Health inspection·January 20, 2026

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Evaluation dated 12/10/2025 did not indicate the fall Resident 2 had. The DON stated the Fall Risk Evaluation for 12/10/2025 should have a higher score. The DON stated for the Fall Risk Evaluation dated 12/14/2025 staff should have indicated the fall when Resident 2 returned from the hospital the Fall Risk Evaluation indicates Resident 2 does not have any history of falls in the last three (3) months. The DON stated if the Fall Risk Evaluation is not accurately documented then the facility will not be doing the proper interventions to prevent falls.During a review of the facility's policy and procedure (P&P) titled, Fall Management Program, last reviewed on 4/4/2025 the P&P indicated to reduce the risk of avoidable falls and falls-related injuries and to ensure timely, evidence-based post-fall evaluation and management consistent with the best practice, federal and state guidance requirements for resident safety, supervision and quality of care. Event ID: Facility ID: 555117 If continuation sheet Page 2 of 6 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 01/20/2026 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record review, the facility failed to ensure one of three sampled residents (Resident 2) who complained of pain received medication according to the physician orders. This failure resulted in Resident 2's pain management to be ineffective resulting in Resident 2 being in pain.Findings:During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 11/4/2025 and re-admitted the resident on 12/14/2026 with diagnoses including fracture of lower end of left tibia (a broken or cracked shinbone[the large, inner bone of the lower leg] just above your ankle joint), fracture of shaft of left tibia (a break in the middle, long part of the left shinbone), difficulty in walking, and pain due to internal orthopedic prosthetic device (man-made, artificial part surgically placed inside the body to replace or support damaged bones or joints), implants (a thing implanted in something else, especially a piece of tissue, prosthetic device, or other object implanted in the body), and grafts (a piece of living tissue that is transplanted surgically).During a review of Resident 2's Physician History and Physical (H&P- a process used by doctors to understand a resident's health and it combines medical history and a physical examination), dated 11/11/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions.During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 11/13/2025, the MDS indicated Resident 2 had the ability to understood and was understood. The MDS indicated Resident 2 was dependent (helper does all the effort) with putting on taking off footwear, and lower body dressing, required substantial assistance (helper does more than half the effort) with toileting, showering, and required partial assistance (helper does less than half the effort) with oral hygiene, upper body dressing and personal hygiene.During a review of Resident 2 Order Summary Report (OSR), dated 11/4/2025, the OSR indicated acetaminophen 325 milligrams (mg- a unit of measurement) to give two (2) tablets by mouth every four (4) hours as needed for mild pain (1-4).During a review of Resident 2 OSR, dated 12/4/2025, the OSR indicated:- Hydrocodone-acetaminophen oral tablet 10-325 mg give one (1) tablet by mouth every four (4) hours as needed for moderate pain (5-7) every four (4) hours as needed for moderate pain.- Hydrocodone-acetaminophen oral tablet 10-325 mg give two (2) tablets by mouth every six (6) hours as needed for severe pain (8-9).During a review of the facility provided fax dated 1/18/2026 at 11:48a.m, the fax indicated a request to fill the following prescriptions:Hydrocodone-acetaminophen oral tablet 10-325 mg take one (1) tablet every four (4) hours by mouth as needed for 30 days for moderate to severe pain.- Hydrocodone-acetaminophen tablet 10-325 mg take one (1) tablet every four (4) hours by mouth as needed for moderate pain (5-7) and take two (2) tablets by mouth every six (6) hours as needed for sever pain (8-9).During a review of Resident 2's medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for January, the MAR indicated on 1/19/2026 at 8:56 p.m. Resident 2 was given acetaminophen 325 two (2) tablets by mouth every four (4) hours as needed for mild pain (1-4) for a pain rating or 9 (sever pain 8-9).During an interview on 1/20/2026 at 11:40a.m. with Resident 2, Resident 2 stated was told the facility ran out of his Norco (Hydrocodone-acetaminophen 10-325 mg) has not gotten it since 1/18/2026 at night. Resident 2 stated his pain is currently 9 out of 10 (pain scale - a tool usually rated 0 to 10 used to measure pain, 0: no pain, 1-3: Mild barely noticeable, 4-6: moderate hard to ignore interferes with activities, 7-9: severe strong pain hard to concentrate prevents normal activity, 10: worst possible unbearable crying or unable to move) it hurt so bad it is causing him a headache. Resident 2 stated was given Tylenol (acetaminophen 325 mg), but it did not help. Resident 2 stated his pain is bad and he takes the pain medication every six (6) hours on the dot because his pain is bad. Resident 2 stated he (Resident 2) did Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 3 of 6 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 01/20/2026 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete therapy today (1/20/2026) the pain did not impede his therapy.During a concurrent interview and record review on 1/20/2026 at 12:33 p.m. of Resident 2's MAR with Licensed Vocational Nurse (LVN) 1, LVN 1 stated found out Resident 2 was out of his pain medication yesterday (1/19/26) on her first day back to work. LVN 1 stated usually she reorders the medication prior to running out usually when there is six (6) tablets left. LVN 1 stated the request for a refill was sent via fax on 1/18/26 at 11:48 a.m., LVN 1 stated she was planning to follow up with pharmacy today. LVN 1 reviewed MAR for the date of 1/19/2026 8:56 p.m. and LVN 1 stated she (LVN 1) gave Resident 2 Tylenol (acetaminophen 325 mg) for a pain level of 9 but the Tylenol is ordered for a pain level of 1-4. LVN 1 stated there can be a possibility that Resident 2's pain may not be alleviated. During a concurrent interview and record review on 1/20/2026 at 4 p.m. of Resident 2's MAR with the Director of Nursing (DON), the DON stated staff should have at least two to three days' worth of medication. The DON stated medications should never run out. The DON reviewed Resident 2's MAR for 1/19/26 at 8:56 p.m. and stated there is a potential for there to be ineffective management of pain for Resident 2. During a review of the facility's policy and procedure (P&P) titled, Pain Management, last reviewed on 4/4/2025, the P&P indicated facility staff will help the resident attain or maintain their highest-level of well-being while working to prevent or manage the resident's pain to the extent possible. The licensed nurse will administer pain medication as ordered and document medication administered on the MAR. Event ID: Facility ID: 555117 If continuation sheet Page 4 of 6 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 01/20/2026 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review. the facility failed to ensure one of three sampled residents (Resident 2) was free of any significant medication error when Licensed Vocational Nurse (LVN) 1, failed to administer medications as ordered.This deficient practice had the potential to negatively affect Resident 2. Findings:During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 11/4/2025 and re-admitted the resident on 12/14/2026 with diagnoses including fracture of lower end of left tibia (a broken or cracked shinbone[the large, inner bone of the lower leg] just above your ankle joint), fracture of shaft of left tibia (a break in the middle, long part of the left shinbone), difficulty in walking, and pain due to internal orthopedic prosthetic device (man-made, artificial part surgically placed inside the body to replace or support damaged bones or joints), implants (a thing implanted in something else, especially a piece of tissue, prosthetic device, or other object implanted in the body) and grafts (a piece of living tissue that is transplanted surgically).During a review of Resident 2's Physician History and Physical (H&P- a process used by doctors to understand patients' health it combines medical history and a physical examination) dated 11/11/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions.During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 11/13/2025, the MDS indicated Resident 2 had the ability to understand and was understood. The MDS indicated Resident 2 was dependent (helper does all the effort) with putting on taking off footwear, and lower body dressing, required substantial assistance (helper does more than half the effort) with toileting, showering, and required partial assistance (helper does less than half the effort) with oral hygiene, upper body dressing and personal hygiene.During a review of Resident 2's Order Summary Report (OSR), dated 11/4/2025, the OSR indicated acetaminophen 325 milligrams (mg- a unit of measurement) give two (2) tablets by mouth every four (4) hours as needed for mild pain (1-4).During a review of Resident 2's OSR, dated 12/4/2025, the OSR indicated:- Hydrocodone-acetaminophen oral tablet 10-325 mg give one (1) tablet by mouth every four (4) hours as needed for moderate pain (5-7) every four (4) hours as needed for moderate pain.- Hydrocodone-acetaminophen oral tablet 10-325 mg give two (2) tablets by mouth every six (6) hours as needed for sever pain (8-9).During a review of the facility provided fax document, dated 1/18/2026 at 11:48 a.m., the fax document indicated a request to fill the following prescriptions:Hydrocodone-acetaminophen oral tablet 10-325 mg take one (1) tablet every four (4) hours by mouth as needed for 30 days for moderate to severe pain.- Hydrocodone-acetaminophen tablet 10-325 mg take one (1) tablet every four (4) hours by mouth as needed for moderate pain (5-7) and take two (2) tablets by mouth every six (6) hours as needed for severe pain (8-9).During a review of Resident 2's Medication Administration Records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for January 2026, the MAR indicated on 1/19/2026 at 8:56 p.m. Resident 2 was given acetaminophen 325 two (2) tablets by mouth every four (4) hours as needed for mild pain (1-4) for a pain rating or 9 (sever pain 8-9).During an interview on 1/20/2026 at 11:40a.m. with Resident 2, Resident 2 stated was told the facility ran out of his Norco (Hydrocodone-acetaminophen 10-325 mg) has not gotten it since 1/18/2026 at night. Resident 2 stated his pain is currently 9 out of 10 it hurt so bad it is causing him a headache. Resident 2 stated was given Tylenol (acetaminophen 325 mg) but it did not help. Resident 2 stated his pain is bad and he takes the pain medication every six (6) hours on the dot because his pain is bad.During a concurrent interview and record review on 1/20/2026 at 12:33 p.m. of Resident 2's MAR with Licensed Vocational Nurse (LVN) 1, LVN 1 stated found out Resident 2 was out of his pain medication yesterday (1/19/26) on her first day back to work. LVN 1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 5 of 6 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 01/20/2026 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete stated usually she reorders the medication prior to running out usually when there is six (6) tablets left. LVN 1 stated the request for a refill was sent via fax on 1/18/26 at 11:48 a.m., LVN 1 stated she was planning to follow up with pharmacy today. LVN 1 reviewed MAR for the date of 1/19/2026 8:56 p.m. and LVN 1 stated she (LVN 1) gave Resident 2 Tylenol (acetaminophen 325 mg) for a pain level of 9 but the Tylenol is ordered for a pain level of 1-4. LVN 1 stated there can be a possibility that Resident 2's pain may not be alleviated. During a concurrent interview and record review on 1/20/2026 at 4 p.m. of Resident 2's MAR with the Director of Nursing (DON), the DON stated staff should have at least two to three days' worth of medication. The DON stated medications should never run out. The DON reviewed Resident 2's MAR for 1/19/26 at 8:56 p.m. and stated there is a potential for ineffective management of Resident 2's pain. During a review of the facility's policy and procedure (P&P) titled, Pain Management, last reviewed on 4/4/2025 the P&P indicated facility staff will help the resident attain or maintain their highest-level of well-being while working to prevent or manage the resident's pain to the extent possible. The licensed nurse will administer pain medication as ordered and document medication administered on the MAR.During a review of the facility's P&P titled, Reordering, Changing, and Discontinuing Medication Orders, last reviewed on 4/4/2025, the P&P indicated:B. Reorder/Refills Orders:1. Refills can be requested via facilities EMAR system; this is the most preferred method. Facility may also request refills by placing the refill strip portion of the medication label on the Refill Order Form and faxing it to the pharmacy Event ID: Facility ID: 555117 If continuation sheet Page 6 of 6