Health inspection·February 20, 2020

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a resident centered comprehensive care plan for three of five sampled residents (Resident 49, 70 and 97) when: 1. Resident 49's care plan intervention for the indwelling catheter tubing (tube inserted into the bladder to drain urine) was not implemented and the indwelling catheter tubing was not positioned in a manner that would allow urine to drain into the urine collection bag. This failure had the potential to allow for backflow of urine and increase the risk for a urinary tract infection (infection in the bladder). 2. Residents 70 and 97 were administered blood thinning medications and did not have a care plan developed with interventions that would monitor side effects from the use of blood thinning medications. This deficient practice had the potential to place Resident 70 and 97 at risk for complications of unmonitored blood thinning medications such as excessive bleeding or bruising. Findings: 1. During a concurrent observation and interview on 2/18/20, at 10:39 a.m., with Licensed Vocational Nurse (LVN) 2, in Resident 49's room, Resident 49's urinary catheter tubing was secured to the side of the bed sheet causing the tubing to rise above the urine collection bag forming a dependent loop (a loop that would cause the urine to run back towards the bladder or pool in the tubing). LVN 2 stated the urinary catheter tubing was not positioned correctly to allow urine to drain into the collection bag. LVN 2 stated to prevent urine infection there should not be a dependent loop in Resident 49's catheter tubing. During a review of Resident 49's Order Summary Report, dated 3/25/19, indicated Indwelling urinary catheter to remain in place due to retention of urine. During a review of Resident 49's Care Plan, dated 3/13/19, the Care Plan indicated, .Position catheter bag and tubing below the level of the bladder . During review of the facility's policy and procedure titled, Urinary Catheter Care, dated 9/14, indicated, .The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder . 2. During a review of Resident 97's admission RECORD (AR), dated 2/19/20, the AR indicated, Resident 97 was admitted to the facility on [DATE] with the diagnosis of chronic embolism (lodging of blood clot inside blood vessel) and thrombosis (formation of blood clot) of unspecified deep veins of unspecified lower extremity. During a concurrent interview and record review on 2/19/2020, at 9:49 a.m., with Licensed Vocational Nurse (LVN) 5, Resident 97's Order Summary, dated 2/19/2020 was reviewed. The Order Summary indicated, . 15 MG [milligram-unit of measure] Rivaroxaban [medication used to prevent blood clot] Give 1 tablet by mouth two times a day . LVN 5 stated rivaroxaban side effects included bleeding. LVN 5 reviewed Resident 97's clinical record for a care plan and stated there was no care plan developed for the use of rivaroxaban. LVN 5 stated the purpose of developing a care plan for rivaroxaban was to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055849 If continuation sheet Page 2 of 21 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 055849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Modesto Post Acute Center 159 E. Orangeburg Avenue Modesto, CA 95350 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 0656 Level of Harm - Minimal harm or potential for actual harm monitor residents receiving blood thinner medications for side effects with implemented goals and interventions to meet the resident needs. LVN 5 stated a care plan should have been developed as soon as the medication was ordered for Resident 97. LVN 5 stated the care plan should include interventions such as monitoring for signs of bleeding, administering medications as ordered and notifying the physician for any side effects. Residents Affected - Some During a review of Resident 70's AR dated 2/19/2020, the AR indicated, Resident 70 was admitted to the facility on [DATE] with the diagnosis of Atherosclerosis (hardening and narrowing of blood vessel) of coronary artery (blood vessels that supply blood to your heart) bypass graft (is a procedure to improve poor blood flow to the heart) without angina pectoris (chest pain). During a concurrent interview and record review on 2/19/2020, at 9:56 a.m., with LVN 5, Resident 70's Order Summary, dated 2/19/2020 was reviewed. The Order Summary indicated, .Clopidogrel [medication used to keep blood flowing smoothly] .75 MG Give 1 tablet by mouth one time a day . LVN 5 stated clopidogrel side effects included bleeding. LVN 5 reviewed Resident 70's care plans and stated there was no care plan developed for the use of clopidogrel. LVN 5 stated a care plan should have been developed as soon as the medication was ordered, the care plan should include interventions such as monitoring for signs of bleeding and notifying the physician for any side effects. During an interview on 2/19/2020, at 10:00 a.m., with Director of Nursing (DON), the DON stated, Residents 70 and 97 should have had a care plan developed for the use of blood thinning medications and that did not occur. The DON stated the purpose of care plan was to monitor and identify problems, set goal and implement interventions to meet residents' needs. The DON stated developing a care plan was the responsibility of the interdisciplinary team and the nurse who obtained the order for blood thinning medication. During a review of the policy and procedure titled, Care Plans - Comprehensive dated 9/10, indicated, .An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident .Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems . Reflect treatment goals, timetables and objectives in measurable outcomes . Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055849 If continuation sheet Page 3 of 21 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 055849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Modesto Post Acute Center 159 E. Orangeburg Avenue Modesto, CA 95350 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide services which meet professional standards of quality for five of six sampled residents (Resident 24, 37, 46, 299 and 300) when: Residents Affected - Some 1. Two of four sampled Licensed Vocational Nurse (LVN) 6 and LVN 2 failed to follow the facility's Policy and Procedure when obtaining a fingerstick blood sample (a procedure in which a finger is pricked with a lancet [a small needle device] to obtain a small quantity of blood for blood sugar testing) for Residents 37, 46, 299, and 300. LVN 6 and LVN 2 used the first drop of blood instead of using a clean blood sample from Resident 37, 46, 299, and 300's fingertips for fingerstick blood sugar level. This practice had the potential for residents on fingerstick blood sugar to have an inaccurate blood sugar level result. 2. Two of four sampled LVNs, LVN 6 and LVN 2 failed to follow the manufacturer's instructions for use when administering insulin lispro (medication for the treatment of diabetes - a disease with high blood sugar levels) with the Flex Pen (a dial-a-dose device, pre-filled insulin pen). LVN 6 and LVN 2 did not prime the insulin lispro flex pen as indicated by the manufacture instructions prior to administration of insulin to Resident 24, 299 and 300. This practice placed Resident 24, 299 and 300 at risk for unsafe administration of insulin medication and possible complications with their blood sugars. Findings: During a medication pass observation on 2/19/2020, at 7:37 a.m., in hallway 3, LVN 6 performed fingerstick blood sugar check to Resident 46. LVN 6 did not discard the first drop of blood and used the first drop of blood for fingerstick blood sugar testing. During a review of Resident 46's Face Sheet (a document containing resident profile information), dated 09/20/19, the Face Sheet indicated, Resident 46 was admitted to the facility with a diagnosis of diabetes mellitus (a disease that results in high blood sugar). During a review of Resident 46's Care Plan, undated, indicated, .Check blood sugar before meals and at bedtime . During a review of Resident 46's Medication Administration Record (MAR), dated 2/19/2020, the MAR indicated Resident 46's blood sugar was 168 (according to the Diabetic association professional reference dated 2019 the normal blood sugar check for a diabetic resident was 125). During a medication pass observation on 2/19/2020, at 7:42 a.m., in hallway 3, LVN 6 performed insulin lispro flex pen administration to Resident 24. LVN 6 did not prime the insulin lispro flex pen prior to administration insulin to Resident 24. During a review of Resident 24's Face Sheet, dated 11/20/19, the Face Sheet indicated, Resident 24 was admitted to the facility with a diagnosis of diabetes mellitus. During a review of Resident 24's Order Summary Report, dated 2/9/2020, the Order Summary Report indicated, Resident 24 had a physician's order for insulin lispro solution pen injector 100 unit/ml (milliliter-unit of measure) inject per sliding scale [blood sugar test results] . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055849 If continuation sheet Page 4 of 21 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 055849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Modesto Post Acute Center 159 E. Orangeburg Avenue Modesto, CA 95350 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 24's MAR dated 2/19/2020, the MAR indicated LVN 6 administered insulin lispro flex pen 4 units to Resident 24. During an interview on 2/19/2020, at 7:47 a.m., with LVN 6, LVN 6 stated she did not discard the first drop of blood and used the first drop of blood to obtain fingerstick blood sugar level for Resident 46. LVN 6 stated she should have discarded the first drop of blood and used the second drop of blood to ensure accurate blood sugar test result. LVN 6 stated the first drop of blood might be contaminated and diluted from the alcohol used to clean Resident 46's fingertips. LVN 6 stated she should have primed the insulin lispro flex pen prior to administering insulin to Resident 24. LVN 6 stated the purpose of priming the insulin flex pen was to ensure the pen was functioning properly and remove the air inside the pen for accurate insulin dosing. During a medication pass observation on 2/19/2020, at 11:31 a.m., in hallway 2, LVN 2 performed fingerstick blood sugar check to Resident 299. LVN 2 did not discard the first drop of blood and used the first drop of blood for fingerstick blood sugar test. During a medication pass observation on 2/19/2020, at 11:33 a.m., in hallway 2, LVN 2 performed insulin pen administration to Resident 299. LVN 2 did not prime the insulin lispro flex pen prior to administration to Resident 299. During a review of Resident 299's Face Sheet dated 2/18/2020, the Face Sheet indicated, Resident 299 was admitted to the facility with a diagnosis of diabetes mellitus. During a review of Resident 299's Order Summary Report, dated 2/18/2020, the Order Summary Report indicated, Resident 299 had a physician's order for insulin lispro solution pen injector 100 unit/ml inject per sliding scale . During a review of Resident 299's MAR, dated 2/19/2020, the MAR indicated Resident 299's blood sugar test results were 155 and LVN 2 administered insulin lispro pen 1 unit to Resident 299. During a medication pass observation on 2/19/2020, at 11:39 a.m., in hallway 2, LVN 2 performed fingerstick blood sugar check to Resident 300. LVN 2 did not discard the first drop of blood and used the first drop of blood for fingerstick blood sugar level. During a medication pass observation on 2/19/2020, at 11:42 a.m., in hallway 2, LVN 2 performed insulin pen administration to Resident 300. LVN 2 did not prime the insulin lispro flex pen prior to administration to Resident 300. During a review of Resident 300's Face Sheet, dated 2/18/2020, the Face Sheet indicated, Resident 300 was admitted to the facility with a diagnosis of diabetes mellitus. During a review of Resident 300's Order Summary Report, dated 2/18/2020, the Order Summary Report indicated, Resident 300 had a physician order for insulin lispro solution, pen injector 100 unit/ml inject 14 units before meals related to type 2 diabetes mellitus. During a review of Resident 300's MAR, dated 2/19/2020, the MAR indicated Resident 300's blood sugar was 206 and LVN 2 administered insulin lispro flex pen, 14 units to Resident 300. During a medication pass observation on 2/19/2020, at 11:49 a.m., in hallway 2, LVN 2 performed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055849 If continuation sheet Page 5 of 21 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 055849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Modesto Post Acute Center 159 E. Orangeburg Avenue Modesto, CA 95350 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 0658 Level of Harm - Minimal harm or potential for actual harm fingerstick blood sugar test on Resident 37. LVN 2 did not discard the first drop of blood and used the first drop of blood for fingerstick blood sugar test. During a review of Resident 37's Face Sheet, dated 12/20/19, the Face Sheet indicated, Resident 37 was admitted to the facility with a diagnosis of diabetes mellitus. Residents Affected - Some During a review of Resident 37's Medication Administration Record (MAR), dated 2/19/20, the MAR indicated Resident 37's blood sugar was 205. During an interview on 2/19/2020, at 11:57 a.m., with LVN 2, LVN 2 stated, she used the first drop of blood when she performed fingerstick blood sugar test on Resident 37, 299 and 300. LVN 2 stated, she was not aware she needed to discard the first drop of blood and use the second drop of blood for fingerstick blood sugar testing. LVN 2 stated she was not educated that she had to prime the insulin lispro flex pen prior to administering insulin to Resident 299 and 300 to ensure insulin dosing was accurate. During an interview on 2/19/2020, at 12:14 p.m., with the Director of Nursing (DON), the DON stated, fingerstick blood sugar testing and insulin administration using an insulin flex pen competency for Licensed Nurse (LN) was conducted upon hire, annually and as needed. The DON stated in obtaining fingerstick blood sugar test sample the LN should have discarded the first drop of blood and used the second drop of blood for the fingerstick blood sugar level to ensure accurate blood sugar result were obtained. The DON stated the first drop of blood might be contaminated or diluted from the alcohol used to clean Resident 37, 46, 299, and 300 fingertips. The DON stated, I don't think we [LN] need to prime the insulin pen before administration. The DON viewed the insulin lispro flex pen administration technique on [Insulin brand name instructions] and stated she did not realize the insulin flex pen needed to be primed before administration to ensure the insulin flex pen was functioning properly and to remove air bubbles inside the insulin flex pen to ensure accurate insulin dose. The DON stated LN were not priming the insulin pens and they should have been. During an interview on 2/19/2020, at 3:11 p.m., with the Director of Staff Development (DSD), the DSD, stated she should have conducted insulin flex pen priming competencies for LN and did not. The DSD stated the LN should have primed the insulin flex pen before administering to Resident 24, 299, and 300 to ensure the insulin flex pen was working properly and for accurate insulin dose. During a review of the facility's policy and procedure titled, Obtaining a Fingerstick Glucose Level dated 10/2011, indicated, The purpose of this procedure is to obtain a blood sample to determine the resident's blood sugar level . Obtain a blood sample by using a sterile lancet (a spring -loaded lancet or manual lancet). Discard the first drop of blood if alcohol is used to clean the fingertips because alcohol may alter the results . During a review of the [brand name] insulin pen professional reference titled Instructions for Use [brand name] dated 11/2019 http://uspl.lilly.com/humalog/humalog.html#ug1, indicated, Instructions for Use [brand name] insulin pen . Priming your pen. Prime before each injection. Priming your pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055849 If continuation sheet Page 6 of 21 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 055849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Modesto Post Acute Center 159 E. Orangeburg Avenue Modesto, CA 95350 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide dialysis services consistent with professional standards of practice for three of three sampled residents (Resident 33, 46 and 349) when the Dialysis (the process of artificial filtering and removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions) coordination of service Assessment Communication Record (DACR - form used to communicate pertinent dialysis resident assessment information from facility nursing staff to dialysis center staff ) form was not fully completed before or after dialysis treatment. The DACR form documents critical information regarding pre and post assessment for each resident before and after dialysis treatment, such as weight, blood pressure and access site condition to ensure resident are in stable condition prior to and after dialysis treatment. Residents Affected - Some This failure resulted in the increased risk to residents experiencing dialysis undetected adverse reactions and not communicate the coordination of resident clinical status from one facility to another. Findings: 1. During an observation on 2/18/20, at 10:30 a.m., Resident 33 stated he had returned to the facility from his dialysis treatment. During a concurrent interview and record review on 2/19/2020, at 8:30 a.m., with the Director of Nursing (DON), the DON stated the DACRs should have been filled-out completely and accurately. Resident 33's doctor orders for dialysis care were reviewed and indicated, [Conduct] pre [before]-and-post [after] dialysis weights . pre-and-post dialysis assessment . assessment of the dialysis access site . Resident 33 had a total of 22 DACRs since the beginning of 2020, which included the components of assessment the doctor ordered. There were 22 DACR reviewed dating from 1/2020 through 2/19/2020 and the DON stated 21 of the 22 DACRs were not fully completed. During a concurrent interview and record review on 2/20/2020, at 8 a.m., with the Medical Records Director (MRD), the MRD stated, The dialysis communication record is for the facility nursing staff and the staff at the dialysis care center to communicate pre-dialysis resident base-line vital signs (pulse, blood pressure, temperature and respirations) and assessment, to compare with post-dialysis assessment information, to determine if the resident was stable or not. During a concurrent interview and record review on 2/20/2020, at 3 p.m., with the DON, the DON stated none of the 21 DACR for Resident 33 completed in 2020 were fully completed and the 21 DACR had missing assessment data and that should not have occurred. 2. During a concurrent observation and interview on 2/18/2020, at 8:50 a.m., Resident 46 was sitting up in bed watching TV. Resident 46 stated her dialysis treatment schedule was Tuesday, Thursday, and Saturday. During an interview on 2/19/2020, at 9:44 a.m., with Licensed Vocational Nurse (LVN) 6, LVN 6 stated Resident 46 had a Permcath (a type of catheter inserted into the blood vessels used for dialysis) and Resident 46's received dialysis treatments on Tuesday, Thursday, and Saturday. During a concurrent interview and record review on 2/19/2020, at 9:53 a.m., with the DON, Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055849 If continuation sheet Page 7 of 21 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 055849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Modesto Post Acute Center 159 E. Orangeburg Avenue Modesto, CA 95350 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 46's DACR, dated 2/1/2020, 2/4/2020, and 2/18/2020 indicated, Resident 46's arteriovenous (AV) fistula (a dialysis access created by connecting an artery to a vein under the skin, usually in the lower arm) site was assessed for bruit (a rumbling sound associated with high pressure blood flow) and thrill (a rumbling sensation you can feel associated with high pressure of blood flow). The DON stated Resident 46 did not have an AV fistula for dialysis access and Resident 46 would not have a bruit and thrill to her Permcath. The DON stated Resident 46 had a Permcath for dialysis access and should be assessed for signs and symptoms of bleeding and infection on the Permcath site. The DON stated the assessment documentation on Resident 46's Dialysis Assessment Communication Record was inaccurate. During a concurrent interview and record review on 2/20/2020, at 3:23 p.m., with LVN 7, Resident 46's DACR, dated 2/4/2020 was reviewed and indicated, Resident 46's AV fistula site was assessed for bruit and thrill. LVN 7 stated she completed Resident 46's DACR dated 2/4/2020. LVN 7 stated Resident 46 did not have an AV fistula for dialysis access and would not have a bruit and thrill. LVN 7 stated her documentation on Resident 46's DACR was inaccurate. 3. During a concurrent observation and interview on 2/18/2020, at 11:38 a.m., with Resident 349, in her room, Resident 349 was observed seated in her room. Resident 349 stated, I go to dialysis three times a week. During a concurrent interview and record review on 2/19/2020, at 10:23 a.m., with LVN 2, Resident 349's DACR, dated 2/15/2020 was reviewed. LVN 2 stated the DACR was missing assessment information such as pain assessment, laboratory results, and if Resident 349 had a catheter (tube placed under the skin) or central line (soft tube inserted in a vein that leads to your heart). LVN 2 stated it was the responsibility of the licensed nurse to ensure the DACR was complete and accurate and it was not. During a concurrent interview and record review on 2/19/2020, at 10:33 a.m., with LVN 3, Resident 349's DACR, dated 2/18/2020 was reviewed. LVN 3 stated the post-dialysis assessment was incomplete with missing assessment information which included laboratory results and whether Resident 349 had a catheter or central line. LVN 3 stated she documented and signed the post assessment DACR. LVN 3 stated she should have filled the post assessment completely without leaving any missing information and she did not do that. During a concurrent interview and record review, on 2/19/2020, at 3:10 p.m., with LVN 4, Resident 349's DACR, dated 2/13/20 was reviewed. LVN 4 stated the post-dialysis assessment was incomplete with missing information which included lab results and whether Resident 349 had a catheter or central line. LVN 4 stated she documented and signed the post assessment record. LVN 4 stated she should not have left any missing information on the form. During an interview on 2/19/2020, at 10:48 a.m., with the DON, the DON stated the dialysis communication record was used to communicate with the dialysis center and the facility. The DON stated the communication record should be filled-out completely with no missing information. The DON stated it was the charge nurses' responsibility to ensure the form was completely filled out. During a review of the policy and procedure titled, Charting and Documentation dated 7/2017, indicated, .The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care . 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055849 If continuation sheet Page 8 of 21 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 055849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Modesto Post Acute Center 159 E. Orangeburg Avenue Modesto, CA 95350 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on observation, interview and record review, the facility failed to ensure Licensed Nurses (LNs) possessed specific competencies required to accurately perform fingerstick blood sugar testing (a procedure in which a finger is pricked with a lancet [a device with an attached small needle used to prick the skin] to obtain a small quantity of blood for blood sugar testing) and for accurate use of insulin lispro Flex Pens (a dial-a-dose device, pre-filled insulin pen for discreet insulin medication administration) for five of six sampled resident's (Resident 24, 37, 46, 299 and 300) when: 1. Two of four sampled Licensed Vocational Nurse (LVN) LVN 6 and LVN 2 did not possess competencies to perform fingerstick blood sugar testing for Resident 37, 46, 299, and 300. LVN 6 and LVN 2 used the first drop of blood from Resident 37, 46, 299, and 300's fingertips for fingerstick blood sugar test. This practice had the potential for residents on fingerstick blood sugar to have inaccurate blood sugar test result. 2. Two of four sampled LVNs, LVN 6 and LVN 2 did not possess competencies for accurate use of the lispro Flex Pen. LVN 6 and LVN 2 did not prime (to remove the air bubbles inside the insulin flex pen) the insulin lispro flex pen (medication for the treatment of diabetes - a disease with high blood sugar levels) prior to administration to Resident 24, 299 and 300. This practice placed residents on insulin at risk for unsafe administration of insulin medication, complications with their blood sugars and potential for inaccurate insulin dosing. (Cross Reference F 658). Findings: During a medication pass observation on 2/19/2020, at 7:37 a.m., in hallway 3, LVN 6 performed fingerstick blood sugar check on Resident 46. LVN 6 did not discard the first drop of blood and used the first drop of blood for fingerstick blood sugar testing. During a review of Resident 46's Face Sheet (a document containing resident profile information), dated 09/20/19, the Face Sheet indicated, Resident 46 was admitted to the facility with a diagnosis of diabetes mellitus (a disease that results in high blood sugar). During a review of Resident 46's Care Plan undated, indicated, .Check blood sugar before meals and at bedtime . During a review of Resident 46's Medication Administration Record (MAR) dated 2/19/2020, the MAR indicated Resident 46's blood sugar was 168 (according to the Diabetic association professional reference dated 2019 the normal blood sugar check for a diabetic resident was 125+). During a medication pass observation on 2/19/2020, at 7:42 a.m., in hallway 3, LVN 6 performed insulin administration using the lispro flex pen on Resident 24. LVN 6 did not prime the insulin lispro flex pen prior to the administration of insulin to Resident 24. During a review of Resident 24's Face Sheet dated 11/20/19, the Face Sheet indicated, Resident 24 was admitted to the facility with a diagnosis of diabetes mellitus. During a review of Resident 24's Order Summary Report dated 2/9/2020, the Order Summary Report indicated, Resident 24 had a physician's order for insulin lispro solution pen injector 100 unit/ml (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055849 If continuation sheet Page 9 of 21 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 055849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Modesto Post Acute Center 159 E. Orangeburg Avenue Modesto, CA 95350 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 0726 (milliliter-unit of measure) inject per sliding scale [blood sugar test results] . Level of Harm - Minimal harm or potential for actual harm During a review of Resident 24's MAR dated 2/19/2020, the MAR indicated LVN 6 administered insulin 4 units using the lispro flex pen to Resident 24. Residents Affected - Some During an interview on 2/19/2020, at 7:47 a.m., with LVN 6, LVN 6 stated she did not discard the first drop of blood and used the first drop of blood to obtain fingerstick blood sugar test for Resident 46. LVN 6 stated she should have discarded the first drop of blood and use the second drop of blood to ensure an accurate blood sugar test result was obtained. LVN 6 stated the first drop of blood might be contaminated and diluted from the alcohol used to clean Resident 46's fingertips. LVN 6 stated she did not prime the flex pen and should have primed the insulin lispro flex pen prior to administering insulin to Resident 24. LVN 6 stated the purpose of priming the insulin flex pen was to ensure the pen was functioning properly and remove the air inside the pen to ensure accurate insulin dosing was administered. During a medication pass observation on 2/19/2020, at 11:31 a.m., in hallway 2, LVN 2 performed fingerstick blood sugar check to Resident 299. LVN 2 did not discard the first drop of blood and used the first drop of blood for fingerstick blood sugar test. During a medication pass observation on 2/19/2020, at 11:33 a.m., in hallway 2, LVN 2 performed insulin pen administration to Resident 299. LVN 2 did not prime the insulin lispro flex pen prior to administration to Resident 299. During a review of Resident 299's Face Sheet dated 2/18/2020, the Face Sheet indicated, Resident 299 was admitted to the facility with a diagnosis of diabetes mellitus. During a review of Resident 299's Order Summary Report dated 2/18/2020, the Order Summary Report indicated, Resident 299 had a physician order for insulin lispro solution pen injector 100 unit/ml inject per sliding scale. During a review of Resident 299's MAR dated 2/19/2020, the MAR indicated Resident 299's blood sugar was 155 and LVN 2 administered insulin 1 unit using the lispro flex pen to Resident 299. During a medication pass observation on 2/19/2020, at 11:39 a.m., in hallway 2, LVN 2 performed fingerstick blood sugar test on Resident 300. LVN 2 did not discard the first drop of blood and used the first drop of blood for fingerstick blood sugar test. During a medication pass observation on 2/19/2020, at 11:42 a.m., in hallway 2, LVN 2 performed insulin administration using the lispro flex pen to Resident 300. LVN 2 did not prime the insulin lispro flex pen prior to the administration of insulin to Resident 300. During a review of Resident 300's Face Sheet dated 2/18/2020, the Face Sheet indicated, Resident 300 was admitted to the facility with a diagnosis of diabetes mellitus. During a review of Resident 300's Order Summary Report dated 2/18/2020, the Order Summary Report indicated, Resident 300 had a physician order for insulin lispro solution, pen injector 100 unit/ml inject 14 units before meals related to type 2 diabetes mellitus. During a review of Resident 300's MAR, dated 2/19/2020, the MAR indicated Resident 300's blood (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055849 If continuation sheet Page 10 of 21 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 055849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Modesto Post Acute Center 159 E. Orangeburg Avenue Modesto, CA 95350 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 0726 sugar was 206 and LVN 2 administered insulin 14 units using the lispro flex pen to Resident 300. Level of Harm - Minimal harm or potential for actual harm During a medication pass observation on 2/19/2020, at 11:49 a.m., in hallway 2, LVN 2 performed fingerstick blood sugar test on Resident 37. LVN 2 did not discard the first drop of blood and used the first drop of blood for fingerstick blood sugar test. Residents Affected - Some During a review of Resident 37's Face Sheet dated 12/20/19, the Face Sheet indicated, Resident 37 was admitted to the facility with a diagnosis of diabetes mellitus. During a review of Resident 37's Medication MAR, dated 2/19/20, the MAR indicated Resident 37's blood sugar was 205. During an interview on 2/19/2020, at 11:57 a.m., with LVN 2, LVN 2 stated, she used the first drop of blood when she performed fingerstick blood sugar test on Resident 37, 299 and 300. LVN 2 stated, she was not aware she needed to discard the first drop of blood and should have used the second drop of blood for fingerstick blood sugar testing. LVN 2 stated she did not prime the Lispro flex pen prior to administering insulin to residents. LVN 2 stated she did not prime the flex pen because she was not educated that she had to prime the insulin lispro flex pen prior to administering insulin to Resident 299 and 300 to ensure insulin dosing was accurate. During an interview on 2/19/2020, at 12:05 p.m., with LVN 2, LVN 2 stated the Director of Staff Development (DSD) conducted in-service training for fingerstick blood sugar checks and during the in-service she had received instructions to use the first drop of blood for checking the blood sugar test. LVN 2 stated We [LNs] do not prime insulin pens, we just dial it [insulin flex pen] to the dose. LVN 2 stated she was unable to recall when she had attended the in-service for fingerstick blood sugar testing and the use of insulin flex pen administration. During an interview on 2/19/2020, at 12:14 p.m., with the Director of Nursing (DON), the DON stated fingerstick blood sugar checks and insulin flex pen administration and use competencies for LNs were conducted upon hire, annually and as needed. The DON stated when obtaining fingerstick blood sugar samples the LN should discard the first drop of blood and use the second drop of blood to ensure accurate blood sugar results. The DON stated the first drop of blood might be contaminated or diluted from the alcohol used to clean Resident 37, 46, 299, and 300's fingertips. The DON stated, I don't think we [LNs] need to prime the insulin pen before administration. The DON viewed the insulin lispro flex pen administration technique on [Insulin brand name manufacturer instruction video] and stated prior to viewing the manufactory instruction video she was not aware the insulin flex pen needed to be primed before administration to ensure the insulin flex pen was functioning properly and to remove the air bubbles inside the insulin flex pen to ensure accurate insulin dose. During a review of the facility's document titled, Job Description of Director of Nursing Services undated, indicated, .To ensure the highest degree of quality care is maintained at all times . Develop and participate in the planning, conducting, and scheduling of timely in-service training classes that provides instructions on 'how to do the job' and ensure a well-educated nursing service department . During an interview on 2/19/2020, at 3:11 p.m., with the DSD, the DSD stated she should have conducted insulin flex pen use competencies for LNs and she did not do that. The DSD stated the LNs should have primed the insulin flex pen prior to administering insulin to Resident 24, 299, and 300 to ensure the insulin flex pen was working properly and for accurate insulin dose. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055849 If continuation sheet Page 11 of 21 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 055849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Modesto Post Acute Center 159 E. Orangeburg Avenue Modesto, CA 95350 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of the facility's document titled, Job Description of Director of Staff Development undated, indicated, .The primary purpose of your job is to plan, organize, develop, and direct all in-service educational programs throughout the facility in accordance with the current applicable federal, stated, and local standards, guidelines and regulations .to assure that the highest degree of quality resident care can be maintained at all times .Conduct regular or special in-service training sessions for staff to ensure they remain current on new procedures . During a review of the facility's policy and procedure titled, Competency of Nursing Staff dated 10/2017, indicated, .licensed nurses . demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plan of care . The facility assessment includes an evaluation of the staff competencies that are necessary to provide the level and types of care specific to the resident population . Facility and resident-specific competency evaluations will be conducted upon hire, annually and as deemed necessary . During a review of the facility's policy and procedure titled, Obtaining a Fingerstick Glucose Level [test], dated 10/2011, indicated, .The purpose of this procedure is to obtain a blood sample to determine the resident's blood sugar level . Obtain a blood sample by using a sterile lancet . Discard the first drop of blood if alcohol is used to clean the fingertips because alcohol may alter the results . During a review of the [brand name] insulin flex pen professional reference titled Instructions for Use [brand name] dated 11/2019 http://uspl.lilly.com/humalog/humalog.html#ug1, indicated, Instructions for Use [brand name] insulin pen . Priming your pen. Prime before each injection. Priming your pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055849 If continuation sheet Page 12 of 21 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 055849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Modesto Post Acute Center 159 E. Orangeburg Avenue Modesto, CA 95350 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to establish and maintain an effective infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable (contagious) diseases and infections when: Residents Affected - Some 1. Certified Nursing Assistant (CNA) 3 did not perform hand hygiene (hand washing or use of hand sanitizer) while providing feeding assistance for two of 16 sampled residents (Resident 59 and 64) after touching unclean equipment, surfaces and residents during meal service. 2. Licensed Vocational Nurse (LVN) 5 did not wear Personal Protective Equipment (PPE - gloves, gown, and mask) prior to entering a contact isolation (precautions used to prevent the spread of infection) room for one of one sampled resident (Resident 70). These failures placed all residents, staff and visitors in the facility at risk of contracting communicable diseases and infections. Findings: During a lunch meal observation on 2/18/2020, at 12:30 p.m., in the memory care dining room, Certified Nursing Assistant (CNA) 3 was providing feeding assistance to Resident 64. CNA 3 touched Resident 64's shoulder with her ungloved hands and then proceeded to feed Resident 64. CNA 3 left Resident 64 and walked across the room without washing her hands. CNA 3 touched unclean plate lids that had been placed in a pile, then walked over to Resident 59. Without washed her hands, CNA 3 removed the lid covering Resident 59's lunch plate, repositioned his plate so the built-up lip was in front of him, cut his meat, moved other food items within his reach and touched Resident 59's shoulder with her ungloved hand. Without washing her hands, CNA 3 returned to continue feeding Resident 64. Resident 64 had been eating with her fingers and putting her fingers in her mouth. CNA 3 removed the soiled place mat where Resident 64 had touched, dropped food and continued to feed Resident 64 without performing hand hygiene. During an interview on 2/18/2020, at 12:40 p.m., with CNA 3, CNA 3 stated she washed her hands before she started assisting resident with their meal service. CNA 3 stated she did not performed hand hygiene between residents and she should have washed her hands after touching unclean surfaces, equipment and between residents to prevent infections and she did not do that. During a review of the policy and procedure titled, Handwashing/Hand Hygiene dated 8/15, indicated, .This facility considers hand hygiene the primary means to prevent the spread of infections . All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . Use an alcohol-based hand rub . or alternatively, soap . and water for the following situations: .Before and after direct contact with residents; .Before and after eating or handling food; .Before and after assisting a resident with meals . 2. During an observation on 2/18/2020, at 8:43 a.m., near Resident 70's room, Resident 70's room had a sign posted on the door frame which indicated, STOP Resident 70 on contact precautions. A transparent three compartment drawer was located next to the door which contained gowns, masks and gloves. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055849 If continuation sheet Page 13 of 21 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 055849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Modesto Post Acute Center 159 E. Orangeburg Avenue Modesto, CA 95350 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 2/18/2020, at 8:53 a.m., near Resident 70's room, LVN 5 entered Resident 70's room without donning (putting on) a gown. LVN 5 removed a medication vial and adjusted the intravenous (IV- tube delivering medication directly into a vein) tubing which was attached Resident 70 and lead to an IV pole. LVN 5 exited Resident 70's room and performed hand hygiene. During an interview on 2/18/2020, at 8:56 a.m., with LVN 5, LVN 5 stated Resident 70 was on contact isolation because he had an infected wound on the left foot. LVN 5 stated she wore gloves but did not wear a gown when entering Resident 70's room. LVN 5 stated she entered Resident 70's room to remove the IV medication from Resident 70 that was empty. During an observation on 2/18/2020, at 9:58 a.m., near Resident 70's room, (Family) FM was observed in Resident 70's room without a gown or gloves assisting Resident 70 with his shoes. FM was observed holding a clear plastic bag and placing Resident 70's personal items into the bag. During an interview on 2/18/2020, at 10:02 a.m., with FM, FM stated she was told that she not required to wear gown or gloves since Resident 70 did not have the flu (respiratory virus). During a concurrent interview and record review on 2/20/2020, at 7:58 a.m., with LVN 5, Resident 70's Order Summary, dated 2/19/2020 was reviewed. The Order Summary indicated, .contact isolation r/t [related to] MRSA [Methicillin-resistant Staphylococcus aureus - (type of bacteria that is resistant to several antibiotics)] in wound . LVN 5 stated Resident 70 was on contact isolation for safety to prevent the transmission of infection to others. LVN 5 stated she did not follow the facility policy titled Isolation Categories of Transmission - Based Precautions and should have worn a gown before entering Resident 70's room. LVN 5 stated it was the responsibility of the nurse to educate family on the facility infection control practices and proper use of PPE and that did not occur. During an interview on 2/20/2020, at 8:09 a.m., with the Director of Nursing (DON), the DON stated, before entering a contact isolation room the nurse and visitors should have worn a gown and gloves. The DON stated Resident 70 was placed on contact isolation to prevent the spread of MRSA infection to staff and residents. The DON stated according to our policy gown and gloves should be worn when there was direct or indirect contact with residents on contact isolation. During a review of the policy and procedure titled, Isolation - Categories of Transmission - Based Precautions, dated 1/12, indicated, .Contact Precautions 1. In addition to Standard Precautions, implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment . Gloves and Handwashing a. In addition to wearing gloves as outlines under Standard Precautions, wear gloves (clean, non-sterile) when entering the room . Gown a. Wear a disposable gown upon entering the Contact Precautions room or cubicle . During a review of the policy and procedure titled, MRSA - Management of Recurrent Skin and Soft Tissue Infection, dated 7/13 , indicated, . CDC [centers for disease control and prevention] recommends contact precautions when the facility (based on national or local regulations deems MRSA to be of special clinical and epidemiologic [widespread] significance . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055849 If continuation sheet Page 14 of 21 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 055849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Modesto Post Acute Center 159 E. Orangeburg Avenue Modesto, CA 95350 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 0912 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide and maintain a minimum of at least 80 square feet per resident in multiple resident rooms (Rooms 101-108, 115-124, 130-137). This failure had the potential for residents to not have reasonable privacy or adequate living space. Findings: During a concurrent observation and interview on 2/18/2020, at 9:20 a.m., with Resident 97, in room [ROOM NUMBER], room [ROOM NUMBER] had three beds; bed A, B, and C. Bed A and bed B were approximately 1 foot apart. Resident 97 in bed A, stated his neighbor in bed B required assistance when getting out of bed. Resident 97 stated he didn't like his bed so close to bed B and that his bed was inches apart from bed B. Resident 97 stated bed B had been inches apart from his bed since he was placed into room [ROOM NUMBER] on 1/24/2020. During a concurrent observation and interview on 2/19/2020, at 3:25 p.m., with Certified Nursing Assistant (CNA) 4, two residents resided in room [ROOM NUMBER] with three beds. CNA 4 stated when transferring resident in bed B she had to move bed B closer to bed A to provide additional space for a safe transfer. CNA 4 stated the room did not have enough room to work (provide resident care). During a concurrent observation and interview on 2/19/2020, at 3:55 p.m., with the Maintenance Supervisor (MS), the MS measured the distance between the beds A, B and C in room [ROOM NUMBER]. The MS stated the distance between bed A and bed B was 18 inches. The MS stated the distance between bed B and bed C was 40 inches. During the Resident Council Meeting on 02/19/2020, at 2 p.m., Resident 39 and 40, complained that the size of room [ROOM NUMBER] was too small and crowded. During a concurrent observation and interview on 2/20/2020, at 10:40 a.m., at Resident 39's bedside, Resident 39 stated she did not want to move from her room, but she would like to have a little more living space. Resident 39 stated she has lived at the facility for four years and has her room the way she likes it. Resident 39 stated her roommate in bed B had a huge oxygen concentrator and her roommate in bed C has a huge wheelchair which restricted living space in the room. Resident 39 stated, We get along like a family, but it gets really cramped. During a concurrent observation and interview on 2/20/2020, at 10:49 a.m., at Resident 40's bedside, Resident 40 stated her wheelchair barely fit between the wall and the bed. Resident 40 stated space was always a tight squeeze and her neighbor in bed B had to have her bed close toward hers to make sure her oxygen machine could fit in the space. During a concurrent observation and interview on 2/20/2020, at 10:53 a.m., at Resident 9's bedside, Resident 9 stated, She was squished in the middle of both bed A and C and her oxygen concentrator, but she liked her roommates. During an interview on 2/20/2020, at 8:15 a.m., with CNA 1, CNA 1 stated, It was hard to get (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055849 If continuation sheet Page 15 of 21 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 055849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Modesto Post Acute Center 159 E. Orangeburg Avenue Modesto, CA 95350 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 0912 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few patient lifts [mechanical lift- a device used to transfer residents] in the rooms, room [ROOM NUMBER] was the hardest. When residents needed to get out of bed with the assistance of a lift. CNA 1 stated the mechanical lift did not fit in the room space. CNA 1 stated all the beds had to be moved over and then the patient lift would get brought into the room. After the patient was moved out of bed into a wheelchair and lift was no longer needed, all the beds would have to be moved back. CNA 1 stated it was a lot of work and took a lot of extra time to move room furniture and make room to provide resident care. During an interview on 2/20/2020, at 11:19 a.m., with the Director of Nursing (DON), the DON stated when residents were admitted to the facility they were placed into any available room. The DON stated resident who required extensive assistance, wheelchairs and oxygen were not taken into consideration and were placed into the first available room. During an observation on 2/20/2020, at 2:30 p.m., with the Maintenance Supervisor, (MS) and Resident Liaison, (RL), the following rooms were measured with a measuring tape by the MS. The rooms and measurements were as follows: Room number Square feet Number of residents 101 229.99 3 102 229.99 3 103 229.99 3 104 229.99 3 105 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055849 If continuation sheet Page 16 of 21 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 055849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Modesto Post Acute Center 159 E. Orangeburg Avenue Modesto, CA 95350 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 0912 229.99 Level of Harm - Minimal harm or potential for actual harm 3 106 Residents Affected - Few 229.99 3 107 229.99 3 108 229.99 3 115 216 3 116 216 3 117 216 3 118 216 3 119 216 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055849 If continuation sheet Page 17 of 21 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 055849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Modesto Post Acute Center 159 E. Orangeburg Avenue Modesto, CA 95350 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 0912 3 Level of Harm - Minimal harm or potential for actual harm 120 219 Residents Affected - Few 3 121 219 3 122 219 3 123 219 3 124 219 3 130 228.99 3 131 228.99 3 132 228.99 3 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055849 If continuation sheet Page 18 of 21 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 055849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Modesto Post Acute Center 159 E. Orangeburg Avenue Modesto, CA 95350 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 0912 133 Level of Harm - Minimal harm or potential for actual harm 228.99 3 Residents Affected - Few 134 228.99 3 135 228.5 3 136 228 3 137 218.5 3 Recommend waiver. ________________________________________________________ Health Facilities Evaluator Supervisor II Signature Date Request waiver. ______________________________________________ Administrator Signature Date FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055849 If continuation sheet Page 19 of 21 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 055849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Modesto Post Acute Center 159 E. Orangeburg Avenue Modesto, CA 95350 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 0922 Have enough backup water supply for essential areas of the nursing home. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure staff were trained to access emergency water supplies. Residents Affected - Many This failure placed residents, staff and visitors at risk of being without water in the event of an emergency. Findings: During an interview on 2/19/20, at 7:41 a.m., with the Administrator (ADM), the ADM stated, he did not know where the emergency water was stored. The ADM stated, I believe it [the emergency water] is in 50 gallon (gal) barrels, and a pump to access the water is outside. The ADM stated he did not know if staff knew how to access the emergency water, or access and assemble the pump, or attach the pump for the emergency water barrels. The ADM stated he did not know if there was a food grade water hose and/or buckets or other receptacle available to carry water in case of an emergency. The ADM stated he was not sure what was written in emergency water policy. During a concurrent interview and record review on 2/19/2020, at 9:22 a.m., with the ADM, the ADM presented an undated document titled, Emergency Water Pump Procedure (EWPP). The EWPP document indicated five-step directions to assemble the pump onto the water barrels to gain access to the emergency water. The ADM stated the instructions were created on 2/19/2020 and were not available on the emergency water barrels until today. During an interview on 2/19/2020, at 11:06 a.m., with the ADM, the ADM stated, In the event of an actual emergency staff need to know how to access emergency water. Emergency water has no value if staff cannot gain access to it. During an interview on 2/19/2020, at 11:24 a.m., with the Maintenance Supervisor (MS), the MS stated, The emergency water is in 50 gal barrels outside, accessible from inside through the door by the laundry. The pump and the wrench to take the cap off the barrel is in the shed that's locked. The [Director of Dietary Services -DDS] has a key to the shed. The key is kept in the binder with the emergency plan on the [DDS's] desk. We [facility] teach everyone [all the staff] at orientation and semi-annually where to find the key to the shed, where the emergency water is located, and where the pump and wrench are stored. I don't have any of this in writing. I teach the information. I do not develop the policy. In the event of a huge catastrophe, we would evacuate. This [emergency water] is in the event of a water pipeline break, for loss of normal water supply. The MS stated he did not know how staff would carry water back into the facility, or if they would think to bring a container for water with them outside. The MS stated he had not ever randomly questioned staff to determine if they would know what to do in case of an emergency and the emergency water needed to be accessed. During an interview on 2/19/2020, at 11: 42 a.m., with the Social Services Director (SSD), the SSD stated, We have a key to the shed, it's in the dietary department in the box with keys in it. And there is also a shed key in the med room [medicine room behind the nurse's station], in the key box behind the door. The key unlocks the shed, and in the shed we get the pump and the wrench. The resident's water pitchers could be used to bring water back into the facility. I can't tell you how we would bring a large amount of water back into the facility. During a concurrent observation and interview on 2/19/2020, at 11:51 a.m., with the Director of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055849 If continuation sheet Page 20 of 21 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 055849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Modesto Post Acute Center 159 E. Orangeburg Avenue Modesto, CA 95350 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 0922 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Nursing (DON), the DON demonstrated the process to access the emergency water. The DON went to the key box located behind the door in the med room. The key index was reviewed, and no shed keys were identified. Keys labeled Dietary were located and removed from the box and taken to the kitchen. In the kitchen, during observation and interview with the DON and DDS, the DDS stated the keys to the shed were kept on the bottom ring of the three-ring emergency binder. The DDS pulled the binder off the shelf and pointed to the bottom ring where the keys were kept but the keys were not there. The DDS stated the keys were not in the binder because she had them out to use. The DDS stated there was no key box in dietary. The DDS was asked if staff would know to carry a container for water out to the water supply. The DDS stated, I don't know what the staff will be thinking. During an interview on 2/19/20, at 1:44 p.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated, emergency water was located in a shed at the back side of the facility. LVN 3 stated a key was required to access the shed, which was with the dietary and maintenance supervisor. LVN 3 stated she would not know where to access the key for the shed if the dietary or maintenance supervisor were not at the facility. During a concurrent interview and record review on 2/20/2020, at 9:10 a.m., with the ADM, the facility document titled Disaster Preparedness Plan Tool dated 12/9/19, indicated, Sources of emergency utilities (power, gas, water) . Bottled water . was included in the handwritten filled-in space. The ADM stated he did not know if there was bottled water stored for the emergency plan. The ADM stated, When I filled that in I think I was thinking of the blue barrels. At one time or another, there may have been bottled water available, but I'm not sure. After further review, the ADM stated, Bottled water is not listed on the Emergency Water Guide Calculation Chart, nor APPENDIX R - Disaster water Supplies which listed the Emergency water supply as Behind the Building and Various other locations (see emergency water guide chart). The ADM stated he was the one that completed the Disaster Preparedness Plan Tool and stated, It's not perfect. During an interview on 2/20/20, at 11:16 a.m., with the DSD, the DSD out lined the steps she would take to get emergency water. The DSD stated: Start with going to the nurse's station, get the key out of the key box in the med room that was added yesterday. Go down hallway 3, out the door, to the shed. Open the door to the shed, get the pump and wrench to open the barrels and insert the pump. Put water into the container that's out in the shed. I would need a cart to wheel it back because it would be heavy. Next, the DSD provided a demonstration. The DSD got the keys and went out to the shed. The DSD put the key in the shed lock and struggled to open the shed door and could not. The DSD stated, I tried, I was not able to unlock the shed to get the pump required to access the water. During a review of the Disaster Preparedness Plan Tool dated 12/9/19, indicated, .SNF [Skilled Nursing Facilities] . are required by Federal regulations to have detailed written plans and procedures to meet all potential emergencies and disasters, such as fire, severe weather . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055849 If continuation sheet Page 21 of 21