Golden Hill Post Acute

Inspectors wroteBased on observation and interviews, the facility failed to ensure resident rights were treated with respect and dignity for one of two resident 's (Resident 1) when the facility staff searched Resident 1's personal belongings without her permission. As a result, Resident 1 was observed anxious and stated she felt disrespected. On 4/20/26 at 9:15 A.M., an onsite investigation was conducted to investigate a Facility Reported Incident (FRI) reporting Resident 1 was involved in a MVA when her SO was driving the vehicle on 3/28/26. A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with aphasia (difficulty with speaking caused by brain damage) and right-sided weakness caused by a stroke. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a care plan for one of three residents (Resident 1) to ensure the safety of Resident 1 was maintained while Out On Pass (OOP) due to a previous motor vehicle accident (MVA) which occurred while OOP. The lack of care plan development posed a potential risk for Resident 1 and the resident's significant other (SO) to have a repeat MVA situation to occur. On [DATE] at 9:15 A.M., an onsite investigation was conducted to investigate a Facility Reported Incident (FRI) reporting Resident 1 was involved in a MVA when her SO was driving the vehicle on [DATE]. A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with aphasia (difficulty with speaking caused by brain damage) and right-sided weakness caused by a stroke. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement new, effective fall preventative measures after each fall incident for two of five residents reviewed for falls (Residents 1 and 2). These failures resulted in Resident 1 falling 13 times, sustaining two broken bones in her face and a broken rib.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care plans for fall prevention were revised and updated with specific resident-centered interventions for two of five residents reviewed for falls (Residents 1 and 2). This failure had the potential to result in additional falls, and an increased risk for injuriesFindings: 1. A review of Resident 1's undated Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included dementia (a loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life) and Parkinson's Disease (a movement disorder of the nervous system that worsens over time). A review of Resident 1's Brief Interview for Mental Status (BIMS, an assessment tool) dated 7/23/25, indicated a score of 0, or severely impaired cognition. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure call lights were answered in a timely manner for three of three residents (Residents 2, 3 and 4) who filed complaints with the California Department of Public Health (CDPH, an agency responsible for regulatory compliance of healthcare facilities). This failure had the potential to negatively affect the overall health and mental wellbeing of the residents.

Inspectors wroteBased on interview and record review, the facility failed to administer medications as ordered by the physician for one of three residents reviewed for medication administration (Resident 4) when:Resident 4 did not receive nine of the 14 medications within 24 hours of her admission; and,Resident 4 received a medication two times when it was scheduled five times over her admission to the facility. This failure had the potential to affect the health and well-being of Resident 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmacy services in accordance with accepted standards of practice when:1. A medication was not in stock for one of five sampled residents (Resident 5) when it was due. This failure had the potential for Resident 5 not to benefit from the full therapeutic effect of her medication. 2. Random controlled medication (medications with a high abuse potential) use audit for four out of eight sampled residents (Residents 6, 9, 37, 73) did not reconcile. The residents' medications were signed out of the controlled drug record (CDR, count sheet), but not documented on the Medication Administration Record (MAR) to indicate they were administered to the residents. This failure resulted in inaccurate accountability and had the potential for abuse and diversion (unlawful distribution or use) of controlled medications. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dignity and respect was provided for one of three sampled residents (73) during lunchtime, when a staff was standing over, while assisting and feeding the resident. This failure had the potential to affect the resident's self-esteem and resident's safety.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a baseline care plan (detailed plan with information about a patient's treatment, goal, and interventions) within 48 hours for three of 16 residents reviewed for baseline care plan related to:1. Resident 10's urinary catheter use.2. Resident 72's pain management.3. Resident 81's oxygen use. This deficient practice placed newly admitted residents with urinary catheters at risk for developing an infection, residents with pain to have unmanaged pain and residents with oxygen to be at risk for low or high oxygen level. Cross Reference to F 697 and F 695.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure comprehensive resident-centered care plans were revised and implemented for two of 16 sampled residents (Resident 20 and 40) when: 1. Resident 20 had an altercation with his roommate and the care plan was not revised.2. Resident 40's activities care plan was not implemented. These failures had the potential to affect resident's care needs. Cross Reference F 679.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide medication therapy in accordance with professional standards of practice for one of five sampled residents (Resident 58) when Licensed Nurse (LN) 11 did not flush (push water through) Resident 58's gastrostomy tube (G-tube, a device used to administer food and medications to individuals with difficulty swallowing) before and in between medication administration. This failure had the potential for Resident 58 not to get the full therapeutic benefit of her medications or to experience complications from her medications clogging in her G-tube. A review of Resident 58's clinical records indicated she was admitted to the facility on [DATE], with diagnoses that included, encounter for attention to gastrostomy. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide routine nail care to one of three residents (Resident 48), reviewed for Activities of Daily Living (ADL, activities related to personal care) for dependent residents. As a result, Resident 48 was at risk for skin injury and infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide individualized therapeutic and/or social activities according to their plan of care for one of one reviewed resident (Resident 40) that promotes their highest physical, mental, and psychosocial well-being. This deficient practice placed Resident 40 at risk for decreased emotional well-being, social isolation, and reduced quality of life due to the lack of meaningful engagement. Cross Reference F 656.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a tube feeding formula was labeled for one of one resident (58) reviewed for Parenteral Nutrition. This failure had the potential to affect Resident 58's health conditions and decline.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and treatment consistently for a Midline catheter (a thin, flexible tube inserted into a vein in the upper arm) for one of one resident (Resident 23) reviewed for Intravenous therapy. This failure had the potential to cause infection and affect Resident 23's health.

Inspectors wroteBased on observation, interview and record review , the facility failed to ensure an oxygen tubing was dated on 2 out of 2 residents (Resident 81,Resident 25) reviewed for Oxygen needs. This failure had the potential to affect Resident 81's and Resident 25's respiratory health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and manage pain for one of two residents investigated for pain management (Resident 72). As a result, the deficient practice had the potential for unmanaged pain. Cross Reference F 655.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of five residents (Resident 72) was free from unnecessary medications when blood pressure (BP) and heart rate (HR) hold parameters were not followed with the administration of medications. This failure had the potential for Resident 72 to experience low BP and low HR.A review of Resident 72's clinical record indicated she had an active order for atenolol 50 milligram (mg, unit of measure) tablet, give one and half tablet by mouth two times a day (at 9 a.m. and 5 p.m.) for hypertension (HTN, high blood pressure). Hold if HR less than 60, originally dated 6/28/25. Resident 72 received doses, as documented on her July 2025 and August 2025 Medication Administration Record (MAR), despite a HR less than 60 on the following dates:7/6/25 HR 53 the 9 a.m. dose was administered7/13/25 HR 57 the 9 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 10% when three medication errors occurred out of 30 opportunities during the medication administration observation for two out of five residents (Residents 5 and 58). This failure resulted in Residents 5 and 58 not receiving medications as ordered and had the potential for both residents not to get the full therapeutic benefit of their medications. This failure also had the potential for Resident 58 to experience complications from her medications clogging in her gastrostomy tube (G-tube, a device used to administer food and medications to individuals with difficulty swallowing). 1. During the medication administration observation on 8/25/25 at 8:45 a.m., Licensed Nurse (LN) 11 was observed preparing and administering a total of 10 medications for Resident 58. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure safe and sanitary measures were met in the kitchen during dietary operations according to standards of practice when food items were free from contaminants. This finding had the potential to expose the facility's residents to unsafe and unsanitary food practices that could lead to widespread foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare and distribute food in a sanitary manner when: 1. Foods were not labeled and dated in the walk-in cooler, 2. A juice dispenser was not sanitized, 3. A damaged spatula was used during food preparation, 4. Racks with compromised surfaces were used for holding sanitized dishes, and, 5. Coffee mugs and bowls appeared to have a white residue on the inside surface. These failures may result in risk for foodborne illness, as well as bacterial, chemical and foreign object contamination to the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Physicians Orders for Life Sustaining Treatment (POLST, a form which outlines a person's choices for end of life care, or Advanced Directive) form was accurate and matched the facility's code status (the level of medical interventions a person wishes to have if their heart or breathing stops), for one of one residents (27) reviewed for Advance Directives. This failure had the potential for Resident 27 to receive the incorrect care in the event of an emergency.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure a care plan was developed related to catheter (tubing connected to the bladder) care for two of five residents (76, 12) reviewed for catheter care, and, 2. Ensure a care plan for fall precautions was implemented for one of three residents (49) reviewed for falls. As a result, the residents (76, 12) were at risk of developing urinary infections, and Resident 49 was at risk for injury from falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently provide hygiene for three of five residents (29, 76, and 12) reviewed for catheter (tube inserted into the bladder) care. This failure had the potential to increase the risk of infection for residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a recipe was followed for a pureed food. This failure had the potential to affect the nutritional value of the food prepared, and further compromise the health of residents receiving the pureed food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nursing interventions to monitor one of 20 (30) sampled residents. This failure had the potential to place Resident 30 at risk for dehydration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a care plan was revised/updated to reflect the current status of two of 20 residents (70, 7) reviewed for care plans when: 1. Resident 70's care plan was not updated to reflect his current wound dressing change procedure which resulted in miscommunication amongst care givers and delay in treatment and, 2. Resident 7's care plan was not revised to reflect discharge plans or goals which had the potential to result in a delayed discharge.

Inspectors wroteBased on interview and record review, the facility failed to document discharge planning for one of two residents reviewed for discharge (7). This failure had the potential for Resident 7 to not receive the appropriate discharge plan.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide out of bed assistance for one of three residents reviewed for ADLs (30). This failure had the potential to result in Resident 30 to experience a further decline in ADLs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for two of 20 residents (30, 66) reviewed for quality of care when: 1a. A physician's order was not followed for Resident 30's enteral feeds (also known as tube feeding, a device used to provide nutrition to those who are unable to swallow safely), 1b. An order was not obtained for Resident 30 before a dressing change and, 2. A physician's order was not followed for Resident 66 who required assistance with meals. These failures had the potential to result in Resident 66 and Resident 30's physical needs not being met.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that range of motion treatments provided by Restorative Nursing Assistants (RNA) was provided for two of four residents (55,16) reviewed for contractures (hardening of muscle and tissues leading to rigidity of joints). This failure had the potential for residents to experience further decrease in range of motion.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure effective pain management for one of one residents reviewed for pain (70). This failure had the potential for Resident 70 to have unrelieved pain.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate food portions were served to residents. This failure had the potential for residents to not have their nutritional and special dietary needs met.

Inspectors wroteBased on interview and record review, the facility failed to have complete accurate medical records for two of 20 residents reviewed for documentation (22, 77) when: 1. Documentation was not completed regarding a lab result for Resident 22. 2. Documentation for a vaccine was not completed for Resident 77. These failures had the potential to result in Resident 22 and Resident 77 to not receive the appropriate treatment or care. 1. Resident 22 was admitted to the facility on [DATE] per the facility's admission Record.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention practices were followed for three of 22 residents (40, 70, CR 1) when: 1a. The DSD failed to wash hands before performing wound care for one resident (40), in between glove changes while performing wound care for two residents (40, 70) and after performing wound care for one resident (70) and, 1b. One staff member did not wash his hands after providing peri-care (cleaning of private areas) to CR 1. 2. In addition, two staff members did not follow the facility's dress code/infection control regarding fingernails. These failures had the potential to cause the spread of infection to residents, staff and visitors.