affecting the right dominant (used more often) side, dysphagia (difficulty swallowing), gastrostomy status (G-tube, tube placed directly into the stomach for long-term feeding, aphasia (loss of ability to understand or express speech as a result of brain damage), and functional quadriplegia (complete immobility due to frailty or severe physical disability).

A review of Resident 7's Occupational Therapy [OT, profession aimed to increase or maintain a person's capability of participating in everyday life activities (occupations)] Evaluation and Plan of Care, dated 7/15/2022, indicated Resident 7 had within functional limits (WFL, sufficient movement without significant limitation) ROM in both shoulders and both elbows. The OT Evaluation indicated Resident 7 had impairment

in both wrists and minimal (unspecified) limitation in both hands.

A review of Resident 7's Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation and Plan of Care, dated 7/15/2022, indicated Resident 7 had severe (unspecified) contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness) in both hips, both knees, and both ankles.

A review of Resident 7's MDS, dated [DATE REDACTED], indicated Resident 7 had severely impaired cognition (ability to think, understand, learn, and remember) and was dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) for eating, oral hygiene, toileting, showering/bathing oneself, upper and lower body dressing, rolling to both sides, and tub/shower transfers.

The MDS also indicated Resident 7 had ROM limitations in both arms and both legs.

A review of Resident 7's MDS, dated [DATE REDACTED], indicated Resident 7 had ROM limitations in one arm and one leg.

A review of Resident 7's OT Evaluation and Plan of Care, dated 2/15/2024, indicated Resident 7 hand impaired ROM in both arms, including right shoulder flexion (lifting the arm upward) 0 to 45 degrees (0-45 degrees, normal 0-180 degrees), right elbow flexion (bending the elbow) 90-150 degrees (normal 0-150 degrees), left shoulder flexion 0-10 degrees, left elbow flexion 20-150 degrees, and left wrist flexion (bending

the wrist downward) 0-45 degrees (normal 0-90 degrees).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 A review of Resident 7's PT Evaluation and Plan of Care, dated 2/15/2024, indicated Resident 7 had impaired ROM in both legs, including both hips fixed (unable to move) to 130 degrees of hip flexion (bending Level of Harm - Minimal harm or the leg at the hip joint toward the body, normal 0-130 degrees) and both knees fixed to 150 degrees of knee potential for actual harm flexion (bending the knee, normal 0-135 degrees).

Residents Affected - Some A review of Resident 7's MDS, dated [DATE REDACTED], indicated Resident 7 had ROM limitations in one arm and one leg.

During a concurrent interview and record review on 6/13/2024 at 2:59 p.m. with the MDSC, Resident 7's MDS assessments, dated 10/21/2023, 1/22/2024, and 4/22/2024, were reviewed. MDSC stated Resident 7's MDS assessment, dated 10/21/2023, indicated Resident 7 had ROM limitation in both arms and both legs. MDSC stated Resident 7's MDS assessments, dated 1/22/2024 and 4/22/2024, were incorrect and should have indicated Resident 7 had ROM limitations in both arms and both legs. MDSC stated MDS assessment (in general) provided a picture of the resident and should be accurate to determine a resident's plan of care.

During an interview on 6/13/2024 at 3:05 p.m. with MDSC, MDSC stated the information on the MDS assessments was submitted to the Federal database. MDSC stated incorrect information for Resident 7 was sent to the Federal database.

A review of the facility's policy and procedure (P&P) titled, RAI Process: Operational Manual - Administrative Policies, revised 10/4/2016, indicated the resident-assessment should accurately depict and identify resident-specific issues. The P&P also indicated the facility would accurately assess each resident's functional capacity and health status.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44376

Residents Affected - Some Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan to:

1. Three out of three sampled residents (Residents 15, 74, and 64) investigated during review of side rails (metal rails that normally hang on the side of the patient's bed)/restraints (devices that limits a patient's movement).

2. One out of one sampled resident (Resident 7) investigated during review of anticoagulants (medicines that help prevent blood clots).

3. One out of two sampled residents (Resident 74) investigated during review of pressure ulcers/injuries (damage to an area of the skin caused by constant pressure on the area for a long time).

These deficient practices placed the residents at risk for not receiving the necessary services and treatment to meet their medical, physical, mental, and psychosocial needs.

4. One of four sampled residents (Resident 41 of accidents care area by failing to develop a comprehensive care plan for Resident 41's use of tobacco.

This deficient practice resulted in Resident 41 smoking in his room and had the potential of resulting in a fire or burns to the resident.

Findings:

1.a A review of Resident 15's Admission Record indicated the facility admitted the resident on 4/13/2018 and readmitted the resident on 12/9/2021, with diagnoses including contracture of joint (a permanent tightening of

the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff), osteomyelitis (an inflammation or swelling of bone tissue that is usually the result of an infection), and muscle wasting (thinning or loss of muscle tissue).

A review of Resident 15's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/8/2024, indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident was totally dependent on mobility and activities of daily living (ADLs).

During an observation on 6/12/2024, at 8:05 a.m., inside Resident 74 ' s room, observed the resident lying down in bed with the left upper side rail up.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 During a concurrent interview and record review on 6/12/2024, at 11:52 a.m., with Registered Nurse 1 (RN 1), reviewed Resident 15's care plans. RN 1 stated the resident did not have a care plan for the use of Level of Harm - Minimal harm or bilateral upper side rails. RN 1 stated there should have been a care plan created to ensure the use of side potential for actual harm rails was appropriate and safe. RN 1 also stated the care plan serves as a guide for the healthcare team to deliver care that is person-centered, safe, and in accordance with the resident's needs. Residents Affected - Some

During an interview on 6/13/2024 at 6:30 p.m., with the Director of Nursing (DON), the DON stated nursing staff should have developed and implemented a care plan on the use side rails to ensure the resident was getting appropriate care and treatment. The DON stated the care plan will serve as a communication tool to all healthcare providers to provide standardized services in order to achieve the resident's targeted goals.

A review of the facility's recent policy and procedure titled, Comprehensive Person-Centered Care Planning, last reviewed on 4/4/2024, indicated to ensure that a comprehensive person-centered care plan is developed for each resident. Within 7 days from the completion of the comprehensive MDS assessment, the comprehensive care plan will be developed. All goals, objectives, interventions etc. from the current baseline care plan will be included in the resident's comprehensive care plan.

1.b A review of Resident 74's Admission Record indicated the facility admitted the resident on 11/14/2023, with diagnoses including abnormalities of gait (a manner of walking or moving on foot) and mobility, muscle wasting and atrophy (decrease in size of a body part, cell, organ, or other tissue), and history of falling.

A review of Resident 74's MDS, dated [DATE REDACTED], indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident required substantial to maximal assistance with mobility and ADLs.

During a concurrent interview and record review on 6/12/2024, at 8:05 a.m., with RN 1, reviewed Resident 74's care plans . RN 1 stated the resident did not have a care plan for the use side rails. RN 1 stated there should have been a care plan created to ensure the use of side rails was appropriate and safe. RN 1 also stated the care plan serves as a guide for the healthcare team to deliver care that is person-centered, safe, and in accordance with the resident's needs.

During an interview on 6/13/2024 at 6:30 p.m., with the Director of Nursing (DON), the DON stated nursing staff should have developed and implemented a care plan on the use side rails to ensure the resident was getting appropriate care and treatment. The DON stated the care plan will serve as a communication tool to all healthcare providers to provide standardized services in order to achieve the resident's targeted goals.

A review of the facility's recent policy and procedure titled, Comprehensive Person-Centered Care Planning, last reviewed on 4/4/2024, indicated to ensure that a comprehensive person-centered care plan is developed for each resident. Within 7 days from the completion of the comprehensive MDS assessment, the comprehensive care plan will be developed. All goals, objectives, interventions etc. from the current baseline care plan will be included in the resident's comprehensive care plan.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 2. A review of Resident 7's Admission Record indicated the facility admitted the resident on 7/15/2024, with diagnoses including hemiplegia (paralysis that affects only one side of the body) and hemiparesis (weakness Level of Harm - Minimal harm or or the inability to move on one side of the body, making it hard to perform everyday activities like eating or potential for actual harm dressing) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area).

Residents Affected - Some A review of Resident 7's H&P, dated 10/18/2023, indicated the resident did not have the capacity to understand and make decisions.

A review of Resident 7's MDS, dated [DATE REDACTED], indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident was dependent on mobility and ADLs and was incontinent of urine and stool (feces). The MDS also indicated the resident was at risk for pressure ulcer/ injury development.

A review of Resident 7's Order Summary Report, dated 12/22/2024, indicated an order for Eliquis oral tablet 5 milligrams (mg, a unit of weight) (Apixaban). Give 1 tablet by mouth two times a day for deep vein thrombosis (DVT, a blood clot that develops within a deep vein in the body, usually in the leg) management.

During a concurrent interview and record review on 6/12/2024, at 12:11 p.m., with RN 1 and LVN 6, reviewed Resident 7's Order Summary Report and Care Plans. LVN 6 stated the resident has an order for Eliquis oral tablet 5 mg but there was no care plan for its use. RN 1 stated it was important to have a care plan on the use of anticoagulant- Eliquis to ensure the healthcare team is providing consistent interventions on monitoring for and avoiding complications on the use of an anticoagulant such as bleeding.

During an interview on 6/13/2024, at 6:30 p.m., with the DON, the DON stated nursing staff should have developed and implemented a care plan on the use of Eliquis to make sure the resident would not develop adverse effects (a harmful or abnormal result) from the medication. The DON stated the care plan provides instructions to the healthcare team on how to care for and monitor the resident on anticoagulants.

A review of the facility's recent policy and procedure titled, Comprehensive Person-Centered Care Planning, last reviewed on 4/4/2024, indicated to ensure that a comprehensive person-centered care plan is developed for each resident. Within 7 days from the completion of the comprehensive MDS assessment, the comprehensive care plan will be developed. All goals, objectives, interventions etc. from the current baseline care plan will be included in the resident's comprehensive care plan.

3. A review of Resident 74's Admission Record indicated the facility admitted the resident on 11/14/2023, with diagnoses including moderate protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), pressure ulcer of sacral region (at the bottom of the spine and lies between the fifth segment of the lumbar spine [L5] and the coccyx [tailbone]), and abnormalities of gait (manner of walking) and mobility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 A review of Resident 74's MDS, dated [DATE REDACTED], indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident required substantial to maximal assistance in Level of Harm - Minimal harm or mobility and activities of daily living (ADLs) and was at risk for developing pressure ulcers/injuries. The MDS potential for actual harm indicated the resident had an unstageable pressure injury (when the stage is not clear) with intervention for pressure reducing device for bed. Residents Affected - Some

A review of Resident 74's Order Summary Report, dated 4/23/2024, indicated an order for low air loss mattress (LALM, an air mattress covered with tiny holes) for wound management every shift.

During a concurrent interview and record review on 6/12/2024, at 12:22 p.m., with RN 1 and LVN 6, reviewed Resident 74's Order Summary Report and Care Plans. LVN 6 stated there was an order for a LALM mattress for wound management but there was no care plan for its use. RN 1 stated it was important to have a care plan on the use of the LALM mattress to ensure the healthcare team is providing consistent interventions to promote healing of pressure injuries and prevent the development of new pressure injuries.

During an interview on 6/13/2024, at 6:30 p.m., with the DON, the DON stated the staff should have developed and implemented a care plan on the use of LALM to make sure the resident would not develop pressure injury. The DON stated the care plan will serve as their guide on what to observe and monitor for a resident on a LALM.

A review of the facility's recent policy and procedure titled, Comprehensive Person-Centered Care Planning, last reviewed on 4/4/2024, indicated to ensure that a comprehensive person-centered care plan is developed for each resident. Within 7 days from the completion of the comprehensive MDS assessment, the comprehensive care plan will be developed. All goals, objectives, interventions etc. from the current baseline care plan will be included in the resident's comprehensive care plan.

43418

1.c A review of Resident 64's Admission Record indicated the facility admitted Resident 64 on 4/16/2024 with diagnoses including, but not limited to, muscle wasting and atrophy.

A review of Resident 64's MDS, dated [DATE REDACTED], indicated Resident 64 had severe cognitive impairment (difficulty understanding and making decisions), and required moderate to maximal assistance with activities of daily living such as hygiene, toileting, and surface-to-surface transfers, and was not using bed rails.

A review of Resident 64's History and Physical (H&P), dated 5/15/2024, indicated Resident 64 was a poor historian and was confused at times.

During an observation on 6/11/2024, at 9:00 a.m., inside Resident 64's room, Resident 64 was lying down in bed with bilateral upper quarter bed rails.

During a concurrent observation and interview with Certified Nursing Assistant (CNA) 4, on 6/13/2024, at 2:47 a.m., inside Resident 64's room, CNA 4 confirmed Resident 64's bed had bed rails on both sides of the bed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 4, on 6/13/2024, at 4:33 p.m., Resident 64's care plans were reviewed and LVN 4 confirmed Resident 64 did not have care Level of Harm - Minimal harm or plans related to the use of bed rails. LVN 4 stated Resident 64 has bed rails on both sides of her bed and potential for actual harm Resident 64 should have an order, assessment, and care plan for bed rail use. LVN 4 further stated care plans guide nurses on what to do and how to deal with specific situations related to the resident. Residents Affected - Some

During an interview with the Director of Nursing (DON), on 6/13/2024, at 6:14 p.m., the DON stated the purpose of care plans are to provide proper care for residents and it standardizes the residents' care. The DON further stated if a care plan is not developed, the facility staff would not be aware of the care to provide for residents.

A review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, last reviewed 4/4/2024, indicated a comprehensive person-centered care plan is developed for each resident and additional changes or updates to the resident's comprehensive care plan will be made based on the assessed needs of the resident. The P&P further indicated the comprehensive care plan will also be reviewed and revised during the onset of new problems, change of condition, to address changes in behavior and care, and other times as appropriate or necessary.

44244

4. A review of Resident 41's Admission Record indicated the facility admitted the resident on 12/3/2021 and readmitted the resident on 5/7/2022 with diagnoses that included type two diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), hypertension (high blood pressure), and schizophrenia (a mental health condition with symptoms of delusions, hallucinations, and disorganized thinking).

A review of Resident 41's Minimum Data Set (MDS - an assessment and care screening tool) dated 3/15/2024, indicated the resident was able to understand others and was able to make himself understood.

The MDS further indicated the resident required supervision for bathing, dressing, toileting, personal hygiene, and mobility.

A review of Resident 41's History and Physical, dated 10/21/2023, indicated the resident had fluctuating capacity to understand and make decisions.

A review of Resident 41's Smoking Safety Evaluation form, dated 5/7/2022, indicated the resident did not utilize tobacco.

A review of Resident 41's Care Plan (CP) titled, Resident smoking inside the room, initiated 2/1/2023, indicated to remind the resident that smoking inside the room is strongly prohibited, explain the importance of compliance with smoking, to educate the resident of the smoking schedule, and notify the physician any changes in condition. The CP further indicated a goal that the resident would have no episodes of smoking inside the room.

During an interview on 6/11/2024 at 9:10 a.m., observe Resident 41 sitting in his wheelchair in the facility smoking patio.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 During an interview on 6/11/2024 at 11:12 a.m., Resident 41 stated he smokes cigarettes, and his smoking supplies are kept on the smoking patio. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 6/12/2024 at 12:35 p.m., with the Minimum Data Set Coordinator (MDSC), reviewed Resident 41's Smoking Safety Evaluation dated 5/7/2022, Smoking Rules Residents Affected - Some agreement form dated 4/9/2024, and Care Plans. The MDSC stated every resident has a smoking evaluation completed at admission. The MDSC stated Resident 41 had one admission smoking evaluation that indicated the resident did not smoke and no smoking assessment was completed. The MDSC stated residents identified as smokers should have a CP for smoking that includes resident specific smoking interventions for safety. The MDSC stated the CP is made so the staff are aware of their responsibilities. The MDSC reviewed Resident 41's CPs and stated, the resident did not have a smoking CP other than the CP indicating the resident was found smoking in his room. The MDSC stated the importance of an accurate smoking evaluation, assessment, and smoking CP is for resident safety because the resident may not be aware and may be in danger of burning himself. The MDSC stated the CP is for all the staff and communicates the resident plan.

During a concurrent interview and record review on 6/12/2024 at 3:12 p.m., the Director of Nursing (DON) reviewed Resident 41's Smoking Safety Evaluation form dated 5/7/2022, Smoking Rules agreement form dated 4/9/2024, and Care Plans. The DON stated a CP is a plan of care for a resident intended for all the facility staff to know a resident's specific needs. The DON stated a smoking assessment and smoking CP include education provided to the resident, resident specific safety measures like wearing a smoking apron,

the resident's need for supervision, the smoking time schedule, and the risks of not complying. The DON stated Resident 41 has been a smoker since his original admission and should have a smoking CP. The DON stated Resident 41 did not have a smoking assessment or CP completed because at admission the resident was not identified as a smoker in the smoking evaluation. The DON stated without a CP, there was

a potential safety risk that could have resulted in a fire or self-harm from burns when Resident 41 was found smoking in his room in 2/2024. The DON stated the facility policy for comprehensive care plans was not followed.

A review of the facility policy and procedure titled, Comprehensive Person-Centered Care Planning, last reviewed 4/4/2024, indicated the purpose of the policy was to ensure that a comprehensive person-centered care plan is developed for each resident. It is the policy of the facility to provide person-centered, comprehensive, and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial wellbeing. The comprehensive CP will be developed within seven days from the completion of the comprehensive assessment. Additional changes or updates to the resident's comprehensive CP will be made based on the assessed needs of the resident.

A review of the facility policy and procedure titled, Resident Safety, last reviewed 4/4/2024, indicated the purpose of the policy was to provide a safe and hazard free environment. Residents will be evaluated on admission, quarterly and whenever there is a change in condition to identify circumstances that pose a risk for the safety and wellbeing of residents. During the comprehensive assessment period the ID members will assess the Resident's safety risk (e.g. smoking, self-administration of medication) as well as any other Resident specific safety risks. After a risk evaluation is completed, a Resident centered care plan will be developed to mitigate safety risk factors.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44376

Residents Affected - Few Based on observation, interview, and record review the facility failed to ensure a resident's care plan was reviewed after each assessment and revised based on changing goals, preferences, and needs of the resident in response to current interventions to one out of three sampled residents investigated during review of restraints care area (Resident 15) by failing to review and update the care plan to reflect the family's preference to have the call light hanging on the wall away from Resident 15's reach.

This deficient had the potential to negatively affect the provision of care and services for Resident 15.

Cross reference

F-F759

Findings:

1. A review of Resident 6's Admission Record indicated the facility admitted the resident on 8/2/0216, and readmitted the resident on 7/26/2023, with diagnoses including type 2 diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar, is too high., long term use of insulin, and moderate protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function).

A review of Resident 6's History and Physical (H&P), dated 12/5/2023, indicated the resident had the capacity to understand and make decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 77 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 A review of Resident 6's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/19/2024, indicated the resident usually had the ability to make self-understood and understand Level of Harm - Minimal harm or others. The MDS indicated the resident was on insulin injections and was receiving a high-risk drug class potential for actual harm medication hypoglycemic (a group of drugs used to help reduce the amount of sugar present in the blood).

Residents Affected - Some A review of Resident 6's Order Summary Report, dated 12/4/2023, indicated an order for insulin aspart injection solution 100 unit (a standard way to quantify the effect of a medication)/milliliters (ml, a unit of volume) (Insulin Aspart). Inject as per sliding scale (the increasing administration of the pre-meal insulin dose based in the blood sugar level before the meal): if 0-139= 0 units; 140-199= 1 unit; 200-249= 2 units; 250-299= 3 units; 300-349= 4 units; 350-400= 5 units, subcutaneously before meals and at bedtime for diabetes mellitus (DM). Call MD for blood sugar (BS) greater than (>) 400 or less than 70.

A review of Resident 6's Location of Administration of insulin for 1/2024 to 6/2024, indicated the following:

3/15/2024 8:25 p.m. Abdomen-Right Lower Quadrant (RLQ)

3/15/2024 8:26 p.m. Abdomen-RLQ

3/16/2024 4:50 p.m. Abdomen-RLQ

3/22/2024 8:19 p.m. Abdomen-RLQ

3/23/2024 5:10 p.m. Abdomen-RLQ

3/23/2024 8:12 p.m. Abdomen-RLQ

3/25/2024 6:51 a.m. Abdomen-Left Lower Quadrant (LLQ)

3/26/2024 2:14 p.m. Abdomen-LLQ

3/29/2024 5:32 p.m. Abdomen-LLQ

3/29/2024 9:33 p.m. Abdomen-RLQ

3/30/2024 3:37 p.m. Abdomen-RLQ

3/30/2024 9:43 p.m. Abdomen-RLQ

4/5/2024 5:11 p.m. Abdomen-RLQ

4/5/2024 9:30 p.m. Abdomen-RLQ

4/6/2024 9:48 p.m. Abdomen-RLQ

4/12/2024 5:50 p.m. Abdomen-Left Upper Quadrant (LUQ)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 78 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 4/13/2024 5:03 p.m. Abdomen-LUQ

Level of Harm - Minimal harm or 4/13/2024 12:07 a.m. Abdomen-RLQ potential for actual harm 4/19/2024 8:24 p.m. Abdomen-RLQ Residents Affected - Some 4/19/2024 8:25 p.m. Abdomen-RLQ

4/20/2024 7:01 p.m. Abdomen-RLQ

4/20/2024 10:57 p.m. Abdomen-RLQ

5/3/2024 9:40 p.m. Abdomen-LUQ

5/4/2024 5:21 p.m. Abdomen-LUQ

5/4/2024 11:19 p.m. Abdomen-RLQ

5/10/2024 7:34 p.m. Abdomen-RLQ

5/10/2024 10:31 p.m. Abdomen-RLQ

5/11/2024 8:45 p.m. Abdomen-RLQ

5/17/2024 7:12 p.m. Abdomen-RLQ

5/18/2024 8:50 p.m. Abdomen-RLQ

5/18/2024 8:51 p.m. Abdomen-RLQ

5/31/2024 8:34 p.m. Abdomen-RLQ

5/31/2024 8:35 p.m. Abdomen-LUQ

6/1/2024 8:21 p.m. Abdomen-LUQ

During a concurrent interview and record review on 6/11/2024, at 2:13 p.m., with Licensed Vocational Nurse 6 (LVN 6), reviewed Resident 6's Order Summary Report and the Location of Administration site of insulin from 1/2024 to 6/2024 of. LVN 6 stated there were multiple occasions that the insulin administration was repeatedly given on the same site. LVN 6 stated the sites of insulin administration should be rotated to prevent skin irritation and lipodystrophy. LVN 6 stated licensed nurses should rotate insulin administration sites and follow the manufacturer's guidelines to rotate insulin administration sites. LVN 6 stated not rotating insulin administration sites is considered a medication error.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 79 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 During an interview on 6/13/2024, at 6:26 p.m., with the Director of Nursing (DON), the DON stated insulin sites of administration should be rotated to prevent skin lumps and discoloration on residents. The DON Level of Harm - Minimal harm or stated not following the manufacturer's guidelines to rotate insulin administration sites constitutes a potential for actual harm medication error.

Residents Affected - Some A review of the facility's recent policy and procedure titled, Medication- Errors, last reviewed on 4/4/2024, indicated medication error means the administration of medication:

A. To the wrong resident;

B. At the wrong time;

C. At the wrong dose;

D. Via the wrong route; or

E. Which is not currently prescribed.

A review of the facility provided manufacturer's guideline- Novolog FlexPen (insulin aspart injection) 100 units/ml, undated, indicated to rotate injections between injection spots #1-4 in the diagram at to the right: stomach, thighs, upper arms, and buttocks.

A review of the facility provided manufacturer's guideline- Novolog insulin aspart injection 100 unit/ml, with initial U.S. approval in 2000, indicated to rotate injection sites within the same region from one injection to the next to reduce risks of lipodystrophy and localized cutaneous amyloidosis.

43455

2. During an observation on 6/11/24 at 9:09 AM, in medication cart 1, Licensed Vocational Nurse (LVN) 1 was observed crushing Metoprolol Succinate ER 50 milligram ([mg]-a unit of measure of mass) tablet and adding them to a small cup filled with water and opening Duloxetine DR 30 mg capsule and pouring the contents to another small cup filled with water, for Resident 295.

According to the manufacturer package insert (a document that provides information about the medication,) dated 3/2006 for Metoprolol succinate ER tablets, the document indicates that Metoprolol succinate ER tablets should not chewed or crushed.

According to the manufacturer medication guide (a document approved by the Food and Drug Administration [FDA - agency responsible for protecting the public health by ensuring the safety, efficacy, and security of human drugs] that gives information to patients about medications to avoid adverse effects,) dated 8/2023 for Duloxetine DR capsules, the document indicates that Duloxetine DR capsules should not be chewed or crushed, to not open the capsule and sprinkle on food or mix with liquids, and opening the capsule may affect how well Duloxetine DR capsules work.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 80 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 During an observation on 6/11/24 at 9:24 AM, with LVN 1, LVN 1 was observed not checking the Percutaneous Endoscopic Gastrostomy ([PEG] - a tube surgically inserted in the stomach to receive nutrition Level of Harm - Minimal harm or and medications) Tube placement, patency, residuals, and not flushing the tube with water, and LVN 1 potential for actual harm grabbing the medication cup containing Metoprolol Succinate ER that LVN 1 had prepared by crushing the tablet for administration into the PEG-Tube for Resident 295. LVN 1 was stopped by the surveyor before any Residents Affected - Some medication was administered to Resident 295 and advised to discuss the PEG-tube technique and medication preparation with the surveyor in the hallway.

During an interview on 06/11/2024 at 9:25 AM, with LVN 1, LVN 1 stated that sustained release medications such as the Metoprolol Succinate ER cannot be crushed, and Duloxetine DR capsule cannot be opened. LVN 1 stated crushing the tablet or opening the capsule makes the release of the medication immediate instead of sustained. LVN 1 stated that administering Metoprolol and Duloxetine as immediate release will provide larger doses to Resident 295 at once resulting in more immediate side effects like gastrointestinal (GI) irritation. LVN 1 stated that LVN 1 will not administer the Metoprolol Succinate ER and Duloxetine DR to Resident 295 and communicate to the doctor for alternate forms of these medications.

During an interview, on 6/12/2024 at 11:44 AM, with the Director of Nursing (DON,) the DON stated that sustained release medications should not be crushed or opened. The DON stated doing so will make the medication immediate release and cause more side effects. The DON stated that pharmacists and several LVN's failed to clarify the Metoprolol Succinate ER and Duloxetine DR orders for alternate options to be administered through the PEG-Tube and not harm Resident 295.

During an interview on 6/12/2024 at 12:47 PM, with the Consultant Pharmacist (CP), the CP stated that Metoprolol Succinate ER should not be crushed, and Duloxetine DR capsule should not be opened for PEG-Tube administrations, based on manufacturer guidance. The CP stated both medication orders should have been clarified for alternate options to be administered through the PEG-Tube.

During a phone interview on 6/13/2024 at 10:31 AM, with the DON, the DON stated that after confirming with

the CP, the physician has changed the Metoprolol succinate ER and Duloxetine DR orders for Resident 295 to forms that can be administered through the PEG-Tube.

During a review of Resident 295's Admission Record (a document containing demographic and diagnostic information,) dated 6/11/2024, indicated the resident was originally admitted to the facility on [DATE REDACTED] with diagnoses including essential hypertension (a condition in which the blood vessels have persistently raised pressure) and depression.

During a review of Resident 295's Order Summary Report (a report listing the physician order for the resident) for June 2024, indicated Resident 295 was prescribed Metoprolol Succinate ER 50 mg tablet to be given by PEG-Tube once a day for hypertension and to hold the dose for Systolic Blood Pressure (SBP) less than 110 or heart rate less than 60, and was prescribed Duloxetine DR capsule 30 mg to be given via PEG-Tube once a day for depression, starting 6/8/2024, and to check for placement, patency and residual, starting 6/7/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 81 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 During a review of Resident 295's MAR ([MAR] - a document of the medications administered to a resident that is part of the resident's permanent medical record]) for June 2024, the MAR indicated Resident 295 was Level of Harm - Minimal harm or prescribed Metoprolol Succinate ER 50 mg tablet to be given by PEG Tube once a day for hypertension and potential for actual harm to hold the dose for SBP less than 110 or heart rate less than 60 and was prescribed Duloxetine DR capsule 30 mg to be given via PEG-Tube once a day for depression, at 09:00 AM. Residents Affected - Some

Review of the facility's Policy and Procedures (P&P), titled Medication Administration General Guidelines for

the Administration of Medications, dated 4/4/2024, the P&P indicated:

The nurse reviews each resident's MAR to determine which medications need to be administered at the given time. The nurse observes the five rights in administering each medication:

e. The right method of administration

The nurse compares the MAR with the medication label three times. The nurse compares the name of the medication, the route of administration and the strength and dose when he/she selects the medication from

the cart or tray, when he/she pours the medication and when he/she returns the medication to the cart.

Review of the facility's P&P, titled Medication Administration Errors, dated 4/4/2024, the P&P indicated:

I. A medication administration error occurs when a resident receives a dose of medication that deviates from

the original physician's order and/or established facility policy and procedures. Types of errors include:

Incorrect preparation of dose

Incorrect administration technique.

Review of the facility's P&P, titled Medication Administration Crushing of Medications, dated 4/4/2024, the P&P indicated:

I. Solid oral dosage forms may be crushed for administration to residents when a resident is unable to swallow a whole tablet/capsule and when doing so does not affect the effectiveness, toxicity or side effects of

the product.

If a liquid alternative is not available, the nurse will consult the Do Not Crush list provided in this manual (see Appendices) and the product label cautionary statements to determine if the product in question may be crushed. If in doubt, the nurse will contact the pharmacist for guidance and clarification. In general, medications that are sustained release products, enteric coated, or are for sublingual or buccal administration will appear on the Do Not Crush list.

If it is determined that the medication in questions may not be crushed, the nurse will contact the physician to obtain an order for an alternative product. Nurse may contact the pharmacist for suggested alternatives.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 82 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Review of facility's P&P, titled Appendix 7. Medications that should not be chewed or crushed, dated 4/4/2024, the appendix indicated The following list of drugs that should not be chewed or crushed is intended Level of Harm - Minimal harm or as a guide, not an all-inclusive list. Any questions should be addressed through pharmacy staff or potential for actual harm manufacturer literature:

Residents Affected - Some Time-Release Tablets - Designed to release medication over a period of 8 to 12 hours. Some formulations are designed to reduce gastric irritation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 83 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43455 Residents Affected - Some Based on observation, interview, and record review the facility failed to:

1. Label two insulin (a medication used to treat high blood sugar) Novolog Flexpens (type of insulin injection device) for Residents 21, with an open date in accordance with the manufacturer's requirements, in one of two inspected medication carts (Medication Cart Station 1).

2. Store one insulin Lantus (long-acting insulin) Solostar (type of insulin injection device) pen and one insulin Humalog (fast-acting insulin) Kwikpen (type of insulin injection device) for Resident 295, in the refrigerator or label at room temperature in accordance with the manufacturer's requirements in one of two inspected medication (Medication Cart 1).

3. Label, remove and discard from use one discontinued Novolin R (short-acting regular human insulin) vial for Resident 65, in accordance with facility requirements in one of two inspected medication carts (Medication Cart 1.)

4. Label one budesonide (medication used to treat difficulty in shortness of breath, wheezing and COPD) inhalation suspension (form of medication that is inhaled) for Resident 16 and one levalbuterol (medication used to treat shortness of breath, wheezing [breathing with a whistling sound in the chest] and Chronic Obstructive Pulmonary Disease [COPD]- a disease that blocks air flow and makes breathing difficult]) inhalation solution (form of medication that is inhaled) for Resident 70, with an open date in accordance with facility requirements and manufacturer's requirements in one of two inspected medication carts (Medication Cart 1.)

5. Label one insulin Novolog Flexpen for Resident 6, in accordance with manufacturer's requirements in one of two inspected medication carts (Medication Cart Station 3.)

6. Label one budesonide and formoterol (a combination medication used to treat COPD) inhalation aerosol (form of medication that is inhaled) for Resident 15, one Anoro (a brand name combination inhalation powder for shortness of breath and wheezing) Ellipta (type of inhalation device) for Resident 33, and one Breo (a brand name combination inhalation powder for COPD) Ellipta for Resident 75, in accordance with facility and manufacturer's requirements in one of two inspected medication carts (Medication Cart 3.)

These practices increased the risk that Residents 6, 15, 16, 21, 33, 65, 70, 75, and 295 could have received medication that had become ineffective or toxic due to improper storage or labeling, possibly leading to health complications resulting in hospitalization or death.

During an observation on [DATE REDACTED] at 12:25 PM, in Medication Cart 1, in the presence of Licensed Vocational Nurse (LVN) 1, the following medications were found either stored in a manner contrary to their respective manufacturer's requirements, not labeled with an open date as required by their respective manufacturer's specifications, expired and not discarded, or stored and labeled contrary to facility policies:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 84 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 1. One open budesonide inhalation suspension foil pack for Resident 16 was found stored at room temperature and not labeled with a date on which foil pack was opened. Level of Harm - Minimal harm or potential for actual harm According to the manufacturer's product storage and labeling, budesonide suspensions should be stored at room temperature between 68 to 77 degrees Fahrenheit and once the foil envelope is opened to be used or Residents Affected - Some discarded within 2 weeks.

2. Two open insulin Novolog Flexpens for Resident 21 were found stored at room temperature without a label indicating when storage or use at room temperature began.

According to the manufacturer's product labeling, opened Novolog Flexpens should be stored at room temperature below 86 degrees Fahrenheit and used or discarded within 28 days of opening or once storage at room temperature began.

3. One opened insulin Novolin R vial for Resident 65 was found stored at room temperature without a label indicating when storage or use at room temperature began.

According to the manufacturer's product labeling, opened Novolin R vials should be stored at room temperature below 86 degrees Fahrenheit and used or discarded within 42 days of opening or once storage at room temperature began.

A review of Resident 65's Order Recap Report (a report summarizing the orders for a resident) for [DATE REDACTED], indicated Resident 65 was prescribed regular human insulin starting [DATE REDACTED] and discontinued on [DATE REDACTED].

4. One open levalbuterol inhalation solution foil pack for Resident 70 was found stored at room temperature and not labeled with a date on which foil pack was opened.

According to the manufacturer's product storage and labeling, levalbuterol solutions should be stored at room temperature between 68 to 77 degrees Fahrenheit and once the foil pouch is opened to be used or discarded within 2 weeks.

5. One unopened insulin Lantus Solostar pen for Resident 295 was found stored at room temperature without a label indicating when storage at room temperature began.

According to the manufacturer's product labeling, unopened Lantus Solostar should be stored in the refrigerator between 36 and 46 degrees Fahrenheit and used or discarded within 28 days of opening or once they've been stored at room temperature.

6. One unopened insulin Humalog Kwikpen for Resident 295 was found stored at room temperature without

a label indicating when storage at room temperature began.

According to the manufacturer's product labeling, unopened Humalog Kwikpen should be stored in the refrigerator between 36 and 46 degrees Fahrenheit and used or discarded within 28 days of opening or once they've been stored at room temperature.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 85 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 During a concurrent interview with LVN 1, LVN 1 stated that the two insulin Novolog Flexpens for Resident 21, the insulin Novolin R vial for Resident 65, and the insulin Lantus Solostar and Humalog Kwikpen for Level of Harm - Minimal harm or Resident 295 were not labeled with a date when use at room temperature began and therefore it is unknown potential for actual harm when they expire and need to be discarded. LVN 1 stated in addition the Novolin R for Resident 65 was discontinued on [DATE REDACTED] and should be removed from the medication cart, and the Lantus Solostar and Residents Affected - Some Humalog Kwikpen for Resident 295 were not open and need to be stored in the refrigerator. LVN 1 stated all

these insulins need to be replaced from pharmacy to ensure expired insulin is not used in error for Resident 21, 65 and 295. LVN 1 stated administering expired insulin will not be effective in keeping the blood sugar stable and can harm Resident 21, 65 and 295 by causing high or low blood sugar levels leading to coma (a state of deep unconsciousness caused by severe injury or illness), hospitalization or death.

During the same interview, LVN 1 stated the budesonide inhalation for Resident 16 and the levalbuterol inhalation solution for Resident 70 was not labeled with a date when the foil pack was opened, and therefore

it is unknown when they expire. LVN 1 stated per facility policy multi-use medications such as inhalation treatments should be labeled with the date when first opened to know when they expire. LVN 1 stated after opening the foil pack should be used within 2 weeks and if used beyond that date are considered expired and lost potency (effectiveness), which can potentially lead to the administration of ineffective medication to Resident 16 and 70 causing harm by not treating the shortness of breath and COPD leading to difficulty in breathing, requiring immediate treatment and potential hospitalization .

During an observation on [DATE REDACTED] at 12:50 PM, in Medication Cart 3, in the presence of LVN 6, the following medications were found either stored in a manner contrary to their respective manufacturer's requirements, not labeled with an open date as required by their respective manufacturer's specifications, expired and not discarded, or stored and labeled contrary to facility policies:

1. One open insulin Novolog Flexpen for Resident 6 was found stored at room temperature without a label indicating when storage or use at room temperature began.

According to the manufacturer's product labeling, opened Novolog Flexpen should be stored at room temperature below 86 degrees Fahrenheit and used or discarded within 28 days of opening or once storage at room temperature began.

2. One open budesonide and formoterol inhalation aerosol for Resident 15 was found stored at room temperature and not labeled with a date on which aerosol inhaler was opened.

According to the manufacturer's product storage and labeling, budesonide and formoterol inhalation aerosol inhaler should be stored at room temperature between 68 to 77 degrees Fahrenheit and once the inhaler foil pouch is removed to be used or discarded within 3 months.

3. One open Anoro Ellipta tray for Resident 33 was found stored at room temperature and not labeled with a date on which use at room temperature began.

According to the manufacturer's product storage and labeling, opened Anoro Ellipta device can be stored at room temperature between 68 and 77 degrees Fahrenheit and used or discarded after 6 weeks of opening

the moisture-protective foil tray.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 86 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 4. One open Breo Ellipta tray for Resident 75 was found stored at room temperature and not labeled with a date on which use at room temperature began. Level of Harm - Minimal harm or potential for actual harm According to the manufacturer's product storage and labeling, opened Breo Ellipta device can be stored at room temperature between 68 and 77 degrees Fahrenheit and used or discarded after 6 weeks of opening Residents Affected - Some the moisture-protective foil tray.

During a concurrent interview with LVN 6, LVN 6 stated the insulin Novolog Flexpen for Resident 6 was not labeled with a date when use at room temperature began. LVN 6 stated per facility policy insulins should be labeled with the date when opened and replaced 28 days after opening. LVN 6 stated without the label LVN 6 is unable to determine when the insulin expires and can potentially administer expired insulin to Resident 6. LVN 6 stated expired insulin has lost its effectiveness and administering expired insulin may result in Resident 6 to experience high blood sugar levels causing loss of consciousness, hospitalization , and death.

During the same interview, LVN 6 stated the budesonide and formoterol for Resident 15, Anoro for Resident 33 and Breo for Resident 75 were not labeled with a date when the foil pouch and trays were opened, and therefore it is unknown when they expire. LVN 6 stated after opening the foil pouch for budesonide and formoterol should be used within 2 weeks, and after opening the foil trays Anoro and Breo should be used within 6 weeks. LVN 6 stated beyond those dates the inhalation treatments are considered expired and ineffective, and will not treat Resident 15, 33 and 75's shortness of breath and COPD and potentially lead to difficulty in breathing, hospitalization and death. LVN 6 stated that all the above medications need to be removed from the medication cart and replaced with new ones from pharmacy.

During an interview on [DATE REDACTED] at 12:08 PM, with Director of Nursing (DON), the DON stated that there is no consistent process of labeling medications with the date open and therefore unable to determine the expiration date. The DON stated that unopened insulin pens should be store in the refrigerator and discontinued mediations immediately removed from the medication cart. The DON stated these failures can potentially lead to the administration of expired medication to residents. The DON stated that expired insulins have lost potency and effectiveness and when administered in error will not be effective in controlling blood sugar levels leading to hyperglycemia (high blood sugar levels) and emergency crisis for Resident 6, 21, 65 and 295 requiring hospitalization s. The DON stated that expired inhalation treatments have lost effectiveness and when administered in error will not treat the shortness of breath or COPD further causing respiratory distress for Resident 15, 16, 33, 70 and 75 requiring immediate treatment, or stoppage of breathing.

Review of the facility's policy and procedures (P&P), titled Medication Storage, dated [DATE REDACTED], the P&P indicated that Medications will be stored in a manner that maintains the integrity of the product, ensures the safety of customers, in accordance with state Department of Health guidelines .

F. Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy.

G. Medications will be stored at the appropriate temperature in accordance with the pharmacy and/or manufacturer labeling.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 87 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 H. Medications requiring refrigeration will be stored in the refrigerator that is maintained between 36 to 46 Fahrenheit. Level of Harm - Minimal harm or potential for actual harm Review of facility's P&P, titled Dating Multiple Dose Vials, dated [DATE REDACTED], the P&P indicated: To establish a mechanism for identifying the date when a multi-dose vial is initially opened in order to decrease the Residents Affected - Some possibility of microbial growth in accidentally contaminated multi-dose product. Multi-dose vials include injectables .

1. The date opened and initials of the individual to first use the vial is to be recorded on the vial.

Review of facility's guide, [untitled] dated [DATE REDACTED], the guide listed the following:

Insulin products (except Levemir, Novolin R, Novolin N, Novolin ,d+[DATE REDACTED]) - Store unopened vials in the refrigerator. May store opened vials at room temperature or in the refrigerator. Discard 28 days after opening or removed from refrigeration.

Novolin R, Novolin N, Novolin ,d+[DATE REDACTED] - Store unopened vials in the refrigerator. Store opened vials at room temperature. Discard 42 days after opening.

Insulin pens and cartridges - Store at room temperature and do not refrigerate after opening. Expiration dates vary by manufacturer.

Review of facility's P&P, titled Medication Return and Disposal of Medications, dated [DATE REDACTED], the P&P indicated: To provide a process for removing medications from the medication area when necessary.

I. Discontinued medications that are not returnable to the pharmacy for credit will be removed from the medication area and destroyed.

2. All medications that are discontinued or expired will be removed from the resident's tray, medication or treatment cart, refrigerator, medication room or other place of storage.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 88 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 43988

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen by:

1. Failing to label and date an open bag of shredded cabbage in the walk-in refrigerator.

2. Failing to wash multiple measuring cups and spoons in a plastic bag used for thickening powder.

3. Failing to dispose one (1) chipped plate lid during lunch tray line.

4. Failing to ensure low temperature dishwasher test strip was not used beyond the expiration date of 6/1/2024.

5. Failing to ensure Certified Nursing Assistant 12 (CNA 12) wore a hair restraint and washed hands when entering the kitchen.

These deficient practices had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, and other toxins) in 8 out of 86 medically compromised residents who receive food from the kitchen.

Findings:

During a tour of the kitchen on 6/11/2024at 7:58 a.m. with the Dietary Supervisor (DS), observed the following:

- A bag of shredded cabbage with no open date in the walk-in refrigerator. The DS verified the bag of shredded cabbage did not indicate the date of when it was opened.

- Multiple unwashed measuring cups and spoons in an open plastic bag used for thickening powder.

The DS verified the bag of shredded cabbage did not indicate the date of when it was opened. The DS stated it is important to label when the bag of shredded cabbage was opened so staff will know when to discard the bag. The DS verified the bag of used multiple measuring cups and spoons were left open. The DS stated the bag should have been closed to prevent contamination. The DS stated the measuring spoons and cups are washed at the end of the day.

During a concurrent observation and interview on 6/11/2024 at 12:13 p.m., observed 1 chipped plate lid that will be used for the next lunch plate. The DS stated that she checks the plate lids everyday and remove or dispose of the chipped and damaged lids. The DS stated it is important to not use damaged lids for resident safety.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 89 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 During a concurrent observation of dish machine chlorine concentration testing and interview on 6/11/2024 at 12:43 p.m. with Dietary Aide 1 (DA 1) in the presence of the DS, DA 1 took a test strip from the container and Level of Harm - Minimal harm or was about to dip the strip in the dish rack with water. Upon inspection of the test strip container, the container potential for actual harm indicated an expiration date of 6/1/2024. DA 1 verified the date indicated in the container is beyond the expiration date and should not be used. The DS verified the date indicated in the test strip container is Residents Affected - Some beyond the expiration and should not be used as the reading would not be accurate upon testing and the dishes might not be properly sanitized. The DS stated DA 1 should have checked the test strip for expiration date prior to use.

During a concurrent observation and interview on 6/11/2024 at 12:50 p.m., observed the door to the kitchen was not locked and CNA 12 entered the kitchen's restricted area without washing his hands and without wearing a hair restraint. The DS stated they were instructed by the Administrator (Adm) to keep the door to

the kitchen unlocked for unknown reason. The DS stated the door to the kitchen should have been closed and locked at all times to prevent residents or on-kitchen staff from entering the kitchen without wearing a hair restraint and washing their hands potentially causing cross-contamination which may lead to food borne illnesses.

During an interview on 6/11/2024 at 1:08 p.m., the Adm stated the kitchen door should be closed and locked at all times to prevent residents and/or non-kitchen staff to enter without hair restraints and washing their hands as it had the potential to contaminate food items in the kitchen which may lead foodborne illnesses.

The Adm stated he did not give instructions to the kitchen staff to keep the door to the kitchen unlocked at all times. The Adm stated staff are supposed to knock on the door or press the doorbell if they need anything from the kitchen.

A review of the policy and procedure provided by the facility titled, Warewashing, last reviewed 4/4/2024, indicated all dishware, serviceware, and utensils will be cleaned and sanitized after each use.

A review of the policy and procedure provided by the facility titled, Receiving, last reviewed 4/4/2024, indicated safe food handling procedures for time and temperature control will be practiced in the transportation, delivery, and subsequent storage of all food items. The policy indicated all food items will be labeled and dated either through manufacturer packaging or staff notation.

A review of the policy and procedure provided by the facility titled, Authorized Kitchen Personnel, last reviewed 4/4/2024, indicated only authorized individuals will have access through food preparation, storage, and service areas to minimize the potential for cross-contamination. The policy indicated the kitchen staff must monitor that the entrance to the food preparation and service area is limited to kitchen staff in proper uniform, delivery persons, and maintenance workers. The policy indicated all authorized personnel must wear appropriate head covering while in the kitchen or production areas.

A review of Food Code 2017 indicated 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 90 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 A review of Food Code 2017 section 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitation- Temperature, pH, Concentration, and Hardness indicated, verifying the adequacy of Level of Harm - Minimal harm or chlorine-based solutions can be accomplished on an on-going basis by confirming that the concentration, potential for actual harm temperature, and pH of the sanitizing solutions comply with paragraphs 4-501.114 (A) using acceptable test methods and equipment. The manufacturer should provide methods (e.g. test strips, kits, etc.) to verify that Residents Affected - Some the equipment consistently generates solution on-site at the necessary concentration to achieve sanitation.

A review of Food Code 2017, section 2-402.11 Effectiveness, indicated employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep the hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single service and single-use articles.

A review of Food Code 2017 section 2-3 Personal Cleanliness subpart 2-301.11 and 2-301.12 indicated employees shall keep their hands and exposed portions of their arms clean for at least 20 seconds, using a cleaning compound in a handwashing sink.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 91 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0825 Provide or get specialized rehabilitative services as required for a resident.

Level of Harm - Minimal harm or 36943 potential for actual harm Based on observation, interview, and record review, the facility failed to provide a Physical Therapy (PT, Residents Affected - Few profession aimed in the restoration, maintenance, and promotion of optimal physical function) evaluation to one of three sampled residents (Resident 19) who had range of motion (ROM, full movement potential of a joint [where two bones meet]) and mobility (ability to move) concerns in accordance with Resident 19's physician order, dated 4/25/2024. This failure resulted in Resident 19 not receiving PT intervention to improve ROM in both legs.

Findings:

A review of Resident 19's Admission Record indicated the facility admitted Resident 19 on 10/30/2019 with diagnoses including Alzheimer's disease (generalized brain deterioration that leads to progressive decline in mental ability severe enough to interfere with daily life), muscle weakness, schizophrenia (mental disorder characterized by abnormal social behavior), and major depressive disorder (depression, a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily functioning).

A review of Resident 19's care plan, dated 9/5/2023, indicated Resident 19 had limited physical mobility related to contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness), generalized weakness, and stiffness in both arms and both legs. The care plan indicated interventions included to provide Resident 19 with PT and Occupational Therapy [OT, profession aimed to increase or maintain a person's capability of participating in everyday life activities (occupations)] referrals as needed.

A review of Resident 19's Rehabilitation Screening Form, dated 4/25/2024, indicated the Restorative Nursing Aide (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) reported a change of condition (unspecified). The Rehabilitation Screening Form indicated to refer to Resident 19's OT and PT Evaluation for details.

A review of Resident 19's physician orders, dated 4/25/2024, indicated OT/PT evaluation and treatment as indicated.

A review of Resident 19's OT Evaluation and Plan of Care, dated 4/25/2024, indicated Resident 19 had decreased ROM, including decreased ROM in both elbows and decreased ability to perform AROM in both arms.

A review of Resident 19's Minimum Data Set (MDS, a comprehensive assessment and care planning tool), dated 4/29/2024, indicated Resident 19 had severely impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 19 did not have any ROM limitations in both arms but had ROM limitations in both legs. The MDS indicated Resident 19 required substantial/maximal assistance (helper does more than half the effort) for eating, upper body dressing, and rolling to both sides and dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) for showering/bathing, lower body dressing, and chair/bed-to chair transfers.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 92 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0825 A review of Resident 19's OT Discharge Summary, dated 6/3/2024, indicated Resident 19 tolerated wearing both elbow splints (material used to restrict, protect, or immobilize a part of the body to support function, Level of Harm - Minimal harm or assist and/or increase range of motion) for three hours. The OT Discharge Summary recommendations potential for actual harm included RNA for passive range of motion (PROM, movement of joint through the ROM with no effort from

the person) to both arms and to apply both elbow splints, five times per week. Residents Affected - Few

During an interview on 6/11/2024 at 1:33 p.m. with the Director of Rehabilitation (DOR), the DOR stated the purpose of therapy (in general) was to assist a resident to achieve the highest function possible, prevent decline, and improve quality of life.

During an observation on 6/12/2024 at 8:30 a.m. in Resident 19's bedroom with Restorative Nursing Aide 1 (RNA 1), Resident 19 was lying in bed with both elbows bent in a 90-degree angle, both hips bent to hip height, and both knees bent in a 90-degree angle. RNA 1 stood on Resident 19's right side and began PROM exercises to the right elbow. RNA 1 extended Resident 19's right elbow, which continued to be in a bent position. RNA 1 performed PROM to Resident 19's right shoulder, wrist, and hand. RNA 1 performed massage to Resident 19's right knee prior to providing PROM to the right leg at the hip and knee joints. RNA 1 extended Resident 19 right hip and knee, which did not completely extend, and remained in bent positions. RNA 1 moved to the left side of Resident 19's bed. RNA 1 performed PROM to Resident 19's left shoulder, wrist, hand but did not perform PROM to the left elbow, which continued to be in a bent position. RNA 1 performed massage to the left knee prior to providing PROM to Resident 19's left leg at the hip and knee joints. RNA 1 extended Resident 19's left hip and knee, which remained in bent positions. RNA 1 applied both elbow splints to Resident 19's arms.

During a concurrent interview and record review on 6/13/2024 at 11:19 a.m. with the DOR and Director of Nursing (DON), Resident 19's physician orders, dated 4/25/2024, for OT/PT evaluation and treatment were reviewed. The DOR stated Resident 19 was seen for an OT evaluation but was not seen for a PT evaluation since Resident 19 was unable to walk. The DOR stated Resident 19 could have PT needs even if Resident 19 was unable to walk. The DON stated the PT evaluation should have been completed for Resident 19 if there was a physician order.

A review of the facility's job description titled Physical Therapist, revised 5/23/2019, indicated the PT evaluated and treated patients and documented the services in the medical record.

A review of the facility's policy and procedure (P&P) titled Quality of Care Compliance Requirements, revised 6/2016, indicated the facility had systems in place that reduce the likelihood of common risk areas associated with the delivery of quality care to facility residents. The P&P indicated common risk areas may include the failure to provide appropriate therapy services. The P&P indicated the provision of therapy was care planned by the clinical team under physician order

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 93 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0839 Employ staff that are licensed, certified, or registered in accordance with state laws.

Level of Harm - Minimal harm or 36943 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure one of three Restorative Residents Affected - Few Nursing Aides (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) did not perform job duties out of the State certification, including managing feeding through a gastrostomy tube (G-tube, tube placed directly into the stomach for long-term feeding) for one of three sampled residents (Resident 7) with limited range of motion [(ROM) full movement potential of a joint (where two bones meet)] and mobility (ability to move).

This failure had the potential for Resident 7 to have complications related to the G-tube, including clogging (causing a blockage) and dislodging (being removed from a fixed position) of the G-tube, which can lead to weight loss and hospitalization .

Findings:

A review of Resident 7's Admission Record indicated the facility admitted Resident 7 on 7/15/2022 with diagnoses including hemiplegia or hemiparesis (weakness or inability to move one side of the body) following

a cerebral infarction (brain damage due to a loss of oxygen to the area) affecting the right dominant (used more often) side, dysphagia (difficulty swallowing), G-tube status, aphasia (loss of ability to understand or express speech as a result of brain damage), and functional quadriplegia (complete immobility due to frailty or severe physical disability).

A review of Resident 7's physician orders, dated 1/24/2024, indicated to provide Jevity 1.5 (specific type of G-tube feeding) through the enteral pump (G-tube feeding machine) at 45 cubic centimeters (measure of volume) per hour for 20 hours.

A review of Resident 7's Minimum Data Set (MDS, a comprehensive assessment and care planning tool), dated 4/22/2024, indicated Resident 7 had severely impaired cognition (ability to think, understand, learn, and remember) and dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) for eating.

During a concurrent observation and interview on 6/12/2024 at 7:30 a.m. in Resident 7's bedroom with Restorative Nursing Aide 1, Restorative Nursing Aide 1 (RNA 1) stood on the left side of Resident 7's bed. Resident 7 was lying awake in bed already wearing a right elbow splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) and right knee splint. Resident 7's G-tube feeding machine was turned off. RNA 1 proceeded to apply splints to Resident 7's left knee and left elbow. RNA 1 lowered Resident 7's bed to the ground, elevated the head-of-the bed, and turned Resident 7's G-tube feeding machine on. RNA 1 stated she turned Resident 7's G-tube feeding off

before the RNA session because Resident 7 was lying flat in bed. RNA 1 stated she turned Resident 7's tube feeding back on after elevating the head-of-the-bed.

During an interview on 6/12/2024 at 8:24 a.m. with RNA 1, RNA 1 stated the licensed nurse was supposed to turn Resident 7's G-tube feeding on and off.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 94 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0839 During an interview on 6/13/2024 at 3:42 p.m. with the Director of Nursing (DON), the DON stated only licensed nurses can turn the G-tube feeding machine off and on since the licensed nurse had to verify the Level of Harm - Minimal harm or resident's G-tube placement and the amount of feeding. potential for actual harm

A review of the facility's undated job description for Licensed Vocational Nurse (LVN) indicated duties and Residents Affected - Few responsibilities included providing nursing care prescribed by a physician in accordance with the legal scope of practice or restriction, and within established standards of care, policies, and procedures.

A review of the facility's policy and procedure (P&P) titled, Compliance with Laws and Professional Standards: Operational Manual - Administrative Policies, revised 1/1/2012, indicated the facility will comply with State and Federal laws relating to the operation of the Facility and care of residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 95 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm 36943

Residents Affected - Few Based on observation, interview, and record review, the facility did not provide accurate documentation for one of three sampled residents (Resident 7) with limited mobility (ability to move) and range of motion [ROM, full movement potential of a joint (where two bones meet)].

This failure resulted in the inaccurate provision of care recorded in Resident 7's clinical record.

Findings:

A review of Resident 7's Admission Record indicated the facility admitted Resident 7 on 7/15/2022 with diagnoses including hemiplegia or hemiparesis (weakness or inability to move one side of the body) following

a cerebral infarction (brain damage due to a loss of oxygen to the area) affecting the right dominant (used more often) side, dysphagia (difficulty swallowing), gastrostomy status (G-tube, tube placed directly into the stomach for long-term feeding), aphasia (loss of ability to understand or express speech as a result of brain damage), and functional quadriplegia (complete immobility due to frailty or severe physical disability).

A review of Resident 7's physician orders, dated 12/29/2023, indicated for the Restorative Nursing Aide (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) to provide Resident 7 with passive range of motion (PROM, movement of joint through the ROM with no effort from the person) exercises to both arms, five times per week as tolerated.

A review of Resident 7's physician orders, order, dated 4/26/2024, indicated for the RNA to provide PROM to both legs, five times per week as tolerated, and to apply both of Resident 7's knee extension splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion), seven times per week as tolerated.

A review of Resident 7's physician orders, dated 5/13/2024, indicated for RNA to apply both hand rolls (rolled towel placed in the palms) for four to six hours (4-6 hours), five times per week as tolerated.

A review of Resident 7's physician orders, dated 6/3/2024, indicated for RNA to apply the right elbow extension splint for 4-6 hours, five times per week as tolerated.

A review of Resident 7's Restorative Nursing (RNA) flow sheet (record of RNA session) for 6/2024 indicated Restorative Nursing Aide 1 (RNA 1) provided PROM to both of Resident 7's arms and legs, applied a right elbow extension splint for four hours (4 hours), applied both hand rolls for 4 hours, and applied both knee splints for 4 hours on 6/11/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 96 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 During an observation on 6/11/2024 at 12:38 p.m. in Resident 7's bedroom, Resident 7 was lying in bed awake but did not verbally respond to questions. Resident 7 actively moved the left arm at the shoulder and Level of Harm - Minimal harm or elbow joints, but the left hand was positioned in a closed fist. Resident 7 shook the head, No, when asked if potential for actual harm Resident 7 could open the left hand. Resident 7 did not have any active movement in the right arm. Resident 7's right elbow was in a bent position and the right wrist was bent downward. Resident 7's right thumb was Residents Affected - Few positioned immediately next to the index finger while the middle, ring, and small fingers were bent completely into a fist. Resident 7 did not have any hand rolls or splints applied to either arm. Resident 7 had a blanket covering both legs.

During an interview on 6/11/2024 at 3:40 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated RNA 1 went to an outpatient appointment with another resident.

During an interview on 6/12/2024 at 8:00 a.m. with RNA 1 and RNA 2, RNA 1 stated she did not provide any treatment to Resident 7 yesterday (6/11/2024).

During a concurrent interview and record review on 6/12/2024 at 8:10 a.m. with RNA 1, Resident 7's RNA flow sheet for 6/11/2024 was reviewed. RNA 1 stated she attempted to provide treatment to Resident 7 multiple times but Resident 7 refused due to pain. RNA 1 stated she applied Resident 7's knee splints from 4:30 p.m. to 7:00 p.m. (2 hours, 30 minutes). RNA 1 stated Resident 7's RNA documentation for 6/11/2024 was inaccurate since Resident 7 did not have both knee splints on for 4 hours. RNA 1 stated Resident 7's RNA documentation was inaccurate for 6/11/2024 because the documentation was completed prior to providing intervention to Resident 7.

During a concurrent interview and record review on 6/12/2024 at 12:30 p.m. with RNA 1, Resident 7's RNA flow sheet for 6/11/2024 was further reviewed. RNA 1 stated Resident 7's hand rolls and elbow splint were not applied on 6/11/2024. RNA 1 stated Resident 7's documentation on the RNA flow sheet for 6/11/2024 was inaccurate.

A review of the facility's policy and procedure (P&P) titled, Documentation: Nursing Manual - Restorative Nursing Program, revised 1/1/2012, indicated the Restorative Nursing Programs should be documented accurately and timely. The P&P indicated the RNA will document the treatment provided daily and to initial

the specific treatment provided to the resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 97 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Level of Harm - Minimal harm or potential for actual harm 43988

Residents Affected - Few Based on interview and record review, the facility failed to arrange provisions of hospice services (a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill)

in a consistent manner to one of one sampled resident (Resident 12) investigated during review of hospice services by failing to:

1. Ensure hospice staff, including registered nurse (RN), licensed vocational nurse (LVN), and hospice aide (HA), provided nursing and visitation notes to the facility.

2. Ensure the calendar of visits from 5/19/2024 to 6/13/2024 was provided by Hospice Provider 1 (HP 1).

3. Ensure there is a designated facility staff to coordinate the hospice care and services for Resident 12.

4. Ensure Resident 12's comprehensive care plan on hospice services was developed and implemented.

5. Ensure Resident 12's certification/recertification of terminal illness form (CTI - a document that requires a physician certify the patient is terminally ill with a prognosis of 6 months or less should the disease run its normal course) was in the resident's medical record.

These deficient practices had the potential to negatively affect the residents' physical comfort and psychosocial well-being and had the potential to result in the delay or lack of necessary hospice care and services.

Findings:

A review of Resident 12's Admission Record indicated the facility admitted the resident on 11/10/2023 with diagnoses including dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and hypertension (a condition in which the force of the blood against the artery walls is too high).

A review of Resident 12's History and Physical, dated 11/30/2023, indicated the resident did not have the capacity to understand and make decisions.

A review of Resident 12's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/22/2024, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision with eating and oral hygiene; dependent

on staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).

A review of Resident 12's Order Summary Report dated 11/10/2023 indicated an order to admit the resident to Hospice Provider 1 (HP 1) for routing level of care with primary diagnosis of dementia.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 98 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 A review of Resident 12's comprehensive care plans did not indicate a care plan was developed and implemented addressing hospice care and services. Level of Harm - Minimal harm or potential for actual harm A review of Resident 12's hospice binder indicated a certification/recertification of terminal illness form dated 11/10/2023. Residents Affected - Few

During a concurrent interview and record on 6/13/2024 at 1:50 p.m. with Registered Nurse 1 (RN 1), reviewed Resident 12's physician's order, care plans, and hospice binder including HP 1 staff notes, calendar of visits, and CTI forms. RN 1 stated all documents pertaining to hospice residents care are placed

in a hospice binder as the HP 1 staff do not have access to the facility's electronic health record. RN 1 stated there was no documented evidence that HP 1 staff notes were in the hospice binder. RN 1 stated the staff notes should have been in the hospice binder so the staff would know what type of care and services were provided to the resident during their (hospice staff) visit. RN 1 stated there was no comprehensive care plan developed and implemented for hospice care and services. RN 1 stated the care plan should been developed and implemented so the staff would be aware of the resident's needs. RN 1 verified the HP 1 CTI form indicated a 60 day face to face evaluation has to be conducted by the hospice physician and the recertification forms filed in the binder so the facility would be aware of the resident's continued need for hospice care and services. RN 1 verified the calendar of visits in the binder are the projected visits of HP 1 staff. RN1 verified there was no calendar of visits from 5/19/2024 to 6/13/2024 provided by HP 1. RN 1 stated it is important to have an updated calendar of visits so the facility staff would be able to coordinate the needs of the resident with HP 1. RN 1 stated she did not who was the facility representative responsible to coordinate care of hospice residents.

During an interview on 6/13/2024 at 7:20 p.m., the Director of Nursing (DON) stated the facility did not have

a designated representative to coordinate hospice care and services. The DON stated there should have been a facility representative to coordinate care with HP 1 to prevent possible delay in providing hospice care and services to the residents. The DON stated HP 1 staff notes should be in the binder so facility would know what care and services were provided to the resident during their visits. The DON stated the comprehensive care plan should have been developed to ensure timely delivery of hospice care and services. The DON stated the calendar of visits should have been updated up to the most current date so the facility staff would be aware of the dates of visit and what services the resident would be receiving. The DON stated the certification/recertification form should have been updated and placed in the hospice binder as it certifies the resident's continued need for hospice services.

A review of the facility's policy and procedure titled Hospice Care of Resident, last reviewed 4/4/2024, indicated the following:

- The hospice care and facility will collaborate on a care plan for the resident.

- Hospice notes will be included in the facility progress notes. Nursing staff will be informed of any changes recommended by the hospice staff.

- All documentation concerning hospice services will be maintained in the resident's medical record.

A review of the facility's agreement contract with HP 1 dated 11/8/2023 indicated the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 99 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 - All healthcare professionals (HCP shall submit a progress note with a client signed time in sheet within the specified time frame. Level of Harm - Minimal harm or potential for actual harm - Provider agrees to comply with and conform to state and federal regulations.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page100of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44244 potential for actual harm Based on observation, interview, and record review, the facility failed to maintain an infection prevention and Residents Affected - Some control program to help prevent the development and transmission of communicable diseases and infections by failing to:

1. Ensure nasal cannulas (NC, a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) were changed weekly and labeled with the date last changed for two of three sampled residents (Resident 81 and 20) reviewed under the respiratory care area and one out of two sampled residents (Resident 15) reviewed under the oxygen care area.

2. Ensure suction canisters (a disposable container connected by tubing to a device that is used to suction fluids from a patient's mouth) and tubing were changed weekly and labeled with the date last changed for one of three sampled residents (Resident 81) reviewed under the respiratory care area.

3. Ensure the NC was not resting on the floor then placed in the clean storage bag by Certified Nursing Assistant 10 (CNA 10) for one of two sampled residents (Resident 20) reviewed under the respiratory care area.

4. Ensure the urinal (a container for urination) was labeled with the resident's identifier for one of one sampled resident (Resident 74) reviewed under the urinary tract infection (a condition in which bacteria invade and grow in the urinary tract) care area.

These deficient practices had the potential to spread infections and illnesses among residents by infectious microorganisms.

Findings:

a. A review of Resident 81's Admission Record indicated the facility admitted the resident on 3/5/2024 and readmitted the resident on 4/25/2024 with diagnoses that included sepsis (a serious condition in which the body responds improperly to an infection), pneumonia (lung infection), acute respiratory failure (a serious condition that occurs suddenly when the lungs cannot get enough oxygen), and dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life).

A review of Resident 81's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 4/29/2024, indicated the resident was able to understand others and was able to make herself understood. The MDS further indicated the resident was dependent on staff for oral hygiene, bathing, dressing, toileting, personal hygiene, and mobility.

A review of Resident 81's History and Physical, dated 4/26/2024, indicated the resident did not have capacity to understand and make decisions.

A review of Resident 81's physician orders indicated the following orders:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page101of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 -Oral suctioning of secretions every four hours as needed for excessive secretions, dated 5/30/2024.

Level of Harm - Minimal harm or -Oxygen at 2 liters per minute (LMP, a unit of measurement) via NC to keep oxygen (O2) saturation (sat, a potential for actual harm measurement of oxygen in the blood) at/above 92 percent (%, a unit of oxygen saturation measurement) as needed, dated 4/25/2024. Residents Affected - Some

A review of Resident 81's Care Plan (CP) titled, Resident has altered respiratory status/difficulty breathing, initiated 5/1/2024, indicated a goal that the resident would have no complications related to shortness of breath and would maintain normal breathing pattern.

A review of Resident 81's CP titled, Resident has a respiratory infection, initiated 5/8/2024, indicated a goal that the resident would be free from signs and symptoms of infection.

a.1. During a concurrent observation and interview on 6/11/2024 at 11:54 a.m., Resident 81 was lying in bed and Certified Nursing Assistant 11 (CNA 11) was at bedside. Observed two used and unlabeled and suction canisters on the resident's nightstand. CNA 11 stated Resident 81 received oral hygiene and the resident's secretions were removed into the suction canisters.

During a concurrent observation and interview on 6/11/2024 at 12:08 p.m., Licensed Vocational Nurse 1 (LVN 1) stood inside Resident 81's room and stated the suction canisters and tubing are not labeled with the date because they are disposed of after they are used. LVN 1 stated the canisters in Resident 81's room were used and should have been thrown out, but they were not.

During an interview on 6/12/2024 at 11:16 a.m., the Infection Preventionist (IP) stated staff empty and rinse

the suction canisters after every use for residents' oral secretions. The IP stated the canisters and tubing should be changed weekly. The IP stated the suction canisters and tubing are labeled with the date last changed. The IP stated the canisters and tubing are changed weekly and dated to prevent bacterial growth from transmitting from the canister through the tubing into the resident's mouth resulting in infections.

During a concurrent interview and record review on 6/12/2024 at 2:47 p.m., the Director of Nursing (DON) reviewed the facility policy and procedure regarding infection control. The DON stated suction canisters are never emptied and re-used. The DON stated canisters are thrown out when they are full and changed every seven days. The DON stated the canister and tubing are changed at the same time and both should be labeled with the date last changed. The DON stated the suction canisters and tubing can grow bacteria and if

they are not changed there is a possible outcome of the resident developing an infection. The DON stated

the facility policies do not specify that suction canisters are changed weekly and dated, but it is the standard of practice, and all tubing is changed weekly and dated. The DON stated the facility policy regarding infection control was not followed.

a.2. During a concurrent observation and interview on 6/11/2024 at 11:54 a.m., Resident 81 was lying in bed and CNA 11 was at bedside. Observed an unlabeled NC inside a clear storage bag labeled with the date 6/6/2024. CNA 11 stated Resident 81 was sometimes put on O2 via NC.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page102of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During a concurrent observation and interview on 6/11/2024 at 12:08 p.m., LVN 1 stood inside Resident 81's room and stated she was taught to label the NC storage bag with the date the NC and bag were changed. Level of Harm - Minimal harm or LVN 1 stated she was never taught to label the NC tubing with the date last changed and she does not label potential for actual harm NC tubing.

Residents Affected - Some During an interview on 6/12/2024 at 11:16 a.m., the IP stated NCs and the storage bag are changed every Thursday. The IP stated both the NC and storage bag should be labeled with the date last changed. The IP stated the importance of changing the NC weekly is to prevent bacteria on the tubing causing lung infections like pneumonia resulting in a decline of the resident. The IP stated the NC should be labeled regardless of whether the tubing was used or not.

During a concurrent interview and record review on 6/12/2024 at 2:47 p.m., the DON reviewed the facility policies and procedures regarding infection control and oxygen tubing. The DON stated the facility policy specifies that NCs are changed weekly and labeled with the date changed. The DON stated when the NC was not labeled the facility policy was not followed. The DON stated NCs are labeled because they can harbor bacteria and cause an infection resulting in respiratory problems in residents.

A review of the facility policy and procedure titled, Infection Control - Policies and Procedures, last reviewed 4/4/2024, indicated the purpose of the policy was to provide infection control policies and procedures required for a safe and sanitary environment. The infection control policy and procedures objectives are the following: to prevent, detect, investigate, and control infections in the facility; maintain a safe, sanitary, and comfortable environment; and establish guidelines for the availability and accessibility of supplies and equipment. Staff are trained on the infection control policies and procedures and department heads ensure that they are implemented and followed.

A review of the facility policy and procedure titled, Oxygen Therapy, last reviewed 4/4/2024, indicated the purpose of the policy was to ensure the safe storage and administration of oxygen in the facility. Oxygen is administered under safe and sanitary conditions to meet resident needs. Oxygen tubing, mask, and cannulas will be changed no more than every seven days and as needed. The supplies will be dated each time they are changed.

b. A review of Resident 20's Admission Record indicated the facility admitted the resident on 11/17/2017 and readmitted the resident on 9/9/2022 with diagnoses that included hemiplegia and hemiparesis (mild to severe loss of strength or paralysis on one side of the body) following cerebral infarction (stroke, when blood flow to

the brain is blocked or there is sudden bleeding in the brain) affecting the left dominant side, and dementia.

A review of Resident 20's MDS dated [DATE REDACTED], indicated the resident was rarely/never able to understand others and was rarely/never able to make herself understood. The MDS further indicated the resident was dependent on staff for oral hygiene, bathing, dressing, toileting, personal hygiene, and mobility; and the resident required oxygen therapy.

A review of Resident 20's History and Physical, dated 4/26/2024, indicated the resident did not have capacity to understand and make decisions.

A review of Resident 20's physician orders indicated the following orders:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page103of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 -Continuous oxygen at 2 LMP via NC to keep O2 sat at/above 92% every shift, dated 10/27/2022.

Level of Harm - Minimal harm or A review of Resident 20's CP titled, Alteration in respiratory function, initiated 10/12/2022, indicated a goal potential for actual harm that the resident has the absence of respiratory distress and would have oxygen treatments administered.

Residents Affected - Some During an observation on 6/11/2024 at 10:31 a.m., Resident 20 was lying in bed wearing a NC connected to

an O2 concentrator (a medical device that provides supplemental oxygen). Observed the NC tubing coiled

on the floor next to the O2 concentrator.

During a concurrent observation and interview on 6/11/2024 at 10:40 a.m., Certified Nursing Assistant 10 (CNA 10) stood at Resident 20's bedside and stated the NC tubing was on the floor and it should not be there. Observed CNA 10 pick up the NC tubing off the floor and placed it in the clear storage bag. CNA 10 stated she was not sure if the NC should be labeled with the date.

During a concurrent observation and interview on 6/11/2024 at 10:46 a.m., Licensed Vocational Nurse 5 (LVN 5) stood at Resident 20's bedside and stated the NC was not labeled with the date. LVN 5 stated she was not sure if the NC tubing should be labeled. LVN 5 stated the NC should not be on the floor because it was an infection control issue and germs could transfer from the dirty floor up the tubing to the resident. The surveyor notified LVN 5 that CNA 10 picked the NC tubing off the floor and placed it in the storage bag. LVN 5 stated the NC tubing belonged in the storage bag and LVN 5 exited the room. Observed the NC remained

on Resident 20 with the additional tubing in the storage bag.

During a concurrent observation and interview on 6/11/2024 at 10:57 a.m., Registered Nurse 1 (RN 1) stood at Resident 20's bedside. RN 1 stated both the NC and storage bag should be labeled with the date changed. RN 1 stated Resident 20's NC was not labeled. RN 1 stated the importance of labeling the NC was

they could not be sure that the bag and NC were changed at the same time. RN 1 stated NC tubing should not touch the floor because the resident is high risk and susceptible to infections. RN 1 stated the dirty NC tubing could lead to respiratory infections. RN 1 stated CNA 10 should not have placed the NC from the floor into the storage bag, and LVN 5 should have changed the NC and storage bag.

During an interview on 6/12/2024 at 11:16 a.m., the IP stated NCs and the storage bags are changed every Thursday. The IP stated both the NC and storage bag should be labeled with the date last changed. The IP stated the importance of changing the NC weekly is to prevent bacteria on the tubing leading to lung infections like pneumonia resulting in resident decline. The IP stated the NC tubing should be off the floor because the floor is dirty, and bacteria can spread up the tubing into the resident's airway via the NC.

During a concurrent interview and record review on 6/12/2024 at 2:47 p.m., the DON reviewed the facility policies and procedures regarding infection control and oxygen tubing. The DON stated once the NC tubing touches the floor, it should be changed because it is considered contaminated. The DON stated the facility policy specifies that NCs are changed weekly and labeled with the date changed. The DON stated when the NC was not labeled the facility policy was not followed. The DON stated NCs are labeled and kept off the floor because they can harbor bacteria and cause an infection resulting in respiratory problems.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page104of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 A review of the facility policy and procedure titled, Infection Control - Policies and Procedures, last reviewed 4/4/2024, indicated the purpose of the policy was to provide infection control policies and procedures Level of Harm - Minimal harm or required for a safe and sanitary environment. The infection control policy and procedures objectives are the potential for actual harm following: to prevent, detect, investigate, and control infections in the facility; maintain a safe, sanitary, and comfortable environment; and establish guidelines for the availability and accessibility of supplies and Residents Affected - Some equipment. Staff are trained on the infection control policies and procedures and department heads ensure that they are implemented and followed.

A review of the facility policy and procedure titled, Oxygen Therapy, last reviewed 4/4/2024, indicated the purpose of the policy was to ensure the safe storage and administration of oxygen in the facility. Oxygen is administered under safe and sanitary conditions to meet resident needs. Oxygen tubing, mask, and cannulas will be changed no more than every seven days and as needed. The supplies will be dated each time they are changed.

44376

c. A review of Resident 15's Admission Record indicated the facility admitted the resident on 4/13/2018, and readmitted the resident on 12/9/2021, with diagnoses including chronic obstructive pulmonary disease (COPD, a chronic inflammatory disease that causes obstructed airflow from the lungs), contact with and exposure to other communicable diseases (illnesses caused by viruses or bacteria that people spread to one another through contact with contaminated surfaces, bodily fluids, blood products, insect bites, or through the air).

A review of Resident 15's History and Physical (H&P), dated 4/29/2024, indicated the resident did not have

the capacity to understand and make decisions.

A review of Resident 15's MDS, dated [DATE REDACTED], indicated the resident usually make self-understood and understand others.

A review of Resident 15's Order Summary Report, dated 5/23/2024, indicated an order for oxygen at 2 liters (L, a unit of volume)/min via nasal cannula to keep oxygen saturation at/above 92% every shift.

During a concurrent observation and interview on 6/11/2024, at 9:48 a.m., with Treatment Nurse 1 (TN 1), inside Resident 15's room, observed the resident receiving oxygen via nasal cannula. The nasal cannula tubing was not labeled with the date last changed. TN 1 stated the nasal cannula tubing should be dated with

the date last changed to inform staff when the next tubing change is due and to prevent respiratory infection.

During an interview on 6/13/2024, at 6:30 p.m., with the DON, the DON stated the nasal cannula tubing should be dated to know when the next tubing change is due. The DON stated they do not use the nasal cannula tubing for more than a week to prevent growth of microorganisms (an organism that can be seen only through a microscope) such as bacteria and viruses from growing inside the tubing that could be inhaled by the resident potentially causing respiratory infections.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page105of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 A review of the facility's recent policy and procedure titled, Infection Control- Policies & Procedures, last reviewed on 4/4/2024, indicated the facility's infection control policies and procedures are intended to Level of Harm - Minimal harm or facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage potential for actual harm transmission of diseases and infections.

Residents Affected - Some A review of the facility's recent policy and procedure titled, Oxygen Therapy, last reviewed on 4/4/2024, indicated oxygen is administered under the safe and sanitary conditions to meet resident's needs. Licensed Nursing staff will administer oxygen as prescribed. The humidifier and tubing should be changed no more than every 7 days and labeled with the date changed.

d. A review of Resident 74's Admission Record indicated the facility admitted the resident on 11/14/2023, with diagnoses including urinary tract infection, retention of urine (a condition in which the body is unable to empty all the urine in the bladder), and presence of urogenital implants (injections of material into the urethra to help control urine leakage).

A review of Resident 74's H&P, dated 11/14/2023, indicated the resident did not have the capacity to make decisions or make needs known.

A review of Resident 74's MDS, dated [DATE REDACTED], indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident required substantial to maximal assistance in toileting and personal hygiene.

During a concurrent observation and interview on 6/11/2024, at 10:26 a.m., with Certified Nursing Assistant 6 (CNA 6), inside Resident 74's room, observed an unlabeled urinal on the bed side table. CNA 6 stated the urinal should be labeled with the resident's room number and date of when it was last changed to prevent switching of urinal bottles with other residents and for infection control.

During an interview on 6/13/2024, at 6:30 p.m., with the DON, the DON stated the urinal should be labeled with the resident's room number and the date last changed for infection control.

A review of the facility's recent policy and procedure titled, Infection Control- Policies & Procedures, last reviewed on 4/4/2024, indicated the facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page106of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44244 potential for actual harm Based on interview and record review the facility failed to educate each resident or the resident's Residents Affected - Few representative regarding the benefits and potential side effects of and offer pneumococcal vaccines (medications used to prevent serious lung infections caused by streptococcus pneumoniae [a type of bacteria]) and influenza vaccines (medication used to prevent a highly contagious respiratory illness, which spreads easily through the air or when people touch contaminated surfaces) for two of five sampled residents (Resident 20 and 81) reviewed during the Infection Control task.

This deficient practice had the potential to result in increased risk for residents to develop complications from pneumonia and influenza.

Findings:

a. A review of Resident 81's Admission Record indicated the facility admitted the resident on 3/5/52024 and readmitted the resident on 4/25/2024 with diagnoses that included sepsis ((a serious condition in which the body responds improperly to an infection ), pneumonia (lung infection), acute respiratory failure (a serious condition that occurs suddenly when the lungs cannot get enough oxygen ), and dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life).

A review of Resident 81's Minimum Data Set (MDS - an assessment and care screening tool) dated 4/29/2024, indicated the resident was able to understand others and was able to make herself understood.

The MDS further indicated the resident was dependent on staff for oral hygiene, bathing, dressing, toileting, personal hygiene, and mobility.

A review of Resident 81's History and Physical, dated 4/26/2024, indicated the resident did not have capacity to understand and make decisions.

A review of Resident 81's physician orders indicated the following order:

-Resident to receive annual (every year) influenza vaccine, dated 4/25/2024.

A review of Resident 81's Care Plan (CP) titled, Resident has altered respiratory status/difficulty breathing, initiated 5/1/2024, indicated a goal that the resident would have no complications related to shortness of breath and would maintain normal breathing pattern.

A review of Resident 81's CP titled, Resident has a respiratory infection, initiated 5/8/2024, indicated a goal that the resident would be free from signs and symptoms of infection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page107of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 During a concurrent interview and record review on 6/13/2024 at 12:43 p.m. the Infection Preventionist (IP) reviewed Resident 81's Progress Notes for 2024 and Immunization Record forms for 2023 and 2024. The IP Level of Harm - Minimal harm or stated at admission and readmission residents are screened for the pneumococcal vaccine, education is potential for actual harm provided regarding the risks and benefits of the vaccine, and the vaccine is administered as needed. The IP stated the influenza vaccine is updated and offered annually based on the most updated strains, education is Residents Affected - Few provided regarding the risks and benefits of the vaccine, and the vaccine is administered annually during the flu season (the time of year, typically between fall and spring, when many people get influenza). The IP stated Resident 81 had an unknown vaccination status. The IP stated she should have reached out to Resident 20's representative regarding vaccinations, but there was no documented evidence that she did.

The IP stated there was no documented evidence that Resident 81 or the resident's representative was offered any vaccinations or provided education regarding the risks and benefits of vaccines for the 2023/2024 season. The IP stated vaccinations are important to protect the resident from contracting viruses and preventing further complications.

During a concurrent interview and record review on 6/13/2024 at 6:17 p.m., the Director of Nursing (DON) reviewed the facility policy and procedures regarding influenza and pneumococcal vaccinations. The DON stated residents are screened at admission for the influenza and pneumococcal vaccines, consent is signed for the vaccinations, and the vaccines are administered when appropriate. The DON stated the influenza strains change and the vaccine is administered annually. The DON stated the facility policies and procedures for influenza and pneumococcal vaccinations were not followed for Resident 81. The DON stated vaccine administration is important in the elderly population because they are higher risk for developing complications. The DON stated if residents are not vaccinated, there is a risk that influenza or pneumonia could spread to other residents leading to complications resulting in hospitalization or a decline in function.

A review of the facility policy and procedure titled, Influenza Prevention and Control, last reviewed 4/4/2024, indicated the facility will follow infection prevention and control policies and procedures to minimize the risk of residents acquiring, transmitting or experiencing complications from influenza. Residents are offered an influenza immunization every year during flu season. The resident or representative must give consent prior to receiving the vaccine. They can refuse the immunization - with such refusal being noted in the resident's medical record. The resident's medical record will include documentation that indicates: the resident or representative was provided education regarding the risk and benefits of the vaccine and whether the resident received the influenza vaccine, or refuses the vaccine.

A review of the facility policy and procedure titled, Pneumococcal Disease Prevention, last reviewed 4/4/2024, indicated the facility will offer pneumococcal immunization to each resident. Pneumococcal vaccination is recommended for: adults [AGE] years old and greater; anyone 2 to [AGE] years old who has a long term health problem, anyone 2 to [AGE] years old who has a disease or condition that lowers the body's resistance to infection, anyone 2 to [AGE] years old who is taking a drug or treatment that lowers the body's resistance to infection, anyone 19 to [AGE] years old who is a smoker or has asthma, and residents of nursing home or long term care facilities. The resident may refuse immunization, with such refusal being documented in the resident's medical record. The resident's medical record shall include documentation that indicates: that the resident or representative was provided education regarding the benefits and potential side effects of the vaccine, a completed copy of the Pneumococcal Vaccination, Informed Consent or Refusal.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page108of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 b. A review of Resident 20's Admission Record indicated the facility admitted the resident on 11/17/2017 and readmitted the resident on 9/9/2022 with diagnoses that included hemiplegia and hemiparesis (mild to severe Level of Harm - Minimal harm or loss of strength or paralysis on one side of the body) following cerebral infarction (stroke, when blood flow to potential for actual harm the brain is blocked or there is sudden bleeding in the brain) affecting the left dominant side and dementia.

Residents Affected - Few A review of Resident 20's MDS dated [DATE REDACTED], indicated the resident was rarely/never able to understand others and was rarely/never able to make herself understood. The MDS further indicated the resident was dependent on staff for oral hygiene, bathing, dressing, toileting, personal hygiene, and mobility. The MDS indicated the resident required oxygen therapy and was offered and declined the influenza and pneumococcal vaccines.

A review of Resident 20's History and Physical, dated 4/26/2024, indicated the resident did not have capacity to understand and make decisions.

A review of Resident 20's physician orders indicated the following orders:

-Pneumococcal vaccine upon admission and as needed unless it has already been given or is medically contraindicated, dated 9/9/2022.

-Resident to receive an annual influenza vaccine, dated 9/9/2022.

A review of Resident 20's CP titled, Alteration respiratory function, initiated 10/12/2022, indicated a goal that

the resident has the absence of respiratory distress.

A review of Resident 20's CP titled, At risk for Covid 19 infection, refused the covid, influenza, and pneumococcal vaccines, initiated 2/28/2022, indicated a goal that the resident would show no signs and symptoms of infection. The CP indicated to evaluate the resident's flu and pneumococcal vaccine status.

During a concurrent interview and record review on 6/13/2024 at 12:43 p.m. the IP reviewed Resident 20's Progress Notes for 2023 and 2024, and Immunization Record forms for 2023 and 2024. The IP stated at admission and readmission residents are screened for the pneumococcal vaccine. The IP stated if the resident has no history of receiving the pneumococcal vaccine and refuses vaccine administration, then the pneumococcal vaccine is offered annually, and education is provided regarding the risks and benefits of the vaccine. The IP stated the influenza vaccine is updated and offered annually based on the most updated strains, education is provided regarding the risks and benefits of the vaccine, and the vaccine is administered annually during the flu season. The IP stated there was no documented evidence that Resident 20 or the resident representative was offered any vaccinations or provided education regarding the risks and benefits of vaccines for the 2023/2024 season. The IP stated Family Member 2 (FM 2) was the resident's representative and did not want Resident 20 to receive vaccinations in the previous years, so she did not offer the vaccines. The IP stated it was important to reoffer vaccines because FM 2 could be re-educated, and they may change their mind. The IP stated the importance of offering, educating, and administering vaccinations is to prevent further complications of influenza and pneumonia in residents that are already high risk for complications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page109of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 During a concurrent interview and record review on 6/13/2024 at 6:17 p.m., the Director of Nursing (DON) reviewed the facility policy and procedures regarding influenza and pneumococcal vaccinations. The DON Level of Harm - Minimal harm or stated residents are screened at admission for the influenza and pneumococcal vaccines, consent is potential for actual harm received, and the vaccines are administered when appropriate. The DON stated if the resident has not received the pneumococcal vaccine and refuses it, then it is important to keep offering it. The DON stated Residents Affected - Few the influenza strains change and the vaccine is administered annually. DON stated the facility policies and procedures for influenza and pneumococcal vaccinations were not followed for Resident 20. The DON stated vaccine administration is important in the elderly population because they are higher risk for developing complications. The DON stated if residents are not vaccinated, there is a risk that influenza or pneumonia could spread to other residents leading to complications resulting in hospitalization or a decline in function.

A review of the facility policy and procedure titled, Influenza Prevention and Control, last reviewed 4/4/2024, indicated the facility will follow infection prevention and control policies and procedures to minimize the risk of residents acquiring, transmitting, or experiencing complications from influenza. Residents are offered an influenza immunization every year during flu season. The resident or representative must give consent prior to receiving the vaccine. They can refuse the immunization - with such refusal being noted in the resident's medical record. The resident's medical record will include documentation that indicates: the resident or representative was provided education regarding the risk and benefits of the vaccine and whether the resident received the influenza vaccine, or refuses the vaccine.

A review of the facility policy and procedure titled, Pneumococcal Disease Prevention, last reviewed 4/4/2024, indicated the facility will offer pneumococcal immunization to each resident. Pneumococcal vaccination is recommended for: adults [AGE] years old and greater; anyone 2 to [AGE] years old who has a long term health problem, anyone 2 to [AGE] years old who has a disease or condition that lowers the body's resistance to infection, anyone 2 to [AGE] years old sho is taking a drug or treatment tha lowers the body's resistance to infection, anyone 19 to [AGE] years old who is a smoker or has asthma, and residents of nursing home or long term care facilities. The resident may refuse immunization, with such refusal being documented in the resident's medical record. The resident's medical record shall include documentation that indicates: that the resident or representative was provided education regarding the benefits and potential side effects of the vaccine, a completed copy of the Pneumococcal Vaccination, Informed Consent or Refusal.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page110of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0887 Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44244

Residents Affected - Few Based on interview and record review the facility failed to educate each resident or the resident's representative regarding the benefits and potential side effects of and offer coronavirus disease -2019 vaccines (COVID-19, a highly contagious viral infection that can trigger respiratory tract infection) for two of five sampled residents (Resident 20 and 81) reviewed during the Infection Control task.

This deficient practice had the potential to result in increased risk for residents to develop complications from pneumonia and influenza.

Findings:

a. A review of Resident 81's Admission Record indicated the facility admitted the resident on 3/5/52024 and readmitted the resident on 4/25/2024 with diagnoses that included sepsis (a serious condition in which the body responds improperly to an infection ), pneumonia (lung infection), acute respiratory failure (a serious condition that occurs suddenly when the lungs cannot get enough oxygen ), and dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life).

A review of Resident 81's Minimum Data Set (MDS - an assessment and care screening tool) dated 4/29/2024, indicated the resident was able to understand others and was able to make herself understood.

The MDS further indicated the resident was dependent on staff for oral hygiene, bathing, dressing, toileting, personal hygiene, and mobility.

A review of Resident 81's History and Physical, dated 4/26/2024, indicated the resident did not have capacity to understand and make decisions.

A review of Resident 81's Care Plan (CP) titled, Resident has altered respiratory status/difficulty breathing, initiated 5/1/2024, indicated a goal that the resident would have no complications related to shortness of breath and would maintain normal breathing pattern.

A review of Resident 81's CP titled, At risk for Covid 19 infection . , initiated 5/1/2024, indicated a goal that

the resident would remain free from signs and symptoms of infection. The CP indicated to provide information about the importance of vaccines to prevent sepsis.

A review of Resident 81's Care Plan (CP) titled, Resident has a respiratory infection, initiated 5/8/2024, indicated a goal that the resident would be free from signs and symptoms of infection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page111of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0887 During a concurrent interview and record review on 6/13/2024 at 12:43 p.m. the Infection Preventionist (IP) reviewed Resident 81's Progress Notes for 2024 Immunization Record forms for 2024. The IP stated at Level of Harm - Minimal harm or admission, readmission, and annually residents are screened and offered the COVID- 19 vaccine, education potential for actual harm is provided regarding the risks and benefits of the vaccine, and the vaccine is administered as needed. The IP stated Resident 81 had an unknown vaccination status. The IP stated she should have reached out to Residents Affected - Few Resident 20's representative regarding vaccinations, but there was no documented evidence that she did.

The IP stated there was no documented evidence that Resident 81 or the resident's representative was offered any vaccinations or provided education regarding risks and benefits of vaccines for the 2023/2024 season. The IP stated vaccinations are important to protect the resident from contracting viruses and preventing further complications.

During a concurrent interview and record review on 6/13/2024 at 6:17 p.m., the Director of Nursing (DON) reviewed the facility policy and procedures regarding COVID-19 vaccinations. The DON stated residents are screened at admission and annually for the COVID-19 vaccine, consent is signed for the vaccination, and the vaccine is administered when appropriate. The DON stated the facility policy and procedure for the COVID-19 vaccine was not followed for Resident 81. The DON stated vaccine administration is important in

the elderly population because they are higher risk for developing complications. The DON stated if residents are not vaccinated, there is a risk that COVID-19 could spread to other residents leading to complications resulting in hospitalization or a decline in function.

A review of the facility policy and procedure titled, COVID-19 Vaccination Program, last reviewed 4/4/2024, indicated the facility will offer SARS-CoV-2 vaccinations (including additional and booster doses) to all residents. They will be encouraged but are not required to be vaccinated or boosted. The staff member who presents the vaccination education materials to the resident or responsible party and receives the declination or agreement for the vaccine is the person responsible for documenting in the resident's medical record.

b. A review of Resident 20's Admission Record indicated the facility admitted the resident 11/17/2017 and readmitted the resident on 9/9/2022 with diagnoses that included hemiplegia and hemiparesis (mild to severe loss of strength or paralysis on one side of the body) following cerebral infarction (stroke, when blood flow to

the brain is blocked or there is sudden bleeding in the brain) affecting the left dominant side and dementia.

A review of Resident 20's MDS dated [DATE REDACTED], indicated the resident was rarely/never able to understand others and was rarely/never able to make herself understood. The MDS further indicated the resident was dependent on staff for oral hygiene, bathing, dressing, toileting, personal hygiene, and mobility. The MDS indicated the resident required oxygen therapy.

A review of Resident 20's History and Physical, dated 4/26/2024, indicated the resident did not have capacity to understand and make decisions.

A review of Resident 20's CP titled, Alteration in respiratory function, initiated 10/12/2022, indicated a goal that the resident has the absence of respiratory distress and would have oxygen treatments administered.

A review of Resident 20's CP titled, At risk for Covid 19 infection, refused the covid, influenza, and pneumococcal vaccines, initiated 2/28/2022, indicated a goal that the resident would show no signs and symptoms of infection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page112of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0887 During a concurrent interview and record review on 6/13/2024 at 12:43 p.m. the IP reviewed Resident 20's Progress Notes for 2023 and 2024, and Immunization Record forms for 2023 and 2024. The IP stated the Level of Harm - Minimal harm or COVID-19 vaccine is offered annually with education provided regarding the risks and benefits of the potential for actual harm vaccine. The IP stated there was no documented evidence that Resident 20 or the resident representative was offered any vaccinations or provided education regarding risks and benefits of vaccinations for the Residents Affected - Few 2023/2024 season. The IP stated Family Member 2 (FM 2) was the resident's representative and did not want Resident 20 to receive vaccinations in the previous years, so she did not offer the vaccines. The IP stated it was important to reoffer vaccines because FM 2 could be re-educated, and they may change their mind. The IP stated the importance of offering, educating, and administering vaccinations is to prevent further complications of COVID-19 in residents that are already high risk for complications.

During a concurrent interview and record review on 6/13/2024 at 6:17 p.m., the Director of Nursing (DON) reviewed the facility policy and procedures regarding COVID-19 vaccinations. The DON stated residents are screened at admission and annually for the COVID-19 vaccine, consent is signed for the vaccination, and the vaccine is administered when appropriate. The DON stated the facility policies and procedures for COVID-19 vaccinations were not followed for Resident 20. The DON stated vaccine administration is important in the elderly population because they are higher risk for developing complications. The DON stated if residents are not vaccinated, there is a risk COVID-19 could spread to other residents leading to complications resulting in hospitalization or a decline in function.

A review of the facility policy and procedure titled, COVID-19 Vaccination Program, last reviewed 4/4/2024, indicated the facility will offer SARS-CoV-2 vaccinations (including additional and booster doses) to all residents. They will be encouraged but are not required to be vaccinated or boosted. The staff member who presents the vaccination education materials to the resident or responsible party and receives the declination or agreement for the vaccine is the person responsible for documenting in the resident's medical record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page113of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0911 Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43418

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure bedrooms accommodate no more than four residents for three of 16 rooms (room [ROOM NUMBER], 21, and 32).

This deficient practice had the potential for residents to not have adequate space for their daily needs.

Findings:

A review of the facility's document titled, Re: Request for Room Waiver Size and Capacity, dated 6/12/2024, indicated room [ROOM NUMBER], 21, and 32, has a total of five resident beds. The document indicated the following:

- room [ROOM NUMBER] has a square footage of 448.85 square feet with an average living space of 89.8 square feet per resident.

- room [ROOM NUMBER] has a square footage of 371.85 square feet with an average living space of 74.4 square feet per resident.

- room [ROOM NUMBER] has a square footage of 422.2 square feet with an average living space of 84.4 square feet per resident.

During the initial tour on 6/11/2024 and multiple observations conducted throughout the recertification survey, room [ROOM NUMBER], 21, and 32 were observed with enough space for residents to move freely and accommodate wheelchair-bound and ambulatory (able to walk) residents. room [ROOM NUMBER] was observed with five residents residing in the room. room [ROOM NUMBER] was observed with four residents residing in the room. room [ROOM NUMBER] was observed with five residents residing in the room.

During a concurrent observation and interview with Resident 58, on 6/11/2024, at 9:05 a.m., inside room [ROOM NUMBER], Resident 58 was lying down in bed, appeared comfortable, with no signs of distress, with four other residents present in the room. Resident 58 stated he feels he has enough room for himself and the other residents and has no concerns regarding the amount of space in his room.

During an interview with Certified Nursing Assistant (CNA) 3, on 6/11/2024, at 9:10 a.m., CNA 3 stated she was assigned to room [ROOM NUMBER] and she had enough space to take care of the residents in the room. CNA 3 further stated two of the residents in the room require total assistance from facility staff and the rest of the residents residing in the room were ambulatory.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page114of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0911 During a concurrent interview and record review with the Administrator (ADM), on 6/13/2024, at 5:28 p.m.,

the facility's document titled, Re: Request for Room Waiver Size and Capacity, dated 6/12/2024, was Level of Harm - Potential for reviewed and the ADM confirmed room [ROOM NUMBER], 21, and 32 had a capacity greater than four minimal harm residents. The ADM stated the residents are respectable with each other and have not brought up concerns being in a five-person bedroom. The ADM stated privacy is able to be maintained in the rooms. The ADM Residents Affected - Some further stated if a resident brings up concerns, they would be able to perform room changes to accommodate

the residents.

A review of the facility's policy and procedure (P&P) titled, Room Waiver, last reviewed 4/4/2024, indicated residents will be screened for medical and personal needs for placement in waiver beds/rooms.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page115of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43418

Residents Affected - Some Based on observation, interview, and record review, the facility failed to provide 80 square feet per resident

in multiple resident bedrooms for 16 of 33 rooms. This deficient practice had the potential to negatively impact the resident's privacy and not have adequate space for nursing care.

Findings:

A review of the facility's document titled, Re: Request for Room Waiver Size and Capacity, dated 6/12/2024, indicated there was enough space to provide care, dignity, privacy, special needs, and safety of the residents to ensure good quality of care. The document indicated the following rooms did not meet the 80 square feet per resident requirement and the waiver request was for the following rooms:

Room Number Capacity Total Square Feet

2 3 221.48

5 3 236.32

6 3 236.32

15 4 300.40

19 3 218.47

20 3 227.13

21 5 371.85

23 3 210.41

24 3 231.41

25 3 202

26 3 234.4

27 3 202.2

28 3 223.2

29 3 224.87

30 3 229

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page116of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 33 3 211.3

Level of Harm - Potential for During the initial tour conducted on 6/11/2024 and multiple observations conducted throughout the minimal harm recertification survey, the observations indicated the square footage of the rooms requested for waiver did not interfere with the care and services provided by the staff. The residents observed had enough space to Residents Affected - Some move about freely inside the rooms and there was enough space for residents' bed, dresser, and resident care equipment.

During the initial tour conducted on 6/11/2024 and multiple interviews with staff members throughout the recertification survey, the interviews indicated the facility staff had no issues or concerns related to space in residents' rooms and were able to conduct resident care with no issues.

During a concurrent observation and interview with Resident 293, on 6/13/2024, at 11:10 a.m., inside room [ROOM NUMBER], Resident 293 stated he had no concerns regarding the space he was allotted in his room. Resident 293 maneuvered himself around the room in a wheelchair with no issues related to space. Resident 293 appeared calm and in no distress.

During a concurrent interview and record review with the Administrator (ADM), on 6/13/2024, at 5:28 p.m.,

the facility's document titled, Re: Request for Room Waiver Size and Capacity, dated 6/12/2024, was reviewed and the ADM confirmed Rooms 2, 5, 6, 15, 19, 20, 21, 23, 24, 25, 26, 27, 28, 29, 30, and 33 had a square footage of less than 80 square feet per resident. The ADM stated the residents have not brought up any concerns related to space in the room. The ADM stated the staff are able to perform nursing care for the residents without issues. The ADM further stated if a resident brings up concerns regarding the space in the room, the facility could do a room change to accommodate the residents.

A review of the facility's policy and procedure (P&P) titled, Room Waiver, last reviewed 4/4/2024, indicated residents will be screened for medical and personal needs for placement in waiver beds/rooms.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page117of117 555117

F-F760

Findings:

During an observation on 6/11/2024 at 09:06 AM, in medication cart 2, licensed vocational nurse (LVN) 5 was observed administering calcium 250 milligram ([mg]-a unit of measure of mass) with vitamin D3 (a medication used as supplement for bone health) 3.1 microgram ([mcg] - a unit of measure of mass) two crushed tablets mixed in applesauce to Resident 36. Resident 36 was observed swallowing spoonsful of the applesauce containing the two crushed tablets of calcium 250 mg with Vitamin D3 3.1 mcg.

During an observation on 6/11/24 at 9:09 AM, in medication cart 1, LVN 1 was observed crushing Metoprolol Succinate ER 50 mg tablet and adding them to a small cup filled with water and opening Duloxetine DR 30 mg capsule and pouring the contents to another small cup filled with water, for Resident 295.

According to the manufacturer package insert (a document that provides information about the medication,) dated 3/2006 for Metoprolol succinate ER tablets, the document indicates that Metoprolol succinate ER tablets should not chewed or crushed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 72 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 According to the manufacturer medication guide (a document approved by the Food and Drug Administration [FDA - agency responsible for protecting the public health by ensuring the safety, efficacy, and security of Level of Harm - Minimal harm or human drugs] that gives information to patients about medications to avoid adverse effects,) dated 8/2023 for potential for actual harm Duloxetine DR capsules, the document indicates that Duloxetine DR capsules should not be chewed or crushed, to not open the capsule and sprinkle on food or mix with liquids, and opening the capsule may Residents Affected - Some affect how well Duloxetine DR capsules work.

During an observation on 6/11/24 at 9:24 AM with LVN 1, LVN 1 was observed not checking the PEG-Tube placement, patency, residuals, and not flushing the tube with water, and LVN 1 grabbing the medication cup containing Metoprolol Succinate ER that LVN 1 had prepared by crushing the tablet for administration into

the Percutaneous Endoscopic Gastrostomy ([PEG] - a tube surgically inserted in the stomach to receive nutrition and medications)-Tube for Resident 295. LVN was stopped by the surveyor before any medication was administered to Resident 295 and advised to discuss the PEG-tube technique and medication preparation with the surveyor in the hallway.

During an interview on 06/11/2024 at 9:25 AM, with LVN 1, LVN 1 stated that sustained release medications such as the Metoprolol Succinate ER cannot be crushed, and Duloxetine DR capsule cannot be opened. LVN 1 stated crushing the tablet or opening the capsule makes the release of the medication immediate instead of sustained. LVN 1 stated that administering Metoprolol and Duloxetine as immediate release will provide larger doses to Resident 295 at once resulting in more immediate side effects like gastrointestinal ([GI] - relating to the stomach) irritation. LVN 1 stated that LVN 1 will not administer the Metoprolol Succinate ER and Duloxetine DR to Resident 295 and communicate to the doctor for alternate forms of these medications.

During an observation on 6/11/2024 at 9:54 AM, in medication cart 2, LVN 5 was observed not administering apixaban 5 mg tablet to Resident 11. LVN 5 informed Resident 11 the apixaban was not available this morning and will have to wait for pharmacy to deliver the medication.

During an interview on 6/11/2024 at 10 AM, with LVN 5, LVN 5 stated that LVN 5 did not administer the apixaban 5 mg to Resident 11 at the scheduled time on 6/11/2024, because it was not available in the medication cart or in the facility. LVN 5 stated LVN 5 will follow up with the pharmacy to expedite the refill of

the apixaban and call the physician to inform the morning dose on 6/11/2024 was not administered. LVN 5 stated that medications should be ordered from the pharmacy when there are 3 days of doses left, and followed up as needed, to ensure timely availability of medications. LVN 5 stated it is important to receive apixaban as ordered by physician for DVT management, and missing doses can harm Resident 11 by causing another DVT leading to hospitalization .

During an interview on 6/11/24 at 11:24 AM, with LVN 5, LVN 5 stated that LVN 5 crushed and administered two tablets of calcium 250 mg with vitamin D3 3.1 mcg to Resident 36 during the morning medication administration on 6/11/24 at 09:06 AM. LVN 5 stated that LVN 5 administered the wrong form of calcium, and that Resident 36 was not prescribed vitamin D3 by the physician.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 73 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 During an interview, on 6/12/2024 at 11:44 AM, with the Director of Nursing (DON,) the DON stated that medication refills should be ordered from the pharmacy about 3 to 4 days before the last dose to prevent Level of Harm - Minimal harm or medications from not being available to the residents at their scheduled times. The DON stated that LVN's potential for actual harm are expected to re-order medications timely and follow-up on the refills to ensure medications are available to residents. The DON stated that LVN's should follow the 5 rights of medication administration to ensure Residents Affected - Some physician orders are followed and the right medications are administered to residents. The DON stated that LVN 5 failed to follow medication administration guideline and physician orders and administered Calcium with Vitamin D3 to Resident 36 for the 9AM dose on 6/11/2024. The DON stated that Resident 11 was not administered apixaban 5 mg tablet for the 9 AM dose on 6/11/2024 due to the medication not being available. The DON stated Resident 11 was prescribed apixaban for DVT management and missing the administration can potentially cause thrombosis (clotting of blood), which is critical because the blood is not properly thinned, and the clot can dislodge and travel to the heart and brain forming an embolism (obstruction caused by clots) and causing a heart attack and stroke. The DON stated that several licensed nurses failed to submit the apixaban 5 mg refill request timely to the pharmacy, to prevent the unavailability and interruption in the medication therapy and ensure continuity of care for Resident 11. The DON stated there needs to be a more proactive approach and better communication to prevent this failure in the future.

During a concurrent interview, the DON stated that sustained release medications should not be crushed or opened. The DON stated doing so will make the medication immediate release and cause more side effects.

The DON stated that pharmacists and several LVN's failed to clarify the Metoprolol Succinate ER and Duloxetine DR orders for alternate options to be administered through the PEG-Tube and not harm Resident 295.

During a phone interview on 6/12/2024 at 12:47 PM, with the Consultant Pharmacist (CP), the CP stated that Metoprolol Succinate ER should not be crushed, and Duloxetine DR capsule should not be opened for PEG-Tube administrations, based on manufacturer guidance. The CP stated both medication orders should have been clarified for alternate options to be administered through the PEG-Tube.

During a phone interview on 6/13/2024 at 10:31 AM, with the DON, the DON stated that after confirming with

the CP, the physician has changed the Metoprolol succinate ER and Duloxetine DR orders for Resident 295 to forms that can be administered through the PEG-Tube.

During a review of Resident 11's Admission Record (a document containing demographic and diagnostic information,) dated 6/11/2024, the Admission Record indicated Resident 11 was originally admitted to the facility on [DATE REDACTED] with diagnoses including acute embolism and thrombosis of unspecified deep veins of bilateral (relating to both) lower extremity (part of the body that includes the hip, thigh, knee, leg, ankle, and foot.)

During a review of Resident 11's Order Summary Report (a report listing the physician order for the resident), dated 6/1/2024, indicated Resident 11 was prescribed apixaban 5 milligram ([mg]- a unit of measure of mass) tablet by mouth two times a day for DVT management, starting 5/17/2024.

During a review of Resident 11's Medication Administration Record ([MAR] - a document of the medications administered to a resident that is part of the resident's permanent medical record], on 6/11/2024 at 11:48 AM, the MAR indicated Resident 11's dose of apixaban 5 mg tablet was due every day at 9 AM and 5 PM, and there was no documentation for the apixaban 5 mg administration on 6/11/2024 for the 9 AM dose.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 74 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 During a review of Resident 36's Admission Record, dated 6/11/2024, indicated the resident was originally admitted to the facility on [DATE REDACTED] with a diagnosis including age related osteoporosis (a condition in which Level of Harm - Minimal harm or the bones become brittle and fragile, typically because of deficiency of calcium.) potential for actual harm

During a review of Resident 36's Order Summary Report, dated 6/1/2024, indicated Resident 36 was Residents Affected - Some prescribed Oyster Shell Calcium 500 mg tablet once a day for supplement, starting 4/16/2023. The clinical

record contained no documentation that the resident should be given a dose of calcium 500mg with vitamin D3.

During a review of Resident 36's MAR for June 2024, the MAR indicated Resident 36's Oyster Shell Calcium 500 mg tablet once a day for supplement was due every day at 09:00 AM.

During a review of Resident 295's Admission Record dated 6/11/2024, indicated the resident was originally admitted to the facility on [DATE REDACTED] with diagnoses including essential hypertension (a condition in which the blood vessels have persistently raised pressure) and depression.

During a review of Resident 295's Order Summary Report for June 2024, indicated Resident 295 was prescribed Metoprolol Succinate ER 50 mg tablet to be given by PEG-Tube once a day for hypertension and to hold the dose for Systolic Blood Pressure (SBP) less than 110 or heart rate less than 60, and was prescribed Duloxetine DR capsule 30 mg to be given via PEG-Tube once a day for depression, starting 6/8/2024.

During a review of Resident 295's MAR for June 2024, the MAR indicated Resident 295 was prescribed Metoprolol Succinate ER 50 mg tablet to be given by PEG Tube once a day for hypertension and to hold the dose for SBP less than 110 or heart rate less than 60 and was prescribed Duloxetine DR capsule 30 mg to be given via PEG-Tube once a day for depression, at 09:00 AM.

Review of the facility's policy and procedures (P&P), titled Medication Administration, dated 1/1/2012, the P&P indicated:

VI. Medication Rights

A. Nursing staff will keep in mind the seven rights of medication when administering medication.

B. The seven rights of medication are:

i. The right medication.

Review of the facility's P&P, titled Medication Administration General Guidelines for the Administration of Medications, dated 4/4/2024, the P&P indicated:

3. The nurse reviews each resident's MAR to determine which medications need to be administered at the given time. The nurse observes the five rights in administering each medication:

c. The right medication

e. The right method of administration

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 75 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 6. The nurse compares the MAR with the medication label three times. The nurse compares the name of the medication, the route of administration and the strength and dose when he/she selects the medication from Level of Harm - Minimal harm or the cart or tray, when he/she pours the medication and when he/she returns the medication to the cart. potential for actual harm

Review of the facility's P&P, titled Medication Errors, dated July 2018, the P&P indicated: Residents Affected - Some II. Medication error means the administration of medication:

E. Which is not currently prescribed.

Review of the facility's P&P, titled Medication Administration Errors, dated 4/4/2024, the P&P indicated:

I. A medication administration error occurs when a resident receives a dose of medication that deviates from

the original physician's order and/or established facility policy and procedures. Types of errors include:

7. Incorrect preparation of dose

8. Incorrect administration technique

9. Administration of medication without a valid order.

Review of the facility's P&P, titled Medication Administration Crushing of Medications, dated 4/4/2024, the P&P indicated:

I. Solid oral dosage forms may be crushed for administration to residents when a resident is unable to swallow a whole tablet/capsule and when doing so does not affect the effectiveness, toxicity or side effects of

the product.

4. If a liquid alternative is not available, the nurse will consult the Do Not Crush list provided in this manual (see Appendices) and the product label cautionary statements to determine if the product in question may be crushed. If in doubt, the nurse will contact the pharmacist for guidance and clarification. In general, medications that are sustained release products, enteric coated, or are for sublingual or buccal administration will appear on the Do Not Crush list.

6. If it is determined that the medication in questions may not be crushed, the nurse will contact the physician to obtain an order for an alternative product. Nurse may contact the pharmacist for suggested alternatives.

Review of facility's P&P, titled Appendix 7. Medications that should not be chewed or crushed, dated 4/4/2024, the appendix indicated The following list of drugs that should not be chewed or crushed is intended as a guide, not an all-inclusive list. Any questions should be addressed through pharmacy staff or manufacturer literature:

3. Time-Release Tablets - Designed to release medication over a period of 8 to 12 hours. Some formulations are designed to reduce gastric irritation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 76 of117 555117 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555117 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44376 potential for actual harm Based on interview and record review the facility failed to ensure residents were free of any significant Residents Affected - Some medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards)

to:

1. One out of two sampled residents (Resident 6) investigated during review of insulin use (a hormone that lowers the level of glucose [a type of sugar] in the blood) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites.

The deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin).

Cross reference