Health inspection·June 24, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an investigation, and results, related to abuse, neglect or mistreatment, when Resident 1, one of one sampled residents, was injured when she was dropped on the floor and her tooth was broken. For alleged violations of neglect or mistreatment that do not result in serious bodily injury the facility must report the allegation no later than 24 hours. The facility must provide in its report sufficient information to describe the alleged violation and indicate how residents are being protected. Within 5 working days of the incident, the facility must provide sufficient information to describe the results of the investigation and indicate any corrective actions taken. Any updates should be included. This failure showed no action was taken for the injury to the Residents tooth. Notice of violation was never made to the California Department of Public Health. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses including kidney disease, heart failure, diabetes, gait and mobility abnormalities, and glaucoma. Resident 1's Minimum Data Set, MDS, an assessment tool, indicated resident had no hearing difficulties, had cognitive impairment (thinking ability), required a two-person assist to move and reposition in bed, to transfer to chair/wheelchair and to dress. Resident 1 weighs 89 pounds, is 5 feet tall, [AGE] years old, and does not walk. During a telephone interview with the Assistant Director of Nurses (ADON) on 6/27/2024, at 12:33 PM, the ADON stated there was no incident report made for the residents injury resulting in the residents damaged tooth and the Department of Public Health was not notified of the fall and tooth injury. During a telephone interview on 7/11/2024, at 4:04 PM, son of Resident 1 stated in October, 2023 facility staff were transferring resident from wheelchair to bed during the day shift and they dropped her on the floor. She broke her tooth in the fall. The son stated he reported it to the facility. The resident did not see a dentist until 7/11/24, nine months after the fall, because the facility said she had no dental insurance and did not pay for her dental work. After a second visit to the dentist a root canal was required and performed after dental insurance was confirmed by the insurance company. A report by the facility to California Department of Public Health was never made for this incident. Review of the facility's policy on Unusual Occurrence Reporting, revised December, 2007, indicated, As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents . 1. Our facility will (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 6 Event ID: 056394 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 056394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Pavilion Healthcare 99 Escuela Drive Daly City, CA 94015 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)