Skyline Healthcare Center - La

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

stated Resident 2 complained and stated she (Resident 2) was not comfortable with CNA 2. RN 2 stated

she (RN 2) volunteered to care for Resident 2 this was around 9 a.m. did Resident 2's perineal care, changed her depend, and provided water. RN 2 stated around 1 p.m. went with CNA 2 to Resident 2's room and Resident 2 was upset stated did not want CNA 2. RN 2 stated explained to Resident 2 there was limited assistance and Resident then yelled at RN 2 and called RN 2 derogatory names. RN 2 stated Resident 2 was in her (Resident 2) wheelchair Resident 2 stated she was soaked in urine, RN 2 stated Resident 2 was soaked. RN 2 stated placed Resident 2 back into bed Resident was upset and wanted things done a certain way. RN 2 stated Resident grabbed CNA 2 by the hair and scratched RN 2. During an

interview on 9/2/2025 at 4 p.m. with the Administrator (Adm), the Adm stated Resident 2 does have behavioral issues but scratching and drawing blood from staff is a brand-new behavior. The Adm stated because this is a new behavior a COC should have been created for Resident 2's behavior. The Adm stated

a COC is to monitor the residents for the COC. The MD must be notified to get new orders. The Adm stated

the MD was not notified of Resident 2's COC. The Adm stated there is a potential for a delay of care because no COC was done to address the resident's behavioral change. During a review of the facility's Policy and Procedures (P&P) titled, Change in Condition Notification, last reviewed on 4/4/2025, the P&P indicated the facility will promptly inform the resident, consult with the resident's Physician and notify the resident's legal representative or an interested family member, if known, when the resident endures a significant change in their condition cause by, but not limited to:b. A significant change in the residents' physical, mental or psychosocial statusII. Change of Condition related to Physician notification is defined as when the Physician must be notified when any sudden and marked adverse change in the resident's condition which is manifested by signs and symptoms different than usual denotes a new problem, complication or permanent change in status and requires medical assessment, coordination and consultation with a Physician and a change in treatment plan.

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

09/02/2025

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 0607

of Public Health Licensing and Certification and others that may be required by state or local law, within five (5) working days of the reported allegation.

Level of Harm - Minimal harm or potential for actual harm 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

09/02/2025

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

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

but a registry and worked at the facility on 8/24/2025 from 7a.m. to 3 p.m. RN 2 stated Resident 2 complained and stated she (Resident 2) was not comfortable with CNA 2. RN 2 stated she (RN 2) volunteered to care for Resident 2 this was around 9 a.m. did Resident 2's perineal care, changed her depend, and provided water. RN 2 stated around 1 p.m. went with CNA 2 to Resident 2's room and Resident 2 was upset stated did not want CNA 2 RN 2 stated explained to Resident 2 there was limited assistance and Resident then yelled at RN 2 and called RN 2 derogatory names. RN 2 stated Resident 2 was in her (Resident 2) wheelchair Resident 2 stated she was soaked in urine, RN 2 stated Resident 2 was soaked. RN 2 stated placed Resident 2 back into bed Resident was upset and wanted things done a certain way. RN 2 stated Resident grabbed CNA 2 by the hair and scratched RN 2. During an interview on 9/2/2025 at 3:33 p.m. with the Director of Staff Development (DSD) the DSD stated spoke to Resident 2 on 8/28/2025 and Resident 2 stated RN 2 and CNA 2 had scratched her (Resident 2). The DSD stated when a resident alleges, they have been scratched that would be considered abuse, this would have been a physical abuse. The DSD stated not sure if we did anything the Adm knew about this incident as of 8/24/2025 was told by RN 2. The DSD stated any type of abuse must be reported within two (2) hours to

the three (3) agencies ombudsmen (OMB), police and SSA. The DSD stated would have to check with Adm not sure if it was reported. The DSD stated CNA 2 has no disciplinary action, only a one-to-one in-service for customer services regarding Resident 2, Resident 2 stated CNA 2 response was not good, the DSD stated CNA 2 has not been suspended. During a concurrent interview and record review of Resident 2's text messages with the Adm on 9/2/2025 at 4 p.m. with the Adm, the Adm stated he (Adm) is the abuse coordinator. The Adm reviewed text between Resident 2 and Adm, the Adm stated on 8/24/2025 Resident 2 alleged staff (RN 2 and CNA 2) started fighting physical. The Adm stated abuse would be any physical, verbal, or wrongdoing against someone. The Adm stated I (Adm) would consider this abuse, the Adm stated I (Adm) should have told the nurse at that time to report to OMB, SSA, police and start the investigation. The Adm stated potential for delayed reporting can be that the resident continues to be at risk for further abuse. During a review of the facility's P&P titled, Abuse, Reporting and Investigations, last reviewed on 4/4/2025, the P&P indicated allegation of abuse, neglect, mistreatment, exploitation, or reasonable suspicion of a crime are to be reported to the Administrator or designated representative immediately. ii. If the suspected perpetrator is an employee, remove the employee immediately from the care of the resident and immediately suspend the employee pending the outcome of the investigation in accordance with the facility policies. 3. Notification of Outside Agencies for all other Cases of Abuse. a. The Adm or designated representative will notify law enforcement by telephone immediately, or as soon as practicable possible, but no longer than (2) hours of the initial report. b. The Adm or designated representative will send a written SOC341 report to the OMB and Law Enforcement and CDPH Licensing and Certification within (24) hours. 8. Suspension of Employees a. Employees of this facility who have been accused of resident abuse or a crime will be suspended from duty until the results of the investigation have been reviewed by the Adm. 9. Informing Resident of Result of Investigation and Corrective Action a. The Adm will inform the resident and his or her representative of the results of the investigation and the corrective action taken within five (5) working days of the reported incident. 10. Providing State Survey Agency and Other Agencies of the Result a. The Adm will provide a written report of the results of all abuse investigations and appropriate action taken, to the California Department of Public Health Licensing and Certification and others that may be required by state or local law, within five (5) working days of the reported allegation.

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

09/02/2025

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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

9/2/2025 at 3:19 p.m. with RN 2, RN 2 stated is not employed by the facility but a registry and worked at the facility on 8/24/2025 from 7a.m. to 3 p.m. RN 2 stated Resident 2 complained and stated she (Resident 2) was not comfortable with CNA 2. RN 2 stated she (RN 2) volunteered to care for Resident 2 this was around 9 a.m. did Resident 2's perineal care, changed her depend, and provided water. RN 2 stated around 1 p.m. went with CNA 2 to Resident 2's room and Resident 2 was upset stated did not want CNA 2 RN 2 stated explained to Resident 2 there was limited assistance and Resident then yelled at RN 2 and called RN 2 derogatory names. RN 2 stated Resident 2 was in her (Resident 2) wheelchair. Resident 2 stated she was soaked in urine. RN 2 stated Resident 2 was soaked. RN 2 stated when placed Resident 2 back into bed Resident was upset and wanted things done a certain way. RN 2 stated Resident grabbed CNA 2 by

the hair and scratched RN 2. During an interview on 9/2/2025 at 3:33 p.m. with the Director of Staff Development (DSD) the DSD stated spoke to Resident 2 on 8/28/2025 and Resident 2 stated RN 2 and CNA 2 had scratched her (Resident 2). The DSD stated when a resident alleges, they have been scratched that would be considered abuse, this would have been a physical abuse. The DSD stated not sure if we did anything the Adm knew about this incident as of 8/24/2025 was told by RN 2. The DSD stated any type of abuse must be reported within two (2) hours to the three (3) agencies ombudsmen (OMB), police and SSA.

The DSD stated would have to check with Adm not sure if it was reported.During a concurrent interview and record review of Resident 2's text messages with the Adm on 9/2/2025 at 4 p.m. with the Adm, the Adm stated he (Adm) is the abuse coordinator. The Adm reviewed text between Resident 2 and Adm, the Adm stated on 8/24/2025 Resident 2 alleged staff (RN 2 and CNA 2) started fighting physical. The Adm stated abuse would be any physical, verbal, or wrongdoing against someone. The Adm stated I (Adm) would consider this abuse, the Adm stated I (Adm) should have told the nurse at that time to report to OMB, SSA, police and start the investigation. The Adm stated did not do any investigation for Resident 2 allegation of abuse. The Adm stated potential for not investigating can be a resident continues to be at risk for further abuse. During a review of the facility's P&P titled, Abuse, Reporting and Investigations, last reviewed on 4/4/2025, the P&P indicated allegation of abuse, neglect, mistreatment, exploitation, or reasonable suspicion of a crime are to be reported to the Administrator or designated representative immediately.ii. If

the suspected perpetrator is an employee, remove the employee immediately from the care of the resident and immediately suspend the employee pending the outcome of the investigation in accordance with the facility policies.3. Notification of Outside Agencies for all other Cases of Abuse.a. The Adm or designated representative will notify law enforcement by telephone immediately, or as soon as practicable possible, but no longer than (2) hours of the initial report.b. The Adm or designated representative will send a written SOC341 report to the OMB and Law Enforcement and CDPH Licensing and Certification within (24) hours.8. Suspension of Employeesa. Employees of this facility who have been accused of resident abuse or

a crime will be suspended from duty until the results of the investigation have been reviewed by the Adm.9.

Informing Resident of Result of Investigation and Corrective Actiona. The Adm will inform the resident and his or her representative of the results of the investigation and the corrective action taken within five (5) working days of the reported incident.10. Providing State Survey Agency and Other Agencies of the Resulta. The Adm will provide a written report on the result of all abuse investigations and appropriate action taken, to the California Department of Public Health Licensing and Certification and others that may be required by state or local law, within five (5) working days of the reported allegation.

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

09/02/2025

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 - Minimal harm or potential for actual harm Residents Affected - Few

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

forced to accept any medical treatment and may refuse specific treatment even though it is prescribed by their Attending Physician.II. When a resident refuses treatment, the Charge Nurse or Director of Nursing Services (DNS) interviews the resident to determine what and why the resident is refusing. The Charge Nurse or DNS will attempt to address the residents' concerns and explain the consequences of the refusal.III. The Charge Nurse or DNS will document information relating to the refusal in the resident's medical record. During a review of the facility's P&P titled, Resident Right, Quality of life, last reviewed on 4/4/2025, the P&P 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 or her highest practicable well-being.I.

Residents are groomed as they wish, including bathing, dressing and oral care.

Event ID:

Facility ID:

If continuation sheet