Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Golden Harbor Healthcare Center during CMS and state inspections, most recent first.
A resident with multiple diagnoses, including pneumonia, did not receive prescribed albuterol sulfate inhalation due to unavailability, and their oxygen saturation levels were not monitored over several days. The DON confirmed that the LNs failed to follow up with the pharmacy or inform the physician about the missing medication, and the resident's vital signs were not adequately monitored, potentially worsening their respiratory condition.
A resident with multiple diagnoses, including pneumonia, did not receive their prescribed albuterol sulfate inhaler due to a failure in pharmaceutical services. The inhaler was not delivered by the pharmacy, and the licensed nurses did not follow up with the pharmacy or inform the physician about the missing medication, contrary to the facility's policy.
A resident inquired about purchasing a firearm, but the Activity Assistant (AA) did not report this until two days later, leading to the discovery of a gun and ammunition in the resident's room. The delay in reporting posed a safety risk to all residents and staff, as the facility's policies on reporting unusual occurrences were not followed.
The facility failed to supervise two high-risk residents adequately. One resident, at high risk for elopement, left the facility unattended and was found at a street intersection. Another resident, with a history of seizures and falls, was not monitored for 50 minutes, contrary to the facility's policy. Staff interviews revealed a lack of adherence to care plans and monitoring protocols.
The facility failed to maintain RN coverage for eight hours a day, seven days a week, as required. A review of payroll data from Q1/2023 to Q1/2024 revealed that no RN was scheduled for eight specific dates in 2023. The Director of Nursing confirmed the requirement for RN presence, and this deficiency could endanger residents' health and safety.
Two residents at high risk for elopement did not have Wanderguard interventions implemented, leading to one resident eloping for nearly an hour. The facility's alarms were not consistently activated, and the administrator was unsure of the Wanderguard system's functionality.
The facility failed to maintain complete records for controlled drugs in the Narcotics Destruction Log. Three pages listing 43 medications lacked essential information such as the date of receipt by the DNS, co-signatures by the licensed nurse and DNS, and page numbers. The DON acknowledged the missing information and the absence of a policy for maintaining these records.
The facility failed to ensure appropriate use of psychotropic medications for three residents. A resident had a PRN order for Olanzapine without an end date, and two residents had PRN Ativan orders exceeding the 14-day limit without reevaluation. Interviews confirmed the lack of stop dates and the need for reevaluation.
The facility failed to monitor medication refrigerator temperatures daily and did not label two vials of Tuberculin PPD with the date they were opened. This oversight could lead to the use of ineffective medications, as confirmed by the Infection Preventionist.
Failure to Administer Medication and Monitor Oxygen Levels
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident who did not receive a prescribed medication, albuterol sulfate inhalation, as ordered by the physician. The resident, who was admitted with multiple diagnoses including osteomyelitis, type II diabetes mellitus, and lobar pneumonia, was experiencing hypoxia, wheezing, and shortness of breath. Despite the physician's order for albuterol sulfate inhalation to be administered every six hours, the medication was not given on multiple occasions due to it not being available at the facility. The Director of Nursing (DON) confirmed that the licensed nurses did not follow up with the pharmacy or inform the physician about the missing medication to seek an alternative. Additionally, the resident's oxygen saturation levels were not monitored from January 27 to January 29, despite the resident's complaints of shortness of breath and wheezing. The DON acknowledged that the licensed nurses and/or certified nurse assistants should have monitored and documented the resident's vital signs daily, including oxygen saturation levels, to assess the resident's condition. The lack of monitoring and administration of the prescribed medication potentially worsened the resident's respiratory condition, as indicated by the DON.
Failure to Provide Albuterol Inhaler as Ordered
Penalty
Summary
The facility failed to provide pharmaceutical services and procedures that ensured the accurate dispensing and administration of medication for a resident. The resident, who was admitted with multiple diagnoses including osteomyelitis, type II diabetes mellitus, and lobar pneumonia, had an order for albuterol sulfate inhalation to be administered every six hours for wheezing. However, the medication was not available and was not administered on several occasions as per the physician's order. The Director of Nursing (DON) confirmed that the licensed nurses documented the absence of the medication in the progress notes, stating that the pharmacy did not deliver the inhaler as expected. The DON acknowledged that the pharmacy should have delivered the medication the same day it was ordered and that the licensed nurses should have followed up with the pharmacy and informed the physician about the missing medication. The facility's policy and procedure indicated that medications should be administered as ordered by the physician and in accordance with professional standards of practice, which was not adhered to in this case.
Failure to Address Potential Firearm Hazard
Penalty
Summary
The facility failed to identify and address a potential accident hazard when an Activity Assistant (AA) did not take appropriate action after a resident inquired about purchasing a firearm. The resident, who had a BIMS score indicating intact cognitive status, asked the AA if they knew where or from whom a gun could be obtained. The AA initially thought the resident was joking and did not report the interaction until two days later. This delay in reporting allowed the resident to have a gun and ammunition in their room, which was discovered by the laundry staff. The Social Services Director (SSD) was informed of the situation after the bullets were found, and the sheriff was called to search the resident's room, where a gun and bullets were confiscated. Interviews with the Director of Staff Development (DSD) and the Interim Activity Director (IAD) revealed that the AA should have reported the incident immediately, as it posed a significant safety risk to all residents and staff. The facility's policies on investigating and reporting accidents and unusual occurrences were not followed, contributing to the deficiency.
Failure to Supervise High-Risk Residents
Penalty
Summary
The facility failed to provide adequate supervision and safety measures for two residents, leading to significant deficiencies. Resident 52, who was at high risk for elopement due to severe cognitive impairment and a history of attempting to leave the facility, managed to elope from the facility unattended. Despite having a care plan that included the use of a WanderGuard system and ensuring exit alarms were functional, these measures were not implemented. The resident was found outside the facility in a street intersection, highlighting a lapse in supervision and monitoring by the staff. Additionally, Resident 43, who had a history of frequent seizures and was at high risk for falls, was not monitored for 50 minutes. The resident expressed concerns about the lack of staff awareness regarding his seizures, which had led to falls from his wheelchair. Despite the facility's policy requiring monitoring every 15 to 30 minutes, this was not adhered to, and there was no documentation of the monitoring that was supposed to occur. Interviews with staff revealed a lack of awareness and adherence to the facility's policies and procedures regarding the safety and supervision of residents at risk. The Director of Nursing acknowledged the deficiencies in monitoring and the failure to follow the care plans designed to prevent such incidents. The facility's policies on wandering, elopement, and seizure management were not effectively implemented, resulting in these serious lapses in resident care.
Removal Plan
- Monitoring/updating residents in the elopement binder
- Activated all the exit door alarms
- All exit door alarms will be activated
- The front door will be disarmed and be monitored by the receptionist and/or designated staff
- The maintenance department will conduct weekly inspection of the exit door alarms
RN Coverage Deficiency
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for eight hours a day, seven days a week, as required. This deficiency was identified during an interview and record review conducted on May 17, 2024, at 11:20 a.m., with the payroll department. The review of payroll data from the first quarter of 2023 to the first quarter of 2024 revealed that there was no RN scheduled for eight specific dates across July, August, and October 2023. During a subsequent interview on the same day at 11:59 a.m., the Director of Nursing confirmed the requirement for RN presence in the facility for eight hours daily. The absence of RN coverage on these dates has the potential to endanger the health and safety of residents and prevent them from reaching their highest practicable level of well-being.
Failure to Implement Elopement Prevention Measures
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan to address the risk of elopement for two residents, resulting in a significant deficiency. Resident 52, who was admitted with diagnoses of alcoholic cirrhosis of the liver and was receiving palliative care, was identified as a high risk for elopement. Despite this, the care plan interventions, including the use of a Wanderguard system, were not implemented. An observation revealed that Resident 52 did not have a Wanderguard bracelet, leading to the resident eloping from the facility for almost an hour without staff knowledge. Similarly, Resident 4, diagnosed with dementia and also identified as a high risk for elopement, did not have the necessary Wanderguard interventions in place. The facility's administrator admitted that the alarms on the side exits were not activated and was unsure if the Wanderguard system was operational, as it had not been in use. The maintenance assistant confirmed that the side exit doors were only recently alarmed during the night shift, indicating a lapse in ensuring the safety measures were consistently applied. These oversights had the potential to result in serious harm to the residents.
Incomplete Controlled Drug Logbook Records
Penalty
Summary
The facility failed to maintain a proper system of records for controlled drugs, specifically in the Narcotics Destruction Log (NDL). During a review, it was found that three pages of the Controlled Drug Logbook (CDL) were incomplete. These pages, which listed a total of 43 medications, lacked essential information such as the date of receipt by the Director of Nursing Services (DNS), co-signatures by the licensed nurse and DNS upon exchange of controlled medications, and page numbers. The absence of these details could hinder accurate accounting and prompt identification of any loss or diversion of controlled medications. The Director of Nursing (DON) acknowledged the missing information on the CDL pages, including the date column, staff co-signatures, and page numeration. During an interview, the DON admitted that there was no existing policy for maintaining CDL records for controlled drugs disposition and that the facility followed the instructions written on the CDL record. The DON emphasized the importance of maintaining consistent narcotic logs to prevent diversion and discrepancies, highlighting the facility's failure to adhere to proper documentation procedures for controlled substances.
Failure to Ensure Appropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary psychotropic drugs. Resident 33 had a PRN order for Olanzapine, an anti-psychotic medication, without an end date, contrary to the facility's policy that requires PRN orders for antipsychotic medications to not be renewed beyond 14 days without a healthcare practitioner's evaluation. Resident 33's medical history included diabetes and dementia, and the medication was prescribed for agitation. Residents 23 and 28 were prescribed PRN Ativan for anxiety, but their orders also lacked a stop date, exceeding the 14-day limit set by the facility's policy. Both residents had diagnoses of dementia and anxiety, with impaired memory and decision-making capacity. Interviews with the RN and DON confirmed the absence of stop dates and acknowledged the need for reevaluation of the medication's appropriateness beyond 14 days. The Pharmacy Consultant also confirmed the policy requirement for reevaluation after 14 days.
Medication Storage and Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure proper monitoring and storage of medications in one of its medication rooms. Specifically, the temperature of the medication refrigerator was not monitored daily for nine days in May 2024, as required by the facility's policy. The acceptable temperature range for the medication refrigerator is between 36°F and 46°F, and the absence of temperature records for these days could lead to medications being stored at improper temperatures, potentially affecting their efficacy. This was confirmed during an interview with the Infection Preventionist (IP), who acknowledged the importance of monitoring refrigerator temperatures to prevent medications from becoming ineffective. Additionally, the facility did not label two multiple dose vials of Tuberculin Purified Protein Derivative (PPD) with the date they were opened. These vials were found in the medication refrigerator without any indication of when they were first accessed, which is against the facility's policy that requires vials to be dated upon opening. The IP confirmed that the vials should be discarded 28 days after opening, but without the date, it is unclear if they were still effective. This oversight could result in the use of ineffective medications for residents, as the vials were stored in an unsealed manufacturer's box with the vial stoppers uncovered.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 618 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hayward
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Morton Bakar Center | 0.3 mi | — | 0 | 0 |
| Bethesda Home | 0.6 mi | — | 0 | 0 |
| We Care Skilled Nursing Facility | 0.6 mi | — | 0 | 0 |
| St Anthony Care Center | 0.6 mi | — | 0 | 0 |
| Serenethos Care Center, Llc | 0.8 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Golden Harbor Healthcare Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.