Health inspection·March 11, 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 interview and record review, the facility Administrator (ADM) and Director of Nursing (DON) failed to report an injury of unknown origin (IUO- injury in which the cause cannot be determined due to lack of witnesses and resident injured unable to express how the injury occurred) to officials including the State Survey Agency (SSA) and adult protective services (APS), immediately, but no later than 24 hours, and according to the facility ' s policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or MisappropriationReporting and Investigating for one of two sampled residents (Resident 1). This failure had the potential for IUO to occur to other residents without appropriate reporting and investigation. Findings: During a review of Resident 1 ' s admission Record (AR), the AR indicated the facility initially admitted Resident 1 on 3/7/2024 and was readmitted on [DATE] with diagnoses that included unspecified intellectual disabilities (a condition that limits intelligence and disrupts abilities necessary for living independently) and generalized muscle weakness (weakness of muscles caused by lack of exercise, ageing, injury, or disease). During a review of Resident 1 ' s Minimum Data Set (MDS- a resident assessment tool) dated 3/6/2025, the MDS indicated Resident 1 had severely impaired cognition (ability to think, remember, and function). The MDS indicated Resident 1 was dependent (helper does ALL the effort. Resident does none of the effort to completely the activity, or the assistance of 2 or more helpers is required for the resident to complete the activity) with toileting hygiene, showering/bathing self, lower body dressing, putting on/taking off footwear, and tub/shower transfers. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort and lifts or holds trunk or limbs, but provides less than half the effort) with upper body dressing, personal hygiene, rolling left and right (in bed), sitting to lying, sitting to standing, chair/bed-to-chair transfers, and walking 10 feet. During a review of Resident 1 ' s Resident Incident Investigation Report Form (RIIRM) dated 2/21/2025, the RIIRM indicated Resident 1 was, Suddenly noted a small skin discoloration under right lower eye. The RIIRM indicated Resident 1 was unable to communicate what happened. The RIIRM indicated the Resident 1 ' s right lower eye discoloration was, More than likely, self-inflicted by Resident 1. During a review of Resident 1 ' s situation-background-assessment-recommendation (SBAR- a written communication tool that helps provide essential, concise information, usually during crucial (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 2 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 03/11/2025 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)