Health inspection·April 2, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a written or electronic record containing all the information the resident needs to effectively manage their own health) for one out of three sampled residents (Resident 1) by failing to ensure Resident 1 had a care plan regarding alleged sexual abuse. This deficient practice had the potential to result in failing to address Resident 40's allegations that may lead to a delay in or lack of delivery of care and services. Findings: During a review of Resident 1's Record of Admission, the Record of admission indicated the facility admitted the resident on 10/12/2023 with diagnoses that included hypertension (the force of your blood pushing against your artery walls is consistently too high, making your heart work harder). During a review of Resident 1's Minimum Data Set (Interdisciplinary Notes, a resident assessment tool), dated 2/7/2025, the MDS indicated that Resident 1 had moderate cognitive (thinking) impairment. During a review of Resident 1's Interdisciplinary Notes, dated 3/28/2025, the Interdisciplinary Notes indicated that Resident 1 verbalized that a man and a woman allegedly sexually assaulted him. During a review of Resident 1's Change of Condition Evaluation, dated 3/28/2025, the Change of Condition Evaluation indicated that Resident 1 alleged that he was raped by two people. During a concurrent interview and record review of Resident 1's Care Plan, on 4/2/2025 at 11:38 a.m., with Registered Nurse (RN) 1, RN 1 stated there was no care plan done regarding Resident 1 alleging that he was sexually abused. RN 1 stated Resident 1 should have a care plan regarding the allegation of sexual abuse to indicate the interventions that need to be done for Resident 1's safety. During an interview on 4/2/2025 at 11:55 a.m., with the Director of Nursing (DON), the DON stated that Resident 1 should have a care plan regarding the alleged sexual abuse. The DON stated having a care plan would indicate the interventions that need to be done for Resident 1. The DON stated if there was no care plan, there were no interventions being done for the resident. During a review of the facility policy and procedures (P&P) titled, Comprehensive Person-Centered Care planning,'' last reviewed on 4/4/2024, the P&P indicated that since the baseline care plan documents the interim approaches for meeting the resident's immediate needs, it must also reflect changes to approaches, as necessary, resulting from significant changes in condition or needs, occurring (continued on next page) 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 2 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 04/02/2025 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)