Skyline Healthcare Center - La
SKYLINE HEALTHCARE CENTER - LA in LOS ANGELES, CA — inspection on September 2, 2025.
Found 5 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 an interview on 9/2/2025 at 4 p.m. with the Administrator (Adm), the Adm stated Resident 2
The Adm stated a COC is to monitor the residents for the COC.
The MD must be notified to get new
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.
555117 09/02/2025
Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039
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, wrongdoing against someone.
The Adm stated Adm would consider this abuse.
The Adm stated Adm should have told the nurse at that time to report to OMB, SSA, police and start the investigation.
The Adm stated Adm did not do any investigation for Resident 2's allegation of abuse.
The Adm stated the 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 of the result of all abuse investigations and appropriate action taken, to 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.
555117 09/02/2025
Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039
During an interview on 9/2/2025 at
when a resident alleges, they have been scratched that would be considered abuse, this would have
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.
- 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.
555117 09/02/2025
Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039
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.
555117 09/02/2025
Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039
maintaining his or her highest practicable well-being.I.
Residents are groomed as they wish, including
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.