Health inspection·March 6, 2025

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, the facility failed to provide treatment and care in accordance with professional standards of practice for one of one sampled resident (Resident 1) when: Residents Affected - Few 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. Findings: During a record review of Resident 1's admission Record , printed on 2/25/25, the admission Record indicated Resident 1 was admitted to the facility in January 2025 with multiple diagnoses including osteomyelitis (inflammation or swelling that occurs in the bone) of left ankle and foot, type II diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar), and lobar pneumonia (a type of lung infection that affects one or more lobes of the lungs). During a record review of Physician's Progress Notes dated 1/28/25, the progress note indicated, Resident 1 was seen by the physician for hypoxia (low levels of oxygen in the body), wheezing. The physician's progress notes also indicated Resident 1 had complaints of shortness of breath and was noted to have left chest wall swelling. During a record review of Resident 1's Order Summary , dated 3/6/25, the Order Summary indicated Resident 1 had an order of albuterol sulfate inhalation with an instruction to give Resident 1 one puff and inhale orally every 6 hours for wheezing. The albuterol sulfate inhalation had was ordered to start on 1/28/25. During a record review of Resident 1's Medication Administration Record (MAR), dated 1/1/25 to 1/31/25, the MAR indicated Resident 1 did not receive the albuterol sulfate inhaler on 1/28/25 at 8:30 p.m., 1/29/25 at 2:30 am, 8:30 a.m., 2:30 p.m., and 8:30 p.m. During a concurrent record review and interview on 3/6/25 at 11:15 a.m. with the Director of (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 3 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 03/06/2025 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)