Health inspection·February 13, 2024

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure professional standards of care were met for Resident 1, when neurological checks (neuro checks, assessment of nerve and motor responses to determine if the nervous system is impaired) and 72-hour alert charting (documentation of assessments and observations) were not completed after Resident 1 sustained a fall in the facility. Residents Affected - Few These failures increased the risk of unrecognized injuries for Resident 1, and could result in a delay in treatment for an injury. Findings: A review of Resident 1 ' s admission RECORD, indicated she was admitted to the facility in 2022 with diagnoses which included dementia (condition characterized by memory disorders, personality changes and impaired reasoning), muscle weakness, and difficulty in walking. A review of Resident 1 ' s clinical record, Progress Notes dated 1/31/24, at 8:30 PM, indicated, .writer was called to room, saw [Resident 1] sitting on the floor next to wheelchair by restroom. Stated she was coming from restroom and fell on floor .stated she was not hurt. Writer and aide assisted resident on her feet was able to move all extremities and walk back to bed .Will continue to monitor and do neuro checks . A review of Resident 1 ' s care plan initiated 2/1/2024, indicated, .had an actual fall on 1/31/24 with no injury r/t [related to] Poor Balance .Interventions .Monitor/document/report PRN [as needed] x 72 h [times 72 hours] to MD [medical doctor] for s/sx [signs and symptoms]: Pain, bruises, Change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation .Neuro checks x 72 hours . A review of Resident 1 ' s clinical document titled, NEUROLGICAL OBSERVATION, dated 1/31/24 through 2/2/24, indicated, neurological checks were to be assessed every 15 minutes for 1 hour, every half hour for 2 hours, every hour for 4 hours, every 4 hours for 16 hours, then every 8 hours for 24 hours, starting at 8:30 PM on 1/31/24. The document indicated; On 1/31/24 at 10:45 PM, 11:15 PM and 2/1/24 at 12:15 AM, .Paper not available . On 2/1/24 at 7:30 PM, the form was blank in the sections titled PUPILS and HAND GRIPS. On 2/1/24 at 11:30 PM, and 2/2/24 at 3:30 AM, the form was blank in the sections titled, LOC [level (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 056132 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden San Andreas Care Center 900 Mountain Ranch Road San Andreas, CA 95249 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)