Inspection visit

Health inspectionSeptember 19, 2024

Q: What happened during the September 19, 2024 survey of GOLDEN MODESTO CARE CENTER?

This was a inspection survey of GOLDEN MODESTO CARE CENTER on September 19, 2024. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Q: Were any deficiencies cited at GOLDEN MODESTO CARE CENTER on September 19, 2024?

Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "PASARR screening for Mental disorders or Intellectual Disabilities"

Q: What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

GOLDEN MODESTO CARE CENTERCMS #0563016 citations on this visit

6 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on interview, record review, and facility policy review, the facility failed to submit a status change to a Level I Pre-admission Screening and Resident Review (PASARR) following a new mental health diagnosis for 1 (Resident #62) of 3 residents reviewed for PASARR. Specifically, Resident #62 had a positive Level I PASARR and was later diagnosed with a new mental health disorder and the facility failed to submit a status change to the resident's Level 1 PASARR evaluation. Findings included: A facility policy titled, admission Criteria, revised in March 2019, indicated, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID, or RD. An admission Record revealed the facility admitted Resident #62 on 06/12/2020. According to the admission Record, the resident had a medical history that included diagnoses of bipolar type schizoaffective disorder (onset date 04/14/2024), bipolar disorder (onset date 06/12/2020), major depressive disorder (onset date 06/12/2020), and anxiety disorder (onset date 06/12/2020). An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/29/2024, revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed the resident received antipsychotic and antidepressant medications during the assessment period. Resident #62's care plan included a focus area revised on 10/12/2023 that indicated the resident received an antipsychotic medication of aripiprazole related to a bipolar disorder diagnosis manifested by mood swings. Interventions directed staff to administer psychotropic medications as ordered and to monitor and document episodes of bipolar depression daily. Resident #62's care plan included a focus area revised on 10/12/2023 that indicated the resident received an antidepressant medication of sertraline related to depression. Interventions directed staff to administer antidepressant medications as ordered by the physician and to monitor and document side effects and effectiveness every shift. Resident #62's Order Summary Report, with active orders as of 09/19/2024, contained an order, dated 08/23/2024, for aripiprazole (antipsychotic) 5 milligrams (mg) by mouth every other day for rapid, alternating changes in mood related to bipolar schizoaffective disorder. Resident #62's Order Summary Report, contained an order, dated 08/23/2024, for sertraline hydrochloric acid (HCl) (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 15 Event ID: 056301 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 056301 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Modesto Care Center 1900 Coffee Road Modesto, CA 95355 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)

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (antidepressant) 12.5 mg by mouth one time a day for sad facial expressions and flat affect related to major depressive disorder. Resident #62's Order Summary Report, contained an order, dated 08/22/2024, for valproic acid 250 mg by mouth every 12 hours for audio/visual hallucinations related to bipolar disorder. Resident #62's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 11/16/2022, revealed the screening was positive for suspected MI. Further review revealed a mental disorder diagnosis of major depressive disorder. Review of Resident #62's medical record during the recertification survey from 09/16/2024 to 09/19/2024 revealed another Level I PASARR had not been completed since 11/16/2022. During an interview on 09/19/2024 at 8:33 AM, the MDS Director stated Level I PASARR screenings were completed at the hospital and he reviewed them for any discrepancies upon admission. The MDS Director further stated when a resident obtained a new mental health diagnosis after admission, a new Level I PASARR should be completed to capture that diagnosis and when Resident #62 obtained their schizoaffective disorder diagnosis, a new Level I PASARR should have been completed. During an interview on 09/19/2024 at 8:40 AM, Medical Records (MR) stated Level I PASARR screenings were completed at the hospital prior to admission and an updated Level I PASARR should be completed with a new mental health diagnosis. MR further stated Resident #62's new diagnosis of schizoaffective disorder was probably missed and that was why a new Level I PASARR had not been completed. During an interview on 09/19/2024 at 10:07 AM, the Director of Nursing (DON) stated the Level I PASARR process screened residents with mental illness to determine if they would benefit from additional services. The DON further stated when a resident received a new mental health diagnosis, staff should complete an updated Level I PASARR to see if the resident qualified for those additional services. During an interview on 09/19/2024 at 10:26 AM, the [NAME] President (VP) of Clinical Operations stated the Level I PASARR screenings were completed prior to admission. The VP of Clinical Operations further stated a new Level I PASARR should be completed with a new mental health disorder to ensure that resident received the care they need for their new diagnosis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056301 If continuation sheet Page 2 of 15 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 056301 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Modesto Care Center 1900 Coffee Road Modesto, CA 95355 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)

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to ensure a Level I Pre-admission Screening and Resident Review (PASARR) was complete and accurate for 2 (Resident #62 and Resident #12) of 3 residents reviewed for PASARR. Specifically, Resident #62 and Resident #12 had a Level I PASARR completed that did not capture all their mental health diagnoses. Residents Affected - Few Findings included: A facility policy titled, admission Criteria, revised in March 2019, indicated, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID, or RD. 1. An admission Record revealed the facility admitted Resident #62 on 06/12/2020. According to the admission Record, the resident had a medical history that included diagnoses of bipolar type schizoaffective disorder (onset date 04/14/2024), bipolar disorder (onset date 06/12/2020), major depressive disorder (onset date 06/12/2020), and anxiety disorder (onset date 06/12/2020). An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/29/2024, revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed the resident received antipsychotic and antidepressant medications during the assessment period. Resident #62's care plan included a focus area revised on 10/12/2023 that indicated the resident received an antipsychotic medication of aripiprazole related to a bipolar disorder diagnosis manifested by mood swings. Interventions directed staff to administer psychotropic medications as ordered and to monitor and document episodes of bipolar depression daily. Resident #62's care plan included a focus area revised on 10/12/2023 that indicated the resident received an antidepressant medication of sertraline related to depression. Interventions directed staff to administer antidepressant medications as ordered by the physician and to monitor and document side effects and effectiveness every shift. Resident #62's Order Summary Report, with active orders as of 09/19/2024, contained an order, dated 08/23/2024, for aripiprazole (antipsychotic) 5 milligrams (mg) by mouth every other day for rapid, alternating changes in mood related to bipolar schizoaffective disorder. Resident #62's Order Summary Report, contained an order, dated 08/23/2024, for sertraline hydrochloric acid (HCl) (antidepressant) 12.5 mg by mouth one time a day for sad facial expressions and flat affect related to major depressive disorder. Resident #62's Order Summary Report, contained an order, dated 08/22/2024, for valproic acid 250 mg by mouth every 12 hours for audio/visual hallucinations related to bipolar disorder. Resident #62's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 11/16/2022, revealed the screening was positive for suspected MI. Further review revealed a mental disorder diagnosis of major depressive disorder; the diagnoses of anxiety and bipolar disorders were not listed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056301 If continuation sheet Page 3 of 15 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 056301 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Modesto Care Center 1900 Coffee Road Modesto, CA 95355 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)

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 09/19/2024 at 8:33 AM, the MDS Director stated Level I PASARR screenings were completed at the hospital and he reviewed them for any discrepancies upon admission. The MDS Director further stated Resident #62's Level I PASARR was inaccurate because it did not include the resident's diagnoses of bipolar and anxiety disorder. During an interview on 09/19/2024 at 8:40 AM, Medical Records (MR) stated Level I PASARR screenings were completed at the hospital prior to admission and that Resident #62's PASARR was inaccurate because it did not capture all the resident's mental health diagnoses. During an interview on 09/19/2024 at 10:07 AM, the Director of Nursing (DON) stated the Level I PASARR process screened residents with mental illness to determine if they would benefit from additional services. The DON further stated Resident #62's Level I PASARR should have captured the resident's bipolar and anxiety disorder diagnoses. During an interview on 09/19/2024 at 10:26 AM, the [NAME] President (VP) of Clinical Operations stated the Level I PASARR screenings were completed prior to admission. The VP of Clinical Operations further stated bipolar and anxiety disorder diagnoses should have been captured on Resident #62's Level I PASARR. 2. An admission Record specified the facility originally admitted Resident #12 on 12/20/2017 with a readmission on [DATE]. According to the admission Record, the resident had a medical history that included diagnoses of delusional disorder (onset date 12/20/2017), psychosis (onset date 12/20/2017), single episode major depressive disorder (onset date 12/20/2017), recurrent depressive disorders (onset date 12/20/2017), and hallucinations (onset date 12/20/2017). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/08/2024, revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed the resident had diagnoses of depression and psychotic disorder. Resident #12's Preadmission Screening and Resident Review (PASRR) Level I Screening dated 11/10/2021 indicated the resident had no diagnosed mental disorder. Resident #12's Level I PASRR letter dated 11/10/2021 specified the Level I PASRR submitted on 11/10/2021 was negative due to no mental illness. During an interview on 09/19/2024 at 8:33 AM, the MDS Director stated a new admission PASRR was completed at the hospital and was reviewed for discrepancies. The MDS Director stated any changes to psychotropics medications, significant change, a cognitive decline, or a new psychiatric diagnosis indicated for another PASRR screen to be completed. The MDS Director stated Resident #12's PASRR screen was inaccurate without the diagnoses addressed. During an interview on 09/19/2024 at 8:40 AM, Medical Records (MR) stated Resident #12's PASRR was inaccurate when it was not marked with all the diagnoses the resident had. During an interview on 09/19/2024 at 10:07 AM, the Director of Nursing (DON) stated the PASRR process screened residents for mental illness to determine if additional psychiatric care would be needed. The DON stated Resident #12 had mental health diagnoses, so the screening form was not accurate. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056301 If continuation sheet Page 4 of 15 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 056301 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Modesto Care Center 1900 Coffee Road Modesto, CA 95355 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)

F 0645 Level of Harm - Minimal harm or potential for actual harm During an interview on 09/19/2024 at 10:26 AM, the [NAME] President (VP) of Clinical Operations stated the PASRR needed to be reviewed when a resident was admitted to make sure it was accurate with diagnoses, medications, and resident history, and they should complete a new one if it was inaccurate. The VP of Clinical Operations stated Resident #12's PASRR was inaccurate without the diagnoses identified. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056301 If continuation sheet Page 5 of 15 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 056301 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Modesto Care Center 1900 Coffee Road Modesto, CA 95355 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)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on interview, record review, and facility policy review, the facility failed to follow pharmacy recommendations for 1 (Resident #19) of 5 residents reviewed for unnecessary medications. Specifically, the facility failed to respond to May and June 2024 pharmacy recommendations for an AIMS (abnormal involuntary movement scale) assessment for Resident #19. Findings included: A facility policy titled, Antipsychotic Medication Use, revised 12/2016, indicated, 17. Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician: a. General/anticholinergic: constipation, blurred vision, dry mouth, urinary retention, sedation; b. Cardiovascular: orthostatic hypotension, arrhythmias; c. Metabolic: increase in total cholesterol/triglycerides, unstable or poorly controlled blood sugar, weight gain; or d. Neurologic: akathisia, dystonia, extrapyramidal effects, akinesia, or tardive dyskinesia, stroke or TIA [transient ischemic attack]. A facility policy titled, Medication Regimen Reviews, revised 05/2019, indicated, 9. An 'irregularity' refers to the use of medication that is inconsistent with accepted pharmaceutical services standards of practice; is not supported by medical evidence; and/or impedes or interferes with achieving the intended outcomes of pharmaceutical services. It may also include the use of medication without indication, without adequate monitoring, in excessive doses, and or in the presence of adverse consequences. The policy revealed, 11. If the physician does not provide a timely or adequate response, or the consultant pharmacist identifies that no action has been taken, he/she contacts the medical director or (if the medical director is the physician of record) the administrator. 12. The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it. An admission Record revealed the facility admitted Resident #19 on 03/29/2017. According to the admission Record, the resident had a medical history that included diagnoses of unspecified dementia, restlessness and agitation, and major depressive disorder. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/06/2024, revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS revealed the resident received antipsychotic and antidepressant medications during the assessment period. Resident #19's care plan included a focus area initiated 10/03/2022, that indicated the resident used antipsychotic medication for agitation manifested by picking at their brief and smearing stool. Interventions directed staff to administer antipsychotic medications as ordered by the physician, monitor for side effects and effectiveness every shift, monitor for adverse reactions of psychotropic medications, and to consult with the pharmacy. Resident #19's Order Summary Report, with active orders as of 09/19/2024, revealed an order dated 09/13/2024 for quetiapine fumarate oral tablet 75 milligrams (mg) by mouth at bedtime. The Order Summary Report revealed an order dated 09/13/2024 for quetiapine fumarate oral tablet 75 mg by mouth one time a day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056301 If continuation sheet Page 6 of 15 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 056301 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Modesto Care Center 1900 Coffee Road Modesto, CA 95355 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)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #19's Consultant Pharmacist's Medication Regimen Review, dated 05/31/2024, revealed a recommendation that included Resident is due for an AIMS assessment due to antipsychotic medication use. It should be done every 3 months. Resident #19's Consultant Pharmacist's Medication Regimen Review, dated 06/28/2024, revealed a recommendation that included Resident is due for an AIMS assessment due to antipsychotic medication use. It should be done every 3 months. Resident #19's Abnormal Involuntary Movement Scale (AIMS), dated 12/05/2023, revealed a score of 1, which indicated the resident had a low risk of movement disorder. Further review revealed the AIMS dated 12/05/2023 was the most recent AIMS score in the resident's record. During an interview on 09/18/2024 at 10:48 AM, Licensed Practical Nurse (LPN) #6 stated she did not know how often AIMS assessments were done for residents. LPN #6 stated if the pharmacist recommended an AIMS assessment for a resident, it was the responsibility of the registered nurse (RN) supervisor or the Director of Nursing (DON) to complete the assessment. During an interview on 09/18/2024 at 12:14 PM, LPN #1 stated the RN on the floor did the AIMS assessment if the pharmacist recommended it. During an interview on 09/18/2024 at 12:51 PM, RN #7 stated the AIMS assessment was done for residents on psychotropic medications every six months. RN #7 stated if the pharmacy made the recommendation for an AIMS assessment, then the specific instructions came down to the floor where they could be implemented. He stated he was not sure why Resident #19 had not received an AIMS assessment in response to the pharmacy recommendation, nor had he seen the recommendation. During an interview on 09/19/2024 at 10:16 AM, the DON stated that staff should follow the medication regimen review recommendations and do the psychotropic monitoring as recommended. The DON stated the facility did not do the AIMS assessment, and she expected staff to do the monitoring recommended by the pharmacist. During an interview on 09/19/2024 at 10:34 AM, the [NAME] President (VP) of Clinical Operations stated that she expected staff to go over the pharmacy recommendations and implement that recommendation. She stated the nursing recommendations are put in with an order that would notify nurses to implement the recommendation. The VP of Clinical Operations stated when the facility transitioned from their old electronic medical record system to a new one, the AIMS assessment changed, and this was likely why Resident #19's AIMS assessment was not done. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056301 If continuation sheet Page 7 of 15 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 056301 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Modesto Care Center 1900 Coffee Road Modesto, CA 95355 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)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, record review, and facility policy review, the facility failed to ensure a medication error rate less than 5 percent (%). There were 2 errors out of 32 opportunities, which resulted in a 6.25% medication error rate for 2 (Resident #5 and Resident #86) of 4 residents observed for medication administration. Residents Affected - Few Findings included: A facility policy titled, Administering Medications, revised 04/2019, specified, 4. Medications are administered in accordance with prescriber orders, including any required time frame. 1. An admission Record revealed the facility admitted Resident #5 on 10/17/2022. According to the admission Record, the resident had a medical history that included diagnoses of constipation and rectal prolapse. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/18/2024, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #5's Order Summary Report, with active orders as of 09/18/2024, revealed an order dated 10/26/2021 for docusate sodium with instructions to give 250 milligrams (mg) by mouth in the evening for constipation. During an observation of medication pass on 09/17/2024 at 8:26 AM, Licensed Practical Nurse (LPN) #2 prepared and administered docusate sodium 100 mg to Resident #5. During an interview on 09/18/2024 at 12:19 PM, LPN #2 stated she had administered the docusate sodium to Resident #5. LPN #2 reviewed Resident #5's physician orders and stated the docusate sodium was not due at the time she administered it, and it was not ordered to be given as needed. 2. An admission Record revealed the facility admitted Resident #86 on 02/16/2024. According to the admission Record, the resident had a medical history that included a diagnosis of type 2 diabetes mellitus. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/08/2024, revealed Resident #86 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #86's Order Summary Report, with active orders as of 09/18/2024, revealed an order dated 08/02/2024 for insulin lispro injection solution 100 unit/milliliters (mL) with instructions to inject 12 units subcutaneously before meals. During an observation of medication pass on 09/17/2024 at 10:59 AM, Licensed Practical Nurse (LPN) #3 prepared insulin lispro to be administered to Resident #86. LPN #3 applied the needle to a Humalog (insulin lispro) KwikPen, then turned the dial to 2 units, then continued to roll the dial to 14 units and stated, I am priming the insulin. LPN #3 went to enter Resident #86's room and the surveyor stopped her and asked about the 2 units to prime. LPN #3 stated again she was priming the insulin. During the observation the [NAME] President (VP) of Clinical Operations was asked to help explain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056301 If continuation sheet Page 8 of 15 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 056301 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Modesto Care Center 1900 Coffee Road Modesto, CA 95355 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)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few what LPN #3 was communicating. The VP of Clinical Operations asked LPN #3 about the two extra units and LPN #3 stated she guessed the resident would get extra units if administered. The VP of Clinical Operations stated LPN #3 would be retrained immediately. During an interview on 09/18/2024 at 6:58 AM, LPN #4 stated the process for insulin administration was to prepare the needle, prime the needle with two units, then turn the dial to the amount the physician ordered. During an interview on 09/18/2024 at 12:27 PM, LPN #1 stated the process for insulin administration was to prime the pen with two units. She stated after it was primed with two units, then turn the dial on the pen to the physician-ordered dose. During a telephone interview on 09/18/2024 at 1:30 PM, the Pharmacy Consultant stated the insulin needle had to be primed to ensure the correct dose was administered. The Pharmacy Consultant stated a couple of units difference in the insulin could make a difference. The Pharmacy Consultant stated if the dial was turned to 14 units without priming the needle, the dose was not correct. The Pharmacy Consultant stated they needed to prime the insulin needle first, then the dial would go back to zero, then turn the dial to the physician-ordered dose to administer the insulin. During an interview on 09/19/2024 at 10:07 AM, the Director of Nursing (DON) stated she expected the nurses to read the physician orders, follow physician orders, and follow all the rights to medication administration. The DON stated she did not want any medications errors; she expected the medication error rate to be less than 5%. During an interview on 09/19/2024 at 10:26 AM, the VP of Clinical Operations stated she expected staff to be educated to prevent medication errors. The VP of Clinical Operations stated the medication error rate was not acceptable and additional training was needed to prevent errors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056301 If continuation sheet Page 9 of 15 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 056301 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Modesto Care Center 1900 Coffee Road Modesto, CA 95355 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)

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm 2. A facility policy titled, Administering Medications, revised in April 2019, indicated, Medications are administered in a safe and timely manner, and as prescribed. Residents Affected - Few An admission Record revealed the facility admitted Resident #62 on 06/12/2020. According to the admission Record, the resident had a medical history that included diagnoses of congestive heart failure (CHF) and hypertension (HTN). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/29/2024, revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS also indicated the resident received a diuretic in the seven days prior to the assessment. Resident #62's care plan included a focus area revised on 05/29/2024 that indicated the resident had a risk for decreased cardiac output related to the presence of a pacemaker. Resident #62's Order Summary Report, with active orders as of 09/18/2024, contained an order, dated 11/15/2022, for amlodipine besylate oral tablet (anti-hypertensive) 10 milligrams (mg) by mouth one time a day for HTN, with instructions to hold if the resident's systolic blood pressure (SBP, the top number of a blood pressure reading) was less than (<) 100 millimeters mercury (mmHg) or heart rate (HR) < 60 beats per minute (bpm). Resident #62's Order Summary Report, contained an order, dated 07/22/2024, for furosemide oral tablet (diuretic) 20 mg by mouth two times a day for CHF, with instructions to hold if SBP < 100 mmHg or HR < 60 bpm. Resident #62's Medication Administration Record [MAR], for the timeframe from 09/01/2024 through 09/17/2024, reveal a transcription on an order for amlodipine besylate oral tablet 10 mg by mouth one time a day for HTN, hold if SBP < 100 mmHg or HR < 60 bpm. Further review revealed staff documented that the medication was administered when the resident's HR was below the prescribed parameters on: - 09/02/2024: 55 bpm - 09/08/2024: 58 bpm - 09/13/2024: 59 bpm Resident #62's MAR for the timeframe from 09/01/2024 through 09/17/2024 reveal a transcription on an order for furosemide oral tablet 20 mg by mouth two times a day for CHF, hold if SBP < 100 mmHg or HR < 60 bpm. Further review revealed staff documented that the medication was administered when the resident's HR was below the prescribed parameters on: - 09/02/2024: 55 bpm - 09/08/2024: 58 bpm - 09/13/2024: 59 bpm Resident #62's August 2024 MAR reveal a transcription on an order for amlodipine besylate oral tablet 10 mg by mouth one time a day for HTN, hold if SBP < 100 mmHg or HR < 60 bpm. Further review (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056301 If continuation sheet Page 10 of 15 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 056301 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Modesto Care Center 1900 Coffee Road Modesto, CA 95355 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)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revealed staff documented that the medication was administered on 08/23/2024 when the resident's HR was 59 bpm. Resident #62's August 2024 MAR reveal a transcription on an order for furosemide oral tablet 20 mg by mouth two times a day for CHF, hold if SBP < 100 mmHg or HR < 60 bpm. Further review revealed staff documented that the medication was administered on 08/23/2024 when the resident's HR was 59 bpm. Resident #62's July 2024 MAR reveal a transcription on an order for amlodipine besylate oral tablet 10 mg by mouth one time a day for HTN, hold if SBP < 100 mmHg or HR < 60 bpm. Further review revealed staff documented that the medication was administered on 07/23/2024 when the resident's HR was 59 bpm. Resident #62's July 2024 MAR reveal a transcription on an order for furosemide oral tablet 20 mg by mouth two times a day for CHF, hold if SBP < 100 mmHg or HR < 60 bpm. Further review revealed staff documented that the medication was administered on 07/23/2024 when the resident's HR was 59 bpm. During an interview on 09/18/2024 at 1:00 PM, Licensed Practical Nurse (LPN) #2 stated it was important to follow vital sign parameters if a medication order specified it. Per LPN #2, Resident #62's HR ran on the lower side and if a resident's HR was below 60 bpm, staff did not want to give a medication that could further lower it. LPN #2 then stated she administered the medications when Resident #62's HR was below the specified parameter because she did not want to stop a daily medication just because their HR was a couple points below the prescribed parameter. During an interview on 09/18/2024 at 1:30 PM, the Pharmacy Consultant stated nursing should not administer medications that lowered a resident's blood pressure or HR if those vital sign readings were already low. The Pharmacy Consultant stated this could cause the resident to become dizzy, increased their fall risk, and could cause heart problems if a resident's HR was too low. During an interview on 09/18/2024 at 3:05 PM, the Nurse Practitioner (NP) stated vital sign parameters were included in the orders to instruct the nurses on when to administer or hold furosemide and amlodipine. The NP stated these medications lowered blood pressure and HR, and nursing should hold the medications if the HR was already low. Per the NP, these medications would further lower the HR causing the resident to become dizzy and increased their fall risk. During an interview on 09/19/2024 at 10:07 AM, the Director of Nursing (DON) stated she expected the nurses to follow the physician's orders and to know the importance of following vital sign parameters when administering medications. The DON then stated she expected the nurses to hold a medication that lowered a resident's HR when it was already low; it could cause the resident's HR to lower further causing adverse effects. During an interview on 09/19/2024 at 10:26 AM, the [NAME] President (VP) of Clinical Operations stated she expected the nurses to hold a medication if there were parameters outlined in the medication order. The VP of Clinical Operations further stated if the physician included parameters on when to hold a medication that affected a resident's HR in the medication order, that medication should be held if a resident's HR was already too low to prevent any adverse effects. Based on observation, interview, record review, facility document review, and facility policy review, the facility failed to ensure 1 (Resident #86) of 4 residents observed for medication administration was free from a significant medication error and failed to follow vital sign parameters when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056301 If continuation sheet Page 11 of 15 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 056301 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Modesto Care Center 1900 Coffee Road Modesto, CA 95355 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)

F 0760 administering medications for 1 (Resident #62) of 5 residents reviewed for unnecessary medications. Level of Harm - Minimal harm or potential for actual harm Findings included: Residents Affected - Few 1. A facility policy titled, Administering Medications, revised 04/2019, specified, 4. Medications are administered in accordance with prescriber orders, including any required time frame. An Instructions for Use for a Humalog (insulin lispro) KwikPen revised by the manufacturer on 07/2023, specified, Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensure that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Step 6: To prime your Pen, turn the Dose Knob to select 2 units. Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 8: Continue holding your Pen with needle pointing up. Push the Dose Knob in until it stops, and '0' is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the needle. If you do not see insulin, repeat priming steps 6 to 8, no more than 4 times. An admission Record revealed the facility admitted Resident #86 on 02/16/2024. According to the admission Record, the resident had a medical history that included a diagnosis of type 2 diabetes mellitus. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/08/2024, revealed Resident #86 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #86's Order Summary Report, with active orders as of 09/18/2024, revealed an order dated 08/02/2024 for insulin lispro injection solution 100 unit/milliliters (mL) with instructions to inject 12 units subcutaneously before meals. During an observation of medication pass on 09/17/2024 at 10:59 AM, Licensed Practical Nurse (LPN) #3 prepared insulin lispro to be administered to Resident #86. LPN #3 applied the needle to a Humalog (insulin lispro) KwikPen, then turned the dial to 2 units, then continued to roll the dial to 14 units and stated, I am priming the insulin. LPN #3 went to enter Resident #86's room and the surveyor stopped her and asked about the 2 units to prime. LPN #3 stated again she was priming the insulin. During the observation the [NAME] President (VP) of Clinical Operations was asked to help explain what LPN #3 was communicating. The VP of Clinical Operations asked LPN #3 about the two extra units and LPN #3 stated she guessed the resident would get extra units if administered. The VP of Clinical Operations stated LPN #3 would be retrained immediately. During an interview on 09/18/2024 at 6:58 AM, LPN #4 stated the process for insulin administration was to prepare the needle, prime the needle with two units, then turn the dial to the amount the physician ordered. During an interview on 09/18/2024 at 12:27 PM, LPN #1 stated the process for insulin administration was to prime the pen with two units. She stated after it was primed with two units, then turn the dial on the pen to the physician-ordered dose. During a telephone interview on 09/18/2024 at 1:30 PM, the Pharmacy Consultant stated the insulin needle had to be primed to ensure the correct dose was administered. The Pharmacy Consultant stated a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056301 If continuation sheet Page 12 of 15 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 056301 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Modesto Care Center 1900 Coffee Road Modesto, CA 95355 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)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few couple of units difference in the insulin could make a difference. The Pharmacy Consultant stated if the dial was turned to 14 units without priming the needle, the dose was not correct. The Pharmacy Consultant stated they needed to prime the insulin needle first, then the dial would go back to zero, then turn the dial to the physician-ordered dose to administer the insulin. During an interview on 09/19/2024 at 10:07 AM, the Director of Nursing (DON) stated she expected the nurses to read the physician orders, follow physician orders, and follow all the rights to medication administration. During an interview on 09/19/2024 at 10:26 AM, the VP of Clinical Operations stated she expected staff to be educated to prevent medication errors. The VP of Clinical Operations stated additional training was needed to prevent errors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056301 If continuation sheet Page 13 of 15 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 056301 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Modesto Care Center 1900 Coffee Road Modesto, CA 95355 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 2. An admission Record indicated the facility admitted Resident #22 on 04/28/2021. According to the admission Record, the resident had a medical history that included a diagnosis of type 2 diabetes mellitus. Residents Affected - Some An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/20/2024, revealed Resident #22 had severe impairment in cognitive skills for daily decision making and had short-term and long-term memory problems per a staff assessment of mental status (SAMS). Resident #22's care plan included a focus area revised on 08/01/2024 that indicated the resident had the potential for impairment in skin integrity. Resident #22's Order Summary Report, with active orders as of 09/18/2024, contained an order dated 08/24/2024 for betadine-soaked gauze and dry gauze over the left big toe daily until resolved. During an observation on 09/18/2024 at 9:58 AM, Licensed Practical Nurse (LPN) #1 provided wound care for Resident #22. A small open area was noted to the resident's left hallux. LPN #1 did not implement enhanced barrier precautions and wore only gloves during the provision of wound care. During an interview on 09/18/2024 at 10:10 AM, LPN #1 stated she was not familiar with enhanced barrier precautions and did not know to wear a gown and gloves when providing wound care. During an interview on 09/18/2024 at 2:11 PM, the Infection Preventionist (IP) stated she did know the specifics about enhanced barrier precautions. The IP stated the facility had not implemented enhanced barrier precautions. Based on observation, interview, record review, and facility policy review, the facility failed to implement enhanced barrier precautions (EBP) during high-contact resident care activities for 2 (Residents #81 and Resident #22) of 2 residents observed during wound care. Findings included: A facility policy titled, Enhanced Barrier Precautions, dated 08/2024, indicated, 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the transmission of multi-drug resistant [sic] organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. The policy revealed, 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs included: h. wound care (any skin opening requiring a dressing). The policy further indicated, 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. 1. An admission Record revealed that the facility admitted Resident #81 on 09/03/2024. According to the admission Record, the resident had a medical history that included diagnoses of type 2 diabetes mellitus with diabetic neuropathy, cellulitis, unspecified open wound on the right foot, and acquired absence of other right toe(s). An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/07/2024, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056301 If continuation sheet Page 14 of 15 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 056301 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Modesto Care Center 1900 Coffee Road Modesto, CA 95355 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some revealed Resident #81 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS also indicated Resident #81 had an infection of the foot, diabetic foot ulcer(s), and surgical wound(s). Resident #81's care plan included a focus area initiated 09/04/2024 that indicated the resident had an actual infection caused by methicillin-susceptible staphylococcus aureus. Interventions directed staff to administer antibiotics per order, monitor intravenous site for signs and symptoms of infection, and provide treatment(s) as ordered. Further review revealed the resident had a peripherally inserted central catheter to their right upper extremity. The care plan also included a focus area initiated 09/04/2024 that indicated the resident had an alteration in skin integrity due to an open wound to their right lower extremity. Interventions directed staff to provide treatment as ordered. Resident #81's Order Summary Report, with active orders as of 09/19/2024, contained an order, dated 09/18/2024, to cleanse distal diabetic foot ulcer to the right plantar foot with normal saline, pat dry, apply a wet to dry betadine dressing, wrap with kerlix, and secure with ace bandage every day and evening shift. The Order Summary Report also contained an order, dated 09/18/2024 to cleanse incision site to right plantar foot with normal saline, pat dry, apply a wet to dry betadine dressing, wrap with kerlix, and secure with ace bandage every day and evening shift. During an observation of wound care for Resident #81 on 09/18/2024 at 1:58 PM, Licensed Practical Nurse (LPN) #5 was observed using standard precautions, not enhanced barrier precautions. LPN #5 did not have on a gown during wound care. During an interview on 09/18/2024 at 2:11 PM, LPN #5 stated that she did not know about enhanced barrier precautions. During an interview on 09/19/2024 at 10:16 PM, the Director of Nursing (DON) stated that EBP was meant to decrease the spread of MDROs in nursing homes. The DON stated direct hands-on care with residents increased the risk of transmission, so full personal protective equipment (PPE), was meant to reduce that risk. The DON stated she expected going forward that staff use a gown and gloves when providing high-contact care. During an interview on 09/19/2024 at 10:34 PM, the [NAME] President of Clinical Operations stated that EBP was meant to protect residents from MDROs. The VP of Clinical Operations stated it was important to protect residents and staff, so nobody transmitted those infections to someone else. The VP of Clinical Operations stated it was her expectation that staff use EBP. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056301 If continuation sheet Page 15 of 15

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Citations

6 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0645GeneralS&S Dpotential for harm
F645 - Preadmission Screening for individuals with a mental disorder and individuals
PASARR screening for Mental disorders or Intellectual Disabilities
0756GeneralS&S Dpotential for harm
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
0759GeneralS&S Dpotential for harm
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
0760GeneralS&S Dpotential for harm
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
0880GeneralS&S Epotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0644GeneralS&S Dpotential for harm
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

FAQ · About this visit

Common questions about this visit

What happened during the September 19, 2024 survey of GOLDEN MODESTO CARE CENTER?

This was a inspection survey of GOLDEN MODESTO CARE CENTER on September 19, 2024. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at GOLDEN MODESTO CARE CENTER on September 19, 2024?

Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "PASARR screening for Mental disorders or Intellectual Disabilities"

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

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Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Health inspection·September 19, 2024