Golden San Andreas Care Center: Opioid Logging Failures - CA
The resident, identified in inspection records only as Resident 5, had been admitted to the facility with low back pain and was prescribed hydrocodone/APAP for pain management. On May 13, May 25, and May 26, doses were signed out of the controlled drug accountability record by a licensed nurse. None of those three doses appeared anywhere on the medication administration record, the document other nurses rely on to know what a resident has already received.
The gap was discovered during a complaint inspection on May 29, when a state surveyor sat down with two licensed nurses and compared the controlled drug record against the medication administration record line by line.
The first nurse, identified as Licensed Nurse 2, confirmed what the documents showed: the doses had been signed out, and nothing had been entered on the medication administration record for any of those dates.
The second nurse, Licensed Nurse 4, confirmed she was the one who had signed out all three doses. She acknowledged she had not documented any of them on the medication administration record. She offered an explanation. Resident 5, she said, usually got anxious when he wanted his medication, and that anxiety had probably distracted her from completing the entry. She knew she should have documented it. She said so plainly: if another nurse came along and saw no record of a dose being given, that nurse might give the medication again.
The consequences of that, she described in clinical terms that left little to the imagination. An extra dose of hydrocodone could cause respiratory depression, the kind of slow, shallow breathing that signals the body is being suppressed. It could cause lethargy. In a worst-case scenario, it could cause an overdose.
The Director of Nurses, interviewed the same afternoon, said the same thing. Medications have to be documented when given, she said, to prevent errors. If Resident 5 had received extra doses of hydrocodone, she acknowledged, there was a real risk of overmedication.
What makes this particular failure worth examining closely is not the complexity of what went wrong. It was not a system failure or an equipment malfunction or a breakdown in communication between departments. It was a nurse removing a controlled opioid from a locked supply three times over the course of two weeks and not completing the second half of the required entry. The controlled drug record got her signature. The medication administration record got nothing.
Hydrocodone is among the most tightly controlled medications in a nursing facility's supply precisely because of the risks Licensed Nurse 4 described. Facilities maintain two parallel records for controlled substances for that reason. The accountability record tracks what comes out of the supply and who took it. The medication administration record tracks what goes into a resident. When both records are complete and consistent, a nurse picking up a chart at the start of a shift can see the full picture. When one of them is blank where it should not be, that picture disappears.
On three separate occasions in May, the picture disappeared for Resident 5.
The facility's own written policy, dated August 2014, spells out the requirement without ambiguity. When a controlled medication is administered, the nurse administering it enters the date and time, the amount given, and her signature on the accountability record at the moment the dose is removed from the supply. Then, after the medication is given, she enters her initials on the medication administration record. Both steps. Both records. The policy has been in place for over a decade.
Licensed Nurse 4 knew the policy. She knew what she had not done. She said so herself during the interview.
What the inspection record does not resolve is what happened in the moments between signing out those doses and walking away from the medication administration record unsigned. Whether Resident 5 received the medication on those three dates, or whether something else happened to those doses, the inspection report does not say. What it says is that the documentation that would answer that question does not exist.
That uncertainty is the core of the problem. A controlled medication tracking system works because it creates a paper trail that accounts for every dose from the moment it leaves the supply to the moment it reaches a resident. When a nurse signs out a dose and the trail goes cold, the system cannot do what it is designed to do. Nobody reviewing that record in the days that followed, or in the weeks that followed, could have known whether Resident 5 had received those doses or not. The medication administration record said nothing.
Inspectors rated the violation at the minimal harm level, meaning the documentation failures had the potential to cause harm rather than resulting in documented harm to Resident 5. The distinction matters for regulatory purposes. It matters less to the question of what another nurse would have done on the evening of May 13, or the afternoon of May 25, or the evening of May 26, if she had picked up Resident 5's chart and seen a clean medication administration record and a resident who was anxious and asking for his pain medication.
She would have had no way to know a dose had already been pulled.
The inspection covered five sampled residents. Inspectors found the documentation gap in one of them.
Licensed Nurse 4 said Resident 5 usually got anxious when he wanted his medication. That anxiety, she said, was probably what distracted her. She did not say it happened once, on a bad shift, when something unusual was going on. She described it as a pattern. Resident 5 usually got anxious. The implication is that the distraction was not a surprise. It was something she encountered repeatedly, across multiple shifts, across multiple weeks, and the documentation still did not get done.
The Director of Nurses did not indicate during her interview that the facility had been unaware of the gap before the inspection. The inspection report does not say whether anyone at the facility had caught the discrepancy between the two records before a surveyor sat down and compared them on May 29.
What is in the record is this: three doses of a controlled opioid were signed out over thirteen days, none of them documented as administered, and it took a complaint inspection to surface the problem.
Resident 5 came to Golden San Andreas Care Center with low back pain. He was prescribed a controlled medication to manage it. On at least three occasions in May, the nurse who gave him that medication walked away without completing the record that would tell every other nurse who came after her what he had already received.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Golden San Andreas Care Center from 2026-05-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
GOLDEN SAN ANDREAS CARE CENTER in SAN ANDREAS, CA was cited for violations during a health inspection on May 29, 2026.
On May 13, May 25, and May 26, doses were signed out of the controlled drug accountability record by a licensed nurse.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.