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Complaint Investigation

Coast Care Convalescent Center

December 23, 2025 · Baldwin Park, CA · 14518 E. Los Angeles St.
Citations 2
CMS Rating 4/5
Beds 48
Provider ID 555199
Healthcare Facility
Coast Care Convalescent Center
Baldwin Park, CA  ·  View full profile →
Inspection Summary

Coast Care Convalescent Center in BALDWIN PARK, CA — inspection on December 23, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0656
Resident Assessment and Care Planning Deficiencies
Potential for More Than Minimal Harm

order to obtain or maintain the highest physical, mental, and psychosocial well-being.

The P&P further indicated that the care plan would be periodically reviewed and revised by Interdisciplinary Team (IDT, a group of healthcare professionals from different disciplines who worked together) at times as appropriate or necessary.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

12/23/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Coast Care Convalescent Center

14518 E.

Los Angeles St.

Baldwin Park, CA 91706

SUMMARY STATEMENT OF DEFICIENCIES

During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 12/18/2025, the MDS indicated Resident 1 had moderate cognitive (ability to understand) impairment.

The MDS indicated Resident 1 required supervision from staff with eating and oral hygiene.

The MDS indicated Resident 1 required maximal assistance (helper did more than half the effort) from staff with toileting hygiene and toileting transferring.

During a review of Resident 1's Order Summary Report (OSR) with active orders as of 12/22/2025, the OSR indicated a physician's order to hold losartan for heart rate less than 60 beats per minute-(BPM) daily, starting on 12/13/2025.

During a review of Resident 1's Care Plan (CP) for hypertensive heart disease revised on 12/22/2025, the CP indicated staff were to maintain optimum quality of life for Resident 1.

The CP interventions indicated staff were to obtain vital signs (measurements of temperature, heart rate, breathing rate, and blood pressure) and administer medication as ordered.

During an interview with the Infection Preventionist Nurse (IPN) 1 on 12/23/2025 at 12:56 PM, the IPN stated it was important for the licensed nurse who received the physician order to carry out and transcribe to electronic MAR (EMAR).

The IPN stated carrying out the physician order meant to do the action as ordered.

The IPN stated that when the physician ordered to hold losartan for heart rate of less than 60 BPM, the licensed nurse should check the resident's heart rate prior to the medication administration and document the readings on the EMAR.

During a concurrent interview and record review on 12/23/2025 at 12:56 PM. with the IPN, Resident 1's Medication Administration Record (MAR) dated 12/13/2025 to 12/22/2025 was reviewed.

The MAR indicated Resident 1 received ten doses of losartan daily at 9 AM from 12/13/2025 to 12/22/2025.

The IPN stated the MAR did not indicate heart rate readings were taken/documented prior to the administration of losartan daily at 9 AM from 12/13/2025 to 12/22/2025.

The IPN stated it was important to monitor the heart rate as ordered.

During a concurrent interview and record review on 12/23/2025 at 2:01 p.m., Resident 1's Vital Summary dated 12/13/2025 to 12/22/2025 was reviewed.

The DON stated there were no heart rate readings documented on 12/13, 12/15, 12/16, 12/17, 12/18, 12/19, 12/20, and 12/22/2025 at 9 AM.

The DON stated the licensed nurse did not carry out the physician order to check Resident 1's heart rate prior to the administration of losartan to Resident 1.

The DON stated the licensed nurse should have followed the physician's order to check the resident's heart rate before administering losartan to Resident 1.

During a review of the facility's undated Policy and Procedure (P&P) titled Physician Orders, the P&P indicated the facility should provide care and services to the resident in accordance with the physician's orders.

During a review of the facility's undated P&P titled Documenting Physician Orders/ Notification, the P&P indicated the licensed nurse should implement and carry out the physician's orders within two hours upon receiving.

During a review of the facility's P&P titled Vital Sign, revised 1/25/2024, the P&P indicated the vital signs would be taken as ordered by the physician and before giving medication when there were conditional parameters (limit that helped measure something) of administration.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in BALDWIN PARK, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Coast Care Convalescent Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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