Health inspection·January 9, 2024

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to provide privacy to one of four sampled residents (Resident 3) while providing bed bath to Resident 3. This failure resulted in violation of Resident 3's right to privacy. Findings: During a review of the Resident 3 ' s admission Record, the admission record indicated Resident 3 was readmitted to the facility on [DATE] with diagnoses that included dysphagia (difficult swallowing) and hypertension (increased blood pressure). During a review of Resident 3 ' s Minimum Data Set (MDS, a resident assessment and care screening tool) dated 11/21/2023, the MDS indicated Resident 3 had clear speech, had the ability to understand others and to make self-understood. Resident 3 required substantial/maximal assistance (helper does more than half the effort) for personal hygiene. Resident 3 was dependent (helper does all of the effort) for rolling left and right, sit to lying and chair/bed-to-chair transfer. During an observation on 1/8/2024 at 10:36 am, in Resident 3 ' s room, Resident 3 was lying in bed. Certified Nursing Assistant 1 (CNA1) provided bed bath to Resident 3. Resident 3 was undressed. There was no curtain in Resident 3 ' s bed to provide privacy to Resident 3 while CNA 1 provided bed bath to the resident. There was a total of four residents in Resident 3 ' s room. There was a male visitor sitting at bedside visiting Resident 3 ' s roommate. During an interview on 1/8/2024 at 10:50 am, CNA1 stated she provided Resident 3 a bed bath without a curtain around Resident 3 ' s bed, exposing Resident 3 ' s body. CNA1 stated she needed to call Maintenance Department to hang a curtain before she provided bed bath to Resident 3. CNA1 stated having a curtain was needed to provide Resident 3 with privacy and dignity. During an interview on 1/8/2024 at 11:36 am, Environment Service Director 1 (EVS 1) stated he removed Resident 3 ' s curtain in the morning of 1/8/2024 and did not replace the curtain immediately. EVS 1 stated he should not leave Resident 3 with no curtain around the bed. EVS 1 stated he needed to hang a curtain at the same time he removed the old curtain to provide Resident 3 with privacy. EVS 1 stated it was resident ' s right for dignity. During a review of the facility ' s Policy and Procedure (P&P) titled, Promoting/Maintaining Resident Dignity, revised 12/19/2022, the P&P indicated, All staff members are involved in providing care (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 01/09/2024 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)