Golden Harbor Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to provide Registered Nurse (RN) coverage eight hours a day, seven days a week. This failure presents a threat to residents reaching their highest practicable level of well-being and had the potential to endanger the health and safety of residents. During a concurrent interview and record review on 8/27/25 at 11:06 a.m. with the Staffing Coordinator (SC), the facility's licensed staffing schedules for the month of January 2024 through March 2024 were reviewed, the staffing schedule indicated there were no Registered Nurses (RN) scheduled to work eight hours a day during the following dates:1. For the month of January 2024: 1/10/24; 1/11/24; 1/16/24 and 1/25/24.2. For the month of February 2024: 2/8/24; 2/9/24 and 2/13/24. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure:1. Controlled substance medications (medication with a high potential for abuse and addiction) were accurately accounted for on the medication administration record (MAR) and the Controlled Drug Record (CDR, an accountability record) for three of four randomly selected residents (Residents 11, 20, and 101);2. The intravenous (IV, administered into the vein) supplies, narcotic, and intramuscular (IM, injected into the muscle) emergency kits (e-kit; a kit/box containing medications and supplies for immediate use during a medical emergency) were replaced according to facility policy and procedure (P&P) after use; 3. Routine medication for one of 50 sampled residents (Resident 16) was available for administration. 4. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were not stored on top of medication carts (med carts) when left unattended, med carts were locked when left unattended, medications with shortened expirations after use were labeled with an opened date, and med carts were kept clean and orderly. The deficient practices had the potential for unauthorized staff/residents to access medications, for residents to receive medications with unsafe and reduced potency, for residents to suffer hazardous cross-contamination to their medications, and for medications to not be safely administered to residents. During a medication pass observation on 8/25/25 at 12:19 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 was observed preparing medications for a Resident 40. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure infection control measures were maintained for six of 51 sample residents (8,25,65,105,93, and 83). This failure had the potential to result in six sampled residents developing and transmitting infections when:1a. Central Supply 1 did not sanitize hands when entering and existing Contact Precaution rooms [ROOM NUMBERS].1b. Central Supply 1 refilled 1/2 empty glove boxes from Contact Precautions rooms [ROOM NUMBERS] using bare hands1c. Registered Nursing Supervisor 1 did not disinfect / sanitize reusable medical equipment (scissors).1d. Certified Nursing Assistant did not know effective properties and dwell time of Sani Wipes for shared COVID reusable medical equipment .1e. Laundry Assistant 1 did not clean the dryer lint trap at the scheduled time and appropriately initial the dryer lint log.2a. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents' medical records were updated to show documentation that advanced directives (written statement of a person's wishes regarding the medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor), were discussed with the residents and/or responsible parties for 14 of 51 sampled residents (Residents 1,2,4,6,7,8,10,11,12,28,33,53,57 and 77). This had potential for the facility to provide treatment and services against the residents' wishes. 1. During a review of Resident 1's admission Record (AR), dated 8/29/25, indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included adult failure to thrive (a sickness characterized by weight loss, decreased appetite, poor nutrition, and inactivity). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect and keep secure when not in use, confidential resident health data and records for a census of 94. This failure had the potential to expose and disclose personal and confidential health information to unauthorized individuals. During a medication pass observation on 8/25/25 at 12:19 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1's computer screen was observed unlocked and accessible to residents and staff passing by when he left to administer medications to Resident 40. During an interview on 8/25/25 at 3 p.m. with LVN 1, LVN 1 confirmed he had left the computer unlocked and unattended when he went to administer medication to Resident 40. During an interview on 8/26/25 at approximately 4:30 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure maintenance services were provided to maintain a comfortable and homelike environment for seven of 51 sampled residents when:For Resident 33, Resident 14, Resident 74, and Resident 81, wall clocks were not provided in their rooms. This failure resulted in emotional distress for not having a wall clock and not knowing what time it was for the residents who occupied those rooms. 2. For Residents 36, 46, and 90, their rooms had peeling paint, missing baseboards, and exposed patchwork. These failures had the potential to decrease residents' quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure patient safety for medication use for three of 51 sample residents (Residents 11, 20 and 104) when:1. Multiple incomplete and unclear PRN (as needed) pain medication orders were not clarified for indication for use (e.g. mild, moderate, or severe pain) prior to administration.2. Insulin was not administered in accordance with manufacturer specifications and standards of practice. These failures had the potential to result in inappropriate medication administration, preventable medication errors, increased risk of adverse drug events, oversedation, and resident harm or death.1a. During a concurrent interview and record review on 8/27/25 at 9:02 a.m. with Director of Nursing (DON), Resident 20's physician's orders were reviewed. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure four of 51 sampled residents (Residents 10, 11, 20, and 101) were free from unnecessary medication when narcotic pain medication was administered not in accordance with physician's orders. This failure had the potential to unnecessarily expose residents to adverse consequences of medications and inadequate indication of use of medications.1. During a concurrent interview and record review on 8/27/25 at 9:02 a.m. with Director of Nursing (DON), Resident 20's physician's orders and Medication Administration Records (MARs) were reviewed. Resident 20's medical record indicated a physician's order for tramadol (a narcotic pain medication) 50 milligrams (mg, a unit of measurement), give 1 tablet by mouth every 6 hours as needed for pain, ordered 8/10/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility had a 11.63% error rate when five medication errors out of 43 opportunities were observed during a medication pass for four of eight Residents (Residents 16, 49, 73 and 104). This failure resulted in medications not given in accordance with the manufacturer's specifications and potential to affect the residents' clinical conditions. During a medication pass observation on 8/25/25 at 10:40 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policy and ensure safety of self-administered medication for one resident (Resident 40) out of a census of 94, when Resident 40 self-administered insulin lispro (a fast-acting insulin to treat diabetes) without a physician's order, evaluation by the Interdisciplinary Team (IDT, a group of professionals, including the resident, their family, physicians, nurses, social workers, and therapists, who collaborate to develop, implement, and monitor the resident's individualized care plan) and applicable care planning. This failure increased the potential for Resident 40 to not receive the full therapeutic effect of the medication, and risk of injury and infection from the incorrect administration of medication. During a medication pass observation on 8/25/25 at 12:08 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of 51 sampled residents (Residents 10 and 13) was free from unnecessary psychotropic medication (drugs that affects brain activities associated with mental processes and behavior) when1. Resident 10 received Cymbalta (a psychotropic medication to treat depression) without implementation of non-pharmacological (non-drug) interventions in an effort to lower the dose or discontinue the medication.2. Resident 13 did not have the appropriate indications for the use of Seroquel (Seroquel is an antipsychotic medication; antipsychotic medications are medications that are used to treat symptoms of psychotic mental disorder such as delusions, hallucinations, paranoia, or confused thoughts). These failures had the potential to result in unnecessary use of medication.1. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one sample resident's (Resident 50) / out of 51 residents, English / Chinese picture board for communication was utilized to effectively communicate with others. This lack of effective communication resulted in Resident 50 feeling unable to communicate with staff and experiencing frustration. During an interview on 8/26/25 at 10:30 a.m. at the facility Resident Council meeting, Resident 50 stated she had a difficult time communicating with and understanding the staff. Resident 50 was noted to be articulate a with hearing deficit. During a record review of Resident 50's admission Record (AR), the AR indicated. [...]

Inspectors wroteBased on observation, interview, and record review, for one of one sampled resident (Resident 14), the facility failed to provide treatment and care consistent with professional standards of practice when a resident was provided a wheelchair (w/c) that was inappropriate for resident's size. This failure had the potential to compromise Resident 14's safety and support while up in the w/c. A record review of Resident 14's admission Record' (AR), printed on 8/27/25, AR indicated resident 14 was admitted to the facility in November 2024 with multiple diagnoses that included diabetes mellitus (high blood sugar), dementia (memory loss), and muscle weakness. A review of Resident 14's Minimum Data Set (MDS, an assessment tool used to direct resident care), dated 7/28/25, indicated Resident 14 was able to understand others and be understood. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe environment was provided for one of three sampled residents (Resident 57) when:1. Licensed Vocational Nurse 4 (LVN 4) failed to assess Resident 57 immediately after CNA 1 reported resident's unwitnessed fall incident. 2. CNA 1 assisted Resident 57 back to the chair without the appropriate Licensed Nurse knowledge and assessment, following the resident's unwitnessed fall to the floor in the resident's room. These failures resulted in delay in receiving the appropriate medical interventions necessary to meet the resident's nursing care needs and potentially placing Resident 57 at risk for further harm or injury post fall. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 51 sampled residents call light (Resident 89) was answered promptly. This failure had the potential for Resident 89's needs not to be met in a timely manner and had the potential to result in skin injuries. During an initial tour of the facility on 8/25/25 at 10:23 a.m. in Resident 89's room, the resident stated she had to wait for a long time before her call light was answered, and also, stated she had to wait a long time for her incontinent briefs to be changed. Call light response time was tested, and Resident 89 pressed her call light at 10:25 a.m. The Assistant Director of Nursing (ADON) was observed to answer the resident's call light at 10:48 a.m. The ADON stated it was not acceptable for the resident to wait for 23 minutes (the amount of time that had passed from 10:25 a.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one of one sampled resident (Resident 1) when: 1. Resident 1 did not receive a medication called albuterol sulfate (used to prevent and treat wheezing, a high-pitched sound that occurs during breathing when the airways in the lungs become narrowed or blocked, and shortness of breath caused by breathing problems) inhalation according to physician's order. 2. Resident 1's oxygen saturation (amount of oxygen you have circulating in the blood) level was not monitored from 1/27/25 to 1/29/25 appropriately when Resident 1 had complaints of shortness of breath and wheezing. This failure had the potential to worsen Resident 1's respiratory condition.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide pharmaceutical services and procedures that assure accurate dispensing and administration when Resident 1's Inhaler medication [Albuterol Sulphate ( Medication that helps with breathing by relaxing the muscles of the airways)] was not available on hand per physician's order. This failure had the potential to cause Resident 1's worsened respiratory condition including respiratory arrest (occurs when breathing stops).

Inspectors wroteBased on interview and record review the facility failed to identify and address a potential accident hazard when Activity Assistant (AA) 1 did not take the appropriate action to prevent accidents after Resident 1 inquired about purchasing a firearm and if the AA knew where or from whom a gun could be obtained. This failure placed the facility ' s 63 residents at risk for harm and injury when a gun and ammunition were found in Resident 1's room.

Inspectors wroteBased on observations, interviews, record reviews, for two of three (Resident 53 and 43) sampled residents who were reviewed for close supervision, the facility failed to ensure Resident 52 and 43 were supervised when, 1. Resident 52 who was high risk for elopement left the facility unattended on 5/14/2024 between 10:15 a.m. and 11:14 a.m., and 2. Resident 43 who had a history of frequent seizures and falls was not monitored for 50 minutes. These failures resulted in Resident 52 eloping from the facility unattended on a sidewalk in a street intersection and had the potential for Resident 43 to sustain an injury if experienced an unwitnessed seizure. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure there was Registered Nurse (RN) coverage eight hours a day, seven days a week, when an RN was not on duty for eight of 12 days sampled. This failure has the potential to endanger the health and safety of residents while presenting a threat to residents from reaching their highest practicable level of well-being.

Inspectors wroteBased on interview and record review, the facility failed to implement a comprehensive person-centered care plan to address the risk of elopement (leaving a facility without staff knowledge) for two (Resident 52 and Resident 4) out of three sampled residents, when 1. Resident 52's Wanderguard (a type of alarm to help protect those at risk for elopement) interventions were not implemented and Resident 52 eloped from the facility. 2. Resident 4's Wanderguard interventions were not implemented. These failures resulted in Resident 52 eloping from the facility for almost one hour without staff knowledge (Cross reference F689) and had the potential for Resident 4 to elope from the facility which could result in injury and/or death.

Inspectors wroteBased on interview and record review, the facility failed to ensure a system of records for controlled drugs (medications regulated by the government due to high risk for potential abuse and dependence) for disposition were followed and maintained when three Controlled Drug Logbook (CDL) pages of the Narcotics Destruction Log (NDL) were not consistently completed with date of Director of Nursing Services (DNS) receipt of controlled medications, no co-signatures by the licensed nurse and DNS upon exchange of controlled medications, and no page number. The failure to complete three CDL pages listing a total of 43 medications had the potential to prevent accurate accounting of controlled medications and prompt identification of loss, extent of loss, or potential diversion of controlled medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of 18 sampled residents (Residents 33, 23, and 28) residents were free from unnecessary psychotropic drugs (medications that are capable of affecting the mind, emotions, and behavior) when: 1. Resident 33's PRN (pro re nata [a Latin phrase], meaning as needed, or as necessary) order for Olanzapine (an anti-psychotic medication used to treat mental disorders) had no end date. 2. Resident 23 had no rationale for continued use of PRN Ativan beyond 14 days (Ativan is a psychotropic medication used to treat anxiety). 3. Resident 28 had no rationale for continued use of PRN Ativan beyond 14 days. These failures had the potential to not promote or maintain Resident 33's highest practicable mental, physical, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were dated and stored under proper temperature controls in the medication refrigerator for one of two medication rooms (a locked room used to store medications and supplies) when: 1. Medication refrigerator temperatures were not monitored daily for nine days out of 31 days in May 2024. 2. Two multiple dose vials of Tuberculin Purified Protein Derivative (PPD, a test used to detect tuberculosis (an illness that affects the lungs), were not labeled with the date the vials were opened. These failures had the potential to result in resident use of ineffective medications.

Inspectors wroteBased on interview, record review, the facility failed to update and revise four of 16 sampled resident (residents 10, 23, 29 and 34) care plans. These failures had the potential for Residents 10, 23, 29 and 34 to receive inappropriate interventions to manage care.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure five (Residents 19, 23, 24, 36, and 39) sampled residents were provided a shower as scheduled for dependent residents. This deficient practice placed residents at risk for poor hygiene, body odor and psychosocial discomfort.

Inspectors wroteBased on interviews and record review, the facility failed to ensure three sampled residents (Resident 19, 24 and 36) received behavioral health care and services when Resident 19, 24 and 36 had not received a psychiatrist (physician specializing in mental health) evaluation as planned and ordered by the physician. This deficient practice had the potential to cause residents continued emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to follow the policy and procedure to conduct infection control surveillance when they did not track, analyze, and create infection control data. This deficient practice had the potential for infections to go undetected or controlled which could spread within the facility.

Inspectors wroteBased on interview and record review, the facility failed to follow the policy and procedure to implement antibiotic stewardship when they did not monitor appropriate use of antibiotics and improved outcomes for residents. This deficient practice had the potential to spread infection in the facility.

Inspectors wroteBased on interviews and record review, the facility failed to make reasonable effort to safeguard the resident's property for one (Resident 36) sampled resident when Resident 36 complained of missing socks which was not investigated. This deficient practice had the potential to cause Resident 36 distress.

Inspectors wroteBased on interview and record review, for one of three residents (Resident 49) reviewed for closed records, the facility failed to notify Resident 49's representative of the decision to transfer Resident 49 to the hospital. This failure had the potential to result in the representative being unaware of changes in Resident 49's health status and whereabouts.

Inspectors wroteBased on interview and closed record review, for two of three sampled residents, (Residents 47 and 49), the facility failed to: 1. Notify in writing, Resident 47 and Resident's Representative 2 (RR 2) of the reason for the discharge in Resident 47's clinical record. 2. Notify in writing, Resident 49 and RR 1 of the hospital transfer. These failures had the potential to result in lack of information to prepare the residents and their resident representatives following the discharge or hospital transfer.

Inspectors wroteBased on interview and closed record review, for one of three sampled residents (Resident 49), the facility did not provide Resident 49 and Resident Representative 1 (RR 1) written information about the facility's bed hold policy before and upon transfer to the hospital. This failure had the potential to result in Resident 49 being unaware of the right to return to the facility during a therapeutic leave according to the bed-hold policy.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the Minimum Data Set (MDS-Resident Assessment and Care Screening tool used to guide care), was accurate for one ( Resident 24) sampled resident when Resident 24's preadmission screening for serious mental illness was not coded accurately. This deficient practice had the potential for residents to not received appropriate mental health care and services.

Inspectors wroteBased on interview and record review, for one of two sampled residents (Resident 27) reviewed for PASRR (Pre-admission Screening and Resident Review (a screening tool to determine if individuals with serious mental illness or intellectual/developmental disability or related condition require nursing facility services or specialized services), the facility failed to follow-up on PASRR level II screening as determined by Resident 27's PASRR Level I screening. This failure had the potential to result in Resident 27 not being provided specialized care and services to address a mental illness.

Inspectors wroteBased on interview and record review, for one of four sampled residents (Resident 14), the facility failed to implement a comprehensive person-centered care plan to address Resident 14's weight gain. This failure resulted in further weight gain that was not addressed appropriately.

Inspectors wroteBased on observation, interview, and record review, for one (Resident 30) of one sampled resident reviewed for skin issues, the facility failed to ensure treatment and care were provided in accordance with the resident's choice when skin care was not provided to address Resident 30's dry skin. This failure had the potential to result in skin breakdown.

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff had the appropriate competencies and skills sets for providing care to residents when staff training for behavioral services were not provided. This failure had the potential to result in inappropriate care that did not meet the needs of the residents with behavioral issues.

Inspectors wroteBased on interviews and record review, the facility failed to ensure two (Residents 27 and 36) sampled residents were free from unnecessary drugs when: 1. Resident 36 was administered trazodone (anti-depressant and sedative medication) for insomnia (inability to fall asleep or stay asleep) without adequate monitoring for hours of sleep. 2. Resident 27 behavioral symptoms were not monitored for the use of lorazepam (anti-anxiety medication). This deficient practice had the potential for residents to receive unnecessary drugs or the appropriate medication dosage to manage their condition which could have adverse side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove expired medication for one of 16 residents (Resident 31). This failure had the potential to result in Resident 31 being given expired medication and did not ensure safe medication administration.

Inspectors wroteBased on interview and record review, for one of four sampled residents (Resident 14), the facility failed to obtain physician ordered laboratory tests. This failure resulted in not monitoring and reporting potential abnormal test results.

Inspectors wroteBased on interviews and record review the facility failed to ensure the staff skills competency evaluations were completed for one [NAME] (CK 1). CK 1's competency evaluation was not completed before food preparation of the residents' meals. This deficient practice had the potential to result in food preparation under unsanitary conditions or foodborne illness.

Inspectors wroteBased on interview and record review, for one of three sampled residents (Resident 42) reviewed for advanced directives, the facility failed to ensure Resident 27's clinical record was complete when the POLST (Physician Order for Life-Sustaining Treatment) form was not completed and signed. This failure had the potential to result in Resident 42 receiving care against her wishes.

Inspectors wroteBased on interview and record review, the facility's quality assessment and assurance committee did not meet quarterly as required. This failure had the potential to result in not identifying quality of care issues and follow up on set goals. Findings During an interview and concurrent review of the facility's records with the Administrator (Admin), on 3/24/22 at 12:42 p.m., Admin stated the facility's last quality assurance (QA) meeting was in November 2021. Admin stated, the QA meetings were to be done every quarter, and the next one would have been done in February 2022. Admin further stated there was no record of the QA meeting having occurred in February 2022.