Health inspection·May 28, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an injury of unknown origin for one of three sampled residents (Resident 1) when Resident 1 was noted to have pain, bruising, and swelling to her right hand and wrist; and discoloration to her left wrist. This failure resulted in Resident 1's injuries of an unknown source to not be investigated, placing Resident 1 at potential risk for harm and/or abuse, and delayed medical intervention. Findings: During a review of Resident 1's admission Record (AR) , dated 5/20/25, the AR indicated Resident 1 was a [AGE] year-old female with medical diagnoses that included dementia (progressive disease of the brain affecting memory, judgement, and mood), schizophrenia (mental illness affecting perceptions of reality), disorders of the bone, other disorders of the brain, disorientation, need for assistance with personal care, bipolar disorder (mental illness with extreme shifts in mood, behavior, and energy), muscle weakness, and others. During a review of Resident 1's Care Plan (CP), dated 4/21/25, the CP indicated Resident 1 skin discoloration to left wrist. During a review of Resident 1's CP dated 4/29/25, the CP indicated Resident 1 has swelling to right hand and wrist. During a review of Resident 1's Progress Notes (PN), dated 4/21/25, at 3:36 p.m., the PN indicated, Resident noted with these new skin issues: . skin discoloration to left wrist. During a review of Resident 1's PN, dated 4/28/25, at 6:30 p.m., the PN indicated Resident 1 was complaining of pain in right wrist and unable to twist wrist. Resident described pain as sharp continuous pain with a pain level of [10 out of a possible 10, 10 being worst pain]. During a review of Resident 1's PN, dated 4/29/25, at 2:41 p.m., the PN indicated a Change in Condition , and noted swelling to right hand and wrist. During a review of Resident 1's PN, dated 4/29/25, at 11:16 p.m., the PN indicated, Applied ice pack to Right and wrist due to swelling. During a review of Resident 1's PN, dated 4/30/25, at 9:53 p.m., the PN indicated a physician's Page 1 of 3 055849 055849 05/28/2025 Modesto Post Acute Center 159 E. Orangeburg Avenue Modesto, CA 95350

F 0609 order was received to x-ray Resident 1's right hand. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 1's Patient Report (PR), dated 4/30/25, the PR indicated x-rays were done on Resident 1's right and left hand, due to Right [and] Left hand pain. The PR indicated there was no fracture, and no abnormality. Residents Affected - Few During a concurrent record review and interview on 5/14/25, at 1:20 p.m., with the Director of Nursing (DON), Resident 1's clinical record was reviewed. The DON stated she was not aware of Resident 1's issues of pain and swelling of her wrists and hands. The DON was not able to produce documentation of a facility investigation into the source of the pain and swelling to the Resident 1's hands, or documentation that this possible Injury of Unknown Source was reported to The Department. The DON stated one possible reason it was not reported was because the x-ray did not show a fracture or injury to the wrists or hands. During a concurrent record review and interview on 5/14/25, at 2:45 p.m., with Registered Nurse (RN) 2, Resident 1's clinical record was reviewed. RN 2 stated she recalled caring for Resident 1. RN 2 stated she recalled making the PN entry on 4/28/25, at 6:30 p.m., when Resident 1 complained of 10 out of 10 pain to her right wrist. RN 2 stated, I assessed the resident. I asked her the pain level, she screamed at me ' 10/10 pain!' During a concurrent record review and interview on 5/14/25, at 3 p.m., with RN 3, Resident 1's clinical record was reviewed. RN 3 stated she recalled caring for Resident 1. RN 3 stated that on 4/29/25, I looked at her [right] wrist. It was swollen with discoloration. I . got the order for the x-ray. During a concurrent record review and interview on 5/28/25, at 11:40 a.m., with the Clinical Resource Corporate Registered Nurse (CRCRN), Resident 1's clinical record was reviewed. The CRCRN stated he recalled Resident 1. The CRCRN stated Resident 1's swollen, discolored, and painful right wrist was not investigated by the facility as an Injury of Unknown Source, nor was it reported to The Department as an Injury of Unknown Source. The CRCRN stated the right wrist could have been an injury because of a fall Resident 1 experienced on 4/12/25, but could not explain why Resident 1's clinical record did not contain documentation of any injury to Resident 1's right wrist until 16 days later. During a concurrent interview and record review on 6/10/25, at 12:25 p.m., with Treatment Registered Nurse (TRN), Resident 1's PN dated 4/21/25, at 3:36 p.m. was reviewed. The TRN stated she was the facility's Treatment Nurse (a nurse who performs all the bandage and dressing changes, monitors wound care, healing progress, and administers medications to the skin). The TRN stated she recalled making the PN and stated she was doing a head-to-toe assessment on Resident 1. The TRN stated she recalled making the entry, skin discoloration to the left wrist and stated she probably updated Resident 1's CP . The TRN stated she was unaware that resident injuries of unknown source needed to be investigated and reported to The Department. During a review of the facility's Policy and Procedure (P&P) titled, Abuse Investigation and Reporting, dated 7/17, the P&P indicated, All reports of resident abuse, neglect, exploitation, misappropriation of resident property mistreatment, and/or injuries of unknown source (abuse ) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. All alleged violations . including injuries of an unknown source . will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: 1. The state licensing/certification agency responsible for surveying/licensing the 055849 Page 2 of 3 055849 05/28/2025 Modesto Post Acute Center 159 E. Orangeburg Avenue Modesto, CA 95350

F 0609 facility [The Department.] Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055849 Page 3 of 3