Health inspection·March 18, 2025

F 0689 [physician] notified . Level of Harm - Minimal harm or potential for actual harm During a review of Resident 1 ' s, Meal tray Ticket, dated 2/19/24, the meal tray ticket indicated, . [Resident 1] Regular, mildly thick, full liquids . Italian sausage sub w/pepper and onion- 1 sandwich, French fries . capri vegetable blend . tropical fruit salad . milk mildly thick . Residents Affected - Few During a review of Resident 1 ' s, Dietary- Diet order, dated 2/19/25, the order indicated, . Full liquid diet full liquid texture, nectar thick consistency, for as tolerated . During an interview on 3/18/25 at 11:46 a.m. with licensed vocational nurse (LVN)1, LVN 1 stated the facility process was for the nurse on shift to check the meal trays before the meals trays were served to the residents. LVN 1 stated the purpose for checking the trays was to ensure the meal tray ticket indicated the ordered resident diet and to ensure the meal matched the ordered diet. LVN 1 stated it was important for all nurses to check the meal trays to prevent any resident from being served the wrong diet or wrong texture. LVN 1 stated the facility expectation was for the facility ' s certified nursing assistant (CNA)s to wait until the nurses checked the meal trays to serve them to the residents. During an interview on 3/18/25 at 12:24 p.m. with CNA 1, CNA 1 stated the facility process was for the nurse on shift to check the meal trays before they were given to the residents. CNA 1 stated it was important for the nurses to check the meal trays to ensure they were for the right resident and their diet. During a concurrent interview and record review on 3/18/24 at 1:10 p.m. with the director of staff development (DSD), Resident 1's diet slip was reviewed. The DSD stated Resident 1 ' s diet slip had the incorrect diet listed. The DSD stated the dietary staff had served Resident 1, a regular diet when Resident 1 had a physician order for a full liquid diet. The DSD stated the facility expectation was for the nurses on shift to print, review and compare the diet order summary to the meal tray ticket and the food being served. The DSD stated all facility staff had been educated on the meal tray ticket process and how to check for inconsistencies to identify any errors prior to serving meal trays to all residents. The DSD it was important to follow the facility process to avoid giving the residents the wrong meal tray and identify mistakes made in the serving process. During an interview on 3/18/24 at 2:00 pm with the director of nursing (DON), the DON stated the facility process was for all nurses on shift to print the diet order summary daily and compare them to the meal trays when they were served from the kitchen prior to CNAs serving them to the residents. During an interview on 3/26/24 at 4:59 p.m. with LVN 2, LVN 2 stated on 2/20/25 while working her shift, there was an incident regarding Resident 1 receiving the incorrect meal tray. LVN 2 stated the facility process was for all nurses on shift to print the diet order summary for all residents and compare them to the meal tray prior to the CNAs serving the trays to the residents. LVN 2 stated, on 2/20/25, the CNAs served all residents in Resident 1 ' s hallway, their meal trays without waiting for the nurses to check the trays. LVN 2 stated the purpose for checking the meal trays was avoid accidently serving the residents the wrong meal tray and to ensure they were receiving the correct diet ordered. During an interview on 3/26/25 at 5:04 p.m. with LVN 3, LVN 3 stated on 2/20/25 while working her shift, there was an incident regarding Resident 1 receiving the incorrect meal tray. LVN 3 stated the facility process was for the nurse on shift to print the diet order summary, check all the diet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056301 If continuation sheet Page 2 of 9 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 03/18/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few slips on the meal tray and check each individual tray for accuracy of the diet ordered. LVN 3 stated on 2/20/25, she had noticed the CNAs on shift had served all meal trays in Resident 1 ' s hallway prior to allowing the nurses on shift to check them for accuracy. LVN 2 stated she had provided all CNAs on shift with education on the importance of allowing the nurse to check all meal trays first prior to serving the residents. LVN 3 stated it was important to check each meal tray to prevent accidently serving residents with the wrong diet or to identify allergies. During a review of the facility ' s, Lesson Plan- Basic Nutrition, dated 2/20/25, the lesson plan indicated, . Objective, upon completion of this program the participant will be able to understand basic nutrition needs for residents . [licensed nurse] to ensure diet order matches tray ticket of food being served, [licensed nurse] to print diet order listing report prior to each meal, prior to meals being distributed [licensed nurse] to ensure diet order matches the ticket on the tray and the food on the plate . During a review of the facility ' s policy and procedure (P&P) titled, Therapeutic Diets, dated 10/2022, the P&P indicated, . All residents have a diet order, including regular, therapeutic, and texture modification, that is prescribed by the attending physician, physician extender, or credentialed practitioner in accordance with applicable regulatory guidelines . therapeutic diet is defined as a diet ordered by a physician, or delegated registered or licensed dietitian, as part of the treatment for a disease or clinical condition. The purpose of a therapeutic diet . to provide food that a resident is able to eat . mechanically altered diet means one in which the texture of the diet is altered. When the texture is modified, the type of texture must be specific and part of the physician ' s or delegated registered or licensed dietitian ' s order . diets are prepared in accordance with the guidelines in the approved diet manual and the individualized plan of care . Based on interview and record review the facility failed to ensure residents were free from accidents for one of five sampled residents (Resident 1) when on 2/20/25, Resident 1 was served a meal tray with a regular consistency (diet with no alterations) and was ordered a full liquid diet with nectar thick consistency. This failure resulted in Resident 1 experiencing episode of coughing and emesis (vomit) and had the potential to cause choking, aspiration and death. Findings: During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for acute respiratory failure (lungs are unable to get enough oxygen), shortness of breath (difficult or labored breathing), dementia (disorder that causes decline in ability to think, memory and judgment), altered mental status (change in mental function). During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 2/24/25, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 0 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was severely cognitively impaired. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056301 If continuation sheet Page 3 of 9 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 03/18/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1's, Interdisciplinary Team (IDT) post incident meeting , dated 2/24/25, the IDT indicated, . Resident is dependent with [activities of daily living] and requires assistance with meals . on 2/20/25 the [charge nurse] noted resident was sitting upright in bed, eating his meal and was noted to have difficulty swallowing with cough. [charge nurse] noted resident was able to spit out food content from mouth with verbal cues preventing chocking incident. [charge nurse] also noted that resident had a small emesis (vomit) of undigested food post coughing episode. No respiratory distress, no decline in [oxygen] saturation, no loss of consciousness during or after episode. Resident recovered rapidly and spontaneously without medical intervention needed. as a precautionary measure resident was sent to [emergency room] to [rule out] aspiration or other complications . During a review of Resident 1's, Situation, background, appearance, review (SBAR) , dated 2/20/25, the SBAR indicated, . Resident received dinner tray that was incorrect from his diet order. No signs and symptoms (s/sx) of respiratory or abdominal distress. Vital signs(VS) within normal limits. [physician] notified . During a review of Resident 1's, Meal tray Ticket , dated 2/19/24, the meal tray ticket indicated, . [Resident 1] Regular, mildly thick, full liquids . Italian sausage sub w/pepper and onion- 1 sandwich, French fries . capri vegetable blend . tropical fruit salad . milk mildly thick . During a review of Resident 1's, Dietary- Diet order , dated 2/19/25, the order indicated, . Full liquid diet full liquid texture, nectar thick consistency, for as tolerated . During an interview on 3/18/25 at 11:46 a.m. with licensed vocational nurse (LVN)1, LVN 1 stated the facility process was for the nurse on shift to check the meal trays before the meals trays were served to the residents. LVN 1 stated the purpose for checking the trays was to ensure the meal tray ticket indicated the ordered resident diet and to ensure the meal matched the ordered diet. LVN 1 stated it was important for all nurses to check the meal trays to prevent any resident from being served the wrong diet or wrong texture. LVN 1 stated the facility expectation was for the facility's certified nursing assistant (CNA)s to wait until the nurses checked the meal trays to serve them to the residents. During an interview on 3/18/25 at 12:24 p.m. with CNA 1, CNA 1 stated the facility process was for the nurse on shift to check the meal trays before they were given to the residents. CNA 1 stated it was important for the nurses to check the meal trays to ensure they were for the right resident and their diet. During a concurrent interview and record review on 3/18/24 at 1:10 p.m. with the director of staff development (DSD), Resident 1's diet slip was reviewed. The DSD stated Resident 1's diet slip had the incorrect diet listed. The DSD stated the dietary staff had served Resident 1, a regular diet when Resident 1 had a physician order for a full liquid diet. The DSD stated the facility expectation was for the nurses on shift to print, review and compare the diet order summary to the meal tray ticket and the food being served. The DSD stated all facility staff had been educated on the meal tray ticket process and how to check for inconsistencies to identify any errors prior to serving meal trays to all residents. The DSD it was important to follow the facility process to avoid giving the residents the wrong meal tray and identify mistakes made in the serving process. During an interview on 3/18/24 at 2:00 pm with the director of nursing (DON), the DON stated the facility process was for all nurses on shift to print the diet order summary daily and compare them to the meal trays when they were served from the kitchen prior to CNAs serving them to the residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056301 If continuation sheet Page 4 of 9 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 03/18/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 3/26/24 at 4:59 p.m. with LVN 2, LVN 2 stated on 2/20/25 while working her shift, there was an incident regarding Resident 1 receiving the incorrect meal tray. LVN 2 stated the facility process was for all nurses on shift to print the diet order summary for all residents and compare them to the meal tray prior to the CNAs serving the trays to the residents. LVN 2 stated, on 2/20/25, the CNAs served all residents in Resident 1's hallway, their meal trays without waiting for the nurses to check the trays. LVN 2 stated the purpose for checking the meal trays was avoid accidently serving the residents the wrong meal tray and to ensure they were receiving the correct diet ordered. During an interview on 3/26/25 at 5:04 p.m. with LVN 3, LVN 3 stated on 2/20/25 while working her shift, there was an incident regarding Resident 1 receiving the incorrect meal tray. LVN 3 stated the facility process was for the nurse on shift to print the diet order summary, check all the diet slips on the meal tray and check each individual tray for accuracy of the diet ordered. LVN 3 stated on 2/20/25, she had noticed the CNAs on shift had served all meal trays in Resident 1's hallway prior to allowing the nurses on shift to check them for accuracy. LVN 2 stated she had provided all CNAs on shift with education on the importance of allowing the nurse to check all meal trays first prior to serving the residents. LVN 3 stated it was important to check each meal tray to prevent accidently serving residents with the wrong diet or to identify allergies. During a review of the facility's, Lesson Plan- Basic Nutrition , dated 2/20/25, the lesson plan indicated, . Objective, upon completion of this program the participant will be able to understand basic nutrition needs for residents . [licensed nurse] to ensure diet order matches tray ticket of food being served, [licensed nurse] to print diet order listing report prior to each meal, prior to meals being distributed [licensed nurse] to ensure diet order matches the ticket on the tray and the food on the plate . During a review of the facility's policy and procedure (P&P) titled, Therapeutic Diets , dated 10/2022, the P&P indicated, . All residents have a diet order, including regular, therapeutic, and texture modification, that is prescribed by the attending physician, physician extender, or credentialed practitioner in accordance with applicable regulatory guidelines . therapeutic diet is defined as a diet ordered by a physician, or delegated registered or licensed dietitian, as part of the treatment for a disease or clinical condition. The purpose of a therapeutic diet . to provide food that a resident is able to eat . mechanically altered diet means one in which the texture of the diet is altered. When the texture is modified, the type of texture must be specific and part of the physician's or delegated registered or licensed dietitian's order . diets are prepared in accordance with the guidelines in the approved diet manual and the individualized plan of care . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056301 If continuation sheet Page 5 of 9 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 03/18/2025 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure therapeutic diets were followed according to physician orders for one of five sampled residents (Resident 1) when on 2/20/25, Resident 1 was served a meal tray with a regular consistency (diet with no alterations) and had physician orders for a full liquid diet with nectar thick consistency (liquid slightly thicker than water). This failure resulted in Resident 1 experiencing an episode of coughing and emesis (vomit) and had the potential to cause choking, aspiration, and death. Findings: During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for acute respiratory failure (lungs are unable to get enough oxygen), shortness of breath (difficult or labored breathing), dementia (disorder that causes decline in ability to think, memory and judgment), altered mental status (change in mental function). During a review of Resident 1's Minimum Data Set (MDS a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment) dated 2/24/25, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS- screening tool used to assess resident cognitive level) score was 0 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills], 8-12 moderate cognitive impairment, 13 -15 cognitively intact) which indicated Resident 1 ' s cognition was severely impaired. During a review of Resident 1 ' s, Interdisciplinary Team (IDT) post incident meeting, dated 2/24/25, the IDT indicated, . Resident is dependent with [activities of daily living] and requires assistance with meals . on 2/20/25 the [charge nurse] noted resident was sitting upright in bed, eating his meal and was noted to have difficulty swallowing with cough. [charge nurse] noted resident was able to spit out food content from mouth with verbal cues preventing chocking incident. [charge nurse] also noted that resident had a small emesis (vomit) of undigested food post coughing episode. No respiratory distress, no decline in [oxygen] saturation, no loss of consciousness during or after episode. Resident recovered rapidly and spontaneously without medical intervention needed. as a precautionary measure resident was sent to [emergency room] to [rule out] aspiration or other complications . During a review of Resident 1 ' s, Situation, background, appearance, review (SBAR), dated 2/20/25, the SBAR indicated, . Resident received dinner tray that was incorrect from his diet order. No signs and symptoms (s/sx) of respiratory or abdominal distress. Vital signs(VS) within normal limits. [physician] notified . During a review of Resident 1 ' s, Meal tray Ticket, dated 2/19/24, the meal tray ticket indicated, . [Resident 1] Regular, mildly thick, full liquids . Italian sausage sub w/pepper and onion- 1 sandwich, French fries . capri vegetable blend . tropical fruit salad . milk mildly thick . During a review of Resident 1 ' s, Dietary- Diet order, dated 2/19/25, the order indicated, . Full liquid diet full liquid texture, nectar thick consistency, for as tolerated . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056301 If continuation sheet Page 6 of 9 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 03/18/2025 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 3/18/25 at 1:10 p.m. with the director of staff development (DSD), the DSD stated the process for meal trays began in the facility kitchen where the dietary cook would have been the first to see the meal tray ticket, then continued with the dietary aid, the nurse in charge and finally the CNA serving the tray to the resident. The DSD stated the meal tray ticket indicated Resident 1 had an order for a regular diet and the food listed was for regular food. The DSD stated the meal tray ticket had the full liquid diet printed in small letters under the Regular diet, but was missed by all staff due to the printing error. The DSD stated it was important for all staff who were serving meal trays, to check the meal tray tickets and orders to prevent accidents of residents being served the wrong meal tray. During a telephone interview on 3/26/25 at 3:51 p.m. with the certified dietary manager (CDM), the CDM stated there was an incident that had occurred with Resident 1 on 2/20/25 in which Resident 1 was served the incorrect diet tray during dinner. The CDM stated there was an error in the facility ' s meal tracking system used for resident diets. The CDM stated the meal tray ticket was printed with the incorrect diet ordered but once they found out about the mistake, the correct diet order was added to the system. The CDM stated the meal tray ticket indicated a regular diet but Resident 1 ' s physician ordered diet was for a full liquid diet which had also been printed in the same meal tray ticket. The CDM stated the process was for the dietary cooks to recheck the meal tray ticket to ensure the correct texture and amount of food was correct. During a telephone interview on 3/27/25 at 10:07 a.m. with cook 1 (CK 1), CK 1 stated she could not recall the incident that occurred on 2/20/25 involving Resident 1. CK 1 stated she could not recall the meal tray ticket used to serve Resident 1 ' s meal tray. CK 1 stated the process was for the CDM to print the meal tray tickets for the day and to have them ready before meals for the staff in the kitchen. CK 1 stated the process was to look at the diet listed on the top of the meal tray ticket and then look at the bottom of the ticket to begin serving the meal ordered. CK 1 stated the incident should not have happened as the meal tray tickets should have been completed and was accurate prior to serving Resident 1 ' s meal. During a review of the facility ' s policy and procedure (P&P) titled, Therapeutic Diets, dated 10/2022, the P&P indicated, . All residents have a diet order, including regular, therapeutic, and texture modification, that is prescribed by the attending physician, physician extender, or credentialed practitioner in accordance with applicable regulatory guidelines . therapeutic diet is defined as a diet ordered by a physician, or delegated registered or licensed dietitian, as part of the treatment for a disease or clinical condition. The purpose of a therapeutic diet . to provide food that a resident is able to eat . mechanically altered diet means one in which the texture of the diet is altered. When the texture is modified, the type of texture must be specific and part of the physician ' s or delegated registered or licensed dietitian ' s order . diets are prepared in accordance with the guidelines in the approved diet manual and the individualized plan of care . Based on interview and record review the facility failed to ensure therapeutic diets were followed according to physician orders for one of five sampled residents (Resident 1) when on 2/20/25, Resident 1 was served a meal tray with a regular consistency (diet with no alterations) and had physician orders for a full liquid diet with nectar thick consistency (liquid slightly thicker than water). This failure resulted in Resident 1 experiencing an episode of coughing and emesis (vomit) and had the potential to cause choking, aspiration, and death. Findings: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056301 If continuation sheet Page 7 of 9 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 03/18/2025 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for acute respiratory failure (lungs are unable to get enough oxygen), shortness of breath (difficult or labored breathing), dementia (disorder that causes decline in ability to think, memory and judgment), altered mental status (change in mental function). During a review of Resident 1's Minimum Data Set (MDS a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment) dated 2/24/25, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS- screening tool used to assess resident cognitive level) score was 0 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills], 8-12 moderate cognitive impairment, 13 -15 cognitively intact) which indicated Resident 1's cognition was severely impaired. During a review of Resident 1's, Interdisciplinary Team (IDT) post incident meeting , dated 2/24/25, the IDT indicated, . Resident is dependent with [activities of daily living] and requires assistance with meals . on 2/20/25 the [charge nurse] noted resident was sitting upright in bed, eating his meal and was noted to have difficulty swallowing with cough. [charge nurse] noted resident was able to spit out food content from mouth with verbal cues preventing chocking incident. [charge nurse] also noted that resident had a small emesis (vomit) of undigested food post coughing episode. No respiratory distress, no decline in [oxygen] saturation, no loss of consciousness during or after episode. Resident recovered rapidly and spontaneously without medical intervention needed. as a precautionary measure resident was sent to [emergency room] to [rule out] aspiration or other complications . During a review of Resident 1's, Situation, background, appearance, review (SBAR) , dated 2/20/25, the SBAR indicated, . Resident received dinner tray that was incorrect from his diet order. No signs and symptoms (s/sx) of respiratory or abdominal distress. Vital signs(VS) within normal limits. [physician] notified . During a review of Resident 1's, Meal tray Ticket , dated 2/19/24, the meal tray ticket indicated, . [Resident 1] Regular, mildly thick, full liquids . Italian sausage sub w/pepper and onion- 1 sandwich, French fries . capri vegetable blend . tropical fruit salad . milk mildly thick . During a review of Resident 1's, Dietary- Diet order , dated 2/19/25, the order indicated, . Full liquid diet full liquid texture, nectar thick consistency, for as tolerated . During an interview on 3/18/25 at 1:10 p.m. with the director of staff development (DSD), the DSD stated the process for meal trays began in the facility kitchen where the dietary cook would have been the first to see the meal tray ticket, then continued with the dietary aid, the nurse in charge and finally the CNA serving the tray to the resident. The DSD stated the meal tray ticket indicated Resident 1 had an order for a regular diet and the food listed was for regular food. The DSD stated the meal tray ticket had the full liquid diet printed in small letters under the Regular diet, but was missed by all staff due to the printing error. The DSD stated it was important for all staff who were serving meal trays, to check the meal tray tickets and orders to prevent accidents of residents being served the wrong meal tray. During a telephone interview on 3/26/25 at 3:51 p.m. with the certified dietary manager (CDM), the CDM stated there was an incident that had occurred with Resident 1 on 2/20/25 in which Resident 1 was served the incorrect diet tray during dinner. The CDM stated there was an error in the facility's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056301 If continuation sheet Page 8 of 9 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 03/18/2025 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few meal tracking system used for resident diets. The CDM stated the meal tray ticket was printed with the incorrect diet ordered but once they found out about the mistake, the correct diet order was added to the system. The CDM stated the meal tray ticket indicated a regular diet but Resident 1's physician ordered diet was for a full liquid diet which had also been printed in the same meal tray ticket. The CDM stated the process was for the dietary cooks to recheck the meal tray ticket to ensure the correct texture and amount of food was correct. During a telephone interview on 3/27/25 at 10:07 a.m. with cook 1 (CK 1), CK 1 stated she could not recall the incident that occurred on 2/20/25 involving Resident 1. CK 1 stated she could not recall the meal tray ticket used to serve Resident 1's meal tray. CK 1 stated the process was for the CDM to print the meal tray tickets for the day and to have them ready before meals for the staff in the kitchen. CK 1 stated the process was to look at the diet listed on the top of the meal tray ticket and then look at the bottom of the ticket to begin serving the meal ordered. CK 1 stated the incident should not have happened as the meal tray tickets should have been completed and was accurate prior to serving Resident 1's meal. During a review of the facility's policy and procedure (P&P) titled, Therapeutic Diets , dated 10/2022, the P&P indicated, . All residents have a diet order, including regular, therapeutic, and texture modification, that is prescribed by the attending physician, physician extender, or credentialed practitioner in accordance with applicable regulatory guidelines . therapeutic diet is defined as a diet ordered by a physician, or delegated registered or licensed dietitian, as part of the treatment for a disease or clinical condition. The purpose of a therapeutic diet . to provide food that a resident is able to eat . mechanically altered diet means one in which the texture of the diet is altered. When the texture is modified, the type of texture must be specific and part of the physician's or delegated registered or licensed dietitian's order . diets are prepared in accordance with the guidelines in the approved diet manual and the individualized plan of care . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056301 If continuation sheet Page 9 of 9