Other·March 20, 2020

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an Abbreviated Standard Survey. Complaint no.: 665157 Representing the California Department of Public Health: ID: 31794, Health Facilities Evaluator Nurse The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Two deficiencies were written as a result of complaint 665157.

F658 SS=D Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i)

F658 04/17/2020 §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(i) Meet professional standards of quality. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V0HU11 Facility ID: CA220000090 If continuation sheet 1 of 21 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055968 (X3) DATE SURVEY COMPLETED 02/03/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN HEIGHTS HEALTHCARE 35 Escuela Dr Daly City, CA 94015 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to follow physician's orders for one out of three sampled residents (Resident 1) when: 1a. There was no evidence the right ankle wound dressing was done on 5/9/19 and 5/16/19,"PM" (afternoon) shift; 1b. There was no evidence the wound dressings were done on 6/11/19, "AM" (morning) shift for all three (3) wounds on the left distal leg, on the left anterior (front of the body) leg and on the right malleolus (ankle) with unstageable ulcer. 1c. There was no evidence the wound dressing was done on 7/9/19, AM shift for all three (3) wounds on the left distal leg, on the left anterior (front of the body) leg and on the right malleolus (ankle) with unstageable ulcer. These failures had the potential for bacterial growth to develop and could cause delay in wound healing. 2. Pain Medications were not administered as ordered by the physician when: (a) Two tablets of Oxycodone and Norco (strong opioid pain medications, classified under Controlled Substance II [CS, are drugs that have a high potential for abuse which may lead to severe psychological or physical dependence] were given for moderate pain instead of one tablet. Failure to follow medication orders had the potential to place resident's care and safety at risk for harm. (b) Two (2) tablets of Tylenol (also known as Acetaminophen, a pain medication) were administered for moderate pain. The order is to give one Tylenol for mild pain. (c) "1/2" (one half) tablet of Oxycodone 5 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V0HU11 Facility ID: CA220000090 If continuation sheet 2 of 21 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055968 (X3) DATE SURVEY COMPLETED 02/03/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN HEIGHTS HEALTHCARE 35 Escuela Dr Daly City, CA 94015 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE mg/tablet was administered on 4/17/19, for moderate pain instead of one tablet as ordered. These failures had the potential for inadequate pain control which could negatively impact resident's quality of life. 3.) There was no evidence the physician was notified as ordered when the resident complained of severe pain. Failure to notify the physician had the potential to negatively impact the effectiveness of pain management for the resident. Findings: 1. (a) During a Closed Record review of the Admission Record (AR) it indicated Resident 1 was admitted on 4/16/19. The Admission History and Physical Notes (H & P) dated 4/17/19 indicated a diagnoses that included type 2 diabetes mellitus (chronic condition that affects the way the body metabolizes sugar [glucose]), peripheral vascular disease (circulatory problem in which narrowed arteries reduce blood flow to the limbs) left lower leg ulcer, and status post left 5th (fifth) toe amputation (removal of a limb by trauma, medical illness, or surgery) due to gangrene (type of tissue death caused by a lack of blood supply) of the left toe. The Minimum Data set (MDS an assessment tool) dated 5/2/19, Section C0200, Brief Interview for Mental Status (BIMS) indicated Resident 1 was oriented to year, date, and month, was able to remember words correctly, and was able to recall after cueing. During an interview on 12/10/19 at 9:22 AM, the Director of Nursing (DON) stated Resident 1 came with a three (3) wounds: leg distal leg FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V0HU11 Facility ID: CA220000090 If continuation sheet 3 of 21 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055968 (X3) DATE SURVEY COMPLETED 02/03/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN HEIGHTS HEALTHCARE 35 Escuela Dr Daly City, CA 94015 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE on the 5th toe amputation (surgical wound), on the left anterior leg and on the right malleolus (ankle), with "unstageable" pressure ulcer and the wound care were done on all three wounds. During a review of the Telephone Order (T.O. means verbal commands given through a phone by a doctor or someone authorized to prescribe drugs) dated 5/8/19 at 3:00 PM, it indicated: "L (left) foot , L anterior leg, L distal leg, cleanse with NS (normal saline). Pat & (and) dry, Apply Santyl (medicine that removes dead tissue from wounds so they can start to heal) dressing 2x (two) daily & cover c (with) dry dressing.", signed and dated by the physician on 10/21/19. During a concurrent interview with the DON and record review on 1/8/20 at 1:55 PM, the May, 2019 Treatment Administration Record (TAR) it indicated the wound care on the left foot and left leg on 5/9/19 and 5/16/19, had the initials of the License Nurse (LN) on the box provided for the "PM (afternoon)" shift. However, the box for the wound care on the right ankle for the PM shift on 5/9/19 and 5/16/19 were empty, no LN initials, and the DON verified the LN initials were missing for the wound care on the right ankle on the PM shift for 5/9/19 and 5/16/19. 1. (b) During a review of the T.O. dated 6/11/19 it indicated, "Open wound on (L) distal foot, open wound on (L) anterior leg, unstageable pressure injury on right lateral (side) malleolus (ankle). Cleanse with NS , pat & dry, Apply medihoney. Cover c (with) non-stick gauze & secure c (with) kerlix BID (2x daily.", signed and dated by the physician on 10/21/19. During a concurrent interview with the DON and record review on of 1/8/20 at 2:35 PM, the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V0HU11 Facility ID: CA220000090 If continuation sheet 4 of 21 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055968 (X3) DATE SURVEY COMPLETED 02/03/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN HEIGHTS HEALTHCARE 35 Escuela Dr Daly City, CA 94015 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE June, 2019 TAR it indicated the initials of the LN were missing on 6/11/19 on the box provided for the "AM (morning) shift", for all three wounds. The DON failed to provided documented evidence that wound care was done on 6/11/19. 1. (c) During a review of the T.O. dated 7/9/19 at 3:00 PM, it indicated, "Daikin's 0.25 % (treatment solution use to kill germs and prevent germ growth in wounds) wet to dry dressing TID (3x a day) on all wounds (open wound on the (L) distal foot, (L) anterior leg, (R) lateral malleolus). Cover c (with) dry dressing & secure c (with) kerlix TID.", signed and dated by the physician on 10/21/19. During a concurrent interview with the DON and record review of the July, 2019 TAR on 1/8/20 at 2:45 PM, indicated on 7/9/19, the initial of the LN for the wound care dressing and treatment was done only once (1x), in the "PM" shift, for all three wounds. The DON verified the initials of the LNs for the "AM" and "NOC" (night) shifts were missing and acknowledged there should had been a wound dressing changed done at least "two times" on 7/9/19, since the previous order was twice daily, and the "TID" dressing changes would start on the following day (7/10/19). During an interview with the DON on 12/20/19 at 9:48 AM, the DON stated the initials by the LNs on the box provided in the TAR would indicate the LNs performed the wound dressing and if there was no initial by the LN, the wound dressing were not done on that day. During a review of the facility policy titled Wound Care with the last revised date of 10/10 it indicated: "The purpose ... is to provide guidelines for the care of wounds ... Documentation: The following ... should be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V0HU11 Facility ID: CA220000090 If continuation sheet 5 of 21 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055968 (X3) DATE SURVEY COMPLETED 02/03/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN HEIGHTS HEALTHCARE 35 Escuela Dr Daly City, CA 94015 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE recorded in the resident's medical record: 1. ... 4. Name and title of the individual performing the wound care. ... 10. The signature and title of the person recording the data. ... ." 2. (a) During a review of the Physician's Orders dated 4/17/19 at 2:00 PM, indicated, "Oxycodone 5 mg (milligrams) , i (one) po (by mouth) Q (every) 4 (four) hours PRN (as needed) for moderate pain", and, "ii (two) po Q 4 (four) hours PRN for severe pain.", signed and dated by the physician on 4/17/19. During a review of the Physician's Orders dated 4/16/19 it indicated, "Monitor pain level every shift/use pain assessment flowsheet rating scale 1-10 document 0 (zero) for no pain, 1-4= mild, 5-8= moderate and 9-10= severe and call the M.D. (physician)." During an interview on 1/16/20 at 2:25 PM, the DON stated the staff needed pain scale, as part of the pain assessment, to determine the correct dose to give. Review of the April 2019 Medication Administration Record (MAR) indicated the following: On 4/18/19 at 5:25AM, Oxycodone 5 mgs. 2 tablets were given for moderate pain (8/10); On 4/21/19 at 1:30PM, Oxycodone 5 mgs. 2 tablets were given for moderate pain (8/10); On 428/19 at 8AM, Oxycodone 5 mgs. 2 tablets were given for moderate pain (8/10). During an interview with the Director of Nursing (DON) on 1/16/20 at 2:25 PM, the DON acknowledged two tablets of Oxycodone were given for moderate pain instead of one tablet as ordered. During a review of the May, 2019 Physician's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V0HU11 Facility ID: CA220000090 If continuation sheet 6 of 21 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055968 (X3) DATE SURVEY COMPLETED 02/03/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN HEIGHTS HEALTHCARE 35 Escuela Dr Daly City, CA 94015 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Orders indicated: "Oxycodone 5 mg give 1 (one) tab ... for moderate pain. Oxycodone 5 mg give 2 (two) tabs as ... for severe pain." During a review of the May, 2019 Physician's Orders indicated, "Monitor pain level ... 5-8= moderate and 9-10= severe and call the M.D. (physician)." During a review of the May, 2019 Medication Administration Record (MARs) indicated the following: On 5/6/19 at 12 AM, Oxycodone 5 mg 2 tablets were given for moderate pain (8/10); On 5/10/19 at 10 PM, Oxycodone 5 mg 2 tablets were given for moderate pain (8/10); On 5/16/19 at 6:00 PM, Oxycodone 5 mg 2 tablets were given for moderate pain (8/10); On 5/17/19 at 3:00 AM, Oxycodone 5 mg 2 tablets were given for moderate pain (8/10); On 5/31/19 at 5:30 AM, Oxycodone 5 mg 2 tablets were given for moderate pain (8/10). During an interview with the DON on 1/16/20 at 2:30 PM and concurrent Record Review (RR) of the May, 2019 MAR, the DON acknowledged two tabs Oxycodone were given for moderate pain instead of one tablet. During a review of the Physician's Order dated 6/4/19 at 12:00 noon indicated, "DC (discontinue) Oxycodone. Norco 5-325 mg 1 (one) tab ... for moderate pain. Norco 5-325 mg 2 (two) tabs ... for severe pain." During a review of the June, 2019 Physician's Orders indicated, "Monitor pain level ... 5-8= moderate and 9-10= severe and call the M.D." During a review of the June, 2019 Medication Administration Record indicated: On 6/5/19 at 12:00 PM, Norco 5-325 mg two FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V0HU11 Facility ID: CA220000090 If continuation sheet 7 of 21 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055968 (X3) DATE SURVEY COMPLETED 02/03/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN HEIGHTS HEALTHCARE 35 Escuela Dr Daly City, CA 94015 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE tablets were given for moderate pain (8/10); On 6/7/19 at 9 PM, Norco 5-325 mg two tablets were given for moderate pain (8/10); On 6/10/19 at 7 PM, Norco 5-325 mg two tablets were given for moderate pain (8/10); On 6/11/19 at 6:30 PM, Norco 5-325 mg two tablets were given for moderate pain (8/10); On 6/13/19 at 8 PM, Norco 5-325 mg two tablets were given for moderate pain (8/10). During an interview with the DON on 1/16/20 at 2:35 PM and concurrent RR of the June, 2019 MAR, the DON acknowledged two tablets of Norco 5-325 mg were administered for moderate pain instead of one table as ordered. During a review of the Physician's Order dated 7/3/19 at 8:00 PM indicated, "Norco 10-325 mg tablet give 1/2 tab ... for moderate pain, give 1 (one) tab ... for severe pain.", signed and dated by the physician on 10/26/19. During a review of the July, 2019 Medication Administration Record indicated: On 7/1/19 at 8 AM, Norco 10-325 mg one tablet was given for moderate pain (8/10); On 7/4/19 at 8 AM, Norco 10-325 mg one tablet was given for moderate pain (8/10); On 7/9/19 at 8:50 AM, Norco 10-325 mg one tablet was given for moderate pain (8/10); On 7/10/19 at 9 PM, Norco 10-325 mg one tablet was given for moderate pain (8/10); On 7/12/19 at 4:35 AM, Norco 10-325 mg one tablet was given for moderate pain (8/10); During an interview with the DON on 1/16/20 at 3:40 PM and concurrent RR of the June, 2019 MAR, the DON acknowledged one half (1/2) tablet of Norco 10-325 mg/tablet should had been given for moderate pain as ordered, instead of one tablet. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V0HU11 Facility ID: CA220000090 If continuation sheet 8 of 21 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055968 (X3) DATE SURVEY COMPLETED 02/03/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN HEIGHTS HEALTHCARE 35 Escuela Dr Daly City, CA 94015 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During a review of the undated facility policy titled Administering Medications it indicated: "Policy Statement: Medications shall be administered in a safe ..., and as prescribed. Policy Interpretation and Implementation: 1. ... 3. Medications must be administered in accordance with the orders, ... ." 2. (b) During review of the June, 2019 Physician's Orders it indicated: "Tylenol 500 mg (milligrams) give 1 (one) oral every six (6) hours PRN for mild pain" During a review of the June, 2019 Physician's Orders indicated: " Monitor pain level ... 58=moderate pain ... ." During a review of the Physician's Order dated 6/4/19 at 12:00 noon it indicated, "... Norco 5325 mg 1 (one) tab (tablet) .... for moderate pain ...." During concurrent interview with the DON and record review of the June, 2019 MAR, on 1/8/20 at 3:17 PM, the DON acknowledged Tylenol "650 mg" was given on "5/3/19 at 10:15 A" (AM) for moderate pain when the order indicated "500 mg". On 6/9/19 at 11:45 (day was not specified) the DON acknowledged two tablets of Tylenol were given for moderate pain, pain scale of 7/10, instead of the stronger pain medication (Norco) as ordered. During a review of the undated facility policy titled Administering Medications it indicated: "Policy Statement: Medications shall be administered in a safe ..., and as prescribed. Policy Interpretation and Implementation: 1. ... 3. Medications must be administered in accordance with the orders, ... ." 2. (c) During a review of the Physician's Orders dated 4/17/19 at 2:00 PM, it indicated, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V0HU11 Facility ID: CA220000090 If continuation sheet 9 of 21 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055968 (X3) DATE SURVEY COMPLETED 02/03/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN HEIGHTS HEALTHCARE 35 Escuela Dr Daly City, CA 94015 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE "Oxycodone 5 mg (milligrams), i (one) po (by mouth) Q (every) 4 (four) hours PRN (as needed) for moderate pain, ii (two) ... for severe pain.", signed and dated by the physician on 4/17/19. During a concurrent interview with the DON and review of the April, 2019 MAR on 1/8/20 at 3:10 PM, the DON acknowledged 1/2 tablet of Oxycodone 5 mg was administered on 4/17/19 at 7:30 AM for moderate pain, pain scale of 7/10, and stated it should be "one" tablet as ordered. During a review of the undated facility policy titled Administering Medications it indicated: "Policy Statement: Medications shall be administered in a safe ..., and as prescribed. Policy Interpretation and Implementation: 1. ... 3. Medications must be administered in accordance with the orders, ... ." 3. During a review of the May, 2019 Physician's Orders indicated: "Oxycodone 5 mg give 1 (one) tab ... for moderate pain. Oxycodone 5 mg give 2 (two) tabs as ... for severe pain." Review of the May, 2019 Physician's Orders also indicated, "Monitor pain level ... 5-8= moderate and 9-10= severe and call the M.D. (physician)." During a review of the May, 2019 Medication Administration Record (MAR) indicated: On 5/8/19 at 4:40 AM, two tablets of Oxycodone 5 mg were given for severe pain (10/10) On 5/8/19 at 9 AM, two tablets of Oxycodone 5 mg were given for severe pain (10/10) On 5/26/19 at 1:00 PM, two tablets of Oxycodone 5 mg were given for severe pain (10/10) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V0HU11 Facility ID: CA220000090 If continuation sheet 10 of 21 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055968 (X3) DATE SURVEY COMPLETED 02/03/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN HEIGHTS HEALTHCARE 35 Escuela Dr Daly City, CA 94015 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During a review of the Physician's Order dated 6/4/19 at 12:00 noon indicated, "DC (discontinue) Oxycodone. Norco 5-325 mg 1 (one) tab ... for moderate pain. Norco 5-325 mg 2 (two) tabs ... for severe pain." During a review of the June, 2019 Physician's Orders indicated, "Monitor pain level ... 5-8= moderate and 9-10= severe and call the M.D." During a review of the June, 2019 MAR indicated: On 6/17/19 at 2:30 AM, two tablets of Norco 5325 mg were given for severe pain (10/10) On 6/21/19 at 12 AM, two tablets of Norco 5325 mg were given for severe pain (10/10) On 6/21/19 at 2:09 PM, two tablets of Norco 5325 mg were given for severe pain (9/10) On 6/28/19 at 3:30 AM, two tablets of Norco 5325 mg were given for severe pain (10/10) During a review of the Physician's Order dated 7/3/19 at 8:00 PM indicated, "Norco 10-325 mg tablet: give 1/2 tab ... for moderate pain, give 1 (one) tab ... for severe pain.", signed and dated by the physician on 10/26/19. During a review of the July, 2019 Physician's Orders indicated: ""Monitor pain level ... 5-8= moderate and 9-10= severe and call the M.D." Review of the July 2019 MAR indicated: On 7/1/19 at 2 PM, one tablet of Norco 10-325 mg was given for severe pain (10/10); On 7/5/19 at 12:30 AM, one tablet of Norco 10325 mg was given for severe pain (10/10); On 7/6/19 at 3:30 PM, one tablet of Norco 10325 mg was given for severe pain (9/10); On 7/7/19 at 9:30 PM, one tablet of Norco 10325 mg was given for severe pain (9/10); FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V0HU11 Facility ID: CA220000090 If continuation sheet 11 of 21 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055968 (X3) DATE SURVEY COMPLETED 02/03/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN HEIGHTS HEALTHCARE 35 Escuela Dr Daly City, CA 94015 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview on 1/14/20 at 9:32 AM, the DON could not provide evidence the physician was notified on the above specified dates in May, June and July, 2019 when the resident complained of severe pain at 9/10 and 10/10 pain level. During a review of the policy titled Clinical Protocol for Pain with the last revised date of 2/18 it indicated: "Assessment and Recognition: 1. ... Treatment/Management: 1. .. 2. The physician will order appropriate ... medication ... . Monitoring: 1. ... . 2. The staff will ... report the resident's ... PRN analgesics. ... . "

F697 SS=G Pain Management CFR(s): 483.25(k)

F697 04/17/2020 §483.25(k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to implement the pain management for one out of three sampled residents (Resident 1) when: 1. Pain assessment were not done before and/or after pain medication administration. This failure had the potential to administer incorrect doses and inaccurately assess the effectiveness of the pain medications which could negatively affect the resident's quality of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V0HU11 Facility ID: CA220000090 If continuation sheet 12 of 21 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055968 (X3) DATE SURVEY COMPLETED 02/03/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN HEIGHTS HEALTHCARE 35 Escuela Dr Daly City, CA 94015 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE life. 2. The physician was not notified for severe pain according to the plan of care. The deficient practice resulted to Resident 1 requiring transfer to the acute care hospital on 7/12/19 for uncontrolled pain on the right leg. Definitions: Pain Management is defined in the facility policy as "the process alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals." Pain Scale (PS) is developed to help medical observers assess the level of pain. There are many different kinds of pain scales, but a common one is a numerical pain scale (NPS) from 0 to 10. Findings: 1. Record review of the Admission Record (AR) indicated Resident 1 was admitted on 4/16/19. The Admission History and Physical Notes (H & P) dated 4/17/19 indicated a diagnoses that included type 2 diabetes mellitus (chronic condition that affects the way the body metabolizes sugar [glucose]), peripheral vascular disease (circulatory problem in which narrowed arteries reduce blood flow to the limbs) left lower leg ulcer, and status post left 5th (fifth) toe amputation (removal of a limb by trauma, medical illness, or surgery) due to gangrene (type of tissue death caused by a lack of blood supply) of the left toe. The Minimum Data set (MDS an assessment tool) dated 5/2/19, Section C0200, Brief Interview for Mental Status (BIMS) indicated Resident 1 was oriented to year, date, and month, was able to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V0HU11 Facility ID: CA220000090 If continuation sheet 13 of 21 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055968 (X3) DATE SURVEY COMPLETED 02/03/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN HEIGHTS HEALTHCARE 35 Escuela Dr Daly City, CA 94015 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE remember words correctly, and was able to recall after cueing. During an interview on 1/16/20 at 2:25 PM, the DON stated the staff needed pain scale, as part of the pain assessment, to determine the correct dose to give. During a review of the May, 2019 Physician's Orders indicated: "Oxycodone 5 mg (milligrams) give 1 (one) tab ... for moderate pain. Oxycodone 5 mg give 2 (two) tabs as ... for severe pain." During a review of the May, 2019 Physician's Orders indicated, "Monitor pain level ... 5-8= moderate and 9-10= severe and call the M.D. (physician)." During a review of the May, 2019 Medication Administration Record (MAR) indicated: On 5/28/19 at 4:45 AM, No documented preassessment of pain level. Oxycodone 5 mg two tablets were given. Post assessment of pain showed "c (with) help"; On 5/28/19 at 10 AM, there was no documented preassessment of pain level. Oxycodone 5 mg two tablets were given. Post assessment of pain showed "c (with) help". During a review of the Physician's Order dated 6/4/19 at 12:00 noon indicated, "DC (discontinue) Oxycodone. Norco 5-325 mg 1 (one) tab ... for moderate pain. Norco 5-325 mg 2 (two) tabs ... for severe pain." During a review of the June, 2019 Physician's Orders indicated, "Monitor pain level ... 5-8= moderate and 9-10= severe and call the M.D." During a review of the June, 2019 MAR FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V0HU11 Facility ID: CA220000090 If continuation sheet 14 of 21 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055968 (X3) DATE SURVEY COMPLETED 02/03/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN HEIGHTS HEALTHCARE 35 Escuela Dr Daly City, CA 94015 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated: On 6/6/19 at 8:10 AM, the pain level preassessment was at 9/10 before the pain medication was given. Norco 5/325 mg two tablets were given. The post assessment of pain showed, "c (with) relief". There was no pain scale documentation. On 6/13/19 at 10:45, the pain level preassessment was at 9/10 before the pain medication was given. Norco 5/325 mg two tablets were given. The post assessment of pain showed, "c (with) relief". There was no pain scale documentation. On 6/17/19 at 2:30 AM, the pain level preassessment was at 10/10 before the pain medication was given. Norco 5/325 mg two tablets were given. The post assessment of pain showed, "c (with) help". There was no pain scale documentation. On 6/26/19 at 5 AM, the pain level preassessment was at 8/10 before the pain medication was given. Norco 5/325 mg two tablets were given. The post assessment of pain showed, "c (with) help". There was no pain scale documentation. During a review of the Physician's Order dated 7/3/19 at 8:00 PM indicated, "Norco 10-325 mg tablet: give 1/2 tab ... for moderate pain, give 1 (one) tab ... for severe pain.", signed and dated by the physician on 10/26/19. During a review of the Physician's Orders date 7/2/19 at 1:50 PM indicated: "Start Oxycodone 5 mg 1 (one) tab ... breakthrough pain.", signed by the provider (Nurse Practitioner) on 7/2/19. During a review of the July, 2019 Physician's Orders indicated: ""Monitor pain level ... 5-8= moderate and 9-10= severe and call the M.D." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V0HU11 Facility ID: CA220000090 If continuation sheet 15 of 21 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055968 (X3) DATE SURVEY COMPLETED 02/03/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN HEIGHTS HEALTHCARE 35 Escuela Dr Daly City, CA 94015 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During a review of the July, 2019 MAR indicated: On 7/8/19 at 8:00 AM, Norco 10-325 mg one tablet was given. There was no documented pain assessment before or after the pain medication was given. On 7/10 19 at 9:00 PM , the preassessment of pain level was documented at 8/10. Norco 10325 mg one tablet was given. The post assessment of pain level was documented as "c (with)help". On 7/11/19 at 1:00 AM, there was no documented preassessment of pain level before Oxycodone 5mg tablet was given. The post assessment of pain level was documented as "c help". On 7/12/19 at 4:35 AM, the preassessment of pain level was 8/10 before Norco 10-325 mg one tablet was given. The post assessment of pain level showed, "c help". During concurrent review of the April, May, June, and July, 2019 MARs and interview on 1/8/20 at 3:20 PM, the Director of Nursing (DON) acknowledged the pain assessments were not documented on 7/8/19 and on 7/11/19 she said the word with "help" meant it was up to the "nursing judgment". During an interview on 1/8/20 at 3:50 PM, the License Vocational Nurse (LVN) 1 explained the word "with help" could mean, pain was less or no pain. During an interview on 1/8/20 at 3:55 PM, LVN 2 explained with "relief" or with "help" could mean pain was not completely gone. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V0HU11 Facility ID: CA220000090 If continuation sheet 16 of 21 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055968 (X3) DATE SURVEY COMPLETED 02/03/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN HEIGHTS HEALTHCARE 35 Escuela Dr Daly City, CA 94015 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During a review facility policy titled Pain Assessment and Management with the last effective date of June, 2016, it indicated: "Purpose: The purposes ... are to help staff identify pain ... to develop interventions that are consistent with the resident's goal and needs ... . Procedure: 1. The pain management program is based on ... facility commitment to resident's comfort. ... 6. Assess the resident's pain and consequences of pain ... . Assessing Pain: 1. ... 2. assess pain using a consistent approach and a standardized pain assessment instrument ... . Monitoring and Modifying Approaches: 1. Reassess resident's pain ... . 3. Monitor the resident by performing a basic assessment ... with standardized assessment tools (e.g. approved pain scale ... . " During a review of the facility policy titled Clinical Pain Protocol with the last revised date of 3/18 indicated: "Assessment and Recognition: 1. ... 3. The staff ... will identify pain ... : a. Staff will use a consistent approach and standardized pain assessment instrument appropriate to the resident's cognitive level. ... . Monitoring: 1. The staff will reassess the individual's pain ... . " 2. Review of the resident's nursing care plan indicated: On 4/16/19, the resident was identified with a problem of "At risk for pain". The goal showed "Episode of pain will be resolved by 7/19". The Approach Plan showed, "Assess location... Administer pain medication as ordered; Assess effectiveness...Notify MD... Oxycodone as ordered ; Tylenol as ordered". During a review of the May, 2019 Physician's Orders indicated: "Oxycodone 5 mg give 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V0HU11 Facility ID: CA220000090 If continuation sheet 17 of 21 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055968 (X3) DATE SURVEY COMPLETED 02/03/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN HEIGHTS HEALTHCARE 35 Escuela Dr Daly City, CA 94015 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (one) tab ... for moderate pain. Oxycodone 5 mg give 2 (two) tabs as ... for severe pain." During a review of the May, 2019 Physician's Orders indicated, "Monitor pain level ... 5-8= moderate and 9-10= severe and call the M.D. (physician)." During a review of the May, 2019 Medication Administration Record (MAR) indicated: On 5/8/19 at 4:40 AM, two tablets of Oxycodone 5 mg were given for severe pain at 10/10 pain scale; On 5/8/19 at 9:00 AM, two tablets of Oxycodone 5 mg were given for severe pain at 10/10 pain scale; On 5/26/19 at 1:00 PM, two tablets of Oxycodone 5 mg were given for severe pain at 9/10 pain scale. During a review of the Physician's Order dated 6/4/19 at 12 noon indicated, "DC (discontinue) Oxycodone. Norco 5-325 mg 1 (one) tab ... for moderate pain. Norco 5-325 mg 2 (two) tabs ... for severe pain." During a review of the June, 2019 Physician's Orders indicated, "Monitor pain level ... 5-8= moderate and 9-10= severe and call the M.D." During a review of the June, 2019 MAR indicated: On 6/17/19 at 2:30 AM, two tablets of Norco 5325 mg were given for severe pain at 10/10 pain scale; 6/21/19 at 12AM, two tablets of Norco 5-325 mg were given for severe pain at 10/10 pain scale; On 6/21/19 at 2:09 PM, two tablets of Norco 5FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V0HU11 Facility ID: CA220000090 If continuation sheet 18 of 21 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055968 (X3) DATE SURVEY COMPLETED 02/03/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN HEIGHTS HEALTHCARE 35 Escuela Dr Daly City, CA 94015 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 325 mg were given for severe pain at 9/10 pain scale; On 6/28/19 at 3:30 AM, two tablets of Norco 5325 mg were given for severe pain at 10/10 pain scale. During a review of the Physician's Order dated 7/3/19 at 8:00 PM indicated, "Norco 10-325 mg tablet: give 1/2 tab ... for moderate pain, give 1 (one) tab ... for severe pain.", signed and dated by the physician on 10/26/19. During a review of the July, 2019 Physician's Orders indicated: ""Monitor pain level ... 5-8= moderate and 9-10= severe and call the M.D." During a review of the July, 2019 MAR indicated: On 7/1/19 at 2:00 PM, one tablet of Norco 10325 mg was given for severe pain at 10/10 pain scale; On 7/5/19 at 12:30 AM, one tablet of Norco 10325 mg was given for severe pain at 10/10 pain scale; On 7/6/19 at 3:30 PM, one tablet of Norco 10325 mg was given for severe pain at 9/10 pain scale; On 7/7/19 at 9:30 PM, one tablet of Norco 10325 mg was given for severe pain at 9/10 pain scale. During an interview on 1/14/20 at 9:32 AM, the DON could not provide any evidence the physician was notified when Resident 1 complained of severe pain at 10/10 pain scale on the dates mentioned above during the months of May, June, and July, 2019. During a review of the policy titled Clinical Protocol for Pain with the last revised date of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V0HU11 Facility ID: CA220000090 If continuation sheet 19 of 21 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055968 (X3) DATE SURVEY COMPLETED 02/03/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN HEIGHTS HEALTHCARE 35 Escuela Dr Daly City, CA 94015 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2/18 it indicated, "Assessment and Recognition: 1...Treatment/Management: 1... 2. The physician will order appropriate ... medication ... . Monitoring: 1... 2. The staff will ... report the resident's ... PRN analgesics... " During a review of the facility policy titled Comprehensive Care Plans with the last revised date of 9/2010, indicated: "An individualized comprehensive care plan ... is developed for each resident. Policy Interpretation/Implementation: 1...5. Care plan interventions are designed ... consideration of the relationship between the resident's problem areas and their causes. ... . 6. Identifying problem areas ... developing interventions that are targeted and meaningful to the resident..." During a review of the Situation Background Assessment Request (SBAR) document dated 7/12/19 at 7:40 PM, indicated "uncontrolled pain 10/10 leg pain bilateral (both legs)", "resident is requesting to be transfer to hospital", and "transfer to ED (Emergency Department) via 911 d/t (due to) uncontrolled pain." During a review of the Emergency Department Notes dated 7/12/19 indicated Resident 1 presented with "progressively worsening right foot/ankle/distal lower leg pain for the last several days." The section on Radiology Studies indicated CT scan (a computerized tomography scan (CT or CAT scan) uses computers and rotating X-ray machines to create cross-sectional images of the body) was done on 7/12/19 and the result of the imaging study was, "concerning for gas forming infection", and the diagnosis included "septic shock (infection throughout the body), osteomyelitis (an infection in a bone), necrotizing fasciitis (an acute disease in which inflammation of the fasciae of muscles or other FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V0HU11 Facility ID: CA220000090 If continuation sheet 20 of 21 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055968 (X3) DATE SURVEY COMPLETED 02/03/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN HEIGHTS HEALTHCARE 35 Escuela Dr Daly City, CA 94015 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE organs results in rapid destruction of overlying tissues), type 2 diabetes (a chronic disease, characterized by high levels of sugar in the blood) ulcer (an open sore on an external or internal surface of the body, caused by a break in the skin or mucous membrane that fails to heal) right lower leg.", electronically signed and dated by the physician on 7/13/19 at 12:09 AM. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V0HU11 Facility ID: CA220000090 If continuation sheet 21 of 21