Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Temple City Healthcare during CMS and state inspections, most recent first.
Water temperatures in 2 of 3 shower rooms were below the facility’s acceptable range, with readings of 90 F, 97 F, and a sink temperature of 74 F. A resident with encephalopathy, muscle weakness, and Parkinsons disease reported the shower water fluctuated between hot and cold, while an MS acknowledged the importance of maintaining comfortable shower temperatures. Records also showed shower temperatures were not checked on two dates, and the facility policy required hot tap water to be 100 F to 110 F.
A facility failed to provide ordered ROM and ambulation services for several residents with mobility limitations. One resident with Parkinson’s disease and dementia declined from walking with a FWW to no longer ambulating, while RNA staff did not document weekly summaries, did not report the decline, and the MDS was inaccurately coded. Another resident with stroke, fractures, weakness, and Parkinson’s disease did not receive ordered ambulation or A/AAROM, had missing RNA summaries, and was later found to have no active RNA services despite prior therapy recommendations. Additional residents had inaccurate JMA findings, missed ROM exercises, missed PT/OT follow-up, and a missing right-hand roll order.
The facility failed to provide enough RNA staffing for 26 residents receiving restorative services. The Facility Assessment Tool indicated two RNAs were needed, but staffing sheets showed only one RNA was usually assigned and that person was also covering the guard, feeding residents, passing out nourishments, and sometimes providing CNA care. Interviews with the RNA, DSD, and ADM confirmed that the facility relied on one full-time RNA, with limited help from other staff, and that some residents did not receive RNA when the RNA was pulled to other duties.
Failure to ensure restorative nursing competency for ambulation care. A resident with Parkinson's disease and dementia had declining mobility, with orders for restorative ambulation using a FWW five times weekly. RNA staff reported the resident's walking decreased from 150 to 200 feet to only a few feet, then to no walking at all, with transfers from bed to chair being treated as restorative care. One RNA stated he did not know how to document refusals or poor tolerance, and the DSD confirmed no competency was completed for that RNA despite the facility policy requiring competency evaluation.
Inaccurate RNA documentation affected several residents with significant mobility and contracture issues, including residents with Parkinson’s disease, dementia, fractures, cerebral infarction, hemiplegia, and multiple contractures. Records showed ROM, ambulation, and splinting services on days when the RNA aide was not working, one resident’s record reflected services during a hospital stay and after the RNA program had been discontinued, and one resident’s record did not match the ordered A/AAROM service. Observations and interviews also showed some ordered ROM and splinting were not provided as documented, and the DON, ADM, and DMR stated the records were inaccurate.
Ineffective QAPI Program Failed to Identify Systemic Care Issues: The facility’s QAPI program was limited to falls and infection control and did not identify issues related to staffing, care plan development, the Restorative Nursing Program, or Trauma Informed Care implementation. The ADM stated that QAPI meetings only addressed issues raised by attendees, and the ADM acknowledged the system for identifying systemic issues was not working. The facility’s written QAPI policy called for an effective system to use feedback, review data, and determine improvement priorities, but surveyors found the program did not identify issues tied to F688, F656, F678, and F638.
The facility failed to follow infection control practices during resident care and feeding, including missing gown use for enhanced barrier precautions, missing hand hygiene before feeding, and missing gown use during ROM and wound care. The facility also had water management and temperature monitoring failures, including out-of-range resident water temperatures, undocumented water heater checks, a malfunctioning dryer thermometer, inaccurate washer temperature documentation, and an IPN who was not familiar with the water management program.
Failure to Obtain Informed Consent for Psychotropic Medications: Two residents with dementia and impaired decision-making capacity received psychotropic meds without documented informed consent. One resident received PRN Lorazepam for anxiety, and another received Quetiapine for schizophrenia, while RN review confirmed no consent was present in the records. The DON stated informed consent is required before psychotropic meds are administered and that the resident or responsible party must be informed of the risks and benefits.
Failure to assess self-administration of medication: A resident with DM and a seizure disorder had an order for magnesium glycinate, but an unattended personal bottle of the supplement was found at the bedside. The MAR showed a scheduled dose, and an LVN stated the IDT had not completed a self-administration assessment to determine whether the resident could safely self-administer the medication or keep it at the bedside.
The facility failed to notify the LPN, physician, and responsible party of significant changes in condition for two residents. One resident developed worsening left-hand contractures, with the middle, ring, and small fingers bent into the palm and painful when extended, after OT had previously documented WFL hand ROM and ordered PROM. Another resident with Parkinson’s disease and dementia declined from ambulating with a FWW to no longer walking, but RNA did not report the mobility decline to nursing staff.
Psychotropic Medications Lacked Required Behavior Monitoring: Two residents with dementia and other cognitive impairment had psychotropic medication orders that did not include or document the specific behaviors being monitored. One resident received PRN Lorazepam for increased anxiety without a documented target behavior on the order or MAR, and another resident received Quetiapine for hallucinations without MAR documentation showing behavior monitoring. RN and DON interviews confirmed the behavior monitoring was not documented as required by the facility policy.
Late Completion and Submission of Annual MDS Assessments: The facility failed to complete and submit Annual MDS assessments on time for two residents. One resident had significant cognitive impairment, contractures, and extensive ADL assistance needs, while another had stroke, fractures, muscle weakness, and Parkinson's disease with varying levels of assistance for ADLs and transfers. The MDSC acknowledged the assessments were late and that one had been overlooked, despite the requirement that MDSs be complete, accurate, and submitted to the Federal database on schedule.
Inaccurate MDS Assessments for ROM and Mobility: Two residents had MDS entries that did not match the record and observations. One resident with Parkinson’s disease, dementia, and difficulty walking had orders and PT documentation showing ambulation with a FWW and restorative walking, but the MDS also marked ambulation and walking as not attempted. Another resident with hemiplegia had orders for PROM to the left arm and left leg, and observations showed left-sided weakness, but the MDS did not identify a limitation in one arm. The MDSC stated the assessments were inaccurate, and the DON noted the incorrect documentation affected reporting and care planning.
A resident whose primary and preferred language was not English had no care plan addressing communication needs. The resident had diagnoses including HTN, DM, and repeated falls, with intact cognition and capacity to make decisions. During observation, an LVN could not understand the resident’s response about pain and relied on another staff member to translate; the resident also did not have a communication board. The DON confirmed the care plan did not address the language barrier.
Care plans were not revised for two residents with mobility and ROM needs. One resident with cerebral infarction, Parkinson’s disease, fractures, weakness, and limited ankle ROM still had PT and RNA ambulation interventions on the CP even though PT had discharged the resident and the RNA order listing did not include the resident; the resident said exercises and walking had not been provided for months. Another resident with hemiplegia and severe cognitive impairment still had PT listed on the CP after PT discharge, and the RNA PROM plan did not specify the joints to receive PROM even though RNA was providing PROM to the left arm and left leg.
Expired BLS/CPR Certifications for DON and CNA: The facility failed to ensure that the DON and a CNA maintained current BLS/CPR certification. During record review and interviews, the DSD stated the DON’s BLS/CPR had expired and that CNA 10’s BLS/CPR had also expired without renewal. Facility policy required CPR-certified staff to be available at all times and direct care staff to recertify annually, and the DON and CNA job descriptions both required current BLS/CPR certification.
Failure to provide pressure relieving devices for a resident at high risk for pressure injuries was identified. The resident had Parkinson's disease, dementia, dysphagia, and contractures with limited ROM and dependence for many ADLs. Staff observed the resident repeatedly positioned in a fetal posture with both legs bent and rotated to one side, and a CNA noted pain during brief changes due to leg contractures. An LVN and the DON stated a pillow between the knees was needed to prevent skin injury and pressure between the legs.
Improper nasal cannula placement during oxygen therapy. A resident with respiratory failure, pneumonitis, asthma, impaired cognition, and SOB had an order for oxygen via NC to keep O2 saturation above 92%, but during observation the NC was on the cheek instead of in the nostrils. A CNA noticed the issue but did not notify nursing, and an RN later confirmed the resident was not receiving oxygen because the NC was not placed correctly and the O2 saturation was below 92%.
Medication orders were not followed for two residents when an LPN gave Tylenol without verifying the missing frequency and gave Hydrocodone-Acetaminophen even though the resident’s pain rating did not match the ordered PRN parameter. One resident had HTN, DM, and repeated falls, and the other had low back pain, a history of falls, and difficulty walking; both were cognitively intact. The DON stated that medication orders must include frequency and that nurses must follow physician orders.
Expired medications were found in two med carts: one resident’s PRN ibuprofen and another resident’s PRN hyoscyamine sulfate were kept past their expiration dates, and staff stated they should have been removed before expiring. A resident with dementia and other diagnoses also had an unattended bottle of magnesium glycinate at the bedside, while the possessions log did not include medications and two bags of the resident’s medications were later observed in the facility. The DON stated the resident’s belongings should have been logged and the bedside bottle should not have been left there.
Food Not Prepared to Ordered Texture or Palatability Standards: Surveyors found that one resident with a mechanically altered diet and swallowing issues received food that was not palatable and was hard to swallow, while another resident on a pureed diet was served puree items that were thick, shiny, and not smooth. Staff used visual checks and non-measuring spoons of thickener when preparing puree, and the RD stated the expected puree consistency should be mashed-potato-like and not overly thick or sticky.
Therapeutic Diet Not Served as Ordered: A resident with CVA-related hemiplegia/hemiparesis, malnutrition, impaired cognition, and swallowing concerns was ordered a mechanical soft/ground therapeutic diet with aspiration precautions. SLP documentation supported the diet order, but the resident’s meal tray included items with inconsistent pureed textures, and the resident stated parts of the meal looked thick and unfamiliar and would not be eaten. The RD stated kitchen staff needed to follow the physician-prescribed diet recipe.
Failure to Complete Ordered SLP Screening and Evaluation: A resident with hemiplegia following CVA was placed on a puree diet with thin liquids after readmission, despite an SLP discharge recommendation for soft and bite-sized foods and thin liquids. Physician orders required an SLP screening/evaluation on admission and for difficulty speaking after stroke, but the SLP and RC stated the screening and evaluation were not completed.
A resident with dementia, impaired cognition, and multiple ADL dependencies was maintained on several psychotropic medications, including scheduled antidepressant, benzodiazepine, mood stabilizer, antipsychotic, and PRN benzodiazepine for behaviors such as crying, yelling, and aggressive anger. Psychiatric evaluations documented ongoing delusions, yet IDT meetings did not include required psychoactive medication reviews, and the MDS coordinator confirmed that quarterly reviews and reassessments after multiple falls were not done. An LVN reported that specific target behaviors and adverse effects (e.g., TD, cognitive impairment, akathisia, parkinsonism) were not being monitored, and an RN acknowledged there was no documentation of non‑pharmacological alternatives before frequent PRN Lorazepam use. This resulted in the resident receiving psychotropic medications without adequate monitoring, behavioral documentation, or IDT review, constituting unnecessary chemical restraint.
A resident with dementia, difficulty walking, and a documented history of multiple recent falls was identified as high risk for falls using the Morse Fall Scale and placed on a high-risk fall care plan. Despite this, after the resident fell while getting out of bed to use the bathroom and later sustained another fall with a facial laceration while again attempting to use the bathroom, the facility did not revise or add individualized interventions to the care plan. Assessments showed severe cognitive impairment and dependence for most ADLs, while staff reported the resident frequently got up, especially at night, to toilet without using the call light. The DON acknowledged that an intervention for frequent visual checks, discussed for this resident, was never entered into the care plan, and the resident went on to experience additional falls, including one resulting in a left hip fracture and loss of prior ambulation ability.
A resident with DM and ESRD on hemodialysis, who was cognitively intact and required staff assistance with several ADLs, experienced a change in attending physician after the original physician stopped responding to facility and pharmacy calls. The DON reported that the Medical Director assumed care and that the resident was only informed of the change, not involved in selecting the new physician. This process conflicted with facility policies on informed consent and physician services, and failed to honor the resident’s right to choose an attending physician.
A resident with diabetes, ESRD on hemodialysis, and neuropathy had an order for Lyrica 150 mg TID that was not administered because the medication was unavailable from the pharmacy. MAR review showed repeated non-administration, while the DON and pharmacist reported that required Schedule II–V medication therapy authorization forms were faxed multiple times but not returned by the attending physician, and the pharmacy was not informed when the medical director assumed care. Facility policies required timely medication regimen review and physician coverage when the attending is unavailable, but these processes did not prevent the interruption in the resident’s ordered Lyrica therapy.
Two residents with severe cognitive impairment were involved in an incident where one threatened the other with a slipper. Although the event was reported internally to the DON and Administrator, it was not reported to CDPH, the ombudsman, or police within the required timeframe, as mandated by the facility's abuse reporting policy.
A resident with multiple medical conditions developed a skin tear to the left shin during a transfer, and although immediate treatment and physician orders were provided, the care plan was not updated to reflect this change in condition. The treatment nurse and DON both confirmed the omission, which was not in accordance with facility policy requiring care plan updates after changes in resident status.
A deficiency was cited when a resident's care plan did not include all necessary needs, lacked measurable timetables, and failed to specify actions, resulting in incomplete planning and documentation for the resident's care.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a deficiency for not following the established care plan.
The facility failed to ensure that an LVN and two CNAs completed their annual competency evaluations, leaving sections of their assessment worksheets blank. Interviews with the DSD and DON revealed that these evaluations are required annually, but they were not completed as per the facility's policy.
The facility failed to maintain sanitary conditions in food service, affecting all residents. Logs for sanitization and dishwashing were incomplete, with missing entries for solution concentration and water temperature. Additionally, a trashcan in the food prep area was left open, contrary to policy, posing contamination risks.
A facility failed to maintain a resident's dignity during meal assistance when a CNA stood over a resident while feeding her, contrary to the facility's policy requiring staff to sit at eye level. The resident, with severe cognitive impairment and requiring moderate assistance with eating, was observed in this situation, which was confirmed by the DON as not adhering to the expected standards of care.
The facility failed to ensure call lights were within reach for two residents with severe cognitive impairments, as required by their care plans and facility policy. The call lights were found stored in drawers, making them inaccessible, which could prevent timely assistance and increase the risk of falls.
A facility failed to complete the Notification of Bed-Hold and Return form for a resident transferred to a GACH, violating the resident's rights to be informed about their return policy. The resident, with diabetes and hypertension, had the mental capacity to make decisions and required limited assistance. The DON confirmed the form should have been signed, but it was not provided, breaching facility policy.
A facility failed to create a care plan for monitoring the side effects of Apixaban, an anticoagulant prescribed to a resident for DVT prophylaxis. The resident, who lacked decision-making capacity, was readmitted with multiple diagnoses, including palliative care. Despite a physician's order for Apixaban, the necessary care plan was not documented, as confirmed by the DON, potentially affecting the resident's care and safety.
A facility failed to monitor a resident for bruising and bleeding while on Apixaban, a blood-thinning medication. Despite a physician's order to monitor for bleeding every shift, the MAR showed no documentation of such monitoring on specific dates. The DON confirmed the lack of evidence that nurses monitored the resident for bleeding, contrary to the facility's anticoagulation therapy policy.
A facility failed to ensure proper labeling and storage of medications. A resident's Depakote was mislabeled as delayed release instead of extended release, contrary to the physician's order. Additionally, expired medications were found in the storage area, which should have been removed according to facility policy. These deficiencies were identified during observations and interviews with staff.
The facility failed to follow infection control protocols, as staff did not perform hand hygiene while distributing meal trays to two residents, and a nebulizer mask for a resident was improperly stored. The facility's policy requires hand hygiene before and after resident contact and proper storage of nebulizer masks in labeled plastic bags to prevent contamination.
A facility failed to obtain consent and provide information about the side effects of Invega Sustenna to a resident with fluctuating decision-making capacity. The resident received sample medication from the former DON without documented consent or instructions, violating the resident's rights.
The facility failed to provide the required minimum of 80 square feet per resident care area in eight rooms, including seven two-bed rooms and one four-bed room. Despite the deficiency, the facility had requested a waiver, claiming no compromise to resident safety. Observations showed residents had enough space for movement and equipment, with no adverse effects noted.
Water temperatures in shower rooms were below the facility’s acceptable range
Penalty
Summary
The facility failed to maintain comfortable water temperatures between 100 F and 110 F in 2 of 3 shower rooms. During observation, the water temperature in one shower room was 90 F, another shower room was 97 F, and the sink water temperature in one shower room was 74 F. The resident involved, Resident 10, had diagnoses including encephalopathy, muscle weakness, and Parkinsons disease, and the MDS dated 12/30/2025 indicated the resident’s cognitive skills for daily decision making were intact. During a concurrent observation and interview, Maintenance Assistant MS 1 stated he was going to recheck the temperature because multiple residents had already taken showers, and he acknowledged the importance of keeping comfortable water temperatures so residents maintain comfort when showering. Resident 10 later stated that the shower room water temperature fluctuates between hot and cold. A record review showed the facility’s Water Temperature 105 - 120 log from 3/25/2026 through 4/17/2026 indicated shower temperatures had not been checked on 4/13/2026 and 4/14/2026 because MS 1 had not had a chance to do it, and MS 1 stated the facility did not log shower temperatures because the sink water temperature is the same as the shower temperature. The facility policy titled Monitoring Water Temperatures dated 4/2015 stated the acceptable hot tap water range was 100 F to 110 F.
Failure to Provide Ordered ROM and Ambulation Services
Penalty
Summary
The facility failed to provide appropriate ROM and ambulation services for multiple residents with mobility limitations. Resident 33 had diagnoses including difficulty walking, Parkinson’s disease, and dementia. PT records showed the resident had previously ambulated with a front wheel walker up to 50 feet with partial/moderate assistance, and the care plan and restorative program called for RNA-assisted ambulation. However, by April 2026 the resident was no longer walking or standing, and the restorative record had missing signatures for several days. RNA 1 stated the resident had not been walking for months, had not documented weekly summaries because he was busy, and had not reported the resident’s refusal to ambulate to licensed staff. The MDS coordinator stated she knew the resident had declined and was no longer able to ambulate or stand, but the MDS was inaccurately coded as if the resident could walk 15 minutes or more, and the decline was not reported to the physician, PT, or DON. Resident 10 had diagnoses including cerebral infarction, fractures, muscle weakness, and Parkinson’s disease. PT records showed the resident had previously required supervision or touching assistance for bed mobility, transfers, and walking with a front-wheeled walker, and later had worsening weakness and ankle ROM limitations. PT discharge summaries recommended RNA ambulation and later ROM exercises to both legs, and physician orders were written for ambulation and A/AAROM. The record showed missing RNA weekly summaries, the order details did not include ambulation distance, and the resident did not receive the ordered ambulation and ROM services during the periods reviewed. The DON discontinued the RNA orders without documenting a reason, and the DMR stated RNA continued services in January because staff were not informed the orders had been discontinued. By February through mid-April 2026, the resident had not received RNA services, and the JMA was inaccurately completed as if there were no ROM changes and the current RNA program should continue. Resident 3’s JMA dated 4/7/2026 did not accurately assess left hand ROM, and Resident 6 did not receive ordered ROM exercises to the legs from 12/30/2025 through 2/25/2026, nor PT and OT services that had been identified on the rehabilitation screening form. The facility also did not conduct an IDT care conference or follow up on recommendations for PT and OT for Resident 6’s mobility. Resident 18 did not receive a right-hand roll as ordered by OT and the physician. The report states these failures had the potential to result in decline of ROM and mobility for Residents 10, 18, and 6, and that Resident 3’s ROM declined from within functional limits to moderate-to-severe limitation in the left hand without additional interventions.
Insufficient RNA Staffing for Residents Receiving Restorative Services
Penalty
Summary
The facility failed to ensure sufficient Restorative Nursing Aide (RNA) staffing to meet the needs of 26 residents receiving RNA services. The Facility Assessment Tool, reviewed on 1/13/2026 and updated 3/25/2026, indicated that two RNA staff were needed to provide support and care for the resident population receiving these services. However, the Nursing Staff Assignment and Sign-in Sheets showed that on multiple dates only one RNA was assigned, with that RNA also covering the guard, feeding residents, passing out nourishments, and at times providing CNA care. The assignments reviewed for 3/4/2026, 3/5/2026, 3/6/2026, 3/11/2026, 3/13/2026, 3/17/2026, 3/18/2026, 3/19/2026, 3/20/2026, 3/30/2026, and 3/31/2026 through 4/10/2026 showed that the RNA duties were combined with other tasks rather than having two RNAs available. RNA 1 stated working hours were 7:00 a.m. to 3:30 p.m. and described daily duties that included feeding a resident breakfast, passing out nourishments, providing the RNA program, and completing resident weights. RNA 1 also stated the facility sometimes pulled RNA 1 to provide CNA services, and that some residents did not receive RNA when this occurred. During interviews, RNA 2 stated the facility assigned RNA 2 to provide RNA only one time because RNA 1 was off, and RNA 3 stated RNA 3 mainly assisted the DSD and also provided CNA care, with RNA services being rare. The DSD stated RNA 1 was the facility’s only full-time RNA and that one RNA did not have sufficient time to provide RNA services to 26 residents, especially when also assigned CNA care and smoking guard duties. The DSD reviewed the Facility Assessment Tool and stated it indicated the need for two RNAs, but did not know why the facility did not provide two RNA staff. The ADM stated the Facility Assessment Tool indicated the need for two RNAs but believed one was sufficient to complete the job duties.
Failure to Ensure Restorative Nursing Competency for Ambulation Care
Penalty
Summary
The facility failed to ensure that 3 of 3 Restorative Nurse Assistants had the competent skills needed to care for a resident whose ambulation had declined. Resident 33 had diagnoses including difficulty walking, Parkinson's disease, and unspecified dementia, and the Minimum Data Set showed severely impaired cognitive skills for daily decision making and dependence on staff for multiple activities of daily living. The Physical Therapy Discharge Summary indicated the resident was ambulating up to 50 feet with a front wheel walker and partial/moderate assistance, and the physician order required restorative ambulation with a front wheel walker five times a week as tolerated. During interview and record review, RNA 1 stated that in January the resident was walking 150 to 200 feet, but by March the resident was walking only 5 to 10 feet in the room, and by April the resident had not been walking and restorative treatment consisted of transfers from bed to chair. RNA 1 stated he considered transferring the resident to be a treatment and did not know what happened to the February and March weekly summaries or how to document when residents refused treatment or did not tolerate treatment well. The DSD reviewed RNA 1's employee file and stated there was no competency completed for RNA 1, despite the facility policy requiring competency evaluation upon hire and annually for nursing staff.
Inaccurate RNA Documentation for ROM and Mobility Services
Penalty
Summary
The facility failed to maintain complete and accurate medical records for residents receiving restorative nursing aide (RNA) services for range of motion (ROM), mobility, and splinting programs. Surveyors found that RNA documentation for four residents reflected services that were not supported by staffing records, resident location, or observed care, and in one case the record did not reflect the ordered services at all. The facility policy titled Record Content stated completed entries must be accurate. For one resident with Parkinson’s disease, dementia, dysphagia, and contractures of both knees and the right hand, the record showed RNA services were provided while the resident was in the hospital and later showed RNA services continued after the resident had been discharged from the RNA program. The record also showed RNA services in April even though the April RNA binder was blank when reviewed, and the RNA aide stated the resident’s knee splints were not applied during observed sessions because the resident could not tolerate the exercises and splints. The Director of Medical Records, Administrator, and DON all stated the resident’s RNA records were inaccurate and should have been complete and accurate. For another resident with cerebral infarction, fractures, muscle weakness, and Parkinson’s disease, the record showed ambulation with a front wheeled walker was provided on days when the RNA aide’s time record showed the aide did not work. The resident also had an order for A/AAROM to both legs, but the RNA record did not include that ordered service. For a resident with acute respiratory failure, dementia, and multiple contractures, the record showed PROM to both arms and legs and PRAFO application on days when the RNA aide was not working, and the resident was observed with severe hand contractures while the aide attempted ROM and the resident screamed. For a resident with hemiplegia after cerebral infarction, the record showed PROM to the left arm and leg five times per week even though the RNA aide stated the resident sometimes did not receive exercises that often because the aide was assigned elsewhere, and the resident stated the exercises were inconsistent.
Ineffective QAPI Program Failed to Identify Systemic Care Issues
Penalty
Summary
The facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program as described in its policy and procedure for QAPI feedback, data collection systems, and monitoring. During interview and record review, the Administrator stated that the facility’s QAPI topics were focused on only two areas: resident falls and infection control. The Administrator also stated that the QAPI program had not identified issues related to staffing, development of care plans, the Restorative Nursing Program, or Trauma Informed Care implementation, and that QAPI meetings only addressed issues brought forward by attendees during the quarterly meetings. The Administrator further stated that the facility’s QAPI system for identifying systemic issues needed improvement because the system was not working. The Director of Nursing stated that an effective QAPI program is essential to identify areas that can be improved in the facility. The facility’s written QAPI policy stated that the program is intended to establish and implement procedures for feedback, data collection, and monitoring, and that the facility will maintain an effective system to obtain and use feedback, review available data, and determine improvement priorities based on facility-identified concerns. The survey team found that the facility’s QAPI program did not identify issues related to F688, F656, F678, and F638.
Infection Control and Water Management Failures
Penalty
Summary
The facility failed to follow its infection control practices during multiple resident care activities. Resident 3 had diagnoses including respiratory failure, pneumonitis, asthma, dementia, and a gastrostomy tube, and the record showed an order for enhanced barrier precautions during high-contact care. During observation, a CNA changed the resident’s position while wearing gloves but no isolation gown, even though the resident’s clothes and bed linens were contacted during care. The CNA stated the gown was forgotten, and the RN and DON stated that gown use was required for high-contact care for this resident because of the gastrostomy tube. The facility also failed to follow hand hygiene and PPE practices during other resident care. During a dining observation, a CNA entered a resident’s room, handled the meal tray, and fed the resident bread without washing hands first. The CNA later stated hands should have been washed before feeding, and the IPN stated staff should wash hands before handling food and that there was an issue with infection control when hand washing was not performed prior to feeding a resident. In another observation, an RNA performed range of motion exercises with Resident 3, who had severe cognitive impairment and contractures, while wearing gloves but no gown, despite the resident being on enhanced barrier precautions and the facility’s policy calling for gown and glove use during high-contact resident care. During wound care for another resident with a wound and enhanced barrier precautions, a TXN removed the old dressing while wearing gloves only and no gown. The facility also failed to follow its water temperature and water management procedures. Shower room water was observed at 90 degrees Fahrenheit on one occasion, and other resident-use sinks were observed at 111 to 115 degrees Fahrenheit, while the facility’s policy stated the acceptable hot tap water range was 100 to 110 degrees Fahrenheit. Water Heater 1, 2, 3, and 4 did not have documented temperature checks, and staff stated there was no method to check the actual water temperature for some heaters. In the laundry area, Dryer A’s built-in thermometer was not functioning, and staff stated they could not tell whether the dryer temperature was too high or too low. Washer 1 and Washer 2 temperatures were documented as 135 degrees Fahrenheit, while direct observation showed about 122 degrees Fahrenheit. The IPN stated she was not familiar with the facility’s water management program, did not know how often it should be reviewed, and was unaware of the Legionella environmental assessment form and the facility’s water temperature monitoring expectations.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent before administering psychotropic medications to two sampled residents. Resident 8 was admitted with diagnoses including dementia, psychosis, and anxiety, and the H&P indicated the resident did not have the capacity to understand and make decisions. The MDS indicated severely impaired cognition. An order was entered for Lorazepam 2 mg by mouth every 8 hours as needed for increased anxiety, and the MAR showed the medication was administered on 4/13/2026, 4/14/2026, and 4/15/2026. Review of the resident’s electronic and paper records from admission through 4/16/2026 did not show an informed consent for Lorazepam, and RN 1 stated there was no informed consent in the record and that informed consent must be obtained before psychotropic medications are given. Resident 11 was admitted and later readmitted with diagnoses including dementia and schizophrenia, and the H&P indicated the resident did not have the capacity to understand and make decisions. The OSR showed an order for Quetiapine fumarate 12.5 mg by mouth at bedtime for schizophrenia and seeing things that do not exist. The MDS indicated severely impaired cognition. During record review, RN 1 stated the resident had been receiving Quetiapine since 11/2025 but no informed consent was found in the records. The DON stated informed consent must be obtained before psychotropic medications are administered and that the resident or responsible party must be informed of the risks and benefits of the medication.
Failure to Assess Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that the interdisciplinary team completed a self-administration assessment for Resident 65 to determine the resident's ability to safely self-administer medications, identify which medications could be self-administered, and determine whether medications could be kept at the bedside. Resident 65 was admitted with diagnoses including DM and seizure disorder, and had a physician order for Magnesium Glycinate 400 mg by mouth daily for supplement. During a concurrent observation and interview, an unattended bottle of Magnesium Glycinate 100 mg with 78 tablets was found on top of Resident 65's bedside table, and the resident stated it was his own personal supplement bottle. The MAR showed a dose of Magnesium Glycinate 400 mg scheduled for the same day, and an LVN stated the medication was not available in the facility's stock. The LVN also stated that no self-administration assessment had been completed by the IDT to evaluate the resident's ability to safely self-administer Magnesium Glycinate and keep a bottle of the medication at the bedside. The facility policy stated that alert residents who desire to self-administer medication are to be assessed by the IDT using the Self-administration of Medication Assessment form, with physician order and care plan if the resident is a candidate.
Failure to Report Residents’ Declines in ROM and Mobility
Penalty
Summary
The facility failed to promptly notify the licensed nurse, physician, and responsible party of significant changes in condition for two residents. One resident had a documented decline in ROM of the left hand that progressed from WFL on OT discharge to moderate-to-severe limitation in the left hand by the time of the survey observations. The resident had diagnoses including acute respiratory failure with hypercapnia, dementia, gastrostomy tube dependence, and multiple contractures, and was dependent for many ADLs. OT had discharged the resident with PROM to both arms five times per week as tolerated, and the physician later ordered gentle PROM to both arms five times per week as tolerated. During the survey, the resident’s left-hand middle, ring, and small fingers were observed completely bent toward the palm, with the fingernails pushing into the palm. When RNA attempted to extend the fingers, the resident screamed in pain, and RNA stated the fingers had been in that bent position for about one month. RNA also stated the change was not reported to the licensed nurse. OT stated the resident’s left hand had moderate-to-severe ROM limitations and that the bent position could affect hygiene and ability to assist with rolling. The DON stated the absence of change-of-condition documentation indicated the licensed nurse, physician, and responsible party were not informed of the decline in left-hand ROM. A second resident had diagnoses including difficulty walking, Parkinson’s disease, and dementia, and was dependent or required substantial assistance for multiple ADLs. The resident had previously been ambulating with a front wheel walker up to 50 feet with partial/moderate assistance, and the restorative order required RNA ambulation five times per week as tolerated. RNA stated that in January the resident walked 150 to 200 feet, in March the resident walked only 5 to 10 feet in the room, and in April the resident had not been walking and was only being transferred from bed to chair. RNA stated the decline in mobility was not reported to nursing staff, and the DON stated the RNA should have notified nursing staff because the resident was no longer ambulating.
Psychotropic Medications Lacked Required Behavior Monitoring
Penalty
Summary
The facility failed to prevent unnecessary use of psychotropic medication for two sampled residents by not documenting the specific behaviors associated with the medications and not monitoring those behaviors as required. Resident 8 was admitted with diagnoses including dementia, psychosis, and anxiety, and was assessed as having severely impaired cognition and no capacity to understand and make decisions. The resident had an order for Lorazepam 2 mg by mouth every 8 hours as needed for increased anxiety, but the order summary did not identify the specific behavior to monitor, and the MAR for April 2026 did not show that the resident's behavior associated with Lorazepam was monitored. RN 1 stated the order should have included the specific behavior for staff to monitor because the frequency of that behavior would indicate the effectiveness of the medication. Resident 11 was admitted and readmitted with diagnoses including dementia and schizophrenia, and was also documented as having severely impaired cognition and no capacity to understand and make decisions. The resident had an order for Quetiapine fumarate 12.5 mg at bedtime for schizophrenia seeing things that do not exist, but the MAR for April 2026 did not indicate that the resident was being monitored for that behavior. RN 1 stated the behavior was not monitored, and the DON stated that all psychotropic medications must have an associated behavior that staff monitor to determine whether the medication is working and whether it needs to be continued. The facility's Psychotropic Medication Use policy stated that medications used to treat behaviors must have a clinical indication and that residents receiving psychotropic medication should be monitored for efficacy, risks, benefits, and harm or adverse consequences.
Late Completion and Submission of Annual MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive MDS assessments for two residents within the required timeframe, and this also delayed transmission of those assessments to the Federal database. For Resident 3, the record showed admission with diagnoses including acute respiratory failure with hypercapnia, G-tube dependence, dementia, and multiple muscle contractures. The Annual MDS for Resident 3 reflected unclear speech, difficulty communicating some words, usually understood verbal content, severely impaired cognition, and extensive assistance needs for rolling, toileting hygiene, bathing, dressing, and bed mobility. For Resident 10, the record showed admission with diagnoses including cerebral infarction, left ankle stress fracture, right femoral neck fracture, muscle weakness, and Parkinson's disease. The Annual MDS for Resident 10 reflected clear speech and comprehension, intact cognition, and assistance needs ranging from setup help for eating, oral hygiene, and upper body dressing to supervision or touching assistance for bed mobility and partial/moderate assistance for lower body dressing and transfers. The MDS Coordinator stated that MDS assessments are used to assess functional level, identify functional declines, and support care planning, and that they must be complete, accurate, and submitted to the Federal database. During record review and interview, the MDS Coordinator acknowledged that the Annual MDS for Resident 3 was completed and submitted late, and that Resident 10's Annual MDS should have been signed and completed earlier than it was. The RAI User Manual stated that the Annual comprehensive completion date is the ARD plus 14 calendar days, and the facility policy indicated the interdisciplinary team completes each resident's MDS according to scheduled assessments due. The report also noted that the MDS Coordinator identified one of the reviewed Annual MDS assessments as late because it had been overlooked.
Inaccurate MDS Assessments for ROM and Mobility
Penalty
Summary
The facility failed to accurately assess two sampled residents on the MDS for range of motion and mobility-related items. For one resident with diagnoses including difficulty walking, Parkinson’s disease, and dementia, the record showed an order for RNA-assisted ambulation with a front wheel walker five days per week and a PT discharge summary stating the resident was ambulating up to 50 feet with partial/moderate assistance. However, the MDS dated [DATE] indicated ambulation was not attempted due to medical condition or safety concerns, while another MDS for the same resident indicated restorative nursing walking services were provided 5 days in the past 7 days even though walking 10 feet was also marked not attempted due to medical condition or safety concerns. During interview, the MDS Coordinator stated she completed the MDS based on physician orders but had not physically seen the resident ambulating, and stated a new MDS was needed to reflect the change in condition when the resident was no longer able to walk. The DON stated discrepancies on the MDS can affect the resident’s wellbeing and that the resident would not receive proper care due to incorrect documentation. The facility policy on MDS accuracy stated every resident should receive an accurate assessment by staff qualified to assess relevant care areas and knowledgeable of the resident’s status, needs, strengths, and areas of decline. For the second resident, the record showed admission with hemiplegia following a cerebral infarction affecting the left non-dominant side. The MDS dated 11/13/2025 indicated no functional limitation in ROM to both arms and a limitation in one leg, yet physician orders dated 2/25/2026 directed RNA to provide gentle PROM to the left arm and left leg five times per week as tolerated. Observations showed the resident using the right hand to hold a phone, RNA performing ROM exercises to the left arm and left leg, the resident moving the right arm and right leg normally, and later slightly moving the left leg with no active movement in the left arm. The MDS Coordinator stated the assessments were inaccurate and that the resident had hemiplegia affecting the left side and should have also indicated functional ROM limitation in one arm; the DON stated the inaccurate MDS assessments resulted in inaccurate reporting to the Federal database and had the potential to prevent the development of care plans.
Failure to Address a Resident’s Language Barrier in the Care Plan
Penalty
Summary
The facility failed to develop a care plan to address the communication needs of a resident whose primary and preferred language was not English. The resident was admitted with diagnoses including hypertension, diabetes mellitus, and repeated falls. The resident's H&P indicated the resident had the capacity to understand and make decisions, and the MDS indicated intact cognition and a preferred language that was not English. The Nursing Admission Assessment and Social Service Assessment also documented that the resident's primary language was not English. Review of the resident's care plans showed no care plan addressing communication needs. During observation, an LVN asked the resident about pain, but the resident responded in a non-English language and the LVN stated he did not understand the response and had to ask another staff member to translate whenever information was needed. The LVN also stated he was not aware of any other way to communicate with the resident and that the resident did not have a communication board. The DON confirmed there was no care plan for the resident's communication needs and stated that staff must develop a care plan for a resident who does not speak English, including possible use of a communication board.
Care plans not updated for PT, ambulation, and RNA services
Penalty
Summary
The facility failed to revise and update the care plan for Resident 10 to reflect current PT and RNA services for ambulation. Resident 10 had diagnoses including cerebral infarction, left ankle stress fracture, right femoral neck fracture, muscle weakness, and Parkinson’s disease. The resident’s care plan continued to include RNA ambulation with a front wheeled walker five times per week as tolerated, and the OSR also showed an order for RNA ambulation with the walker. However, the PT evaluation documented significant weakness, ROM limitations in both ankles, and dependence for transfers and ambulation, and the PT discharge summary later recommended RNA ROM to both legs five times per week as tolerated. The resident’s OSR then showed an order for A/AAROM to both legs five times per week as tolerated, but the RNA order listing did not include the resident. During interview, Resident 10 stated the facility had not provided the leg exercises and walking for a couple of months and said the resident was unable to stand or walk. The facility also failed to revise and update Resident 6’s care plan to specify the RNA program and to discontinue PT services. Resident 6 had diagnoses including hemiplegia following a cerebral infarction affecting the left non-dominant side. The care plan continued to include PT interventions five times per week for 30 days, while the OSR showed an order for RNA to provide gentle PROM to the left arm and left leg five times per week as tolerated. The care plan for decline in mobility and RNA for PROM exercises stated only to provide RNA treatments as ordered, without identifying the joints to receive PROM. The MDS showed severe cognitive impairment, substantial/maximal assistance for several ADLs and bed mobility tasks, and functional limitation in ROM to one leg. Observations and interviews confirmed that Resident 6 was receiving PROM to the left arm and left leg from RNA staff, while the right arm and right leg moved normally. The MDS Coordinator stated the resident’s care plans would not be reviewed and revised until the quarterly review date, and that this would not reflect the resident’s current plan of care. The MDS Coordinator also stated the PT care plan should have been discontinued upon discharge from PT services and that the RNA care plan did not specify the joints for PROM. The facility policy stated the comprehensive care plan must describe services provided to the resident and be modified as necessary to reflect changes in care, service, and treatment.
Expired BLS/CPR Certifications for DON and CNA
Penalty
Summary
The facility failed to ensure that two of 53 nursing staff members, the DON and CNA 10, had current BLS/CPR certifications. During a concurrent interview and record review, the DSD reviewed the DON’s employee file and stated that the DON’s BLS/CPR certification had expired in 11/2025. The DSD stated she was unaware of the expiration because she did not keep the DON’s employee file in her office and did not check it. The DON later stated he was not aware that his own BLS/CPR certification had expired and was not aware whether staff could provide direct patient care with an expired BLS/CPR certification. During another interview and record review, the DSD reviewed the Employee Log and stated that CNA 10’s BLS/CPR certification expired in 1/2026 and that CNA 10 did not renew the card. The DSD stated she did not know that a staff member should not be assigned to provide direct patient care if the staff member had an expired BLS/CPR certification. Facility policy stated that CPR-certified staff would be available at all times, that staff would maintain current CPR certification with hands-on skills practice and in-person assessment, and that all direct patient care personnel would recertify in BLS/CPR annually. The CNA job description required a current California CNA certification and a current BLS/CPR certification, and the DON job description stated the DON was responsible for ensuring education, training, and competency validation were completed per state and federal regulations.
Failure to Provide Pressure Relieving Device for Resident with Contractures
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for Resident 18, who was admitted and later readmitted with diagnoses including Parkinson's disease, dementia, dysphagia, and contractures of both knees and the right hand. The resident's MDS showed substantial to maximal assistance was needed for eating and the resident was dependent for hygiene, upper body dressing, lower body dressing, rolling in bed, and transferring from lying to sitting. A JMA documented no active movement in the right arm and multiple ROM limitations, including limited passive ROM in the right shoulder and moderate-to-severe or moderate limitations in the right wrist, hips, and knees. The Braden Scale identified the resident as high risk for pressure injuries. Observations showed Resident 18 repeatedly lying in bed in a fetal position with both hips and knees bent and rotated to the right side. During one observation, the resident's left knee was directly on top of the right inner thigh, and during another, the resident's legs were again rotated to the right after the incontinence brief was changed. A CNA stated the resident had contractures to both legs that caused pain during brief changes. An LVN later observed the resident in the same fetal position with a pillow between the knees and stated the pillow was used to prevent pressure injuries between the legs. The DON stated the resident's legs were usually rotated to the right with the hips and knees bent and that a pillow should be placed between the legs to prevent the knees from rubbing together and to prevent skin injuries. The facility policy stated each resident receives the care and services necessary to retain or regain optimal skin integrity to the extent possible.
Improper Nasal Cannula Placement During Oxygen Therapy
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for one sampled resident. Resident 3 had diagnoses including respiratory failure, pneumonitis, and asthma, and the care plan included oxygen via nasal cannula to maintain oxygen saturation above 92%. The resident’s record also showed severely impaired cognition, dependence for multiple activities of daily living, and shortness of breath. A physician order directed oxygen at 1-2 L/NC if oxygen saturation was below 92% and to keep oxygen saturation above 92% every shift. During an observation on 4/13/2026 at 10:05 AM, Resident 3 was lying in bed with the nasal cannula on the left cheek, and the prongs were not in the nostrils. CNA 7 stated the cannula was not placed under the nostrils and that he had noticed it a few minutes earlier but did not inform the licensed nurses. RN 1 later stated the resident was not receiving oxygen because the cannula was not placed correctly and assessed the oxygen saturation as below 92%. The DON stated that all nursing staff are responsible for ensuring the cannula is placed correctly and that if it is not placed right away, the resident will not receive the oxygen required. The facility’s oxygen therapy policy stated oxygen is to be administered as ordered, the nasal cannula is to be placed on the resident and adjusted for a snug fit, and oxygen usage is to be monitored frequently.
Medication Orders Not Followed for Pain Medications
Penalty
Summary
Licensed Vocational Nurse 3 administered Tylenol to Resident 38 even though the physician order did not include the medication frequency. Resident 38 was admitted with diagnoses including hypertension, diabetes mellitus, and repeated falls, and the history and physical stated the resident had the capacity to understand and make decisions. The order summary showed Tylenol 325 mg, 2 tablets for mild pain, with a maximum daily acetaminophen limit, but no direction for how often it could be given. During observation and interview, LVN 3 stated he had reviewed the order and administered the medication, then later acknowledged that the order did not say how often it could be administered and that he should have verified that information before giving it. LVN 3 also administered Hydrocodone-Acetaminophen to Resident 1 without following the physician’s pain-rating parameter. Resident 1 was admitted and readmitted with diagnoses including low back pain, history of falling, and difficulty in walking, and the resident’s MDS and history and physical indicated intact cognition and capacity to make decisions. The order summary showed Hydrocodone-Acetaminophen 5-325 mg, 1 tablet every 6 hours as needed for moderate pain rated 4 to 6. During the medication administration observation, Resident 1 stated his pain was 7 out of 10, and LVN 3 stated he would administer the medication. After administration, LVN 3 reviewed the order and stated it was not correct to give the medication because the resident’s pain rating was 7 out of 10, not 4 to 6. The DON stated that medication orders must include frequency and that nurses must follow physician orders, noting that not following the order creates a risk of overmedicating the resident and that the medication could be ineffective to manage pain if the order is not followed. The facility’s policies cited in the report stated that medication orders should be supported by appropriate care processes, that staff should review whether frequency and duration are appropriate, and that staff should implement the medication regimen as ordered.
Expired Medications in Carts and Unsecured Resident Medications
Penalty
Summary
The facility failed to ensure that medications and biologicals were stored in accordance with accepted professional principles when expired medications were found in two medication carts. In one cart, Resident 4’s Ibuprofen 200 mg tablets, ordered as needed for pain management, was found with an expiration date of 4/14/2026 during an inspection on 4/15/2026. In the other cart, Resident 8’s Hyoscyamine Sulfate 0.125 mg tablets, ordered as needed for excessive secretions, was found with an expiration date of 4/1/2026 during the same inspection. Staff interviews indicated the medications should have been removed before expiration, and the DON stated licensed nurses were responsible for checking medication carts and removing expired medications before the expiration date. Resident 4 had diagnoses including diabetes mellitus, dysphagia, and dementia, and the H&P stated the resident did not have the capacity to understand and make decisions. Resident 8 had diagnoses including dementia, psychosis, and anxiety, and the H&P stated the resident did not have the capacity to understand and make decisions; the MDS indicated severely impaired cognition. The facility policy titled Storage of Medications stated that outdated, contaminated, or deteriorated medications are to be immediately removed from stock and that medication storage conditions are monitored on a routine basis. The facility also failed to properly secure and account for a resident’s medications and personal belongings. Resident 65 had an unattended bottle of Magnesium Glycinate on the bedside table during observation, and the resident stated it was his own personal supplement bottle. LVN 4 stated the resident had a physician order for Magnesium Glycinate 400 mg daily. The resident’s clothing and possession inventory log did not document medications, and later two bags of the resident’s medications were observed in the facility, including multiple prescription and over-the-counter items. The DON stated all of the resident’s belongings needed to be logged in the possessions log and that the bottle of Magnesium Glycinate should not have been left at the bedside table.
Food Not Prepared to Ordered Texture or Palatability Standards
Penalty
Summary
The facility failed to prepare food in a form designed to meet individual needs for two residents. For one resident with a history of stroke-related hemiplegia/hemiparesis, malnutrition, moderately impaired cognition, swallowing concerns, and a mechanically altered diet order, the record showed speech therapy recommended thin liquids and mechanical soft/ground textures. The resident’s care plan and diet orders referenced mechanical soft, ground, and aspiration safety precautions, yet the resident later reported that ground meat sat at the back of the throat and was hard to swallow, and stated the food was not the best and sometimes looked like mush. Surveyors observed and reviewed the preparation of pureed foods for another resident with diabetes, CHF, dysphagia, severely impaired cognition, and a pureed diet order. During a test tray review, several pureed items appeared thick, shiny, and not uniformly smooth, and the Dietary Supervisor and Dietary District Manager tested the texture by spoon and plate methods. The District Manager noted the puree should not be too thick or too thin, but the observed items held their form and adhered to the spoon in a way that did not match the expected consistency. In the kitchen, a head cook was observed adding thickener to a bread-and-milk puree using a regular spoon rather than a measuring utensil, adding multiple spoonfuls while visually checking the mixture and returning it to the oven. Additional observations at meals showed the resident with the pureed diet receiving trays with foods that were thick, did not demonstrate a smooth consistency, and were not readily identifiable. That resident stated the food was not good or tasty, did not look appetizing, and sometimes was thick and stuck to the inside of the mouth, making it hard to swallow. The RD stated that pureed foods should have a mashed-potato-like consistency and that adding too much thickener could make the puree thicker and harder, which was not the desired consistency. The facility’s policies stated food should be palatable, attractive, and prepared to conserve flavor and appearance, and that pureed food should appear and taste like real food and have a smooth, non-sticky consistency.
Therapeutic Diet Not Served as Ordered
Penalty
Summary
The facility failed to ensure that Resident 58’s therapeutic diet was served as prescribed by the physician. Resident 58 was admitted and later readmitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, hyperlipidemia, and unspecified protein-calorie malnutrition. The record also showed moderately impaired cognitive skills, need for set up or clean up assistance with meals, possible swallowing disorder symptoms, and dental problems affecting chewing. Speech therapy documentation dated 6/10/2025 showed the SLP recommended thin liquids and a mechanical soft diet with ground textures. The order summary later listed a fortified mechanical soft no added salt diet with mechanical soft texture, ground meat, and pureed vegetables, bread/tortilla, fresh fruits, and cocktails for aspiration safety precautions. The care plan also identified a mechanically altered diet and directed that the resident’s diet be provided as ordered. During observation, the resident’s dinner tray and meal ticket showed a cheese quesadilla, pureed Mexican rice, pureed cream style corn, pureed scalloped apples, and sour cream. The resident’s plate contained a few pieces of eaten quesadilla and three scoops of food that appeared inconsistent in texture and appearance, including one thick orange scoop, one smooth white scoop, and one shiny thick yellow-brown scoop. The resident stated the brown scoop looked thick and that he would not eat it because he did not know what it was, and he also stated the orange and white scoops tasted okay but he did not know what they were. The RD stated it was important for kitchen staff to follow the recipe of the physician-prescribed therapeutic diet, whether regular, mechanical soft, or pureed.
Failure to Complete Ordered SLP Screening and Evaluation
Penalty
Summary
The facility failed to provide Speech Language Pathology (SLP) evaluation or screening for Resident 6 in accordance with physician orders dated 12/30/2025 and 1/12/2026. Resident 6 was admitted and readmitted with diagnoses including hemiplegia following a cerebral infarction affecting the left non-dominant side. The record included an SLP discharge summary recommending soft and bite-sized foods and thin liquids, but after the resident returned from the hospital on 12/30/2025, the resident was placed on a puree diet with thin liquids instead. The physician’s order dated 12/30/2025 directed an SLP evaluation/screening upon admission and quarterly as indicated, and the physician’s order dated 1/12/2026 directed an SLP evaluation for difficulty speaking after stroke. During interviews, the Rehabilitation Coordinator stated the facility used mechanical soft diet terminology instead of soft and bite-sized foods, and SLP 1 stated the resident did not receive the SLP screening or evaluation upon readmission. The resident’s MDS indicated clear speech but difficulty communicating or finishing some words, and the resident stated not knowing why the diet was pureed. The facility’s staff therapist job description listed evaluation of patients based on physician referral/orders as an essential function.
Failure to Monitor and Review Psychotropic Medications Leading to Unnecessary Chemical Restraint
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident receiving multiple psychotropic medications was free from unnecessary chemical restraints. The resident had diagnoses including unspecified dementia, difficulty walking, and Non-Hodgkin lymphoma, and was admitted from a general acute care hospital with recurrent falls and later documented as lacking capacity to make medical decisions. The resident’s MAR over a two‑month period showed scheduled Duloxetine for depression, Clonazepam for anxiety, Depakote for irritation and mood stabilization, Seroquel for schizophrenia with aggressive anger, and PRN Lorazepam for anxiety manifested by yelling and screaming, with the Lorazepam dose increased after a physician call related to inability to sleep and roaming. Psychiatric evaluations documented that the resident remained delusional, believing people were in her room, yet the quarterly IDT meeting and a later IDT admission review documented no medication review, contrary to the facility’s psychoactive medication management policy requiring at least quarterly review of response to psychoactive medications and consideration of continued use, dose reduction, or discontinuation. The MDS showed the resident had a severely impaired BIMS score and required substantial to maximal assistance with most ADLs, but there was no evidence that this functional and cognitive status was incorporated into a systematic review of the psychotropic regimen. The MDS coordinator confirmed that the required IDT psychoactive medication reviews were not conducted, including after multiple falls. Nursing staff interviews further demonstrated a lack of appropriate monitoring and use of alternatives related to the psychotropic medications. An LVN stated the resident was being monitored for crying, yelling, anger, and resisting care, and that monitoring was intended to support medication reduction, but also acknowledged that behaviors tied to each medication and side effects such as tardive dyskinesia, cognitive impairment, akathisia, and parkinsonism were not being monitored. An RN reported that Lorazepam was used when the resident was getting out of bed and crying, and that she could not stay with the resident due to other duties. The RN also stated there was no documentation of non‑pharmacological alternatives attempted before administering PRN Lorazepam, despite it being given repeatedly over two consecutive months, indicating the resident was subjected to psychotropic use without documented behavioral monitoring, side‑effect monitoring, or attempts at alternatives as required by facility policy.
Failure to Revise Fall Prevention Care Plan After Repeated Falls in a High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to keep a resident as free from accident hazards as possible and to provide adequate supervision to prevent accidents, particularly related to falls. The resident had a history of multiple falls prior to admission from an assisted living facility, with 3–4 emergency room visits in a two‑week period, and was admitted with diagnoses including unspecified dementia, difficulty in walking, and Non‑Hodgkin lymphoma. A History and Physical dated 11/15/2025 documented that the resident did not have the mental capacity to understand and make medical decisions. A Morse Fall Scale completed on 12/3/2025 showed a score of 105, indicating high fall risk. The resident’s care plan, initiated on 10/17/2025, identified high risk for falls due to confusion, gait/balance problems, psychoactive drug use, and unawareness of safety needs, with goals for the resident to remain free of falls and injury and interventions including anticipating and meeting needs and following the facility fall protocol. Despite these identified risks, the facility did not adequately update or individualize the care plan after repeated falls. On 12/28/2025, a post‑fall assessment documented that the resident fell while attempting to get out of bed to go to the bathroom and was found with no apparent injury and assisted to the bathroom. However, no new interventions were added to the high‑risk falls care plan after this fall. On 1/7/2026, another post‑fall assessment indicated the resident slipped when attempting to get up to use the bathroom, and progress notes documented an open cut to the bridge of the nose with bruising, requiring transfer to a general acute care hospital and repair of the laceration with Dermabond. The resident was also treated for a UTI and then readmitted to the facility the same day. Further assessments and staff interviews showed that the resident remained severely cognitively impaired and dependent for most ADLs, including toileting and walking short distances, yet continued to attempt to get up and use the bathroom without calling for assistance. The MDS dated 1/20/2026 documented severe cognitive impairment and substantial/maximal assistance needs for toileting and mobility. Nursing staff, including an LVN and RN supervisor, reported that the resident never called for help, frequently tried to get up without telling anyone, believed she could still move normally despite weakness, and often got up at night to use the bathroom without assistance. The DON acknowledged that although the resident could use the call light, she chose not to, and that an intervention for frequent visual checks was not entered on the resident’s care plan, despite the facility’s policy requiring care plans to be re‑evaluated and modified with significant changes in status. The resident subsequently experienced additional falls, including a fourth fall from standing on 1/21/2026 resulting in a left hip fracture and the need for surgical hemi‑arthroplasty, followed by a decline in ADL function from walking 10 feet to no longer walking after readmission.
Failure to Involve Resident in Choice of Attending Physician
Penalty
Summary
The facility failed to honor a resident's right to choose an attending physician when changing medical providers. A cognitively intact resident with diagnoses including Diabetes Mellitus and ESRD on hemodialysis was admitted with functional limitations requiring varying levels of staff assistance for ADLs such as bathing, dressing, toileting hygiene, and footwear. The resident’s admission record and MDS confirmed intact decision-making abilities. When the initially assigned attending physician stopped responding to calls from facility and pharmacy staff regarding the resident’s care, the facility did not engage the resident in selecting a new physician. Instead, the DON reported that the issue with the non-responsive attending physician was communicated to the Medical Director, who then assumed care of the resident, as reflected in an order summary documenting transfer of care from the first physician to the Medical Director. The DON stated that the resident was informed of the change in physician but was not involved in choosing the replacement provider. This process did not align with the facility’s own policies on Informed Consents and Physician Services, which state that residents have the right to make informed decisions about their care and that physicians are responsible for supervising medical care, including responding when contacted by the facility.
Failure to Administer Ordered Lyrica Due to Lack of Timely Physician Authorization
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services and administer Lyrica as ordered for a resident with neuropathy. The resident was admitted with diagnoses including diabetes mellitus and end stage renal disease on hemodialysis, and had intact cognition but required varying levels of assistance with ADLs. The physician’s order, dated at admission, specified Lyrica 150 mg by mouth three times daily for neuropathy. Review of the MARs for December and January showed that Lyrica was not administered, with documentation indicating the medication was unavailable from the pharmacy. The DON reported that the pharmacy had faxed a Request for New/Continuance of Schedule II–V Medication Therapy authorization to the facility and the attending physician, but the physician did not respond. The DON stated the attending physician was not responding to the facility or pharmacy regarding the resident’s care, and that the medical director subsequently took over the resident’s care. The registered pharmacist stated that the pharmacy faxed the authorization request on two occasions, but the authorization was not received from the physician until several weeks later, and the pharmacy was not informed of the change in attending physician. Facility policies on Medication Therapy and Physician Services required review of the medication regimen shortly after admission and ensuring another physician supervises care when the attending is unavailable, but Lyrica remained unavailable and was not administered as ordered during the period reviewed.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents within the required two-hour timeframe to the ombudsman, local police department, and California Department of Public Health (CDPH), as mandated by the facility's Abuse and Neglect Prohibition Policy. The incident occurred when a certified nurse assistant (CNA) heard a commotion and found one resident holding a slipper and another resident reporting that she had been threatened with it. Both residents had severely impaired cognition and memory, with one diagnosed with paranoid schizophrenia and bipolar disorder, and the other with major depressive disorder and hypertension. The incident was documented in the residents' records and reported internally to the Director of Nursing (DON) and the Administrator (ADM), but not to the required external authorities. Interviews with staff and residents confirmed that the resident with cognitive impairment became agitated, believed her bed was occupied by another, and threatened the other resident with a slipper. The threatened resident expressed fear during the incident. Staff responded by separating the residents and moving one to a different room. Despite these actions, the facility did not classify the event as abuse and therefore did not escalate or report it to CDPH, the ombudsman, or the police as required by policy. A review of the facility's policies confirmed that all alleged violations involving abuse must be reported immediately, but not later than two hours, to the appropriate authorities. The facility's failure to report the incident as required resulted in underreporting of abuse allegations and a failure to follow established abuse protocols.
Failure to Update Care Plan After Resident Skin Tear
Penalty
Summary
The facility failed to develop and implement a resident-specific care plan following a change in condition involving a skin tear to the left shin. The resident, who had a history of cellulitis of the right lower limb, chronic respiratory failure, and lack of coordination, sustained a skin tear during a transfer from a shower chair to a wheelchair. Immediate treatment was provided, including cleansing, application of steri strips, and a dry dressing, and a physician's order was obtained for ongoing wound care and skin maintenance. Despite these interventions, there was no documented evidence that the care plan was updated to reflect the new skin tear. The treatment nurse confirmed that the care plan was not revised to include the new condition, and acknowledged the importance of updating care plans after such changes. The Director of Nursing also stated that care plans should be updated after any change in condition to ensure all staff are aware of the necessary interventions. The facility's policy requires care plans to be modified as needed to reflect changes in status, but this was not followed in this instance.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was observed through review of the resident's records and care plans, which did not contain all necessary elements to ensure comprehensive care as required.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
A deficiency was identified when appropriate treatment and care were not provided according to physician orders, as well as the resident's preferences and goals. The report notes a failure to ensure that care was delivered in alignment with the established plan, which is required to meet the individual needs and wishes of the resident. This lapse resulted in the resident not receiving care as intended, based on their documented preferences and medical directives.
Failure to Complete Annual Competency Evaluations for Staff
Penalty
Summary
The facility failed to ensure that one Licensed Vocational Nurse (LVN) and two Certified Nursing Assistants (CNAs) had the necessary competencies and skills to provide quality care to residents. The deficiency was identified through interviews and record reviews, which revealed that the annual competency assessments and evaluations for these staff members were incomplete. Specifically, the competency evaluation worksheets for the LVN and CNAs were found to have sections left blank, indicating that their skills and competencies were not properly assessed. This lack of evaluation could potentially impact the quality of care provided to residents. The Director of Staff Development (DSD) and the Director of Nursing (DON) were interviewed and confirmed that competency evaluations are supposed to be conducted upon hiring and annually for all staff. However, they were unable to explain why the annual competency assessments for the LVN and CNAs were not completed in the previous year. The facility's policy, revised in July 2019, mandates annual competency evaluations for all employees, but this policy was not adhered to in these cases.
Sanitation and Documentation Deficiencies in Food Service
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage, preparation, and distribution, affecting all 47 residents. The Sanitization Bucket Log, which tracks the concentration of Quaternary Ammonia solution used to sanitize food preparation areas, had missing entries for several time slots on 3/14/2025. Staff were supposed to fill out the log after each meal and use, but many columns were left blank, with the last entry recorded at 7:30 AM. The Dietary Supervisor acknowledged the oversight and stated that all kitchen staff are responsible for completing the log, but it was not consistently done. Additionally, the Dish Machine Cleaning Log, which records the temperature of water during dishwashing and the sanitation concentration, also had missing entries for 3/14/2025, with the last entry made at breakfast. The facility's policy requires these logs to be completed, but this was not adhered to. Furthermore, during a kitchen tour, a trashcan in the food preparation area was found open, contrary to the facility's policy that requires trash to be contained in covered, leak-proof containers. This oversight posed a risk of contamination and pest attraction.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain or enhance a resident's dignity and respect during meal assistance. Specifically, a Certified Nursing Assistant (CNA) was observed standing over Resident 27 while assisting her with a meal, rather than sitting at eye level as required by the facility's policy. This action was noted during a meal observation in the dining room, where the CNA was feeding lunch to the resident who was seated in a wheelchair. Resident 27, who was admitted to the facility with diagnoses including diabetes mellitus and hypertension, had a history of fluctuating capacity to understand and make decisions. According to the Minimum Data Set, her cognitive skills for daily decision-making were severely impaired, and she required moderate assistance with eating. The Director of Nursing confirmed that staff should sit while feeding residents, aligning with the facility's policy to ensure safety, comfort, and dignity during meal assistance.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to accommodate the needs of two residents by not ensuring their call lights were within reach, as required by the facility's policy. Resident 1, who has Parkinson's Disease and severe cognitive impairment, and Resident 12, who has Type 2 Diabetes Mellitus and unspecified dementia, both had care plans indicating they were at risk for falls and required their call lights to be within reach. However, during an observation, it was found that the call lights for both residents were stored inside their personal belongings drawer, making them inaccessible. The Director of Nursing (DON) confirmed that call lights should be within the residents' reach and acknowledged that the residents had a behavior of placing their call lights in drawers. The facility's policy, dated August 2017, mandates that call lights be plugged in and within reach when residents are in bed or confined to a chair. This oversight had the potential to prevent the residents from receiving timely assistance, which could lead to accidents and falls.
Failure to Provide Bed-Hold Notification
Penalty
Summary
The facility failed to complete the Notification of Bed-Hold and Return form for a resident who was transferred to a General Acute Care Hospital (GACH). This form is crucial as it informs the resident or their representative about their rights to return to the facility after hospitalization. The deficiency was identified during a review of the resident's clinical records, which revealed that the necessary notification was not provided when the resident was transferred to the hospital. The Director of Nursing confirmed that the bed hold notification form should have been acknowledged and signed by the resident or their responsible party, and that the bed hold is valid for seven days. The resident involved was admitted to the facility with diagnoses of diabetes mellitus and hypertension. The resident had the mental capacity to make medical decisions and required limited assistance for activities of daily living. On the day of transfer, the resident exhibited symptoms of red-colored urine and a pain level of 5-6 out of 10. Despite these conditions, the facility did not adhere to its policy and procedure, which mandates providing written notification of the bed-hold policy upon admission and at the time of transfer, in accordance with federal and state guidelines.
Failure to Develop Care Plan for Anticoagulant Monitoring
Penalty
Summary
The facility failed to develop a resident-specific care plan for monitoring the side effects of Apixaban, an anticoagulant medication prescribed for DVT prophylaxis. This deficiency was identified during a review of Resident 35's records, which showed a lack of documented evidence of a care plan addressing the monitoring of Apixaban's side effects, such as bruising and bleeding. The Director of Nursing (DON) confirmed the absence of this care plan during an interview and record review, acknowledging that it should have been initiated when the medication was first ordered. Resident 35 was readmitted to the facility with diagnoses including palliative care, peripheral vascular disease, and hypertension. The resident lacked decision-making capacity, and a physician had ordered Apixaban to be administered twice daily. Despite the facility's policy requiring comprehensive care plans to be developed within seven days of a comprehensive assessment, the necessary care plan for Apixaban was not in place, potentially compromising the resident's care and safety.
Failure to Monitor Resident on Apixaban for Bleeding
Penalty
Summary
The facility failed to prevent the unnecessary use of medication by not monitoring a resident for bruising and bleeding while receiving Apixaban, a blood-thinning medication. The resident, who was readmitted to the facility with conditions including peripheral vascular disease and hypertension, was prescribed Apixaban for DVT prophylaxis. Despite a physician's order to monitor for bleeding every shift, the Medication Administration Record (MAR) showed no documentation of monitoring for bleeding or bruising on specific dates. During an interview and record review, the Director of Nursing (DON) confirmed the absence of documented evidence that licensed nurses monitored the resident for bleeding or side effects of Apixaban during the specified periods. The facility's policy on Anticoagulation Therapy Management requires monitoring for signs and symptoms of bleeding and notifying the physician if bleeding is noted. However, this protocol was not followed, leading to the deficiency.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to accepted professional principles. Specifically, a resident's medication, Depakote, was incorrectly labeled as Divalproex Sodium DR (delayed release) instead of ER (extended release) as per the physician's order. This discrepancy was identified during a review of the resident's Medication Administration Record (MAR) by an LVN, who noted that the bubble pack label did not match the physician's order. The LVN acknowledged the importance of matching the physician's order with the medication label to ensure the correct medication form is administered, as the different release forms could affect the resident's behavior. The Director of Nursing also emphasized the importance of following the physician's order and verifying it with the pharmacy. Additionally, the facility failed to properly manage the storage of medications and supplies, as observed in the house supply medication storage room. Expired medications, including Curad triple antibiotic ointment and Stomahesive protective powder, were found in the storage area. A treatment nurse confirmed that expired medications should not be included in the house supply to prevent their use, as they may not be effective. The facility's policy and procedure on medication storage indicated that outdated or deteriorated medications should be immediately removed from stock and disposed of according to procedures.
Infection Control Deficiencies in Hand Hygiene and Equipment Storage
Penalty
Summary
The facility failed to implement its infection control policy and procedure, resulting in deficiencies involving three residents. Activity Assistant 1 and CNA 4 did not perform hand hygiene while distributing meal trays to two residents. This lapse in protocol was observed when CNA 4 did not wash hands between setting up meal trays for the two residents, despite the facility's policy requiring hand hygiene before and after physical contact or care procedures. Interviews with the staff confirmed the failure to adhere to hand hygiene practices, which are crucial to preventing cross-contamination between residents. Additionally, the facility did not properly store a nebulizer mask for a third resident, which was found in the resident's personal belongings drawer instead of a clear plastic bag as required by the facility's guidelines. The Director of Nursing confirmed that nebulizer masks should be stored in labeled plastic bags to prevent contamination. The failure to store the nebulizer mask properly could lead to contamination, posing a risk of infection to the resident.
Failure to Obtain Consent for Medication Administration
Penalty
Summary
The facility failed to inform and provide written information to a resident regarding their right to be informed and sign a written consent about the use and side effects of the medication Invega Sustenna before administration. The resident, who was admitted with diagnoses including Parkinson's disease, encephalopathy, and muscle weakness, had fluctuating capacity to understand and make decisions. Despite this, there was no documented evidence of consent or instructions provided to the resident about the medication's side effects. The deficiency occurred when the facility's former Director of Nursing provided sample medication of Invega Sustenna to be administered to the resident because the pharmacy did not deliver the medication. Licensed Vocational Nurses were instructed to administer the sample medication without ensuring the resident's consent or providing necessary information about the medication. Interviews with staff and a review of the resident's clinical record confirmed the lack of documented consent and information provided to the resident, resulting in a violation of the resident's rights.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident care area in eight out of twenty-eight resident rooms. These rooms included seven two-bed capacity rooms and one four-bed capacity room. The deficiency was identified during a survey, which included observations, interviews, and record reviews. The rooms in question did not meet the space requirements, with some rooms providing as little as 68.5 square feet per resident. Despite this, the facility had previously requested a room waiver, asserting that the variance would not compromise the health, welfare, and safety of the residents. During the survey, the Administrator confirmed that there had been no changes in the number of bed occupancies in the affected rooms and that no complaints had been received from residents, families, or staff regarding room sizes. Observations during the survey indicated that residents had enough space to move freely, and there was adequate room for wheelchairs, walkers, or canes. The survey did not observe any adverse effects on the adequacy of space, nursing care, comfort, or privacy for the residents in the affected rooms.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Temple City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fidelity Health Care | 0.7 mi | ★★★★★ | 3 | 0 |
| Santa Anita Convalescent Hospital | 1.2 mi | ★★★★★ | 17 | 0 |
| The Gardens Of El Monte | 1.2 mi | ★★★★★ | 23 | 0 |
| Baldwin Gardens Nursing Center | 1.2 mi | ★★★★★ | 16 | 0 |
| Santa Fe Lodge | 1.3 mi | ★★★★★ | 21 | 0 |
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