Health inspection·October 1, 2024

F 0624 Level of Harm - Minimal harm or potential for actual harm 8/27/24 and not prior to this date. DON stated, there was no documentation in Resident 1 ' s chart or copies of faxes indicating that referrals had been sent to any SNFs to assist Resident 1 in transfer to another facility. DON stated, Resident 1 should have been provided with sufficient preparation and orientation to ensure a safe and orderly discharge from the facility. DON stated, Resident 1 ' s safety was at risk due to a lack of discharge planning. Residents Affected - Few During a telephone interview on 10/3/24 at 3:17 PM with Administrator (ADM), ADM stated, Resident 1 was given a 30-day notice on 8/6/24 but Resident 1 ' s responsible party was not issued a 30-day notice until 9/5/24. ADM stated, ADM had wrongly assumed Resident 1 could have discharged home with her mother because that was where Resident 1 used to reside prior to being admitted to the SNF. ADM stated, Resident 1 ' s mother had said that the apartment was too small for Resident 1 to return to. ADM stated, DON and SSD had not submitted documentation regarding Resident 1 ' s current ability to perform Activities of Daily Living (ADLs). During a review of Resident 1's admission Record (AR, documents containing resident demographic information and medical diagnosis), dated 10/1/24, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included .ANOXIC BRAIN DAMAGE .ABNORMALTIES OF GAIT AND MOBILITY .MUSCLE WEAKNESS .UNSTEADINESS ON FEET .MAJOR DEPRESSIVE DISORDER .CONTRACTURE [a stiffening/shortening at any joint, that reduces the joint ' s range of motion], RIGHT ANKLE .CONTRACTURE, LEFT ANKLE .TOBACCO USE .GENERALIZED ANXIETY DISORDER . During a review of Resident 1's Minimum Data Set (MDS, an assessment tool which indicates physical, medical and cognitive abilities), dated 7/3/24, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS) score was 15 out of 15 which indicated Resident 1 had no cognitive impairment (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills], 8-12 moderate cognitive impairment, 13-15 cognitively intact). During a review of Resident 1's Nursing Care Plan (CP), undated, the CP indicated, .The resident has limited physical mobility r/t ANOXIC BRAIN DAMAGE, CONTRACTURE, RIGHT ANKLE, CONTRACTURE, LEFT ANKLE, MUSCLE WEAKNESS Date initiated 10/14/2016 . During a review of Resident 1's CP, undated, the CP indicated, .Resident requires LTC [Long Term Care] due to family unable to provide care needed Date Initiated: 01/08/2016 . During a review of Resident 1 ' s Progress Notes (PN), dated 8/27/24, the PN indicated, .Social services spoke with resident and resident ' s mother in regard to resident not following smoking guidelines per facility policies, she would receive a notice to discharge home with her mother or alternative placement .Social services spoke with Resident ' s mother in regard to a discharge plan. The resident ' s mother stated that resident cannot return home due to limited space .resident ' s mother stated ' They lived in a 2-bedroom [ROOM NUMBER] bath apartment with no space for her wheelchair or for her to get around, we are low on income because both me and my husband are both on disability ' . During a review of the Department of Health Care Services Office of Administrative Hearings and Appeals (a government entity that handles discharge appeals for long-term care residents) document titled, Decision and Order, dated 9/25/24, the document indicated, .SUMMARY .The appeal is GRANTED. [Facility] has not complied with the legal requirements to involuntary discharge [Resident 1] in that it did not provide Resident with sufficient preparation and orientation to ensure a safe and orderly discharge from Facility. Therefore, the discharge is improper, and Resident shall be permitted to remain in Facility .On August 6, 2024, Facility issued a Notice of Proposed Transfer/Discharge .to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055849 If continuation sheet Page 2 of 3 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 10/01/2024 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 0624 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident .Authorized Representative testified they did not receive the Notice until September 5, 2024. Administrator ' s testimony confirmed that Notice was not given to Authorized Representative until September 5, 2024 .Resident ambulates with a wheelchair .Facility did not submit medical records documenting Resident ' s current ability to perform the activities of daily living .Facility did not submit a post-discharge plan of care identifying Resident ' s post-discharge needs and how those need would be met at Location .Authorized Representative identified Location as the apartment she resides in with her husband .she and her husband are both disabled, living alone .Additionally, Location is not wheelchair accessible or equipped with handicap accessories . During a review of the facility's policy and procedure titled, Transfer or Discharge, Facility- Initiated, dated 10/22, indicated, .Facility-initiated transfers or discharges .require resident/representative notification and orientation, and documentation .the resident and his or her representative are given a thirty (30)-day advance written notice of an impending transfer or discharge from this facility .A post-discharge plan is developed for each resident prior to his or her transfer or discharge .A member of the interdisciplinary team will review the final post-discharge plan with resident and family . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055849 If continuation sheet Page 3 of 3