Golden Empire

Inspectors wroteBased on interview and record review, the facility failed to protect the resident from abuse for one of four sampled residents (Resident 1) when Resident 1 was found crying and saying, Get him away from me, as Resident 2 was witnessed by staff inappropriately touching Resident 1 while touching his genitals. This failure has resulted inResident 1 not being free from abuse by Resident 2, andResident 1's right to be free from abuse not being protected.

Inspectors wroteBased on interview and record review the facility failed to ensure an allegation of abuse was reported timely and immediately within the required time frame for one of four sampled residents (Resident 1) when an allegation of abuse was not reported per federal regulation. This failure of timely reporting had the potential to cause a delayed response by enforcement agencies to ensure residents' safety.

Inspectors wroteBased on interview and record review the facility failed to ensure annual performance reviews were completed for Certified Nursing Assistants (CNAs) for one of three sampled staff (CNA 1). This failure had the potential for the facility to be unaware of staffing performance concerns for CNA 1, with the potential for all resident care to be negatively affected. During a review of CNA 1's current employee file, employee file indicated, most recent performance review was completed 5/17/2021. File indicated, CNA 1 was hired on 5/1/2018. During an interview on 2/6/26, at 9:22 a.m., with Director of Staff Development (DSD), DSD stated, the most recent performance review we have documented for CNA 1 is dated 5/17/2021. DSD stated, performance reviews are supposed to be done annually for all CNAs. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure treatment and care in accordance with professional standards of nursing were provided for one of three sampled residents (Resident 1), when the facility did not develop care plan interventions, monitor, and notify the physician regarding Resident 1's known history of THC (tetrahydrocannabinol, the ingredient in cannabis [marijuana] that can alter mood, perception, and reduce pain) substance abuse. This failure had the potential to result in Resident 1's unmet medical needs, delayed treatment, and injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the confidentiality of Identifiable information for a census of 137 residents, when residents' meal tickets with personal information were accessible to view by other residents and visitors. These failures decreased the facility's potential to protect residents' identifiable information.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate assessments were completed for four of 36 sampled residents (Resident 9, Resident 98, Resident 129, and Resident 133) when: 1. Resident 9's Minimum Data Set (MDS- a federally mandated resident assessment tool) was incorrectly marked for invasive mechanical ventilator (a breathing machine connected to a tube inserted into the windpipe through the neck);2. Resident 98's MDS did not reflect the resident's terminal prognosis;3. Resident 129's MDS did not indicate resident was on hospice care; and, 4. Resident 133's MDS assessments were not consistent with resident's status. These failures increased the potential for residents not to receive consistent care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure:Medications and medical supplies were not available for residents' use past their expiration dates in three of three medication carts;Crash carts (storage of supplies needed in emergency situations) were checked regularly, and medical supplies were complete and were not past their expiration dates; andA medication was stored in the Resident Food Refrigerator at the memory unit. These failures had the potential for residents to receive medications with unsafe or reduced potency from being used past their expiration dates, and the potential for malfunctioning equipment and delays during emergency situations for a census of 137.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in a sanitary manner for a census of 137 residents, when: 1. Expired, undated, unlabeled, spoiled, unsealed opened food items, and a dirty food tray were found in the walk-in refrigerator, walk-in freezer, and in the cooking area in the kitchen;2. The floor in the walk-in freezer was dirty;3. Cooking equipment and utensils were not clean;4. Undated and expired food items were stored in the resident food refrigerators in the three nursing units and temperature logs were inconsistent; 5. No written instructions were followed for cooking spinach; and 6. There were no air gaps for the plumbing system under the sinks and dishwashing machine in the kitchen. These failures had the potential to contaminate food in the kitchen and cause foodborne illnesses among residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure trash was stored in a sanitary manner for a census of 137 when, trash dumpsters were observed with open lids. This failure had the potential to create breeding ground for insects and rodents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain effective infection prevention and control measures to prevent the occurrence and spread of infections to residents, when: 1. The enhanced barrier precautions (EBP, infection control measures to prevent spread of infections) signage was not accurately assigned; 2. The nursing staff did not implement EBP for Resident 36;3. The nursing staff did not close the door of rooms on isolation precautions for COVID-19 positive residents;4. Blood Pressure (BP) cuff and BP machine were not disinfected with appropriate disinfectant;5. Resident 66's nebulizer (a machine that turns liquid medicine into a mist that can be easily inhaled) mask was not labeled and stored properly; and,6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an effective pest control program was implemented for a census of 137 residents, when flies were observed in the kitchen. This failure decreased the facility's potential to maintain a pest-free environment in the kitchen that prevented food contamination.

Inspectors wroteBased on interview and record review the facility failed to ensure one resident (Resident 26) out of a census of 137 was protected from abuse when Resident 26 slapped Resident 52 on the right side of her face. This failure had potential to result in physical injury for Resident 52. During a review of Resident 52's clinical record, the record indicated Resident 52 was admitted in April of 2025, with a diagnosis of Dementia (a decline in mental ability severe enough to interfere with daily life). A review of Resident 52's Medical Data Set (MDS, a federally mandated resident assessment tool), dated 6/4/25 indicated the resident had severe cognitive impairment. During a review of Resident 52's progress noted dated 8/16/25, the note indicated, . a CNA [Certified Nursing Assistant] looked up to see [Resident 26] slap [Resident 52] across the right side. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a significant change in status assessment (SCSA- an assessment to reflect a major decline or improvement in the resident's status) was completed for one of 36 sampled residents (Resident 129) when Resident 129 was enrolled in a hospice program (compassionate care for people who are near the end of life provided within a health care facility). This failure increased the potential for plan of care not to be updated to meet the current needs for Resident 129. A review of the admission Record indicated Resident 129 was admitted [DATE] with diagnoses including frontotemporal neurocognitive disorder (group of brain disorder leading to significant changes in behavior, movement, language and personality) and major depressive disorder (persistent feeling of sadness and loss of interest in activities). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure professional standards of care were followed for two of 36 sampled residents (Resident 116 and Resident 47), when:1. The nurse did not document an assessment of Resident 116's mid-upper arm for proper Peripherally Inserted Central Catheter (PICC) line management per physician order; and 2. The facility altered Resident 47's Insulin administration record. These failures had the potential to negatively affect Resident 116's and Resident 47's health and their ability to achieve their highest practical well-being due to not receiving treatment and services in a timely manner and inaccurate medical information. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 36 sampled residents (Resident 47) received treatment and care in accordance with professional standards of practice, when the facility did not follow physician's orders for insulin (a medication that lowers high level of glucose in the blood) and glucose gel (sweet liquid containing sugar used to quickly raise blood sugar), and did not monitor blood sugar as directed by physician on multiple occasions when Resident 47's blood sugar dropped to critically low levels. These failures increased the risks for Resident 47 for possible complications of hypoglycemia (when the blood sugar is lower than normal) and hyperglycemia (high blood sugar), which could affect resident's health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that pain management was provided, consistent with professional standards of practice for one of 36 sampled residents (Resident 122), when the resident received inadequate pain management and, when non-pharmacological (non-medication) interventions were not used in conjunction with pain medication administration to manage pain. This failure placed Resident 122 at risk for unmanaged pain that had the potential to affect resident's sleep and diminish the residents' quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement an efficient process to accurately document and secure emergency medications (E-Kit) for a census of 137. This failure had the potential for emergency medications to be unavailable when needed, and the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions.

Inspectors wroteBased on interview and record review, the facility failed to ensure coordination of care between the hospice team (care designed to provide supportive care for physical, psychological, spiritual, and emotional needs to a terminally ill resident) and the facility for one of 36 sampled residents (Resident 133), when the resident's clinical records did not include hospice documents. This failure placed Residents 133 at risk for not receiving services necessary to promote comfort and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility's Medical Director (MD) attended the Quality Assurance and Performance Improvement (QAPI, a program that helps healthcare facilities consistently evaluate and improve their services and improve the quality of life and quality of care for residents) committee meetings. This failure had the potential for the QAPI meetings to lack medical guidance for medical care concerns, lack quality care improvement activities, lack effective evaluation of the program resulting in negative outcomes and decline in quality of care for a census of 137 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free from accidents and hazards that were within the facility's control, when the facility did not provide supervision to prevent one of three residents sampled for elopement (to leave a health care facility without permission or authorization), from leaving the facility without staff awareness and wandered in their wheelchair toward a busy street. Staff had not noticed Resident 1 missing until a staff member saw him on the street in his wheelchair on her way to work. This failure had the potential to result in physical harm, getting ran over by a car, and exposure to the elements (weather) for all residents who wander and/or have the potential to elope. This could have serious negative impacts on their safety, physical and emotional well-being. [...]

Inspectors wroteBased on interview and record review, the infection preventionist (IP) failed to report two potential infectious disease outbreaks withing 24 hours to the California Department of Public Health (CDPH), in accordance with the facility's Unusual Occrrence Reporting policy. This failure had the potential for infection to spread to residents, staff and visitors and negatively impact residents health and safety and delayed oversight by CDPH.

Inspectors wroteBased on interview and record review, the infection preventionist (IP) failed to report a flu and Respiratory Syncytial Virus (RSV - contagious virus that causes infections of the respiratory tract) outbreak in the facility in accordance to accepted national standards. This failure had the potential to cause a community wide outbreak for both RSV and Flu by potentially not preventing further transmission of the diseases.

Inspectors wroteBased on interview, record and facility policy review, the facility failed to implement their Abuse policy and investigate an injury of unknown origin for one of three residents who were sampled for abuse (Resident 1), when Resident 1 was found to have a bruise on her left hip and the facility could not determine where the bruise came from, in order to rule out abuse. This failure had the potential for residents not to be protected against abuse in the facility, which could negatively impact their quality of life and physical, emotional and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled resident's (Resident 1) care plans were developed when: 1. A care plan was not developed when a bruise of unknown origin was found on Resident 1's left hip. 2. A care plan was not developed when Certified Nursing Assistant (CNA) A trimmed Resident 1's fingernails and caused lacerations (cuts) on two of her fingers with the nail clippers. These failures had the potential to result in Resident 1's needs not being identified, evaluated and reevaluated, and had the potential to contribute to unwanted pain and infection which could negatively impact her quality of life and ability to attain or maintain her highest practicable level of well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure quality care was provided for one of three residents (Resident 1), who were sampled for quality of care when: 1. Certified Nursing Assistant (CNA) A trimmed Resident 1's fingernails and cut the skin and caused lacerations (cuts) on two fingers of her right hand with the nail clippers and the facility had not conducted corrective reeducation with CNA A, to prevent this from happening again. 2. Licensed Vocational Nurse (LN) B did not follow the wound care treatment directions for Resident 1's lacerated fingers, in accordance with what the physician ordered. These failures had the potential to cause Resident 1 unnecessary pain, discomfort and infection and have a negative impact on her quality of life and physical, emotional, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report an outbreak of scabies (tiny mites that crawled under the skin, caused itching, a rash, and was easily spread from person-to-person) to the California Department of Public Health (CDPH, worked to protect the public ' s health) when three residents and one staff member tested positive for scabies. This failure had the potential to cause further spread of scabies to other residents.

Inspectors wroteBased on interview and record review, the facility failed to monitor one out of three sampled residents (Resident 2) that were prescribed an antipsychotic medication (altered brain activity) when there was no monitor in place for staff to evaluate the response or effectiveness of Resident 2 ' s prescribed Haloperidol (Haldol, an antipsychotic) use. This failure could result in the unnecessary use of an antipsychotic medication and cause a decline in overall health status.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to follow infection control standards for hand hygiene for three of seven sampled residents (Residents 58, 67 and 378) when: 1. A Licensed Nurse (LN) handled multiple meal trays and then handled a drinking straw without performing hand hygiene, for Resident 58. 2. A Certified Nursing Assistant (CNA) handled multiple meal trays and then handled a drinking straw without performing hand hygiene, for Resident 67. 3. A LN did not perform hand hygiene before or after she obtained a blood sample from Resident 378, and then cleaned medical equipment while wearing the same gloves used to obtain the blood sample. 4. The Infection Preventionist (IP) was observed to lick her fingers before turning pages of documents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety and sanitation guidelines were followed when: 1. Food was not labeled in the walk-in refrigerator. 2. Food equipment was stored in an unclean area. 3. Food stored in Resident 41's room was not labeled and had expired. These failures had the potential to cause food borne illnesses in a medically vulnerable population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to publicly post the Nursing Hours Per Patient Day (NHPPD) sheets in a prominent place every day. This failure had the potential to prevent residents and visitors from having access to complete staffing information.