Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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 | — | 9 | 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 | — | 3 | 0 |
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