Health inspection·July 1, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few normal, typically below 60 beats per minute in adults) or everything could have dropped. LN stated the normal range for a PR would be 60 to 100 bpm. LN 3 further stated if a resident had a PR reading of 46, she would do a full set of VS and would have assessed and monitored the resident to check for any changes. LN 3 stated at that point, she would have rechecked VS every 15 minutes and would have notified the MD and potentially could have sent the resident out to the hospital if they had gotten worse. LN 3 further stated if a resident had a PR reading of 46, she would have initiated alert charting and would have endorsed it to the next shift. LN 3 stated it was important to start the alert charting for a change of condition for abnormal VS readings because it was not the resident's baseline and needed to be communicated to the MD for their suggestions. LN 3 further stated that the residents at the facility are elderly, and their condition could have changed quickly so it would have been important to have reported to the physician right away for abnormal VS readings.During a concurrent interview and record review on 7/1/25, at 1:32 p.m., with LN 1, Resident 1's PR readings on 3/19/25 were reviewed. LN 1 confirmed Resident 1 had three PR readings of 46 entered at 8:30 a.m., 8:32 a.m., and 5:08 p.m. LN 1 stated the first two PR readings on 3/19/25 were taken in the morning shift and the third was taken for evening shift. LN 1 further stated that by looking at Resident 1's overall PR readings, the PR ranged from 60 to 90, and that a PR reading of 46 was low. LN 1 stated if she was the nurse who got the PR reading of 46, she would have monitored Resident 1 and rechecked the PR to have been sure. LN 1 further stated the nurse should have assessed Resident 1 for symptoms and should have notified the MD. LN 1 stated it was important to have checked Resident 1's vitals to have seen if there was a potential change in resident's condition, so the resident needed to be monitored.During a concurrent interview and record review on 7/1/25, at 2:14 p.m., with LN 2, Resident 1's EHR (electronic health record) was reviewed. LN 2 confirmed the PR readings of 46 on 3/19/25 were low and stated she was the LN who entered those PR readings on Resident 1's EHR. LN 2 stated she got Resident 1's vitals from the CNA's vitals on 3/19/25 and was entered in Resident 1's chart. LN 2 further stated she did not recall if she had reported the low PR to the MD or if she questioned the CNA about the low PR readings. LN 2 stated she did not recall if Resident 1 had symptoms or issues on 3/19/25. LN 2 reviewed Resident 1's EHR and confirmed no notes were found for endorsing low PR to the next shift or reporting to the MD.During a concurrent interview and record review on 7/1/25, at 5:09 p.m., with the Director of Nursing (DON), Resident 1's EHR was reviewed. The DON stated the CNA staff were primarily taking vitals for the residents. The DON further stated it was expected for the CNA to have reported abnormal vital signs to the LN and the LN to have reviewed the resident's vitals. The DON confirmed the three 46 PR readings on 3/19/25 were all the same and stated it was her expectation for the LN to have rechecked these PR readings. The DON stated it was important to check resident's vitals so the staff could follow the physician's orders for medication administration and to follow the correct MD order.2. A review of Resident 2's admission RECORD, indicated Resident 2 was admitted to the facility in 2018 with diagnoses that included generalized muscle weakness, rheumatoid arthritis (a chronic autoimmune disease that causes inflammation and damage to the joints), subluxation of the left knee (a partial or incomplete dislocation of the kneecap) and lumbosacral scoliosis (lower part of the spine is curved sideways).A review of Resident 2's progress notes for alert charting following Resident 2's fall on 3/1/25 indicated no noted injuries from the fall incident.A review of Resident 2's physician orders indicated Resident 2 had an order dated 3/5/25 for left knee x-ray due to fall.A review of Resident 2's left knee x-ray result, dated 3/5/25, via fax received on 3/6/25 at 3:55 a.m., indicated, .IMPRESSION: Arthroplasty [surgical replacement of a joint] is seen however the prostheses [artificial joint] appear to be dislocated at the knee joint . with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056132 If continuation sheet Page 2 of 3 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 07/01/2025 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete handwritten noted with staff initials and dated 3/5/25.During an interview on 7/3/25, at 9:06 p.m., with LN 3, LN 3 stated she was the LN who completed the change of condition when Resident 2 had an unwitnessed fall on 3/1/25. LN 3 further stated she did not recall if Resident 2 had any injuries when she had the fall on 3/1/25. LN 3 stated she did not recall Resident 2 complaining of knee pain when she had the fall and was just complaining of her usual hip or leg pain which was routine for Resident 2. LN 3 further stated she was not aware that Resident 2 had a left knee x-ray ordered on 3/5/25 and of the result. LN 3 stated if the x-ray result was abnormal, the LN would call the MD and then fax the result. LN 3 further stated if the MD or the physician assistant could not be reached then the x-ray result would be faxed over. LN 3 stated once an x-ray result was faxed over to the physician, the staff would use a stamp to note that it was sent and then would be sent to medical records and the LN would also add a progress note in the resident's chart to document the call and fax to the MD. LN 3 further stated it was important to report any test result to the MD because the MD would dictate or determine the plan of care for the resident. LN 3 stated the risk of not reporting x-ray results to the MD including the potential to worsen or if there was a fracture it could impact the resident's care and reduce the resident's quality of life.During a concurrent interview and record review on 7/3/25, at 1:18 p.m., with LN 4, Resident 2's medical record was reviewed. LN 4 stated she was the one who obtained the physician's order for Resident 2's left knee x-ray because Resident 2 was complaining of left knee pain on 3/5/25. LN 4 confirmed there were no progress notes indicating the MD was notified about the left knee x-ray results. LN 4 stated it was important to report diagnostic results to the MD because they oversaw Resident 2's care. LN 4 further stated if x-ray results were not reported to the MD, it could potentially put Resident 2's health at stake or her condition could get worse.During a concurrent interview and record review on 7/1/25, at 3:50 p.m., with UM 2, Resident 2's medical record was reviewed. UM 2 stated the expectation was for the LN to have noted the result and faxed to the MD if there were no abnormalities. UM 2 further stated if there were abnormalities in the x-ray then the LN should have called the MD to have reported the result. UM 2 confirmed that Resident 2's left knee x-ray result dated 3/5/25 should have been reported to the MD and faxed over. UM 2 further confirmed Resident 2's left knee x-ray result did not indicate that it was faxed over and there were no notes found indicating it was sent to the MD. UM 2 confirmed Resident 2 was seen by the MD on 3/7/25 at the facility and there was no note that the left knee x-ray result was reviewed. UM 2 stated the LN should have contacted the MD and documented if the result was relayed to the MD.During a concurrent interview and record review on 7/1/25, at 5:09 p.m., with the DON, Resident 2's medical record was reviewed. The DON stated that her expectation was that the MD would have already reviewed the diagnostic result if the LN already noted that the result was received. The DON reviewed Resident 2's left knee x-ray dated 3/5/25 and confirmed it was received by the LN based on the date and initials on it. The DON stated that usually a result report with a similar note would have meant that the LN would have reported it to the MD. The DON further stated the importance of reporting any normal or abnormal diagnostic results to the MD was for the MD to prescribe treatment if needed. Event ID: Facility ID: 056132 If continuation sheet Page 3 of 3