Health inspection·November 13, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings: During a review of Resident 1 ' s admission Record, printed 11/11/24, the record indicated Resident 1 was admitted [DATE] with multiple diagnosis including a primary diagnosis of paraplegia, complete (the loss of muscle function in the lower part of the body including both legs). During a review of Resident 1 ' s Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident ' s cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.), dated 9/7/24, the record indicated Resident 1 ' s BIMS score was 15. During an interview on 11/12/24, at 1:48 p.m. with Social Services Director (SSD), SSD stated laundry staff found live bullets in Resident 1 ' s laundry on 11/11/24 at approximately 8:40 a.m. to 8:50 a.m. SSD stated they called the Sheriff because they suspected Resident 1 may have had a gun. SSD stated the Sheriff came at approximately 11:30 a.m. and searched Resident 1 ' s room with their permission. SSD stated the sheriff found and confiscated a gun and bullets. During an interview on 11/12/24, at 3:36 p.m. with AA, AA stated on 11/9/24, at approximately 3:00 p.m. to 3:30 p.m., Resident 1 came in activity room and showed AA their bank account on their phone, then asked if AA knew where they could buy a gun or who they can buy a gun from. AA stated they thought the resident was joking. AA stated she did not report the interaction till 11/11/24. AA stated she notified Interim Activity Director (IAD) on 11/11/24, at approximately 10:00 a.m., about the interaction AA had with Resident 1. AA stated IAD advised them to notify SSD. AA then notified SSD about the interaction on 11/11/24 at approximately 10:30 a.m. During an interview on 11/12/24, at 4:40 p.m., with Director of staff Development (DSD), DSD stated AA should have notified their immediate supervisor immediately when Resident 1 asked about buying a gun because it was a safety risk and could have placed all the other residents and staff at risk for harm. DSD stated any unusual incident or unusual occurrence should have been reported immediately (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 11/13/2024 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)