Temple City Healthcare
Inspection Findings
F-Tag F0656
F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Based on interview and record review the facility failed to develop a resident specific care plan that reflected Resident 1's change in condition of a skin tear to the left shin.This deficient practice had the potential for Resident 1 to not receive appropriate care, treatment, and/or services.During a review of Resident 1's admission Record (AR), the AR indicated an admission to the facility on 9/18/2024 with diagnoses that included cellulitis of right lower limb, chronic respiratory failure, and lack of coordination.
During a review of Resident 1's History and Physical Assessment (H&P), dated 11/3/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's SBAR (Situation Background Assessment Recommendation) Communication Form and progress note dated 10/24/2025, timed at 10:11 AM, the SBAR indicated during resident care, Resident 1 was transferring from the shower chair to the wheelchair with assistance and hit her log on the foot pedal which caused a skin tear to the left shin. The note indicated pressure and steri strips were applied to stop bleeding and shin was covered with dry dressing. During a review of Resident 1's Order Summary dated 10/24/2025, the Order Summary indicated the physician ordered treatment of left shin skin tear: cleanse with normal saline, pat dry, apply collagen particles, apply calcium alginate dressing, cover with dry dressing every day shift for 14 days and skin maintenance cleanse with normal saline pat dry, apply barrier cream, every day shift for 30 days. During a concurrent interview and record review of Resident 1's care plans on 11/13/2025 at 12:24 PM, treatment nurse (TN), stated she could not find documented evidence of a care plan that indicated Resident 1's skin tear. TN 1 stated that when there was a change of condition like Resident 1's skin tear, there should be a care plan update. TN 1 stated she did not update and add a care plan for Resident 1's new skin tear. TN 1 stated it was important to have a care plan for the skin tear to prevent it from happening again and to continue interventions to monitor the skin tear. TN 1 stated the care plan should also include a goal for staff to follow and accomplish. During an interview on 11/13/2025 at 1:03 PM, the Director of Nursing (DON) stated a care plan should be added or updated after any change of condition so that staff would be on the same page and know the interventions for residents to get better. The DON stated staff would be in-serviced to remind them to update the care plan when there was any change of condition. A
review of the facility's policy and procedure titled Comprehensive Plan of Care, dated 12/2016 indicated the comprehensive care plan must describe services that are provided to the resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being that will accommodate resident needs, request and refusal to treatment. The P&P indicated to re-evaluate and modify care plans as necessary to reflect changes in care, service, treatment, quarterly, and with significant change in status assessment.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
TEMPLE CITY HEALTHCARE 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 TEMPLE CITY HEALTHCARE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.