Golden Harbor Healthcare Center

In the surveyor’s words

From the most serious findings on record at Golden Harbor Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 17, 2024

  Based on observations, interviews, record reviews, for two of three (Resident 53 and 43) sampled residents who were reviewed for close supervision, the facility failed to ensure Resident 52 and 43 were supervised when, 1. Resident 52 who was high risk for elopement left the facility unattended on 5/14/2024 between 10:15 a.m. and 11:14 a.m., and 2. Resident 43 who had a history of frequent seizures and falls was not monitored for 50 minutes. These failures resulted in Resident 52 eloping from the facility unattended on a sidewalk in a street intersection and had the potential for Resident 43 to sustain an injury if experienced an unwitnessed seizure. […]

• No harm, potential for more than minimal, widespreadF727Aug 29, 2025

  Based on interview and record review, the facility failed to provide Registered Nurse (RN) coverage eight hours a day, seven days a week. This failure presents a threat to residents reaching their highest practicable level of well-being and had the potential to endanger the health and safety of residents. During a concurrent interview and record review on 8/27/25 at 11:06 a.m. with the Staffing Coordinator (SC), the facility's licensed staffing schedules for the month of January 2024 through March 2024 were reviewed, the staffing schedule indicated there were no Registered Nurses (RN) scheduled to work eight hours a day during the following dates:1. For the month of January 2024: 1/10/24; 1/11/24; 1/16/24 and 1/25/24.2. For the month of February 2024: 2/8/24; 2/9/24 and 2/13/24. […]

• No harm, potential for more than minimal, widespreadF755Aug 29, 2025

  Based on observation, interview and record review, the facility failed to ensure:1. Controlled substance medications (medication with a high potential for abuse and addiction) were accurately accounted for on the medication administration record (MAR) and the Controlled Drug Record (CDR, an accountability record) for three of four randomly selected residents (Residents 11, 20, and 101);2. The intravenous (IV, administered into the vein) supplies, narcotic, and intramuscular (IM, injected into the muscle) emergency kits (e-kit; a kit/box containing medications and supplies for immediate use during a medical emergency) were replaced according to facility policy and procedure (P&P) after use; 3. Routine medication for one of 50 sampled residents (Resident 16) was available for administration. […]

• No harm, potential for more than minimal, widespreadF761Aug 29, 2025

  Based on observation and interview, the facility failed to ensure medications were not stored on top of medication carts (med carts) when left unattended, med carts were locked when left unattended, medications with shortened expirations after use were labeled with an opened date, and med carts were kept clean and orderly. The deficient practices had the potential for unauthorized staff/residents to access medications, for residents to receive medications with unsafe and reduced potency, for residents to suffer hazardous cross-contamination to their medications, and for medications to not be safely administered to residents.During a medication pass observation on 8/25/25 at 12:19 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 was observed preparing medications for a Resident 40. […]

• No harm, potential for more than minimal, widespreadF880Aug 29, 2025

  Based on observation, interviews and record reviews, the facility failed to ensure infection control measures were maintained for six of 51 sample residents (8,25,65,105,93, and 83). This failure had the potential to result in six sampled residents developing and transmitting infections when:1a. Central Supply 1 did not sanitize hands when entering and existing Contact Precaution rooms [ROOM NUMBERS].1b. Central Supply 1 refilled 1/2 empty glove boxes from Contact Precautions rooms [ROOM NUMBERS] using bare hands1c. Registered Nursing Supervisor 1 did not disinfect / sanitize reusable medical equipment (scissors).1d. Certified Nursing Assistant did not know effective properties and dwell time of Sani Wipes for shared COVID reusable medical equipment .1e. […]