Health inspection·July 21, 2023

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 incident of alleged resident financial abuse to one of two sampled residents (Resident 1) to the California Department of Public Health (State Agency) not later than two hours after the allegation was made. This deficient practice may potentially resulted Resident 1 being subjected to additional financial abuse. Findings: During a review of Resident 1 ' s admission Record indicated Resident 1 was admitted on [DATE], with diagnoses that included heart failure (heart cannot pump enough blood to meet the body ' s needs) and hypertension (high blood pressure). During a review of Resident 1 ' s Physician Order Sheet indicated an order to admit the resident under Hospice Care (a program that gives special care to people who are near the end of life and stopped treatment to cure or control their disease) due to diagnosis of chronic systolic congestive heart failure ( a specific type of heart failure that occurs in the heart ' s left ventricle). During a review of Resident 1 ' s Minimum Data Set (a standardized assessment and care planning tool) dated 6/21/23, indicated the resident had short term memory recall problem and required limited assistance (staff provide weight bearing support) in most levels of activities of daily living with one-person physical assist. During a concurrent observation and interview, on 7/21/23 at 2:10 p.m., Resident 1 was lying in bed alert and coherent. Resident 1 stated, he notified Family Member 1, that Family Member 2 used his pin number to get $300 to $500 from his debit card without his permission. Resident 1 stated, Family Member 1 reported to facility ' s Social Service staff about the unauthorized use of his debit card by Family Member 2. During a concurrent interview and record review, on 7/21/23 at 3:21 p.m., with the Social Service Designee (SSD), Resident 1's Interview Record dated 7/10/23, indicated the SSD received a phone call from Family Member 1 at 9:09 a.m. on 7/10/23. Family Member 1 notified the SSD that Family Member 2 had previously withdrawn a total amount of $3,000 from Resident 1 ' s bank account without the resident ' s consent. Family Member 1 believes Family Member 2 was only visiting Resident 1 to ask for his debit card. Family Member 1 informed the SSD that Family Member 2 had the pin number to Resident 1 ' s debit card and would attempt to withdraw more money after visiting the resident on 7/10/23 or (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: 555107 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 555107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Care Center 3541 Puente Avenue Baldwin Park, CA 91706 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)