Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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
Based on interview and record review, the facility failed to locate one of one sampled resident (Resident 1),
who eloped (the act of leaving a facility unsupervised and without prior authorization) from the dialysis
center (a facility that provides treatment to cleanse the blood of wastes and extra fluids artificially through a
machine when the kidney(s) have failed).
Residents Affected - Few
This deficient practice had the potential to result in compromise to Resident 1's safety and well-being.
Findings:
During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1
on 10/15/2024, with diagnoses that included encounter for surgical aftercare (the medical care a person
receives after surgery, including care in the hospital and after discharge) following surgery on the digestive
system (a group of organs that break down the foods eaten so they can be absorbed into the body and
used for energy and nutrients), end stage renal disease (a permanent condition that occurs when the
kidneys are no longer able to function), and dependence on renal dialysis.
During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool),
dated 10/22/2024, the MDS indicated Resident 1 was understood by others and had the ability to
understand others. The MDS indicated Resident 1 required the use of a walker. The MDS indicated
Resident 1 required supervision or touching assistance (helper provides verbal cues and/or
touching/steadying and/or contact guard assistance as resident completes activity) with oral hygiene, upper
body dressing, lower body dressing, and personal hygiene.
During a review of Resident 1's Care Plan (CP), dated 10/15/2024, the CP indicated Resident 1 was at risk
for falls related to unstable gait (walking in an abnormal, uncoordinated, or unsteady manner) requiring an
assisted device (walker).
During a review of Resident 1's CP, dated 10/15/2024, the CP indicated Resident 1 had chronic pain
related to a history of surgery.
During a review of Resident 1's CP, dated 10/15/2024, the CP indicated Resident 1 needed hemodialysis
related to renal (kidney) failure.
During a review of Resident 1's CP, dated 11/1/2024, the CP indicated Resident 1 left against medical
advice (AMA - choosing to leave the hospital/facility before the treating physician recommends discharge).
The CP indicated the goal was that Resident 1 will be safe from injury and harm. The CP intervention
included to attempt to reach Resident 1 by phone.
(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
11/05/2024
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)
F 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During a review of Resident 1's Nurses Progress Note (NPN), dated 11/1/2024 at 6:47 pm, the NPN
indicated the Licensed Vocational Nurse (LVN) 1 was doing rounds at 5:45 pm and noticed that Resident 1
was not back from dialysis. The NPN indicated LVN 1 contacted the dialysis center at 6 pm and the dialysis
center informed LVN 1 that Resident 1 finished dialysis at 4:10 pm. The NPN indicated LVN 1 contacted the
transportation service at 6 pm and LVN 1 was informed that when the driver went to pick up Resident 1
from the dialysis center at 3:30 pm, Resident 1 refused to leave with the driver from the transportation
service. The NPN indicated Resident 1 told the driver that Someone was already there at the dialysis center
to pick up Resident 1.
During a review of Resident 1's NPN, dated 11/1/2024 at 9:57 pm, the NPN indicated the facility reported
the incident to the police department.
During a review of Resident 1's NPN, Resident 1's NPN did not indicate documented evidence of the
facility's attempt to locate Resident 1 after the elopement on 11/1/2024.
During an interview on 11/5/2024 at 1:13 pm, with LVN 1, LVN 1 stated the dialysis center informed LVN 1
on 11/1/2024 around 7 pm that there was a camera footage from the dialysis center of Resident 1 walking
alone and nobody was there to pick up Resident 1. LVN 1 stated the dialysis center is ten minutes away
from the facility. LVN 1 stated staff did not go out to the dialysis center to look for Resident 1. LVN 1 stated if
a resident was missing, staff was required to notify the Director of Nursing (DON), search for the resident in
the premises, call the police, notify family, attempt to call the resident, and notify the physician. LVN 1 stated
staff would search for the missing resident by driving around the area, call the hospitals nearby, and go out
to search for the resident. LVN 1 stated Resident 1 could be at risk for accidents, falls, losing consciousness
from not having medication or from having low blood pressure, and bleeding from the dialysis catheter (a
tubing used for exchanging blood to and from a dialysis machine and a patient).
During an interview on 11/5/2024 at 12:50 pm and at 1:40 pm, with the DON, the DON stated after the
DON spoke to Resident 1's physician, nothing else was done. The DON stated they did not contact the
hospitals to look for Resident 1. The DON stated no one answered the phone when DON contacted
Resident 1's phone number. The DON stated according to the dialysis center, there was a camera footage
of Resident 1 walking the streets and Resident 1 was not seen getting in a car. The DON stated if
elopement happened in the facility, staff would search the facility and surroundings and have staff drive
around the streets to look for the resident. The DON stated they would also call the closest hospitals. The
DON stated the facility should have still followed up with hospitals and should have kept following up with
the police department to locate Resident 1. The DON stated Resident 1 would be at risk for missing dialysis
which could lead to fluid overload and kidney complications.
During a review of the facility's policy and procedure (P&P) titled, Elopements and Wandering Residents,
revised on 12/19/2022, the P&P indicated the procedure for locating missing resident: any staff member
becoming aware of a missing resident will alert personnel using facility approved protocol (e.g. internal alert
code); the designated facility staff will look for the resident. If the resident is not located in the building or on
the grounds, the Administrator of designee will notify the police department and serve as the designated
liaison between the facility and the police department. The administrator or designee should also notify the
company's corporate office. The DON or designee shall notify the physician and family member or legal
representative. The Police will be given a description and information about the resident; include any
photos. All parties will be notified of the outcome once the resident is located. Appropriate reporting
requirements to the State Survey agency shall be conducted.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555107
If continuation sheet
Page 2 of 2
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Back to topCitations
1 citation 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.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
FAQ · About this visit
Common questions about this visit
What happened during the November 5, 2024 survey of VICTORIA CARE CENTER?
This was a inspection survey of VICTORIA CARE CENTER on November 5, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at VICTORIA CARE CENTER on November 5, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
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
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.