Coast Care Convalescent Center

F 0656 Level of Harm - Minimal harm or potential for actual 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.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Coast Care Convalescent Center

14518 E. Los Angeles St.

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 0658

Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to follow the physician's order for one of three sampled residents (Resident 1) when the licensed nurse did not take Resident 1's heart rate prior to administration of losartan (medication for high blood pressure) as ordered, from 12/13/2025 to 12/22/2025. These violations had the potential to compromise Resident 1's health and safety.Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was originally admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including hypertensive heart disease (high blood pressure [HTN] damaged the heart over time) and generalized muscle weakness. 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.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet