Golden Heights Healthcare

Inspectors wroteBased on interview, and record review, the facility failed to:Report, investigate, and provide a 5-Day Investigation Report to the State Survey Agency for an unwitnessed fall with injury that occurred on 01/03/2026 for one of the four sampled residents (Resident 2). Report within 24 hours the allegation that staff did not provide oral hygiene care to Resident 2 on 01/03/2026 at 5:30 PM and to investigate and submit the required 5 Day Investigation Report for the incident reported to the State Survey Agency on 01/12/2026. This failure had the potential to reduce accountability for resident safety, increase the risk that future suspicious injuries would be overlooked, delay corrective actions when allegations are confirmed, and diminish assurance of a safe living environment for residents.1. [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor two (Residents 1 and Resident 2 ) of 12 sample residents for signs and symptoms of emotional harm after alleged abuse. This failure had the potential for lack of and/or delayed provision of emotional support for Residents 1 and 2.

Inspectors wroteBased on interview and record review, the facility failed to have correct and complete information on the POLST forms for one of three sampled residents (Resident 1). Acting on incomplete or erroneous information on a POLST form could contribute to a resident's death. In order for a POLST form to be valid in California it must be signed and dated by a physician, nurse practitioner, or physician's assistant, and the patient or the patient's legally recognized health care decision maker. [California Emergency Medical Services Authority, DNR, POLST and Medallion Information, https:// emsa.ca.gov/dnr_and_polst_forms/ accessed on [DATE]]. Resident 1's POLST form was not signed or dated with anyone's signature or any dates. When Resident 1 was admitted to the skilled nursing facility, her physician's orders indicated she was a full code. [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct a thorough investigation into an allegation of abuse for Resident 1, one of one sample resident. Review of the facility ' s investigation indicated only staff were interviewed regarding this allegation. Facility stated no residents were interviewed because all residents of interest were non-interviewable. The investigation was not thorough because the facility failed to: 1. Attempt to interview responsible parties of non-interviewable residents 2. Conduct assessments of non-interviewable residents for signs and symptoms of abuse (defensive bruising, bruising in private areas, change in social behavior etc.). The lack of a thorough investigation did not ensure all residents were protected from abuse.

Inspectors wroteBased on observation, interview, facility document review, and facility policy review, the facility failed to accurately record the discard date on the label for a potentially hazardous food (thawed chicken breast) stored in 1 of 3 refrigerators and failed to conduct temperature monitoring prior to placing a potentially hazardous cold food (chocolate mousse) on residents' meal trays that was identified prior to the tray line service with a temperature of 47.3 degrees Fahrenheit. This failure had the potential to affect 88 of 88 residents who received meals from the facility's kitchen.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff conducted finger-stick blood sugar (FSBS) checks in accordance with physician's orders for 1 (Resident #33) of 3 residents observed for blood sugar monitoring. Specifically, staff failed to perform Resident #33's FSBS before meals as specified by the physician.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure that medications were stored in a safe and secure manner for 2 (Resident #2 and Resident #27) of 2 residents observed with medications at their bedside.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure staff did not document the administration of medications after the resident refused to take them for 1 (Resident #27) of 1 resident reviewed for refusal of medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 3 sampled residents (Resident 1) received care in accordance with professional standards of practice when there was no evidence of nursing notes and vital signs by night shift nurse on 6/14/24 for Resident 1. This failure had the potential to delay identifying symptoms of atrial fibrillation (Afib, an irregular and often rapid heart rate that commonly causes poor blood flow and can increase the risk of stroke) for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were answered in a timely manner for five of six residents (Resident 1, 2, 3, 4, and 6). The resident responsible party and confidential interview reported a pattern of delayed response to call lights and waiting for a long period of time for staff assistance. Additionally, there was no policy and procedure in place for the use of call light. These failures resulted in delayed provision of care and services for Resident 1, 2, 3, 4, and 6; and had the potential to negatively impact the resident ' s physical, mental, and emotional well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide protection to Resident 1 and other residents when Certified Nursing Assistant (CNA) 1 was not suspended immediately after an alleged abuse to Resident 1 was reported on 1/13/24. This failure placed Resident 1 at risk for further abuse and placed the other 15 residents assigned to CNA 1 for potential abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff had the knowledge and competency to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of one of three sampled residents (Resident 1) when: 1. Two Certified Nursing Assistants (CNA) failed to recognize inappropriate use of restraint after observing Resident 1's hand was tied to her bed; and 2. Two nursing staff (Licensed Vocational Nurse [LVN] and CNA) were unaware that they could report instances or allegations of abuse to the state agency (which is CDPH - California Department of Public Health) and the local Ombudsman's Office. These resulted in failure to recognize a situation that could indicate abuse and placed the residents' safety at risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from the use of physical restraint (any device, equipment or material that cannot be easily removed by the resident and limits his/her freedom of movement or normal access to his/her body) for discipline purposes and staff convenience when CNA (Certified Nursing Assistant) 1 placed a mitten on Resident 1's right hand and tied her right hand to her bed. This failure had the potential to cause physical harm, pain or mental anguish to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) and the local Ombudsman within the required two-hour period for one of three sampled residents (Resident 1) when CNA (Certified Nursing Assistant) 1 placed a mitten on Resident 1's right hand and tied her right hand to her bed. This failure had the potential to cause delay in the abuse investigation and increased risk of harm to the residents by placing Resident 1 at risk for potential repeated abuse, and other residents at risk for potential abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its infection control and prevention practices during a COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) outbreak when: 1. The Licensed Nurse 1 (LN1) did not wash hands before wearing gloves and before entering the room of four residents, Resident 1 (R1), Resident 2 (R2), Resident 3 (R3) and Resident 4 (R4), who were on transmission-based precautions (TBP - used in addition to standard precautions for patients who are known or suspected infections with pathogens that can be transported by airborne, droplet, or contact routes). 2. [...]

Inspectors wroteBased on food preparation observations, dietary management staff interview and departmental document review, the facility failed to ensure correct portioning for greater than 90 residents when the dessert for the noon meal was not prepared using the proper scoop size. Consistently providing incorrect food portions may result in over or undernutrition further compromising medical status.

Inspectors wroteBased on meal distribution observation, interview and departamental record review, the facility failed to ensure resident meals were palatable when residents complained about the taste and temperature of served meals.

Inspectors wroteBased on observation, interview, and record review, the facility interdisciplinary team failed to complete a self-administration of medications assessments for three of three sampled residents (Residents 39, 10, and 68) when: 1. A bottle of cough medicine was in plain sight on the overbed table next to the resident's bed, a bottle of vitamin D and other numerous medication bottles was at the foot of the bed of Resident 39; 2. A bottle of vitamin D, a bottle of trubiotic (supplement used for healthy stomach and bowels), was in plain sight in the open bedside cabinet, and an albuterol inhaler and 2 bottles of vitamin c was on the overbed table of Resident 10; 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of three (3) sampled residents (Resident 1) was provided with reasonable accommodation when the resident's request to fix the uneven arm rest of his power wheelchair was not followed through by the staff. This deficient practice had the potential to negatively impact the resident's quality of life and may place resident at risk of harm.

Inspectors wroteBased on interview and record review the facility failed to complete a baseline care plan (BCP) for one of three sampled resident (Resident 92) when there was no evidence of documentation of a completed baseline care plan. A BCP includes minimum healthcare information necessary to properly care for each resident immediately upon their admission, which would address resident-specific health and safety concerns to prevent decline, injury, such as elopement or fall risk, and would identify needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary. This deficient practice had the potential to result in inadequate care and services rendered to the resident.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and to implement the Care Plans (CP, a road map for patient care) and CP interventions for five (5) of 23sampled residents (Residents 85, 20, 35, 92, and 66) when: 1. Resident 20 did not have a care plan to address the wound on the left leg; 2. Resident 85 did not have a care plan to address the contractures to both upper extremities (arms); 3. Resident 35 did not have a care plan to address the assistance required during meals; 4. Resident 92 did not have a care plan to address the left leg gangrene (tissue death caused by an infection or lack of blood flow). 5. For Resident 66, the staff did not implement the Care Plan intervention to notify the Physician and the Registered Dietitian (RD) of the significant weight loss of 8-9 % in two weeks, on 4/23. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident's Care Plan was updated /revised for one of three (3) sampled residents (Resident 66) when, the CP Interventions to address weight loss did not include the recommendations made by the Registered Dietitian (RD). Failure to revise/update the CP had the potential to delay the care and services, cause miscommunication among caregivers, and cause further decline in the resident's health and well-being which could further compromise her medical condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision and assistance during meals for one of three sampled residents (Resident 35) when staff did not provide supervision and assistance to Resident 35 during lunch. This failure had resulted to Resident 35 had not adequately consumed her meal.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatment and services for one of three residents reviewed, to address the contractures of both upper extremities (BUE, both arms) for Resident 85. This failure had the potential to result to reduced functional range of motion for activities of daily living.

Inspectors wroteBased on interview and record review, it was evident that the facility failed to secure the services of a licensed pharmacist who could provide comprehensive consultation on all aspects of pharmacy services. This lapse was demonstrated by the fact that the monthly medication passes consistently returned medication error rates exceeding 5%, and there was no noticeable improvement over time.

Inspectors wroteBased on observations, interviews, and a review of records, it was found that the facility failed to maintain a medication error rate of less than 5%. During the medication pass, three medication errors were observed out of twenty-five opportunities, resulting in an error rate of 12%.

Inspectors wroteBased on food production observations, dietary staff interview and departmental document review the facility failed to ensure 2 staff members (Dietary Staffs [DS] 2 and 3) were competent in position associated functions when 1) DS 2 failed to follow the standard of practice for the preparation of pureed food items. Failure to ensure proper food preparation, utilizing standardized recipes may result in compromising the nutritional status of resident; and 2) DS 3 did not take food temperatures in accordance with food safety standards. Failure to fully follow food safety standards may result in providing residents with food that is not properly cooked and/or held and may result in foodborne illness and poor meal quality.

Inspectors wroteBased on meal plating observations, dietary management staff interview the facility failed to ensure meals were plated in accordance with physician ordered therapeutic diets. Failure to comprehensively follow physician ordered diets may result in further compromising patient medical status.

Inspectors wroteBased on meal distribution observations the facility failed to maintain food sanitation when staff returned soiled meal trays to the patient tray cart while unpassed meal trays remained in the cart.

Inspectors wroteBased on observation, interview and records review, the facility failed to monitor the hospice services provided by the hospice agency for one of three residents reviewed, Resident 58, when the hospice agency did not comply with their consented number of weekly visits to Resident 58. This failure resulted in the resident looking unkempt, dry, ashy, dishelved and angry.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement its policy and procedure on infection control and standards of practice, titled fraser health, for two of 19 sampled residents (Resident 39 and 90) when: 1. For Resident 39, 1a. The wound vac connecting tubing was in plain sight uncovered, lying on the floor. 1b. The used, dirty pair of scissors was used to cut the clean foam wound dressing. 1c. The overbed table was not cleaned and disinfected. 2. For Resident 90, the yankauer suction (an oral suction device) and its connecting tubing was undated, unlabeled and not changed (every week) as per Standard of Practice. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs (is generally a drug or chemical whose manufacture, possession, or use is regulated by a government) in sufficient detail to enable an accurate reconciliation. This deficient practice had the potential for diversion of controlled medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food under sanitary conditions when one kitchen staff member (KS) did not perform hand washing after picking up a pot that had fallen on the floor and before handling clean cookware used during food preparation. This failure had the potential to contaminate food served to the residents placing them at risk for food borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store garbage properly when the compost dumpster was not covered. This failure had the potential for rodents and insects to access the garbage which could potentially expose the residents to serious health risks.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a care plan for four of 19 residents when: 1. Resident 55 did not have a care plan for infection 2. Resident 72 did not have a care plan for infection 3. Resident 334 did not have a care plan for methicillin resistant staphylococcus aureus infection (MRSA infection - bacterial infection that is difficult to treat because of resistance to some antibiotics). 4. Resident 64 did not have a care plan for Divalproex (a medication used to treat manic behaviors) This deficient practice increased the risk of infection for Resident 55, Resident 72, and Resident 334. For Resident 64, this deficient practice raised the likelihood of the resident experiencing adverse effects from Divalproex.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the medication error rate was less than 5%. For four of five residents (Resident 38, 26, 64 and 41) observed during medication passes, there were 9 errors in 29 opportunities which resulted in a medication error rate of 31.03%. 1. For Resident 38, (a.) folic acid and vitamin B 12 were not given according to physician's order and (b.) dorzolamide and brimonidine eye drops were not given according to professional standards of practice. 2. For Resident 26, the atenolol was not given according to physician's orders. 3. For Resident 64 , fluphenazine and fluticasone nasal spray were not given according to physician's orders. 4. For Resident 41, metoprolol and senna were not given according to professional standards of practice. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 2 of 19 sampled residents (Resident 26 and 38) were free from any significant medication error when medications were not given according to physician's order. This deficient practice had the potential to cause Resident 26 and 38 discomfort and jeopardize their health and safety.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and secure medication storage when: 1. The facility stored medical supplies past expiration date including syringes and gloves in the medication room. 2. The facility did not ensure the medication room was accessed only by authorized staff. This deficient practice had the potential for unsafe medication administration and loss or diversion of all medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe storage and consumption of food brought in by visitors when unlabeled leftover food items were found in the rooms of three of 80 residents (Resident 331, 333, and 50). This failure had the potential for the residents to consume food that was potentially expired and could cause foodborne illnesses (an infection caused by consuming food or drink contaminated with disease-causing germs).

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain appropriate infection prevention control and practices when: 1. The medication tray and medication cart was not disinfected properly between patient use. 2. A staff's jacket was found hanging in the medication room storage. This deficient practice had the potential for spread of infection within the facility including residents and visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Minimum Data Set (MDS - a resident assessment tool), for one of 19 sampled residents (Resident 1), was submitted in a timely manner when the MDS dated [DATE] for Resident 1 was not submitted until [DATE]. This deficient practice had the potential to misrepresent the current condition of Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to accurately document the Minimum Data Set (MDS - a resident assessment tool) for one of 19 residents (Resident 82) when the MDS for Resident 82, dated 9/21/19, indicated Resident 82 was discharged to the hospital instead of the community. This deficient practice had the potential to misrepresent the discharge location of Resident 82.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the services provided by the facility met professional standards of quality when Licensed Vocational Nurse (LVN) 2 did not administer eye drops to Resident 38 according to professional standards. This deficient practice had the potential to compromise the effectiveness of the medication which could result in Resident 38 not receiving the full benefits of the medication.

Inspectors wroteBased on interview and record review, for one of 19 sampled resident (Resident 73), there was no documentation the pharmacy consultant identified significant drug-drug interactions for Resident 73's medications. This deficient practice had the potential for Resident 73 to receive unnecessary drugs which could lead to untoward effects affecting Resident 73's mental, physical, functional, and psychosocial status. Definitions: Adverse consequence is a broad term referring to unwanted, uncomfortable, or dangerous effects that a drug may have, such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status. It may include various types of adverse drug reactions and interactions (e.g., medication-medication, medication-food, and medication-disease. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor for specific target behavior/s (actual undesirable/unwanted behaviors that occur as a result of the medical condition) for the use of Divalproex (a medication used for treatment of manic behaviors) for one of two sampled residents (Resident 64). This failure placed Resident 64 at risk of continued use of medications without adequate indication for use, adequate monitoring, or performing gradual dose reductions, which can subsequently put the resident at risk for harm related to unnecessary psychotropic medication (any drug capable of affecting the mind, emotions, and behavior) use.