Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Julia Temple Healthcare Center during CMS and state inspections, most recent first.
The facility failed to establish an effective antibiotic stewardship program, resulting in delayed infection mapping and unnecessary antibiotic use for a resident. Despite not meeting McGeer criteria for a UTI and having no bacterial growth in the urine culture, the resident was given Bactrim. Staff interviews revealed that the infection preventionist did not consult the medical director for every antibiotic case, leading to the oversight.
The facility failed to provide necessary assistance and cueing to residents during meals, leading to inadequate nutritional intake. Residents with severe cognitive impairments and malnutrition were observed not receiving the required support, resulting in them consuming less than 25% of their meals. The facility did not adhere to its policy on assisting diners, which emphasizes meeting individual needs and promoting independence.
The facility failed to provide an activities program that met the needs of three residents, including a resident with severe cognitive impairment who was not engaged in meaningful activities, a resident with moderate cognitive impairments who was not invited to group activities, and a resident with severe cognitive impairments who was not consistently engaged in activities matching her interests.
The facility failed to maintain effective infection control, with staff not following hand hygiene protocols and not sanitizing shared equipment. A CNA did not sanitize hands or equipment between residents, and during meals, food was handled with bare hands, and residents ate from each other's plates. These actions risked infection spread, as confirmed by the IP and DON.
The facility failed to effectively develop and implement discharge plans for two residents, resulting in inadequate communication and documentation. One resident, with a history of CVA, was not informed about his discharge criteria, while another resident with moderate cognitive impairment had no documented discharge planning discussions. Staff interviews revealed a lack of consistent documentation and communication with residents and their representatives.
A resident experienced multiple episodes of diarrhea over several days without timely intervention from the facility. Despite requests from the resident's representative for anti-diarrheal medication, the facility delayed notifying the physician and obtaining the necessary medication. The facility's policy required prompt communication of changes in condition, but this was not followed, leading to a delay in treatment.
The facility failed to maintain the dignity and privacy of two residents. One resident had a medication patch removed publicly, exposing her lower back, while another was isolated in a hallway, away from social activities. The DON acknowledged these actions were inappropriate and not in line with the residents' care plans.
A resident with Alzheimer's disease wandered into another resident's room, leading to a physical altercation where the resident was scratched. The facility failed to prevent this incident despite the assailant's known history of wandering and agitation. Both residents had severe cognitive impairments, and the facility's interventions were insufficient to prevent the abuse.
A facility failed to implement fall prevention interventions for a high-risk resident with severe cognitive impairments and a history of falls. Despite a care plan requiring a walker, soft helmet, and supervision, the resident was observed walking without assistance or safety equipment. Multiple fall incidents occurred, highlighting the lack of consistent adherence to the care plan by staff.
Failure in Antibiotic Stewardship and Unnecessary Antibiotic Use
Penalty
Summary
The facility failed to establish an effective antibiotic stewardship program, as evidenced by their inability to map infections in a timely manner. According to the Centers for Disease Control and Prevention (CDC) Core Elements of Antibiotic Stewardship for Nursing Homes, tracking antibiotic use is crucial for improving antibiotic stewardship. However, the facility's infection preventionist (IP) did not complete the infection mapping until the end of the month, which was contrary to the facility's policy that required infections to be mapped as soon as they were identified. This delay in mapping infections hindered the facility's ability to identify patterns and trends in infections promptly. Additionally, the facility failed to ensure that a resident was not given an antibiotic unnecessarily. The resident, who was moderately cognitively impaired and had a history of urinary tract infections (UTIs), was given Bactrim, an antibiotic, despite not meeting the McGeer criteria for a UTI. The resident experienced an acute change in mental status, but did not exhibit other symptoms such as fluctuating behavior, altered level of consciousness, or inattention. Furthermore, the resident's urinalysis showed no bacterial growth, yet the antibiotic treatment continued. Interviews with the facility's staff revealed that the infection preventionist did not consult the medical director for every antibiotic case, only when there were concerns. The IP admitted that the resident's urine culture results, which showed no bacterial growth, were overlooked, and the antibiotic should have been discontinued. The director of nursing and clinical nurse resource confirmed that the facility followed the McGeer criteria and that the provider should have waited for culture results before starting antibiotics. This oversight led to the resident receiving unnecessary antibiotic treatment.
Failure to Assist Residents with Eating
Penalty
Summary
The facility failed to provide appropriate care and services for activities of daily living (ADL) to maintain or improve the abilities of four residents. Specifically, the facility did not ensure that these residents received necessary cueing or assistance while eating, which is crucial for maintaining their nutritional intake and overall health. The facility's policy on assisting diners, which emphasizes providing assistance in a manner that meets individual needs and promotes independence, was not adhered to during the survey observations. Resident #366, who has severe cognitive impairments and is malnourished, was observed not receiving the required set-up and physical assistance during meals. Despite her care plan indicating the need for such assistance, she was left to eat alone, resulting in her consuming less than 25% of her meals on several occasions. Similarly, Resident #370, with severe cognitive impairments and malnutrition, was observed struggling to eat without proper assistance or cueing, leading to inaccurate meal intake documentation. Resident #27, who also has severe cognitive impairments and malnutrition, was observed eating less than 25% of her meals without receiving necessary encouragement or assistance. Additionally, Resident #43, with severe cognitive impairments and a dislike for certain foods, was not offered meal replacements or adequate assistance, resulting in her consuming less than 25% of her meals. These observations highlight a significant deficiency in the facility's adherence to care plans and policies designed to support residents' nutritional needs and independence.
Failure to Meet Residents' Activity Needs
Penalty
Summary
The facility failed to implement an activities program that met the interests and supported the well-being of three residents. Resident #79, who was severely cognitively impaired and primarily spoke Spanish, was not provided with activities that matched his preferences or language needs. Despite his interest in music, reading, and social activities, he was often left alone with English materials and not invited to group activities. Observations showed that staff did not engage with him meaningfully, and documentation of one-on-one activities was inconsistent. Resident #11, with moderate cognitive impairments, was not invited to participate in group activities despite her interest in social interactions, music, and religious services. Observations revealed that she was often left alone in her room, and there were discrepancies between documented activities and actual participation. Staff interviews indicated that she was not consistently encouraged to join activities, and refusals were not properly documented. Resident #364, who had severe cognitive impairments and required assistance with activities, was not consistently invited to participate in activities that matched her interests. Despite her preferences for outdoor activities, music, and social interaction, she was often left without meaningful engagement. Staff interviews revealed a lack of understanding of her interests, and she was not consistently invited to participate in scheduled activities.
Infection Control Deficiencies in Hand Hygiene and Meal Service
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by staff not adhering to proper hand hygiene protocols and not sanitizing shared medical equipment between uses. Observations revealed that a certified nursing aide (CNA) did not sanitize her hands after providing care to each resident and failed to disinfect the vital signs cart between residents. Interviews with the infection preventionist (IP) and the director of nursing (DON) confirmed that hand hygiene and equipment sanitation were expected practices to prevent the spread of infection. Additionally, the facility did not ensure appropriate infection control standards during meal times. A CNA was observed handling food with bare hands without performing hand hygiene, and residents were seen eating from each other's plates. This lack of intervention by staff allowed for potential cross-contamination and the spread of infection. The IP and DON acknowledged that food should not be handled with bare hands and that residents should not consume food from other residents' plates due to risks of infection and dietary complications. The observations and interviews highlight a systemic issue in the facility's infection control practices, particularly concerning hand hygiene and meal service protocols. The failure to adhere to these standards poses a risk of infection transmission among residents, as confirmed by the facility's own policies and CDC guidelines.
Deficient Discharge Planning and Communication
Penalty
Summary
The facility failed to develop and implement an effective discharge plan for two residents, leading to deficiencies in communication and documentation. Resident #466, a 77-year-old with a history of cerebral vascular accident and other conditions, expressed frustration over not being informed about his progress and discharge criteria. Despite being cognitively intact, he was not provided with the necessary information to facilitate his discharge, and there was no documentation in his electronic medical record (EMR) regarding meetings or discussions about his discharge plan. Similarly, Resident #362, an 85-year-old with moderate cognitive impairment and other medical conditions, was not included in the care planning process. Her representative reported a lack of communication and information regarding her discharge. The EMR lacked documentation of interdisciplinary meetings or an active discharge planning process, and there was no record of discussions with the resident's representative about her progress or potential services for care at home. Interviews with staff, including the Rehabilitation Transitions Director (RTD), revealed that while initial care plans were created, there was a failure to document ongoing discharge planning and communication with residents and their representatives. The RTD admitted to not documenting discharge planning in the EMR and acknowledged that attempts to meet with residents and their representatives were not consistently recorded. The Nursing Home Administrator confirmed that discharge planning should involve residents and their families and be documented in the EMR, highlighting a systemic issue in the facility's discharge planning process.
Failure to Provide Timely Treatment for Diarrhea
Penalty
Summary
The facility failed to provide timely treatment and care for a resident experiencing multiple episodes of diarrhea, which was not in accordance with professional standards of practice. The resident, who was cognitively intact and frequently incontinent of bowel and bladder, experienced several episodes of diarrhea over a period of days. Despite the resident's representative requesting anti-diarrheal medication on multiple occasions, the facility did not obtain a physician's order for the medication until several days later. The facility's policy required that changes in a resident's condition be promptly communicated to a physician, and that symptoms be documented in nursing progress notes. However, the facility did not adhere to this policy, as there were no progress notes related to the resident's diarrhea until after the physician was notified and prescribed Imodium. The resident experienced six episodes of large loose stools before the physician was contacted and an anti-diarrheal medication was ordered. Interviews with staff revealed that the facility's procedure for handling diarrhea included notifying the provider and monitoring the resident for 72 hours. However, this procedure was not followed in a timely manner for the resident in question. The director of nursing and clinical nurse resource acknowledged that the provider should have been notified sooner, and that the resident's medications should have been reviewed for potential side effects causing the diarrhea.
Failure to Ensure Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure the dignity and privacy of two residents, leading to deficiencies in their care. Resident #19, who has severe cognitive impairments and difficulty communicating, was observed on two occasions having a lidocaine patch removed in the dining room during group activities. This action exposed her lower back in a public setting, violating her right to privacy. The Director of Nursing (DON) acknowledged that such procedures should be conducted in private, indicating a lapse in adhering to the facility's policy on residents' rights and dignity. Resident #44, who suffers from Alzheimer's disease, dementia, and generalized muscle weakness, was repeatedly placed in a back hallway facing the wall, away from other residents and activities. This placement isolated her from social interactions and activities, contrary to her communication care plan, which emphasized the importance of her being positioned to promote communication with others. The DON admitted that the resident's placement was not ideal and that she should have been included in communal activities, highlighting a failure to provide a dignified existence for the resident.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent an incident of physical abuse between two residents, identified as Resident #68 and Resident #22. On the date of the incident, Resident #68 wandered into Resident #22's room and began packing up Resident #22's belongings, mistakenly believing it was her room. This led to a disagreement between the two residents, during which Resident #68 scratched Resident #22 on the neck. The staff intervened to separate the residents, but the incident highlighted a failure in the facility's abuse prevention measures. Resident #22, an 83-year-old with severe cognitive impairments and a history of dementia, was the victim in this incident. Her care plan included interventions for depression and behavior problems related to her dementia. Despite these measures, the facility did not adequately protect her from the aggressive behavior of Resident #68, who had a documented history of wandering and entering other residents' rooms, which was known to agitate other residents. Resident #68, an 82-year-old with Alzheimer's disease and severe cognitive impairments, had a history of behaviors such as wandering into other residents' rooms and becoming agitated when redirected. The facility's records indicated that Resident #68 had previously exhibited similar behaviors, yet the interventions in place were insufficient to prevent the altercation with Resident #22. The facility's failure to effectively monitor and manage Resident #68's behavior contributed to the incident of abuse.
Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The facility failed to ensure adequate supervision and interventions to prevent accidents for Resident #88, who was identified as a high fall risk. Despite having a care plan in place that included the use of a walker, soft helmet, and supervision, the resident was observed multiple times walking without assistance or the prescribed safety equipment. Staff members, including CNAs and nurses, were observed not offering the resident her walker or assistance, and she was not wearing her soft helmet during these times. Resident #88, a 77-year-old with severe cognitive impairments and a history of falls, was admitted with diagnoses including unspecified dementia and muscle weakness. The resident required assistance for various activities of daily living and was noted to have poor safety awareness. Despite these needs, the facility's staff did not consistently implement the fall interventions outlined in her care plan, such as ensuring she wore a soft helmet and providing assistance with ambulation. The facility's failure to implement these interventions was further highlighted by multiple fall incidents, both witnessed and unwitnessed, where the resident was found sitting on the floor or attempting to self-transfer without assistance. Interviews with staff revealed a lack of consistent adherence to the care plan, with some staff unaware of the requirement for the resident to wear a soft helmet. The Director of Nursing acknowledged the challenges in supervising all residents at all times but confirmed that Resident #88 was considered a high fall risk and required specific interventions to mitigate this risk.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 516 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Englewood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Englewood Post Acute And Rehabilitation | 0.6 mi | ★★★★★ | 0 | 0 |
| Wellsprings Care Center | 0.6 mi | ★★★★★ | 15 | 0 |
| Suites At Clermont Park Care Center, The | 2 mi | ★★★★★ | 8 | 0 |
| South Valley Post Acute Rehabilitation | 2.5 mi | ★★★★★ | 17 | 0 |
| Brookshire Post Acute | 2.7 mi | ★★★★★ | 3 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.