Health inspection·May 28, 2025

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 (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 05/28/2025 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 0609 facility [The Department.] Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055849 If continuation sheet Page 3 of 3