Inspection visit
Health inspection
12 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 12 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review, the facility failed to provide reasonable accommodation
of needs for one of one sampled resident (Resident 46) who was at risk for fall, by failing to ensure the
resident's call light was within reach as indicated in the facility's Policy and Procedure, titled Answering the
Call Light and the resident's plan of care.
Residents Affected - Few
This deficient practice had the potential for Resident 46 not to receive or received delayed care to meet the
necessary services that could potentially result in falls and/or accidents.
Findings:
During a review of Resident 46's admission Record, the admission record indicated the facility admitted
Resident 46 on 8/8/2021 with diagnoses that included epilepsy (a neurological disorder marked by sudden
recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with
abnormal electrical activity in the brain) and peripheral vascular disease ( a condition in which there is a
build-up of fat and narrowing of arteries in the limbs, reducing blood flow).
During a review of Resident 46's History and Physical (H&P), dated 8/9/2021, the H&P indicated Resident
46 did not have the capacity to understand and made decision.
During a review of Resident 46's untitled care plan initiated on 9/27/2021, the care plan indicated Resident
46 had poor safety awareness. The care plan interventions included for the nursing staff to place the call
light within reach and answer promptly.
During a review of Resident 46's Minimum Data Set (MDS, a standardized assessment and care planning
tool), dated 9/2/2023, the MDS indicated Resident 46 had severely impaired cognition (mental action or
process of acquiring knowledge and understanding) for daily decision making. The MDS indicated,
Resident 46 required total dependence with two-person physical assistance with bed mobility, transfer,
dressing, eating, toilet use and personal hygiene.
During a review of Resident 46's Fall Risk Assessment (method of assessing a patient's likelihood of
falling), dated 11/27/2023, the assessment indicated Resident 46 was assessed as at high risk for fall due
to disorientation, chair bound (required assist with elimination) and predisposing disease conditions.
During a concurrent observation and interview on 12/1/2023 at 6:07 pm, with Treatment Nurse 1 (TN 1),
Resident 46 was sitting on a wheelchair with the call light on the right side of the wheelchair. TN 1 stated
Resident 46 was unable to reach the call light. TN 1 stated it was important that the call light was within
reach for Resident 46's safety.
(continued on next page)
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
Page 1 of 20
Event ID:
555055
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555055
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Baldwin Gardens Nursing Center
10786 Live Oak Avenue
Temple City, CA 91780
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0558
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
During an interview on 12/2/2023 at 5:44 pm, with the Director of Nursing (DON), the DON stated the call
light needed to be within reach all the time to attend Resident 46's needs and to ensure resident's safety.
During a record review of the facility's Policy and Procedure (P&P) titled, Answering the Call Light, revised
on March 2010, the P&P indicated, when the resident is in bed or confined to a chair, be sure the call light
is within easy reach of the resident.
Event ID:
Facility ID:
555055
If continuation sheet
Page 2 of 20
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555055
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Baldwin Gardens Nursing Center
10786 Live Oak Avenue
Temple City, CA 91780
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to develop and implement an individualized person-centered
plan of care (details why a person received care, assessed health or care needs, medical history, personal
details, expected and aimed outcomes, and what care and support will be delivered, how, when and by
whom) with measurable objectives, timeframe, and interventions to meet the residents' needs for one of
one sampled resident (Resident 36) who had type 2 diabetes mellitus (DM - a chronic condition that affects
the way the body processes blood sugar) and was on Humulin R (type of insulin [a hormone that works by
lowering levels of sugar in the blood]) as indicated in the facility's Policy and Procedure titled Care Plans,
Comprehensive Person-Centered.
This deficient practice had the potential for Resident 36 to not receive the necessary care, treatment and/or
services.
Findings:
During a review of Resident 36's admission record, the record indicated the facility admitted Resident 36 on
7/15/2022 with diagnoses that included type 2 diabetes mellitus, dementia (long term and often gradual
decrease in the ability to think and remember severe enough to affect a person's daily functioning) and
urinary tract infection (UTI, an infection in any part of the urinary system).
During a review of Resident 36's Minimum Data Set (MDS, a standardized assessment and care planning
tool), dated 11/2/2023, the MDS indicated, Resident 36 required moderate assistance with oral hygiene,
upper body dressing and personal hygiene.
A review of Resident 36's History and Physical assessment dated [DATE], the assessment indicated
Resident 36 did not have the capacity to make decisions.
During a review of Resident 36's Physician order, dated 11/19/2023, the order indicated for Resident 36 to
receive Humulin R subcutaneously (administering medication where a short needle is used to inject a
medication into the tissue layer between the skin and the muscle) per sliding scale coverage (progressive
increase in the insulin dose, based on pre-defined blood glucose ranges) before meals and at bedtime for
type 2 DM.
During a review of Resident 36's Physician order, dated 11/19/2023, the order indicated for Resident 36 to
receive Jardiance Oral Tablet (used to treat high blood sugar levels) 10 milligrams (mg- unit of
measurement) one tablet by mouth one time a day for type 2 DM.
During a concurrent interview and record review on 12/2/2023 at 12:36 pm with the Infection Preventionist
Nurse (IPN), Resident 36's medical record was reviewed. IPN stated there was no clinical documentation
that a care plan was developed for Resident 36 to address type 2 DM and insulin use. IPN stated, a care
plan needed to be initiated and implemented for Resident 36 to receive the care the resident needed.
During a concurrent interview and record review on 12/3/2023 at 8:11 am, with the Director of Nursing
(DON), the DON stated a care plan was not developed for Resident 36 who had a diagnosis of type 2 DM
and was on insulin use. The DON stated it was important that a care plan needed to be initiated
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555055
If continuation sheet
Page 3 of 20
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555055
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Baldwin Gardens Nursing Center
10786 Live Oak Avenue
Temple City, CA 91780
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
for Resident 36 for the staff to know the interventions and necessary treatment the resident needed.
Level of Harm - Minimal harm
or potential for actual harm
During a review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive
Person-Centered, revised 12/2016, the P&P indicated the Interdisciplinary Team (IDT), in conjunction with
the resident and his/her family or legal representative, develops and implements a comprehensive,
person-centered care plan for each resident. The P&P indicated each resident's comprehensive
person-centered care plan will be consistent with the resident's rights to participate in the development and
implementation of his or her plan of care.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555055
If continuation sheet
Page 4 of 20
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555055
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Baldwin Gardens Nursing Center
10786 Live Oak Avenue
Temple City, CA 91780
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0679
Provide activities to meet all resident's needs.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, the facility failed to provide activities in accordance with the
resident's comprehensive assessment for one of two sampled residents (Resident 50).
Residents Affected - Few
This deficient practice had the potential to not support the physical, mental, and psychosocial well-being of
Resident 50.
Findings:
During a review of Resident 50's admission Record, the admission record indicated the facility admitted the
resident on 10/11/23 with diagnoses that included metabolic encephalopathy (build-up of toxins causing
brain dysfunction,) and dementia (long term and often gradual decrease in the ability to think and
remember severe enough to affect a person's daily functioning).
During a review of Resident 50's Minimum Data Set (MDS - a standardized assessment and care planning
tool) dated 11/6/23, the MDS indicated Resident 50 was rarely/never able to express ideas and wants and
rarely/never understands verbal content. The MDS indicated Resident 50 was dependent in all activities of
daily living.
During an interview on 12/2/23 at 5:24 pm, the Activities Director (AD) stated the facility provided activities
to residents based on the resident's activity preferences. The AD stated, AD conducted the activities
assessment upon admission and if the resident was not able to respond, AD would find out the resident's
preferences from the family.
During an interview on 12/2/23 at 5:30 pm, the AD did not respond when asked how Activities Staff identify
what activities needed to be provided based on Resident 50's activity preferences. The AD did not respond
how the Activities Department will use the information regarding Resident 50's activity interests on the
Activities Review assessment.
During a review of Resident 50's initial Activities Review dated 11/7/23, on 12/2/23 at 5:34 pm, the review
indicated Resident 50's past activity interests included sensory stimulation such as aromatherapy and hand
massages.
During a concurrent interview with the AD and review of Resident 50's Activity Attendance Record for the
month of November 2023 on 12/2/23 at 5:35 pm, the record indicated in-room activities were provided
including conversation, watching TV, and listening to music. The Activities Director stated sensory
stimulation was not provided as indicated on Resident 50's Activities Review.
During a review of the facility's Policy and Procedure (P&P) titled Activity Evaluation dated June 2018, the
P&P indicated an activity evaluation is conducted as part of the comprehensive assessment to help develop
activities plan that reflects the choices and interests of the resident. The resident's lifelong interests,
spirituality, life roles, goals, strengths, needs and activity pursuit patterns and preferences are included in
the evaluation. The activity evaluation is used to develop individual activities care plan that will allow the
resident to participate in activities of his/her choice and interest.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555055
If continuation sheet
Page 5 of 20
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555055
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Baldwin Gardens Nursing Center
10786 Live Oak Avenue
Temple City, CA 91780
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to provide needed care and services by failing
to:
Residents Affected - Some
a. Assess one of one sampled resident (Resident 17) who developed edema (swelling caused by too much
fluid trapped in the body's tissues) of the left lower leg.
This deficient practice had the potential to result in delayed care and services to address Resident 17's
edema.
b. Complete a Situation, Background, Assessment, Recommendation (SBAR-a written communication tool
that helps provide essential, concise information during crucial situations) report for one of one sampled
resident (Resident 7), when Resident 7 was transferred to General Acute Care Hospital 1 (GACH 1) for a
medical emergency.
This deficient practice had the potential to result in Resident 7's health information not communicated
between healthcare providers affecting the quality of care for Resident 7.
Findings:
a. During a review of Resident 17's admission Record, the admission record indicated Resident 17 was
admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease
(COPD, type of obstructive lung disease characterized by long-term poor airflow) and congestive heart
failure (a long-term condition that happens when the heart cannot pump blood well enough to supply the
body).
During a review of Resident 17's Minimum Data Set (MDS, a resident assessment and care screening tool)
dated 11/3/2023, the MDS indicated Resident 17 had clear speech, sometimes understood others, and
sometimes made self-understood. Resident 17 was dependent (helper does all of the effort, resident does
none of the effort to complete the activity) for eating, dressing and personal hygiene.
During a review of Resident 17's progress notes dated 11/26/2023, timed 2:03 pm, the notes indicated
Resident 17 did not have edema to upper and lower extremities.
During an observation on 12/1/2023 at 6:26 pm, Resident 17 was lying in bed awake. Resident 17's left
lower leg was swelling and edematous.
During a concurrent observation and interview on 12/2/2023 at 4:42 pm, in Resident 17's room, Licensed
Vocational Nurse 2 (LVN 2) assessed Resident 17's left lower extremity and stated Resident 17's left lower
leg had 2+pitting edema (edema assessment by applying pressure on the affected area, measuring the
depth of the pit [depression] and how long it lasts [rebound time]. +1: up to 2mm of depression, rebounding
immediately; +2: 3-4mm of depression, rebounding in 15 seconds or less). LVN 2 stated, there was no
documentation in Resident 17's medical record that Resident 17 developed edema of the left lower leg after
11/26/2023. LVN 2 stated Resident 17 had a history of edema and needed to be continuously monitored for
any changes of edema to avoid fluid overload. LVN 2 stated certified nursing assistants (in general) needed
to report to the Charge Nurse if they observed any resident's skin issues when providing shower or bed
bath to the resident. LVN 2 stated Resident 17's recurrent edema should be reported to the physician for
medical treatment.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555055
If continuation sheet
Page 6 of 20
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555055
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Baldwin Gardens Nursing Center
10786 Live Oak Avenue
Temple City, CA 91780
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
During a review of the facility's Policy and Procedure (P&P) titled, Change in Resident's Condition or
Status, revised 2/2021, the P&P indicated The nurse will notify the resident's attending physician or
physician on call when there has been a significant change in the resident's physical/emotional/mental
condition.
b. During a review of Resident 7's admission Record, the admission record indicated Resident 7 was
originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included
hemiplegia and hemiparesis affecting left non-dominant side (paralysis of partial or total body function on
one side of the body and one-sided weakness without complete paralysis), dysphagia (difficulty swallowing)
and gastrostomy (a surgical procedure used to insert a tube, G-tube, through the abdomen into the
stomach so that feeding can be delivered directly into the stomach bypassing the mouth and throat.)
During a review of Resident 7's Physician Order dated 7/15/2023, the order indicated to transfer Resident 7
to GACH for further evaluation.
During a review of Resident 7's medical record from 7/15/2023 -7/21/2023, the medical record did not
indicate an SBAR was completed for Resident 7 on 7/15/2023.
During a review of Resident 7's Minimum Data Set (MDS, a resident assessment and care screening tool)
dated 11/14/2023, the MDS indicated Resident 7 had unclear speech, sometimes understood others, and
sometimes made self-understood. Resident 7 was dependent (helper does all of the effort, resident does
none of the effort to complete the activity) for dressing, personal hygiene, and bed-to-chair transfer.
During an interview and concurrent review of Resident 7's medical record on 12/3/2023 at 8:22 am, the
facility's Director of Nursing (DON) stated Resident 7 was transferred to GACH 1 due to medical emergency
of chest pain. The DON stated, there was no SBAR documented in Resident 7's medical record when
Resident 7 was transferred to GACH 1 on 7/15/2023. The DON stated, an SBAR should be completed and
documented every time the resident had a change of condition or transferred to the hospital for emergency.
The DON stated, the SBAR was important, so other healthcare professionals know the resident's condition
and the care the resident needed based on the SBAR. The DON stated SBAR was used as a summary
report for the resident upon a change of condition and a communication tool between staff for continuity of
care.
During a review of the facility's Policy and Procedure (P&P) titled, Change in a Resident's Condition or
Status, revised 2/2021, the P&P indicated, Prior to notifying the physician or healthcare provider, the nurse
will make detailed observations and gather relevant and pertinent information for the provider, including
information prompted by the Interact SBAR Communication Form.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555055
If continuation sheet
Page 7 of 20
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555055
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Baldwin Gardens Nursing Center
10786 Live Oak Avenue
Temple City, CA 91780
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to assess and monitor the presence of white
sediments (visible particles in the urine that may contain red or white blood cells, casts or bacteria that
could indicate infection) in the urine for one of four sampled residents (Resident 36) with suprapubic
catheter (a hollow flexible tube that is inserted into the bladder through a cut in the abdomen used to drain
urine from the bladder) as indicated in the facility's Policy and Procedure, titled Suprapubic Catheter Care
and the resident's plan of care.
This deficient practice had the potential for Resident 36 not to receive care or delayed care and treatment
for urinary tract infection (UTI, condition in which bacteria invade and grow in any part the urinary system),
hospitalization or sepsis (severe infection).
Findings:
During a review of Resident 36's admission record, the admission record indicated the facility readmitted
Resident 36 on 10/27/23 with diagnoses that included dementia (long term and often gradual decrease in
the ability to think and remember severe enough to affect a person's daily functioning) and obstructive and
reflux uropathy (a condition that allows urine to go back up into the ureters [a tube that carries urine from
the kidneys to the bladder] and kidneys causing repeated urinary tract infections).
During a review of Resident 36's Minimum Data Set (MDS, a standardized assessment and care planning
tool), dated 11/2/2023, the MDS indicated, Resident 36 required moderate assistance with oral hygiene,
upper body dressing and personal hygiene.
During a review of Resident 36's History and Physical assessment dated [DATE], the assessment indicated
Resident 36 did not have the capacity to make decisions.
During a review of Resident 36's Care Plan titled, Suprapubic Catheter, initiated on 11/19/2023, the care
plan indicated interventions including nursing staff to monitor/record/report to physician for signs and
symptoms of UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color,
increased pulse, increase temperature, urinary frequency, foul smelling urine, fever, chills, altered mental
status, change in behavior and change in eating patterns.
During a review of Resident 36's Physician's Order Summary Report, the report indicated an order on
11/19/2023 for staff to monitor Resident 36's suprapubic catheter for presence of sediments and cloudy
urine, every shift.
During a review of Resident 36's Physicians Order Summary Report, the report indicated an order on
11/19/2023 for staff to monitor Resident 36's suprapubic catheter for signs and symptoms of infection such
as foul odor, drainage, irritation/redness, tenderness, or suprapubic discomfort, observe the meatus
(urinary opening) for any tear, bleeding, blister and notify the physician if noted, every shift.
During an observation on 12/1/2023 at 5:41 pm with Treatment Nurse 1 (TN 1), Resident 36 was awake in
bed. Resident 36 had suprapubic catheter hanging at the right side of the resident's bed frame.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555055
If continuation sheet
Page 8 of 20
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555055
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Baldwin Gardens Nursing Center
10786 Live Oak Avenue
Temple City, CA 91780
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Resident 36's catheter tubing and bag had white sediments and the urine was cloudy and dark yellow in
color.
During an interview on 12/1/2023 at 5:42 pm., with TN 1, TN 1 stated Resident 36's catheter tubing and bag
contained white sediments and cloudy yellow colored urine which could be signs and symptoms of UTI. TN
1 stated she was monitoring Resident 36's catheter tubing and bag. TN 1 stated catheter tubing needed to
be monitored to prevent UTI.
During a concurrent observation and interview on 12/2/2023 at 12:46 pm, with Infection Prevention Nurse
(IPN), Resident 36's suprapubic catheter tubing had white sediments and cloudy urine. IPN stated Resident
36 had history of UTI. IPN stated catheter tubing should be monitored by the licensed nurses for signs and
symptoms of UTI such as sediments and cloudiness.
During an interview on 12/2/2023 at 5:46 pm, with the facility's Director of Nursing (DON), the DON stated
licensed nurses were monitoring residents' catheter tubing every 8 hours to check for the signs and
symptoms of UTI such as fever, blood in the urine, sediments, and cloudiness. The DON stated Resident
36's suprapubic catheter needed to be monitored for sediments and cloudiness of the urine to prevent UTI.
During a review of the facility's Policy and Procedure (P&P) titled, Suprapubic Catheter Care, revised
10/2010, the P&P indicated, to check the urine for unusual appearance (i.e., color, blood, etc.). The P&P
indicated to observe the resident for signs and symptoms of urinary tract infection and urinary retention and
report findings to the supervisor.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555055
If continuation sheet
Page 9 of 20
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555055
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Baldwin Gardens Nursing Center
10786 Live Oak Avenue
Temple City, CA 91780
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0693
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and
provide appropriate care for a resident with a feeding tube.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to ensure the head of bed was kept elevated to
30 to 45 degrees for one of two sampled residents (Resident 16) with ongoing G-tube (a tube inserted
through the abdomen that delivers nutrition directly to the stomach) feeding.
This deficient practice had the potential to result in complications from aspiration (food, liquid, or other
material enters a person's airway and lungs by accident).
Findings:
During a review of Resident 16's admission Record, the admission record indicated Resident 16 was
readmitted to the facility on [DATE], with diagnoses that included pneumonia (respiratory infection),
metabolic encephalopathy (a brain disorder) and type 2 diabetes mellitus (a long-term medical condition
resulting in unusual blood sugar levels).
During a review of Resident 16's Minimum Data Set (MDS, a resident assessment and care screening tool)
dated 10/10/2023, indicated Resident 16 had clear speech, sometimes understood others, and sometimes
made self-understood. Resident 16 was dependent (helper does all of the effort, resident does none of the
effort to complete the activity) for personal hygiene, dressing and toileting hygiene.
During an observation and concurrent interview on 12/1/2023 at 6:01 pm, Resident 16 was lying in bed with
head of bed not elevated in accordance with the facility's policy and procedure. Resident 16 had ongoing
G-tube feeding at 50 milliliters (ml)/hour through a feeding pump. The Director of Nursing (DON) stated
Resident 16's head of bed was not elevated in accordance with the facility's policy and procedure. The DON
stated Resident 16's head of bed needed to be elevated at least 30 degrees while receiving G-tube feeding
to prevent aspiration. The DON stated Resident 16 can develop aspiration pneumonia if Resident 16's tube
feeding formula entered Resident 16's airway or lungs.
During a review of the facility's Policy and Procedure titled, Enteral Feedings-Safety Precaution, revised
11/2018, the P&P indicated, Elevate the head of the bed at least 30 degrees during tube feeding and at
least 1 hour after feeding.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555055
If continuation sheet
Page 10 of 20
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555055
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Baldwin Gardens Nursing Center
10786 Live Oak Avenue
Temple City, CA 91780
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to ensure safe administration of medication for
one of three sampled residents (Resident 7) during medication pass administration. Licensed Vocational
Nurse 4 (LVN 4) crushed Alfuzosin (medication used to treat symptoms of an enlarged prostate in men,
including difficulty urinating) Hydrochloride (HCL) Extended Release (ER-medications that slowly released
over a period of time, that do not immediately release the active ingredients of the medication into the body,
through the use of enteric coating which should not be crushed) and administered the medication to
Resident 7 through the G-tube (external opening into the stomach for medication/nutritional support).
This deficient practice had the potential to result in rapid absorption of a large dose of the drug that was
intended to be released slowly over many hours which can cause harm to Resident 7.
Findings:
During a review of Resident 7's admission Record, the admission record indicated Resident 7 was
readmitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis affecting left
non-dominant side (paralysis of partial or total body function on one side of the body and one-sided
weakness without complete paralysis), dysphagia (difficulty swallowing) and gastrostomy (a surgical
procedure used to insert a G-tube).
During a review of Resident 7's Minimum Data Set (MDS, a resident assessment and care screening tool)
dated 11/14/2023, the MDS indicated Resident 7 had unclear speech, sometimes understood others, and
sometimes made self-understood. Resident 7 was dependent (helper does all of the effort, resident does
none of the effort to complete the activity) for dressing, personal hygiene, and bed-to-chair transfer.
During a review of Resident 7's Order Summary Report for December 2023, the report indicated the
physician ordered for staff to administer to Resident 7 Alfuzosin HCL ER oral tablet, extended release 24
hour 10 milligrams (mg-unit of measurement) one tablet one time a day for Benign Prostatic Hyperplasia
(BPH- the prostate and surrounding tissue expands causing difficulty urinating).
During a medication pass observation on 12/2/2023 at 8:07 am, in Resident 7's room, LVN 4 crushed
Alfuzosin HCL ER on e tablet to powder, mixed with water, and administered the medication to Resident 7
through the G-tube.
During an interview on 12/2/2023 at 9:54 am, LVN 4 stated, Alfuzosin HCL ER was an extended-release
medication meaning it was coated for slow release of the ingredient to the body. LVN 4 stated crushing an
extended-release medication may alter the effectiveness of the medication and resulted in administration of
a large dose all at once. LVN 4 stated she should not crush the Alfuzosin medication for Resident 7.
During a review of the facility's Policy and Procedure (P&P) titled, Administering Medication through an
Enteral Tube, revised 11/2018, the P&P indicated, Do not crush enteric coated, sustained release (slow
release), buccal (between the gums and the inner lining of the mouth cheek), sub-lingual (under the
tongue), or enzyme-specific medications.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555055
If continuation sheet
Page 11 of 20
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555055
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Baldwin Gardens Nursing Center
10786 Live Oak Avenue
Temple City, CA 91780
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
During a review of the facility's P&P titled, Crushing Medications, revised 4/2018, indicated, Medication
shall be crushed only when it is appropriate and safe to do so, consistent with physician orders. The nursing
staff and/or consultant pharmacist shall notify attending physician who gives an order to crush a drug that
the manufacturer states should not be crushed (For example, long acting or enteric coated medication).
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555055
If continuation sheet
Page 12 of 20
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555055
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Baldwin Gardens Nursing Center
10786 Live Oak Avenue
Temple City, CA 91780
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0805
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual
needs.
Based on observation, interview and record review, the facility failed to ensure nectar-thickened fluid (liquid
having the same thickness as vegetable juices and milkshakes) was provided to one of one sampled
resident (Resident 21) in accordance with the physician's order.
This deficient practice had the potential for aspiration (accidentally swallowing food or liquid into the lungs)
for Resident 21.
Findings:
During a review of Resident 21's admission Record, the admission record indicated the facility admitted the
resident on 8/1/2022 with diagnoses that included dysphagia (difficulty swallowing).
During a review of Resident 21's Minimum Data Set (MDS - a standardized assessment and care planning
tool) dated 10/18/23, the MDS indicated Resident 21 rarely/never able to express ideas and wants and
rarely/never understands verbal content. The MDS indicated Resident 21 was totally dependent with all
activities of daily living.
During an observation on 12/3/23 at 9:50 am, Certified Nursing Assistant 3 (CNA 3) delivered a pitcher of
water to Resident 21's bedside table.
During a review of the Diet Order list with the Dietary Services Supervisor (DSS) on 12/3/23 at 9:52 am, the
list indicated Resident 21's diet was pureed (food has a soft, pudding-like consistency) fortified (food with
added vitamins, minerals, and other nutrients,) nectar thickened fluids. During a concurrent interview, the
DSS stated Resident 21 needed nectar-thickened water not thin liquid (thin liquid flow quickly, take little or
no effort to drink.) The DSS stated the facility needed to provide pre-packaged thickened water and juices
to Resident 21. The facility staff should not deliver regular water on a water pitcher to Resident 21.
During an interview on 12/3/23 at 10:15 am, CNA 3 stated the water on the water pitcher CNA 3 gave to
Resident 21 was regular and not thickened. CNA 3 stated if the thin liquid water was given to Resident 21,
the water could go to Resident 21's lungs and cause shortness of breath.
During a review of Resident 21's recapped Physician Orders as of 12/3/23, the order indicated for Resident
21 to receive fortified diet, pureed texture with nectar thick liquid consistency.
During a review of the facility's Policy and Procedure (P&P) titled Dysphagia - Clinical Protocol dated
September 2017, the P&P indicated if a modified consistency diet or other restrictions are indicated,
nursing will obtain an order for such restrictions from the physician.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555055
If continuation sheet
Page 13 of 20
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555055
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Baldwin Gardens Nursing Center
10786 Live Oak Avenue
Temple City, CA 91780
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0808
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or
licensed dietitian, to the extent allowed by State law.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to ensure dietary supplement was served as
ordered for one of one sampled resident (Resident 22).
This deficient practice had the potential to affect the resident's dietary intake which could result in
inadequate nutrition or further weight loss of Resident 22.
Findings:
During a review of the facility's admission Record, the admission record indicated Resident 22 was
admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure) and
dementia (long term and often gradual decrease in the ability to think and remember severe enough to
affect a person's daily functioning).
During a review of Resident 22's care plan for nutritional and dehydration risk, initiated 4/13/2023, the care
plan interventions included for staff to provide Ensure Clear twice a day with lunch and dinner.
During a review of Resident 22's Minimum Data Set (MDS, a standardized assessment and care planning
tool), dated 11/6/2023, the MDS indicated Resident 22 required set up with eating and oral hygiene.
During a review of Resident 22's Order Summary Report for December 2023, the order indicated to
administer to Resident 22 Ensure two times a day at lunch and dinner for weight loss.
During an observation and concurrent interview on 12/1/2023 at 5:44 pm, Resident 22 was sitting in a
wheelchair eating dinner. Resident 22 stated she did not receive the Ensure (liquid nutrition
drink/supplement that contains high-quality protein and essential nutrients) that she was getting every
dinner. Resident 22's meal ticket on the tray indicated to give Resident 22, 8 ounces Ensure Clear. There
was no Ensure Clear on Resident 22's tray.
During an observation and concurrent interview on 12/1/2023 at 6:32 pm, with Treatment Nurse 1 (TN 1),
TN 1 stated there was no Ensure on Resident 22's dinner tray. TN 1 stated Resident 22's dinner tray did not
match Resident 22's meal ticket. TN 1 stated, meal trays should be checked by two staff before it will be
delivered to the residents.
During an interview on 12/2/2023 at 5 :55 pm, with the Director of Nursing (DON), the DON stated staff
needed to ensure residents received proper diet. The DON stated, Ensure supplement needed to be
provided to Resident 22 as indicated on the meal ticket to meet Resident 22's nutritional needs. The DON
stated, meal trays needed to be checked by license nurses accurately so that no food items or therapeutic
diet will be missed in the resident's meal tray. The DON stated missed therapeutic diet can cause weight
loss to Resident 22.
During a review of the facility's Policy and Procedure (P&P) titled Food and Nutrition Service, dated
10/2018, the P&P indicated each resident is provided his or her daily nutritional and special dietary needs,
taking into consideration the preferences of each resident. P&P indicated food and nutrition services staff
will inspect food trays to ensure that the correct meal is provided to each
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555055
If continuation sheet
Page 14 of 20
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555055
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Baldwin Gardens Nursing Center
10786 Live Oak Avenue
Temple City, CA 91780
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0808
resident.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555055
If continuation sheet
Page 15 of 20
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555055
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Baldwin Gardens Nursing Center
10786 Live Oak Avenue
Temple City, CA 91780
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview, and record review, the facility failed to ensure opened food items had use
by date for one of one dry storage area in the kitchen.
Residents Affected - Some
This deficient practice had the potential for foodborne illnesses.
Findings:
During an observation of the dry food storage area in the Kitchen on 12/1/23 at 5:18 pm, the following items
were opened and did not have use-by-date label:
One plastic storage container of breadcrumbs that was opened on 9/14/23.
One plastic storage container of sweetened coconut flakes that was opened on 9/7/23.
One bottle of onion powder that was opened on 12/16/22 and will expire on 8/15/25.
One bottle of curry powder that was opened on 8/10/23 and will expire on 7/31/24.
One bottle of black pepper that was opened on 9/24/23 and will expire on 4/24/25.
One bottle of chili powder that was opened on 11/20/23 and will expire on 4/4/24.
During an interview on 12/1/23 at 5:40 pm, the Dietary Services Supervisor (DSS) stated the kitchen staff
needed to abide by the expiration date of the food item such as the expiration date of the breadcrumbs,
sweetened coconut flakes, onion powder, curry powder, and black pepper. The DSS stated since the
breadcrumbs and sweetened coconut flakes were transferred from the original container, there was no
expiration date information on the storage container.
During an interview on 12/1/23 at 6:30 pm, the DSS stated she could not find any Policy and Procedure
(P&P) for how long the breadcrumbs can be stored. The DSS provided a print-out of a google search
indicating breadcrumbs could be stored for up to one year and opened coconut flakes could last up to 5
months if kept in an airtight container in a cool, dry place.
During a review of the facility's P&P titled Canned and Dry Goods Storage dated 2018 and a concurrent
interview with the DSS on 12/2/23 at 3:56 pm, the P&P did not indicate storage information for opened
breadcrumbs and opened sweetened coconut flakes. The P&P indicated storage guidelines for unopened
food items (chili powder, spices) was 6 to 12 months. The DSS stated the facility did not have storage
guidelines for opened food items. The DSS stated the storage life for opened food items will not be 6 to 12
months since the food items had been exposed to air, moisture and light that could affect the food quality
and food safety and would place the residents at risk for foodborne illness. During the same interview, the
DSS stated if the opened food item had no use-by-date label on, the food item could have expired and used
during food preparation. The DSS stated she would consult with the Registered Dietitian to get information
on storage guidelines opened food items.
During a review of the facility's P&P titled Sanitation and Infection Control, dated 2018, the P&P indicated
all open food items will have an open date and use-by-date per manufacturer's guidelines.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555055
If continuation sheet
Page 16 of 20
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555055
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Baldwin Gardens Nursing Center
10786 Live Oak Avenue
Temple City, CA 91780
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
The P&P indicated canned and dry foods should be stored according to Dry Goods Storage Guidelines.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555055
If continuation sheet
Page 17 of 20
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555055
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Baldwin Gardens Nursing Center
10786 Live Oak Avenue
Temple City, CA 91780
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to follow its Policy and Procedure titled
Confidentiality of Information and Personal Privacy by ensuring the resident's identifiable, personal, and
medical information were not exposed on the computer screen unattended and in view of unauthorized
persons for two of two sampled residents (Residents 1 and 47).
This deficient practice resulted in Residents 1 and 47's violation of resident's right for privacy to keep their
personal and medical records confidential and not readily observable and accessible by others.
Findings:
a. During a review of Resident 1's admission Record, the admission record indicated the facility admitted
Resident 1 on 10/30/2023 with diagnoses that included muscle weakness, anemia (lack of red blood cells
to carry adequate oxygen to the body's tissues), and hypertension (increase blood pressure).
During a review of Resident 1's History and Physical assessment dated [DATE], the assessment indicated
Resident 1 did not have the capacity to understand and make decisions.
During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning
tool), dated 11/3/2023, the MDS indicated, Resident 1 cognition (mental action or process of acquiring
knowledge and understanding) for daily decision making was severely impaired. The MDS indicated,
Resident 1 required total dependence with two-person physical assistance with oral hygiene, toileting
hygiene, personal hygiene, upper and lower dressing.
During an observation of the facility's nursing station on 12/3/2023 at 9:49 am, one computer screen was
observed unattended and logged on, exposing Resident 1's identifiable, personal, and medical information.
During a concurrent observation and interview on 12/3/2023 at 9:50 am, with Licensed Vocational Nurse 2
(LVN 2), LVN 2 returned to the nursing station and stated the computer screen should not have been left on
and unattended because other people might see and access Resident 1's information. LVN 2 stated it was
a violation of HIPAA (Health Insurance Portability Accountability Act, a federal law that required the creation
of national standards to protect sensitive patient health information from being disclosed without the
patient's consent or knowledge) to expose resident's personal and medical information and Resident 1's
personal information should be kept private. LVN 2 stated unauthorized person can access and see
Resident 1's information if the computer screen was left unattended.
b. During a review of Resident 47's admission Record, the admission record indicated the facility admitted
Resident 47 on 7/1/2023 with diagnoses that included dysphagia (difficulty swallowing), and metabolic
encephalopathy (condition in which the brain function is disturbed due to diseases or toxins in the body).
During a review of Resident 47's History and Physical assessment dated [DATE], the assessment indicated
Resident 47 did not have the capacity to understand and make decisions.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555055
If continuation sheet
Page 18 of 20
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555055
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Baldwin Gardens Nursing Center
10786 Live Oak Avenue
Temple City, CA 91780
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
During a review of Resident 47's MDS dated [DATE], the MDS indicated, Resident 47 required limited
assistance with one-person physical assistance with bed mobility, transfer (how resident moves between
surfaces including to or from bed, chair, wheelchair, standing position), dressing, toilet use and personal
hygiene.
During an observation of the facility's nursing station on 12/3/2023 at 10:01 am, one computer screen was
observed unattended and logged on, exposing Resident 47's identifiable, personal, and medical
information.
During a concurrent observation and interview with the Infection Preventionist Nurse (IPN) on 12/3/2023 at
10:03 am, the IPN stated, the computer screen should not be left on and unattended exposing residents'
information. IPN stated, it was a HIPPA violation by exposing residents personal and medical information.
During a concurrent observation and interview with the Minimum Data Set Coordinator (MDSC) on
12/3/2023 at 10:04 am, MDSC stated she was working on Resident 47's medical file and left the nursing
station with the computer screen on, exposing Resident 47's information. MDSC stated, she completely
forgot to close the application in the computer showing Resident 47's information, when she left the nursing
station. MDSC stated exposing Resident's 47 information was a violation of HIPAA.
During an interview on 12/3/2023 at 10:05 am, with the Director of Nursing (DON), the DON stated, I kept
on reminding the staff to close the application when walking away from their computer. The DON stated,
staff needed to maintain confidentiality of resident's personal records because people could go in and out
of the nurse's station and could access residents' information.
During a review of facility's Policy and Procedure (P&P) titled Confidentiality of Information and Personal
Privacy, dated 10/2017, the P&P indicated, the facility will safeguard the personal privacy and confidentiality
of all resident personal and medical records. The P&P indicated access to resident personal and medical
records will be limited to authorized staff and business associates.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555055
If continuation sheet
Page 19 of 20
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555055
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Baldwin Gardens Nursing Center
10786 Live Oak Avenue
Temple City, CA 91780
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to ensure the nasal cannula tubing (a
device used to deliver oxygen to a resident) did not touch the floor for one of six sampled residents
(Resident 58) in accordance with the facility's Policy and Procedure, titled Departmental (Respiratory
Therapy) - Prevention of Infection.
Residents Affected - Few
This deficient practice had the potential to increase the risk of infection to Resident 58.
Findings:
During a review of Resident 58's admission Record, the admission record indicated the facility admitted
Resident 58 on 10/5/2023 with diagnoses that included chronic respiratory failure (condition in which not
enough oxygen passes from the lungs into the blood) with hypoxia (low levels of oxygen in the body
tissues), dependence on supplemental (treatment that provides with extra oxygen to breathe) oxygen and
congestive heart failure (CHF, heart disease that affects the pumping action of the heart muscle).
During a review of Resident 58's History and Physical (H&P), dated 10/5/2023, the H&P indicated Resident
58's had the capacity to make medical decisions.
A review of Resident 58's Physician Order, dated 10/5/2023, the order indicated to administer oxygen at
two (2) liters per minute (L/min) via nasal cannula (a device with two prongs that sit below the nose used to
deliver supplemental oxygen) continuously for CHF.
During a review of Resident 58's Minimum Data Set (MDS, a standardized assessment and care planning
tool), dated 10/10/2023, the MDS indicated, Resident 58 required total dependence with toileting hygiene,
shower/bathe self, lower body dressing and putting on/taking off footwear.
During an observation on 12/1/2023 at 6:35 pm, with Treatment Nurse 1 (TN 1), Resident 58 was awake
lying in bed with oxygen tubing touching the floor. TN 1 stated oxygen tubing should not touch the floor
because the floor was dirty, and Resident 58 could get an infection.
During an interview on 12/2/2023 at 5:46 pm with the facility's Director of Nurses (DON), the DON stated
oxygen tubing needed to be off the floor to prevent infection. The DON stated, Resident 58's oxygen tubing
should not be touching the floor because it will result to cross contamination (the process by which bacteria
or other microorganisms are unintentionally transferred from one substance or object to another, with
harmful effect).
During a review of the undated facility's Policy and Procedure (P&P) titled, Departmental (Respiratory
Therapy) - Prevention of Infection, the P&P indicated, infection control considerations related to oxygen
administration is to keep oxygen tubing off the floor.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555055
If continuation sheet
Page 20 of 20
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Back to topCitations
12 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F679 - Activities
Provide activities to meet all resident's needs.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F808 - Therapeutic Diets
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the December 3, 2023 survey of BALDWIN GARDENS NURSING CENTER?
This was a inspection survey of BALDWIN GARDENS NURSING CENTER on December 3, 2023. The surveyor cited 12 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BALDWIN GARDENS NURSING CENTER on December 3, 2023?
Yes, 12 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.