Golden San Andreas Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Jan 30, 2024

  Based on interview and record review, the facility failed to protect the right of Resident 45, 1 of 25 female residents in the facility with a diagnosis of dementia (impaired ability to remember or make decisions) to be free from sexual abuse, when interactions of a sexual nature occurred between a male resident (Resident 36) who had a history of known sexual behaviors directed towards females in the facility, and Resident 45; and the facility lacked a process to evaluate the capacity for residents in the facility to consent to sexual activity. […]

• Actual harm, isolatedF686May 13, 2025

  Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2) received care to prevent the development of pressure ulcers/injuries (PU/PI - areas of damaged skin caused by staying in one position for too long, usually over an area on the body where a bone is close to the skin's surface (bony prominence)) when: 1. Resident 1 was at risk for developing pressure ulcers and worsening of a shearing wound (a force that causes the skin and underlying tissues to move in opposite directions, often due to pressure and friction) on the coccyx (tailbone). […]

• Actual harm, isolatedF689Oct 15, 2024

  Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1) received adequate supervision and that care plan (an individualized set of goals and interventions specific to the Resident 1 ' s needs) interventions were implemented to prevent an injury when, Resident 1 ' s care plan interventions of a fall mat (a soft pad at the side of the bed to soften a fall) and two person staff assist with activities of daily living (ADL ' s; a term used to collectively describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility) were not implemented and Resident 1 fell from the bed on 9/24/24. […]

• Actual harm, isolatedF688Jan 30, 2024

  Based on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure that two of twenty-one sampled residents (Resident 64 and Resident 49) functional abilities did not diminish when: 1. Resident 64 had a decline in her ability to feed herself and services were not provided to determine the cause and/or maintain her abilities. 2. Resident 49 was not provided Restorative Nursing Assistant (RNA, nursing aide program that helps residents to maintain their function and joint mobility) services per her care plan interventions. […]

• Actual harm, isolatedF684Nov 10, 2023

  Based on interview and record review the facility failed to ensure quality care was provided to one of three sampled residents (Resident 2) when: 1. Staff were notified on [DATE] that Resident 2 had signs and symptoms of a urinary tract infection (UTI, a common infection which happens when bacteria, often from the skin or rectum, enter the urinary system) by Resident 2's family member but assessment and monitoring of Resident 2's condition was not done; and, 2. Resident 2 had a lung infection which began on [DATE]. Resident 2's physician examined her on [DATE] and did not document an assessment of Resident 2's lung infection was done; and, 3. […]