F 0755
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, the facility:
Residents Affected - Few
1. Did not ensure prescribed medication for Resident 1 was available on the scheduled administration time
on 3/18/25 at 4:00 PM, and 3/19/25 at 12:00 AM and 8:00AM.
2. Did not properly account for the receipt of the controlled medication (drugs or substances that are
regulated by the government due to their potential for abuse and addiction) (diazepam- a controlled
substance to treat anxiety, muscle spasms, and seizures) for Resident 1.
These failures resulted in the potential for reduced effectiveness to prevent a worsening of symptoms or
flare-ups of muscle spasms or increased physical discomfort related to complex regional pain syndrome or
potentially leading to anxiety or mood swings. Improper accounting practices during the receipt of this
controlled medication compromises the facility's ability to maintain adequate medication availability and
meet the resident's needs.
Findings:
1. During a concurrent interview and record review on 3/19/25 at 1:35 PM with the Assistant Director of
Nursing (ADON) and Licensed Vocational Nurse (LVN1) of Resident 1's medication administration record
(MAR) dated March 1-31, 2025, was reviewed. MAR indicated , Valium (Diazepam) oral tablet 5mg give 1
tablet by mouth every 8 hours for muscle spasms related to complex regional pain syndrome, and the
nursing/MAR notes dated 3/18/25 at 5:14 PM, 3/19/25 at 12:22 AM, 3/19/25 at 8:00AM, and 3/19/25 at 3:56
PM, were reviewed. Resident 1's March MAR and March 18-19, 2025 Nursing Notes indicated 3 doses
(3/18/25 at 4:00 PM, 3/19/25 12:00 AM, and 3/19/25 at 8:00AM) of diazepam were not given. Both the
ADON and LVN1 stated the resident's last dose of diazepam was given on 3/18/25 at 8:00 AM, and
Resident 1 missed the next 3 doses due to no inventory.
During an interview on 3/19/25 at 3:40 PM with LVN2, LVN2 stated the day nurse endorsed to him that
there was no diazepam for Resident 1's 4:00 PM dose, and pharmacy had been called. LVN2 stated he
notified the Family Nurse Practitioner (FNP) who was close by and he filled an order for 60 tabs which was
faxed to pharmacy 3/18/25 at 3:50 PM. LVN2 stated he did not document a nursing note at the time he
notified FNP of no supply, but when told by ADON to make a late entry of this, he complied. LVN2 admitted
this was an error stating if it's not documented, it wasn't done, and I will do better next time.
During an interview on 3/19/25 at 4:10 PM with Director of Nursing (DON), DON stated Resident 1 missed
3 doses of diazepam 5mg due to no supply. DON agreed facility did not ensure diazepam was
(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 2
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
03/20/2025
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)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
available for this Resident and was not administered scheduled medication on time. DON agreed the facility
Policy and Procedure (P/P) titled Administering Medications was not followed.
During a review of Resident 1's Order Summary Report, dated 3/20/25, the Order Summary Report
indicated diazepam oral tablet 5mg give 1 tablet by mouth every 8 hours for muscle spasms related to
complex regional pain syndrome I.
2. During a concurrent interview and record review on 3/19/25 at 3:40 PM with LVN2, a faxed verification
report dated 3/18/25 at 3:50 PM was reviewed. The verification report indicated that 60 tablets of diazepam
5mg were ordered for Resident 1 by the FNP. LVN2 stated FNP filled order for 60 tabs which was faxed to
pharmacy 3/18/25 at 3:50 PM.
During concurrent interview and record review on 3/19/25 at 4:00 PM with ADON, Manifest ID for
rx#54009414 for Resident 1, dated 3/4/25 at 10:19 PM; Controlled Drug Record, dated 3/4/25, and LVN2's
Nursing Note dated 3/19/25 at 8:53 PM were reviewed. The Manifest ID indicated that 90 tablets of
diazepam 5mg for Resident 1 were delivered, and signed by LVN2. The Controlled Drug Record indicated
31 tabs of diazepam 5mg for Resident 1 was accepted on 3/8/25 at 8:00 AM. LVN2's Note indicated 42
tablets of diazepam were received from pharmacy today for the Resident. ADON stated there was a
discrepancy of these documents.
During a review of the facility's policy and procedure titled, Administering Medications, dated April 2019,
indicated, medications are administered in a safe and timely manner, and as prescribed. The Controlled
Medication Storage indicated under Procedures E (1 & 2)- any discrepancy in controlled substance
medication counts is reported to the director of nursing immediately. The director or designee investigates
and makes every reasonable effort to reconcile all reported discrepancies
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056394
If continuation sheet
Page 2 of 2
