Health inspection·November 12, 2024

F 0550 Level of Harm - Actual harm 15 years. The Ombudsman stated the residents understood the need for a quarantine room, and they have no problem moving into different rooms for short periods of time, but this move would be permanent, and the residents strongly opposed the move, preferring to stay in the same rooms they had been in for years. The Ombudsman stated, These [six] residents are really upset. Residents Affected - Few During an interview on 10/23/24, at 12:25 p.m., with Resident 1 and Resident 2, in their shared room, Resident 2 stated, I ' ve been in this room for five years. I ' ve had the same roommate [Resident 1] for five years. I don ' t like it at all, being told we have to move. I want to stay here in this room. Resident 1, who was non-verbal during the interview, nodded her head in agreement with her roommate, Resident 2, as Resident 2 spoke. During an interview on 10/23/24, at 12:30 p.m., with Resident 6, in his room, Resident 6 stated, I ' ve been in this room for 15 years. They told me they were going to move me to a different room. I don ' t like it at all. They haven ' t given me any information on who my new roommates are going to be. We are supposed to move on 10/30/24. All my things are here, my medical supplies are here, just where I want them. I want to stay in my room. During an interview on 10/23/24, at 12:45 p.m., with the Administrator, the Administrator stated, The room changes are being done because I am short on isolation rooms. The Administrator stated in the event of a future outbreak of an infectious disease, the facility would need more rooms to isolate residents from other residents to prevent the spread of the potential infectious disease. The Administrator stated there were no such needs in the facility at the present time. During an interview on 10/23/24, at 12:45 p.m., with the Infection Prevention Nurse (IPN), the IPN stated in the event some residents in the facility catch an infectious disease, and the facility needs to isolate them from other residents, the facility could place three residents with the same infectious disease (a process called cohorting) in the rooms with three beds. The IPN stated, We want to get those three 2-bed rooms available, in the possible event that isolation rooms are needed in the future because it is easier to cohort two residents with the same infectious disease in a 2-bed room than it is with three residents in a 3-bed room. The IPN stated there was no current infectious disease in the facility that required the proposed room changes. During a review of a letter from the facility to the Ombudsman (letter), dated 10/2/24, the letter indicated, Enclosed are copies of the 30-day notices given to six [Resident 1, Resident 2, Resident 3, Resident 4, Resident 5 and Resident 6] Residents for room changes. I met with the Residents today, with the Ombudsman present, and I explained that I need those semi-private [2-bed rooms] rooms to accommodate the infectious diseases. During a review of Resident 1 ' s document titled, Notice of Proposed Transfer/Discharge (NOPTD), dated 10/1/24, the NOPTD indicated, For the reasons explained below, a decision has been made to transfer [Resident 1] from current room to another room. Date of this Notification to Resident: 10/1/24. Date of Transfer: 10/30/24. [Reason:] The health of individual in the facility would otherwise be endangered. During a review of Resident 2 ' s document titled, NOPTD, dated 10/1/24, the NOPTD indicated, For the reasons explained below, a decision has been made to transfer [Resident 2] from current room to another room. Date of this Notification to Resident: 10/1/24. Date of Transfer: 10/30/24. [Reason:] The health of individual in the facility would otherwise be endangered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055849 If continuation sheet Page 2 of 9 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 11/12/2024 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 0550 Level of Harm - Actual harm During a review of Resident 3 ' s document titled, NOPTD, dated 10/1/24, the NOPTD indicated, For the reasons explained below, a decision has been made to transfer [Resident 3] from current room to another room. Date of this Notification to Resident: 10/1/24. Date of Transfer: 10/30/24. [Reason:] The health of individual in the facility would otherwise be endangered. Residents Affected - Few During a review of Resident 5 ' s document titled, NOPTD, dated 10/1/24, the NOPTD indicated, For the reasons explained below, a decision has been made to transfer [Resident 5] from current room to another room. Date of this Notification to Resident: 10/1/24. Date of Transfer: 10/30/24. [Reason:] The health of individual in the facility would otherwise be endangered. During a review of Resident 6 ' s document titled, NOPTD, dated 10/1/24, the NOPTD indicated, For the reasons explained below, a decision has been made to transfer [Resident 6] from current room to another room. Date of this Notification to Resident: 10/1/24. Date of Transfer: 10/30/24. [Reason:] The health of individual in the facility would otherwise be endangered. The NOPTD indicated Resident 6 refused to sign the document. During a review of Resident 1 ' s admission Record (AR), dated 10/30/24, the AR indicated Resident 1 was a [AGE] year-old female and had been a resident of the facility since 2012. The AR indicated Resident 1 ' s diagnoses included Major Depressive Disorder (a serious mood disorder that causes severe symptoms that affect how a person feels, thinks, and handles daily activities, such as sleeping, eating, or working). During a review of Resident 1 ' s Minimum Data Sheet (MDS, a comprehensive, standardized assessment tool), dated 10/2/24, the MDS indicated at Question C0500 a score of 15 out of a possible 15, which indicated Resident 1 was cognitively intact (having sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the resident ' s environment). During a review of Resident 1 ' s Progress Notes (PN), dated 10/1/24, at 11:37 a.m., the PN indicated Resident was issued with a 30 day notice to move rooms in the facility in order to be able to increase our isolations rooms to accommodate our resident ' s needing isolation for recovery. Resident ' s mother was contacted due to mother being resident ' s [Responsible Party]. Mother did refuse to sign and stated they would not like for her daughter to move. Resident 1 ' s PN dated 10/8/24, at 11:12 a.m., indicated, Social services went to visit resident to check on Resident ' s mental status from initiating the room change that will be happening at the end of the month in October. Resident stated they did not want to move rooms and won ' t be moving. Resident stated this has been her room for a while and did not feel comfortable to change. During a review of Resident 2 ' s AR, dated 10/24/24, the AR indicated Resident 2 was an [AGE] year-old female and had been a resident of the facility since 2015. The AR indicated Resident 2 ' s diagnoses included Generalized Anxiety Disorder (a mental health disorder that produces fear, worry, and a constant feeling of being overwhelmed); and Major Depressive Disorder. During a review of Resident 2 ' s Order Summary Report (OSR), dated 10/24/24, the OSR contained a physician ' s order that indicated Resident has capacity to make decision for self[.] During a review of Resident 2 ' s MDS, dated 8/13/24, the MDS indicated at Question C0500 a score of 15 out of a possible 15, which indicated Resident 2 was cognitively intact. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055849 If continuation sheet Page 3 of 9 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 11/12/2024 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 0550 Level of Harm - Actual harm Residents Affected - Few During a review of Resident 2 ' s PN, dated 10/1/24, at 1:22 p.m., the PN indicated Resident was issued with a 30 day notice to move rooms in the facility in order to be able to increase our isolations rooms to accommodate our resident ' s needing isolation for recovery. Resident refused to move. Resident 2 ' s PN dated 10/1/24, at 3 p.m., indicated Resident daughter . was notified [of notice of room change] and refused to sign document. Resident 2 ' s PN dated 10/8/24, at 10:24 a.m., indicated, Social services went to visit resident to check on Resident ' s mental status from initiating the room change that will be happening at the end of the month in October. Resident stated that they did not want to move rooms and did not feel comfortable with change. During a review of Resident 3 ' s AR, dated 10/30/24, the AR indicated Resident 3 was a [AGE] year-old female and had been a resident of the facility since 2021. The AR indicated Resident 3 ' s diagnoses included Aphasia (a language disorder that makes it hard for a person to read, write, and speak clearly). During a review of Resident 3 ' s OSR, dated 10/30/24, the OSR contained a physician ' s order that indicated Resident has capacity to make her own decisions[.] During a review of Resident 3 ' s MDS, dated 10/23/24, the MDS indicated at Question C0500 a score of 13 out of a possible 15, which indicated Resident 3 was cognitively intact. During a review of Resident 3 ' s PN, dated 10/1/24, at 8:39 a.m., the PN indicated Resident was issued with a 30 day notice to move rooms in the facility in order to be able to increase our isolations rooms to accommodate our resident ' s needing isolation for recovery. Resident did refuse to sign and stated they would not like to move. Resident 3 ' s PN dated 10/8/24, at 11:22 a.m., indicated, Social services went to visit resident to check on Resident ' s mental status from initiating the room change that will be happening at the end of the month in October. Resident stated they did not want to move rooms and won ' t be moving. Resident stated this has been her room for a while and did not feel comfortable to change. During a review of Resident 5 ' s AR, dated 10/24/24, the AR indicated Resident 5 was a [AGE] year-old male and had been a resident of the facility since 2023. The AR indicated Resident 5 ' s diagnoses included Legal blindness, as defined in USA. During a review of Resident 5 ' s OSR, dated 10/24/24, the OSR contained a physician ' s order that indicated Resident has the capacity to make his own medical decision[.] During a review of Resident 5 ' s MDS, dated 8/15/24, the MDS indicated at Question C0500 a score of 15 out of a possible 15, which indicated Resident 5 was cognitively intact. During a review of Resident 5 ' s PN, dated 10/1/24, at 8:46 a.m., the PN indicated Resident was issued with a 30 day notice to move rooms in the facility in order to be able to increase our isolations rooms to accommodate our resident ' s needing isolation for recovery. Resident . stated they would not like to move. Resident 5 ' s PN dated 10/8/24, at 9:43 a.m., indicated, Social services went to visit resident to check on his mental status from initiated room change that will be happening at the end of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055849 If continuation sheet Page 4 of 9 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 11/12/2024 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 0550 month of October. Resident stated they did not like the idea of moving rooms and was not open to moving rooms. Resident stated this has been his room since admission and did not feel comfortable to change. Level of Harm - Actual harm Residents Affected - Few During a review of Resident 6 ' s AR, dated 10/24/24, the AR indicated Resident 6 was a [AGE] year-old male and had been a resident of the facility since 2009. The AR indicated Resident 6 ' s diagnoses included Generalized Anxiety Disorder and Major Depressive Disorder. During a review of Resident 6 ' s OSR, dated 10/24/24, the OSR contained a physician ' s order that indicated Resident is capable to make his own medical decision[.] During a review of Resident 6 ' s MDS, dated 9/18/24, the MDS indicated at Question C0500 a score of 15 out of a possible 15, which indicated Resident 6 was cognitively intact. During a review of Resident 6 ' s PN, dated 10/1/24, at 8:49 a.m., the PN indicated Resident was issued with a 30 day notice to move rooms in the facility in order to be able to increase our isolations rooms to accommodate our resident ' s needing isolation for recovery. Resident did refuse to sign and stated they would not like to move. Resident 6 ' s PN dated 10/8/24, at 11:22 a.m., indicated, Social services went to visit resident to check on Resident ' s mental status from initiating the room change that will be happening at the end of the month in October. Resident stated they did not want to move rooms and won ' t be moving. Resident stated this has been her room for a while and did not feel comfortable to change. During a review of the facility ' s Policy and Procedure (P&P), titled Multidrug-Resistant Organisms, dated 8/19, the P&P indicated, in part: Infection Precautions: Consider the individual resident ' s clinical situation and facility resources in deciding whether to implement contact precautions. 2. During an interview on 10/22/24, at 4 p.m., with the Ombudsman (a government official who advocates for the rights of nursing home residents and helps resolve issues), the Ombudsman stated that Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6 were all given a 30-day notice from the facility that they would have to move to different rooms within the facility. The Ombudsman stated the facility sent out mandatory room transfer notices impacting the six residents, only because they each resided in the facility ' s only 2-bed rooms, and informed them they are being moved into 3-bed rooms elsewhere in the facility. The Ombudsman stated there were only three rooms in the facility with 2 beds, and these six residents resided in these three rooms. The Ombudsman stated the facility is doing this for the need for possible future quarantine rooms, in the possible event they need to isolate residents, in the future, to control an infectious disease that was not currently occurring in the facility. The Ombudsman stated some residents had been in their rooms for years and stated as an example that Resident 6 had been in his room for 15 years. The Ombudsman stated the residents understood the need for a quarantine room, and they have no problem moving into different rooms for short periods of time, but this move is permanent, and the residents strongly opposed the move, preferring to stay in the same rooms they had been in for years. The Ombudsman stated, These [six] residents are really upset. During an interview on 10/23/24, at 12:45 p.m., with the Administrator, the Administrator stated, The room changes are being done because I am short on isolation rooms. The Administrator stated in the event of a future outbreak of a potential infectious disease, the facility would need more rooms to isolate residents from other residents to prevent the spread of the infectious disease. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055849 If continuation sheet Page 5 of 9 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 11/12/2024 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 0550 Administrator stated there were no such needs in the facility at the present time. Level of Harm - Actual harm During an interview on 10/23/24, at 12:45 p.m., with the Infection Prevention Nurse (IPN), the IPN stated in the event some residents in the facility catch an infectious disease, and need to isolate them from other residents, the facility could place three residents with the same infectious disease (a process called cohorting) in the rooms with three beds. The IPN stated, We want to get those three 2-bed rooms available, in the possible event that isolation rooms are needed in the future because it is easier to cohort two residents with the same infectious disease in a 2-bed room than it is with three residents in a 3-bed room. The IPN stated there was no current infectious disease in the facility that required the proposed room changes. Residents Affected - Few During a review of a letter from the facility to the Ombudsman (letter), dated 10/2/24, the letter indicated, Enclosed are copies of the 30-day notices given to six [including Resident 4] Residents for room changes. I met with the Residents today, with the Ombudsman present, and I explained that I need those semi-private [2-bed rooms] rooms to accommodate the infectious diseases. During a review of Resident 4 ' s document titled, Notice of Proposed Transfer/Discharge (NOPTD), dated 10/1/24, the NOPTD indicated, For the reasons explained below, a decision has been made to transfer [Resident 4] from current room to another room. Date of this Notification to Resident: 10/1/24. Date of Transfer: 10/30/24. [Reason:] The health of individual in the facility would otherwise be endangered. The NOPTD indicated Resident 4 refused to sign the document. During an interview on 10/23/24, at 1:10 p.m., with Resident 4, Resident 4 stated, Hell no, I don ' t want to move! I ' ve been in this bed for over a year. I ' d be more willing to go to the mortuary [a facility that processes dead bodies for burial]. During a review of Resident 4 ' s admission Record (AR), dated 10/24/24, the AR indicated Resident 4 was a [AGE] year-old female and had been a resident of the facility since 2014. Resident 4 ' s diagnoses included Generalized Anxiety Disorder (a mental health disorder that produces fear, worry, and a constant feeling of being overwhelmed), and Major Depressive Disorder (a serious mood disorder that causes severe symptoms that affect how a person feels, thinks, and handles daily activities, such as sleeping, eating, or working). During a review of Resident 4 ' s Order Summary Report (OSR), dated 10/24/24, the OSR contained a physician ' s order that indicated Resident is capable to make her own decision by herself. During a review of Resident 4 ' s Minimum Data Sheet (MDS, a comprehensive, standardized assessment tool), dated 9/13/24, the MDS indicated at Question C0500 a score of 15 out of a possible 15, which indicated Resident 4 was cognitively intact. During a review of Resident 4 ' s Progress note, dated 9/3/24, written by her attending physician (Physician 1), the PN indicated Resident 4 was seen at bed side for follow up. No new nursing concerns reported. [Resident 4] has history of depression, symptoms stable with current management. Assessment and Plan: Depression . We will continue current medication and consider mental health evaluation if needed. During a review of Resident 4 ' s Progress Notes (PN), dated 10/1/24, at 8:52 a.m., the PN indicated Resident was issued with a 30 day notice to move rooms in the facility in order to be able to increase our isolations rooms to accommodate our resident ' s needing isolation for recovery. Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055849 If continuation sheet Page 6 of 9 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 11/12/2024 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 0550 Level of Harm - Actual harm Residents Affected - Few did refuse to sign and stated they would not like to move. Resident 4 ' s PN dated 10/8/24, at 11:20 a.m., indicated, Social services went to visit resident to check on Resident ' s mental status from initiating the room change that will be happening at the end of the month in October. Resident stated they did not want to move rooms and won ' t be moving. Resident stated this has been her room for a while and did not feel comfortable to change. During a review of Resident 4 ' s OSR, dated 10/22/24, the OSR indicated Resident 4 was prescribed: · Fluoxetine 10 mg [milligrams, a unit of measurement] once daily for verbalization of sadness, prescribed on 7/8/24; and, · Trazadone 100 mg at bedtime for depression manifested by unable to sleep, prescribed on 10/22/23. Resident 4 ' s OSR indicated nursing staff was monitoring her for side effects from the Fluoxetine such as nausea, vomiting, anxiety, sexual dysfunction, insomnia, dizziness, weight loss or gain, tremors, sweating, drowsiness, fatigue, dry mouth, diarrhea, constipation, headaches and increase risk for fall. The OSR indicated nursing staff were monitoring Resident 4 for side effects from the Trazadone such as daytime drowsiness, confusion, loss of appetite in the morning, increased risk for fall and fractures, dizziness. The OSR indicated Resident 4 was prescribed 12 different routine medications, and an additional six different medications on an as needed basis. Resident 4 ' s PN dated 10/22/24, at 8:30 a.m., indicated, Resident [4] verbalize to [Certified Nursing Assistant, or CNA] during shower suicidal thoughts due scheduled room change. Per resident she does not want to move from her room. [Physician] notified, new order for psych[iatric] consult[ation]. Resident placed on spot checks. During a review of Resident 4 ' s Care Plan (CP), dated 10/22/24, the CP indicated, Resident [4] verbalizes suicidal ideation. Resident 4 ' s PN dated 10/23/24, at 4:34 p.m., indicated, Stated she doesn ' t understand why she has to change rooms. Resident 4 ' s PN dated 10/24/24, at 8:14 a.m., indicated, Resident was evaluated by facility psychologist [Doctor 1] . [due to] recent suicidal ideations. Resident chief complaint was noted as depression, sadness, loss of health or independence, anger, frustration, anxiety in adjusting to care, confusion or memory loss impairing her capacity to receive care or treatment. The resident ' s compliance was noted as resistive and argumentative. The resident ' s mood was noted as depressed, anxious, irritable, angry, and labile [a state of emotional instability characterized by frequent and dramatic mood swings]. [Doctor 1] recommends to increase . psychotropic medications [medications that affect the mind, emotions, and behavior] for continued mood / behavior management. Resident 4 ' s PN dated 10/24/24, at 12:45 p.m., indicated, Resident asked . what room will she be moved to. Told resident I don ' t know the room number yet . Resident stated she does not want to move but if she does, she wants the same roommate. Resident 4 ' s PN dated 10/26/24, dated 0:37 a.m., indicated, Resident is on behavior monitoring for increasing Fluoxetine [a psychotropic medication used for depression] from 10 mg to 20 mg and Trazadone [also a psychotropic medication used for depression] from 100 mg to 150 mg . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055849 If continuation sheet Page 7 of 9 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 11/12/2024 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 0550 Level of Harm - Actual harm During a review of Resident 4 ' s Progress Note – 30 Day Follow Up (PN30FU), dated 10/29/24, written by Nurse Practitioner 1, the PN30FU indicated Resident 4 ' s medication Fluoxetine was increased from 10 mg daily to 20 mg daily on 10/26/24; and Resident 4 ' s medication Trazadone was increased from 100 mg to 150 mg at bedtime on 10/25/24. Residents Affected - Few During a concurrent record review and interview on 11/12/24, at 1:39 p.m., with the Social Services Director (SSD), Resident 4 ' s clinical record was reviewed. The SSD stated she had worked in the facility since February 2024, and was familiar with Resident 4. The SSD stated Resident 4 had informed a Certified Nursing Assistant that she didn ' t want to be alive anymore due to her impending room change. The SSD stated she then interviewed Resident 4 about this statement, but during her interview, Resident 4 did not express to her that Resident 4 wanted to end her life. The SSD stated Resident 4 stated she was concerned about the room change and did not want to do it. The SSD stated, To me, she seemed more irritable. The SSD stated facility staff had been expressing to her that Resident 4 had seemed more depressed since the first of October [the date Resident 4 received the 30-day notice to change rooms]. The SSD stated, We can ' t infringe on their rights to not want to move. It was hard to give the notice. I agree that the resident who have been in their rooms for years matters. This situation could have been approached differently. There was no pressing need at that time for isolation rooms in the facility. The SSD stated she reviewed Doctor 1 ' s notes after his visit to Resident 4 on 10/24/24, and stated it is within her job expectations to speak to the psychologist and review residents ' psychotropic medications. The SSD stated, My understanding, based on [Doctor 1 ' s] note, was that [Resident 4 ' s] behavior change was due to the room change. The SSD stated, I would agree that after 10/1/24, [Resident 4] was depressed, irritable, angry, and labile. The resident is often irritable, but I noticed an increase in her irritability. During a concurrent record review and interview on 11/12/24, at 2:03 p.m., with the Activities Director (AD), Resident 4 ' s clinical record was reviewed. The AD stated, [Resident 4] was very upset [about the room change]. I talk to her every day. Her biggest concern was what room she was going to go to. I felt bad for the residents having to move rooms. I told the residents if they are not happy with moving rooms, they can call the Ombudsman. When I spoke to [Resident 4], I heard her say she would take pills. I assumed it meant an overdose for a lethal event. I did let the team know and a psych consult was made. After the medication dosage increase, [Resident 4] never made a comment like that to me again. During a concurrent record review and interview on 11/12/24, at 2:20 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 4 ' s clinical record was reviewed. LVN 1 stated, I ' ve worked here about 20 years, I know [Resident 4]. LVN 1 stated she recalled when a Certified Nursing Assistant told her that during a shower that Resident 4 had expressed suicidal ideations, and she was upset over her proposed room change. The CNA told me [Resident 4] wanted to kill herself over this. I wrote the note in the Progress Notes, I wasn ' t more specific on how she would do it. I then spoke to [Resident 4], she denied any suicidal ideations to me, but stated she did not want to move. During a review of Resident 4 ' s untitled document from her clinical record, but commonly referred to as a physician telephone order (PTO) dated 10/22/24, at 8:35 a.m., the PTO indicated Resident 4 had a physician ' s order for May have Psych eval[uation] and treat[ment related to] suicidal ideation verbalized. During a review of Resident 4 ' s Psych Referral Form (PRF), dated 10/22/24, the PFR indicated, Emotional and Behavioral Problems [-] Suicidal Thinking or Gestures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055849 If continuation sheet Page 8 of 9 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 11/12/2024 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 0550 Level of Harm - Actual harm Residents Affected - Few During a concurrent record review and interview on 11/12/24, at 2:30 p.m., with the Director of Nursing (DON), Resident 4 ' s Psychologist Consultation / Follow-Up (PCFU), written by Doctor 1, dated 10/24/24, was reviewed. The DON verified Doctor 1 had documented on the PCFU Resident 4 demonstrated Depression, sadness, loss of health or independence with Chief Complaints of Anger, frustration, anxiety in adjusting to care, and Presenting problems and History of Confusion or memory loss impairing capacity to receive care, treatment. The PCFU indicated Resident 4 ' s Current Medication were fluoxetine 10 mg and Trazadone 100 mg. The PCFU indicated Resident [4] presents as alert, lucid, communicative, mood and affect angry, upset over room change, threatening to harm herself, denied any intent or plan during contact. [Complains of] depression, [decreased] sleep, can be tried on fluoxetine 20 mg [every day], Trazadone 150 mg [at bedtime.] The DON confirmed the documentation. During a review of the National institute of Health, National Library of Medicine, National Center for Biotechnical Information website titled, Depression: Learn More – How effective are antidepressants?, dated 4/15/24, the website indicated, in part: Antidepressants are a key part of treating depression. They aim to relieve symptoms and prevent depression from coming back. The main aim of treatment with antidepressants is to relieve the symptoms of severe depression, such as feeling very down and exhausted, and prevent them from coming back. They are also meant to make you feel emotionally stable again and help you follow a normal daily routine. They are also taken to relieve symptoms such as restlessness, anxiety and sleep problems, and to prevent suicidal thoughts. This information is about using medication to treat the most common form of depression, known as major depressive disorder. Like all medications, antidepressant can have side effects. Ove half of all people who use antidep[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055849 If continuation sheet Page 9 of 9