Golden Empire

In the surveyor’s words

From the most serious findings on record at Golden Empire, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Dec 1, 2023

  Based on observation, interview, and policy review, the facility failed to follow infection control standards for hand hygiene for three of seven sampled residents (Residents 58, 67 and 378) when: 1. A Licensed Nurse (LN) handled multiple meal trays and then handled a drinking straw without performing hand hygiene, for Resident 58. 2. A Certified Nursing Assistant (CNA) handled multiple meal trays and then handled a drinking straw without performing hand hygiene, for Resident 67. 3. A LN did not perform hand hygiene before or after she obtained a blood sample from Resident 378, and then cleaned medical equipment while wearing the same gloves used to obtain the blood sample. 4. […]

• No harm, potential for more than minimal, patternF583Aug 22, 2025

  Based on observation, interview, and record review the facility failed to ensure the confidentiality of Identifiable information for a census of 137 residents, when residents' meal tickets with personal information were accessible to view by other residents and visitors.These failures decreased the facility's potential to protect residents' identifiable information.Findings:During an observation on 8/19/25 at 10:21 a.m. in the facility main dining room, the residents' breakfast trays being returned to kitchen were found unattended with meal tickets on them. Each meal ticket had resident's name, facility identification number, resident's colored photograph, room number, bed number and dining location in an easy to view status. […]

• No harm, potential for more than minimal, patternF641Aug 22, 2025

  Based on interview and record review, the facility failed to ensure accurate assessments were completed for four of 36 sampled residents (Resident 9, Resident 98, Resident 129, and Resident 133) when: 1. Resident 9's Minimum Data Set (MDS- a federally mandated resident assessment tool) was incorrectly marked for invasive mechanical ventilator (a breathing machine connected to a tube inserted into the windpipe through the neck);2. Resident 98's MDS did not reflect the resident's terminal prognosis;3. Resident 129's MDS did not indicate resident was on hospice care; and, 4.Resident 133's MDS assessments were not consistent with resident's status. […]

• No harm, potential for more than minimal, patternF761Aug 22, 2025

  Based on observation, interview, and record review, the facility failed to ensure:Medications and medical supplies were not available for residents' use past their expiration dates in three of three medication carts;Crash carts (storage of supplies needed in emergency situations) were checked regularly, and medical supplies were complete and were not past their expiration dates; andA medication was stored in the Resident Food Refrigerator at the memory unit.These failures had the potential for residents to receive medications with unsafe or reduced potency from being used past their expiration dates, and the potential for malfunctioning equipment and delays during emergency situations for a census of 137.Findings: During a concurrent observation and interview on 8/20/25 at 3:02 p.m. […]

• No harm, potential for more than minimal, patternF812Aug 22, 2025

  Based on observation, interview, and record review, the facility failed to store food in a sanitary manner for a census of 137 residents, when: 1. Expired, undated, unlabeled, spoiled, unsealed opened food items, and a dirty food tray were found in the walk-in refrigerator, walk-in freezer, and in the cooking area in the kitchen;2. The floor in the walk-in freezer was dirty;3. Cooking equipment and utensils were not clean;4. Undated and expired food items were stored in the resident food refrigerators in the three nursing units and temperature logs were inconsistent; 5. No written instructions were followed for cooking spinach; and 6. […]