Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Pavilion Healthcare during CMS and state inspections, most recent first.
A resident with a PEG tube and history of aspiration pneumonia did not receive tube feeding at the prescribed rate due to nursing staff failing to verify and monitor the pump settings. The feeding rate was mistakenly set at 200 mL/hr instead of the ordered 60 mL/hr, leading to the resident developing aspiration pneumonia and sepsis, and ultimately passing away. The facility's policy for verifying tube feeding orders and monitoring was not followed.
A resident with a PEG tube and a history of dysphagia and aspiration pneumonia received Jevity at 200 mL/hr instead of the ordered 60 mL/hr after staff failed to verify pump settings during shift changes and when hanging a new bottle. The resident developed nausea, coughing, congestion, and crackles, was sent to the ED for suspected aspiration, and hospital records later documented aspiration PNA and acute hypoxemic respiratory failure as the likely cause of death.
A resident with cognitive impairment, language barriers, and mobility issues eloped twice during the night shift, each time wearing only a nightgown. Staff failed to check the Wanderguard alarm for functionality, and there was inadequate supervision at the facility's exit. The resident was found outside the facility on both occasions, and staff interviews revealed gaps in training and adherence to elopement prevention policies.
A resident with chronic pain and significant physical disabilities did not receive a scheduled fentanyl patch on time due to delays in medication delivery and lack of timely refill requests and documentation. Nursing staff and the ADON confirmed that the patch was not available at the scheduled time, and facility records showed no evidence of a timely pharmacy request or physician signature prior to the missed dose.
A resident missed three doses of diazepam due to a lack of inventory, and there was a discrepancy in the accounting of the controlled medication. The facility failed to follow its policy for administering medications safely and timely, compromising medication availability for the resident.
A facility failed to accurately assess a resident's MDS, omitting diagnoses of dementia, fracture, and osteopenia. The resident was observed with a bandaged forearm and unable to explain the fracture. The MDS Nurse did not include these diagnoses, citing a lack of communication and reliance on the clinical record. The DON stressed the need for accurate MDS assessments, while Social Services confirmed the dementia diagnosis. This resulted in an inaccurate reflection of the resident's health status.
A resident with a fractured left forearm did not have a splint applied as per the physician's order due to unavailability. The resident, with end-stage renal failure and dementia, had a fracture with minimal healing and significant osteopenia. The splint was on hold for several days, and the facility did not contact the orthopedic department directly, leading to a delay in proper immobilization.
A resident with end-stage renal failure and dementia developed unexplained bruises on the left forearm and hand. Despite documentation and care plan interventions, no investigation was conducted to determine the cause of the bruises, as confirmed by interviews with nursing staff. This failure to investigate was contrary to the facility's policy on abuse and neglect, which required thorough assessment and documentation.
A facility failed to include osteopenia in a resident's care plan, despite the resident's diagnoses of end-stage renal failure, dementia, and a history of fractures. An orthopedic note indicated significant osteopenia, but the care plan was not updated to address this condition. Interviews with nursing staff confirmed the oversight, highlighting a lapse in the facility's care planning procedures.
The facility failed to provide necessary training and performance evaluations for three CNAs, as required by policy. Employee files lacked documentation of initial training and competency assessments, which are crucial for ensuring staff are adequately trained before working independently with residents. The absence of these evaluations indicates a failure to adhere to procedures, potentially leading to untrained CNAs providing unsafe care.
A resident with multiple health conditions returned from hospitalization to find personal items missing from his closet, including headphones, a Bluetooth speaker/microphone, and Lysol spray cans. The loss led to feelings of depression and disappointment. Social Services and the ADON acknowledged the issue, and the Ombudsman was informed for follow-up.
A resident with multiple health conditions, including a stage 4 pressure ulcer and functional quadriplegia, was neglected by the facility, not receiving a sponge bath for a month despite repeated requests. This neglect led to discomfort, embarrassment, and a worsening of the resident's pressure ulcer, resulting in sepsis upon hospital admission.
A resident with multiple health issues, including a pressure ulcer and bone infection, experienced a delay in receiving PRN pain medication, waiting 1-2 hours despite activating the call light. The call light was later found disconnected, and attempts to report the issue were unsuccessful. The resident suffered significant pain and discomfort due to this delay.
A resident with cognitive impairment was injured during a transfer, resulting in a broken tooth. The facility failed to report the incident to the California Department of Public Health and did not investigate the occurrence. The resident did not receive dental care for nine months due to an incorrect claim of no dental insurance.
A resident with glaucoma experienced depression and visual difficulties after the facility failed to replace or reimburse for three lost pairs of prescription eyeglasses. Despite reports from the resident's son and documentation of the loss, the facility did not assist in obtaining a new prescription or conduct an investigation, contrary to their Lost and Found policy.
A resident with diabetes did not receive foot care services, such as toenail clipping, for 2 1/2 years, leading to immobility and pain. The facility failed to adhere to its foot care policy, as confirmed by the ADON, who could not provide evidence of prior podiatry care.
A resident with multiple health issues suffered a tooth injury from a fall, and the facility failed to assist in obtaining dental care for nine months. The incident was not reported, and the facility initially claimed the resident lacked dental coverage. The resident's son arranged for dental care, resulting in a delayed root canal. The facility did not follow its policy on incident reporting.
The facility failed to report the results of an abuse investigation involving two residents to the State Survey Agency within the mandated five working days. Despite an argument and a police call, the facility did not submit the required investigative report on time.
A resident experienced significant pain due to delayed response to call lights for pain medication on two consecutive evenings. The facility's policy requires call lights to be answered within five minutes, but residents reported ongoing issues with response times and CNAs not addressing their needs. This failure resulted in pain and suffering for the resident.
A resident with a right leg wound experienced unnecessary pain due to the facility's failure to provide timely pain medication on two occasions during the evening shift. Despite having a care plan that included administering medications and assessing pain, the resident waited over an hour for relief, resulting in significant discomfort. The resident's pain management regimen was effective when administered, but delays in medication delivery led to unmanaged pain.
The facility failed to implement their Legionella water management program, putting all 229 residents at risk. Interviews with maintenance staff and the Regional Maintenance staff revealed no process or documentation for monitoring Legionella, despite the facility's policy requiring such measures.
The facility failed to ensure the confidentiality of medical information for a resident readmitted from the hospital. The resident was observed wearing wristbands indicating a fall risk and latex allergy, which were not removed by the staff, compromising the resident's privacy and dignity.
The facility failed to report an allegation of physical abuse involving a resident with severe cognitive impairment to CDPH within the required two-hour timeframe. The incident was reported approximately four and a half hours after it occurred, contrary to the facility's policy.
The facility failed to ensure MDS assessments accurately reflected the use of an antipsychotic medication and physical behaviors for a resident with Alzheimer's and severe dementia, and inaccurately recorded the discharge location for another resident with multiple diagnoses. The errors were due to oversight and unfamiliarity with the EHR system.
The facility failed to update PASARR screenings for two residents after they were diagnosed with new mental illnesses. Despite procedures requiring review and update of PASARRs upon changes in condition, the facility did not complete new screenings for these residents.
The facility failed to accurately complete a Level I PASARR Screening for a resident with severe major depressive disorder and schizoid personality disorder, resulting in a Negative Level I Screening and no Level II evaluation. The discrepancy was acknowledged by the ADON and Admissions Director, who confirmed the expectation for accurate PASARRs.
The facility failed to ensure staff administered medication as ordered by the physician for a resident with atrial fibrillation. Despite a care plan and physician's order for Pradaxa 150 mg twice daily, the resident did not receive the medication for several days. The facility's policy mandates timely and accurate medication administration.
The facility failed to post the total number of and actual hours worked for licensed and unlicensed nursing staff per shift in a prominent location accessible to residents and visitors. Observations revealed that the staffing information was not updated in a timely manner and did not include the required breakdown of staff by discipline. Interviews with staff indicated a lack of understanding and communication regarding the proper posting of staffing information.
Failure to Administer Tube Feeding per Physician Order Resulting in Aspiration Pneumonia
Penalty
Summary
A deficiency occurred when a resident with a history of digestive system surgery, aspiration pneumonia, dysphagia, and sepsis did not receive tube feeding in accordance with physician orders and the comprehensive care plan. The resident was admitted with orders for Jevity 1.5 via PEG tube at 60 mL/hr for 20 hours daily, with water flushes every 6 hours. Nursing documentation confirmed the resident was tolerating feedings at the prescribed rate prior to the incident. On the evening of the incident, an LVN hung a new bottle of Jevity but did not verify or adjust the feeding pump's rate, nor did he check the settings during his shift or at shift change. The following nurse also failed to check the pump settings when starting her shift and again when replacing the Jevity bottle during the night. Both nurses acknowledged they did not confirm the pump's rate, and the pump was later found to be running at 200 mL/hr instead of the ordered 60 mL/hr. The facility's policy required verification of provider orders and monitoring of tube feeding settings, but this was not followed. The error was discovered the next morning when a nurse found the resident experiencing nausea and checked the pump, identifying the incorrect rate. The resident subsequently developed symptoms of aspiration, including cough and congestion, and was transferred to the hospital, where she was diagnosed with aspiration pneumonia and sepsis. Hospital records confirmed the tube feeding rate error and linked it to the resident's acute hypoxemic respiratory failure and subsequent death.
Tube feeding pump set at incorrect rate
Penalty
Summary
The facility failed to ensure that a resident with a PEG tube received tube feeding in accordance with the physician order, the comprehensive person-centered care plan, and the resident’s goals. The resident was admitted with diagnoses including dysphagia, aspiration pneumonia, sepsis, and aftercare following digestive system surgery, and the MDS indicated the resident was cognitively intact and on tube feeding. The care plan for tube feeding included a goal that the resident would be free of aspiration, and the active order was for Jevity 1.5 via PEG at 60 mL/hour for 20 hours with water flushes of 200 mL every 6 hours. On the morning the problem was identified, an RN found the tube feeding pump running at 200 mL/hour instead of the ordered 60 mL/hour. The RN documented that the resident was spitting up saliva and complained of severe nausea, and the RN stopped the feeding and notified the MD. Later that day, the resident developed coughing and congestion, crackles were heard bilaterally, and the MD ordered transfer to the ED for a chest X-ray to rule out aspiration pneumonia. The facility’s MAR showed that two LVNs had signed for the tube feeding during the prior evening and night shifts, and the DON stated that when a nurse signs the MAR, the nurse is supposed to verify that the rate is accurate. Interviews showed that the evening LVN had hung a new bottle of Jevity but did not check the feeding rate during the shift and did not verify the pump settings with the oncoming nurse at shift change. The night LVN stated she checked the pump around 2 AM to replace an empty bottle, but she did not check or reset the feeding rate and acknowledged she overlooked the settings. The RN stated the resident reported nausea during the night but did not tell the night nurse because she thought it would go away. Hospital records later documented that the tube feeds had been mistakenly increased from 60 cc/hour to 200 cc/hour for 12 hours, and the discharge summary listed acute hypoxemic respiratory failure with aspiration pneumonia as the likely cause, noting that the resident died on 11/19/25.
Failure to Prevent Elopement and Ensure Supervision for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide an environment free from accident hazards and did not ensure adequate supervision for a resident who was at risk for elopement. The resident, who had a history of traumatic brain injury, confusion, memory problems, impaired cognition, and lower leg impairment, did not speak or understand English and was not always understandable in her primary language. Despite these risk factors, the resident eloped from the facility twice during the night shift, each time wearing only a nightgown and without appropriate outerwear. On both occasions, the resident was found outside the facility, once in an apartment building and once near a shopping mall underpass, and was confused when found. Police were notified, and the resident was taken to a hospital after the second incident. Staff interviews and record reviews revealed that the Wanderguard alarm, intended to prevent elopement, was not checked for functionality, and staff were not properly oriented or trained in its use. The LVN assigned to the resident on the night of the first elopement stated they had never checked the Wanderguard alarm and had not received orientation. The facility's policy required evaluation for wandering risk, implementation of interventions, and regular checks of monitoring systems, but these procedures were not followed. The ADON could not explain how the resident exited the facility undetected, and there was a lack of consistent supervision at the front desk during the night shift.
Failure to Provide Timely Pain Medication Due to Refill and Documentation Lapses
Penalty
Summary
A deficiency occurred when a resident with complex regional pain syndrome, functional quadriplegia, and generalized muscle weakness did not receive a scheduled fentanyl transdermal patch at the prescribed time. The resident was cognitively intact at admission but later became moderately impaired. On the scheduled day, the fentanyl patch, which was to be applied at 9 AM, was not administered until 6:18 PM, resulting in a significant delay. The delay was due to the facility not having the fentanyl patch available at the scheduled time. Nursing staff reported that the patch had been ordered from the pharmacy five days prior, but it had not arrived by the time it was needed. The pharmacy was waiting for the physician's signature before delivering the medication, and there was no documentation showing that the refill was requested or that efforts were made to obtain the necessary signature before the scheduled administration time. Facility policy indicated that medication refills should be requested 3-5 days before depletion, but there was no evidence that this process was followed for the resident's fentanyl patch. The facility's Assistant Director of Nursing acknowledged that the scheduled dose was not applied on time and that there was no documentation of a timely refill request or physician signature prior to the missed dose.
Medication Administration and Accounting Deficiency
Penalty
Summary
The facility failed to ensure that prescribed medication for a resident was available and administered on time. Specifically, the resident missed three doses of diazepam, a controlled substance prescribed for muscle spasms related to complex regional pain syndrome, due to a lack of inventory. The Assistant Director of Nursing (ADON) and a Licensed Vocational Nurse (LVN1) confirmed that the resident's last dose was given in the morning, and subsequent doses were missed. The Director of Nursing (DON) acknowledged that the facility did not follow its policy and procedure for administering medications, which requires medications to be administered safely, timely, and as prescribed. Additionally, there was a discrepancy in the accounting of the controlled medication. A faxed verification report indicated that 60 tablets of diazepam were ordered, but the Controlled Drug Record showed that only 31 tablets were accepted on a different date. The ADON noted a discrepancy between the documents, and the facility's policy requires any discrepancy in controlled substance medication counts to be reported and investigated immediately. This failure to properly account for the receipt of controlled medication compromised the facility's ability to maintain adequate medication availability for the resident.
Inaccurate MDS Assessment Due to Omitted Diagnoses
Penalty
Summary
The facility failed to ensure an accurate assessment of the Minimum Data Set (MDS) for a resident, resulting in the omission of critical diagnoses such as dementia, fracture, and osteopenia. During an observation, the resident was found awake and verbally responsive, with a bandage on the left forearm, but unable to explain how the fracture occurred. Interviews revealed that the MDS Nurse did not include these diagnoses in the MDS, despite the resident's clinical record indicating their presence. The MDS Nurse stated that the physician order was not used as a source of information, and dementia was care planned by social services. Additionally, osteopenia could have been added if there had been better communication with the nursing staff. The Director of Nursing emphasized the importance of the MDS as an accurate assessment of the resident's current status, stating that the MDS nurse should thoroughly review the chart and take additional steps if documentation does not match. The Social Services Designee confirmed that the resident was admitted with a diagnosis of dementia. The failure to accurately document these active diagnoses in the MDS resulted in an inaccurate reflection of the resident's health status, as outlined in the CMS Resident Assessment Instrument (RAI) 3.0 Manual.
Failure to Apply Splint as Ordered for Resident with Fractured Forearm
Penalty
Summary
The facility failed to adhere to a physician's order for a resident who had a fractured left forearm. The resident, who was admitted with end-stage renal failure and dementia, had a minimally displaced left radial shaft fracture with minimal healing and significant osteopenia. The physician's order required the splint to be kept on most of the time, with removal only once a day for cleaning. However, the splint was missing as noted in the nurses' notes, and the treatment administration record indicated that the splint was on hold for several days. The Director of Nursing acknowledged that the splint was on hold due to unavailability. A registered nurse mentioned that the resident's son arranged an orthopedic appointment where a splint was applied, but the facility did not contact the orthopedic department directly. This inaction led to the resident not having the splint as ordered, potentially risking further complications due to the fracture not being properly immobilized.
Failure to Investigate Unexplained Bruises
Penalty
Summary
The facility failed to thoroughly investigate a change in condition for a resident who developed bruises of unknown origin on the left forearm and the top of the left hand. The resident was admitted with diagnoses including end-stage renal failure and dementia. On a specific date, nurses' notes documented the presence of discoloration on the resident's left forearm and hand, and a physician ordered monitoring and application of an ice pack. The care plan included instructions to keep the area clean and dry and to report significant changes to the medical doctor. Despite these measures, interviews with a registered nurse and the assistant director of nursing revealed that no investigation was conducted to determine the possible causes of the bruises. The facility's policy on abuse and neglect required a thorough assessment and documentation of findings, including injury assessment and consideration of factors such as medications and behavior. The lack of investigation into the bruises meant that the resident might not have received the necessary care and services, as the potential causes of the bruises were not explored.
Failure to Address Osteopenia in Resident's Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident diagnosed with osteopenia, which was not addressed in their care plan. The resident was admitted with end-stage renal failure, dementia, and a history of fractures. An orthopedic note from September 2024 indicated significant osteopenia and degenerative changes in the wrist, but this condition was not included in the resident's care plan. Interviews with the Assistant Director of Nursing and the Director of Nursing revealed that the care plan did not address the resident's osteopenia. The facility's policy requires a comprehensive, person-centered care plan with measurable objectives and timetables to meet the resident's needs, developed by the Interdisciplinary Team in conjunction with the resident and their family. However, the care plan for this resident was not updated to reflect the osteopenia diagnosis, indicating a lapse in the facility's adherence to its care planning procedures.
Failure to Train and Evaluate CNAs
Penalty
Summary
The facility failed to ensure that three Certified Nursing Assistants (CNAs) received the necessary training and performance evaluations as required by facility policy. The employee files for CNA 1, CNA 2, and CNA 3 lacked documentation of initial training and competency assessments. These CNAs were hired in October 2023, and their employment ended between February and April 2024. The Director of Staff Development (DSD) acknowledged the absence of onboarding documents and competency assessments for these CNAs, which are crucial for validating that staff are adequately trained before working independently with residents. The facility's policy mandates a performance evaluation at the end of a 90-day probationary period and annually thereafter, but this was not completed for the CNAs in question. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) both emphasized the importance of competency assessments to ensure CNAs can perform their duties properly. The lack of these evaluations and assessments indicates a failure to adhere to the facility's procedures, potentially leading to untrained CNAs providing unsafe care to residents.
Loss of Resident's Personal Possessions
Penalty
Summary
The facility failed to retain the personal possessions of a resident, leading to depression, disappointment, and mental anguish. The resident, who was admitted with multiple diagnoses including osteomyelitis of the vertebra, pressure ulcer, diabetes mellitus, heart failure, chronic pain syndrome, functional quadriplegia, and a history of pulmonary embolism, had good cognition and required assistance for mobility and hygiene. Upon returning from hospitalization, the resident discovered that two pairs of headphones, a Bluetooth speaker/microphone, and two cans of Lysol disinfectant spray were missing from his closet. The resident expressed feelings of depression and disappointment over the loss during an interview. Social Services, along with the Assistant Director of Nurses, acknowledged the missing items and noted the issue, while the Ombudsman was informed and planned to follow up on the situation.
Neglect in Resident Hygiene Care
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect, resulting in the resident not receiving a sponge bath for one month. The resident, who was admitted with multiple serious health conditions including osteomyelitis of the vertebra, a stage 4 pressure ulcer, diabetes mellitus, heart failure, chronic pain syndrome, functional quadriplegia, and a history of pulmonary embolism, required staff assistance for hygiene care. Despite having good cognitive function and the ability to communicate, the resident repeatedly requested a sponge bath, which was not provided due to staff claiming they ran out of time or passing the responsibility to the next shift. The neglect led to the resident experiencing discomfort, humiliation, and embarrassment, as well as a worsening of his pressure ulcer, which contributed to sepsis upon hospital admission. The facility's policy on bed baths, which aims to promote cleanliness and observe skin condition, was not followed, resulting in a significant lapse in care for the resident.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide timely PRN pain medication to Resident 1, who was suffering from pain due to a pressure ulcer and bone infection. Resident 1, admitted with multiple diagnoses including osteomyelitis of the vertebra, pressure ulcer, diabetes, heart failure, chronic pain syndrome, and functional quadriplegia, reported waiting 1-2 hours for pain relief on a specific date. Despite activating the call light, no staff responded, and the call light was later found disconnected, rendering it unusable. Attempts to report the issue to a nurse manager were unsuccessful as she was in a meeting. The resident experienced significant pain and discomfort due to this delay in care, which was reported to the Ombudsman and the California Department of Public Health. The Assistant Director of Nurses confirmed that staff are instructed not to disconnect call lights and are expected to respond to residents' requests for care.
Failure to Report and Investigate Resident Injury
Penalty
Summary
The facility failed to report and investigate an incident involving a resident who was injured during a transfer from a wheelchair to a bed. The resident, who had cognitive impairment and required a two-person assist for transfers, was dropped on the floor, resulting in a broken tooth. Despite the incident, no report was made to the California Department of Public Health, and the facility did not document the occurrence or initiate an investigation as required by their policy. The resident, who had multiple diagnoses including kidney disease, heart failure, and diabetes, did not receive dental care for the injury until nine months later. The delay was attributed to the facility's claim of a lack of dental insurance, which was later confirmed to be incorrect. The resident's son reported the incident to the facility, but no action was taken to address the injury or report it to the appropriate authorities, as mandated by federal and state regulations.
Failure to Replace Lost Eyeglasses for Resident with Glaucoma
Penalty
Summary
The facility failed to assist a resident in obtaining or being reimbursed for eyeglasses after staff lost three pairs of the resident's prescription eyeglasses. The resident, who has glaucoma and vision difficulties, was admitted with multiple diagnoses including kidney disease, heart failure, diabetes, gait and mobility abnormalities, and cognitive impairment. The resident required a two-person assist for mobility and did not walk. Despite the resident's son reporting the loss of eyeglasses multiple times, the facility did not replace or reimburse the resident for the lost items, nor did they assist in obtaining a new prescription. The resident's personal effects inventory indicated the presence of eyeglasses, and a facility Theft and Lost Report confirmed the loss of prescription glasses. However, the facility did not follow through with their policy on Lost and Found, which requires immediate investigation of misappropriation or mistreatment of resident property. The facility did not refer the resident to optometry or ophthalmology for a new prescription, and no investigation into the lost eyeglasses was conducted, leading to the resident experiencing depression and additional visual difficulties.
Neglect in Providing Foot Care Services
Penalty
Summary
The facility failed to provide necessary foot care services to a resident, who had been admitted with multiple diagnoses including diabetes, for a period of 2 1/2 years. This resident, who required assistance for mobility and had cognitive impairments, did not receive any podiatry services such as toenail clipping since admission. The lack of foot care resulted in overgrown and uncomfortable toenails, contributing to immobility and pain. The facility's policy on foot care, revised in March 2018, mandates that residents receive appropriate care to maintain foot health, especially those with conditions like diabetes. However, the facility did not adhere to this policy, as evidenced by the Assistant Director of Nurses' inability to provide records of any podiatry care prior to May 2024. This neglect was in violation of the facility's abuse and neglect prevention policy, which emphasizes the protection of residents from neglect and the provision of necessary care.
Failure to Provide Timely Dental Care for Resident's Injury
Penalty
Summary
The facility failed to assist a resident in obtaining dental care for a tooth injury caused by a fall, which occurred nine months prior. The resident, who was admitted with multiple diagnoses including kidney disease, heart failure, diabetes, and cognitive impairment, required significant assistance for mobility and daily activities. Despite the injury occurring in October 2023, the facility did not report the incident or notify the Department of Public Health. The resident's son reported that the facility initially claimed the resident did not have dental coverage and did not pay for the dental care, although a former administrator had stated the facility would cover the costs. The resident eventually received a root canal after dental insurance was confirmed, with the son arranging all appointments. The facility's policy on investigating and reporting accidents and incidents was not followed, as no incident report was made for the resident's injury. The policy requires that all accidents or incidents involving residents be investigated and reported to the administrator, with a detailed report submitted to the director of nursing services within 24 hours. This report should include the date and time of the incident, the nature of the injury, circumstances surrounding the accident, and witness accounts. The failure to adhere to these procedures resulted in a lack of care and services for the resident for an extended period.
Failure to Report Abuse Investigation Timely
Penalty
Summary
The facility failed to ensure the result of its investigation of an abuse allegation involving two residents was reported within five working days to the State Survey Agency. On 1/29/24, Resident 1 called the police, alleging verbal abuse by her roommate, Resident 2. Both residents' admission records and skilled charting indicated an argument occurred, leading to Resident 1's police call. However, the facility did not submit an investigative report within the mandated timeframe. During interviews on 5/16/24, the Assistant Director of Nursing (ADON) confirmed that the new Administrator was searching for the investigative report but was unable to provide evidence that it had been submitted to the California Department of Public Health within the required five working days. The facility's policy on abuse investigation and reporting, last revised in 7/17, mandates prompt reporting and thorough investigation of abuse allegations, with findings to be reported to appropriate agencies within five working days. This policy was not followed in this instance.
Delayed Pain Management and Call Light Response Issues
Penalty
Summary
The facility failed to treat a resident with dignity and respect by not providing timely pain management. The resident, who was admitted with multiple diagnoses including diabetes mellitus, urinary tract infection, and chronic pain syndrome, reported waiting over an hour for pain medication on two consecutive evenings. This delay in response to the resident's call light for pain relief resulted in significant pain and suffering for the resident. Interviews and reviews of Resident Council Meeting notes revealed ongoing issues with call light response times. Residents reported that call lights were sometimes turned off without their needs being addressed, and CNAs did not consistently perform two-hour checks or respond to call lights when covering for others. The facility's policy requires call lights to be answered within five minutes, but this standard was not met, contributing to the resident's distress and violation of their rights.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide timely pain management for a resident with a right leg wound, resulting in unnecessary pain and suffering. The resident, who was admitted with multiple diagnoses including diabetes mellitus, urinary tract infection, and chronic pain syndrome, reported waiting over an hour for pain medication on two occasions during the evening shift. Despite having a care plan in place that included administering medications as ordered and assessing pain every shift and as needed, the resident experienced significant discomfort due to the delay in receiving pain relief. The resident's pain management regimen included medications such as Lidocaine patch, Oxycodone, Dilaudid, and Lyrica, which were noted to provide relief within 5-10 minutes once administered. However, the delay in administering these medications on the specified dates led to the resident experiencing unmanaged pain. The resident's care plan also included interventions like assisting with positioning for comfort and notifying medical staff with signs of unmanaged pain, but these measures were not effectively implemented to prevent the resident's prolonged discomfort.
Failure to Implement Legionella Water Management Program
Penalty
Summary
The facility failed to implement their Legionella water management program, which had the potential to affect all 229 residents. The facility's policy, revised in September 2022, outlined a comprehensive water management program aimed at preventing, detecting, and controlling water-borne contaminants, including Legionella. The policy specified the formation of an interdisciplinary water management team and detailed descriptions and diagrams of the water system. However, interviews with maintenance staff and the Regional Maintenance staff revealed that there was no process or documentation for monitoring Legionella in place. The Maintenance Assistant and Regional Maintenance staff were unaware of any existing program or plan addressing Legionella, and the facility lacked documentation related to monitoring for Legionella. Further interviews with the President of Clinical Operations and the Assistant Director of Nursing confirmed the absence of any documentation or monitoring process for Legionella. The Administrator also stated that she expected staff to monitor for Legionella and maintain records, but this was not being done. The deficiency was evident as the facility did not have a functioning water management program to monitor and control the presence of Legionella, as required by their policy, putting all residents at risk.
Failure to Maintain Resident Confidentiality
Penalty
Summary
The facility failed to ensure the confidentiality of medical information for one resident, identified as Resident #185, who was readmitted from the hospital. Upon readmission, Resident #185 was observed wearing wristbands that identified them as a fall risk and indicated a latex allergy. These wristbands, which contained medical information, were not removed by the facility staff, contrary to the facility's policy on resident rights and confidentiality. The resident had moderately impaired cognition and was readmitted with diagnoses including abnormalities of gait and mobility and abnormal posture. Despite the facility's policy prohibiting unauthorized disclosure of resident information, the wristbands remained on the resident for several days after readmission, visible to others and compromising the resident's privacy and dignity. Interviews with facility staff, including an LVN and an RN, revealed that it was common for residents to be admitted with wristbands from the hospital, and these should have been removed during the initial assessment. The staff admitted to being unaware that Resident #185 still had the wristbands on. The facility's Administrator confirmed that the expectation was for the nurse performing the initial assessment to remove any wristbands. This oversight led to a breach of the resident's right to privacy and confidentiality as outlined in the facility's policy and federal and state laws.
Failure to Timely Report Allegation of Physical Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident to the California Department of Public Health (CDPH) within the required two-hour timeframe. The facility's policy mandates that any suspicion of abuse must be reported immediately, defined as within two hours if it involves abuse or results in serious bodily injury. On 03/21/2024, a resident alleged they were hit on the chest by another resident at 8:30 AM. However, the facility did not report this incident to CDPH until 1:01 PM, approximately four and a half hours after the allegation was made. The resident involved in the incident had a medical history of Alzheimer's disease and severe dementia with other behavioral disturbances, and a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment. The facility's Administrator and Assistant Director of Nursing (ADON) both acknowledged that the report should have been made to CDPH by 10:30 AM, in accordance with the facility's policy. This delay in reporting constitutes a failure to comply with the mandated reporting requirements for suspected abuse.
Inaccurate MDS Assessments for Medication, Behaviors, and Discharge Location
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the use of an antipsychotic medication and physical behaviors directed towards others for one resident and accurately reflected the discharge location for another resident. For Resident #197, who had a medical history including Alzheimer's disease and severe dementia, the MDS did not reflect the physical behaviors or the use of an antipsychotic medication during the seven-day look-back period, despite documentation indicating the resident exhibited behaviors such as biting and hitting and was on quetiapine fumarate. The MDS nurse responsible for the assessment was unaware of these behaviors and the medication due to unfamiliarity with the facility's electronic health record (EHR) system and missed the relevant information in the physician's orders. For Resident #237, who had multiple diagnoses including surgical aftercare and type two diabetes mellitus, the discharge MDS inaccurately indicated that the resident was discharged to a Short-Term General Hospital when, in fact, the resident was discharged home. This discrepancy was identified through a review of the resident's progress notes, which documented that a family member picked up the resident. The MDS nurse acknowledged the error as an oversight, and the Assistant Director of Nursing confirmed that the MDS should have been coded to reflect the correct discharge location.
Failure to Update PASARR Screenings for New Mental Illness Diagnoses
Penalty
Summary
The facility failed to complete a new Level I Preadmission Screening and Resident Review (PASARR) after residents were diagnosed with a new mental illness for two residents. Resident #41 was admitted with a primary diagnosis of unspecified psychosis and later received a new diagnosis of schizoaffective disorder. Despite this new diagnosis, the facility did not update the Level I PASARR Screening, which initially indicated a neurocognitive disorder and psychosis but did not reflect the new diagnosis of schizoaffective disorder. The State of California's Department of Health Care Services had closed the case, indicating no serious mental illness, and required a new Level I Screening to reopen it, which was not done by the facility. Similarly, Resident #164 was admitted and later diagnosed with paranoid schizophrenia. The resident's initial Level I PASARR Screening was negative for serious mental illness, and no new PASARR was completed after the new diagnosis. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that PASARRs were supposed to be reviewed and updated if a resident experienced a change in condition or received a new diagnosis. However, this procedure was not followed, leading to the deficiency in updating the PASARR screenings for both residents.
Inaccurate PASARR Screening for Resident with Mental Disorders
Penalty
Summary
The facility failed to ensure a Level I Preadmission Screening and Resident Review (PASARR) was accurately completed for one resident. Specifically, the facility did not reflect the presence of a serious diagnosed mental disorder for a resident who had severe major depressive disorder with psychotic symptoms and schizoid personality disorder. The resident's Level I PASARR Screening incorrectly answered 'No' to the question about serious mental illness, resulting in a Negative Level I Screening and no Level II evaluation being required. This discrepancy was identified during a review of the resident's records and interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Admissions Director, who acknowledged the inaccuracy and the expectation for PASARRs to be accurate. The ADON explained that PASARRs are completed before admission and reviewed for accuracy, and if a resident is admitted without a PASARR, an MDS nurse is responsible for completing one. The Admissions Director stated that she reviews PASARRs from the hospital and notifies the Director of Nursing (DON) if a PASARR is positive. The Administrator confirmed the expectation for accurate PASARRs. The failure to accurately complete the PASARR for the resident with serious mental disorders led to the deficiency identified in the report.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to ensure staff administered medication as ordered by the physician for one resident. The facility's policy on administering medications, revised in April 2019, mandates that medications be administered safely, timely, and as prescribed. Resident #180, admitted on 05/18/2023 with diagnoses including unspecified atrial fibrillation, had a care plan initiated on 05/18/2023 that directed staff to administer medications as ordered. An order dated 05/18/2023 required Pradaxa 150 mg to be administered twice daily. However, during an interview on 04/08/2024, a registered nurse confirmed that the resident had not received Pradaxa since 04/05/2024. The facility administrator stated that she expected staff to administer medications within the prescribed timeframe.
Failure to Post Required Staffing Information
Penalty
Summary
The facility failed to ensure they posted the total number of and the actual hours worked for licensed and unlicensed nursing staff directly responsible for resident care per shift. This included RNs, LPNs, LVNs, and CNAs. The facility's policy required this information to be posted within two hours of the beginning of each shift in a prominent location accessible to residents and visitors. However, observations revealed that the staffing information was not posted in a conspicuous area and did not include the required breakdown of staff by discipline or the total number of staff working per shift. Additionally, the staffing information was not updated in a timely manner, as evidenced by the posting not being changed to reflect the current date on multiple occasions. Interviews with facility staff, including the Assistant Administrator, Staffing Coordinator, and ADON, indicated a lack of understanding and communication regarding the proper posting of staffing information. The Staffing Coordinator stated she was only instructed to post the projected hours for the day and was unaware of the requirement to include the total number of each discipline working per shift. The ADON confirmed that the detailed breakdown of staff by discipline was kept in a binder at each nurses' station, which was not accessible to residents or visitors. The Administrator expected the daily staffing to include the census and be broken down by shift, but this was not being done consistently. The facility's failure to post the required staffing information in a prominent and accessible location, as well as the lack of timely updates, had the potential to affect all 229 residents residing in the facility. The observations and interviews highlighted a systemic issue with the facility's compliance with its own policy and state regulations regarding the posting of direct care staffing numbers.
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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.
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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 Heights Healthcare | 0 mi | ★★★★★ | 0 | 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 |
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