Golden Empire

Based 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.Findings: During a concurrent observation and interview on 8/19/25 at 10:45 a.m. with Dietary Supervisor 1 (DS 1), flies were observed in the kitchen. Flies were observed flying around and landing on kitchen counters, food processors, cooking utensils, dishes, and food. DS 1 confirmed the presence of flies in the kitchen and stated it posed a risk for food contamination.During a concurrent observation and interview on 8/19/25 at 11:55 a.m. with the Maintenance Supervisor (MS), MS confirmed the flies problem in the kitchen. MS stated the last pest control was conducted on 8/8/25 and agreed the issues were not resolved.During an interview on 8/19/25 at 3:40 p.m. with the Registered Dietitian (RD), the RD confirmed an infestation of flies in the kitchen.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.During a review of Resident 26's clinical record, the record indicated Resident 26 was admitted in November of 2024, with a diagnosis of dementia. A review of Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). A review of Resident 129's physician order revised 2/28/25 indicated, Terminal care via [name of hospice program] with prognosis of 6 month [sic] or less…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings A review of Resident 116’s medical record indicated Resident 116 was admitted to the facility in June of 2025 with diagnoses of Infection and Inflammatory reaction due to Internal Right Knee Prosthesis (a surgical procedure to implant an artificial body part) and Type Two Diabetes (a chronic disease where the body doesn’t produce enough insulin to maintain normal blood sugar levels). Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings:A review of Resident 47's admission Record indicated the facility admitted Resident 47 to the facility in 2022. Resident 47's diagnoses included type I diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control) with diabetic ketoacidosis (DKA, a life-threatening complication of DM when the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings:A review of the admission Record indicated the facility admitted Resident 122 in the spring of 2025 with multiple diagnoses which included chronic pain and depression. A review of the Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 4/14/25 indicated Resident 122 was cognitively intact and had no hallucinations or delusions. Resident 122's Pain Interview assessment dated [DATE] indicated the resident experienced pain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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.Findings:During an inspection of the Station 2 Medication Storage Room on 8/20/25 at 4:13 p.m. with Licensed Nurse 10 (LN 10), the E-Kit containing insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) was observed inside the medication refrigerator with a red tag (indicating the E-Kit had been opened by the facility). The E-Kit logs inside indicated one vial of Humalog (insulin lispro, a fast-acting insulin) 100units/mL (milliliters, a unit of measurement) was removed on 8/7/25, and one vial Lantus (insulin glargine, a long-acting insulin) 100units/ml was removed on 8/14/25. LN 10 confirmed that the E-kit was opened on 8/14/25 and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings:A review of 'Inpatient Service Agreement' between the [name of the hospice agency] and facility, dated 11/16/2023 indicated the hospice and the facility will communicate with each other and document such communications to ensure that the needs of the patients are addressed and met 24 hours a day. The agreement policy indicated, The Hospice is providing the facility with a copy of the patient's plan of care [POC]. at the time of the patient's admission or as soon.as possible, and.specify the inpatient services to be furnished.The Hospice . patient's clinical record includes a record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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.During a concurrent interview and record review with the Administrator (ADM) and Director of Nursing (DON) on 8/22/25 at 2:10 p.m., the ADM stated that from January to May 2025 the facility held QAPI meetings monthly when they reviewed quality reports, identified the concerns with residents' care, discussed quality safety concerns, and ensured corrective actions were implemented. The ADM stated that the Medical Director (MD), who have been in the facility since…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.During a review of the facility policy and procedure titled, Wandering/Elopement, dated 4/17/24, indicated, It is the policy of this facility to protect residents from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings: A review of a facility policed titled, Unusual Occurrences, with a reviewed date of 4/17/2025, indicated, Unusual occurrences shall be reported to the Department of Health Services and/or the local Health officer. The administrator/designee shall report the following unusual occurrences to the Department of Health Services according to accepted National Standards. A review of a facility policy titled, Infection Prevention and Control Program, with a revision date of 12/2023, indicated, Outbreak management is a process that consists of . reporting the information to appropriate public health authorities . A review of a facility policy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings: A review of a facility policy titled, Unusual Occurrences, with a reviewed date of 4/1/2024, indicated Administrator/designee shall report the following unusual occurrences within 8-24 hours to the Department of Health Services . Epidemic outbreaks of any disease, prevalence of communicable disease (an infection that can be transmitted from one person to another). During an interview on 3/11/2025 at 2:27 PM with IP, stated the fact that the outbreak occurred on a weekend was the problem since she does not work weekends and did not know she needed to report it. IP stated, I did miss a weekend, but I didn ' t report it in 24 hours. I am now aware I should '…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: A review of the facility's policy titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property; Prevention Of reviewed 4/17/24, indicated, D. Complaints, observations, suspicions, or reporting of incidents, falls, bruises and skin tears (of suspicious or unknown origin) will be investigated to rule out abuse. Occurrences, patterns, and trends will be assessed by administrative staff, licensed staff, and the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: A review of the facility's policy titled, Wound Care (Other than Pressure Ulcers) dated 4/17/24, indicated, If a skin condition is identified, i.e. skin tear, bruise, laceration, abrasion, etc. the licensed nurse will: implement or update a care plan. 1. During a review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: During a record review of facility policy titled, Wound Care (Other than Pressure Ulcers) 4/17/24, indicated The licensed nurse will track effectiveness of treatments and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings: A review of AFL 23-08 (All Facilities Letter (AFL), information regarding updated rules, provided to facilities, from CDPH), dated 1/18/23, indicated, the purpose of the AFL reminded facilities of the requirement to report outbreaks (more cases of a disease or infection than expected) to CDPH along with the local public health officer (public health, a resource to the community, that assisted facilities during an outbreak of disease or infection). A review of the undated policy titled, Outbreak Reporting, indicated, the facility would Report all suspected and confirmed outbreaks . to CDPH and the local public health…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: A review of the facility ' s policy and procedure (P&P) titled, Care of Residents with Dementia and Care of Residents with Dementia Receiving an Antipsychotic Medication, revised 12/29/23, indicated, antipsychotic medications would be closely monitored for effectiveness. A review of Resident 2 ' s undated Admissions Record, indicated, Resident 2 was admitted to the facility on [DATE] with the diagnosis of dementia (memory loss) and severe major depressive disorder (a sad mood) with psychotic features (symptoms that affected the mind…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. These failures had the potential to spread germs which could have caused illness and threatened the residents' health and well-being. Findings: A review was made of a facility policy titled, Hand Hygiene & Donning Gloves, revised 2/13/19,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings: 1. During a review of facility's policy titled, Labeling and Dating of Foods, dated 2023, indicated all food items in the storeroom, refrigerator, and freezer need to be labeled and dated. Newly opened food items will need to be closed and labeled with an open date and use by date that follows the various storage guidelines. All prepared foods need to be covered, labeled, and dated. Leftovers will be covered, labeled, and dated. During the initial tour of the facility kitchen on 11/28/2023 at 9:15 am, with Registered Dietician (RD) and Food Service Supervisor (FSS), the following food items were observed not labeled or dated: a. A metal pan on the bottom shelf with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings: During a concurrent interview and record review on 11/30/23 at 9:16 AM, with the Director of Nursing (DON), staffing sheets were hanging on a bulletin board in the hallway near the lobby. The sheets were titled, [Facility Name] Direct Care Staff, with a line below the title for the date. A table was divided into three sections, one each for the day shift, evening shift, and night shift. Four columns were titled, Registered Nurses (RNs); Licensed Vocational Nurses (LVNs); Unlicensed Nursing Staff; and Other Direct Care Staff, with the numerical information written in by hand for each shift. Beneath the table was the Resident Census number. When asked if those were the NHPPD sheets, DON thought they were, but was not sure. During an interview on 11/30/23 at 12:10 PM, the Staffing Coordinator…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.