Health inspection·September 3, 2025

F 0558 Level of Harm - Minimal harm or potential for actual harm as needed to engage in their preferred activities on a routine basis.A review of a facility policy titled, Dignity, revised 2021, indicated, .Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.When assisting with care, residents are supported in exercising their rights. For example, residents are.encouraged to attend the activities of their choice. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055011 If continuation sheet Page 2 of 4 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 055011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River View Post Acute 1611 Scenic Drive 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on observation, interview, and record review, the facility failed to ensure an allegation of abuse was reported to the Department timely for one of three sampled residents (Resident 1) when Resident 1 alleged certified nursing assistant (CNA) 3 forcefully grabbed her legs on 8/2/25 but the incident was not reported to the Department until 8/7/25. This failure resulted in a delay in the abuse investigation process and decreased the facility's potential to protect Resident 1 and other residents in the facility from physical and psychosocial harm.A review of Resident 1's admission RECORD, indicated, she was admitted to the facility in late 2024 with diagnoses which included bipolar disorder (a mental health condition that causes changes in a person mood, energy, and ability to function). A review of Resident 1's minimum data set (MDS, a federally mandated resident assessment and screening tool which identifies care needs) dated 7/29/25, indicated, .Section C-Cognitive Patterns. Brief Interview for Mental Status (BIMS) [a tool used to screen for cognitive impairment]. indicated, a score of 14 points which suggested cognition/thinking/decision making was intact. A review of Resident 1's clinical document, written by the Administrator in Training (AIT), titled, Progress Notes, dated 8/7/25, at 5 PM, indicated, .At around 4:30pm, resident informed writer that a CNA had hurt her legs over a week ago and was concerned why the same CNA was scheduled to work the night shift with her again.[Resident 1] explained.the saturday [sic] before (on the evening of 7/26/25).CNA, forcefully grabbed her behind the ankles and squeezed while trying to drag her off the bed. She was very upset and crying at this time.A review of Resident 1's clinical document, written by the AIT, titled, Progress Notes, dated 8/7/25, at 10:41 PM, indicated, .when resident was interviewed by officer [police].she added to her report that the CNA started the altercation by throwing her resident's arms around before grabbing her legs. She [Resident 1] also stated that she is starting to believe that it could have been last Saturday (8/2/25).During a telephone interview on 9/3/25, at 7:34 AM, with licensed nurse (LN) 2, LN 2 stated, on 8/2/25, Resident 1 reported CNA 3 grabbed her by the ankles and pulled on her. LN 2 further stated she assessed Resident 1's ankles and no redness or marks were observed.During an interview on 9/3/25, at 9:05 AM, in Resident 1's room, Resident 1 stated when she had needed help to go to the bathroom CNA 3 flung her arms over and then grabbed her by the back of the ankles and squeezed hard. Resident 1 stated CNA 3 caused her pain and made bruises like finger marks on her left ankle. During a telephone interview on 9/3/25, at 10:39 AM, with LN 4, LN 4 stated the incident with Resident 1 occurred on Saturday 8/2/25, at approximately 6 PM. LN 4 further stated CNA 3 had reported that Resident 1 was angry and asked LN 4 to check on her. LN 4 stated Resident 1 was agitated when they went to check on her and asked LN 4 and CNA 3 to leave her room. LN 4 stated she had assumed the other nurse (LN 2) would document the incident. LN 4 further stated after the incident happened, training on abuse reporting was conducted and now she understood the reporting process and what should have been done because it was a serious issue. During a telephone interview on 9/3/25, at 10:48 AM, with LN 2, LN 2 confirmed she had not documented or reported Resident 1's allegation of abuse, but she should have. LN 2 further stated she should have made sure the allegation was documented and reported for the safety of Resident 1, the facility, and everyone.During an interview on 9/3/25 at 12:11 PM, the AIT confirmed two LN's and CNA 3 were aware of Resident 1's allegations of abuse on 8/2/25, but the incident did not come to his attention until 8/7/25. The AIT confirmed because he did not learn about the incident until five days later, the report to the Department was delayed.During an interview on 9/3/25, at 2:54 PM, with the Director of Nurses (DON), the DON stated it was her expectation that allegations of abuse would be reported to the Department within two hours of the occurrence. The DON further stated it was important to report abuse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055011 If continuation sheet Page 3 of 4 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 055011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River View Post Acute 1611 Scenic Drive 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 0609 Level of Harm - Minimal harm or potential for actual harm for the safety of the residents.A review of a facility policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised 9/22, indicated, .If resident abuse.is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.Immediately is defined as.within two hours of an allegation involving abuse.or within 24 hours of an allegation that does not involve abuse. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055011 If continuation sheet Page 4 of 4