Santa Anita Convalescent Hospital in Temple City: Inspection Record Review, Complaints and Abuse Reports (Updated October 30, 2026)

According to the citation, CDPH made an unannounced visit on June 20, 2025 to investigate a facility-reported allegation of sexual abuse. The department determined that on the night of June 19, 2025, a licensed vocational nurse (LVN 1) found Resident 2 on top of Resident 1 in her room, with her pants and diaper pulled down. Resident 1 was a 76-year-old woman with dementia and severe cognitive impairment. The citation states that Resident 2 said he was having sex with her. A hospital sexual assault nurse documented positive exam findings, and Resident 1 was started on HIV prevention medication (post-exposure prophylaxis).

CDPH found that Resident 2 had a physician's order for a one-to-one sitter (constant observation), and the facility did not provide one between 11 PM and 11:20 PM that night. Inspectors found that licensed staff did not monitor or document Resident 2's sexually inappropriate behavior seen on June 12, 2025, did not put interventions in place to protect other residents, and did not tell his physician about that behavior. According to the citation, Resident 1 later showed a dysphoric (uneasy, unhappy) mood during a psychologist visit.

CDPH issued a Class A citation with a $25,000 penalty; CDPH records list it as appealed, with an amount due of $22,500. The 2567 report states the federal survey cited F600 (freedom from abuse and neglect) at severity J and F689 (accident hazards and supervision) at severity G, and that CDPH called an immediate jeopardy situation on June 24, 2025. According to the report, the facility's removal plan included reviewing residents with sexually inappropriate or wandering behavior, updating care plans and training staff on one-to-one supervision. The immediate jeopardy was removed on June 26, 2025.

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The 2567 report states that inspectors investigating a complaint in January 2025 found the facility did not prevent accidents for two residents. Resident 1 had dementia, a history of falls and severe cognitive impairment, and his care plan called for staff to supervise him while he sat in his wheelchair. According to the report, on January 3, 2025, CNA 1 left Resident 1 in his wheelchair without supervision. He was later found outside a building lying on the ground, holding his left arm, with a 1-centimeter cut over his left eyebrow.

Inspectors found that paramedics took Resident 1 to an acute care hospital, where he was found to have a displaced fracture (a break where the bone pieces moved out of line) at the neck of the left humerus, the upper arm bone. The 2567 report states that during the January 7, 2025 visit, inspectors also saw a pointed knife about four inches long on a shelf in Resident 3's room. The treatment nurse and the unit manager told inspectors residents are not allowed to have knives and that the facility has confused residents who wander.

According to the report, the facility's weapons policy bans blades longer than three inches. A licensed vocational nurse told inspectors that Resident 3's family had brought the knife on January 5, so it stayed in the room for about two days, and that staff should have checked the room for hazards. The federal survey cited F689 (free of accident hazards, supervision and devices) at severity G.

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According to the citation, Resident 88, a 74-year-old woman on dialysis, came back from the dialysis center on May 21, 2024 with new swelling and bruising under her right arm. She said she was hurt while being moved from the dialysis chair to her wheelchair. CDPH found that her care plan addressed pain on the right side of her chest from fractures (breaks) of the ninth and tenth ribs. At 10:18 AM, inspectors saw her moaning and grimacing, and she rated her pain 9 out of 10.

The department determined that a licensed vocational nurse (LVN 15) gave her Tylenol, which is meant for mild pain, and that staff did not reassess her pain when it did not work. Inspectors found that LVN 15 and Registered Nurse 2 could not get into the automated medication dispenser to obtain Tramadol, a stronger pain medication, and did not call the physician about it. According to the citation, staff also did not tell the physician that her pain was severe and uncontrolled.

CDPH found that Resident 88 had severe pain that was not relieved for 13 hours, from 10:10 AM to 11:09 PM, and she was then transferred to an acute care hospital. CDPH issued a Class A citation with a $25,000 penalty; CDPH records list it as appealed, with an amount due of $18,750. The 2567 report states that the federal survey from the same inspection cited F697 (pain management) at severity G, describing the same failures to assess her pain, give pain medication as ordered and notify the physician.

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According to the citation, CDPH investigated a facility-reported fall during the facility's annual recertification survey in May 2024. Patient 1 was a 60-year-old man with moderately impaired thinking skills who needed partial help to walk. The department determined that he had an unwitnessed fall on April 11, 2024, and a fall risk assessment that day rated him at moderate risk.

CDPH found that licensed nurses did not create a fall care plan before or after that first fall, and that no interdisciplinary falls committee met to look for the cause, as the facility's fall program required. Inspectors found that the nurses' notes for April 11 had no details about the fall or his assessment afterward. The director of nursing told inspectors that the committee meeting and the care plan should have been done after the first fall. According to the citation, staff also did not give Patient 1 the walking assistance he needed on May 1, 2024.

CDPH found that on May 1, 2024, Patient 1 was found lying on the floor during morning rounds and had broken his right femur (thigh bone). He was taken to an acute care hospital, where he had a hip hemiarthroplasty, a surgery that replaces half of the hip joint. CDPH issued a Class A citation with a $25,000 penalty; CDPH records list it as appealed, with an amount due of $20,000. The 2567 report from the federal survey of the same inspection lists F689 (free of accident hazards, supervision and devices) at severity G.

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According to the citation, CDPH investigated a facility-reported fall during the annual recertification survey in May 2024. Patient 1 was an 87-year-old woman with dementia, severely impaired decision-making and a habit of wandering. CDPH found she was rated high risk for falls after an earlier fall on April 23, 2024. A physician's order from March 2024 told staff to monitor her whereabouts, and her care plan called for frequent visual checks.

The department determined that staff did not monitor where Patient 1 was, as the physician's order, her care plan and the facility's fall program required. Inspectors found that on May 8, 2024, she had an unwitnessed fall on a patio and was found with a cut about three centimeters long on her right upper eyelid. She was sent to an acute care hospital by 911.

According to the citation, a CT scan (a detailed X-ray image) at the hospital showed fractures of the right zygomatic arch (cheekbone), the right orbital floor (the bone under the eye) and walls of the maxillary sinus. On May 23, 2024, inspectors saw Patient 1 wandering in a hallway without staff supervision. CDPH issued a Class A citation with a $25,000 penalty; CDPH records list it as appealed, with an amount due of $20,000. The 2567 report from the federal survey of the same inspection lists F689 (free of accident hazards, supervision and devices) at severity G.

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According to the citation, CDPH made an unannounced visit on April 9, 2024 to investigate a facility report of a missing patient. Patient 1 was a 72-year-old man with depression and bipolar disorder (a condition with mood swings between lows and highs). The citation states he went missing on April 8, 2024 at 7:20 AM. Four days later, on April 12, his body was found on the facility premises, and paramedics pronounced him dead. The medical examiner's report listed the cause of death as suicide.

CDPH found that staff did not monitor or respond to Patient 1's repeated statements about feeling depressed and lonely. On March 25, 2024 he said it was "hard to live with this loneliness" and that he was "tired of living this way." The department determined that the facility did not review or update his care plan to address his history of suicidal thoughts, and did not carry out the plans a psychologist wrote in March 2024.

Inspectors found that Patient 1 arrived from a hospital in December 2023 taking Fluoxetine (an antidepressant) and Olanzapine (a bipolar medication), and these were not continued at the facility through April 8, 2024. According to the citation, his physician ordered a psychiatry consult in December 2023, and the facility could not show he was ever seen by a psychiatrist. CDPH issued a Class AA citation with a $120,000 penalty. The 2567 report states the federal survey cited F742 (treatment and services for mental and psychosocial concerns) at severity K.

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According to the citation, CDPH made an unannounced visit on July 27, 2023 to investigate a facility report of a patient's death. Patient 1 was a 75-year-old woman with COPD (a lung disease that makes breathing hard), heart failure and a history of respiratory failure. Her physician ordered staff to check her oxygen level every two hours and keep it between 95% and 100%.

CDPH found that staff did not monitor her oxygen every two hours as ordered and did not start a care plan for her COPD. On July 25, 2023 at 5 PM she was short of breath, with oxygen readings of 76% and 88%. The department determined that staff did not notify her physician of this change in condition, and that licensed staff put her on a non-rebreather mask (a high-flow oxygen mask) at 8 liters per minute without a physician's order. Inspectors found the facility did not follow its own policies on change of condition, physician orders and care planning.

According to the citation, at 5:18 PM Patient 1 was found not making sense, and at 5:23 PM she became unresponsive with a fading pulse. Staff started CPR at 5:25 PM, and paramedics pronounced her dead at 6:08 PM. CDPH issued a Class AA citation with a $120,000 penalty; CDPH records list it as appealed, with a final amount due of $108,000. The 2567 report states the federal survey cited F580 (notifying the physician of changes) at severity J and also lists F695 (respiratory care) at severity J. According to the report, inspectors identified an immediate jeopardy on July 28, 2023, and it was removed on July 31 after the facility submitted an acceptable removal plan.

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According to the citation, CDPH made an unannounced visit to investigate a complaint about a patient with multiple pressure ulcers (bed sores) who was later placed in hospice. Patient 1 was an 87-year-old woman with Parkinson's disease. The facility's own admission assessment in October 2022 noted she was bedridden and her skin was at high risk from moisture, friction and shear.

CDPH determined that licensed staff did not assess, monitor and document weekly wound checks for skin breakdown noted on October 25, 2022, February 5, 2023 and March 23, 2023. The department found that on ten different dates between April 1 and April 24, 2023, certified nurse assistants reported skin breakdown to licensed nurses, and the nurses did not assess it, tell the physician or provide treatment. Inspectors found that staff also did not turn her every two hours, as her care plan required, on 11 dates in April 2023.

CDPH found that Patient 1 developed ten pressure ulcers of different stages on several parts of her body, plus moisture-associated skin damage, without treatment. On April 30, 2023 she was sent to an acute care hospital with decreased consciousness, fast and labored breathing, and cold, clammy skin. According to the citation, she was diagnosed with sepsis (a serious bloodstream infection) and cellulitis (a skin infection), was later discharged with infected pressure ulcers on her buttocks, was placed in hospice, and died on May 25, 2023. CDPH issued a Class A citation with a $25,000 penalty. The 2567 report states the federal survey cited F686 (care to prevent and heal pressure ulcers) at severity H.

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According to the citation, CDPH made an unannounced visit on May 11, 2023 to investigate a complaint about a patient found dead in his bed in a pool of blood. Patient 1 was a 64-year-old man with end stage kidney disease who received dialysis three times a week through an AV shunt, a vein in his arm surgically connected for dialysis. He had severely impaired decision-making. His care plan from January 2023 said he was at risk for shunt rupture and bleeding because he picked at the access site.

CDPH determined that for about four months, from January 13 to May 6, 2023, staff did not reevaluate, monitor or manage his behavior of picking at and touching the shunt site, and from April 13 did not revise his care plan to prevent it. The department found that licensed nurses did not assess the behavior for possible causes, did not contact his physician, and did not try non-drug approaches, as the facility's behavior policy required. Inspectors found there was no regular communication about his behavior between nursing staff, the dialysis provider and the physician.

According to the citation, on May 6, 2023 at 2:10 AM, staff found Patient 1 in bed bleeding at the shunt site. Staff called 911 and started CPR, and paramedics pronounced him dead at 2:55 AM. CDPH issued a Class A citation with a $25,000 penalty. The 2567 report states the federal survey cited F698 (dialysis) at severity K for not providing dialysis care that met professional standards, including watching for and reporting behavior that affects access sites.

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The 2567 report states that inspectors investigating a complaint in January 2023 found the facility did not keep Resident 1 free from accidents. Resident 1 had COPD (a lung disease), heart failure and functional quadriplegia, meaning he could not move on his own because of severe frailty. His assessment showed moderate cognitive impairment, and he needed two staff members to help him move in bed. The facility rated him high risk for falls.

Inspectors found that on January 7, 2023, CNA 1 provided care and repositioned Resident 1 alone while he was in bed. According to the report, he fell out of bed and landed face down on the floor. A licensed vocational nurse wrote that CNA 1 reported the fall at 1:40 PM. Resident 1 had two cuts on the right side of his face, one about 2.5 centimeters long near his right ear.

The 2567 report states that Resident 1 was sent to an acute care hospital, where a CT scan (a detailed X-ray image) of his facial bones showed nondisplaced fractures (breaks where the bone stayed in line) of the right cheekbone, parts of the upper jaw and bones around both eye sockets. An assistant director of nursing also noted an occipital fracture, a break in the back of the skull. The federal survey cited F689 (free of accident hazards, supervision and devices) at severity G.

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