Skyline Healthcare Center - La
SKYLINE HEALTHCARE CENTER - LA in LOS ANGELES, CA — inspection on June 13, 2024.
Found 7 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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.
555117
Form Approved OMB
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
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.
555117
Form Approved OMB
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
- 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
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.
555117
Form Approved OMB
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
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], 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:
555117
Form Approved OMB
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
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.
555117
Form Approved OMB
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
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.
555117
Form Approved OMB
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