Santa Anita Convalescent Hospital
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
room. LVN 1 stated she then went to the patio to look for Resident 1 and when she did not find him. LVN 1 stated he notified RN 1 around 5 PM. LVN 1 stated a code green was called but the facility staff did not find Resident 1. LVN 1 stated Resident 1 was then found later that night at GACH. LVN 1 further stated residents are checked every 1 to 2 hours to ensure their safety. During an interview on 11/4/2025 at 1:28 PM with Receptionist 1, Receptionist 1 stated when someone presses the button located on the side of the facility's side parking gate, it rings the phone in at the reception desk. Receptionist 1 stated, she is then able to enter a code that opens the gate. Receptionist 1 also stated she typically does not speak to the person who pressed the button to ask for their identity. During an interview on 11/4/2025 at 2:38 PM with Receptionist 2, Receptionist 2 stated she was the Receptionist on 11/1/2025 and stated on 11/1/2025, when the phone notified her that someone was at the parking gate, she did not ask who was requesting to open the gate and input the code to open it. Receptionist 2 stated she was not aware and was never trained that she needed to speak to the person at the gate to ask or screen who they were. During an interview on 11/5/2025 at 1:33 PM with Assistant Administrator (AADM), AADM stated the normal process for when someone presses the side parking gate button is for the receptionist to ask the person's name and what
they are there for since it is only authorized personnel who are allowed to use the back parking lot. AADM stated on 11/1/2025 when the person pressed the side parking button, the receptionist should have asked who they were, for their name and if they were an employee and because that process was not followed, Resident 1 was able to leave the facility. During an interview on 11/5/2025 at 2:05 PM with QA, QA stated that staff became complacent with Resident 1's behavior of always staying out in the patio or his room and did not expect that he would ever wheel himself out to the back parking lot side gate and leave. QA stated
the receptionist probably assumed the person who pressed the side parking lot gate button was either staff or a delivery coming in. During a review of the facility's policy and procedure (P&P) titled, Wandering and Elopement, revised 6/1/2017, the P&P indicated its purpose was, To enhance the safety of residents of the facility, and further indicated:a. If Facility Staff observes a resident leaving the premises without having followed proper procedures, he/she may:a. Try to prevent departure in a courteous manner.b. Get help from other Facility Staff in the immediate vicinity, if necessary; andc. Direct another Facility Staff member to inform the Charge Nurse or Director of Nursing Services that a resident is trying to leave the premises.
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SANTA ANITA CONVALESCENT HOSPITAL in TEMPLE CITY, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in TEMPLE CITY, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from SANTA ANITA CONVALESCENT HOSPITAL or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.