Health inspection·February 24, 2025

F 0574 The resident has the right to receive notices in a format and a language he or she understands. 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 provide the resident representative (RR - An individual chosen by the resident or authorized by State or Federal law to act on behalf of the resident) with resident ' s Notice of Proposed Discharge form in a language they understand for one of three sampled residents (Resident 1). Residents Affected - Few This deficient practice had the potential to result in the RR being unaware of how to contact the State agency and how to appeal a discharge if necessary. Findings: During a review of Resident 1 ' s admission Record, (not dated), the admission Record indicated, Resident 1 was admitted on [DATE] with the following diagnoses including depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), muscle weakness, and Alzheimer ' s disease (a disease characterized by a progressive decline in mental abilities). During a review of Resident 1's History and Physical (H&P), dated 2/11/2025, the H&P indicated Resident 1 did not have the mental capacity to understand and make decisions. During a review of Resident 1 ' s Physician Order, dated 2/18/2025, the Physician Order indicated Resident 1 was scheduled to be discharged to home on 2/21/2025. During an interview on 2/21/2025 at 2:51 p.m. with Resident 1 ' s RR, the RR stated he does not understand English. The RR also stated he received Spanish translation during telephone discussion of Resident 1 ' s discharge with the case manager and social worker but was not notified of the appeal process. During a concurrent interview and record review on 2/24/2025 at 12:25 p.m. with the Social Services Director (SSD), Resident 1 ' s Notice of Proposed Transfer/Discharge, dated 2/24/2025, was reviewed. The Notice of Proposed Transfer/Discharge signed by the RR was in English. The SSD stated Resident 1 ' s RR is Spanish Speaking. The SSD also stated the Notice of Proposed Transfer/Discharge form provides residents and their representatives with information about the proposed discharge including how to appeal. The facility was not able to provide a policy and procedure regarding providing documents to residents and their resident representatives in the language that they understand. Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 555117 Printed: 05/15/2026 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 555117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2025 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)