Golden Merced Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of three sampled residents were safe from physical abuse when Resident 1 slapped the face of Resident 2 twice. This failure resulted in Resident 2 experiencing blood in the mouth, pain, redness to the face, and mental anguish evidenced by weeping. During a review of Resident 1's admission Record (AR), dated 5/20/26, the AR indicated Resident 1 was an [AGE] year-old female admitted to the facility with diagnoses that included Alzheimer's Disease and dementia (progressive diseases of the brain affecting memory, mood, and judgement). During a review of Resident 1's Minimum Data Sheet (MDS, a comprehensive, standardized assessment tool), dated 4/30/26, the MDS indicated at Question GG 0170-K, that Resident 1 was able to walk about the facility independently. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement adequate supervision, care planned interventions and Interdisciplinary Team's (IDT- a mandated group of healthcare professional including physicians, nurses, social workers, and therapists who collaborate to create and manage a comprehensive, individualized care plan for resident) recommended safety measures for 1 of 3 sampled residents (Resident [Res] 1) who was at high risk for falls. Resident 1 had four falls between 4/19/26 and 4/25/26, including an initial fall resulting in a right hip fracture (partial or complete break in a bone, often caused by high-force impact or stress) on 4/19/26, and two additional falls within four hours of readmission to the facility on 4/23/26 and another fall on 4/25/26. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe environment for one of four residents (Resident 3) when a Certified Nursing Assistant (CNA 2) failed to get the help and assistance of a second caregiver for a bed bath and linen change, as required by Resident 3's clinical documentation, and instead performed this activity without help. This failure resulted in Resident 3 falling from her bed to the floor, causing pain, anxiety, and a skin tear to her right wrist. During a review of the document titled SOC 341 dated, 3/30/26, the SOC 341 indicated that on 3/30/26, a charge nurse was called into [Resident 3's] room by CNA [2] at approximately 10 am related to a fall related to a bed bath. [Charge Nurse] assessed resident. Resident reported right arm skin tear on [top of] wrist. [Resident 3] was sent to the [Emergency Department] for further evaluation at 10:15 [a. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately identify and document all wounds present on readmission when the facility did not document the sacral wound identified in the hospital discharge summary and this wound was not reported to the wound care provider. This failure resulted in the resident's sacral wound not being identified, assessed, communicated, or treated following re-admission from the hospital. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a safe environment and adequate supervision to prevent elopement ( a person left a place without anyone knowing or without permission) for 1 of 3 sampled residents (Resident 1), when the Wander Guard alarm system failed to activate when Resident 1 exited through a secured door and staff were not immediately alerted to the resident's departure. This failure resulted in Resident 1 leaving the facility unsupervised, placing Resident 1 at risk for serious injury, harm or death due to potential environmental hazards, including vehicular traffic. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility was free from accidents or hazards when one of three sampled residents (Resident 1) eloped (exited the facility without supervision or staff knowledge) from the facility when staff did not respond to a security alarm timely. This failure had the potential for Resident 1 to become lost, disoriented, physically injured from a fall or traffic collision, when he was found approximately 350 feet away from the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) had elopement (when a resident leaves the facility, or a designated safe area within the facility, without proper authorization or supervision, which potentially endangers themselves) risk factors assessed when he was admitted to the facility. This failure resulted in Resident 1 eloping from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safety and security of the residents when 15 of 15 sliding glass doors (located in resident rooms that exited to the exterior of the building) were noted to be unsecured, with no system to alert staff if a person entered or exited the facility via these 15 doors. This failure resulted in one resident (Resident 1) eloping (the act of leaving facility premises, or enters an unsafe area, without facility knowledge and/or supervision) via one of the 15 unsecured sliding glass doors twice in one day, and after the second elopement was found by staff 0.6 miles from the facility in a confused state. This placed Resident 1 at significant risk for injury, including trauma from a traffic collision; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents' food preferences for food brought in from the outside were met by warming food up when the facility microwave was removed from the resident food storage area and staff was instructed, they could no longer warm up food for residents. This failure resulted in residents' frustration and denial of food preferences not being warmed to acceptable temperatures for palatability. This failure resulted in residents not having the ability to warm up their frozen foods which lead to frustration and denial of food preferences not being warmed to acceptable temperatures for palatability.

Inspectors wroteBased on interview, and record review the facility failed to develop and implement a baseline care plan (a document which specified goals, interventions, and monitoring strategies for patients) for three of nine sampled residents (Residents 221, 222, and 421) when: 1. Residents 221 and 222 did not have their baseline care plans completed within 48 hours of their admission to the facility This failure had the potential to cause Residents 221 and 222 to not have their respiratory care needs met 2. Resident 421 did not have his baseline care plan for a PICC (peripherally inserted central catheter- a thin, flexible tube that is inserted into a vein in the upper arm used to deliver medications directly into the heart) completed within 48 hours of his admission to the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement comprehensive care plans for four of 12 sampled residents (Resident 71 and Resident 72, Resident 47 and Resident 223) when: 1. Resident 71 had an incomplete care plan for anxiety medication, and no care plan for Sertraline (anti-depressant medication) and Olanzapine (antipsychotic medication that alters brain chemistry to help reduce symptoms of the mind where there has been some loss of contact with reality). 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to meet professional standards of quality for three of six sampled residents (Residents 4, 221, and 321) when 1. Resident 221's physician order for routine oxygen administration was not followed This failure had the potential to cause Resident 221 to experience negative health effects from lack of oxygen. 2. Resident 321 had an incorrect medication order for a Lidocaine Patch (medication that is used to relieve pain). This failure had the potential to result in incorrect placement of the Lidocaine Patch and the potential for the resident to experience ineffective pain control. 3. Resident 4's order for use of Pressure Reduction mattress for pressure redistribution was not being followed. This failure had the potential for Resident 4 to experience delayed healing of a wound, and to not receive necessary wound care.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly store medication in three of five medication carts and one of two medication storage rooms when: 1. South one medication cart contained: a. An unopened insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) pen intended for refrigeration storage for Resident 56, and b. No open dates were placed on medications for Resident 78, Resident 99, Resident 322, Resident 222, and Resident 72. 2. South two medication cart contained: a. Six insulin pens with no open dates for Resident 68, Resident 53, Resident 5, and Resident 17. b. Expired medication for Resident 66, c. Four eye drop bottles did not have an open date, and d. Three respiratory medications did not have an open date. 3. North one medication cart contained: a. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store and distribute food in accordance with professional standards for food service safety when: 1. The facility had a clear plastic bag of what appeared to be frozen chicken with no labels or closure device, stored in one of two freezers. 2. The chest freezer did not have a thermometer to monitor the internal freezer temperature. 3. The cook did not take the temperature of the tray of meat loaf or the tray of au gratin potatoes during the lunch tray line service. These failures had the potential to place residents in the facility at risk for food born illness.

Inspectors wrote4. During a review of Resident 371's AR, dated [DATE], the AR indicated, Resident 371 was admitted to the facility on [DATE] with diagnoses which included acute embolism and thrombosis of left lower extremity (a blood clot forming in a vein in the left leg, potentially blocking blood flow and leading to complications) and acquired absence of the left leg (surgical removal of the leg). During an observation on [DATE] at 4:20 p.m. in Resident 371's room, LVN 5 was changing resident 371's dressing. LVN 5 was not wearing a gown. LVN 5 stated Resident 371 had an amputated leg, and a wound had developed on it. LVN 5 stated Resident 371 was at risk for infection. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner that maintained dignity and respect for two of three sampled residents (Resident 25 and 47) when: 1. Resident 25's urinary catheter (flexible tube inserted into bladder to drain urine) bag was uncovered and visible to other residents and visitors. This failure had the potential to compromise Resident 25's dignity and privacy by exposing their foley catheter bag, leading to embarrassment or psychosocial harm. 2. A 20-minute time limit for morning Activities of Daily Living (ADL- tasks done on a daily basis to take care of your body, like bathing, brushing hair, brushing teeth, eating, and using the bathroom) care, for Resident 47, was implemented by using a timer, resulting in the resident feeling rushed and singled out. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement a significant change of condition for Resident 42 when the resident was admitted to the facility on [DATE], was unable to make her needs known and be her own responsible party (RP- health care decision maker) Resident experienced a major improvement in mentation on 3/3/25 and no significant change of condition was completed. This failure had the potential to result in a lack of further improvement for Resident 72 when there were no updates in plan of care to reflect the change in mentation.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer parenteral fluids (Parenteral fluids administered by injection through the tissue and circulatory system) in accordance with professional standards of practice for two of three sampled residents (Resident 421 and 422), when: 1. Resident 421 was admitted to the facility on [DATE] with a peripherally inserted central catheter (PICC, tube that is inserted into a vein in the upper arm to the heart) for the purposes of administering intravenous (IV - through the vein) antibiotics (medicines that fight bacterial infections). The facility did not have an approved policy and procedure that followed the standards of practice to instruct and guide nurses on the care of the PICC line. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an unknown number of residents' collective right to privacy was respected when Resident 3 frequently took photographs, with her smartphone, of an unknown number of residents without their consent. This failure resulted in an unknown number of residents having their privacy violated when Resident 1 frequently took their photographs without their consent.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 3) had a care plan intervention in place by not placing a non-skid mat on the seat of her wheelchair, in an effort to reduce her frequent falls. This failure had the potential to result in an increased risk for falls for Resident 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement physical interventions to reduce hazards and risks identified in their fall prevention program for 2 of 3 sampled residents (Resident 1 and Resident 2), and failed to ensure three of three sampled staff could not describe other key interventions of the fall prevention program when: 1. Resident 1 did not have non-skid socks (socks that have grips to prevent slipping when standing and walking) that were ordered by her physician as a fall prevention intervention. 2. Resident 2 had one transfer bar (bed rails attached to bed to aid resident when getting in and out of bed) attached to her bed when two transfer bars were ordered by her physician as a fall prevention intervention. 3. Three of three staff could not define what the 4 P's (1. Pain [address pain management] 2. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure 1 (Resident #84) of 2 resident's food choices were provided per the resident's request. Specifically, the facility failed to honor Resident #84's preference for fried or poached eggs with their breakfast.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure the designated interdisciplinary team member obtained the hospice plan of care specific to 1 (Resident #27) of 2 sampled residents reviewed for hospice services.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were treated with respect and dignity for one of five sampled residents (Resident 1), when two Certified Nursing Assistants (CNA 3 and 4) did not stop providing care to the resident when the resident said to stop. This failure violated Resident 1 ' s right to be treated with respect and dignity and posed the risk to negatively impact Resident 1 ' s self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection and control practices to ensure a provision of a safe and sanitary environment for 103 out of 103 residents when: 1. One of two shower rooms had mold on the shower curtain. 2. Monitoring and tracking of deep cleaning for 52 of 52 resident rooms were not done as per policy. These failures had the potential to result in the development and transmission of communicable diseases, illness, and infections.

Inspectors wroteBased on interview and record review the facility failed to provide adequate supervision (observation, oversight, and guidance of the individual by staff close enough to intervene and protect from harm) to prevent accidents for one of three sampled residents (Resident 1), when the facility failed to develop effective interventions for falls which occurred on 7/1/23, 7/4/23 and 7/8/23. These failures resulted in Resident 1 experiencing another fall on 7/8/23 with injuries of an Intracerebral Hemorrhage (bleeding inside the brain), right zygomatic (bones on upper side of the face that forms the cheek and part of the eye socket) fracture and right clavicle (collarbone) fracture along with pain and hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 22 sampled residents (Resident 76) were free from accidents and injury when Certified Nursing Assistant (CNA) 1 and CNA 6 used a mechanical lift sling (a hammock like cloth device used to hold the resident during transfer with a mechanical lift) past its manufactured recommended safe used by date of six months. The sling ripped during transfer and Resident 76 fell from the mechanical lift onto the floor and sustained a fracture (broken bone) of the right foot fifth toe. As a result of this failure, Resident 76 suffered a broken bone to the right foot fifth toe and was afraid to get out of bed in case of another fall.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility assessment addressed the federal expectation to develop a water management program for the risk reduction of Legionella (a water borne bacteria which can cause life threatening pneumonia) and other water-borne pathogens (germs that cause disease) in accordance with CMS letter revision date 7/6/18. This failure resulted in the increased risk of not being prepared to address the risk of infections to residents for Legionella and/or other water-borne pathogens.

Inspectors wroteBased on interview and record review, the facility failed to establish and implement a comprehensive antibiotic (ATB) stewardship (program designed to reduce unnecessary use of antibiotics and to limit the spread of antibiotic resistance in bacteria) and surveillance program to identify, track, and monitor resident antibiotic use when: 1. The Director of Staff Development (DSD) did not accurately monitor the use of antibiotic of resident infections on the monthly line listing surveillance logs for eight of eight sampled residents (Resident 74, Resident 92, Resident 79, Resident 6, Resident 34, Resident 91, Resident 48 and Resident 46). 2. The facility did not have documented monthly line listing surveillance logs for seven of 12 sampled months (June 2018, July 2018, August 2018, September 2018, October 2018, November 2018 and December 2018). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure to store, prepare and serve food safely when: 1. An undated opened box of brown sugar, open bottle of ground spice pimiento, opened box of kosher salt were stored and ready for use in the condiments shelves in the kitchen. 2. An undated zip lock bag with 10 pieces of cooked pancake were stored and ready for use in the freezer 1 in the kitchen. 3. An undated and/or no use by date open boxes containing chicken, salami, pork [NAME] were stored and ready for use in freezer 2 in the kitchen. 4. Undated nutritional shakes were stored and ready for use in the kitchen walk in refrigerator and in the north nurse's station refrigerator. These failures to ensure effective dietetic service operations placed residents that received meal form the kitchen at risk for food borne illness and the growth of microorganisms.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services which met professional standards of quality when Licensed Nurse (LN) 1 administered a blood pressure (pressure of the blood with in the arteries and produced primarily by the contraction of the heart muscles) medication to Resident 37 without first checking Resident 37s heart rate and not following physicians order for one of two sampled residents. This failure had the potential risk for Resident 37 to receive medication with a possible side effect of a low heart rate.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled Certified Nursing Assistants (CNA) 2 received appropriate competencies and skills set training when CNA 2 had not received competency training on orientation in order to provide safe use of the mechanical lift (a device used to transfer non ambulatory residents) and sling (a hammock like cloth device used to hold the resident during transfer with a mechanical lift) on residents. This failure had the potential to place residents requiring the use of the mechanical lift for transfers at risk for falls and injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective infection prevention and control program when: 1. Registered Nurse (RN) 1 did not follow the facility policy and procedure titled Instillation of Eye Drops and administered eye drops without wearing gloves during the eye drop medication administration. 2. One whisk (wire kitchen utensil) was stored with the clean utensils on the cart in the kitchen. These failures had the potential for spread of infection and cause foodborne illness to residents.