Health inspection·December 3, 2025

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 2) was free from unnecessary medication when, Resident 2 was prescribed an as needed lorazepam (anti-anxiety) medication that did not have the required 14-day stop date or a note from the doctor explaining why the lorazepam did not need a stop date.This failure had the potential for Resident 2 to not be properly evaluated for the continued need of lorazepam and could result in continued use of an unnecessary medication and possible harmful side effects.Findings:Review of Resident 2's admission RECORD, indicated Resident 2 was admitted to the facility with diagnosis including but not limited to, anxiety disorder (excessive, persistent fear and worry that significantly disrupt daily life) and depression.During a concurrent interview and record review on 12/3/25 at 12:16 PM with Licensed Nurse (LN) 1, Resident 2's .Order Summary: Lorazepam Oral Tablet 0.5 milligram [mg-a unit measure] (Lorazepam) Give 1 tablet by mouth every 6 hours as needed for anxiety/restlessness ., signed by the doctor on 12/1/25, was reviewed. LN 1 stated that any as-needed psychotropic medications (drugs that affect how a person thinks, feels, or acts) like anti-anxiety medication must have a 14 day stop date so the resident could be checked to make sure the medicine was still needed and safe. LN 1 further stated that if Resident 2 kept receiving lorazepam without a stop date and without evaluation, Resident 2 would be at risk for side effects. During an interview on 12/3/25 at 4:13 PM, with the Assistant Director of Nursing (ADON), the ADON stated that when nurses received an order for an as-needed anti-anxiety medication, nurses were expected to ensure the medication had a 14-day stop date. The ADON stated that the purpose of the 14-day stop date was to give temporary relief of the resident's symptoms, and if the medication needed to continue, the doctor had to provide a new order after re-assessment. The ADON further stated that anti-anxiety medications could cause harmful side effects in elderly residents and could lead to a potential addiction, which was why anti-anxiety medications needed to have a 14-day stop date. During a concurrent interview and record review on 12/5/25 at 9:38 AM with Minimum Data Set Coordinator (MDSC), Resident 2's doctor's Progress Notes, dated 11/27/25, were reviewed. Resident 2's doctor's progress notes indicated, .Assessment:.Depression/Anxiety: Continue.and [lorazepam]. The MDSC stated that the doctor's last assessment of Resident 2 was on 11/27/25, as documented in the progress notes, before Resident 2 received an as-needed order for lorazepam for anxiety on 12/1/25. The MDSC stated that the doctor did not document a reason for why the lorazepam order on 12/1/25 did not include a stop date. The MDSC further stated that as-needed anti-anxiety medication required a stop date or the resident would be at risk for chemical restraint (drug used to control behavior or limit movement that is not part of normal treatment) and harmful side effects. During a concurrent interview and record review on 12/5/25 at 9:45 AM with the MDSC, Resident 2's Medication Administration Record (MAR), dated for the month of 12/25, was reviewed. Resident 2's MAR indicated, on 12/1/25 at 10:15 PM, on 12/2/25 at 10:26 PM and 12/3/25 at 11:12 PM, Resident 2 received lorazepam 0.5mg as needed for anxiety. The MDSC stated (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 055011 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 12/03/2025 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)