Inspection citations
12’21
2’23
46’24
54’25
6’26
120 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| May 15, 2026 | E · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| May 15, 2026 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| May 15, 2026 | E · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
| Jan 20, 2026 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Jan 20, 2026 | D · potential | Provide safe, appropriate pain management for a resident who requires such services. | Complaint |
| Jan 20, 2026 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Complaint |
| Sep 2, 2025 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| Sep 2, 2025 | D · potential | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Complaint |
| Sep 2, 2025 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Sep 2, 2025 | D · potential | Respond appropriately to all alleged violations. | Complaint |
| Sep 2, 2025 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Aug 9, 2025 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Complaint |
| Aug 9, 2025 | J · harm | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| Aug 9, 2025 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Aug 9, 2025 | J · harm | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Aug 9, 2025 | E · potential | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Complaint |
| Aug 9, 2025 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Complaint |
| Aug 9, 2025 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
| Aug 9, 2025 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| May 22, 2025 | D · potential | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Routine |
| May 22, 2025 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Routine |
| May 22, 2025 | D · potential | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Routine |
| May 22, 2025 | E · potential | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Routine |
| May 22, 2025 | D · potential | Assess the resident when there is a significant change in condition | Routine |
| May 22, 2025 | B · minimal | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. | Routine |
| May 22, 2025 | B · minimal | Ensure each resident receives an accurate assessment. | Routine |
| May 22, 2025 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| May 22, 2025 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Routine |
| May 22, 2025 | E · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| May 22, 2025 | D · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Routine |
| May 22, 2025 | E · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| May 22, 2025 | E · potential | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Routine |
| May 22, 2025 | D · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| May 22, 2025 | D · potential | Post nurse staffing information every day. | Routine |
| May 22, 2025 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| May 22, 2025 | D · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| May 22, 2025 | E · potential | Ensure that residents are free from significant medication errors. | Routine |
| May 22, 2025 | E · potential | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Routine |
| May 22, 2025 | E · potential | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Routine |
| May 22, 2025 | D · potential | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Routine |
| May 22, 2025 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| May 22, 2025 | E · potential | Dispose of garbage and refuse properly. | Routine |
| May 22, 2025 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Routine |
| May 22, 2025 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| May 22, 2025 | E · potential | Implement a program that monitors antibiotic use. | Routine |
| May 22, 2025 | D · potential | Keep all essential equipment working safely. | Routine |
| May 22, 2025 | B · minimal | Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Routine |
| May 22, 2025 | B · minimal | Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Routine |
| May 6, 2025 | D · potential | Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Complaint |
| May 6, 2025 | G · harm | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| May 6, 2025 | E · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
| Apr 14, 2025 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| Apr 14, 2025 | D · potential | Provide safe, appropriate pain management for a resident who requires such services. | Complaint |
| Apr 14, 2025 | D · potential | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Complaint |
| Apr 2, 2025 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Apr 1, 2025 | G · harm | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Apr 1, 2025 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Feb 24, 2025 | D · potential | The resident has the right to receive notices in a format and a language he or she understands. | Complaint |
| Feb 24, 2025 | E · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Jan 3, 2025 | D · potential | Develop and implement policies and procedures for flu and pneumonia vaccinations. | Complaint |
| Sep 1, 2024 | E · potential | Provide safe, appropriate pain management for a resident who requires such services. | Complaint |
| Sep 1, 2024 | K · harm | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Complaint |
| Sep 1, 2024 | D · potential | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Complaint |
| Sep 1, 2024 | E · potential | Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Complaint |
| Sep 1, 2024 | E · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
| Sep 1, 2024 | E · potential | Provide and implement an infection prevention and control program. | Complaint |
| Jun 13, 2024 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Complaint |
| Jun 13, 2024 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Routine |
| Jun 13, 2024 | D · potential | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Routine |
| Jun 13, 2024 | D · potential | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Routine |
| Jun 13, 2024 | D · potential | Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Routine |
| Jun 13, 2024 | D · potential | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. | Routine |
| Jun 13, 2024 | E · potential | Ensure each resident receives an accurate assessment. | Routine |
| Jun 13, 2024 | E · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Jun 13, 2024 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Routine |
| Jun 13, 2024 | E · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Jun 13, 2024 | E · potential | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Routine |
| Jun 13, 2024 | D · potential | Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. | Routine |
| Jun 13, 2024 | D · potential | Provide activities to meet all resident's needs. | Routine |
| Jun 13, 2024 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Jun 13, 2024 | D · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Complaint |
| Jun 13, 2024 | G · harm | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Routine |
| Jun 13, 2024 | E · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Jun 13, 2024 | D · potential | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Complaint |
| Jun 13, 2024 | E · potential | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Routine |
| Jun 13, 2024 | D · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Jun 13, 2024 | D · potential | Provide safe, appropriate dialysis care/services for a resident who requires such services. | Routine |
| Jun 13, 2024 | E · potential | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Routine |
| Jun 13, 2024 | D · potential | Observe each nurse aide's job performance and give regular training. | Routine |
| Jun 13, 2024 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Jun 13, 2024 | E · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Jun 13, 2024 | E · potential | Ensure that residents are free from significant medication errors. | Routine |
| Jun 13, 2024 | E · potential | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Routine |
| Jun 13, 2024 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Jun 13, 2024 | D · potential | Provide or get specialized rehabilitative services as required for a resident. | Routine |
| Jun 13, 2024 | D · potential | Employ staff that are licensed, certified, or registered in accordance with state laws. | Routine |
| Jun 13, 2024 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Routine |
| Jun 13, 2024 | D · potential | Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Routine |
| Jun 13, 2024 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Jun 13, 2024 | D · potential | Develop and implement policies and procedures for flu and pneumonia vaccinations. | Routine |
| Jun 13, 2024 | D · potential | Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Routine |
| Jun 13, 2024 | B · minimal | Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Routine |
| Jun 13, 2024 | B · minimal | Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Routine |
| Apr 4, 2024 | E · potential | Ensure that residents are free from significant medication errors. | Complaint |
| Jan 8, 2024 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Jan 8, 2024 | G · harm | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Nov 14, 2023 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Nov 14, 2023 | D · potential | Post nurse staffing information every day. | Complaint |
| Oct 22, 2021 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Oct 22, 2021 | E · potential | Honor the resident's right to organize and participate in resident/family groups in the facility. | Routine |
| Oct 22, 2021 | E · potential | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Routine |
| Oct 22, 2021 | E · potential | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Routine |
| Oct 22, 2021 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Oct 22, 2021 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Oct 22, 2021 | E · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Routine |
| Oct 22, 2021 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Oct 22, 2021 | D · potential | Ensure that residents are free from significant medication errors. | Routine |
| Oct 22, 2021 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Oct 22, 2021 | B · minimal | Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Routine |
| Oct 22, 2021 | B · minimal | Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Routine |
Medicare's severity letters: A–C minimal harm, D–F potential for more than minimal harm, G–L actual harm or immediate danger. Source: CMS health deficiencies file, processed October 1, 2026.
Questions to ask on a visit
Skyline Healthcare Center - LA
3032 Rowena Ave, Los Angeles, CA 90039 · (323) 665-1185
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 555117
- Certified beds
- 99
- Legal owner
- Skyline Healthcare & Wellness Center, LLC
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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