Temple City Healthcare

During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had severely impaired cognition and memory.

The MDS also indicated Resident 2 required setup or clean-up assistance with eating, partial/moderate assistance with oral hygiene, substantial/maximal assistance with personal hygiene, and was dependent with chair/bed-to-chair transfer, and with toileting hygiene and shower/bathe self.

During a review of Resident 2's SBAR, dated 12/21/2025, the SBAR indicated Resident 2 reported that Resident 1 was confused and thought Resident 2 was in her bed and waved a slipper at Resident 2 and told Resident 2 to get off from the bed.

During an interview on 12/26/2025 at 11:13 AM with Resident 2, Resident 2 stated Resident 1 was her room [room [ROOM NUMBER]] when the incident on 12/21/25 occurred. Resident 2 stated she was lying in her bed and Resident 1 started yelling angerly at Resident 2 and stated that Resident 2 was lying in Resident 1's bed. Resident 1 told Resident 2 to get out of her bed. Resident 2 stated Resident 1 had a slipper in her hand and threatened to hit Resident 2. Resident 2 stated she yelled Stop, Stop. Resident 2 stated the incident was scary for her. Resident 2 stated Resident 1 was reassigned to a different room.

During an interview on 12/26/2025 at 11:24 AM with CNA 1, CNA 1 stated on 12/21/2025 around 5 PM, she was in the hallway across from room [ROOM NUMBER] and heard Resident 2 yelling Stop, stop and saw Resident 1 walking out from room [ROOM NUMBER]. CNA 1 stated Resident 2 reported Resident 1 was trying to hit her.

During an interview on 12/26/2025 at 12:05 PM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 12/22/2025 around 9 AM, she heard a commotion coming from room [ROOM NUMBER]. LVN 1 stated that when she arrived at room [ROOM NUMBER], she observed Resident 1 put down her slipper on floor and walked out from room [ROOM NUMBER].

During a telephone interview on 12/26/2025 at 1:10 PM with the Administrator (ADM), the ADM stated she was informed about incident between Resident 1 and Resident 2 on 12/21/2025 but did not report the incident to California Department of Public Health (CDPH), the ombudsman and the police on 12/21/2025.

During a telephone interview on 12/26/2025 at 1:21 PM with the Director of Nursing (DON), the DON stated on 12/21/2025, Resident 1 threaten to hit Resident 2 with her slipper because Resident 1 thought Resident 2 was on Resident 1's bed.

The DON stated Resident 1 was confused and was trying to protect her property and space.

The DON stated the facility did not determine the incident between Resident 1 and 2 as abuse and did not escalate it to the level for reporting to CDPH, the ombudsman and police department.

During a review of the facility's policy and procedure (P&P) titled, Abuse and Neglect Prohibition Policy, dated 6/2022, the P&P indicated upon receiving information concerning a report of suspected or alleged abuse, mistreatment, neglect, or exploitation the Administrator or designee will perform the following: all alleged violations-immediately but not later than 2 hours-if the alleged violation involves abuse or results in serious bodily injury or 24 hours if the alleged violation does not involved abuse and does not result in serious bodily injury.

The P&P indicated to report the incident to the local ombudsman or the local law enforcement agency; and that the Licensing and Certification Program District Office is required to receive these reports.

During a review of the facility's P&P titled, Resident to Resident Altercation, updated on December 2026, the P&P indicated if two residents are involved in an altercation staff will report incidents, findings, and corrective measures to appropriate agencies as outlined in the facility's abuse reporting policy.

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