Health inspection·June 12, 2023

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 Based on interviews and record review, the facility failed to provide and ensure services to maintain personal hygiene for one (Resident 1) of three sampled residents. The certified nursing assistants did not bathe or shower Resident 1 as scheduled. Residents Affected - Few This failure had the potential for poor hygiene and skin health concerns. Findings: Review of the Annual Minimum Data Set MDS- Resident Assessment tool used to guide care, dated 10/18/21, Resident 1 had unclear speech, sometimes made herself understood. Resident 1 had limited range of motion and impairment to the shoulder, elbow, wrist , had hip, knee, ankle and foot. Resident 1 required full staff performance with one-person physical assist for personal hygiene, including combing hair, brushing teeth, shaving, washing and drying face and hands. Resident 1's diagnoses included hemiplegia or hemiparesis ( muscle weakness one onse side of the body or or paralysis on one side of the body from a stroke). During an interview on 4/27/23 at 11:50 a.m., Resident 1 made incomprehensible sounds and repeatedly pointed to her hair. Resident 1 had short hair. Review of Resident 1 ' s Activities of Daily living (ADLs) care plan, undated indicated, Resident 1 had ADL self-care performance deficit related to poor safety awareness, seizure disorder and history of stroke, and included staff to shower as scheduled. Review of the facility ' s shower schedule indicated Resident 1 was scheduled to shower twice weekly, on Wednesdays and Saturdays in the evening (3 PM to 11:00 PM) shift. Review of Resident 1 ' s ADL documentation for March and April 2023 indicated bathing or shower/bed bath was not provided for Resident 1 every Wednesday and Saturday on evening shift. During an interview on 5/31/23 at 3:05 p.m., with the Certified Nursing Assistant (CNA 1), CNA 1stated he was assigned to provide care for Resident 1 in the evening shifts. CNA 1 stated he did not bathe or gave showers to Resident 1 because the nursing assignments did not include names of residents scheduled for shower. During an interview on 5/30/23 at 11:30 a.m., with the Director of Nursing (DON), DON stated, CNA 2 was also assigned to provide Resident 1 showers or bed bath but no longer worked at the facility. During an interview and concurrent review of the shower schedule and Resident 1 ' s ADL records, on (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056471 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 06/12/2023 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)