Golden Modesto Care Center

In the surveyor’s words

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

• Actual harm, patternF689Aug 17, 2023

  Based on observation, interview and record review, the facility failed to provide adequate supervision to ensure the resident environment was accident-free for four of ten sampled residents (Residents 2, 3, 7, and 8) when Licensed Nurses failed to follow facility policy and procedures and professional standards in developing and implementing resident-specific and comprehensive care plan interventions meant to prevent falls for Residents 2, 3, 7 and 8. These failures resulted in avoidable falls for Residents 2, 3, 7 and 8. Each resident suffered an injury requiring transport, assessment, and healthcare services at a General Acute Care Hospital (GACH). […]

• Actual harm, isolatedF692Aug 21, 2025

  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… […]

• Actual harm, isolatedF689Dec 11, 2024

  Based on interview and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for one of three residents, (Resident 1), when Resident 1 was admitted on [DATE] with history of abnormalities of gait and mobility, assessed with severe cognitive impairment and the need for assistance with mobility, and experienced falls on 11/7/24, 11/8/24, 11/11/24, 11/14/24 and 11/15/24 and did not provide supervision and effective interventions to prevent falls in accordance with policies and procedures and professional standards of practice. […]

• Actual harm, isolatedF689Oct 10, 2024

  Based on interview and record review the facility failed to ensure residents received adequate supervision to prevent accidents according to the facility' s policy and procedure (P&P) for one of three sampled residents (Resident 1), when the facility had knowledge of Resident 1' s history of falls and Parkinson's disease (brain disorder that causes uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) on admission and did not provide interventions and supervision to prevent an unwitnessed fall with injury on [DATE] and an unwitnessed fall with injury on [DATE]. […]

• Actual harm, isolatedF689Apr 26, 2024

  Based on interview and record review, the facility failed to provide supervision and services for the prevention of accidents for two of five sampled residents (Resident 1 and Resident 2) when Resident 1 and Resident 2 were both admitted with diagnoses that included dysphagia (difficulty swallowing or chewing) and were not evaluated or treated in accordance with professional standards of practice and the comprehensive care plan. Speech Therapy was not consulted, swallow evaluations (to determine the presence and severity of dysphagia as well as to determine the need for further testing) not conducted, meals were not supervised, modified meals to prevent the risk of choking and risk of aspiration (sucking food into the airway) were not served. […]