Skyline Healthcare Center-Los Angeles in Los Angeles: Inspection Record Review, Complaints and Abuse Reports (Updated October 30, 2026)

According to the citation, Resident 1 was a 47-year-old man with type 2 diabetes, high blood pressure and chronic kidney disease. A physician's order dated 7/15/2025 told staff to notify his doctor if his blood sugar was above 350 mg/dl. At 4 a.m. on 7/19/2025 he had a change of condition: he was nauseated, vomited once, and Licensed Vocational Nurse 1 recorded a blood sugar of at least 382 mg/dl.

CDPH found the physician was not notified as the order required. Inspectors found staff did not take his vital signs or perform a full nursing assessment during the change of condition, and Licensed Vocational Nurse 1 did not report it to the nurses coming on for the 7 a.m. shift. CDPH determined staff did not follow the facility's policies on change of condition notification, diabetic care, blood sugar monitoring, vital signs and shift communication. According to the citation, he was found unresponsive in his room at 7:50 a.m. and was pronounced dead at the facility at 8:05 a.m., with type 2 diabetes listed as an underlying condition that contributed to his death.

According to the citation, CDPH classified the violation as Class AA, with a $120,000 penalty. The 2567 report states the facility was cited under F684, quality of care, and F580, notification of changes, both at severity J. It states inspectors called an immediate jeopardy on 8/7/2025 and removed it on 8/9/2025 after verifying the facility's removal plan, which included a shift-to-shift change of condition hand-off report and training for licensed nurses.

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According to the citation, on 4/22/2025 at 8:40 p.m. Resident 1 and Resident 2, who shared a room, had a verbal argument that turned physical, and Resident 2 punched Resident 1 on the left side of the face with a closed fist. Resident 1 was a 67-year-old man with paralysis and weakness from strokes and chronic obstructive pulmonary disease (a long-term lung disease). CDPH determined the facility failed to protect his right to be free from physical abuse by another resident.

CDPH found that on 4/22/2025 Resident 1 had swelling on the left side of his face and rated his pain seven out of ten. According to the citation, he was sent by ambulance to an acute care hospital on 4/23/2025 at 11:25 a.m., where he was diagnosed with a displaced nasal bone fracture (a broken nose with the bone pieces shifted out of place). The citation also states that Resident 2 had a history of verbal behaviors toward others, such as threatening, screaming and cursing, and had a care plan on aggression.

According to the citation, CDPH classified the violation as Class A, with a $25,000 penalty. The 2567 report states the facility was cited under F600 at severity G, finding the facility did not protect Resident 1 from being struck by Resident 2 while under the facility's care.

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The 2567 report states that on 3/21/2025 at 7 a.m., Resident 2 scratched the right lower foot of her roommate, Resident 1, while a staff member was wheeling Resident 2 out of their room in a wheelchair. According to the report, Resident 1 had parkinsonism (a brain condition causing slow movement, stiffness and tremors) and quadriplegia (loss of function in all four limbs), and depended on staff for toileting and showers.

Inspectors found the scratch measured 10 centimeters long and 0.3 centimeters wide and needed first aid and daily wound treatments. The 2567 report states Resident 1 was visibly upset and said the scratch shook her and made her scared. Inspectors found the facility failed to protect her right to be free from physical abuse by another resident.

The 2567 report states the facility was cited under F600 at severity G for this finding. The same survey also cited F609, reporting of alleged violations, at severity D. The full narrative of the F609 finding is in the linked report.

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The 2567 report states the facility had no system in place to safeguard prescribed and controlled medications, such as opioid pain pills. Inspectors found staff did not follow the facility's policy requiring the incoming and outgoing nurse to count and sign for controlled drugs at every shift change. According to the report, the August 2024 count sheets for the four medication carts were missing 12, 18, three and 18 signatures, and one cart was found unlocked when not in use.

The 2567 report states that on 8/18/2024 at 7:30 a.m. the facility could not account for 10 tablets of hydrocodone-acetaminophen for Resident 1, six tablets of the same drug for Resident 2, and four tablets of oxycodone-acetaminophen for Resident 3. Inspectors found these practices put residents at risk of receiving more or less medication than prescribed and made it hard to detect loss or drug diversion. The report also states the facility did not ensure Residents 1, 9 and 10 were given hydrocodone-acetaminophen at times when nurses had taken doses from those residents' controlled drug records, which had the potential to leave their pain uncontrolled.

The 2567 report states the facility was cited under F755, pharmacy services and records, at severity K. According to the report, inspectors called an immediate jeopardy on 8/29/2024. The 2567 report states the facility submitted a removal plan on 9/4/2024, and inspectors confirmed it was carried out and removed the immediate jeopardy that day.

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According to the citation, Resident 7 was a 73-year-old woman admitted on 7/15/2022 with paralysis on her right side after a stroke, difficulty swallowing, a feeding tube and functional quadriplegia. After therapy ended on 8/3/2022, her therapists and physician ordered restorative nursing care, including passive range of motion exercises (staff moving her joints for her) for both arms and legs, a resting splint for her right hand, and splints for both knees.

CDPH found the facility did not provide the passive range of motion exercises from 8/3/2022 to 9/30/2022 and did not apply the right hand splint for about six months, through 2/10/2023. Inspectors found the knee splints were never obtained from 8/3/2022 to 3/26/2024, about 19 months. According to the citation, staff also did not check her joint mobility every quarter as her care plan required, did not apply ordered hand rolls (rolled towels placed in the palms) and a right elbow splint, and the facility's rehabilitation screening policy did not include assessments to identify functional decline.

According to the citation, she developed contractures (shortened, stiff muscles and tendons) of the right hand, right elbow, both shoulders and legs, felt pain with movement, and could not get out of bed, including for a shower. CDPH classified the violation as Class A, with a $25,000 penalty. The 2567 report states the facility was cited under F688, range of motion and mobility, at severity G.

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According to the citation, Resident 1 was a 58-year-old man with encephalopathy (brain dysfunction causing confusion), nerve damage and a history of stroke. He was assessed as a high fall risk and as needing two staff members to help with moving in bed, transfers and toileting. CDPH found that on 12/4/2023 CNA 1 provided care and turned him in bed alone, without the required second staff member.

Inspectors found that at about 2:50 p.m. on 12/4/2023 he fell off the bed. According to the citation, CNA 1 admitted being aware that he needed two-person assistance. CNA 1 stated not realizing he was already at the edge of the bed, and said no other staff were available because it was the end of the shift. CNA 1 also stated the fall could have been prevented with help from another staff member. A licensed vocational nurse told inspectors a red star sticker on his doorway nameplate meant he needed two-person assistance.

According to the citation, the fall caused pain and an acute fracture of the left femur (thigh bone), and he had surgery at an acute care hospital to fix his left hip with an intramedullary hip screw. CDPH classified the violation as Class A, with a $20,000 penalty. The 2567 report states the facility was cited under F689, accident hazards and supervision, at severity G, and describes the fall as avoidable.

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