Health inspection·May 27, 2025

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During concurrent observation and interview on 05/22/25 at 9:31 AM, Resident 525 stated getting help by pushing the call button when there is pain and then the lady comes in. Resident 525 stated having pain at the time of interveiw then requested for the nurse. During observation on 05/22/25 at 9:43 AM, Registered Nurse (RN) 4 entered Resident 525's room. RN 4 asked Resident 525 if something was needed and Resident 525 responded nothing. Shortly after, Resident 525 verbalized I have pain. RN 4 responded with I gave you Meloxicam (a type of medicine to relieve pain and reduce swelling in the body). Resident 525 reported pain level of 9 out of 10 to RN 4 and RN 4 responded but the medication is working and told Resident 525 that RN 4 will return to check on Resident 525 later. During an interview on 05/22/25 at 9:42 AM with RN 4, RN 4 confirmed Meloxicam 7.5 mg was and Tylenol 500 mg were recorded as last given at 8:40 AM on 05/22/25. RN 4 also noted a new pain medication order for Norco (a type of combined pain medication that includes acetaminophen, also know as Tylenol, and hydrocodone, a stronger pain reliever) that was ordered by Medical Doctor (MD) 2 on 05/22/25. RN 4 confirmed Norco was not available in medication cart for Resident 525. During a review of handwritten Physician Orders for Resident 525 dated 05/21/25, there are 2 orders that include: Celebrex 100 mg PO BID for pain x 14 days and Norco 5-325 PO q6hrs PRN pain give 1 hour before dressing changes signed by MD 1. During concurrent interview and record review on 05/22/25 at 9:59 AM with RN 7, RN 7 confirmed the EHR did not contain a progress note by MD 1 or MD 2 for the new medication orders for Celebrex 100 mg and Norco 5-325. RN 7 confirmed there was no documentation in the EHR or the Resident 525's paper chart describing the reasons why Resident 525 had new medication orders. During concurrent interview and record review on 05/22/25 at 10:11 AM with RN 4 and RN 7, RN 4 confirmed RN 4 did not document the 9 out of 10 pain for Resident 525. RN 4 confirmed Norco 5-325 was not given to Resident 525. RN 4 noted Norco 5-325 was for dressing changes only, but RN 7 confirmed the order for Norco 5-325 was to be given every 6 hours for pain and before dressing changes. RN 7 confirmed RN 4 had read the order for Norco 5-325 incorrectly. During concurrent interview and record review on 05/22/25 at 10:18 AM with RN 7, RN 7 provided an unsigned paper prescription order for hydrocodone-acetaminophen (also know as Norco) 5-325 mg. RN 7 confirmed this as the reason Norco 5-325 was not in medication cart for Resident 525. During a review of the MAR on 05/22/25 at 12:43 PM in PCC, pain level 9 out of 10 was not documented for the observation made on 05/22/25 at 9:43 AM by RN 4 for the order Monitor Pain every shift Indicate pain level and location if applicable Document Non-pharmacological pain interventions 1.Rest 2.Repositioning 3.None Document Y if nonpharmacological pain interventions were effective or N if not effective, NA for 0 pain -Start Date 05/09/2025 0700. During interview 05/22/25 at 1:42 PM with MD 1, MD 1 confirmed writing orders for Celebrex 100 mg and Norco 5-325 mg on 05/21/25 for Resident 525. MD 1 was uncertain if MD 1 had written a progress note for Resident 525 explaining reason for writing orders for Celebrex 100 mg and Norco 5-325 mg and Resident 525 did not have a change in condition. MD 1 notes MD 1's usual process is to type progress notes in a document program outside of PCC and later scans the progress note into PCC. MD 1 notes that orders or monitoring parameters for pain management are not entered by prescribers into PCC for monitoring a resident's pain for residents taking pain medication, but are instead common practice. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056394 If continuation sheet Page 2 of 9 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 05/27/2025 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 0657 MD 1 noted I don't put in orders for monitoring or how to monitor and then added nursing does that. Level of Harm - Minimal harm or potential for actual harm During a review of Admission-readmission Nursing Evaluation - V 11 dated 05/09/25 section 2. NEUROLOGICAL item 6. PAIN Evaluation notes no answer for 1. Resident Conditions/Diagnosis contributing to pain; notes Yes for 2. Is resident interviewable?; notes No for 3. Does the resident have pain?; notes a. No Pain for 12. Pain Scale:; notes b. No for 14. Does the resident exhibit any physical signs and symptoms of pain; and the remaining questions within the 6. PAIN Evaluation are not answered. Section 10. INTEGUMENTARY/SKIN ISSUES notes Yes for 1.Skin Issues, A. Does resident have pressure ulcers, skin tears, bruises, abrasions, burns or other skin issues? and under Indicate Pressure Ulcers and/or other wound types the entry includes Site: 53) Sacrum, Type: Pressure, Length: 5.5, Width: 5.5, Depth: 0.2, and Stage: Unstageable. Residents Affected - Few During a review of the Minimum Data Set (MDS) dated [DATE] for Resident 525, section Pain Assessment Interview was completed and noted pain or hurting at any time in the last 5 days; noted frequently experiencing pain or hurting over the last 5 days; noted occasionally having pain that med it hard to sleep at night; noted occasionally having limited participation in rehabilitation therapy sessions due to pain; noted frequently limiting day-to-day activities (excluding rehabilitation therapy sessions) because of pain; and noted a Pain Intensity of 9 on the Numeric Rating Scale (00-10). During review of CAA Worksheet with ARD of 05/13/2025 under Care Plan Considerations, a response of Yes is noted under the question Will Pain - Functional Status be addressed in the care plan? with the overall objective to Slow or minimize decline and minimize risks. During a review of the Care Plan Report with admission date of 05/09/25 for Resident 525, assessment, goals, and interventions/tasks related to pain was not include within the Care Plan Report. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056394 If continuation sheet Page 3 of 9 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 05/27/2025 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 30) received the necessary behavioral health care and services to attain or maintain the highest practicable mental and psychosocial well- being in accordance with the comprehensive assessment and plan of care. This failure resulted in Resident 30 having loud verbal outbursts, using foul language, inappropriate hand gestures when interacting with staff and other residents, including Resident 30 throwing urine at his roommate. Findings: A review of a Resident 30's Quarterly Minimum Data Set (MDS, a resident assessment tool). Dated 4/24/2025, indicated that Resident 30 has multiple diagnosis including Bipolar Disorder (a mental health condition characterized by intense mood swings), unspecified. During a concurrent interview and observation on 5/20/25 at 1:26 PM, Resident 30 was observed lying in bed with urinal, appearing to be a quarter filled, hanging on the left raised quarter siderail. Resident 30 reported he wants to go home. When asked about potential roommates, Resident 30 raised his middle finger and said I hate them (roommates). They (staff) do not care who they put in here. Resident 30 stated there used to be two other roommates and now there is only one. Resident 30 stated They moved the other motherfucker!. Resident 30 stated facility did not act on his concerns when he brought concerns to staff attention. During an observation on 5/20/2025 from 1:35 PM to 2:11 PM, there were multiple observations of Resident 30 yelling loudly and using profanity. On 5/20/2025 at 1:35 PM, Resident 30 was heard yelling Nurse! Nurse! repeatedly. The Licensed Vocational Nurse (LN1) and the Assistant Director of Nursing (ADON1) entered resident 30's room at 1:37PM and both came out at 1:41PM. However, Resident 30 continued to yell Fucking asshole! and other profanities in his room. Even with his door closed, Resident 30's volume was so loud that, his yelling could be heard from 2East hallway. On 5/20/2025 at 1:48 PM, Resident 30 continued yelling Where is my nurse! I need my water! ADON1 entered Resident 30's room at 1:48PM and exited room at 1:49PM. At 1:50PM, Resident 30 started yelling, Nurse! Nurse! Nurse!. At 1:50PM the Registered Nurse Supervisor (RN7) and ADON1 entered Resident 30's room. RN7 and ADON1 exited room at 1:54PM. Thirteen minutes later, on 5/20/2025 at 2:11PM, Resident 30 started yelling Nurse! Nurse!. The same pattern of yelling started again on 5/21/2025. During a subsequent observation on 5/21/2025 at 3:22PM in 2East Hallway, Resident 30 noted yelling Nurse!, Nurse! During an interview on 5/20/25 at 1:41 PM with LN 1, LN 1 stated facility staff was aware of Resident's 30 behaviors of throwing water on the floor or throwing meal trays across the room. LN 1 stated no roommate was assigned to bed B for safety reasons due to Resident 30 throwing urine on his last roommate. LN 1 stated there are days when Resident 30 can be angry and yelling non-stop. LN 1 stated while caring for Resident 30, she has observed Resident 30 having intermittent disagreements with his current roommate. These episodes sometimes escalated into Resident 30 yelling profanities and raising his middle finger at his roommate. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056394 If continuation sheet Page 4 of 9 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 05/27/2025 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 0740 Level of Harm - Minimal harm or potential for actual harm In a concurrent interview and record review on 5/20/2025 at 1:42PM, with LN 1, LN 1 reviewed an electronic record titled admission Record and reported Resident 30 has been a patient in the facility since June 2022. LN 1 states, Resident 30 has documented behaviors of being disruptive, throwing urine on the floor, flipping furniture, and urinating on the floor dating back to 2024. LN 1 stated It's .mood changes and angry outbursts. Residents Affected - Few During a concurrent interview and record review on 5/21/25 at 1:28 PM with the Case Manager (CM1) when reviewing policy titled Care Planning- Interdisciplinary Team last revised in March 2022, CM1 stated if the facility had concerns regarding a resident's behavioral needs, then the facility would refer them to outpatient/community services such as psychiatric, mental health, or relocation/discharge if the facility was unable to meet their needs. CM1 stated if a resident was unable to request services, the Social Services department would interview other facility staff, family members, Certified Nursing Assistants, Charge nurses (nursing manager), and monitor for changes in Resident's routine. When asked if the above interventions were carried out for Resident 30, CM1 verified they were not. A review of Resident 30's assessment titled Care Plan Report initiated on 3/11/2025 last revised on 3/11/2025 indicated a problem for Cognitive Loss due to: BIMS. BIMS =Brief Interview of Mental Status, a tool to assess memory, thinking, and reasoning. Resident 30 had a score of six out of fifteen. This indicated Resident 30 was severely impaired in his memory and reasoning. There was a documented intervention for staff to Anticipate resident needs. During a concurrent interview and record review on 5/21/2025 at 2:53PM with Licensed Vocational Nurse (LN2), LN2 stated Resident 30 was very unpredictable, had wild mood swings, will suddenly begin to scream and yell, and become very agitated. During a concurrent interview and observation on 5/21/2025 at 3:08PM with Certified Nurse Assistant (CNA2), CNA2 states Resident 30 is very moody with frequent changes in mood and behaviors, including the use of profanity. CNA2 stated the facility Nursing Supervisors were made aware of behaviors on several occasions. Durning a concurrent interview and record review on 5/22/25 at 11:00 AM with the Director of Nursing (DON), a review of Resident 30's assessment titled Care Plan Report initiated on 1/15/2025 last revised on 1/15/2025 indicated a problem for Lithium use due to: Bipolar Disorder [A mood disorder] with interventions to Monitor behaviors to assist and assure lowest possible therapeutic doses are given, Monitor changes in condition, and Monitor target behavior(s) via Point Click Care electronic medication administration record (E-MAR [An electronic health record]) initiated on 1/15/2025 as well. DON stated a change in condition assessment can be initiated due to abnormal behavior, any noted side effect form anti-psychotic medication use, or change in behavior that was noted in diagnosis. DON defined abnormal behavior as any behavior that resident does not usually display or if the resident becomes more erratic. A review of Resident 30's electronic medication administration record (E-MAR), indicated targeted behavior monitoring for Rapid nonstop talking was the only behavior log noted in record. DON verified the facility did not have any additional monitoring for behaviors outside of the targeted behavior noted in the E- MAR. During a concurrent interview and record review on 5/22/2025 at 11:17 AM with the DON, nursing progress notes dated 5/29/2023, 5/30/2023, 6/3/2023, 6/8/2024, and 6/15/2024 stated Resident 30 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056394 If continuation sheet Page 5 of 9 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 05/27/2025 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few noted urinating on the floor, throwing urinals against the trash can, and throwing furniture. DON verified that in 2023 there was a pattern of inappropriate behavior. Further review of a nursing progress note titled Episode of agitation on 2/12/25, indicated Resident 30 threw a cup of water at the door. DON stated the facility cannot monitor all behaviors, the nursing staff monitor for one off behaviors. DON stated the facility was unable to monitor every resident, and monitoring was initiated if the behavior was new. DON verified no documentation for monitoring Resident 30's behaviors of loud verbal outbursts, using profanity, throwing items was currently in place. A review of Resident 30's progress note dated 3/10/25 published by social services department, stated behaviors will be closely monitored for any changes in mood and behaviors. DON verified there is no documentation of monitoring of any changes in mood and behaviors in resident's record. During a concurrent interview and record review on 5/22/2025 at 3:01PM with ADON1, ADON1 stated the facility protocol for residents with new behaviors included informing the primary care physician or nurse practitioner to request for med review and behavioral monitoring, report to the facility social services department, and initiate behavior monitoring every shift if the resident was on psychotropic medication. ADON1 stated Resident 30 had a new behavior of throwing urine. ADON 1 verified the facility did not initiate behavioral monitoring for the new behavior identified. ADON 1 also verified Resident 30's assessment titled Care Plan Report initiated on 1/15/2025 last revised on 1/15/2025, stated facility staff will do interventions indefinitely. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056394 If continuation sheet Page 6 of 9 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 05/27/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure safe and sanitary condition was met for food storage in the kitchen when there were expired strawberry topping and sliced turkey in the refrigerator. These failures had the potential to result in putting residents at risk for foodborne illness (a disease caused by consuming contaminated food or drink). Findings: During a concurrent observation and interview on 5/19/25 at 2:54 PM with Dietary Supervisor (DS) 1 and Dietary Manager (DM) in the kitchen, there was one container of strawberry topping in the refrigerator with the date 6/15/23 labeled on the lid. DS 1 removed the label with the date on it, then re-attached it when asked. A picture of the container of expired strawberry topping was taken. DM acknowledged, the labeled date meant use by date when asked. DM stated, It has to be expired, when asked if the strawberry topping was expired. During a concurrent observation and interview on 5/19/25 at 3:04 PM with DM in the kitchen, there was expired sliced turkey in a plastic bag in the refrigerator. The label on the bag indicated, Opened 05/13/25 . Discard 05/17/25 . DM acknowledged, the sliced turkey was expired when asked. A picture of the expired sliced turkey was taken. DM stated, Stomachache . There is a possibility of foodborne illness, when asked what the risks are of eating expired food. He stated, the facility's dietary staff might forget to discard the expired strawberry topping and sliced turkey. During an interview on 5/21/25 at 9:26 AM with Certified Dietary Manager (CDM), the pictures of the expired strawberry topping and sliced turkey were shown to her. CDM acknowledged, the strawberry topping and sliced turkey were expired and were not discarded timely when asked. She stated, the expired food can create food borne illness when asked if these items are used. Review of the facility's policy and procedure (P&P) titled, Food Storage updated in October 2017 indicated, . Food storage areas are maintained in a clean, safe, and sanitary environment . 10. Opened items have use by dates indicated on them . The Federal Food Code 2022 describes foodborne illness. The Food Code indicated, . Foodborne illness in the United States is a major cause of personal distress, preventable illness and death . Most foodborne illnesses occur in persons who are not part of recognized outbreaks. For many victims, foodborne illness results only in discomfort or lost time from the job. For some, especially . older adults in health care facilities, and those with impaired immune systems, foodborne illness is more serious and may be life threatening . Epidemiological (relating to the branch of medicine which deals with the incidence, distribution, and control of diseases) outbreak data repeatedly identify five major risk factors related to employee behaviors and preparation practices in . food service establishments as contributing to foodborne illness: o Improper holding temperatures, o Inadequate cooking, such as undercooking raw shell eggs, o Contaminated equipment, o Food from unsafe sources, and o Poor personal hygiene . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056394 If continuation sheet Page 7 of 9 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 05/27/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain infection control program and practices designed to help prevent the development and transmission of diseases and infections when the PICC (Peripherally Inserted Central Catheter: a long, thin, flexible tube inserted into a vein, usually in the arm, and advanced to a larger vein near the heart. It provides access to the bloodstream for delivering medications, fluids, and blood draws for a prolonged period, reducing the need for frequent needle insertions.) line dressing was overdue to change for one of 2 sampled residents (Resident 380). Residents Affected - Few This failure had the potential to develop infection in Resident 380. Findings: Review of Resident 380's clinical record indicated, Resident 380 was admitted to the facility with diagnoses including diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it gets), and chronic kidney disease (a progressive condition where the kidneys gradually lose their ability to filter waste and excess fluid from the blood). During a concurrent observation and interview on 5/20/25 at 1:45 PM with Resident 380 in his room, Resident 380 had a PICC line dressing on his left upper arm. The PICC line dressing date was 5/11/25. Resident 380 stated, he had PICC line because he was a hard stick (a patient whose veins are difficult for medical professionals, such as phlebotomists or nurses, to access for blood draws or IV [Intravenous: Into your vein; into your blood stream, putting drugs or fluids directly into your blood] placement). During a concurrent observation and interview on 5/20/25 at 2:12 PM with Registered Nurse (RN) 3, Resident 380's PICC line dressing was observed. RN 3 stated, Resident 380 had the PICC line because they could not find a vein when he was getting IV fluid before. RN 3 stated, the PICC line dressing should be changed every night when asked. RN 3 acknowledged, the PICC line dressing was dated as 5/11/25. During an interview on 5/20/25 at 2:31 PM with RN 3, RN 3 stated, the PICC line dressing should be changed every 7 days. RN 3 stated, there is a risk of infection when asked if the dressing is not changed every 7 days. During an interview on 5/22/25 at 2:13 PM with Assistant Director of Nursing (ADON) 2, ADON 2 stated, It can develop infection, when asked about the risk of not changing the PICC line dressing timely. She stated, 7 days when asked how often it should be changed. During a concurrent interview and record review on 5/27/25 at 1:17 PM with ADON 1, Resident 380's doctor's orders were reviewed. ADON 1 verified there was no doctor's order for the PICC line dressing change. Review of the facility's policy and procedure (P&P) titled, PICC DRESSING CHANGE dated March 2023 indicated, I. To Be Performed By: RNs and IV Certified LVNs (Licensed Vocational Nurses) according to state law and facility policy . E. Change catheter securement device (a medical accessory used to securely hold a catheter in place) every 7 days . F. Change antimicrobial disc (a dressing used to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056394 If continuation sheet Page 8 of 9 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 05/27/2025 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 0880 reduce the risk of infection at the insertion site of a PICC line) every 7 days . Level of Harm - Minimal harm or potential for actual harm Review of the facility's P&P titled, Infection Control Policies and Practices revised 3/19/25 indicated, . 2. The objectives of facility infection control policies, protocols, and practices are to: a. Support prevention, detection, investigation, and transmission of infections . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056394 If continuation sheet Page 9 of 9