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 Page 1 of 6 056394 056394 06/24/2024 Golden Pavilion Healthcare 99 Escuela Drive Daly City, CA 94015

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few report the following events to appropriate agencies . g. Allegations of abuse, neglect . 2. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within (2) hours of such incident or as otherwise required by federal and state regulations. 3. A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within (48) hours of reporting the event or as required by federal and state regulations . 056394 Page 2 of 6 056394 06/24/2024 Golden Pavilion Healthcare 99 Escuela Drive Daly City, CA 94015

F 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Resident 1, one of one sampled resident, was assisted to obtain or was reimbursed for eyeglasses after staff lost three pairs of residents prescription eyeglasses. Resident has glaucoma and vision difficulties. Residents Affected - Few This failure resulted in creating depression and additional visual difficulties for the resident. 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 an interview on 7/11/2024, at 4:04 PM, resident 1's son stated the facility has lost the residents eyeglasses, at least, three times. Resident's son stated he has reported the loss of each of the eyeglasses to the facility and the social worker. Resident's son stated he filled out a report on 5/18/2024 the facility lost the last pair of eyeglasses. He states his mother is depressed over the loss of the last pair of eyeglasses. The facility has not replaced or reimbursed the resident for any of the eyeglasses. Review of Resident 1's Inventory of Personal Effects dated 9/30/2021 and 10/4/2021 indicated one pair of eyewear, Brown/Bronze, and one pair of Gold-colored eyeglasses were in her personal effects. The form was signed by the resident and resident's son. Review of facility Theft and Lost Report dated 6/14/2024 indicated, Prescription Glasses, lost. Were items noted on Inventory List: YES. Were items marked: YES. Resident will be referred to optometry/ophthalmology for review of new prescription. Residents son gave a copy of prescription. Signed by Social Services, and Director of Nursing. Review of the facility policy on Lost and Found, revised January, 2008, indicated, Our facility shall assist all personnel and residents in safe guarding their personal property .8. Reports of misappropriation or mistreatment of resident property are immediately investigated. The facility did not assist or refer the resident to optometry/ophthalmology to obtain appointment for new prescription eyeglasses. No investigation of lost prescription eyeglasses was made. 056394 Page 3 of 6 056394 06/24/2024 Golden Pavilion Healthcare 99 Escuela Drive Daly City, CA 94015

F 0687 Provide appropriate foot care. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure foot care (podiatrist service) was provided to Resident 1, one of one sampled resident, when she did not receive any foot care service, e.g,, toe nail clipping, since admission, for 2 1/2 years, and has a condition that poses a risk to foot health (e.g., diabetes) this resulted in immobility, and overgrown, uncomfortable toe nails and feet. Residents Affected - Few This failure resulted in neglect to the resident, caused pain, and loss of ability to walk. 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 or vision 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. Review of the facility policy on Abuse, Neglect, Exploitation, . revised April, 2021, indicated, Residents have the right to be free from abuse, neglect, exploitation . This includes but is not limited to freedom from corporal punishment, . physical abuse . Policy Interpretation and Implementation: The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect and exploitation .by anyone including but not necessarily limited to a. facility staff .2. Develop ad implement policies and protocols to prevent and identify: a. abuse or mistreatment of residents; b. neglect of residents . 3. Ensure adequate staffing and oversight/support to prevent burnout, stressful working situations and high turnover rates. 4. Conduct employee background checks and not knowingly employ or otherwise engage any individual who has: a. been found guilty of abuse, neglect, exploitation . by a court of law; b. had a finding entered into the state nurse aide registry concerting abuse, neglect, exploitation .or c. a disciplinary action in effect against his/her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation . 5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive and emotional problems . 8. Identity and investigate all possible incidents of abuse, neglect, . 9. Investigate and report any allegations within time frames required by federal requirements . Record review of Resident 1's foot care treatment showed resident received foot care for the first time since being admitted to the facility, in May, 2024, and her toenails were clipped for the first time after 2 1/2 years. Pictures of clipped toe nails are included in records. During an interview on 6/24/2024 at 1:05 PM, the Assistant Director of Nurses, ADON, stated Resident received podiatry care on 5/15/2024. She could not provide evidence of any previous podiatry care performed since admission. Review of facility policy on Foot Care, revised March, 2018, indicated, Residents will receive appropriate care and treatment in order to maintain mobility and foot health. Policy Interpretation and Implementation: 1. Residents will be provided with foot care and treatment in accordance with professional standards of practice. 2. Overall foot care will include the care and treatment of medical 056394 Page 4 of 6 056394 06/24/2024 Golden Pavilion Healthcare 99 Escuela Drive Daly City, CA 94015

F 0687 Level of Harm - Minimal harm or potential for actual harm conditions associated with foot complications (e.g., diabetes .) . 4. Trained staff may provide routine foot care (e.g., toenail clipping) within professional standards of practice for residents without complicating disease processes. Resident with foot disorders or medical conditions associated with foot complications will be referred to qualified professionals. Residents Affected - Few 056394 Page 5 of 6 056394 06/24/2024 Golden Pavilion Healthcare 99 Escuela Drive Daly City, CA 94015

F 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assist Resident 1, one of one sampled resident, to obtain dental care for a facility caused tooth injury, due to fall, for nine months. Facility must refer resident promptly, within 3 days, for dental services. Residents Affected - Few This failure resulted in lack of care and services for nine months to resident. 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, 5 feet tall, [AGE] years old, and does not walk. During a telephone interview with Resident 1's son on 7/11/2024 at 4:04 PM, son stated in October, 2023, the facility staff dropped his mother on the floor and broke her front tooth. A report of the incident was not made by the facility. The facility said resident did not have dental coverage. And the facility did not pay for the dental care. The Administrator then, who is gone now stated the facility would pay for residents dental care. The residents second visit to the dentist determined a root canal was required and performed after dental insurance was confirmed. The residents son made all the appointments During a telephone interview the Assistant Director of Nurses, ADON, on 6/27/2024 at 12:33 PM, stated there was no incident report made for the residents injury and Department of Public Health was not notified. Review of the facility's policy on Accidents and Incidents-Investigating and Reporting, revised July, 2017, All accidents or incidents involving residents, . occurring on these premises shall be investigated and reported to the administrator. 1. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable, shall be included on the Report of Incident/Accident form: .a. The date and time the accident or incident took place; b. The nature of the injury/illness (e.g., bruise, fall, nausea, etc.); c. The circumstances surrounding the accident .; e. The name of witnesses and their accounts of the accident .f. The injured persons account; . 5. The nurse supervisor/charge nurse and/or department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the director of nursing services within 24 hours of the incident/accident .7. Incident/Accident reports will be reviewed by the Safety Committee for trends related to accident or safety hazards in the facility and analyze any individual resident vulnerabilities. 056394 Page 6 of 6