Health inspection·December 26, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to report an allegation of abuse for two of three sampled residents (Resident 1 and Resident 2) within 2 hours to the ombudsman, local police department, and to California Department of Public Health (CDPH) in accordance with the facility's Policy and Procedure titled, Abuse and Neglect Prohibition Policy. On 12/21/25 between 5 PM and 6 PM, a commotion was heard by certified nurse assistant (CNA) 1 and when CNA1 arrived at Resident 1 and Resident 2's room [room [ROOM NUMBER]], Resident 1 was observed with a slipper in her hand, and Resident 2, reported to CNA 1 that Resident 1 threatened to hit Resident 2 with the slipper. This deficient practice resulted in the facility underreporting allegations of abuse and had the potential for the facility not to follow abuse protocols. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 1/16/2025 with diagnoses that included paranoid schizophrenia (a serious brain disorder that distorts a person's thinking, perception of reality, and emotions) and bipolar disorder (a mental health condition causes extreme mood swings). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 12/12/2025, the MDS indicated Resident 1 had severely impaired cognition (ability to understand and make decisions) and memory. The MDS also indicated Resident 1required supervision or touching assistance with eating, partial/moderate assistance with oral hygiene, personal hygiene and chair/bed-to-chair transfer, and substantial/maximal assistance with toileting hygiene and shower/bathe self. A review of Resident 1's Care Plan for Potential to be physically aggressive related to anger, initiated 12/16/25, indicated the goal was that Resident 1 will not harm self or others. The Care Plan goal indicated to monitor, and document observed behavior and attempted interventions in behavior logs. During a review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR) Communication Form and Progress Note, dated 12/21/2025, the SBAR indicated Resident 1 was agitated and confused. The SBAR indicated Certified Nursing Assistant (CNA) 1 heard arguing coming from Resident 1's room (room [ROOM NUMBER]). When CNA 1 arrived at room [ROOM NUMBER], Resident 2 stated Resident 1 threatened to hit Resident 2 with Resident 2's slipper. During a review of Resident 1's Progress Note (PN), dated 12/21/2025 at 6:46 PM, the PN indicated CNA 1 heard noise coming from room [ROOM NUMBER]. The PN indicated Resident 2 stated that Resident 1 threatened to use Resident 1's slipper to hit Resident 2. The PN indicated the incident was reported to the Director of Nursing (DON) and the Administrator (ADM). During a review of Resident 1's Interdisciplinary Team (IDT) Conference, dated 12/22/2025, the IDT Conference indicated Resident 2 stated that Resident 1 was waving a slipper in Resident 2's face, and stated that Resident 2 was in Resident 1's bed. Resident 1 stated Resident 2 would hit Resident 1 if Resident 1 did not get out the bed. The IDT indicated a room change was conducted and Resident 1 was moved to room [ROOM NUMBER] During a review of Resident 2's AR, the AR indicated the facility originally admitted Resident 2 on 9/17/2024 and readmitted on [DATE] with diagnoses that included Page 1 of 2 056413 056413 12/26/2025 Temple City Healthcare 5101 Tyler Avenue Temple City, CA 91780

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few major depressive disorder (a serious mood disorder causing persistent sadness, loss of interest, and significant impairment in daily life) and hypertension (high blood pressure). 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. 056413 Page 2 of 2