Health inspection·January 13, 2025

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to thoroughly investigate a change in condition for one of three sampled resident (resident 1) when Resident 1 developed bruises to the left forearm and on top of the left hand with unknown origin. Residents Affected - Few The facility failure has the potential for Resident 1 to not receive the necessary care and services. Findings: A review of the admission records indicated Resident 1 was admitted with diagnoses including end stage renal (kidney) failure (when the kidneys stopped working) and dementia (decline in memory or other thinking skills). A review of the nurses' notes dated 12/7/24, indicated, Resident 1 was noted with discoloration on the: left forearm measuring six (6) centimeters (cm, a unit of measurement) by (X) three (3) cm, top of left-hand site 1: 2.5 cm X two (2) cm, top of left-hand site 2: One (1) X one cm. A review of the physician order dated 12/7/24, indicated, to monitor discoloration on the left lower arm and to apply ice pack to the left wrist. A review of the care plan intervention dated 12/7/24, indicated, to keep area clean and dry, pat skin dry after bathing, report to Medical Doctor (MD) significant change in the skin. During an interview on 1/13/25, Registered Nurse 1 acknowledged that there was no investigation completed for the possible causes of the bruises found on Resident 1 LFA and top of the hand. During the interview on 1/13/25, Assistant Director of Nursing acknowledged there was no investigation completed for the possible causes of the bruises on Resident 1 LFA and top of left hand. A review of the Policy and Procedure titled, Abuse and Neglect - Clinical Protocol dated 3/2018, indicated, The nurse will assess the individual and document related findings. Assessment data will include: injury assessment (bleeding, bruising, deformity, swelling, etcetera [ect.]), pain assessment; current behavior; patients age and sex, all current medications, especially anticoagulants, non-steroidal anti-inflammatory drugs, salicylate, ; other platelet inhibitors; vital signs; behavior over last 24 hours (bruise could be related to movement disorder or aggressive behavior); history of any tendency towards bruising; all active diagnosis; and any recent labs . Page 1 of 4 056394 056394 01/13/2025 Golden Pavilion Healthcare 99 Escuela Drive Daly City, CA 94015

F 0641 Ensure each resident receives an accurate assessment. 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 accurate assessment of the Minimum Data Set (MDS, a standardized assessment tool) for one of three sampled residents (Resident 1) when the MDS did not document dementia (decline in memory or other thinking skills), fracture (broken bone) and osteopenia (bone density loss, weak bones) as active diagnoses. Residents Affected - Some The facility failure resulted to inaccurate MDS to reflect Resident 1's current health status. Findings: During an observation on 1/105:02 PM, Resident 1 was awake, verbally responsive, sitting up in bed, with bandage to left forearm. Resident 1 was not able to relate how she sustained the fracture to the left forearm. During an interview on 1/3/25 @1:06 PM, MDS Nurse 1 reviewed the MDS dated [DATE], for Resident 1, acknowledged that dementia, osteopenia, and fracture was not entered in the MDS and stated that when completing the MDS, the residents clinical record is reviewed. MDS Nurse 1 also stated the physician order is not a source of information and dementia was care planned by the social services. MDS Nurse 1 further stated osteopenia could have been added if the nurses have communicated with the MDS Nurse. The MDS Nurse that completed Resident 1's MDS is no longer employed in the facility. During an interview on 1/13/24, at 1:41 PM, Social Services Designee 1 reviewed the care plan and stated that Resident 1 was admitted with diagnosis of dementia. During an interview on 1/16/25, at 4:00 PM, the Director of Nursing stated, MDS is an accurate assessment of resident's current status. The DON further stated that the MDS nurse dig through the chart and when the documentations does not match the facility take an additional step or redo the assessment. .Section I: Active Diagnoses .The items in this section are intended to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessments is to generate an updated, accurate picture of the resident's status . Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) 3.0 Manual. 056394 Page 2 of 4 056394 01/13/2025 Golden Pavilion Healthcare 99 Escuela Drive Daly City, CA 94015

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review the facility failed to develop a comprehensive plan of care for one of three residents (Resident 1) when osteopenia (bone density loss, weak bones) was not addressed. Residents Affected - Few The facility failure has the potential for Resident 1 to not receive necessary care and services. Findings: A review of the admission records indicated Resident 1 was admitted with diagnoses including end stage renal (kidney) failure (when the kidneys stopped working) and dementia (decline in memory or other thinking skills) and history of fractures (broken bones). A review of the Orthopedic notes dated 9/17/24, indicated, an Xray (a test that takes a pictures of the structures inside the body particularly the bones) result from 7/16/24 as followed: .Significant osteopenia evident along with degenerative changes about the wrist. During an interview on 1/10/25, at Assistant Director of Nursing reviewed the care plan for Resident 1 and stated that she did not see a care plan to address osteopenia. During an interview on 1/17/25, at 10:00 AM, the Director of Nursing stated that care plan is specific to the resident needs and guides the staff in providing care. The DON further stated that everyone is responsible in the development of the resident's care plan. They DON acknowledged a comprehensive care plan was not developed to address osteopenia. A review of the facility Policy and Procedure titled, Care Plan, Comprehensive Person Centered, dated 12/2016, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetable to meet resident's physical, psychological and functional needs is developed and implemented for each resident . The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident . Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition change . A review of the Policy and Procedure titled, Care Planning - Interdisciplinary Team, dated 9/2013, indicated, .Our facility's Care Planning /Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident . 056394 Page 3 of 4 056394 01/13/2025 Golden Pavilion Healthcare 99 Escuela Drive Daly City, CA 94015

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to follow the physician (Medical Doctor, MD) order for one of three sampled resident (Resident 1) when the splint (a supportive device to immobilize [to stop or reduce movement] and protect a broken bone) was not applied to the fractured left forearm. Residents Affected - Some The facility failure had the potential for Resident 1 to develop complication and further resident harm. Findings: A review of the admission records indicated Resident 1 was admitted with diagnoses including end stage renal (kidney) failure (when the kidneys stopped working) and dementia (decline in memory or other thinking skills) and history of fracture (broken bones). During an observation on 1/13/25, at 10 AM, Resident 1 was awake, verbally responsive, sitting up in bed. Resident 1 was not able to relate how she sustained the fracture to the left forearm. A review of Orthopedic note dated 9/17/24, indicated, Resident 1 has a minimally displaced left radial (one of the two bone in the forearm) shaft (makes up most of the bone length) fracture sustained around 4/14/24, with minimal healing at the area of the fracture site, no callus formation (soft tissue bridge that form at the site of the broken bone eventually hardening as the it heals) seen. The orthopedic notes further stated significant osteopenia was (bone density loss, weak bones) evident. A review of the physician order dated 7/18/24, indicated, .keep splint for most of the time, may remove once a day with arm fully supported with a pillow just to gently clean the skin around the arm . A review of the nurses' notes dated 12/1/24, indicated that the splint for the left forearm was missing. A review of the treatment administration record for 12/2024, indicated the splint was on hold on 12/2 to 12/9/24. A review of the orthopedic note dated 12/10/24, indicated resident was seen and that a splint was applied during the visit. During an interview on 1/10/25, at, 4:30 PM, the Director of Nursing reviewed the Treatment administration record, acknowledged the splint for the left arm fracture was on hold, and stated, It is on hold because we don't have them. During an interview on 1/13/25, at 11:35 AM, Registered Nurse 1 stated the Resident 1's son arranged the appointment and took the resident to the orthopedic clinic on 12/10/24. RN 1 also stated that they could have contacted the orthopedic department directly. RN 1 further stated they waited for when the splint becomes available 056394 Page 4 of 4