Golden San Andreas Care Center
GOLDEN SAN ANDREAS CARE CENTER in SAN ANDREAS, CA — inspection on May 29, 2026.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a concurrent interview and record review on 5/29/26 at 11:44 AM with Licensed Nurse (LN) 2, Resident 5's clinical document titled, ANTIBIOTIC OR CONTROLLED DRUG RECORD, dated 5/1/26 through 5/31/26, was compared with Resident 5's MAR, dated 5/1/26 through 5/31/26.
The ANTIBIOTIC OR CONTROLLED DRUG RECORD indicated doses of hydrocodone/APAP were signed out by a licensed nurse on the following dates: 5/13/26 at 8 PM5/25/26 at 4 PM5/26/26 at 8 PM LN 2 confirmed the doses were signed out on the ANTIBIOTIC OR CONTROLLED DRUG RECORD, and not documented as administered on the MAR for the dates of 5/13/26, 5/25/26, and 5/26/26.
During a concurrent interview and record review on 5/29/26 at 2:18 PM with LN 4, Resident 5's clinical document titled, ANTIBIOTIC OR CONTROLLED DRUG RECORD and the MAR, for the dates of 5/1/26 through 5/31/26 were reviewed. LN 4 confirmed she signed out hydrocodone/APAP on the ANTIBIOTIC OR CONTROLLED DRUG RECORD for Resident 5 on 5/13/26, 5/25/26, and 5/26/26 and did not document it on the MAR. LN 4 stated Resident 5 usually got anxious when he wanted his medication which probably distracted her (LN 4) from documenting the medication as administered in the MAR. LN 4 further stated she had not documented on the MAR that Resident 5 had been given the medication doses, and she should have, to ensure other LNs did not inadvertently administer another dose of medication. LN 4 stated if Resident 5 received an extra dose of hydrocodone/APAP he could experience respiratory depression (slow, shallow breathing pattern), lethargy, (feeling very tired) or experienced an overdose (too much medication given in too short of a time frame could lead to injury or death) of the medication.
During an interview on 5/29/26 at 2:20 PM with the Director of Nurses (DON), the DON stated medications should be documented when given to prevent medication errors.
The DON further stated there was a risk to Resident 5 of being overmedicated if he received extra doses of hydrocodone/APAP. A review of a facility policy and procedure titled, PREPARATION AND GENERAL GUIDELINES.CONTROLLED MEDICATIONS, dated 8/2014, indicated, .When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR).Date and time of administration.amount administered.Signature of the nurse administering the dose on the accountability record at the time the medication is removed from the supply.Initials of the nurse administering the dose on the MAR after the medication is administered.
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.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.