Health inspection·August 21, 2025

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete grooming and showering.During a concurrent interview and record review on 8/21/25 at 1:12 p.m. with CNA 3, Resident 7's, Point of Care (POC)-Showers, dated 7/1/25-7/31/25, was reviewed. The POC indicated there were no documented refusals or changes in Resident 7's schedule to move showers to a different date, shift or time. CNA 3 stated the facility process was to give all resident showers on the scheduled date, document the shower, refusal to shower or any changes in the schedule on the residents POC. CNA 3 validated Resident 7 had not received a scheduled shower on 7/18/25, 7/25/25 and 7/29/25. CNA 3 stated all residents have the right to shower and live with dignity and respect.During a concurrent interview and record review on 8/21/25 at 1:40 p.m. with the director of staff development (DSD), Resident 7's, CNA Shower Review Forms, dated 7/15/25 and 7/22/25, were reviewed. The forms indicated Resident 7 received a total of two showers for the month of July. The forms indicated Resident 7 had not received a scheduled shower on 7/18/25, 7/25/25, and 7/29/25. The DSD stated the facility expectation was for the CNAs to follow the shower schedule for each resident and to document the showers, baths or refusals on the POC and notify the nurse. The DSD stated it was not acceptable to have a resident refuse a shower and not document it to alert the nurse and other staff. The DSD stated Resident 7 had not received a shower on 7/18/25, 7/25/25 and 7/29/25 after review of all CNA documentation.During an interview on 8/21/25 at 2:12 p.m. with the director of nursing (DON), the DON stated the facility expectation was for all residents to receive their scheduled showers on the scheduled dates. The DON stated if the resident was refusing the showers, the CNA should have alerted the nurse and completed documentation in the POC and on the shower forms. The DON stated, the facility did not have a policy and procedure (P&P) on showers or Activity of Daily Living (ADL).During a review of the facility's policy and procedure (P&P) titled, Notice of Resident Rights, dated 7/2015, the P&P indicated, . Each resident of a skilled nursing facility has the rights. The Center will seek to ensure that those rights are not violated. The Center will establish and implement written policies and procedures that include these rights and will make a copy of these policies available to the Resident, Resident's Representatives, or the public upon request. General rights. To be encouraged and assisted throughout the period of stay to exercise rights as a resident. To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. 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 08/21/2025 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a baseline care plan (included initial goals based on admission orders, physician orders, summary of residents medication, services and treatments to be administered by the facility, and conditions and risks affecting the residents health and safety) within 48 hours of residents admission according to the facility's policy and procedure (P&P) titled, Baseline Care Plan, for one of seven sampled residents (Resident 7) when Resident 7 did not have a baseline care plan for diagnosis and treatment for Chronic Kidney failure (a condition where the kidneys gradually lose their ability to filter waste products and excess fluid from the blood), heart failure (condition where the heart muscle cannot pump blood effectively enough to meet the body's needs) and hypertension (condition characterized by persistently elevated blood pressure readings).This failure placed Resident 7 at risk of delay in care and needs going unmet upon admission and during her stay in the facility.During a review of Resident 7'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 7 was admitted to the facility on [DATE] with diagnosis for Diabetes Mellitus (DM- increased sugar in the blood), bacterial infections, kidney failure, obesity, muscle weakness, hypertension (high blood pressure), heart failure, bradycardia (slow heart rate).During a review of Resident 7's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 5/20/2025, the MDS indicated, Resident 7's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 15 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 7 was cognitively intact.During a concurrent interview and record review on 8/21/25 at 11:05 a.m. with the minimum data set (MDS) nurse, Resident 7's electronic medical record (EMR) for care plans was reviewed. The EMR indicated the baseline care plan was not completed for Resident 7. The MDS stated the process was to initiate the baseline care plans on admission to the facility by the admitting nurse. The MDS stated the importance of the baseline care plans was to establish a plan of care based on Resident 7's needs upon admission. The MDS stated it was important to have a plan of care established to ensure all staff were meeting Resident 7's needs.During an interview on 8/21/25 at 12:58 p.m. with licensed vocational nurse (LVN) 4, LVN 4 stated it was the facility process to ensure all care plans were complete and accurate according to the residents' needs. LVN 4 stated it was important to complete a baseline care plan upon admission to ensure all residents' needs were met and to know how to properly care for each individual resident.During an interview on 8/21/25 at 1:40 p.m. with the director of staff development (DSD), the DSD stated the facility process was for the admitting nurse to initiate the baseline care plan upon resident admission. The DSD stated the baseline care should have been completed within 48 hours from admission for Resident 7. The DSD stated that there should have been a care plan initiated for every diagnosis Resident 7 was being admitted to the facility with. The DSD stated it was important to establish a baseline care plan to ensure residents were being treated with the appropriate interventions. The DSD stated every resident was different and had different needs therefore the care plan was used to ensure all resident needs and preferences were met. The DSD stated if there was no baseline care plan created upon admission, there was a risk that the residents needs would not be met and staff would not be aware of the appropriate interventions to assist them.During an interview on 8/21/25 at 2:12 p.m. with the director of nursing (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 08/21/2025 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete (DON), the DON stated there was no expectation for the facility staff to initiate a baseline care plan. The DON stated the baseline care plan should not have included every diagnosis residents had upon admission if the diagnosis was being treated with medications or other services. The DON stated the baseline care plan should have consisted of new diagnosis or changes in condition while in the facility.During a review of the facility's policy and procedure (P&P) titled, Baseline Care Plan, dated 7/2025, the P&P indicated, .A baseline plan of care (BPOC) is developed and provided to each resident and/or his/her Representative, following admission. The facility develops the baseline plan of care for each resident, within 48 hours of admission. The baseline plan of care includes information regarding care and services sufficient to promote safe delivery of care. The baseline plan of care consists of the following, Physician Orders, Dietary Orders, Therapy Services, Applicable Social Services Intervention, Applicable PASARR Recommendations, Initial Goals. 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 08/21/2025 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement a comprehensive systemic approach to ensure effective monitoring and systems to maintain acceptable parameters of nutritional status for one of five sampled residents (Resident 1), when Resident 1 had one documented weight on 6/6/25 since being admitted to the facility on [DATE]. Staff did not complete a weight on admission and weekly as ordered by the physician, Resident 1 was not consuming meals to its entirety or refused meals, the facility was aware of Resident 1's refusal to be weighed and the Restorative Nursing Assistant (RNA) did not follow up with the licensed nurses.This failure resulted in a 16% weight loss of 21.2 pounds (lbs.) in two (2) months placing Resident 1 at risk for unmonitored significant weight loss that could have worsened Resident 1's diagnosed heart condition and placed her at risk for inadequate nutritional intake.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 of congestive heart failure (condition in which the heart doesn't pump blood as it should), Dementia (loss of memory, language and other thinking abilities), osteomyelitis (inflammation of a bone caused by infection), Diabetes Mellitus (DM- increased sugar in the blood).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 5/20/2025, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 15 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 cognitively intact.During a telephone interview on 8/12/25 at 12:00 p.m. with family member (FM) 1, FM 1 stated, there were concerns regarding Resident 1 refusing meals and possible weight loss. FM 1 stated, Resident 1 had expressed that the facility food did not taste good and therefore Resident 1 did not consume her meals. FM 1 stated Resident 1 appeared to have lost weight since admission to the facility but was unaware how much weight she had lost.During a concurrent observation and interview on 8/12/25 at 1:01 p.m. with Resident 1, in Resident 1's room, Resident 1 was observed lying in bed appearing thin and frail. Resident 1 stated she had resided in the facility for a few months. Resident 1 stated she disliked the food in the facility and would consume a small portion or none of the food served during mealtimes. Resident 1 stated she was unaware if the facility staff had noticed weight loss or weight gain since admission and stated she was unaware if she had experienced weight loss during her stay.During a review of Resident 1's, Nutrition Evaluation, dated 5/18/25, the evaluation indicated, . At risk for weight fluctuations r/t PO [related to by mouth] intake, DM, and diuretic (medication used to eliminate excess fluid buildup in the body) therapy. Resident with obesity which can have a negative effect on their health, including but not limited to altered cardiac output, fluid retention, altered blood sugars, ineffective breathing patterns. estimated total daily 1544-1930 calories, protein intake daily 77-93 gram (g). The evaluation indicated the nutritional evaluation was completed by the Registered Dietitian (RD) and documented risks for weight fluctuations after review of Resident 1's evaluation.During a record review of Resident 1's, Order Summary, dated 8/19/2025, the order summary indicated, . Weekly Weights one time a day every Fri (Friday) for Admission.During a review of Resident 1's Electronic Medical Record (EMR) titled, Weights, the EMR indicated, Resident 1 had a documented weight of 130 pounds on 6/6/2025. The document indicated there were no other weights documented on the EMR since admission on [DATE].During a review of the Residents Affected - Few (continued on next page) 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 08/21/2025 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 0692 Level of Harm - Actual harm Residents Affected - Few facility's handwritten document titled, Daily weights, dated 5/15/25 for Resident 1, the document indicated, Resident 1 had refused weights from 5/15/25 to 6/3/25, 6/5/25, 6/26/25 to 7/7/25. The document did not indicate any further attempts for weight check after 7/7/25. The document did not indicate if the nurse or physician was made aware of Resident 1's refusals. Concurrent review of the document and Resident 1's EMR indicated there was no documentation or evidence indicating the nurse and the physician were made aware of Resident 1's refusals and multiple attempts to re weigh.During a concurrent interview and record review on 8/12/25 at 1:40 p.m. with licensed vocational nurse (LVN) 1, Resident 1's electronic medical record (EMR) was reviewed, including document titled Weights. The document indicated Resident 1 was only weighed on 6/6/2025 since the admission to the facility and there were no other weights documented in the EMR. The EMR indicated there was no documentation indicating Resident 1 had refused to be weighed by the restorative nursing assistant (RNA). LVN 1 stated Resident 1 should have documented weight checks monthly. LVN 1 stated if Resident 1 had refused to be weighed, the RNA who was assigned to weigh all residents, should have notified the nurse. LVN 1 stated the facility process included documentation of missed weights, physician and resident representative notification.During an interview on 8/12/25 at 2:43 p.m. with RNA 1, RNA 1 stated, part of the RNA duties was to complete weekly and monthly weights for every resident in the facility. RNA 1 stated the RNAs' would receive a list of all residents who needed to be weighed monthly and weekly from the MDS nurse. RNA 1 stated, once the weights were completed and recorded on the list provided by the MDS nurse, the completed list was given back to the MDS nurse who would document the weights obtained in the residents EMR. RNA 1 stated there had been no resident refusals for the month of August 2025 and all residents including Resident 1, should have been weighed. RNA 1 stated, if a resident refused to be weighed, it should have been documented on the list and notified the MDS nurse. RNA 1 stated the facility process was for every resident to be weighed on admission, 24 hours after admission, weekly for four weeks after admission, then monthly unless the physician orders otherwise.During a concurrent interview and record review on 8/12/25 at 2:51 p.m. with the director of staff development (DSD), Resident 1's document titled, Weights, dated 6/6/25 and Resident 1's electronic medical record (EMR) were reviewed. The document indicated Resident had a documented weight of 130 pounds on 6/6/2025 and no other documented weights since admission. The EMR indicated there was no documentation indicating Resident 1 had refused to be weighed by the RNA. The DSD stated all residents should have been weighed in the facility on admission, 24 hours after admission, weekly for four weeks after admission, then monthly unless the physician orders otherwise. The DSD stated if Resident 1 had refused to be weighed by staff, the nurse should have documented the refusal in the EMR. The DSD stated, based on the lack of documentation indicating Resident 1 had refused to be weighed by the RNA in Resident 1's EMR, there was no way to definitively say if Resident 1 had weight loss or weight gain since admission.During a concurrent telephone interview and record review on 8/12/25 at 2:58 p.m. with the Registered Dietitian (RD), Resident 1's document titled, Weights, dated 6/6/25, and Resident 1's, Nutrition Evaluation, dated 5/18/25 were reviewed. The document weights indicated Resident 1 had a documented weight of 130 pounds on 6/6/2025. The document Weights indicated there were no other documented weights since admission. The evaluation indicated, . At risk for weight fluctuations r/t PO intake, DM, and diuretic therapy. Resident with obesity which can have a negative effect on their health, including but not limited to altered cardiac output, fluid retention, altered blood sugars, ineffective breathing patterns. The RD stated Resident 1's nutrition evaluation was completed on admission and resident was weighed to reflect the current weight status at the time of assessment. The RD stated nutrition assessments were completed every three months and as needed if there were (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 08/21/2025 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 0692 Level of Harm - Actual harm Residents Affected - Few changes. The RD stated the facility process was for the nursing staff to identify any weight loss, meal preference changes or refusal of meals. The RD stated if there was a concern, the nursing staff would notify the dietary supervisor. The RD stated the facility process was for the staff to offer resident alternatives and communicate with the dietary supervisor of the changes in meal consumption. The RD stated if Resident 1 was refusing meals and weight checks, the nursing staff should have documented the occurrences and attempted to trigger an alert for all staff to be made aware that there was a potential problem. The RD stated there was no documentation reflecting refusals of weight checks and meals from the record review at this time. The RD stated the facility process was to identify residents who were experiencing weight loss and include them in the weekly weight committee where residents would be monitored closely to avoid weight changes if possible.During an interview on 8/12/25 at 3:14 p.m. with the dietary services manager (DSM), the DSM stated the facility process was for the nursing staff to monitor Resident 1's meal intake and weight checks. The DSM stated if there was a change in food preferences or changes in meal consumption, it was the nursing department's responsibility to inform the DSM of the changes. The DSM stated she had not received any complaints or reports indicating Resident 1 was refusing meals and losing weight. The DSM stated she was part of the weight loss committee that met on a weekly basis to discuss residents who were at risk for weight fluctuations. The DSM stated Resident 1 was not part of the group of Residents that were being monitored for weight and nutrition concerns. The DSM stated Resident 1 should have been monitored and staff should have documented the refusal of weight checks and meals to incorporate Resident 1 into the weight loss committee to monitor her weight loss closely.During a review of Resident 1's, Nutrition Care Plan, dated 5/16/25, the care plan indicated, . [Resident 1] has a diet order. Controlled Carbohydrate Diet (CCD) Soft and Bite sized texture, Thin Liquid consistency, Goal: The resident will maintain adequate nutritional status as evidenced by maintaining weight, no signs and symptoms of malnutrition. Interventions: Provide, serve diet as ordered. Monitor intake and record q meal.During a review of Resident 1's, Noncompliance Care Plan, dated 5/16/25, the care plan indicated, . [Resident 1] is resistive to care noncompliant. being weighed r/t adjustment to nursing home. Goal: [Resident 1] needs will be met by staff daily.During an interview on 8/12/25 at 3:37 p.m. with the director of nursing (DON), the DON stated the facility process was for all residents to have been weighed on admission and then monthly, unless the physician ordered residents to be weighed more often. The DON stated Resident 1 should have been weighed as ordered and if Resident 1 had refused to be weighed by staff, the nurse should have documented the refusal in the EMR. The DON stated the problem was the staff were writing the weights on a list provided by the MDS nurse, but the refusals were not being documented in the EMR to reflect the attempts. The DON stated as a result, staff were not aware if Resident 1 had gained or lost weight. The DON stated there should have been progress notes or a documented refusal to alert the staff to monitor Resident 1 closely. The DON stated, moving forward, the facility will be implementing a new system to assist with documenting all weights and refusals by the residents.During a telephone interview on 8/12/25 at 3:43 p.m. with the MDS nurse, the MDS nurse stated the list of residents to be weighed was provided to the RNAs. The MDS nurse stated once the RNA completed the weights, the list would be given back to the MDS nurse to be reviewed. The MDS nurse stated it was the RNA's responsibility to document and inform the nurse of residents' weights and refusals. The MDS nurse stated, once the list of completed weights was reviewed, the list would be discarded, and there were no other paper records for the weights that were completed. The MDS nurse stated it was the nurse's responsibility to ensure weights were documented in the EMR and all refusals were addressed. The MDS nurse stated it was also the nurse's responsibility to document the (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 08/21/2025 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 0692 Level of Harm - Actual harm Residents Affected - Few refusal and attempts to re-weigh the resident. The MDS nurse stated that the monthly weights were reviewed for the month of August 2025, but there were no refusals to be weighed by any resident. The MDS nurse stated she was not aware of Resident 1's refusal to be weighed every month.During a telephone interview on 8/22/25 at 3:30 p.m. with the DON, the DON stated the facility obtained a current weight for Resident 1 on 8/21/25. The DON stated Resident 1's current weight was 108.8 lbs. The DON stated Resident 1 had a physician order for weekly weight checks that was initiated on admission but was not completed. The DON stated Resident 1 had a significant weight loss of 16% from the previous weight checked on 6/6/25 of 21.2 lbs.During a review of the Resident 1's, Diet Order, dated 5/23/25, the order indicated, . Consistent Carbohydrate (CCD) diet soft and bite sized texture, thin liquid consistency.During a review of the document titled, Diet Average Detail Report- Averages for days 1-28), dated 4/18/25, the document indicated, . CCD diet. Protein 91.175 g (gram- unit of measure), and Energy kCal (calories) 2, 066.76 kCal . The document indicated that Resident 1 should have consumed the amount of nutrition listed on a daily average, when Resident 1 consumed 75-100% of all meals.During a review of Resident 1's document titled, Documentation Survey Report-Nutrition- Meal intake, dated 5/2025, 6/2025, 7/2025 and 8/2025. The report indicated the meal intake percentage (0%- Refused meals completely or consumed one or two bites, 25%-a small amount was consumed, 50% approximately half of food is consumed, 75%Majority of the food is consumed but one or more items are left, 100%- all meal is consumed) for breakfast, lunch and dinner. The document indicated Resident 1 consumed: May 16th-31st 2025: Resident 1 ate 25% or less, approximately 258 calories and 11 grams of protein for 10 meals out of 45 with four of those meals' resident refused. Resident 1 ate 25 to 50% and approximately 775 calories and 34 grams of protein for 17 meals (38% of the time). Resident 1 ate 51 to 75%, approximately 1300 calories and 56 grams of protein for 18 meals (40% of the time). June 1st- 30th 2025: Resident 1 ate 26 to 50% and approximately 775 calories and 34 grams of protein for 48 meals (53% of the month). Resident ate 0 to 25% and approximately 258 calories and 11 grams protein for 9 meals. Resident 1 refused meals 18 times and ate 0 to 25% for 9 meals. Resident 1 ate between 51 to 75%, approximately 1300 calories and 56 grams of protein for 12 meals out of 90 in the month. July 1st- 31st 2025: Resident 1 ate 0 to 25%, approximately 258 calories and 11 grams of protein for 28 meals in the month or 30% of the time. Resident 1 ate 26 to 50%, approximately 775 calories and 34 grams of protein for 31 meals in the month or 33% of the time and refused meals 20 times. Resident 1 ate 51 to 75% for 9 meals (9.7% of the time) in the month. August 1st31st 2025: Resident 1 refused meals 43 times (46% of the time). Resident 1 ate 0 to 25%, approximately 258 calories and 11 grams of protein for 20 meals (21.5% of the time). Resident 1 ate 26 to 50%, approximately 775 calories and 34 grams of protein for 20 meals in the month of August. Resident 1 ate 51 to 75 % for 5 meals. The document indicated there was no documented meal intake recorded for breakfast on 5/29/25 & 6/4/25, lunch on 5/25/25, 5/29/25, 6/4/25, & 8/9/25, dinner on 7/9/25 & 7/31/25, therefore there was no indication of the nutritional intake Resident 1 received for the undocumented dates. During a record review of the facility's policy and procedure (P&P) titled, Weights, dated 8/28/2020, the P&P indicated, . The Center uses weights as one component of data collection needed to evaluate resident's nutritional status, fluid retention, or diuresis. Weighing Criteria, New Admits, weigh the day of admission then weekly for one month, if weights and nutritional status are stable after one month, weigh the resident monthly. Weekly Weights, the following are guidelines for residents who may need to be weighed weekly (not all inclusive): Food intake has declined and persisted, Slow trending of weight loss/gain. New or altered diuretic schedule (unless physician orders more frequently). Multiple Stage II and any Stage III or IV pressure ulcers. Significant change of condition. Re-weigh. When the (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 08/21/2025 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 0692 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Nutrition Hydration Skin Committee or designee reviews the weights, the Committee determines which residents are evaluated. The team or designee reviews the resident's status and makes recommendations. Obtaining and Recording Weights: Weights are obtained by nursing personnel designated by the Director of Nursing Services. The staff member weighing the resident records the weight on the Weight Worksheet. The nurse reviews the current weight and compares it to prior weight on Weight Worksheet. The nurse requests a re-weigh in accordance with the re-weigh definition outlined above. The nurse records validated weights on the Weight Record in the resident's medical record. Licensed nurses will notify physician, resident/responsible party of significant change in weight and document notification in progress notes. Progress note to include responses.During a professional reference review retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2892745/pdf/nihms156446.pdf, Patterns of Weight Change Preceding Hospitalization for Heart, dated October 2007, indicated, . Increases in body weight are associated with hospitalization for heart failure and begin at least [one] week before admission. Daily information about patients' body weight identifies a high-risk period during which interventions to avert decompensated heart failure that necessitate hospitalization for Heart Failure . Frequent monitoring of heart failure patients' clinical status, specifically their body weights, can alert clinicians to the early stages of heart failure decompensation. By focusing on weight changes, clinicians would be well positioned to implement interventions that could prevent decompensation of heart failure that necessitates hospitalization .During a review of professional reference titled, Practice Paper of the American Dietetic Association, dated 2010, indicated, . In older adults, a 5% or more unplanned weight loss in 30 days often results in protein-energy undernutrition as critical lean body mass is lost . that may trigger sarcopenia [a condition characterized by loss of skeletal muscle mass and function] and functional decline [a loss of independence in self-care capabilities and deterioration in mobility and in activities of daily living]. (Practice Paper of the American Dietetic Association: Individualized Nutrition Approaches for Older Adults in Health Care Communities, October 2010 Journal of the American Dietetic Association). During a review of a professional reference publication titled, Nutrition Care of the Older Adult from the Academy of Nutrition and Dietetics, dated 2016, indicated, . The goal of Medical Nutrition Therapy is to maintain or restore the individual's usual body weight . Event ID: Facility ID: 056301 If continuation sheet Page 9 of 9