Golden Merced Care Center

In the surveyor’s words

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

• Actual harm, isolatedF689Sep 1, 2023

  Based on interview and record review the facility failed to provide adequate supervision (observation, oversight, and guidance of the individual by staff close enough to intervene and protect from harm) to prevent accidents for one of three sampled residents (Resident 1), when the facility failed to develop effective interventions for falls which occurred on 7/1/23, 7/4/23 and 7/8/23. These failures resulted in Resident 1 experiencing another fall on 7/8/23 with injuries of an Intracerebral Hemorrhage (bleeding inside the brain), right zygomatic (bones on upper side of the face that forms the cheek and part of the eye socket) fracture and right clavicle (collarbone) fracture along with pain and hospitalization . […]

• Actual harm, isolatedF689Aug 25, 2021

  Based on interview and record review, the facility failed to ensure one of three sample residents (Resident 1) received adequate supervision and assistance with activities of daily living (ADL- term used in healthcare to refer to people's daily self-care activities such as grooming/personal hygiene, dressing, toileting/continence) care, when Resident 1 required two staff for ADL care per Resident 1's assessed need (care plan- direction on the type of nursing care the individual may need) and Nursing Assistant (NA) 1 turned Resident 1 in bed independently (without the assistance of another staff) on 7/2/21. This failure resulted in Resident 1 falling out of bed and onto the floor on 7/2/21. […]

• No harm, potential for more than minimal, widespreadF880Oct 4, 2023

  Based on observation, interview, and record review, the facility failed to maintain infection and control practices to ensure a provision of a safe and sanitary environment for 103 out of 103 residents when: 1. One of two shower rooms had mold on the shower curtain. 2. Monitoring and tracking of deep cleaning for 52 of 52 resident rooms were not done as per policy. These failures had the potential to result in the development and transmission of communicable diseases, illness, and infections. Findings: During an interview on 9/7/23 at 8:55 a.m. with Resident 1, Resident 1 stated there was mold on the shower curtains in the shower room. […]

• No harm, potential for more than minimal, widespreadF802Mar 24, 2023

  Based on observation, interview, and record review, the facility failed to ensure the food and nutrition services staff safely carried out the meal service functions according to facility policies and procedures when food substitutions which were not approved by the Registered Dietitian (RD) were served to residents. These failures had the potential to negatively affect food intake of residents which may result in altered nutrition status for 79 residents who consumed food from the kitchen. Cross reference F803 and F 804 Findings: During a concurrent observation, interview, and record review on 9/12/22, at 11:00 A.M., lunch meal was being prepared in the kitchen. The Cook (CK) was heating a large metal batch pan of cauliflower in the oven. […]

• No harm, potential for more than minimal, widespreadF803Mar 24, 2023

  Based on observation, interview, and record review, the facility failed to ensure the food and nutrition services staff safely and correctly carried out the meal service functions according to facility policy and procedure when: 1. Menu substitutions served to residents with therapeutic diets were not approved by the kitchen Nutrition Services Manager (NSM) or the Registered Dietitian (RD) prior to serving the food item. 2. The renal therapeutic menu was not followed for 10 residents on a renal diet. These failures had the potential to decrease food intake, which may alter nutrition status and lead to weight loss in the 79 residents who received food from the kitchen. Cross reference F804 Findings: 1. […]