Skyline Healthcare Center - La

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

workplace use of these devices can raise a number of Issues involving safety, security, and privacy.Therefore, the Company has adopted the following rules regarding the use of personal communication devices in the workplace. during working hours. Employees should conduct personal business during lunch breaks and other rest periods. This Includes the use of personal communication devices (including cell phones) for personal business (including personal phone conversations and text messages, personal e-mails, and Internet use for personal reasons). Minimal or incidental use Is permitted (like a child confirming safe arrival at home after school).Violation of this policy may result in discipline, up to and including termination of employment.Unless properly authorized, employees must refrain from the use of any form of personal electronic communication devices during normal work hours.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/09/2025

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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Resident 1 was not in distress (negative state). RN 1 stated that LVN 1 should have immediately notified MD 1 regarding the elevated BS result (382 mg/dl), nausea and vomiting, as these symptoms indicated a potential underlying medical issue that required further medical intervention. RN 1 stated that MD 1 might have ordered an insulin injection due to the high BS level. RN 1 also stated that Resident 1's Physician's Order dated 7/15/2025 instructed staff to notify MD 1 if Resident 1's BS exceeded 350 mg/dl. RN 1 stated that failure to act on these symptoms could have led to a worsening condition, and potentially death. During

an interview on 8/7/2025 at 11:05 a.m., with RN 1, RN 1 stated that Resident 1's BS level greater than 350 mg/dl, along with nausea and vomiting constituted a COC, as these symptoms were abnormal for Resident

1. 1. RN 1 stated that Resident 1 required a thorough assessment and appropriate medical intervention from

MD 1. RN 1 further stated that LVN 1 was responsible for obtaining Resident 1's vital signs and reporting all presenting symptoms to MD 1 in order to receive appropriate medical orders to address Resident 1's COC.

During a review of Resident 1's Certificate of Death , dated 8/6/2025, the Certificate of Death indicated that

the immediate cause of death for Resident 1 was cardiopulmonary arrest (a life-threatening medical emergency where the heart stops effectively pumping blood and the body stops breathing), with underlying conditions contributing to the cause of death listed as respiratory failure (a life-threatening medical condition where the lungs can't adequately exchange gases to meet the body's needs) and type 2 DM.

During a review of the current facility-provided P&P titled, Change of Condition Notification, last reviewed

on 4/4/2025, the P&P indicated, To ensure .? physicians are informed of changes in the resident's condition

in a timely manner. During a review of the current facility-provided P&P titled, Blood Glucose (refers to the concentration of glucose [simple sugar that serves as the body's primary source of energy] in the bloodstream) Monitoring, last reviewed on 4/4/2025, the P&P indicated, Notify the healthcare provider of a Blood Sugar Level . higher than 250 (mg/dl) unless otherwise indicated in the physician order. During a

review of the current facility-provided P&P titled, Diabetic Care, last reviewed on 4/4/2025, the P&P indicated, In any case where the resident's blood sugar is . greater than 350 (mg/dl), the Attending Physician must be notified: unless otherwise noted on the Physician's order. Nursing staff will monitor the resident for signs and symptom of hypoglycemia (low BS level) or hyperglycemia, initiate intervention if necessary, and notify the Attending Physician and responsible party if the signs and symptoms are present.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/09/2025

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 0656 Level of Harm - Minimal harm or potential for actual harm

know what to do with the resident because there was no proper endorsement given. During a review of the facility policy and procedure titled, Staff Competency Validation, last reviewed on 4/4/2025, indicated, Staff are required to have competency validation based on their job description or assigned duties.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/09/2025

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 0684 Level of Harm - Immediate jeopardy to resident health or safety

and treatment. The facility will utilize a 24-hour report system in the form of a 24-Hour Communication Log as a means of communication changes in condition, other important aspects of residents' care. The log will be maintained at each nursing station to facilitate inter-shift communication and assist in the provision of optimum resident care. During a review of the current facility-provided P&P titled, Alert Charting Documentation, last reviewed on 4/4/2025, the P&P indicated, To ensure the timely, ongoing assessments and documentation of residents who have had a change in condition while at the facility.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/09/2025

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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

Assessment Tool did not indicate frequency of competency and performance evaluations. The Admin stated

he (Admin) will update the Facility Assessment Tool. [NAME] an interview on 8/9/2025, at 2:50 p.m., with the DON, the DON stated the facility should ensure that staff are competent on an annual basis and if any gaps in competency, the facility can identify it and address it.

During a review of facility’s Employee Handbook dated 1/2024, the Employee Handbook indicated, “PERFORMANCE EVALUATIONS: Employees may receive periodic performance reviews. The review will generally be conducted by their supervisor. The first performance evaluation may be after completion of the Introductory Period. After that review, performance evaluations may be conducted annually, on or around their anniversary date. The frequency of performance evaluations may vary depending upon length of service, job position, past performance, changes in job duties or recurring performance problems.

Performance evaluations· will Include factors such as the quality and quantity of the work performed, knowledge of the job, their Initiative, their work attitude and their demeanor toward others.

Performance evaluations are designed to help employees become aware of progress, areas for Improvement and objectives or goals for future work performance.”

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/09/2025

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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three sampled residents (Residents 5) by failing to follow the physician's order to hold (temporarily suspending its administration) midodrine (medication used to treat low blood pressure) for systolic blood pressure (sbp- the top number in a blood pressure reading, representing the pressure in your arteries when your heart beats) more than 110 millimeter of mercury (mmHg-unit of measurement).This failure had the potential to result in unnecessarily elevating Resident 5's blood pressure.Findings:During a

review of Resident 5's admission Record, the admission Record indicated the facility admitted Resident 5

on 5/8/2025, with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (a stroke where brain tissue dies due to a lack of blood supply), essential hypertension (persistently high blood pressure for which no specific underlying cause can be identified), and history of falling.During a

review of Resident 5's History and Physical (H&P- a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 5/16/2025,

the H&P indicated Resident 5 had fluctuating capacity to understand and make decisions.During a review of Resident 5's Minimum Data Set (MDS-a resident assessment tool), dated 6/7/2025, the MDS indicated Resident 5's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 5 was dependent on staff for eating and showering.During a review of Resident 5's Physician Order, dated 6/3/2025, the Physician Order indicated midodrine hydrochloride oral tablet five milligrams (mg- metric unit of measurement, used for medication dosage and/or amount), give one tablet enterally (the process of delivering food or medication directly into

the gastrointestinal system, allowing for absorption and processing by the body) three times a day for hypotension (low blood pressure). The Physician Order indicated to hold if Resident 5's blood pressure is over 110 mmHg.During a record review of Resident 5's Medication Administration record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 8/2025, the MAR indicated midodrine was administered on the following dates and times:1. 8/2/2025, at 10 p.m., with a blood pressure of 132/80 mmHg.2. 8/4/2025, at 6 a.m. with a blood pressure of 124/87 mmHg.3. 8/7/2025, at 6 a.m. with a blood pressure of 124/76 mmHg.During an interview on 8/9/2025, at 2:50 p.m., with the Director of Nursing (DON), the DON stated the nurses failed to follow the physician's order to hold the midodrine for blood pressure above 110 mmHg. The DON stated Resident 5 could have elevated blood pressure and experienced adverse effects (harmful or undesirable consequences that occur because of a treatment, medication, or medical procedure) from the medication.During a review of facility's policy and procedure (P&P), titled, Medication Administration, dated 1/1/2012, and last reviewed on 4/4/2025, the P&P indicated, Medication will be administered directed by a Licensed nurse and upon the order of a physician or licensed independent practitioner.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/09/2025

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 0842 Level of Harm - Minimal harm or potential for actual harm

During a review of facility’s P&P, titled, “Completion and Correction”, dated 1/1/2012 and last reviewed on 4/4/2025, the P&P indicated, “The facility will work to complete and correct medical records in a standard manner to provide the highest quality and accuracy in documentation….

Entries will be complete, legible, descriptive and accurate…. Documentation content…

Residents Affected - Few

I. Each time a physician is notified via phone or in person regarding the resident’s condition.”

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/09/2025

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 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 followed an infection control policy and procedure for one of three sample residents (Resident 1) by offering a trash can when Resident 1 had an episode of vomiting.This deficient practice had the potential risk of transmission of bacteria that can lead to infection of Resident 1.During a review of Resident 1's admission Record, the admission Record indicated the facility initially admitted Resident 1 on 12/3/2021 and readmitted on [DATE REDACTED] with a diagnosis of type 2 diabetes mellites with hyperglycemia (body isn't using insulin properly, causing blood sugar and hypertension (high blood pressure).During a review of Resident 1's History and Physical (H & P), dated 9/13/2024, the H & P indicated that Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/12/2025, the MDS indicated Resident 1 thought process was intact and required supervision assistance from staff to complete activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily).During a concurrent interview and record review on 8/6/2025 at 2:31 p.m. with Infection Preventionist (IP) 1, Resident 1's Progress Notes, dated 7/19/2025, were reviewed. IP stated it indicated that LVN 1 offered trashcan to Resident 1 in case Resident 1 had an episode of vomiting again. IP stated that LVN 1 should not offer trash can because it contains a lot of bacteria and must offer a clean basin instead.During an interview on 8/6/2025 at 2:49 p.m. with RN 1, RN 1 stated LVN 1 should not offer trash can to Resident 1 and must provide a clean basin due to cross contamination Resident 1 could get infection from the trash can.During a review of the facility policy and procedure titled, Infection Control Policies and Procedures, last reviewed on 4/4/2025, indicated, To provide infection control policies and procedures required for a safe and sanitary environment.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet