The October incident left the facility without a roadmap for staff to follow, despite physician orders for daily wound care that would continue for two weeks.
Resident 1 was transferring from a shower chair to her wheelchair with staff assistance on October 24 when she struck her leg on the foot pedal, according to a progress note timed at 10:11 AM. The impact caused a skin tear that required immediate attention.
Staff applied pressure and steri strips to stop the bleeding, then covered the wound with a dry dressing. The facility's physician quickly ordered a comprehensive treatment plan: cleanse the wound daily with normal saline, pat dry, apply collagen particles and calcium alginate dressing, then cover with dry dressing. The orders specified this routine should continue every day shift for 14 days.
The doctor also ordered preventive skin maintenance for 30 days — daily cleansing with normal saline, patting dry, and applying barrier cream.
But nearly three weeks later, when federal inspectors arrived for a complaint investigation, the treatment nurse couldn't locate any care plan addressing the resident's skin tear.
"When there was a change of condition like Resident 1's skin tear, there should be a care plan update," the treatment nurse told inspectors on November 13. She acknowledged she had failed to create or update a care plan for the new wound.
The treatment nurse explained that a care plan for the skin tear was "important to have to prevent it from happening again and to continue interventions to monitor the skin tear." She said the plan should include goals for staff to follow and accomplish.
Without an updated care plan, staff lacked standardized guidance for preventing future injuries or monitoring the wound's progress, even as they carried out the physician's daily treatment orders.
The Director of Nursing confirmed that care plans should be added or updated after any change in condition "so that staff would be on the same page and know the interventions for residents to get better."
The nursing director promised that staff would receive in-service training to remind them about updating care plans when residents experience changes in condition.
Resident 1 had been admitted to Temple City Healthcare on September 18, 2024, with multiple health challenges including cellulitis of her right lower limb, chronic respiratory failure, and lack of coordination. A November 3 assessment indicated she retained the capacity to understand and make decisions about her care.
The facility's own policy, dated December 2016, requires comprehensive care plans that describe services provided to help residents "attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being." The policy specifically mandates re-evaluating and modifying care plans "as necessary to reflect changes in care, service, treatment, quarterly, and with significant change in status assessment."
The skin tear represented exactly the type of significant change that should trigger an immediate care plan update under the facility's written procedures.
Federal inspectors found the failure had potential to result in Resident 1 not receiving appropriate care, treatment, or services. Without a care plan specifically addressing her new vulnerability to skin injuries during transfers, staff had no systematic approach to prevent similar incidents.
The deficiency occurred despite clear physician orders and the facility's own policies requiring care plan updates when residents experience changes in condition. The gap between medical orders and care planning left staff without the comprehensive guidance needed to address both treatment and prevention.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Temple City Healthcare from 2025-11-13 including all violations, facility responses, and corrective action plans.