Temple City Healthcare

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.

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