Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Golden Heights Healthcare during CMS and state inspections, most recent first.
The facility did not document required monitoring for emotional harm in two residents following allegations of abuse by a CNA. Despite policy and DON expectations for 72-hour monitoring, medical records lacked evidence that staff assessed mood or emotional well-being after the incidents.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors during their review of documentation and information handling practices.
A resident reported that a male CNA performed pericare in a rough manner, causing pain but no injury. The facility's investigation included interviews with the resident and ten staff members, but did not include interviews with other residents or their responsible parties, nor did it assess non-interviewable residents for signs of abuse. The facility's policy lacked direction for investigating when residents are non-interviewable, resulting in an incomplete investigation.
The facility failed to properly label thawed chicken and monitor the temperature of chocolate mousse, potentially affecting all residents receiving meals. The DFS acknowledged incorrect use of the labeling system, leading to a 30-day discard date instead of four days. Additionally, chocolate mousse was served at temperatures above the required 41°F, despite instructions to cool it further. The Administrator and DON emphasized the need for adherence to food safety guidelines.
A resident with diabetes did not receive timely FSBS checks as per physician's orders. An LPN performed the check after the resident began eating lunch, citing a delayed return from a lunch break. The DON confirmed that FSBS checks should occur before meals to ensure accurate readings.
Two residents were found with unauthorized medications at their bedside, indicating a failure in the facility's medication storage and administration policies. One resident with cognitive impairment was using Vicks VapoRub without a physician's order, while another resident with intact cognition was left with stool softeners to self-administer, contrary to policy. Staff interviews revealed a lack of adherence to protocols, resulting in unsecured medications accessible to residents.
A resident refused to take their medications, but an LPN documented them as administered, contrary to facility policy. The resident, with a history of renal dialysis dependence, was observed with the medications left on their table. The DON and Administrator confirmed that the MAR should reflect the refusal, not administration.
A resident with a history of atrial fibrillation and other health issues was not properly monitored by the night shift nurse, who failed to document vital signs and nursing notes. This lack of documentation potentially delayed the identification of symptoms related to the resident's condition. The resident was later found unconscious and transferred to a hospital, where they passed away. The facility's policy required routine checks, but the night shift nurse did not comply.
The facility failed to ensure timely responses to call lights for five residents, leading to delayed care and services. Observations and interviews revealed that call lights were often left unanswered for extended periods, particularly at night. The facility's call light system relied on visual alerts, and staff did not consistently respond promptly. The lack of a specific policy for call light use contributed to the delays, negatively impacting residents' well-being.
A resident with multiple health issues was found restrained without a doctor's order by a CNA, who did not report the action. Despite the incident being reported, the CNA continued to work for two more shifts, maintaining access to the resident and others. The facility's policy requires immediate suspension of staff accused of abuse, which was not followed.
A resident with multiple health conditions was found with her hand improperly restrained to prevent her from pulling out a nasogastric tube. Two CNAs failed to recognize this as a restraint due to lack of knowledge, and an LVN did not report the incident as abuse to the appropriate authorities. The facility's training program includes identifying restraints and reporting abuse, but staff were unaware of these protocols.
A resident with dementia and other medical conditions was improperly restrained by a CNA who tied her hand to the bed to prevent her from pulling out her NGT. This action was taken without a physician's order and was not reported to the charge nurse. The restraint was discovered by another CNA during the morning shift, and staff confirmed it was unauthorized and considered abuse.
A facility failed to report an alleged abuse incident involving a resident's hand being restrained without a physician's order to the CDPH and Ombudsman within the required two-hour period. The incident was discovered by an LVN, who released the resident and informed the DON. However, the DON did not report the incident until four days later, contrary to facility policy.
Failure to Monitor for Emotional Harm After Alleged Abuse
Penalty
Summary
The facility failed to monitor two residents for signs and symptoms of emotional harm following allegations of abuse. In the first case, a resident delivered a letter to the Administrator alleging abuse by a CNA. Despite the Director of Nursing's (DON) stated expectation that nurses should monitor alleged victims of abuse every shift for 72 hours, there was no documented evidence in the resident's medical record that such monitoring for emotional harm occurred. In the second case, a nurse reported witnessing a CNA slapping another resident on the arm. Again, upon review, the DON was unable to find documentation that the resident was monitored for emotional harm for 72 hours following the incident. The facility's policy, revised in March 2018, requires staff and physicians to monitor individuals who have been abused for issues related to their medical condition, mood, and function. However, record reviews for both residents did not show evidence that nursing staff followed this protocol after the alleged abuse incidents. The lack of documentation indicates that the required monitoring for emotional harm was not performed as per facility policy.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation and review of facility practices related to the handling and documentation of resident medical records. The report notes that the required standards for protecting confidential information and maintaining accurate, complete records were not met.
Failure to Conduct Thorough Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse involving a resident who reported that a male CNA performed pericare in a rough manner, causing pain but no injury. The resident, who was alert and able to communicate, stated that the incident occurred before lunch on a Thursday prior to her discharge, but could not recall the aide's name. The Administrator interviewed the resident and ten staff members who worked with her during the relevant period, but none recalled the event or any complaints. Assignment sheets showed multiple aides worked with the resident, making it difficult to identify the alleged perpetrator. The investigation did not include interviews with other residents who may have been present, as the Administrator stated they were non-interviewable, and there was no attempt to interview responsible parties or families of these residents. Additionally, the facility did not conduct assessments of non-interviewable residents for signs or symptoms of abuse, such as bruising or behavioral changes. The facility's abuse policy lacked guidance on investigating when residents in the area are non-interviewable. As a result, the investigation was incomplete and did not ensure that all residents were protected from potential abuse.
Food Safety and Temperature Control Deficiencies
Penalty
Summary
The facility failed to accurately label and date thawed chicken breasts stored in one of the refrigerators, which could potentially affect all 88 residents receiving meals from the facility's kitchen. The Director of Food Service (DFS) acknowledged that the automatic labeling system was used incorrectly, resulting in a label that indicated a 30-day discard date instead of the correct four-day use-by date for thawed chicken. The error was not caught by the dietary supervisors during their rounds, and the Director of Nursing (DON) expressed concern about the potential risk of salmonella due to the incorrect labeling. Additionally, the facility did not conduct proper temperature monitoring for chocolate mousse before serving it to residents. The chocolate mousse was found to be at a temperature of 47.3 degrees Fahrenheit, which is above the required 41 degrees Fahrenheit for cold foods. Despite instructions to cool the mousse further, it was placed on resident meal trays without rechecking the temperature, which was still too high. Dietary staff, including Dietary Aide (DA) #4 and Dietary Supervisor (DS) #3, acknowledged the failure to ensure the chocolate mousse was served at the correct temperature. The Administrator and DON both emphasized the importance of adhering to food safety guidelines and ensuring that food is served at the correct temperatures. The Administrator stated that staff should not serve food that does not meet temperature requirements and expected the DFS and supervisors to monitor and supervise food handling practices. The report highlights the facility's failure to follow established policies for food labeling and temperature control, which could pose a risk to resident safety.
Failure to Conduct Timely Blood Sugar Checks
Penalty
Summary
The facility failed to conduct finger-stick blood sugar (FSBS) checks in accordance with physician's orders for a resident with type two diabetes mellitus and diabetic chronic kidney disease. The resident's care plan indicated a risk for hyperglycemia or hypoglycemia, and an active order required FSBS monitoring before meals and at bedtime. However, during an observation, a Licensed Practical Nurse (LPN) performed the FSBS check after the resident had already started eating lunch, contrary to the physician's order. The LPN admitted to delaying the FSBS check due to taking a lunch break, despite being trained to perform the checks before meals. The Director of Nursing (DON) confirmed that the FSBS checks should be conducted before meals, specifically between 11:00 AM and 11:30 AM for lunchtime, to ensure accurate results. The DON emphasized that performing the FSBS check during a meal could lead to inaccurate readings, which would not align with the physician's intent. The Administrator also stated that FSBS checks should be completed before meals as per the physician's order, highlighting the importance of timing in obtaining accurate blood sugar levels.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to ensure medications were stored securely, as evidenced by two residents having unauthorized medications at their bedside. Resident #2, who had a history of dementia and moderate cognitive impairment, was observed using a jar of Vicks VapoRub without a physician's order or a self-administration assessment. The resident was seen applying the ointment to their nostrils and storing it in their nightstand, which was accessible and visible. Staff members, including RNs and CNAs, were unaware of the ointment's presence until it was pointed out during observations, indicating a lapse in the facility's medication storage policy. Resident #27, who had intact cognition, was found with a medicine cup containing docusate sodium and senna on their over-bed table. The resident had declined to take the medication when initially offered by an LPN, who then left the medication for the resident to self-administer later. This action was against the facility's policy, as there was no physician's order or assessment allowing the resident to self-administer medications. The DON confirmed that the medication should not have been left at the bedside and should have been offered again by the nurse. Interviews with staff, including the DON and Administrator, revealed a lack of adherence to the facility's policies regarding medication administration and storage. The staff members involved did not follow the protocol of removing unauthorized medications from residents' rooms and ensuring that medications were administered in the presence of a nurse. The facility's failure to comply with these policies resulted in medications being left unsecured and accessible to residents who were not assessed for self-administration.
Improper Documentation of Medication Refusal
Penalty
Summary
The facility failed to ensure proper documentation of medication administration for a resident who refused to take their medications. The facility's policy on administering medications requires that if a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication should initial and circle the MAR space provided for that drug and dose. However, an LPN documented that medications were administered to a resident despite the resident's refusal to take them at the scheduled time. The resident, who had a medical history of dependence on renal dialysis, was observed with a medication cup containing the refused medications on their over-the-bed table. The LPN admitted to leaving the medications with the resident and signing off on the MAR as if the medications had been administered, trusting that the resident would take them later. The Director of Nursing and the Administrator both stated that the MAR should reflect the resident's refusal and that medications should not be documented as administered if they were not. This discrepancy in documentation was identified during an observation and interview process, highlighting a failure to adhere to the facility's medication administration policy.
Failure to Document Vital Signs and Nursing Notes
Penalty
Summary
The facility failed to ensure that a resident received care in accordance with professional standards of practice, as there was no evidence of nursing notes and vital signs recorded by the night shift nurse on a specific date. This oversight had the potential to delay the identification of symptoms related to atrial fibrillation, a condition the resident was diagnosed with. The resident had a medical history that included atrial fibrillation, hypertension, benign prostatic hyperplasia, diabetes, and a history of transient ischemic attack. The resident was admitted to the facility for rehabilitation after being diagnosed with new-onset atrial fibrillation at a hospital, where they were prescribed Amiodarone and Apixaban. The resident was found unconscious and vomiting by facility staff and was transferred to a hospital, where they later passed away. The death certificate indicated the cause of death as non-traumatic intracerebral hemorrhage and hypertension. Interviews and record reviews revealed that the night shift nurse failed to document the resident's vital signs and nursing notes. The Director of Nursing confirmed the absence of documentation for the night shift and stated that the facility's policy required routine resident checks at least once per shift. The facility's practice included taking vital signs at the beginning of each shift and under specific conditions, but the night shift nurse did not adhere to these practices.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to ensure call lights were answered in a timely manner for five of six residents, leading to delayed provision of care and services. Resident 1's daughter reported that call light issues were particularly severe at night, with waits of 35 minutes or more. This delay resulted in Resident 1 developing a urinary tract infection due to being left in a wet diaper for an extended period. Observations confirmed that Resident 1 was left waiting for assistance while holding her call light, and staff were aware of the delay but did not respond promptly. The facility's call light system displayed room numbers and wait times on a monitor, but staff did not consistently respond to these alerts in a timely manner. During interviews, staff acknowledged the delays and explained that the call light system did not produce sound alerts, relying instead on visual cues on a monitor. The receptionist was responsible for paging CNAs to respond to call lights, but this process was not always effective. Observations showed multiple instances where call lights were on for extended periods, with staff either not responding or turning off the lights without providing immediate assistance. The Director of Nursing confirmed that there was no specific policy and procedure for the use of call lights, only for the paging system. The facility's records and interviews with staff and residents indicated a pattern of delayed responses to call lights, particularly at night. The facility's policy required staff to respond to call lights within five minutes, but this was not consistently followed. The lack of a specific policy for call light use and the reliance on a visual monitoring system without sound alerts contributed to the delays in providing care. The facility's failure to address these issues resulted in negative impacts on residents' physical, mental, and emotional well-being.
Failure to Suspend CNA After Alleged Abuse Incident
Penalty
Summary
The facility failed to provide protection to a resident and other residents when a Certified Nursing Assistant (CNA) was not suspended immediately after an alleged abuse incident was reported. The incident involved a resident with multiple diagnoses, including dysphagia, dementia, rheumatoid arthritis, and osteoarthritis, who was found with her right hand bound with a mitten, surgical gloves, and a plastic bag, loosely secured to the side rail of her bed. This was done to prevent the resident from pulling out her nasogastric tube (NGT). The CNA responsible for this action did not inform anyone about the restraint, which was done without a doctor's order. The incident was discovered by another CNA and reported to a Licensed Vocational Nurse (LVN), who immediately released the resident from the restraint and informed the Director of Nursing (DON). The LVN confirmed that there was no order for restraint and recognized the action as abuse. The Interim Director of Nursing also confirmed that the use of a mitten and tying the resident's hand to the bed constituted a restraint without a doctor's order, which is considered abuse. Despite the report of the incident, the CNA continued to work for two consecutive night shifts, maintaining access to the resident and other residents under her care. The Director of Staff Development verified that the CNA worked these shifts and stated that the facility's policy requires immediate suspension of staff accused of abuse pending investigation. The Administrator was informed of the incident two days later and acknowledged that staff involved in abuse should be suspended immediately for the safety of the residents.
Inadequate Staff Competency and Reporting Awareness
Penalty
Summary
The facility failed to ensure that nursing staff had the necessary knowledge and competency to provide appropriate care, resulting in a deficiency related to resident safety and well-being. Specifically, two Certified Nursing Assistants (CNAs) did not recognize the inappropriate use of a restraint on a resident. The resident, who had conditions including dysphagia, dementia, rheumatoid arthritis, and osteoarthritis, was found with her right hand bound with a mitten, surgical gloves, and a plastic bag, loosely secured to the side rail of her bed to prevent her from pulling out her nasogastric tube. The CNAs involved did not report this as a restraint due to their lack of knowledge, despite having observed the situation during their shifts. Additionally, the facility's nursing staff, including a Licensed Vocational Nurse (LVN) and a CNA, were unaware of their ability to report instances or allegations of abuse to the California Department of Public Health (CDPH) and the local Ombudsman's Office. This lack of awareness was evident when the CNA reported the restraint to the LVN, who acknowledged it as abuse but did not report it to the appropriate authorities. The facility's Director of Staff Development confirmed that training on identifying restraints and reporting abuse is part of the orientation and ongoing training for all nursing staff. However, the deficiency indicates a gap in the staff's understanding and application of this training.
Unauthorized Use of Physical Restraint on Resident
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, which were applied without a medical order. A Certified Nursing Assistant (CNA) placed a mitten on the resident's right hand and tied it to the bed's side rail to prevent the resident from pulling out her nasogastric tube (NGT). This action was taken during the night shift when the resident was restless and attempting to remove her NGT. The CNA did not inform anyone about the restraint, nor was there a physician's order for such an intervention. The resident involved had a medical history that included dysphagia, dementia, rheumatoid arthritis, and osteoarthritis. She was admitted with a feeding tube and was dependent on facility staff for activities of daily living. The incident was discovered when another CNA found the resident restrained during the morning shift. The restraint involved a mitten, surgical gloves, a plastic bag, and a towel, all used to secure the resident's hand to the bed. Interviews with staff, including Licensed Vocational Nurses (LVNs) and the Director of Staff Development, confirmed that the restraint was applied without proper authorization and was considered abuse. The facility's policy on restraints clearly states that they should only be used to treat medical symptoms and never for staff convenience or discipline. The incident was not reported to the charge nurse, and the CNA involved admitted to tying the resident to prevent her from pulling out the NGT and to complete her rounds before the shift ended.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the California Department of Public Health (CDPH) and the local Ombudsman within the required two-hour period. The incident involved a Certified Nursing Assistant (CNA) who placed a mitten on the resident's right hand and tied it to the bed to prevent the resident from pulling out a Nasogastric Tube. This restraint was discovered by staff on January 13, 2024, but was not reported to the authorities until January 17, 2024, four days later. The resident involved had a medical history including dysphagia, dementia, rheumatoid arthritis, and osteoarthritis. Interviews with facility staff revealed that the incident was recognized as abuse, as there was no physician's order for the restraint. The Licensed Vocational Nurse (LVN) who discovered the restraint immediately released the resident and reported the incident to the Director of Nursing (DON). However, the DON failed to report the incident to the appropriate authorities within the required timeframe. The facility's policy mandates immediate reporting of such incidents, but this protocol was not followed, leading to a delay in the investigation and potential risk to the resident and others.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 850 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Daly City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Golden Pavilion Healthcare | 0 mi | ★★★★★ | 2 | 0 |
| Ahmc Seton Medical Center | 0.8 mi | ★★★★★ | 34 | 0 |
| Pacifica Nursing And Rehabilitation Center | 1.7 mi | ★★★★★ | 4 | 0 |
| San Francisco Post Acute | 2.9 mi | ★★★★★ | 0 | 0 |
| San Bruno Skilled Nursing | 4.5 mi | ★★★★★ | 18 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Golden Heights Healthcare.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.