Health inspection·January 16, 2026

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some therefore had not administered medications as ordered. RN 1 stated medications should have been administered on time to residents one hour before or one hour after the scheduled time. RN 1 stated she was aware that there were some residents who were not administered medications. RN 1 stated she should have addressed the missing medications, but she had not. RN 1 stated it was wrong to not administer medications to residents as scheduled and should have notified the resident's physician right away. RN 1 stated there was a potential for adverse side effects for Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, and Resident 9 when the medications were not administered as ordered.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 hypertension , Psoriatic arthritis (condition causing joint pain, stiffness, and swelling, with scaly skin rash), Anemia (blood disorder where the blood lacks enough red blood cells to carry oxygen to the body's tissues).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 10/31/25, 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 review of Resident 1's document titled, Situation, Background, Appearance and Review (SBAR), dated 12/26/25, the SBAR indicated, .Resident did not receive any morning medications. no adverse effects or complications noted. Vital signs within baseline. No signs or symptoms medication withdrawal, distress, or change in condition observed. Recommendations of Primary Clinicians, Resident's with medication orders for one time a day to be given immediately.During a review of Resident 1's, Order Summary Report, dated 12/26/25, the order summary indicated, . Folic acid oral tablet 800 mcg (microgram-unit of measurement), give 800 mcg by mouth one time a day for supplement. Brand name oral tablet 20 mg (milligram-unit of measurement) (furosemide) give one tablet by mouth one time a day for hypertension. Methotrexate sodium tablet 15 mg give one tablet by mouth one time a day every Friday for Psoriatic Arthritis. Metoprolol Succinate extended release tablet 24 hour 25 mg give one tablet by mouth one time a day for hypertension. During a review of Resident 1's, Medication Administration Record (MAR), dated 12/2025, the MAR indicated, the following medications were not administered on 12/26/25, Folic acid oral tablet give 800 mcg, (brand name) Furosemide oral tablet 20 mg, Methotrexate Sodium tablet 15 mg, Metoprolol Succinate extended-release tablet 25 mg.During a review of Resident 2's admission Record, the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnosis for hypertension, Diabetes (condition characterized by high blood sugar resulting from the body's inability to produce or properly use insulin), heart failure (a chronic, manageable condition where the heart muscle is too weak or stiff to pump enough oxygen-rich blood to meet the body's needs), Respiratory failure (a condition when there is not enough oxygen passes from lungs to the blood), anemia, Chronic obstructive Pulmonary disease (a progressive group of lung diseases that block airflow, causing severe breathing difficulties, cough, and wheezing).During a review of Resident 2's Minimum Data Set, dated [DATE], the MDS indicated Resident 2's Brief Interview for Mental Status score was 14 out of 15 which indicated Resident 2 was cognitively intact.During a review of Resident 2's document titled, Situation, Background, Appearance and Review (SBAR), dated 12/26/25, the SBAR indicated, .Resident did not receive any morning medications. Resident was unable to receive scheduled morning medications. Morning medications were not administered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056301 If continuation sheet Page 2 of 7 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 01/16/2026 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 - Some Resident assessed afternoon shift with no Adverse effects or complications noted . Recommendations of Primary Clinicians, Resident's with medication orders for one time a day to be given immediately.During a review of Resident 2's, Order Summary Report, dated 12/26/25, the order summary indicated, . Amlodipine Besylate oral tablet 10 mg give one tablet by mouth one time a day for high blood pressure. Clopidogrel Bisulfate oral tablet 75 mg give one tablet by mouth one time a day for blood thinner. Ferrous sulfate oral tablet 325 mg give one tablet by mouth two times a day for supplement. Furosemide oral tablet give 40 mg by mouth two times a day for high blood pressure. Insulin Glargine Solution 100 unit/ML inject 15 unit subcutaneously (under the skin) one time a day for high blood sugar. Insulin Lispro injection Solution 100 unit/mL inject per sliding scale. before meals and at bedtime for Diabetes. Pantoprazole sodium oral tablet delayed release 40 mg give one tablet by mouth two times a day for ulcer before meals. Potassium Bicarbonate oral tablet give 10 mEq (milliequivalent- a unit of measurement) by mouth two times a day for supplement take with furosemide. Sennosides tablet 8.6 mg give two tablet by mouth two times a day for constipation. Sucralfate suspension 1 GM/10 mL give 1 gram by mouth before meals for gastrointestinal (stomach) bleed. Tolterodine tartrate oral tablet give 2 mg by mouth two times a day for overactive bladder.During a review of Resident 2's, Medication Administration Record (MAR), dated 12/2025, the MAR indicated, the following medications were not administered on 12/26/25, Amlodipine Besylate oral tablet 10 mg, Clopidogrel Bisulfate oral tablet 75 mg, Insulin Glargine solution100 unit/mL (milliliter- measurement of unit), multivitamin oral tablet, Polyethylene Glycol 3350 powder, Budesonide inhalation suspension 1mg/2 mL, Docusate sodium oral capsule 100 mg, Ferrous sulfate oral tablet 325 mg, Furosemide oral tablet 40 mg, Gabapentin Capsule 300 mg, Potassium Bicarbonate oral tablet 10 mEq, Sennosides tablet 8.6 mg, Tolterodine tartrate oral tablet 2 mg, Hydralazine HCL oral tablet 25 mg, Sucralfate suspension 1 gm/10 mL, insulin lispro injection solution 100 unit/ml.During a review of Resident 3's admission Record, the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnosis for Benign prostatic hyperplasia (enlargement of the prostate gland), hypernatremia (high concentration of sodium (salt)in the blood) abscess of liver (a pocket of pus (infected fluid) that forms inside the liver).During a review of Resident 3's Minimum Data Set, dated [DATE], the MDS indicated Resident 3's Brief Interview for Mental Status score was 10 out of 15 which indicated Resident 3 had moderate cognitive impairment.During a review of Resident 3's document titled, Situation, Background, Appearance and Review (SBAR), dated 12/26/25, the SBAR indicated, .Resident did not receive any morning medications. Resident was unable to receive scheduled morning medications. Morning medications were not administered. Resident assessed afternoon shift with no Adverse effects or complications noted . Recommendations of Primary Clinicians, Resident's with medication orders for one time a day to be given immediately.During a review of Resident 3's, Order Summary Report, dated 12/26/25, the order summary indicated, . Cholecalciferol Tablet 1000 unit give 1000 IU by mouth one time a day for supplement. Cozaar oral tablet 100 mg give 100 mg by mouth one time a day for hypertension. Dapagliflozin Propanediol oral tablet 10 mg give 10 mg by mouth one time a day for Diabetes. Donepezil HCL oral tablet 10 mg give 10 mg by mouth one time a day for dementia (a decline in mental abilities-such as memory, reasoning, and thinking-severe enough to interfere with daily life, personality, and behavior). Finasteride oral tablet 5 mg give 5 mg by mouth one time a day for benign prostatic hyperplasia. Memantine HCL oral tablet 10 mg give 10 mg by mouth one time a day for dementia. Metformin HCL oral tablet 500 mg give 500 mg by mouth two times a day for Diabetes with meals. Tamsulosin HCL oral capsule 0.4 mg give 0.4 mg by mouth two times a day for benign prostatic hyperplasia.During a review of Resident 3's, Medication Administration Record (MAR), dated 12/2025, the MAR indicated, the following medications were not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056301 If continuation sheet Page 3 of 7 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 01/16/2026 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 - Some administered on 12/26/25, Cholecalciferol Tablet 1000 unit, Cozaar Oral tablet 100 mg, Dapagliflozin Propanediol oral tablet 10 mg, Finasteride oral tablet 5 mg, Memantine HCl oral tablet 10 mg, Vitamin B & C complex oral tablet, Metformin HCl oral tablet 500 mg, Tamsulosin HCl oral capsule 0.4 mg.During a review of Resident 4's admission Record, the AR indicated, Resident 4 was admitted to the facility on [DATE] with diagnosis for Hypertension, hyperlipidemia (high levels of fats in the blood), muscle spasm (sudden, involuntary, painful tightening of a muscle), Peripheral vascular disease (a circulation disorder where blood vessels outside the heart, in the limbs and organs, narrow, weaken, or block).During a review of Resident 4's Minimum Data Set, dated [DATE], the MDS indicated Resident 4's Brief Interview for Mental Status score was 14 out of 15 which indicated Resident 4 was cognitively intact.During a review of Resident 4's document titled, Situation, Background, Appearance and Review (SBAR), dated 12/26/25, the SBAR indicated, .Resident did not receive any morning medications. Resident was unable to receive scheduled morning medications. Morning medications were not administered. Resident assessed afternoon shift with no Adverse effects or complications noted . Recommendations of Primary Clinicians, Resident's with medication orders for one time a day to be given immediately.During a review of Resident 4's, Order Summary Report, dated 12/26/25, the order summary indicated, . Brimonidine Tartrate Ophthalmic Solution 0.2% instill one drop in both eyes one time a day separate eye drops by 3-5 minutes. Klor-Con 10 oral tablet extended release (Potassium Chloride) give one tablet by mouth one time a day for supplement. Methylcellulose oral powder give 19 gram by mouth one time a day for supplement. Neomycin sulfate oral tablet give 1000 mg by mouth two times a day related to hepatic encephalopathy (a temporary, reversible decline in brain function caused by severe liver disease ). Propranolol HCL oral tablet give 10 mg by mouth two times a day related to hypertension. Timolol Maleate Ophthalmic solution 0.5% instill one drop in both eyes two times a day related to glaucoma ( an eye disease due to increased pressure inside the eye).During a review of Resident 4's, Medication Administration Record (MAR), dated 12/2025, the MAR indicated, the following medications were not administered on 12/26/25, Brimonidine Tartrate Ophthalmic Solution 0.2%, Klor-Con 10 oral tablet extended release, Methylcellulose oral powder, Azelastine HCl Ophthalmic solution 0.05%, Neomycin sulfate oral tablet 1000 mg, Propranolol HCl oral tablet 10 mg, Timolol Maleate Ophthalmic solution 0.5%.During a review of Resident 5's admission Record, the AR indicated, Resident 5 was admitted to the facility on [DATE] with diagnosis for Respiratory failure, Chronic obstructive pulmonary disease, heart failure, hyperlipidemia, muscle weakness, rosacea (a chronic skin condition).During a review of Resident 5's Minimum Data Set, dated [DATE], the MDS indicated Resident 5's Brief Interview for Mental Status score was 14 out of 15 which indicated Resident 5 was cognitively intact.During a review of Resident 5's document titled, Situation, Background, Appearance and Review (SBAR), dated 12/26/25, the SBAR indicated, .Resident did not receive any morning medications. no adverse effects or complications noted. Vital signs within baseline. No signs or symptoms medication withdrawal, distress, or change in condition observed. Recommendations of Primary Clinicians, Resident's with medication orders for one time a day to be given immediately.During a review of Resident 5's, Order Summary Report, dated 12/26/25, the order summary indicated,. Empagliflozin Oral Tablet 10 MG Give 1 tablet by mouth one time a day for Diabetes, Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 MG Give 25 mg by mouth one time a day for hypertension, Multivitamin-Minerals Oral Tablet Give 1 tablet by mouth one time a day for Promote wound Healing, Spironolactone (medication remove excess fluid, salt and swelling) Oral Tablet 25 MG Give 0.5 tablet by mouth one time a day, Furosemide Tablet 20 MG Give 20 mg by mouth two times a day for edema (swelling), Lisinopril Oral Tablet 5 MG Give 1 tablet by mouth two times a day for hypertension .During a review of Resident 5's, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056301 If continuation sheet Page 4 of 7 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 01/16/2026 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 - Some Medication Administration Record (MAR), dated 12/2025, the MAR indicated, the following medications were not administered on 12/26/25, Empagliflozin Oral Tablet 10 MG, Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 MG, Multivitamin-Minerals Oral Tablet, Spironolactone Oral Tablet 25 MG, Furosemide Tablet 20 MG, Lisinopril Oral Tablet 5 MG.During a review of Resident 6's admission Record, the AR indicated, Resident 6 was admitted to the facility on [DATE] with diagnosis for Heart failure, Atrial fibrillation (irregular heart beat), compression fracture (A type of break in a bone caused by pressure and in which the bone collapses), hyponatremia (low concentration of sodium (salt)in the blood.During a review of Resident 6's Minimum Data Set, dated [DATE], the MDS indicated Resident 6's Brief Interview for Mental Status score was 8 out of 15 which indicated Resident 6 had moderate cognitive impairment.During a review of Resident 6's document titled, Situation, Background, Appearance and Review (SBAR), dated 12/26/25, the SBAR indicated, .Resident did not receive any morning medications. Resident was unable to receive scheduled morning medications. Morning medications were not administered. Resident assessed afternoon shift with no Adverse effects or complications noted . Recommendations of Primary Clinicians, Resident's with medication orders for one time a day to be given immediately.During a review of Resident 6's, Order Summary Report, dated 12/26/25, the order summary indicated,. Amlodipine Besylate oral tablet 10 mg give 10 mg by mouth one time a day for high blood pressure. Atorvastatin Calcium oral tablet 20 mg by mouth one time a day for high cholesterol. Hydralazine HCL oral tablet 25 mg give 25 mg by mouth two times a day for high blood pressure. Isosorbide Mononitrate tablet extended release 30 mg give 30 mg by mouth one time a day for congestive heart failure (Heart muscle is too weak or stiff to pump blood efficiently) .Losartan Potassium oral tablet 100 mg give 100 mg by mouth one time a day for hypertension. Magnesium Oxide oral tablet 400 mg give 400 mg by mouth one time a day for supplement. Omeprazole oral capsule delayed release 20 mg give one capsule by mouth one time a day for indigestion. Sennosides tablet 8.6 mg give two tablet by mouth two times a day for constipation. Tamsulosin HCL oral capsule 0.4 mg give one capsule by mouth one time a day for benign prostatic hyperplasia.During a review of Resident 6's, Medication Administration Record (MAR), dated 12/2025, the MAR indicated, the following medications were not administered on 12/26/25, Amlodipine Besylate oral tablet 10 mg, Atorvastatin Calcium oral tablet 20 mg, Isosorbide Mononitrate extended release 30 mg, Losartan Potassium oral tablet 100 mg, Magnesium Oxide oral tablet 400 mg, Omeprazole oral capsule delayed release 20 mg, Tamsulosin HCl oral capsule 0.4 mg, Apixaban oral tablet 5 mg, Docusate Sodium oral capsule 100 mg, Hydralazine HCl oral tablet 25 mg, Sennosides tablet 8.6 mg, Insulin Lispro solution.During a review of Resident 7's admission Record, the AR indicated Resident 7 was admitted to the facility on [DATE] with diagnosis for Chronic obstructive Pulmonary Disease, Schizophrenia (a chronic, severe brain disorder), Personality Disorder (a chronic mental health condition).During a review of Resident 7's Minimum Data Set, dated [DATE], the MDS indicated Resident 7's Brief Interview for Mental Status score was 9 out of 15 which indicated Resident 7 had severe cognitive impairment.During a review of Resident 7's document titled, Situation, Background, Appearance and Review (SBAR), dated 12/26/25, the SBAR indicated, .Resident did not receive any morning medications .Resident was unable to receive scheduled morning medications. Morning medications were not administered. Resident assessed afternoon shift with no Adverse effects or complications noted . Recommendations of Primary Clinicians, Resident's with medication orders for one time a day to be given immediately.During a review of Resident 7's, Order Summary Report, dated 12/26/25, the order summary indicated, . Benztropine Mesylate oral tablet 0.5 mg give 1 tablet by mouth one time a day for Schizophrenia. Buspirone HCL oral tablet 10 mg give two tablet by mouth three times a day for schizophrenia. Humalog Injection Solution 100 unit/ML inject as per sliding (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056301 If continuation sheet Page 5 of 7 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 01/16/2026 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 - Some scale. before meals and at bedtime. Metformin HCL oral tablet 850 mg give one tablet by mouth two times a day for diabetes. Prednisone oral tablet 10 mg give one tablet by mouth one time a day for infection for three days. Umeclidinium-Vilanterol Inhalation Aerosol Powder Breath activated 62.5-25 mcg/act one puff inhale orally one time a day for COPD. Vitamin D3 oral tablet give 2000 unit by mouth one time a day for supplement.During a review of Resident 7's, Medication Administration Record (MAR), dated 12/2025, the MAR indicated, the following medications were not administered on 12/26/25, Benztropine Mesylate oral tablet 0.5 mg, Prednisone oral tablet 10 mg, Umeclidinium-Vilanterol Inhalation Aerosol Powder Breath activated 62.5-25 mcg/act, Vitamin D3 oral tablet, Metformin HCl oral tablet 850 mg, Buspirone HCl oral tablet 10 mg, Humalog injection solution 100 unit/mL.During a review of Resident 8's admission Record, the AR indicated Resident 8 was admitted to the facility on [DATE] with diagnosis for Kidney failure (A condition in which the kidneys stop working and are not able to remove waste and extra water from the blood or keep body chemicals in balance), Sepsis (a life-threatening medical emergency caused by the body's extreme, dysfunctional response to an infection), Hydronephrosis ( a condition where one or both kidneys become swollen and stretched due to a build-up of urine).During a review of Resident 8's Minimum Data Set, dated [DATE], the MDS indicated Resident 8's Brief Interview for Mental Status score was 15 out of 15 which indicated Resident 8 was cognitively intact.During a review of Resident 8's document titled, Situation, Background, Appearance and Review (SBAR), dated 12/26/25, the SBAR indicated, .Resident did not receive any morning medications. Resident was unable to receive scheduled morning medications. Morning medications were not administered. Resident assessed afternoon shift with no Adverse effects or complications noted . Recommendations of Primary Clinicians, Resident's with medication orders for one time a day to be given immediately.During a review of Resident 8's, Order Summary Report, dated 12/26/25, the order summary indicated, . Amlodipine Besylate oral tablet 5 mg give 5 mg by mouth one time a day for hypertension. [name brand] oral capsule 200 mg give 200 mg by mouth one time a day for swelling. Lactobacillus Capsule give two capsule by mouth one time a day for probiotics. Eliquis oral tablet 2.5 mg give 2.5 mg by mouth two times a day for anticoagulation. Nepro 237 mL, Tizanidine HCl oral tablet give 4 mg by mouth two times a day for muscle spasms. Benzonatate oral capsule 100 mg by mouth three times a day for allergies. Cholestyramine oral packet 4 gm give two packets by mouth three times a day for cholesterol .During a review of Resident 8's, Medication Administration Record (MAR), dated 12/2025, the MAR indicated, the following medications were not administered on 12/26/25, Amlodipine Besylate oral tablet 5 mg, [name brand] oral capsule 200 mg, Lactobacillus Capsule, Eliquis oral tablet 2.5 mg, Nepro 237 mL, Tizanidine HCl oral tablet, Benzonatate oral capsule 100 mg, Cholestyramine oral packet 4 gm.During a review of Resident 9's admission Record, the AR indicated Resident 9 was admitted to the facility on [DATE] with diagnosis for Hypertension, Necrotizing Vasculopathy (a serious medical condition where blood vessels become severely inflamed), Lupus [a chronic disease where the body's immune system (a complex network of cells, tissues, organs, and the substances that helps the body fight infections and other diseases) mistakenly attacks its own healthy cells, tissues, and organs].During a review of Resident 9's Minimum Data Set, dated [DATE], the MDS indicated Resident 9's Brief Interview for Mental Status score was 12 out of 15 which indicated Resident 2 had moderate cognitive impairment.During a review of Resident 9's document titled, Situation, Background, Appearance and Review (SBAR), dated 12/26/25, the SBAR indicated, .Resident did not receive any morning medications. Resident was unable to receive scheduled morning medications. Morning medications were not administered. Resident assessed afternoon shift with no Adverse effects or complications noted . Recommendations of Primary Clinicians, Resident's with medication orders for one time a day to be given (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056301 If continuation sheet Page 6 of 7 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 01/16/2026 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete immediately.During a review of Resident 9's, Order Summary Report, dated 12/26/25, the order summary indicated, . Aspirin oral tablet 81 mg by mouth one time a day for deep vein thrombosis (a serious condition where a blood clot (thrombus) forms in a deep vein). Bactrim DS oral tablet 800-160 mg give one tablet by mouth one time a day every Monday, Wednesday, Friday for prophylaxis (action taken to prevent disease ). Docusate Sodium capsule 100 mg give one capsule by mouth one time a day for constipation. Ferrous Sulfate tablet 325 mg give one tablet by mouth one time a day for supplementation. Hydroxychloroquine Sulfate oral tablet 200 mg give two tablet by mouth one time a day for Lupus. Omeprazole oral tablet delayed release 20 mg, Eliquis oral tablet 5mg give 5 mg by mouth two times a day for deep vein thrombosis. Mycophenolate Mofetil oral tablet 500 mg give two tablets by mouth two times a day for Lupus.During a review of Resident 9's, Medication Administration Record (MAR), dated 12/2025, the MAR indicated, the following medications were not administered on 12/26/25, Aspirin oral tablet 81 mg, Bactrim DS oral tablet 800-160 mg, Docusate Sodium capsule 100 mg, Ferrous Sulfate tablet 325 mg, Hydroxychloroquine Sulfate oral tablet 200 mg, Omeprazole oral tablet delayed release 20 mg, Eliquis oral tablet 5mg, Mycophenolate Mofetil oral tablet 500 mg.During a review of the facility's job description titled, Registered Nurse, dated 10/2020, the job description indicated, . The primary purpose of this position is to provide skilled nursing care to residents under the medical direction of the residents' attending physician and within the scope of nursing practice for the state. Administer medications according to practitioner orders and report adverse consequences, side effects or any medication errors .During a review of the facility's policy and procedure (P&P) titled, Medication Administration-General Guidelines, dated 10/2017, the P&P indicated, . Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personal authorized to administer medications do so only after they have familiarized themselves with the medication. The facility has sufficient staff to allow administering of medications without unnecessary interruptions. Medications are administered in accordance with written orders of the attending physician. Medications are administered without unnecessary interruptions. Medications are administered within 60 minutes of scheduled time (1 hour before and 1 hour after), except before and after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility . Event ID: Facility ID: 056301 If continuation sheet Page 7 of 7