Health inspection·March 24, 2022

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based 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. Findings: Review of admission Record indicated Resident 49 was admitted to the facility with diagnoses that included a subarachnoid hemorrhage (bleeding in the space that surrounds the brain), dysphagia (difficulty swallowing), and acute respiratory failure (when fluids build up in the air sacs in the lungs). Resident 49's admission Record indicated Resident Representative (RR) 1 was Resident 49's emergency contact. Review of the Progress Notes titled, SBAR (situation, background, assessment and recommendation) Change of Condition dated 12/22/21, indicated Resident 49 had severe cramping to the right side groin area with protrusion of the area and very tender to touch. Resident 49 was transferred to the acute hospital via 9-1-1. During a joint interview and concurrent review of the clinical record with the Social Services Director (SSD) and Medical Records Director (MRD), on 3/24/22 at 9:55 a.m., SSD and MRD both stated there was no documentation that RR 1 was notified of the transfer. SSD stated there should still be a resident representative notification for 9-1-1 hospital transfers. During an interview with the Licensed Vocational Nurse (LVN) 1 on 3/24/22 at 9:45 a.m., LVN 1 stated, when transferring a resident to the hospital, the licensed nurse should call to notify the resident representative of the situation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056471 If continuation sheet Page 2 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Harbor Healthcare Center 442 Sunset Boulevard Hayward, CA 94541 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Level of Harm - Minimal harm or potential for actual harm Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on interview and closed record review, for two of three sampled residents, (Residents 47 and 49), the facility failed to: Residents Affected - Few 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. Findings: 1. Review of Resident 47's admission Record indicated Resident 47 was admitted to the facility with diagnoses that included Alzheimer's dementia (memory loss and impaired decision-making ability), and pneumonia (infection of the lungs caused by bacteria, virus or fungi). Review of Resident 47's Progress Notes Dated 12/21/21 indicated Resident 47 was picked up by ambulance and discharged to a board and care. During an interview with the Social Services Director (SSD) on 3/23/22 at 3:09 p.m., SSD stated Resident 47 and RR 2 were not notified in writing about the reason for discharge. SSD stated having a heavy workload and that the facility was very short staffed at the time Resident 47 was discharged . 2. Review of Resident 49's admission Record indicated Resident 49 was admitted to the facility with diagnoses that included subarachnoid hemorrhage (bleeding in the space that surrounds the brain), dysphagia (difficulty swallowing), and acute respiratory failure (when fluids build up in the air sacs in the lungs). Review of the Progress Notes SBAR (Situation, Background, Assessment, Review) Change of Condition dated 12/22/21 indicated Resident 49 had severe cramping to the right side groin area with protrusion of the area and very tender to touch. Resident 49 was transferred to the acute hospital via 9-1-1. During an interview with SSD on 3/24/21 at 9:55 a.m., SSD stated Resident 49 and RR 1 were not notified in writing of the reason for transfer to the hospital. SSD also stated, there was no written notification sent to the Ombudsman. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056471 If continuation sheet Page 3 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Harbor Healthcare Center 442 Sunset Boulevard Hayward, CA 94541 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Based 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. Findings: Review of the admission Record indicated Resident 49 was admitted to the facility with diagnoses that included subarachnoid hemorrhage (bleeding in the space that surrounds the brain), dysphagia (difficulty swallowing), and acute respiratory failure (when fluids build up in the air sacs in the lungs). Resident 49's admission Record indicated RR 1 was Resident 49's emergency contact. Review of the Progress Notes Situation, Background, Assessment, Review (SBAR), a communication process among healthcare professionals) Change of Condition dated 12/22/21, indicated Resident 49 had severe cramping to the right side groin area with protrusion of the area and very tender to touch. Resident 49 was transferred to the acute hospital via 9-1-1. During an interview with the Licensed Vocational Nurse (LVN) 1 on 3/24/22 at 9:45 a.m., LVN 1 stated, when transferring a resident to the hospital, the resident and resident representative should be given a written notice that the bed would be held for them for seven days while the resident is in the hospital. During an interview and concurrent review of Resident 49's clinical records with the Social Services Director (SSD) on 3/24/22 at 9:55 a.m., SSD stated, there was no documentation that the bed hold was offered and the policy was provided to Resident 49 and RR 1. Review of the facility's undated policy and procedure titled, Bed Holds reflected the facility was to provide the opportunity for each resident who is transferred to a hospital to hold a bed. The policy indicated, at the time of transfer, the facility will make three copies of a written notice that will specify the duration of the bed hold. The policy also indicated, of the three copies, one will be provided to the resident, another will be given to the family or resident representative and the third copy will be kept in the resident's chart. - FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056471 If continuation sheet Page 4 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Harbor Healthcare Center 442 Sunset Boulevard Hayward, CA 94541 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based 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. Residents Affected - Few This deficient practice had the potential for residents to not received appropriate mental health care and services. Findings: Review of the Annual Minimum Data Set, MDS - resident assessment tool used to guide care, dated 7/28/21, indicated section A- Preadmission Screening and Resident Review (PASRR) was coded zero which indicated Resident 24 was not currently considered by the state level 11 PASRR process to have a serious mental illness. Resident 24's diagnoses included schizophrenia, (a long term mental disorder of a type involving a breakdown in the relation between thought, emotion, and behavior leading to faulty perception, withdrawal from reality into fantasy and delusion and a sense of mental fragmentation). Review of the State of California-Department of Health Care Services letter dated 2/11/19 indicated Resident 24's Level II PASRR evaluation was completed at the facility on 12/18/18 by a licensed clinical psychologist and a psychiatrist consultation was recommended. During a review of Resident 24's MDS and concurrent interview on 3/23/22 at 12:05 p.m., MDS coordinator (MDS) stated Resident 24's section A screening for serious mental illness was coded zero because Resident 24 had no behavior manifestation during the seven days look back. During an interview on 3/24/22 at 8:53 a.m., Registered Nurse (RN 1) stated Resident 24's PASRR Level II was completed in 2019. RN 1 stated Resident 24's MDS section A PASRR was not coded accurately. The facility's policy and procedure titled PASRR (Preadmission Screening & Resident Review), dated 1/2016 indicated; c. Section III- Mental Illness Screen -The purpose of this section is to record any established or suspected mental illness. Any individual with a recent history of mental illness or who is suspected of having a mental illness requires a PASRR Level II evaluation. The facility's policy and procedure titled Resident Assessment Instrument (RAI), revised October 2010 indicated, All persons who have completed any portion of the MDS Resident Assessment Form MUST sign such document attesting to the accuracy of such information. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056471 If continuation sheet Page 5 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Harbor Healthcare Center 442 Sunset Boulevard Hayward, CA 94541 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Residents Affected - Few This failure had the potential to result in Resident 27 not being provided specialized care and services to address a mental illness. Findings: Review of Resident 27's admission Record indicated Resident 27 was re-admitted to the facility on [DATE] with diagnoses that included bipolar disorder (mental health condition that causes extreme mood swings that include emotional highs and lows), depression (persistently depressed mood and loss of interest in activities) and anxiety disorder (feelings of worry, anxiety or fear strong enough to interfere with daily activities). During an interview and concurrent review of Resident 27's clinical record with the Licensed Vocational Nurse (LVN) 2 on 3/22/22 at 11:11 a.m., LVN 2 stated a PASRR I was completed on 2/10/22. Resident 27's PASRR level I screening dated 2/10/22 indicated a level II Mental Health Evaluation is required. LVN 2 stated Resident 27's clinical record did not indicate documentation that a level II PASRR was completed nor any follow-up to set up an appointment to have the evaluation completed. Review of Resident 27's Order Summary Report indicated an order to give lorazepam (treats anxiety) tablet 0.5 milligram (mg), one tablet by mouth, every 24 hours as needed for anxiety. The report also indicated an order for Resident 27 to receive trazodone (treats depression) 50 mg, half tablet by mouth as needed for sleep or insomnia. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056471 If continuation sheet Page 6 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Harbor Healthcare Center 442 Sunset Boulevard Hayward, CA 94541 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings: Review of Resident 14's admission Record indicated Resident 14 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (blood sugar disorder), hypothyroidism (thyroid gland does not produce enough thyroid hormone, and major symptoms include fatigue, constipation, dry skin and unexplained weight gain), and heart failure. Review of Resident 14's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 1/8/22, the Swallowing/Nutritional Status, indicated Resident 14 had a weight gain of five percent (5%) or more in the last month or 10 % or more in the last six months. The MDS also indicated Resident 14 was not on a physician-prescribed weight gain regimen. Review of Resident 14's Registered Dietician (RD) Nutrition Note/Weight Variance Review dated 1/4/22 indicated Resident 14 had a weight gain of 5.2% over one month (from 12/3/21 to 1/4/22). RD recommendations included to add NAS (No added salt) to the diet order and request for a BMP (Basic Metabolic Panel) blood test. Review of the RD Nutrition Note for weight variance dated 3/17/22 indicated Resident 14 had a weight gain of 11.9% over six months (significant weight gain), and recommendations by the RD included to change diet to CCHO (Controlled Carbohydrate, to help diabetics in keeping their carbohydrate consumption at a steady level) diet, pureed texture (soft, pudding-like consistency). Order CMP (Complete Metabolic Panel) blood test. Review of Resident 14's Order Summary Report indicated a diet order dated 12/11/20 for Resident 14 to be on a regular diet, pureed texture, honey-thickened liquids. The report did not indicate any changes to Resident 14's diet order. Review of the History and Physical by Resident 14's physician dated 3/17/22, indicated under assessment/plan, Resident 14 needed labs (laboratory tests) that included TSH ( thyroid test), Free T4 (another thyroid test), HgbA1C (test for diabetic sugar control over a few months), CMP, CBC (Complete Blood Count), a test to check several components of the blood, like red blood cells), lipid panel (cholesterol, a waxy substance in the blood) and triglycerides (type of fat). Review of Resident 14's Physician Orders dated 3/17/22 indicated orders for routine labs- TSH, free T4, HgbA1c, CMP, CBC, lipid panel. Review of Resident 14's nutrition care plan, last revised 1/15/22, indicated the goal was for Resident 14 to maintain weight within 175 pounds (lbs)- 185 lbs. The interventions listed to achieve the goal included for staff to obtain and monitor laboratory tests as ordered and for RD to evaluate and make diet change recommendations as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056471 If continuation sheet Page 7 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Harbor Healthcare Center 442 Sunset Boulevard Hayward, CA 94541 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview and concurrent review of Resident 14's clinical records with Licensed Vocational Nurse (LVN) 1 on 3/22/22 at 12:51 p.m., LVN 1 stated the lab tests ordered by the physician on 3/17/22 were not done. LVN 1 stated she would make the lab requisition so that the labs could be done as soon as possible. During an interview with Registered Nurse (RN) 1 on 3/23/22 at 9:20 a.m., RN 1 stated, the labs that were ordered by the physician should have been carried out the same day or the next day. Event ID: Facility ID: 056471 If continuation sheet Page 8 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Harbor Healthcare Center 442 Sunset Boulevard Hayward, CA 94541 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings: During a record review of Resident 34's admission Record dated 3/22/22, the admission Record indicated Resident 34 was admitted on [DATE]. During a record review of Resident 34's Minimum Data Set (MDS, an assessment tool used to guide care), the Functional Status dated 2/25/22 indicated Resident 34 needed extensive assistance and total dependence with bed mobility, transfer, locomotion on and off the unit, toilet use and personal hygiene and bathing. During a concurrent interview and record review on 3/23/22, at 1:14 p.m., with the Director of Nursing (DON), of Resident 34's Activities of Daily Living (ADL) Self Care Performance Deficit Care Plan, revised 11/21/21, indicated the care plan was not updated since 11/21/21. DON stated the care plan was not updated on time. During a record review of Resident 10's admission Record, dated 3/21/22, the admission Record indicated Resident 10 was admitted on [DATE]. During a record review of Resident 10's MDS Functional Status dated 12/24/21, indicated Resident 10 needed limited assistance to extensive assistance with bed mobility, transfer, walk in room, walk in corridor, locomotion on and off the unit, dressing, toilet use and personal hygiene. Also, Resident 10 needed physical help in part of bathing and supervision while eating. During a concurrent interview and record review on 3/23/22, at 1:15 p.m., with DON, Resident 10's ADL Self Care Performance Deficit Care Plan, revised 9/25/21, was reviewed. DON stated the care plan was not updated on time and last revised on 9/25/21. During a record review of Resident 29's admission Record dated 3/21/22, the admission Record indicated Resident 34 was admitted on [DATE]. During a record review of Resident 29's MDS Section I, Active Diagnosis, dated 2/10/22, the MDS indicated Resident 29 had Non-Alzheimer's Dementia. During a concurrent interview and record review, on 3/24/22, at 11:50 a.m., of Resident 34's Impaired Thought Process Related to Dementia Care Plan, revised 8/15/21, DON stated the care plan was not updated or revised since 8/15/21. During an interview on 3/24/22 at 11:50 a.m., DON stated If they don't revise or update the residents' care plans, it's a risk to the resident because staff can't measure (evaluate) their (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056471 If continuation sheet Page 9 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Harbor Healthcare Center 442 Sunset Boulevard Hayward, CA 94541 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete interventions. [NAME] stated resident care plans are supposed to be updated and revised quarterly and for a change of condition. During a review of the facility's policy and procedure (P&P) titled, Care Planning (undated) which indicated, Resident care planning includes . continual reassessment, and updating at least quarterly, and upon change of condition, until resident's discharge. Event ID: Facility ID: 056471 If continuation sheet Page 10 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Harbor Healthcare Center 442 Sunset Boulevard Hayward, CA 94541 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Residents Affected - Some This deficient practice placed residents at risk for poor hygiene, body odor and psychosocial discomfort. Findings: During the resident's council meeting on 3/22/22 at 10:32 a.m., four residents in attendance stated they received showers once a week, and when the facility was short of staff they did not get showered. Review of Annual Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 7/16/21, indicated: Resident 19 required one-person, physical assist with transfer between surfaces, including to and from bed, chair, wheelchair and standing. Resident 19 required physical help with bathing activity. Review of the MDS dated [DATE] indicated Resident 23 required one person, physical assist with transfer between surfaces, including to and from bed, chair, wheelchair and standing. Resident 23 required physical help with bathing activity. Review of the MDS dated [DATE], indicated: Resident 24 required one person physical assist with transfer between surfaces including to and from bed, chair, wheelchair and standing. Resident 24 required physical help with bathing activity. During an observation on 3/22/22 at 8:15 a.m., Resident 24's hair was not groomed or combed. Review of the Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 12/29/21, indicated Resident 36 required one-person, physical assist with transfer between surfaces including, to and from bed, chair, wheelchair and standing. Resident 36 required physical help in part of bathing activity. During an interview on 3/22/22 at 10:32 a.m., Resident 36 stated she is showered once a week, and when the facility was short of staff, she did not get a shower. Review of the MDS dated [DATE] indicated Resident 39 required two-person, physical assist with transfer between surfaces including to and from bed, chair, wheelchair and standing. Resident 39 required physical help with bathing activity. Review of Residents 19, 23, 24, 36 and 39's ADL (activity of daily living) self-care deficit care plans, indicated to shower as scheduled. During an interview on 3/23/22 at 8:45 a.m., the Certified Nursing Assistant 1 (CNA 1) stated residents are scheduled for showers, two times a week. CNA 1 further stated, sometimes residents are not showered as scheduled because of staffing shortage. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056471 If continuation sheet Page 11 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Harbor Healthcare Center 442 Sunset Boulevard Hayward, CA 94541 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Review of the shower schedule and shower sheets on 3/23/22, with CNA 1, indicated residents are scheduled for showers twice a week. Further review indicated from 3/1/22 to 3/23/22, Resident 19 was showered on 3/18/22 and 3/22/22. Resident 23 was showered on 3/16/22 and 3/22/22. Resident 24 was showered on 3/17/22 and 3/22/22. Resident 36 was showered on 3/1/22, 3/10/22, 3/18/22 and 3/22/22. Resident 39 was showered 3/2/22. 3/9/22 and 3/16/22. Residents Affected - Some During an interview on 3/23/22 at 8:45 a.m., CNA 1 stated Resident 24 did not receive a shower as scheduled because of staffing shortage. During an interview on 3/24/22 at 8:28 a.m., CNA 2 stated residents did not receive their shower as scheduled because the facility did not have enough CNAs. During an interview on 3/24/22 at 8:58 a.m., Registered Nurse (RN 1) stated the facility was aware that residents were not showered as scheduled and was working on it. The facility's policy and procedure titled, Bathing A Resident, undated indicated, It is the policy of this facility to meet the hygienic needs of residents. Residents will be bathed at least twice weekly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056471 If continuation sheet Page 12 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Harbor Healthcare Center 442 Sunset Boulevard Hayward, CA 94541 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based 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. Residents Affected - Few This failure had the potential to result in skin breakdown. Findings: Review of Resident 30's admission Record indicated Resident 30 was admitted to the facility with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD, a chronic lung disease that obstructs airflow from the lungs) and Chronic Kidney Disease. Review of Resident 30's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 2/6/22, indicated Resident 30 had a Brief Interview for Mental Status (BIMS, an assessment of resident's orientation to time and capacity to remember) score of 15, meaning no cognitive impairment. During an observation and concurrent interview with Resident 30, on 3/21/22 at 111:20 a.m., Resident 30's feet had very dry, flaky skin. Resident 30 stated having asked the staff to apply lotion to both feet because they have gotten so dry, but staff had not done anything. During an interview with the Certified Nursing Assistant 3 (CNA 3) on 3/23/22 at 9:54 a.m., CNA 3 stated she had never applied lotion or A & D (used as a moisturizer to treat or prevent dry, scaly skin) ointment to Resident 30's feet because CNA 3 thought the licensed nurses were already doing it. During an interview with CNA 1 on 3/23/22 at 9:57 a.m., CNA 1 stated, CNAs were supposed to apply A & D to the residents' skin as part of routine skin care. During an interview with the Director of Nursing (DON), on 3/23/22 at 10:39 a.m., DON stated skin care is part of basic ADL (activities of daily living) care for every resident, and it should be provided by the CNA assigned to the resident. Review of Resident 30's podiatry (foot specialist physician) service follow-up dated 2/23/22 indicated, dry and scaly plantar (sole of the foot) skin on both feet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056471 If continuation sheet Page 13 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Harbor Healthcare Center 442 Sunset Boulevard Hayward, CA 94541 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based 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. Findings: Review of the facility's Facility Assessment, last reviewed 11/25/21, indicated the services provided by the facility included mental health and behavior services, specifically behavior management. Furthermore, the facility would ensure staff competencies to include caring for residents with mental and psychosocial disorders, residents with history of trauma and post-traumatic stress disorder, and non-pharmacological interventions to address behaviors. During an interview and concurrent review of the staff training records with the Infection Preventionist (IP), on 3/24/22 at 11:52 a.m., IP stated she began working at the facility on 3/21/22 and has yet to audit staff competencies. IP stated she could not find the record if there was training provided for staff on behavior management. IP also stated Certified Nursing Assistant 4 (CNA 4) did not have a record of having the skills check/competency. During an interview and concurrent review of the staff training records with Registered Nurse 1 (RN 1), on 3/24/22 at 1:44 p.m., RN 1 stated there were no staff training provided for behavior management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056471 If continuation sheet Page 14 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Harbor Healthcare Center 442 Sunset Boulevard Hayward, CA 94541 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings: During a residents council meeting on 3/22/22 at 10:35 a.m., Resident 36 stated living in the facility was hard, especially during COVID-19 (a virus causing respiratory illness and outbreak that is easily spread) outbreaks when residents were in their rooms all the time. Resident 36 stated most of the residents at the facility have behavioral issues. Resident 36 stated the facility did not provide much needed counseling for residents. Review of Resident 19's Minimum Data Set (MDS- an assessment and care screening tool used to guide care), dated 1/16/22 indicated, Resident 19 had diagnoses that included schizophrenia (a long term mental disorder involving breakdown in the relation between thought, emotion and behavior leading to faulty perceptions, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion and a sense of mental fragmentation). Review of the behavior care plan dated 10/16/20, indicated Resident 19 had behavior manifested by verbal abuse, unprovoked anger, and history of drug abuse. The interventions included for staff to follow up with psychiatry. Review of Resident 24's MDS dated [DATE] indicated Resident 24 had diagnoses that included schizophrenia. Review of the physician orders dated 6/3/21 indicated Resident 24 was prescribed a psychiatrist evaluation. Review of Resident 36's Minimum Data Set (MDS- an assessment and care screening tool used to guide care), dated 12/29/21 indicated Resident 36 diagnoses included anxiety disorder and depression. Review of behavior care plan dated 8/17/21, indicated Resident 36 had psychosocial well-being problem related to major depression interventions included referral for psychiatry evaluation. Review of order summary dated 4/7/17 indicated the physician prescribed a psychology evaluation for Resident 36. During an interview on 3/22/22 at 2:41 p.m., Social Services Director (SSD) stated Resident 19, 24 and 36 had not being evaluated and followed up by the psychiatrist or psychologist. During an interview on 3/24/22 at 12:57 p.m., Registered Nurse 1 (RN 1) stated the facility had not followed up with Residents 19, 24 and 36's referral for psychiatry/ psychology evaluation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056471 If continuation sheet Page 15 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Harbor Healthcare Center 442 Sunset Boulevard Hayward, CA 94541 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 The Facility Assessment Tool dated November 25, 2021 indicated services and care we offer are based on our residents needs, and included mental health and behavior, psychiatry, and psychological consults. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056471 If continuation sheet Page 16 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Harbor Healthcare Center 442 Sunset Boulevard Hayward, CA 94541 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. 2. Review of Resident 27's admission Record indicated Resident 27 was re-admitted to the facility in December 2021 with diagnoses that included bipolar disorder (mental illness with mood swings from depressive lows to manic highs) and depression. Review of Resident 27's Order Summary Report, as of 3/23/22, indicated Resident 27 had an order dated 1/6/22 for lorazepam tablet 0.5 mg, one tablet by mouth, every 24 hours as needed for anxiety, and trazodone 50 mg, one half-tablet by mouth as needed, for sleep or insomnia dated 2/22/22. During an interview and concurrent review of Resident 27's clinical record with the Registered Nurse 2 (RN 2) on 3/23/22 at 11:58 a.m., RN 2 stated Resident 27 did not have any negative behaviors and was very calm, pleasant and friendly. RN 2 also stated Resident 27's March 2019 MAR indicated lorazepam was administered on 3/5/22 but there was no documentation if the medication worked to relieve anxiety or not. RN 2 stated Resident 27 did not receive trazodone from 3/1/22 to 3/23/22, and there was no documentation that Resident 27 was monitored for the number of hours of sleep to evaluate if trazodone was needed. RN 2 also stated Resident 27's clinical record did not indicate a care plan was developed to address the use of trazodone. Review of the Consultant Pharmacist's documented, Note To Attending Physician/Prescriber dated 2/17/22 indicated, for both lorazepam and trazodone, use should be limited to a total of 14 days unless clinically contraindicated. Please discontinue therapy after 14 days, or document reasons for continuation. The note indicated there was no response from the Attending Physician. Based 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. Findings: 1. Review of Resident 36's Minimum Data Set (MDS- an assessment and care screening tool used to guide care), dated 12/29/21 indicated, Resident 36 had trouble falling or staying asleep, or sleeping too much. Resident 36 diagnoses included anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and depression (sadness or loss of interest). Review of the physician orders dated 3/7/22 indicated Resident 36 was prescribed trazodone 50 mg (milligram) by mouth, at bedtime for sleep. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056471 If continuation sheet Page 17 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Harbor Healthcare Center 442 Sunset Boulevard Hayward, CA 94541 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the Medication Administration Record (MAR), dated 3/1/22 through 3/31/22, in the presence of the Director of Nursing (DON) indicated, Resident 36 was administered trazodone 50 mg by mouth at bedtime for insomnia, on 3/8/22 through 3/23/22. Further review showed the hours of sleep were not monitored after the administration of trazodone to evaluate the effects of the medication. During an interview on 3/24/22 at 9:56 a.m., with the Director of Nursing (DON), DON stated Resident 36's hours of sleep were not monitored for the use of Trazodone. Event ID: Facility ID: 056471 If continuation sheet Page 18 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Harbor Healthcare Center 442 Sunset Boulevard Hayward, CA 94541 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings: During a record review of Resident 31's admission Record dated 3/24/22, the admission Record indicated Resident 31 was admitted on [DATE]. During a record review of Resident 31's Order Summary Report dated, 3/24/22, which indicated Resident 31 had a discontinued doctor's order for Heparin (blood thinner) Sodium (Porcine) Solution 5000 unit/milliliter ordered on 10/19/21. During a concurrent observation and interview, on 3/23/22, at 10:45 a.m., in the Medication Room, with the Infection Preventionist (IP), Resident 31's Heparin was observed to have an expiration date of 2/22. IP stated Resident 31's Heparin expired February 2022, and was not supposed to keep expired medications in the medication room. IP further stated the expired medications can cause complications and life-ending conditions to the resident. IP removed the expired medication from the medication room. During a review of the facility's policy and procedure (P&P) titled, Storage of Medications, revised April 2007, which indicated, The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056471 If continuation sheet Page 19 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Harbor Healthcare Center 442 Sunset Boulevard Hayward, CA 94541 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, for one of four sampled residents (Resident 14), the facility failed to obtain physician ordered laboratory tests. Residents Affected - Few This failure resulted in not monitoring and reporting potential abnormal test results. Findings: Review of Resident 14's admission Record indicated Resident 14 was admitted to the facility with diagnoses that included diabetes mellitus (blood sugar disorder), hypothyroidism (thyroid gland does not produce enough thyroid hormone, and major symptoms include fatigue, constipation, dry skin and unexplained weight gain), and heart failure. Review of the History and Physical by Resident 14's physician dated 3/17/22, indicated under assessment/plan, Resident 14 needed labs (laboratory tests) that included TSH ( thyroid test), Free T4 (another thyroid test), HgbA1C (test for diabetic sugar control over a few months), CMP, CBC (Complete Blood Count), a test to check several components of the blood, like red blood cells), lipid panel (cholesterol, a waxy substance in the blood) and triglycerides (type of fat). Review of Resident 14's Physician Orders dated 3/17/22 indicated orders for routine labs- TSH, free T4, HgbA1c, CMP, CBC, lipid panel. During an interview and concurrent review of Resident 14's clinical records with Licensed Vocational Nurse (LVN) 1 on 3/22/22 at 12:51 p.m., LVN 1 stated the lab tests ordered by the physician on 3/17/22 were not done. LVN 1 stated she would make the lab requisition so that the labs could be done as soon as possible. During an interview with Registered Nurse (RN) 1 on 3/23/22 at 9:20 a.m., RN 1 stated, the labs that were ordered by the physician should have been carried out the same day or the next day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056471 If continuation sheet Page 20 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Harbor Healthcare Center 442 Sunset Boulevard Hayward, CA 94541 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based 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. Findings: During an observation of the tray line, on 3/22/22 at 11:49 a.m., in the presence of the Dietary Supervisor (DS) and Dietician (RD), [NAME] 1 used the same paper towel to clean the thermometer while checking the prepared food temperatures. During an interview on 3/22/22 at 11:49 a.m., [NAME] 1 stated she was sorry and forgot to use alcohol wipes to clean the thermometer. Note: Checking the temperature without cleaning the thermometer probe between readings can lead to microbes being transferred from contaminated items to those that are thought to be safe or cross contamination). During an interview on 3/22/22 at 8:34 a.m., DS stated he did not document the skills competency evaluations for the dietary staff. DS could not provide documentation of [NAME] 1 and other dietary staff's competencies to carry out food services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056471 If continuation sheet Page 21 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Harbor Healthcare Center 442 Sunset Boulevard Hayward, CA 94541 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based 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. Findings: Review of Resident 42's admission record indicated Resident 42 had been known to the facility since August 2021. Resident 42 was admitted with diagnoses that included malignant neoplasm of central nervous system (condition when abnormal cells form in the brain or spinal cord) and acute ischemic heart disease (blockage of blood flow to the heart). Resident 42 had contracted COVID-19 (viral respiratory infection that could cause severe complication including death) after being admitted to the facility. Review of the Physician Orders dated 3/15/22 indicated an order for the POLST (Physician Order for Life-Sustaining Treatment, a standardized medical order that indicates specific type of life-sustaining treatments a seriously ill resident does or does not want) completion. During an interview and concurrent review of Resident 42's clinical record with Licensed Vocational Nurse 2 (LVN 2), on 3/22/22 at 11:a.m., LVN 2 stated there was no POLST in Resident 42's clinical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056471 If continuation sheet Page 22 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Harbor Healthcare Center 442 Sunset Boulevard Hayward, CA 94541 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility's quality assessment and assurance committee did not meet quarterly as required. Residents Affected - Few 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056471 If continuation sheet Page 23 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Harbor Healthcare Center 442 Sunset Boulevard Hayward, CA 94541 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based 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. Residents Affected - Some This deficient practice had the potential for infections to go undetected or controlled which could spread within the facility. Findings: During an interview and concurrent record review with the Infection Preventionist (IP), on 3/24/22 at 10:30 a.m., IP stated and showed the infection control surveillance was last documented in August 2021. IP stated she could not provide documentation of conducting infection control surveillance from September 2021 to currently. IP stated she was new to the facility and was trying to contact the previous IP about the infection control surveillance records, but was unsuccessful. During an interview with Registered Nurse 1 (RN 1), on 3/24/22 at 12:15 p.m., RN 1 stated the infection control surveillance should be done monthly to make sure there were no outbreaks. During an interview with RN 1 on 3/24/22 at 12:23 p.m., RN 1 stated she could not find the binders that contained infection control surveillance from September 2021 to the time of the survey. Review of the facility's policy and procedure titled, Infection Control Surveillance not dated, indicated .4. Maintaining current surveillance data allows the Infection Preventionist to present an accurate, quantitative and timely picture of most infection problems that might arise. It also allows for monitoring the effect of intervention strategies on infection rates . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056471 If continuation sheet Page 24 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Harbor Healthcare Center 442 Sunset Boulevard Hayward, CA 94541 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based 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. Residents Affected - Some This deficient practice had the potential to spread infection in the facility. Findings: During an interview and concurrent record review with the Administrator (Admin), on 3/24/22 at 10:43 a.m., Admin stated she could not find documentation that their antibiotic stewardship was done in September, October and November of 2021. During an interview with the Registered Nurse 1 (RN) 1 on 3/24/22 at 12:15 p.m., RN 1 stated the antibiotic stewardship monitoring should be done monthly to make sure there were no outbreaks and to make sure the use of antibiotics were needed. During an interview with Admin on 3/24/22 at 12:16 p.m., Admin stated antibiotic stewardship monitoring should be done to make sure antibiotics were not used unnecessarily. During an interview with RN 1 on 3/24/22 at 12:23 p.m., RN 1 stated she could not find the antibiotic stewardship binders that contained September, October and November 2021 monitoring due to staff leaving and office locations changing. Review of the facility's policy and procedure titled, Antibiotic Stewardship, revised December 2016, indicated Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. 1. The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056471 If continuation sheet Page 25 of 25