Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Golden Modesto Care Center during CMS and state inspections, most recent first.
A resident with dysphagia and dementia had an active diet order for a regular diet with minced and moist texture and mildly thick liquids, while a speech therapy evaluation recommended puree solids and nectar thick liquids. Nursing staff, the DON, and the speech therapist all described a facility process requiring nurses to notify the physician of new speech therapy diet recommendations, update the diet order in the medical record, and inform dietary, but this process was not followed. The diet order was not changed to match the speech therapy recommendations, and the physician and dietary department were not properly notified, contrary to the facility’s Diet Changes policy and professional documentation standards.
A contracted RN failed to administer any scheduled morning medications to nine residents during a single morning medication pass, despite physician orders and facility policy requiring medications to be given within a defined time window. Staff interviews confirmed that the RN left all scheduled morning medications in the cart and did not provide an explanation. The affected residents had multiple chronic conditions, including HTN, DM, HF, COPD, atrial fibrillation, kidney failure, and lupus, and their MARs showed numerous missed doses of antihypertensives, anticoagulants, insulin and other DM agents, diuretics, cardiac drugs, psychiatric medications, and supplements. SBAR documentation for each resident recorded that morning medications were not administered and that residents were later assessed with no adverse effects noted at that time, while facility policies and the RN job description required timely administration of medications as ordered by practitioners.
A deficiency was cited when a resident was not provided with sufficient food and fluids to maintain their health, as required. The report does not include further details about the circumstances or the resident's condition.
A resident admitted with multiple complex medical conditions did not have a baseline care plan developed within 48 hours, as required by facility policy. Staff interviews and record reviews confirmed that the necessary plan, which should have included physician orders, dietary and therapy services, and initial goals, was not completed, resulting in a lack of formal guidance for the resident's care.
A resident's representative requested medical records, but due to the absence of a medical records director and lack of communication among staff, the facility did not provide the records within the required timeframe. Facility policy required records to be provided within 30-60 days, but the request was not fulfilled, resulting in the resident's right to access their health information not being honored.
A resident with severe cognitive impairment was served a meal tray with regular consistency instead of the ordered full liquid diet with nectar thick consistency, leading to coughing and emesis. The facility's protocol for checking meal trays was not followed, as CNAs served the trays without waiting for nurses to verify them. The resident was sent to the emergency room as a precaution to rule out aspiration.
A resident with severe cognitive impairment was served a regular meal instead of a physician-ordered full liquid diet with nectar thick consistency, leading to coughing and emesis. The error was due to a printing issue on the meal tray ticket, which was missed by staff. The facility's policy required adherence to prescribed diets, but this was not followed.
A resident with severe cognitive impairment and a history of falls was not provided with consistent one-on-one supervision as required by the facility's policy. Despite being at high risk for falls, the resident experienced multiple falls, culminating in a serious injury due to a lack of supervision during a shift change. Staff interviews confirmed that the facility's process for managing fall risks was not followed, leading to the resident's avoidable fall and hospitalization.
A resident with severe cognitive impairment was administered insulin without a physician's order due to incorrect documentation by an LVN. The resident, who had no history of diabetes, was at risk for hypoglycemia. The error was identified the next day, highlighting the importance of accurate medication administration and adherence to facility policies.
A resident with moderate cognitive impairment was neglected when a CNA refused to assist her to the restroom, instructing her to wet her brief instead. This led to the resident feeling humiliated and in pain. Other staff confirmed this was against facility policy, which mandates assisting residents with their needs.
A resident with a high fall risk and Parkinson's disease experienced multiple unwitnessed falls due to inadequate supervision and delayed implementation of fall prevention protocols. Despite being identified as high risk upon admission, necessary interventions such as neuro checks and a fall program were not promptly initiated, leading to significant injuries and hospitalization. Staff interviews revealed a lack of communication and documentation, contributing to the facility's failure to adhere to its policies.
A resident with multiple medical conditions experienced an unwitnessed fall resulting in a dislocated finger. The facility failed to document the resident's change of condition or complete a post-fall assessment, contrary to its policies. The lack of documentation and assessment was confirmed by the LVN and DON, highlighting a lapse in adherence to professional standards.
The facility failed to implement enhanced barrier precautions during wound care for two residents, despite having a policy in place. One resident with diabetes and an open wound received care without a gown from an LPN unaware of the precautions. Another resident with cognitive impairment also received wound care without proper precautions. The Infection Preventionist was unfamiliar with the specifics of the precautions, and the facility had not implemented them.
A facility failed to update a Level I PASARR for a resident after a new diagnosis of bipolar type schizoaffective disorder. Despite the facility's policy requiring updated screenings for new mental health diagnoses, the resident's PASARR was not revised, as confirmed by interviews with the MDS Director, Medical Records, and the DON. This oversight meant the resident's care plan did not reflect the new diagnosis, potentially affecting the care provided.
The facility failed to accurately complete Level I PASARR screenings for two residents, omitting key mental health diagnoses. One resident's screening missed bipolar and anxiety disorders, while another's inaccurately indicated no mental disorder despite a history of delusional disorder and psychosis. Staff interviews confirmed these inaccuracies, highlighting the need for accurate PASARR screenings to determine appropriate care.
A facility failed to follow pharmacy recommendations for a resident on antipsychotic medication, neglecting to conduct an AIMS assessment as advised in May and June 2024. The resident, with a history of dementia and agitation, was on a care plan requiring monitoring for medication side effects. Despite this, staff interviews revealed confusion over assessment responsibilities, and the facility's transition to a new electronic system was cited as a possible reason for the oversight.
The facility exceeded the acceptable medication error rate with two errors out of 32 opportunities. One resident received docusate sodium at the wrong time, and another was at risk of receiving an incorrect insulin dose due to improper priming of the insulin pen by an LPN. The errors were identified during a survey, highlighting the need for adherence to medication administration protocols.
A long-term care facility failed to prevent significant medication errors involving insulin administration and adherence to vital sign parameters for medications. An LPN incorrectly primed an insulin pen, risking an incorrect dose for a diabetic resident. Additionally, medications were administered to a resident with heart conditions despite orders to hold them if the heart rate was below 60 bpm. Staff interviews revealed misunderstandings about the importance of following these parameters, highlighting a need for improved adherence to medication protocols.
Two residents with dysphagia were not evaluated or treated according to professional standards, leading to a risk of choking and aspiration. One resident was found unresponsive with food obstructing the airway, resulting in death. The facility failed to consult Speech Therapy, conduct swallow evaluations, supervise meals, or provide modified diets.
Failure to Implement and Document Speech Therapy Diet Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to follow and document recommended dietary changes according to professional standards of practice and the facility’s Diet Changes policy for one resident with dysphagia and dementia. The resident was admitted with diagnoses including dysphagia and dementia, and an MDS dated 11/26/2025 showed a BIMS score of 12, indicating moderate cognitive impairment. The resident’s Order Summary Report for diet listed a regular diet with minced and moist texture and mildly thick liquids, while a Speech Therapy Evaluation and Plan of Treatment dated 12/6/26 recommended puree solids and nectar thick liquids, creating a discrepancy between the active diet order and the speech therapy recommendations. Interviews with nursing staff and the DON confirmed that the facility’s established process required nursing staff to assess swallowing concerns, notify the physician to request a speech therapy evaluation, and, once recommendations were received, notify the physician of the new recommendations, update the diet order in the medical record, and notify dietary staff. LVN 1 and LVN 2 both described this process, stating that after speech therapy completed an evaluation and provided new recommendations, nursing staff were responsible for notifying the physician, changing the diet order, and communicating the change to dietary. The DON similarly stated that once speech therapy recommendations were received, the licensed nurse should notify the physician to obtain new diet orders, change the diet order in the record, and notify dietary immediately. The speech therapist confirmed that the new diet recommendations for puree solids and nectar thick liquids differed from the previous diet order and stated that the new diet should have been changed by facility staff on the day the evaluation was completed, with nursing staff following up with the physician and ensuring the diet was changed in the medical record. Review of the facility’s Diet Changes policy indicated that Nursing Services must notify the Food & Nutrition Department in writing of any diet change. A professional reference from the American Nurses Association on Principles for Nursing Documentation emphasized that documentation must be clear, accurate, complete, and properly authenticated. Despite these standards and policies, the resident’s diet order in the medical record was not updated to reflect the speech therapy recommendations, and the physician was not notified of the recommended diet change.
Failure to Administer Scheduled Morning Medications to Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from significant medication errors when a contracted RN did not administer any scheduled morning medications to nine sampled residents on 12/26/25. Interviews with facility staff confirmed that the facility’s process required nurses to follow physician orders and administer medications within one hour before or after the scheduled time, and that not doing so created a potential for harm. The Director of Staff Development stated that the RN working that morning did not administer any scheduled morning medications for the nine residents for an unknown reason, and emphasized the importance of following the rights of medication administration, including right dose, right time, and right route. The DON reported being notified that the scheduled morning medications were still in the medication cart and that the RN would not provide an explanation. In a telephone interview, the RN who worked that morning acknowledged she was responsible for administering medications to the nine residents and stated she was not aware of the facility’s medication administration schedule times, resulting in medications not being administered as ordered. She stated that medications should have been given within one hour before or after the scheduled time and admitted she knew some residents did not receive medications and that she did not address the missing doses or notify the physicians. She acknowledged that it was wrong not to administer medications as scheduled and that there was a potential for adverse side effects for the affected residents when medications were not administered as ordered. Record review showed that each of the nine residents had multiple ordered medications that were not administered on the morning of 12/26/25, as documented on their Medication Administration Records (MARs) and supported by SBAR notes indicating that morning medications were not given. These residents had significant medical diagnoses including hypertension, diabetes, heart failure, respiratory failure, COPD, atrial fibrillation, kidney failure, sepsis, lupus, necrotizing vasculopathy, and other chronic conditions. The missed medications included antihypertensives, anticoagulants (including Eliquis and aspirin), insulin and other diabetes medications, diuretics, heart failure medications, dementia medications, psychiatric medications, antibiotics, and various supplements and GI medications. SBAR documentation for each resident noted that morning medications were not administered and that residents were assessed later with no adverse effects or complications noted at that time, with recommendations that one-time-a-day medications be given immediately. Review of the facility’s RN job description and medication administration policy confirmed that RNs were required to administer medications according to practitioner orders and that medications were to be administered within 60 minutes of the scheduled time in accordance with written physician orders. The facility’s policy titled “Medication Administration–General Guidelines” specified that medications are to be administered as prescribed, in accordance with good nursing principles, by authorized personnel who are familiar with the medications, and within 60 minutes of the scheduled time. The policy also stated that the facility must have sufficient staff to allow medication administration without unnecessary interruptions and that medications are to be administered according to the established medication administration schedule. Despite these requirements, the contracted RN on the morning of 12/26/25 did not administer any of the scheduled morning medications for the nine residents, leaving all of their ordered morning doses documented as not given on the MARs. This failure to follow physician orders and facility policy regarding medication administration times constituted the medication error deficiency identified by the surveyors.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the resident's well-being. Specific details about the actions or inactions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Initiate Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident who was admitted with multiple significant diagnoses, including chronic kidney failure, heart failure, hypertension, diabetes mellitus, bacterial infections, obesity, muscle weakness, and bradycardia. Review of the resident's admission record and Minimum Data Set (MDS) confirmed that the resident was cognitively intact and had complex medical needs. However, the electronic medical record showed that no baseline care plan was completed for this resident, despite facility policy requiring such a plan to be developed within 48 hours of admission. Interviews with facility staff, including the MDS nurse, LVN, director of staff development, and director of nursing, revealed inconsistencies in understanding and implementing the baseline care plan process. Staff acknowledged the importance of completing a baseline care plan upon admission to ensure all resident needs were met and to guide appropriate care. The facility's policy specified that the baseline care plan should include physician orders, dietary orders, therapy services, social services interventions, PASARR recommendations, and initial goals. The absence of a baseline care plan for this resident meant that care and services were not formally planned or communicated to staff as required by facility policy.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to honor a resident's right to access and obtain medical records when the resident's representative requested records and the facility did not provide them within the required timeframe. The request for records was made on 1/8/25, but due to the absence of a medical records director (MRD) since 1/23/25 and lack of a designated staff member to handle such requests, the records were not provided within the 30-60 day period outlined in the facility's policy. The director of nursing (DON) and the administrator (ADM) both stated they were unaware of the request, as the former administrator and MRD had not communicated the request before leaving their positions. Facility policy required that requests for medical records be fulfilled within 30 days, or 60 days if the records were not maintained on site, with a possible 30-day extension if written notice was provided. However, the facility did not act on the request within these timeframes, and no written notice of delay was given. As a result, the resident's representative was not provided with the necessary medical records, and the resident's right to access their own health information was not respected.
Resident Served Incorrect Diet Leading to Potential Choking Hazard
Penalty
Summary
The facility failed to ensure that a resident was free from accidents when the resident was served a meal tray with a regular consistency, despite having an order for a full liquid diet with nectar thick consistency. This incident occurred on 2/20/25 and involved a resident who was admitted with acute respiratory failure, shortness of breath, dementia, and altered mental status. The resident was severely cognitively impaired, as indicated by a Brief Interview for Mental Status score of 0 out of 15. On the day of the incident, the charge nurse observed the resident having difficulty swallowing, accompanied by coughing. The resident was able to spit out the food with verbal cues, preventing a choking incident, but experienced a small emesis of undigested food. Although there was no respiratory distress or decline in oxygen saturation, the resident was sent to the emergency room as a precaution to rule out aspiration or other complications. The facility's process required nurses to check meal trays before they were served to residents, but this protocol was not followed, leading to the resident receiving the incorrect meal. Interviews with facility staff, including licensed vocational nurses and certified nursing assistants, revealed that the meal tray checking process was not adhered to, as CNAs served the meal trays without waiting for nurses to verify them. The director of staff development confirmed that the resident's diet slip had the incorrect diet listed, and the dietary staff served a regular diet instead of the ordered full liquid diet. The facility's policy and procedure required that all diet orders be checked against meal tray tickets to ensure accuracy, but this was not done, resulting in the resident receiving the wrong diet.
Failure to Follow Therapeutic Diet Orders
Penalty
Summary
The facility failed to ensure that therapeutic diets were followed according to physician orders for a resident who was served a meal tray with a regular consistency, despite having physician orders for a full liquid diet with nectar thick consistency. This incident occurred on 2/20/25 and resulted in the resident experiencing an episode of coughing and emesis, with the potential to cause choking, aspiration, and death. The resident, who was admitted with diagnoses including acute respiratory failure, shortness of breath, dementia, and altered mental status, had a severely impaired cognitive level as indicated by a Brief Interview for Mental Status score of 0 out of 15. The error was traced back to a printing issue on the meal tray ticket, where the full liquid diet was printed in small letters under the regular diet, leading to it being missed by all staff involved in the meal service process. The director of staff development and the certified dietary manager both acknowledged the mistake, noting that the meal tray ticket was printed with the incorrect diet order due to an error in the facility's meal tracking system. The dietary staff, including the cook, were expected to check the meal tray tickets to ensure the correct diet was served, but this process failed in this instance. The facility's policy and procedure on therapeutic diets, dated 10/2022, required that all residents have a diet order prescribed by the attending physician or a delegated registered or licensed dietitian. The policy emphasized the importance of preparing diets in accordance with the guidelines in the approved diet manual and the individualized plan of care. Despite these guidelines, the failure to follow the prescribed therapeutic diet for the resident led to the incident, highlighting a breakdown in the facility's processes for ensuring accurate meal service according to physician orders.
Failure to Provide Adequate Supervision Leads to Resident's Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident who was admitted with a history of gait and mobility abnormalities, severe cognitive impairment, and a need for assistance with mobility. The resident experienced multiple falls within a short period, specifically on 11/7/24, 11/8/24, 11/11/24, 11/14/24, and 11/15/24. Despite being assessed as high risk for falls, the facility did not implement effective interventions or provide consistent one-on-one supervision as required by their policies. The resident's care plan and fall risk evaluations indicated a high risk for falls, and the interdisciplinary team recommended interventions such as placing a fall mat, changing the resident's room for better visibility, and assigning one-on-one care. However, these interventions were not consistently implemented. On the night of 11/14/24 to the morning of 11/15/24, there was a lapse in one-on-one supervision, which led to the resident falling and sustaining serious injuries, including fractures that required surgical intervention. Interviews with facility staff, including CNAs, LVNs, and the DON, revealed that the facility's process for managing residents with multiple falls was not followed. The staff acknowledged that the resident should have been under one-on-one supervision after experiencing two or more falls within 24 hours, but this was not consistently provided. The lack of supervision during a critical time led to the resident's avoidable fall and subsequent hospitalization.
Medication Error: Insulin Administered Without Physician Order
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when insulin was administered without a physician's order or diagnosis. The resident, who was admitted with multiple diagnoses including syncope, Parkinson's disease, and hypertension, was given insulin lispro, a medication intended for another resident. This error occurred due to incorrect documentation by an LVN, who mistakenly recorded the physician's order for insulin on the wrong resident's electronic medical record. The resident in question had a severe cognitive impairment, as indicated by a Brief Interview for Mental Status score of 4 out of 15. The error was identified the following day when the LVN realized the mistake and contacted the physician. The resident did not have a history of diabetes and was not receiving blood sugar checks prior to the medication error, which increased the risk of hypoglycemia. Interviews with facility staff, including the DON and other nurses, highlighted the importance of accurate documentation and administration of medications to the correct resident. The facility's policy and procedure documents emphasized the need for safe and timely medication administration and the prevention of adverse consequences and medication errors. However, the error in this case was a result of a failure to adhere to these policies, leading to the administration of an unauthorized drug to the resident.
Neglect of Resident's Restroom Needs
Penalty
Summary
The facility failed to protect a resident from neglect when a certified nursing assistant (CNA) did not provide necessary assistance to a resident who requested help to use the restroom. The incident involved Resident 2, who has a diagnosis of dementia and moderate cognitive impairment, and was reported by Resident 1, who is cognitively intact. Resident 1 observed CNA 1 telling Resident 2 to wet her brief in bed because CNA 1 did not have time to assist her to the restroom. This led to Resident 2 feeling humiliated and neglected, as she held her urine until she was in pain and eventually urinated on herself. Interviews with other staff members, including CNA 2, CNA 3, CNA 4, and LVN 1, confirmed that it was the facility's expectation for staff to assist residents with their needs, especially those who are continent and require assistance to the restroom. These staff members stated that refusing to assist Resident 2 was a form of neglect and not in line with the facility's policies. The facility's policy and procedure documents also emphasize the residents' right to be free from abuse and neglect, and the importance of treating residents with kindness, respect, and dignity. The facility's Director of Staff Development and the administrator acknowledged the incident as neglect and abuse. The administrator confirmed that CNA 1 was removed from the facility pending investigation. The facility's policy on abuse, neglect, exploitation, and misappropriation prevention program, as well as the resident rights policy, were reviewed, highlighting the residents' rights to be free from abuse and neglect.
Failure to Implement Fall Prevention Protocols
Penalty
Summary
The facility failed to provide adequate supervision and interventions to prevent accidents for a resident with a known history of falls and Parkinson's disease. Upon admission, the resident was identified as having a high risk for falls, with a fall risk score of 21. Despite this, the facility did not implement necessary fall prevention protocols immediately, as required by their policy. The resident experienced multiple unwitnessed falls, resulting in significant injuries, including a dislocated finger, a subdural hematoma, and a traumatic brain injury, which ultimately led to hospitalization. The facility's care plan for the resident, which included interventions such as neuro checks, non-skid footwear, and a low bed, was not implemented in a timely manner. The fall program, which should have been initiated upon admission, was delayed by several days. Staff interviews revealed that the resident exhibited behaviors such as self-transferring and ambulating without assistance, yet appropriate monitoring and supervision were not consistently provided. The facility's failure to adhere to its own policies and procedures for fall prevention and supervision contributed to the resident's injuries. Interviews with staff, including LVNs and CNAs, highlighted a lack of communication and documentation regarding the resident's condition and fall incidents. The Director of Nursing was not made aware of the resident's fall with injury until several days later, indicating a breakdown in the facility's process for reporting and addressing changes in resident condition. The facility's policy on managing falls and fall risks was not effectively implemented, resulting in inadequate supervision and safety measures for the resident.
Failure to Document Resident's Fall and Condition
Penalty
Summary
The facility failed to adhere to its policies and procedures and meet professional standards of quality care for a resident who experienced an unwitnessed fall with injury. The incident involved a resident with a history of multiple medical conditions, including acute gastroenteropathy, abnormalities of gait and mobility, muscle weakness, encephalopathy, and a history of falling. The resident was found kneeling on the floor and later complained of pain in the left little finger, which was diagnosed as a dislocation after being sent to the hospital. The nursing staff did not document the resident's change of condition or complete a post-fall assessment, which was required by the facility's process for handling falls. The Licensed Vocational Nurse (LVN) on duty acknowledged that there was no documentation regarding the fall, and the Director of Nursing (DON) confirmed that no change of condition assessment, post-fall assessment, or neurological checks were completed. This lack of documentation and assessment was contrary to the facility's policy, which mandates thorough documentation of any changes in a resident's condition and incidents involving the resident. The facility's policy on charting and documentation emphasizes the importance of complete and accurate records to facilitate communication among the interdisciplinary team and ensure appropriate care. The failure to document the resident's fall and subsequent condition could lead to an inaccurate assessment and delay in care, as noted by the DON and the Administrator. This deficiency highlights a significant lapse in the facility's adherence to its own standards and professional nursing practices.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) during high-contact resident care activities, specifically during wound care for two residents. Resident #81, admitted with a medical history including type 2 diabetes mellitus, cellulitis, and an open wound on the right foot, was observed receiving wound care without the use of a gown by LPN #5, who was unaware of the EBP requirements. The resident's care plan indicated an infection caused by methicillin-susceptible staphylococcus aureus and the presence of a peripherally inserted central catheter, necessitating the use of EBP to prevent the spread of multi-drug resistant organisms (MDROs). Similarly, Resident #22, with a history of type 2 diabetes mellitus and severe cognitive impairment, was observed receiving wound care for an open area on the left big toe by LPN #1, who also did not use a gown and was unfamiliar with EBP. The facility's Infection Preventionist admitted to not knowing the specifics of EBP, and the facility had not implemented these precautions, despite their policy indicating the necessity of gown and glove use during high-contact care activities to reduce MDRO transmission.
Failure to Update PASARR Following New Mental Health Diagnosis
Penalty
Summary
The facility failed to submit a status change to a Level I Pre-Admission Screening and Resident Review (PASARR) following a new mental health diagnosis for a resident. The resident, who was admitted on June 12, 2020, had a medical history that included bipolar disorder, major depressive disorder, and anxiety disorder. On April 14, 2024, the resident was diagnosed with bipolar type schizoaffective disorder, but the facility did not update the Level I PASARR evaluation to reflect this new diagnosis. The facility's policy requires that all new admissions and readmissions be screened for mental disorders, intellectual disabilities, or related disorders per the Medicaid PASARR process. Interviews with facility staff, including the MDS Director, Medical Records personnel, and the Director of Nursing, revealed that a new Level I PASARR should have been completed when the resident received the new diagnosis of schizoaffective disorder. The MDS Director and Medical Records personnel acknowledged that the new diagnosis was missed, and the Director of Nursing confirmed that the PASARR process is intended to determine if residents with mental illness would benefit from additional services. The failure to update the PASARR evaluation meant that the resident's care plan did not reflect the new diagnosis, potentially impacting the services and care provided.
Inaccurate PASARR Screenings for Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure accurate completion of Level I Pre-Admission Screening and Resident Review (PASARR) for two residents, leading to deficiencies in capturing all mental health diagnoses. Resident #62 was admitted with a history of bipolar type schizoaffective disorder, bipolar disorder, major depressive disorder, and anxiety disorder. However, the PASARR screening only noted major depressive disorder, omitting the bipolar and anxiety disorders. Interviews with the MDS Director, Medical Records staff, and the Director of Nursing confirmed the inaccuracies in the PASARR screening, which should have included all relevant mental health diagnoses. Similarly, Resident #12 was admitted with a history of delusional disorder, psychosis, major depressive disorder, recurrent depressive disorders, and hallucinations. The PASARR screening for this resident inaccurately indicated no diagnosed mental disorder. The MDS Director and Medical Records staff acknowledged the discrepancies, noting that the PASARR screening failed to reflect the resident's mental health diagnoses accurately. The Director of Nursing also confirmed that the PASARR process should have identified the resident's mental health conditions to determine the need for additional psychiatric care. The VP of Clinical Operations stated that PASARR screenings are completed prior to admission and should be reviewed for accuracy regarding diagnoses, medications, and resident history. Both residents' PASARR screenings were found to be inaccurate, as they did not capture all the necessary mental health diagnoses, which is essential for determining the appropriate level of care and services required for residents with mental disorders.
Failure to Conduct AIMS Assessment for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to follow pharmacy recommendations for a resident who was reviewed for unnecessary medications. Specifically, the facility did not respond to pharmacy recommendations made in May and June 2024 for an AIMS (Abnormal Involuntary Movement Scale) assessment for a resident who was on antipsychotic medication. The facility's policy on antipsychotic medication use required nursing staff to monitor and report side effects and adverse consequences to the attending physician, but this was not adhered to in the case of the resident. The resident, admitted in March 2017, had a medical history including unspecified dementia, restlessness, agitation, and major depressive disorder. The resident's care plan, initiated in October 2022, included the use of antipsychotic medication for agitation, with specific interventions for monitoring side effects and consulting with the pharmacy. Despite these directives, the resident's medication regimen reviews in May and June 2024 indicated that an AIMS assessment was due, but the facility did not conduct the assessment as recommended. Interviews with facility staff revealed a lack of clarity and communication regarding the responsibility for conducting AIMS assessments. LPNs and RNs were unsure of the frequency of AIMS assessments and the process for implementing pharmacy recommendations. The Director of Nursing acknowledged that the facility did not perform the AIMS assessment as recommended, and the VP of Clinical Operations suggested that a transition to a new electronic medical record system may have contributed to the oversight.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with 2 errors out of 32 opportunities, resulting in a 6.25% error rate. The first error involved a resident with a history of constipation and rectal prolapse, who was administered docusate sodium 100 mg in the morning instead of the prescribed 250 mg in the evening. The LPN responsible acknowledged the mistake, noting that the medication was not due at the time it was given and was not ordered as needed. The second error involved a resident with type 2 diabetes mellitus, who was to receive insulin lispro before meals. An LPN prepared the insulin using a KwikPen, priming it with 2 units and then setting it to 14 units, which would have resulted in an incorrect dose. The VP of Clinical Operations intervened, and the LPN admitted the resident would receive extra units if administered. The Pharmacy Consultant confirmed the importance of priming the needle correctly to ensure the accurate dose. The DON and VP of Clinical Operations expressed expectations for adherence to physician orders and medication administration protocols.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors during the administration of insulin. A Licensed Practical Nurse (LPN) was observed preparing insulin lispro for a resident with type 2 diabetes mellitus. The LPN incorrectly primed the insulin pen by turning the dial to 14 units instead of the required 2 units for priming, which could result in administering an incorrect dose. The Vice President of Clinical Operations confirmed the error and indicated that the LPN would be retrained. Another deficiency was identified in the administration of medications to a resident with congestive heart failure and hypertension. The resident's medication orders included specific parameters to hold medications if the heart rate was below 60 beats per minute. Despite these instructions, the resident received amlodipine and furosemide on multiple occasions when their heart rate was below the prescribed threshold. Interviews with nursing staff revealed a misunderstanding of the importance of adhering to these parameters, as one LPN admitted to administering the medications despite the low heart rate. The Pharmacy Consultant and Nurse Practitioner emphasized the risks associated with administering these medications when the resident's heart rate was already low, which could lead to adverse effects such as dizziness and increased fall risk. The Director of Nursing and the VP of Clinical Operations both expressed expectations that nurses follow physician orders and vital sign parameters to prevent such errors. These deficiencies highlight a lack of adherence to medication administration protocols and the need for staff education on the importance of following prescribed parameters.
Failure to Provide Adequate Supervision and Services for Dysphagia
Penalty
Summary
The facility failed to provide adequate supervision and services for the prevention of accidents for two residents diagnosed with dysphagia. Both residents were not evaluated or treated in accordance with professional standards of practice and their comprehensive care plans. Specifically, Speech Therapy was not consulted, swallow evaluations were not conducted, meals were not supervised, and modified meals to prevent the risk of choking and aspiration were not served. These failures resulted in a risk of choking and aspiration, and for one resident, it could have contributed to a fatal event where the resident was found pulseless while eating, with the coroner's preliminary report indicating the cause of death as asphyxia due to aspiration from food. Resident 1 was admitted with a diagnosis of dysphagia and had a severe cognitive impairment. Despite this, the resident was not evaluated by a speech therapist, and the facility staff did not monitor for signs of dysphagia such as pocketing or choking. The resident's meal plan included foods that were not appropriately modified for dysphagia, and the resident was left unsupervised during meals. This lack of supervision and failure to provide a suitable diet led to an incident where the resident was found unresponsive with food pocketed in the cheeks, which obstructed the airway and required emergency intervention. Resident 2, also diagnosed with dysphagia, was not evaluated by a speech therapist since admission. The resident had a regular diet order despite having dental issues and experiencing facial nerve pain that affected swallowing. The facility did not refer the resident to speech therapy for evaluation, nor did they monitor the resident's eating habits, which could have identified the need for dietary adjustments. The facility's failure to adhere to its policy and procedure for managing residents with dysphagia contributed to the risk of choking and aspiration for Resident 2.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 224 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Modesto
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crestwood Manor | 0.6 mi | ★★★★★ | 11 | 0 |
| Modesto Post Acute Center | 0.7 mi | ★★★★★ | 17 | 0 |
| Valley Skilled Nursing Center | 0.7 mi | ★★★★★ | 3 | 0 |
| River View Post Acute | 1.5 mi | ★★★★★ | 35 | 0 |
| Garden City Healthcare Center | 1.7 mi | ★★★★★ | 20 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.