Skyline Healthcare Center - La

F-F600

Findings:

a. During a review of Resident 1 ' s Admission Record (AR), the AR indicated the facility admitted Resident 1

on 2/12/2025 with diagnoses including parkinsonism (a broad term that refers to brain conditions that caused slowed movements, rigidity [stiffness], and tremors), quadriplegia (a severe medical condition characterized by the partial or total loss of function in all four limbs [arms and legs] and the torso [the main part of the body that contains the chest, abdomen, pelvis, and back), and depression (a persistent state of sadness and loss of interest that can significantly affect how you feel, think, and behave, making it hard to enjoy life or carry out daily activities).

During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool) dated 2/16/2025,

the MDS indicated Resident 1 had intact cognition (refers to the mental processes involved in knowing, learning, and understanding). The MDS indicated Resident 1 was dependent (helper does all the effort and resident does none of the effort to complete the activity) with toileting hygiene, and shower.

During a review of Resident 1 ' s Change in Condition (COC- when there is a sudden change in a resident ' s condition) Evaluation, dated 3/21/2025 at 7:50 a.m., the COC Evaluation indicated Resident 1 stated Resident 2, a roommate, scratched Resident 1 ' s right lower foot while Resident 2, seated on Resident 2 ' s wheelchair 1 while being wheeled out of Residents 1 and 2 ' s room by a staff member (name not indicated).

The COC Evaluation indicated there was a noted red line (no other descriptions indicated) in Resident 1 ' s right lower foot and staff (LVN 2) cleaned the skin area (the skin area with the red line).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 8 555117 Department of Health & Human Services Printed: 08/31/2025 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 04/01/2025

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 0609 During a review of Resident 1 ' s COC Evaluation, dated 3/21/2025 at 8:30 a.m., the COC Evaluation indicated Resident 1 had a red line scratched mark measuring 10 cm in length by 0.3 cm in width which Level of Harm - Minimal harm or Resident 1 got from Resident 2 who scratched Resident 1 ' s right lower foot. potential for actual harm

During a review of Resident 1 ' s Order Summary Report (OSR), dated 3/21/2025, the OSR indicated Residents Affected - Few Resident 1 ' s Physician/Medical Doctor (MD) 1 ordered to clean Resident 1 ' s right foot red line scratched mark with normal saline (a mixture of water and salt with a salt concentration of 0.9 percent [% - per one hundred], for every 1 liter [L - 1,000 milliliter, a unit of measurement] of water, there are nine grams [unit of measurement] of salt), pat dry, apply bacitracin ointment (a topical antibiotic ointment, essentially a cream, used to prevent infection in minor skin injuries like cuts, scrapes, and burns), and leave the wound open to air every day shift for 21 days.

During a review of Resident 1 ' s Skin Check (SC), dated 3/21/2025 at 4:47 p.m., the SC indicated Resident 1 ' s right lower foot was noted with a red line scratched mark measuring 10 cm in length by 0.3 cm in width.

During a review of Resident 1 ' s Psychiatric Follow Up Note (PN - a clinical document used by mental health professionals to record the progress of a resident ' s treatment after the initial evaluation), dated 3/21/2025,

the PN indicated Resident 1 alleged that her roommate (Resident 2) became agitated and while staff was managing Resident 2 ' s behavior (the way in which one acts or conducts oneself, especially toward others, Resident 2 scratched Resident 1 ' s foot (right lower foot). The PN indicated Resident 1 did not answer questions when prompted (encourage to say something) as she (Resident 1) was visibly upset. The PN indicated Resident 1 had a diagnosis of depression.

During a review of Resident 1 ' s Treatment Administration Record (TAR - a daily documentation record used by a licensed nurse to document treatments given to a resident), dated 3/2025, the TAR indicated on 3/21/2025 Resident 1 ' s right foot scratch was cleaned with normal saline, patted dry, bacitracin ointment applied, and left the wound open to air.

b. During a review of Resident 2 ' s AR, the AR indicated the facility admitted the resident on 4/16/2024 and readmitted the resident on 5/13/2024, with diagnoses that included dementia (a general term for a decline in mental ability that interferes with daily life, encompassing symptoms like trouble remembering, thinking, or making decisions), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in activities, and other symptoms that significantly affect daily functioning), and general anxiety disorder (a mental health condition that produces fear, worry, and a constant feeling of being overwhelmed).

During a review of Resident 2 ' s MDS, dated [DATE REDACTED], the MDS indicated Resident 2 had severely impaired cognition (a significant and substantial decline in a person ' s ability to think, learn, remember, and make decisions, which significantly impacts their daily functioning). The MDS indicated Resident 2 needed substantial/maximal assistance with sit to stand.

During a review of Resident 2 ' s COC Evaluation, dated 3/21/2025 at 7 a.m., the COC Evaluation indicated Resident 2 was noted with episode of increased aggression through striking out for no apparent reason. The COC indicated Resident 2 was noted yelling and screaming to Certified Nurse Assistant (CNA) 1, and was combative.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 8 555117 Department of Health & Human Services Printed: 08/31/2025 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 04/01/2025

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 0609 During an interview on 4/1/2025 at 11 a.m. with Resident 1, Resident 1 stated Resident 1 did not recall the date of the incident, but it was early in the morning at around 6 a.m. Resident 1 saw her roommate Resident Level of Harm - Minimal harm or 2 swung a detachable bed remote control at CNA 1. Resident 1 stated Resident 2 was walking out of the potential for actual harm room to the door with CNA 1, but Resident 2 turned towards Resident 1 and scratched Resident 1 ' s right foot. Resident 1 stated Resident 1 was lying in bed and could not defend herself. Resident 1 stated, Resident Residents Affected - Few 1 sustained a 10 cm-scratch.

During an interview on 4/1/2025 at 2:14 p.m. with Resident 1, Resident 1 stated the incident with Resident 2 scratching Resident 1 ' sright lower foot brought (back) her PTSD from a previous incident. Resident 1 stated

it (Resident 2 scratching her right lower foot) shook her and made her (Resident 1) scared.

During an interview on 4/1/2025 at 2:23 p.m. with CNA 1, CNA 1 stated she worked on 3/20/2025 from 11 p. m. to 7 a.m. and was assigned to care for Residents 1 and 2. CNA 1 stated on 3/21/2025 at around 6:45 a.m. , Resident 2 sat up in Resident 2 ' s bed upset and began to shout and yell at the Housekeeper (HK) 1 who was cleaning Resident 1 and Resident 2 ' s room. CNA 1 stated Resident 2 stood up wanting to walk, grabbed the detachable remote control of the bed, and began to swing the bed remote control at CNA 1. CNA 1 stated Licensed Vocational Nurse (LVN) 2 and LVN 3 came to Resident 2 ' s room. CNA 1 stated Resident 2 had the bed remote control in Resident 2 ' s left hand and was walking towards the door. CNA 1 stated CNA and the LVNs (LVNs 2 and 3) were walking around Resident 2 to support Resident 2 from falling but also avoiding getting hit by Resident 2. CNA 1 stated CNA 1 saw Resident 2 walked all the way to Resident 1 ' s bed (nearest the door) and scratched Resident 1 ' s foot (right lower foot). CNA 1 stated Resident 1 said, She (Resident 2) scratched my foot.

During a concurrent interview and record review on 4/1/2025 at 3:57 p.m., the facility-provided Transmission Verification Report (a document that verifies the successful transmission of a fax), dated 10/1/2013 at 9:15 p. m., was reviewed with the DON. The DON stated the Transmission Verification Report ' s date of 10/1/2013 at 9:15 p.m. was incorrect. The DON stated this was regarding a resident to resident abuse (Resident 1 and Resident 2) which she (DON) sent to the SSA on 3/21/2025 at around 11:40 a.m. the DON stated Resident 2 scratched Resident 1 ' s right lower foot on 3/21/2025 at around 7 a.m. to 7:30 a.m. The DON stated she saw Resident 1 on 3/21/2025 at around 9 a.m. in the hallway and Resident 1 told her (DON) Resident 2 scratched Resident 1 ' s right lower foot. The DON stated Resident 2 scratching Resident 1 ' s right lower foot is considered physical abuse. The DON stated the facility does not allow abuse because Resident 1 can psychosocially (refers to how both the psychological [relating to the mental and emotional state] and social factors contribute to a person ' s overall well-being, development, and functioning) feel unsafe in Resident 1 ' s environment and the potential for further harm. The DON stated knowledge or suspicion of physical abuse must be reported within two hours. The DON stated her staff should have reported to the Administrator and/or the DON and should have reported the incident immediately. The DON stated staff knew about the incident around 7:45 a.m. and it was reported around 11:30 a.m. (by the DON) to the SSA indicated a delay

in the reporting. The DON stated the potential for not reporting within the two-hour timeframe can place the residents at further risk for abuse.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 8 555117 Department of Health & Human Services Printed: 08/31/2025 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 04/01/2025

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 0609 During a review of the facility ' s P&P titled, Reporting Abuse, last reviewed on 4/4/2024, the P&P indicated,

The facility will report known or suspected instances of physical abuse to the proper authorities by telephone Level of Harm - Minimal harm or or through a confidential internet reporting tool as required by state and federal regulations. I. If the potential for actual harm reportable event results in serious bodily injury, a telephone report shall be made to the local law enforcement agency immediately and no later than two (2) hours) of the observation, knowledge or suspicion Residents Affected - Few of the physical abuse. In addition, a written report shall be made to . the California Department of Public Health (or SSA) . within two (2) hours of the observation, knowledge, or suspicion of the physical abuse.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 8 555117