Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Golden Hill Post Acute during CMS and state inspections, most recent first.
Staff searched a cognitively intact resident's personal belongings without her permission while attempting to locate her communication device. The resident, who had aphasia and right-sided weakness from a stroke, became visibly anxious and distressed after her roommate informed her that a male CNA and the SSD had gone through her items. Both staff later acknowledged they should have obtained the resident's consent before searching her belongings, contrary to facility expectations and resident rights policy.
A resident with aphasia and right-sided weakness from a stroke, but cognitively intact per BIMS, was involved in a motor vehicle accident while Out On Pass as a passenger in a car driven by her significant other, who had a seizure history. After the facility learned from the ED that the resident had been in an accident and returned, the IDT documented the event and recommended a care conference but did not develop or implement a care plan addressing the resident’s safety during future OOPs. The resident reported feeling scared and stated the driver should not drive her anymore, and nursing and leadership staff acknowledged they believed the significant other should no longer drive the resident; however, no corresponding OOP safety interventions were added to the care plan so that all staff would be aware.
Two residents with severe cognitive impairment and known fall histories experienced repeated falls because staff did not consistently implement or update individualized fall-prevention measures after each incident. One resident with dementia and Parkinson’s disease fell multiple times in her room, hallway, and dining area, with some falls lacking any new interventions and with fall-risk identifiers (such as a yellow wristband and floor mat placement) not consistently in use. Another resident with encephalopathy, dementia, and prior brain injury also had numerous falls, many occurring at night near his bed, some resulting in injury, and several without new fall-prevention steps documented. Staff interviews revealed poor awareness of the true number of falls, uncertainty about residents’ diagnoses, and inconsistent use of the facility’s fall-risk identification system, despite policies requiring observation for causes of falls and initiation of individualized interventions.
Surveyors found that the facility did not consistently develop and update individualized fall-prevention care plans for two cognitively impaired residents with extensive fall histories. Over multiple months, each resident experienced numerous falls in and around their rooms and common areas, yet care plans often lacked new or resident-specific interventions after events, and some falls prompted no new measures at all. Staff interviews revealed that the DON and direct-care staff were unaware of the total number of falls, some staff did not know the residents’ diagnoses or specific care plan details, and CNAs relied on verbal reports rather than reviewing care plans. Observations showed inconsistent use of the facility’s fall-risk identification system, including missing colored wristbands, and fall equipment not always in active use, despite internal documents stating that individualized interventions should be initiated after a fall.
Multiple cognitively intact residents and a family member reported that call lights for medications, toileting, and personal care were often unanswered for 40–90 minutes, despite repeated Resident Council complaints over several months. One resident with quadriplegia described frequent hour‑long waits and a 90‑minute delay for medication, while another resident left AMA after experiencing prolonged waits and hearing staff socializing near the nurses’ station instead of responding. A family member observed CNAs sitting at the nurses’ station while call lights alarmed and was told assigned staff were on break or busy. Surveyors observed staff walking past active call lights, turning off call lights without providing care, and addressing a private caregiver instead of the resident, with staff later acknowledging they should have responded differently. Several residents reported that staff routinely turned off call lights and returned much later, and facility leadership acknowledged that call light response remained an ongoing problem.
A resident with diabetes, hypertension, and heart failure did not receive multiple physician-ordered medications within 24 hours of admission, including diabetes, BP, cholesterol, anticoagulant, antidepressant, and ophthalmic medications, because they were documented by nursing staff as not available and pending pharmacy delivery. Over a five-week stay, the resident also received a prescribed weekly dulaglutide injection only twice despite five documented opportunities, with nursing notes repeatedly citing waiting for pharmacy or providing no explanation for missed doses. The DON reported that medications were expected to be available within eight hours of admission and that nurses should have escalated unavailable medications, but acknowledged that although unavailability was documented, the issue was not resolved and medications were not administered as ordered, contrary to facility policies on admission medication ordering and medication administration.
A resident's care plan was found to be incomplete, lacking coverage of all needs and missing measurable timetables and specific actions. Surveyors observed that the care plan did not fully address the resident's requirements due to insufficient assessment and planning.
Resident Belongings Searched Without Permission, Causing Distress
Penalty
Summary
Facility staff searched a cognitively intact resident's personal belongings without obtaining her permission, violating her right to be treated with respect and dignity and to retain and use personal possessions. The resident, who had aphasia and right-sided weakness due to a stroke and a BIMS score of 13/15 indicating she was cognitively intact, was admitted earlier in the month. During an onsite investigation related to a previously reported motor vehicle accident involving the resident and her significant other, surveyors observed the resident in the courtyard attempting to communicate with a male CNA, who later returned with paper and pen for written communication, which the resident refused. Later that morning, the resident's roommate reported that a female and a male staff member had been searching the resident's personal belongings in their shared room. Following this report, the resident was observed shaking her head, grimacing, placing her hand on her forehead, repeating "no" and "why," and moving anxiously in her wheelchair. The CNA and the Social Services Director acknowledged they had searched the resident's belongings in an effort to locate her communication device and admitted they should have obtained the resident's permission before doing so. The resident stated she felt disrespected by the search. Facility leadership confirmed that staff are expected to obtain resident permission before searching personal belongings, and the facility's resident rights policy states that residents have the right to be treated with consideration, respect, and full recognition of their dignity and individuality.
Failure to Care Plan for Resident Safety While Out On Pass After Motor Vehicle Accident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a care plan addressing a resident’s safety while Out On Pass (OOP) following a motor vehicle accident (MVA) that occurred during an OOP. The resident had been admitted with aphasia and right-sided weakness due to a stroke, and a recent MDS showed a BIMS score of 13/15, indicating intact cognition. During an interview in the courtyard, the resident reported that her significant other (SO) had been driving at the time of the MVA, stated that the SO had a history of seizures and was on medication, and expressed feeling scared about the accident and that the SO should not drive her anymore. Emergency room records documented that the resident was a passenger, that the driver fled the scene, and that the resident sustained no injuries and was safe for discharge. The facility’s IDT documentation showed that the resident did not return within the allowed OOP time and that the facility learned from the emergency room that the resident had been in an MVA, with the resident returning to the facility afterward. The IDT record noted recommendations for a care conference with the resident and her SO, but there was no recommendation to develop and implement a care plan for OOP safety. The charge nurse acknowledged that the existing care plan did not address protection from potential future MVAs with the SO and stated that nursing staff had discussed that the SO should no longer drive the resident, but this was not incorporated into the care plan so all staff would be aware. During interviews, leadership staff, including the administrator and ADON, stated that the SO should not drive the resident for safety, and that this should have been included as an intervention in the resident’s care plan, confirming that no such care plan intervention had been developed or implemented.
Failure to Implement Effective, Individualized Fall Prevention After Repeated Falls
Penalty
Summary
The deficiency involves the facility’s failure to implement new, effective fall prevention measures after each fall incident for two residents with severe cognitive impairment and known fall risk. For the first resident, who had dementia, Parkinson’s disease, a BIMS score of 0, and no decision-making capacity, surveyors documented 13 separate falls over several months in various locations including her room, the hallway, and the dining room. Although some new interventions were occasionally added to the care plan after certain falls—such as lowering the bed, moving the resident closer to the nurse’s station, adding floor mats, consulting PT and pharmacy, increasing monitoring, and ordering a scoop mattress—several falls had no new interventions documented, and causative factors were not consistently identified. At the time of observation, the resident’s room displayed a gold star indicating fall risk, but she was not wearing the required yellow wristband, and a fall mat was leaning against the wall rather than in use. Staff interviews further showed gaps in awareness and understanding of the resident’s fall history and underlying conditions. The DON stated that all falls were tracked and discussed with leadership but was not aware of how many falls this resident had sustained. Nursing staff, including LNs and CNAs, acknowledged that the resident had fallen multiple times but underestimated the number of falls, with some believing she had fallen only two to three times. Several staff members, including CNAs and an LN, reported difficulty working with the resident, described her as not listening, and were unsure of her diagnosis or why she behaved as she did, despite prior dementia education. One CNA and one LN suggested that 1:1 supervision might have helped prevent further falls, and staff reported that the resident fell more often when her family member was not present. The second resident also had a history of falls, encephalopathy, dementia, brain injury, and severely impaired cognition, with a BIMS score of 7. This resident experienced at least 13 falls, most occurring in or near his bed, often at night or in the early morning, and sometimes associated with injuries such as bleeding from a dislodged Foley catheter, a reddened area on the lower back, a hip bruise, and a skin tear. While some new interventions were added after certain falls—such as ensuring the bed was in the lowest position, increasing visual checks, offering toileting, obtaining a pharmacist consult, scheduled toileting, a psychiatric evaluation, moving the resident closer to the nurse’s station, ordering lab tests, a scoop mattress, positioning the bed against the wall, and getting the resident up in a wheelchair during the day—multiple falls had no new fall-preventive measures documented. During observation, this resident’s room also had a gold star indicating fall risk, but he was not wearing the yellow wristband that staff, including CNA 4 and the DON, stated should be used to identify residents at risk for falls. Across both residents, the facility’s own policies required observation for the cause of each fall and initiation of individualized interventions. However, the COC forms and care plans did not consistently document causative factors, times, or locations of falls in sufficient detail to identify trends, and new interventions were not implemented after every fall. The DON later acknowledged that the COCs should have included more information to identify trends and that care plans should be updated to meet individual needs. The Medical Director stated that all falls were discussed in QAPI with a goal to reduce falls, and agreed that earlier use of interventions such as scoop mattresses or 1:1 supervision could have prevented injuries. Despite these processes, the two residents continued to experience repeated falls, and required fall-risk identifiers, such as yellow wristbands, were not consistently in place as observed by surveyors.
Failure to Maintain Individualized, Updated Fall-Prevention Care Plans for Two High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to develop and revise comprehensive, resident-centered fall prevention care plans with specific, measurable interventions for two residents with severe cognitive impairment and documented fall histories. For the first resident, who had dementia, Parkinson’s disease, a BIMS score of 0, and no capacity to make decisions, the record showed at least 13 falls over several months in various locations including the room, hallway, and dining room. After each fall, Change in Condition Evaluations and care plan entries documented limited or repetitive fall prevention measures such as lowering the bed, moving the resident closer to the nurse’s station, adding floor mats, consulting PT, pharmacy, or RNA, and offering toileting or increased monitoring. Several falls (including those on 8/11/25 and 11/14/25) had no new fall-preventive interventions added to the care plan. Despite multiple falls and a serious injury event on 2/1/26 that resulted in facial fractures and a broken rib, the care plan revisions did not reflect detailed, individualized strategies tied to identified causes or patterns of the falls. Staff interviews and observations further demonstrated gaps in care planning and staff awareness for this resident. The DON stated she was not aware of how many times the resident had fallen, although she reported that the IDT met after each fall to assess patterns and update the care plan. Nursing staff and CNAs acknowledged that the resident had fallen multiple times, but several were unsure of the exact number of falls, the resident’s diagnoses, or the specific care plan interventions. One nurse stated that dementia was probably the reason the resident tried to get up without assistance and commented that a 1:1 might have worked to prevent more falls, while another nurse said they were “trying everything” but it was not effective. CNAs reported relying on verbal report and morning huddles rather than reviewing care plans, and some did not know the resident’s diagnosis of dementia despite having received general dementia education. Observations showed the resident near the nurse’s station with a gold star posted outside the room but without a colored wristband, and fall equipment such as a fall mat leaning against the wall rather than in use. For the second resident, who had encephalopathy, dementia, brain injury, a history of falling, and a BIMS score of 7, the facility documented at least 13 falls or injury events, most occurring in or near the resident’s bed, often at night or in the early morning. The care plan was intermittently updated with general interventions such as keeping the bed in the lowest position, increasing visual checks, offering toileting, obtaining pharmacist and psychiatric consults, moving the resident closer to the nurse’s station, ordering lab tests, using a scoop mattress, positioning the bed against the wall, and getting the resident up in a wheelchair during the day. However, multiple falls (including those on 11/6/25, 11/25/25, 12/19/25, and 12/27/25) did not result in any new fall-preventive measures being added to the care plan. Observations showed the resident in bed with the bed low, landing mats in place, and the mattress curved upward, but without the yellow wristband that staff stated should be used to identify residents at risk for falls. A CNA assigned to observe several fall-risk residents stated she knew this resident had fallen before but did not know how many times or whether he had sustained injuries, and she described the gold star and yellow wristband system as important for staff awareness, even though the wristband was not present. The DON later acknowledged that, despite adding interventions, both residents continued to fall and that care plan interventions should be appropriate and individualized, while the facility’s undated "Fall System" document referenced individualized interventions without evidence that such individualized, resident-specific measures were consistently implemented or updated in the care plans.
Ongoing Delays in Call Light Response and Failures in Resident Dignity
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ rights to dignity, self-determination, communication, and timely response to call lights. Multiple residents with intact cognition reported prolonged waits, often up to an hour or more, for staff to respond to call lights for medications, toileting, and personal care. One resident with quadriplegia reported routinely waiting an hour or more for call light response and specifically described a 90‑minute wait for medication, stating that long delays in receiving medication or toileting assistance could cause serious complications to her health. Resident Council minutes from October 2025 through February 2026 repeatedly documented resident complaints about delayed call light response, including concerns about registry staff performance, lack of CNA communication during breaks, and difficulty finding available CNAs during some shifts. Another resident admitted for aftercare following joint replacement surgery and needing assistance with personal care reported that she chose to leave the facility AMA due to call light response problems. She described waiting over an hour for a call light to be answered, and when a staff member finally entered her room, the staff member stated they would get her CNA, even though that staff member was actually the CNA assigned to her. This resident’s room was near the nurses’ station, and she reported hearing staff seated for long periods, laughing and talking, while she waited for assistance. A third resident’s family member documented that call lights often took up to 40 minutes for staff to respond and reported observing three CNAs sitting at the nurses’ station while call lights were alarming. When the family member requested assistance, staff frequently stated that the assigned staff person was on break or busy with other residents and that no other staff were available to help. Surveyor observations and staff interviews further demonstrated failures in timely and appropriate call light response and respect for resident dignity. During an observation, an admissions employee walked past an active call light without responding and acknowledged that all staff were expected to answer call lights but admitted she had not done so, stating she had kept another resident waiting about an hour. In another observation, a resident in a wheelchair requested help to use the bathroom; a CNA entered, turned off the call light without addressing or looking at the resident, and stated he could not assist because the resident requested female CNAs, acknowledging he should have left the call light on since he could not provide the requested care. A subsequent CNA arrived and spoke to the resident’s private caregiver instead of the resident, later admitting she should have addressed the resident directly and consulted coworkers about the resident’s toileting needs. Additional residents reported that staff routinely turned off call lights and left, with actual assistance often delayed about an hour, and described feeling as though no one could see them or that staff had an attitude when they finally responded. The Activities Director and DON both acknowledged that call light response was an ongoing problem, and the Activities Director stated that additional training and monitoring had not improved the process.
Failure to Provide Ordered Medications and Ensure Timely Pharmacy Delivery
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services and administer medications as ordered for a resident admitted with diabetes, hypertension, and heart failure. Upon admission, the resident had 14 scheduled medications ordered by the physician as of 11/5/26. Review of the Medication Administration Record (MAR) showed that on 11/6/26, within 24 hours of admission, the resident received only five of the 14 prescribed medications, three of which were supplements and two over-the-counter medications for pain and allergies. The remaining nine medications, including two diabetes medications, three blood pressure medications, a cholesterol medication, a blood thinner, an antidepressant, and eye drops, were not administered. For each of these missed medications, the Licensed Nurse documented that the medications were not available and that the facility was waiting for pharmacy delivery. The resident also had a physician’s order dated 11/5/25 for dulaglutide, a once-weekly injection to control blood sugar, ordered to be given one time a day with no specific day of the week indicated. Nursing notes on 11/6/25 and 11/13/25 documented that the facility was waiting for the pharmacy to deliver this medication, and notes on 11/27/25 and 12/4/25 documented that the medication was not administered without providing any explanation. Over the five-week admission period, the MAR showed five opportunities to administer dulaglutide, but it was given only twice. The DON stated that all medications should be available within eight hours of admission and that if medications were not available, nurses should have notified the DON or Assistant DON to find a solution. The DON acknowledged that although LNs documented that medications were not available, no staff resolved the issue and the medications were not administered as they should have been. Facility policies required ordering medications from the pharmacy with delivery within eight hours of admission and accurate preparation and administration of medications as ordered.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified regarding the development and implementation of a complete care plan for a resident. The care plan did not address all of the resident's needs, and it lacked measurable timetables and specific actions. This failure resulted from incomplete assessment and planning, as the care plan did not comprehensively cover the resident's requirements as observed by surveyors.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near San Diego
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arroyo Vista Nursing Center | 1.8 mi | — | 0 | 0 |
| Brighton Place San Diego | 2.3 mi | — | 1 | 0 |
| St. Pauls Health Care Center | 2.6 mi | — | 4 | 0 |
| Balboa Nursing & Rehabilitation Center | 2.8 mi | — | 7 | 0 |
| Castle Manor Nursing & Rehabilitation Center | 2.9 mi | — | 0 | 0 |
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