Other·August 8, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health Licensing and Certification during a RECERTIFICATION Survey. Representing the California Department of Public Health by Federal ID: 36476 RN HFEN, 31267 RN HFEN, 38641 RN HFEN, 20362 RN HFEN, 35688 RN HFEN, 39605 RN HFEN, 39818 RN HFEN, and 39946 RN HFEN. Capacity: Census: Sample: Random: 121 113 30 15 The following Complaint, and Facility Reported Incident (FRI) were investigated during the RECERTIFICATION Survey: Complaint CA00583230: Substantiated with deficiency. Complaint CA00581078: Unsubstantiated with no deficiency. FRI CA00586825: Unsubstantiated with no deficiency.

F550 SS=E Resident Rights/Exercise of Rights CFR(s): 483.10(a)(1)(2)(b)(1)(2)

F550 06/19/2018 §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 1 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 2 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on observation, interview and record review, the facility failed to ensure residents were treated with dignity and respect consistent with enhancing each resident's quality of life for two of 31 sampled residents (Residents 20 and 417) and four random residents (Residents 122, 11, 85 and 53) when: 1. On 5/16/18 staff dressed a cognitively impaired resident, Resident 20, in mismatched colored shoelaces on her shoes against the facility policy to care for vulnerable and cognitively impaired residents with dignity and respect. 2. Staff did not respond in a timely manner to Resident 417's request for assistance to the bathroom and as a consequence urinated in the bed. Resident 417 expressed extreme frustration and felt disrespected because of this occurrence. 3. Staff did not address Resident 122's need for assistance with her breakfast tray and did not remove the plastic wrapping. Resident 122 was physically incapable to remove the plastic wrap, did not eat her breakfast and felt disrespected and helpless. 4. On 5/15/18 staff seated Residents 53, 85 and 11 at the same table in the Assisted Dining Room and did not serve and feed the residents at the same time against the facility policy to serve and feed residents who sit at the same table at the same time. These failures resulted in the facility not promoting the rights of residents to a dignified and respectful existence consistent with enhancing their quality of life. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 3 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: 1. On 5/16/18 at 10:20 a.m., during an observation, Resident 20 was seated in a wheelchair in the North Lobby of the facility. Resident 20's tennis shoes were observed to have mismatched shoelaces: the right shoe had white laces and the left shoe had black laces. Resident 20 was asked if she minded her shoelaces were of different colors, but Resident 20 did not respond. The Minimum Data Set (MDS - an assessment tool that measures resident characteristics) for Resident 20 indicated a Brief Interview for Mental Status (BIMS - an assessment tool to measure cognitive status) score of 4 (a score of 0-7 indicates severe cognitive impairment) and had diagnoses of Aphasia (an impairment characterized by the inability to speak or comprehend speech) and Hemiplegia (paralysis of one side of the body). On 5/16/18 at 3:14 p.m., during an interview, the Licensed Nurse (LN) 5 stated the night staff had gotten Resident 20 dressed early in the morning for her dialysis treatment which was located outside of the facility. LN 5 stated the night staff should have not dressed Resident 20 in tennis shoes with mismatched shoelaces. On 5/16/18 at 3:14 p.m., during an interview, the Licensed Nurse Unit Manager (LNUM) stated she was aware Resident 20 was dressed with mismatched shoelaces on her tennis shoes. LNUM did not respond when asked whether or not mismatched shoelaces were appropriate for Resident 20. LNUM was unaware Resident 20 was incapable of making the decision to wear mismatched shoelaces because LNUM stated that perhaps Resident 20 chose to wear mismatched shoelaces. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 4 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 5/16/18 at 3:30 p.m., during an interview, the Social Services Director (SSD) stated mismatched shoelaces on Resident 20 was a dignity issue because Resident 20 relied on staff to dress and place shoes on her. On 5/17/18 at 8:03 a.m., during an interview regarding the mismatched shoelaces, the Director of Nursing (DON) stated, "It should have been rectified once she returned from dialysis. Probably when she came back, it must have slipped their (staff) mind." On 5/17/18 at 8:05 a.m., during an interview regarding the mismatched shoelaces, the Administrator stated, "It should have been fixed." The facility's policy and procedure titled, Quality of Life-Dignity" dated 8/2009 indicated "Each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect and individuality 11. Demeaning practices and standard of care that compromise dignity are prohibited. Staff shall promote dignity and assist resident as needed 12. Staff shall treat cognitively impaired residents with dignity and sensitivity..." 2. On 5/15/18 at 11:32 a.m., during an interview, Resident 417 stated, "I came in on Friday [5/11/18]. I think it was Sunday [5/13/18] night. I kept pushing my buzzer [call light] and no one came to my room. I had to pee in my bed, it was very upsetting. I am an independent person. I got so frustrated that I wanted to scream." Resident 417's husband stated, "I came in Monday the 14th [May] and she told me she had to pee in the bed because no one can answer the call light to take her to the bathroom and it all happened in the same night." Resident 417's husband stated, "I have FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 5 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE talked to the nurses, CNA [certified nursing assistant], and Administrator about what happened ..." On 5/17/18 at 8.10 a.m., during an interview, License Nurse (LN) 6 stated Resident 417 was continent, wore briefs and used the bedpan with assistance. When asked if the resident had been incontinent, LN 6 stated that she was not aware of the resident being incontinent, but she could ask the CNA. The facility document titled "Bladder Elimination" dated 5/11/18 - 5/17/18, indicated Resident 417 was incontinent on 5/13/18 on two occasions. On 5/18/18 at 10:28 a.m. during a telephone interview, CNA 13 stated Resident 417 knew how to use the call light. CNA 13 stated he charted on 5/13/18 the resident was incontinent because he was not able to go to the resident in time. CNA 13 stated he was answering other call lights. The facility policy and procedure titled "Quality of Life- Dignity" dated 8/2009, indicated resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect and individuality...11. Demeaning practices and standard of care that compromise dignity are prohibited. Staff shall promote dignity and assist resident as needed by... b. promptly responding to the president's request for toileting assistance." 3. On 5/17/18 at 8:10 a.m., during a concurrent observation and interview, Resident 122 stated CNA 5 brought her breakfast tray in her room. The lids of the food dishes were wrapped in plastic and Resident 122 stated she requested CNA 5 to peel off the plastic wraps because she was unable to do it. Resident 122 showed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 6 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE both of her hands with contractures and stated, "I could not use my arthritic hands." Resident 122 stated CNA 5 left in a hurry without helping her. Resident 122 pointed at the call light on the floor and stated, "I could not even use it [call light]." Resident 122 stated, that she did not eat her breakfast meal. Resident 122 stated CNA 5 came later and retrieved the untouched breakfast tray. On 5/17/18 at 8:30 a.m., during an interview, CNA 5 stated she brought the breakfast tray to Resident 122. CNA 5 stated the resident did not request the plastic wrappings to be removed, otherwise she would have helped Resident 122. CNA 5 was unable to answer if she noticed Resident 122 had not eaten her breakfast. CNA 5 stated she should have been concerned about Resident 122 not eating her meal. On 5/17/18 at 3:15 p.m., during an interview, LN 3 stated the expectation would be that CNA 5 should have given the resident her full attention in order for her to anticipate the resident's needs. LN 3 stated the resident did not have to ask for help because CNA 5 would be expected to remove the plastic wrappings of the food containers and set food in front of the Resident 122. CNA 5 would be expected to ensure Resident 122 had all that she needed before she left the resident's room. On 5/17/18 at 3:25 p.m., during an interview, Registered Nurse Supervisor (RNS) stated CNA 5 would be expected to pay attention to what the Resident 122 had said and wanted to be compassionate in doing her job. 4. On 5/15/18 at 12:41 p.m., during an observation in the Assisted Dining Room, table 6 had three residents. Staff served Resident 53 her lunch meal and started feeding her. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 7 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 85 was served his lunch meal at 12:45 p.m., and he started eating. Resident 11 was served her lunch last at 12:49 p.m. On 5/18/18 at 10:08 a.m., during an interview, the Director of Staff Development (DSD) stated the facility had a new dining program they followed which had a resident seating chart. The DSD stated, "All CNA's were in-serviced for this (new dining program) ... Feeders are seated here [pointed to diagram- table 6] ... the feeder table with 4 feeders, may have 3 staff ... [we] want everybody to be served at the same time. It would be unfair to not have food at the same time. One resident may say where is my food? I want to eat too." The DSD stated, "They [staff] should have fed them [the three residents] at the same time. Residents not served at the same time ... should not have happened." On 5/18/18 at 10:39 a.m., during an interview, the RNA stated, "Table 6 is a feeder table ...everybody in that table needs assistance." She stated, "[The staff must] serve everybody at the same time. I would start with [Resident 11] first because her daughter can start feeding her then serve [Resident 85] because he can feed himself then serve [Resident 53], sit with her and feed her." RNA stated not serving each resident at a different time was wrong and should not occur. On 5/18/18 at 11:11 a.m., during an interview, the DON stated, "Serve everybody on the table at the same time ... That was how I trained them [staff]. Feed the residents at the same time." The facility policy and procedure titled, "Quality of Life-Dignity" dated 9/2009, indicated "Each resident would be cared for in a manner that promotes and enhances the quality of life, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 8 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE dignity, respect and individuality...1. Residents shall be treated with dignity and respect at all times. 2. "Treated with dignity" means the resident will be assisted in maintaining and enhancing his or her self-esteem and self worth..."

F565 SS=E Resident/Family Group and Response CFR(s): 483.10(f)(5)(i)-(iv)(6)(7)

F565 06/19/2018 §483.10(f)(5) The resident has a right to organize and participate in resident groups in the facility. (i) The facility must provide a resident or family group, if one exists, with private space; and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 9 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner. (ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation. (iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings. (iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility. (A) The facility must be able to demonstrate their response and rationale for such response. (B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group. §483.10(f)(6) The resident has a right to participate in family groups. §483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to make prompt efforts to resolve the residents grievances and to keep the residents informed of progress towards a resolution through the facility designated Grievance Officer for six of 15 random residents(Resident 14, Resident 31, Resident 55, Resident 79, Resident 81 and Resident 86) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 10 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and two of 31 sampled residents (Resident 29 and Resident 77) when resident Council members complained regarding the facility food, soup was cold, food coming out cold to the social dining room, and hot food not being served hot enough. For Resident 14, Resident 29, Resident 31, Resident 55, Resident 77, Resident 79, Resident 81 and Resident 86, these failures placed the residents at risk of not having their grievances resolved that could of improved the residents' quality of life and services received from the facility. Findings: On 5/16/18 at 10:09 a.m., The Resident Council Meeting was held at the Pinion Vineyard Room in the presence of 8 council members. On 5/16/18 at 10:20 a.m., during an interview, the Resident Council Minutes dated 4/23/18, 3/27/18 and 2/20/18, were discussed with the residents. The discussion included complaints regarding the food, soup was cold, food coming out cold to the social dining room, and hot food not being served hot enough. When asked, if these complaints for the last three months were already resolved, the group stated "No, nothing has changed." When residents were asked if the facility had given them a time frame the resident stated "No." Residents were asked, could you expect a complete review of the grievances' made to the facility?, the group stated "No." When asked if they knew about or had worked with the Grievance Officer who was responsible for the complaints, the group answered, "No." On 5/16/18 at 3:00 p.m., an interview with the Administrator(ADM)and the Activity Director FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 11 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (AD). AD stated, she was in charge of taking the minutes for the meetings and attended with the administrator, as preferred by the council for support. However, the Social Director (SD) stated, the meetings were held 3/27/18 and 4/23/18, were attended by the Recreational Services Assistant (RSA). The ADM stated, the facility has a Grievance Officer. When ADM was asked if the residents were apprised of progress of the investigations toward a resolution of the residents' complaints, the ADM provided no further information. On 5/17/18 at 7:35 a.m., during an interview, the Dietary Supervisor (DS)was informed of the residents' complaints about the food served to the residents documented in the Resident Council minutes of the meetings dated 2/20/18, 3/27/18 and 4/23/18. The DS stated, she knew of the complaints last February and they tried to address the issue. If there were still complaints about the food temperature last March and April, their department was not informed about it. The DS stated she thought there were no more problems about the food temperature. On 5/17/18 at 7:50 a.m. during an interview, the RSA validated she was the one who attended the resident's last two month's council meeting in the absence of the AD. When informed that the DS did not receive the food complaints on the last two months of the Resident Council Meetings, the RSA stated, food complaints from the council meetings should have been forwarded to the dietary department so that the issue could be dealt with. The facility's undated policy and procedure titled, "Filing Grievance / Complaints" indicated, "Our Grievance Officer is responsible to oversee the grievance process FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 12 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and track grievances through to their conclusions and coordinate with state or federal officials as necessary. You can expect a final action or a status report on your grievance within 10 business days..."

F577 SS=C Right to Survey Results/Advocate Agency Info CFR(s): 483.10(g)(10)(11)

F577 06/19/2018 §483.10(g)(10) The resident has the right to(i) Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility; and (ii) Receive information from agencies acting as client advocates, and be afforded the opportunity to contact these agencies. §483.10(g)(11) The facility must-(i) Post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility. (ii) Have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request; and (iii) Post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public. (iv) The facility shall not make available identifying information about complainants or residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to post the results of the most recent abbreviated survey document titled, "Statement of Deficiencies" in a place readily accessible to residents and their FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 13 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE representatives. This failure had the potential to violate the rights of the residents and their representatives to be informed of abbreviated survey deficiencies and the facility's plan of correction. Findings: On 5/15/18 at 9:20 a.m., during an observation, a labeled "Survey Inspection" binder was located in a holder on the wall in the hallway. The binder contained the health recertification survey deficiencies and the life safety recertification survey deficiencies. There was no abbreviated survey document available. On 5/15/18 at 9:25 a.m., during a concurrent interview and record review, the Director of Nursing (DON) stated, "I don't see the complaint results in the binder. I would think it should be there." The facility policy and procedure titled, "Survey Results, Examination of" dated 4/07, indicated "...1. Copies of all survey reports (e.g., complaint...) along with approved plans of correction..for noted deficiencies, are on file in the administrative office..." The facility policy and procedure titled, "Resident Rights" dated 12/16, indicated "...1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to...w. examine survey results..."

F580 SS=D Notify of Changes (Injury/Decline/Room, etc.) CFR(s): 483.10(g)(14)(i)-(iv)(15) FORM CMS-2567(02-99) Previous Versions Obsolete

F580 Event ID: J3XY11 06/19/2018 Facility ID: CA030000072 If continuation sheet 14 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is(A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 15 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c) (9). This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to ensure resident's change of condition (COC), transfer to the hospital and death was immediately informed to the attending physician for 1 of 31 sampled resident (Resident 115). When Resident 115 was seen at 2 a.m. in his wheelchair, unresponsive, no palpable pulse and not breathing. This failure resulted in Resident 115's physician not being fully informed of his resident's medication condition. Findings: Resident 115's clinical record indicated , the resident was admitted to the facility on 1/12/18 with an admitting diagnosis of Hypoxemia (an abnormally low concentration of oxygen in the blood), Congestive Heart Failure (a heart condition that causes symptoms of shortness of breath, weakness, fatigue, and swelling of the legs, ankles, and feet)... Resident 115's progress notes dated 2/16/18 at 2:50 a.m., indicated the Resident 115 had no SOB ( Shortness of breath) and verbalized he would take his duoneb (inhalation solution used to prevent bronchospasm in people with chronic obstructive pulmonary disease). The progress note indicated the nurse was not administering the duoneb because the nurse believed the medication was making the resident nervous. "The resident was seen at 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 16 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE a.m., in his bed with Bilevel Positive Airway Pressure Bipap (a type of ventilator-a device that helps with breathing in place connected to the oxygen concentrator at 3 L/M (unit of measure). Resident 115 was seen at 2 a.m. in his wheelchair, unresponsive, no palpable pulse and not breathing. Nine one one (911) was notified, Cardio - Pulmonary Resuscitation (CPR) was initiated. Paramedics arrived at approximately 2:10 a.m. and CPR was continued and the resident was sent to the hospital at approximately 2:45 a.m. The resident's daughter and son were immediately notified and updated on the resident's medical status." At 3:30 a.m., the facility received a call from the hospital that the resident had expired. Resident 115's clinical record, indicated the resident's attending physician was not notified of the resident's change of condition (COC) on 2/16/18 or updated on the resident's subsequent hospitalization and death. On 5/18/18 at 9:30 a.m., during a concurrent record review and interview, the Medical Information Director (MID) reviewed the clinical record and was unable to find documentation of Resident 115's attending physician notification of Resident 115's COC and transfer to the hospital. The MID stated, there was no transfer discharge to the hospital documented in the resident's clinical record. The MID stated, there was no transfer discharge documented in this case because the 911 personnel were doing CPR and the resident was transferred immediately to the hospital. On 5/18/18 at 10 a.m., during an interview, the Director of Nursing (DON) stated when there is a change of condition of a resident or there is a need to transfer a resident to a hospital, the expectation would be that the RN would notify the resident's attending physician. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 17 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 5/18/18 at 10:43 a.m., during an interview, the Medical Director (MD- Resident 115's primary physician) stated he had expected the facility to have informed him of Resident 115's COC, transfer to the hospital and of the death. The MD stated, since he was not informed of the client's COC, hospitalization and death, there was no transfer discharge documented or included in the resident's clinical records. The facility's policy and procedure titled "Transfer or Discharge, Emergency", dated 9/2012 indicated, "Our facility shall make an emergency transfer or discharge when it is in the best interest of the resident... 1. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: a. Notify the resident's Attending Physician..."

F583 SS=D Personal Privacy/Confidentiality of Records CFR(s): 483.10(h)(1)-(3)(i)(ii)

F583 06/19/2018 §483.10(h) Privacy and Confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. §483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. §483.10(h)(2) The facility must respect the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 18 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service. §483.10(h)(3) The resident has a right to secure and confidential personal and medical records. (i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws. (ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law. This REQUIREMENT is not met as evidenced by: Based on observation, staff interview and record review, the facility failed to ensure the facility did not violate the right of the resident to personal privacy of his physical body and during the provision of his personal care for 1 of 10 random sampled residents (Resident 64) when: 1. Certified Nurse Assistant ( CNA) 5 exposed Resident 64's uncovered body in the hallway after his shower and dressing resident in front of the staff, residents passing by and a visitor watching. For Resident 64 , the facility failed to respect the resident's right to privacy during the provision of care and services which had resulted in the violation of the resident's right to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 19 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE be cared for in a manner and in an environment that honors the resident's privacy. Findings: On 5/15/18 at 9:02 a.m.,during an observation at the facility south hallway, Certified Nurse Assistant ( CNA) 5 wheeled Resident 64's wheelchair in the hallway and into his room with the resident's gown loosely tied up, exposing approximately 6-8 inches of the resident's back. On 5/15/18 at 9:32 a.m., during an interview, CNA 5 stated, the resident just had a shower and came out of the shower room. When CNA 5's attention was directed to the resident's exposed back, CNA 5 stated she should have placed another gown on the resident's back to keep the resident covered. On 5/15/18 at 9:34 a.m., during an observation, CNA 5 then, wheeled the resident's wheelchair inside the resident's room to dress the resident and closed the curtain. CNA 5 then, opened the curtain and wheeled and parked the resident's wheelchair in the resident's doorway. CNA 5 left the resident and came back, then put a pair of socks on the resident's feet in front of the staff, residents passing by and a visitor watching. On 5/15/18 at 9:45 a.m., during an interview, CNA 5 stated she should have put the resident's sock behind a closed curtain or she should have closed the resident's door to provide the resident with privacy. On 5/15/18 at 12:25 p.m., during an interview, Licensed Nurse (LN) 1 stated CNA 5 was expected to properly cover the resident's body after shower and during transport of the resident passing common areas and the public. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 20 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE LN 1 stated CNA 5 should have gathered all the resident's clothing prior to the resident's shower and putting the resident's socks or any of the resident's clothing in the privacy of the resident's room. On 5/15/18 at 12:35 p.m., during an interview, the Registered Nurse (RN) 1 stated she expected CNA 5 to bring the resident all the way back to his room and to finish providing care to the resident with privacy. The facility's policy and procedure titled,"Quality of Life-Dignity" dated 8/2009 indicated," 10. Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures." The facility's policy and procedure titled,"Confidentiality of Information and Personal Privacy,"dated 4/2017 indicated,"Our facility will protect and safeguard resident ... personal privacy."

F584 SS=E Safe/Clean/Comfortable/Homelike Environment F584 CFR(s): 483.10(i)(1)-(7) 06/19/2018 §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 21 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; §483.10(i)(3) Clean bed and bath linens that are in good condition; §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2) (iv); §483.10(i)(5) Adequate and comfortable lighting levels in all areas; §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and §483.10(i)(7) For the maintenance of comfortable sound levels. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to maintain an orderly environment for four of 52 bedrooms (Rooms 42, 43, 44 and 45) when: 1. Room 43's bedroom trash can was without a liner. 2. Peri Wipes laid on top of the bedside table and the residents bed in Rooms 42, 43, 44 and 45. These failures resulted in a disorderly and unhomelike environment for the residents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 22 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: 1. On 5/15/18 at 8:09 a.m., during an observation in Room 43, a trash can did not have a liner and had trash inside. On 5/15/18 at 8:11 a.m., during a concurrent observation and interview in Room 43, Certified Nursing Assistant (CNA) 14 stated, "There should be a liner in every trash container." On 5/15/18 at 11:32 a.m., during an interview, the Director of Staff Development (DSD) stated, "The liners in the trash is housekeeping responsibility." On 5/18/18 at 11:57 a.m., during an interview, the License Nurse Unit Manager stated, when housekeeping leaves, it is the CNA's [Certified Nursing Assistants] duty to put a liner in the trash can." 2. On 5/15/18 at 8:10 a.m., during an observation in Room 42, there was an open peri wipes container that laid on top of the bedside table. On 5/15/18 at 8:10 a.m., during an observation in Room 44, there were two open peri wipes containers that laid on top of the night stand. On 5/15/18 at 8:11 a.m., during a concurrent observation and interview, peri wipes laid on top of the night stand. CNA 14 stated, "The wipes should be in the closet. I don't know why it's in here [on top of the night stand]." On 5/15/18 at 8:15 a.m., during an observation in Room 45, there were two open peri wipes container that laid on top of the bedside table. CNA 15 stated, " It (the Peri-Wipes) should be inside the closet, not outside." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 23 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 5/15/18 at 11:32 a.m., during an interview, the DSD stated, "The wipes should be put back in the closet right away, after they use it." The facility policy and procedure titled, "Quality of Life- Homelike Environment" dated 5/17, indicated "Policy Statement: Residents are provided with a safe, clean, comfortable and homelike environment... 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary and orderly environment..."

F604 SS=E Right to be Free from Physical Restraints CFR(s): 483.10(e)(1), 483.12(a)(2)

F604 06/19/2018 §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2). §483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility mustFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 24 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure four of 31 sampled residents (Resident 29, Resident 89, Resident 42 and Resident 71) and one of 15 random residents (Resident 4) were free from physical restraints when: 1. Resident 29, Resident 89, Resident 42, Resident 71, and Resident 4 had a position change alarm (wheelchair alarm) (alerting devices intended to monitor a resident's movement that emits an audible loud sound when the resident moves) in place without a physician's order, no medical justification, no consent was obtained from the resident or resident's responsible party and no assessment or evaluation was done to determine the need for the wheelchair alarm. These failures resulted in: 1. Resident 29 felt angry when the position change alarm [wheelchair alarm] emitted a loud audible sound every time she moved which restricted her movement. 2. Resident 89 felt irritated when the position change alarm [wheelchair alarm] emitted a loud audible sound every time he moved. 3. Resident 42 felt irritated when the position change alarm [wheelchair alarm] emitted a loud audible sound every time she moved." 4. Resident 71 to have a position change alarm [bed alarm] without assessment or evaluation FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 25 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE of the need to have a bed alarm. 5. Resident 4 relied on the position change alarm [bed alarm] to seek assistance from staff members. Findings: 1. Resident 29's Minimum Data Set (MDS- an assessment tool used to identify resident function and needs) dated 3/1/18, indicated Resident 29 required extensive assistance from one staff member to transfer from one surface to another. The MDS also indicated on the Brief Interview Mental Status, (BIMSassessment of cognitive status) a score of 6 out of 15 which indicated severe cognitive impairment. On 5/15/18 at 10:30 a.m., during an observation in Resident 29's room, Resident 29 was sitting on her wheelchair with a wheelchair alarm in place. On 5/15/18 at 3:42 p.m., during an interview, the Minimum Data Set (MDS) coordinator stated, "The consultant said that we don't need an order for alarms. It's just a nursing measure." On 5/16/18 at 8:30 a.m., during a concurrent observation and interview, Resident 29 sat in her wheelchair with the wheelchair alarm placed on the back of the wheelchair in the "on" position. Resident 29 stated, "I hear it all the time. It makes me so nervous. I don't like it. The staff tells me I need it. What can I do. It goes off all the time. Every time I move, it makes a noisy sound. They [facility staff] did not explain to me what it was for. They just put it in there [at the back of the wheelchair]. It makes me feel angry. I feel like I can't move. This thing [wheelchair alarm] has been here for a long time as far as I can remember." On 5/16/18 at 9:11 a.m., during an interview, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 26 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE LN 1 stated, "I have been working here for a year and a half. The admit [admission] nurse determines if they have a fall, we give them an alarm. I will notify the CNA's [Certified Nursing Assistants] if the resident needs an alarm. The bed alarm and the wheelchair alarm notify us if they want to get up or if they need help. They [the residents] get agitated. I see it limits their movement then it becomes a restraint. The DSD [Director of Staff Development] gives us [facility staff] inservice on bed alarms but she did not tell us it is a restraint." On 5/16/18 at 9:21 a.m., during an interview, LN 9 stated, "The IDT [Interdisciplinary Team] determines [when residents have a history of falls] if a resident requires a bed alarm. The nurse in the IDT or the nurse assigned to the resident will notify the doctor and get a doctor's order for the alarm. I did not get inserviced by the DSD about alarms [wheelchair and bed alarm]. I don't know about the others [staff]. If it inhibits the resident's movement then it will be considered as a mental restraint." On 5/16/18 at 9:30 a.m., during an interview, Registered Nurse (RN) 1 stated, "Nursing is responsible for notifying the doctor if residents needs alarm [wheelchair and bed alarm]. For the staff, the alarms tell us if the resident is ambulating or out of wheelchair. It tells the resident they are not supposed to stand up. If the resident feels annoyed with the sound [the bed and chair alarms emitting a loud sound] then it's a possible restraint." Review of Resident 29's clinical record indicated a physician's order was not obtained prior to placement of the wheelchair alarm. No consent was obtained from the resident or her responsible party and no assessment or evaluation was done to determine the need for Resident 29's wheelchair alarm. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 27 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2. Resident 89's face sheet (a document containing resident profile information) indicated Resident 89 was admitted to the facility on 1/12/18, with diagnoses of muscle weakness and difficulty in walking. Resident 89's admission MDS assessment dated 1/19/18, indicated Resident 89's BIMS score of 15 out of 15, which indicated no cognitive impairment. On 5/15/18 at 10:00 a.m., during an observation in the north hallway, Resident 89 was sitting in his wheelchair with a wheelchair alarm in place. On 5/15/18 at 3:42 p.m., during an interview, the MDS coordinator stated, "The consultant said that we don't need an order for alarms. It's just a nursing measure." On 5/16/18 at 8:43 a.m., during a concurrent observation and interview, Resident 89 was sitting in his wheelchair with a wheelchair alarm in place. Resident 89 stated, "I don't know why I have this machine that beeps. It makes a lot of noise. I feel like I want to get it and take it off. They did not even tell me what it's for. They just put it there. It makes me irritated." On 5/16/18 at 9:11 a.m., during an interview, LN 1 stated, "I have been working here for a year and a half. The admit [admission] nurse determines if they have a fall, we give them an alarm. I will notify the CNA's [Certified Nursing Assistants] if the resident needs an alarm. The bed alarm and the wheelchair alarm notify us if they want to get up or if they need help. They [the residents] get agitated. I see it limits their movement then it becomes a restraint. The DSD [Director of Staff Development] gives us [facility staff] inservice on bed alarms but she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 28 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE did not tell us it is a restraint." On 5/16/18 at 9:21 a.m., during an interview, LN 9 stated, "The IDT [Interdisciplinary Team] determines if a resident requires a bed alarm. The nurse in the IDT or the nurse assigned to the resident will notify the doctor and get a doctor's order for the alarm. I did not get inserviced by the DSD about alarms [wheelchair and bed alarm]. I don't know about the others [staff]. If it inhibits the resident's movement then it will be considered as a mental restraint." On 5/16/18 at 9:30 a.m., during an interview, RN 1 stated, "Nursing is responsible for notifying the doctor if resident's needs alarm [wheelchair and bed alarm]. For the staff, the alarms tell us if the resident is ambulating or out of wheelchair. It tells the resident they are not supposed to stand up. If the resident feels annoyed with the sound [the bed and chair alarms emitting a loud sound] then it's a possible restraint." Review of Resident 89's clinical record indicated no physician's order was obtained prior to placement of the wheelchair alarm. No consent was obtained from the resident or her responsible party and no assessment or evaluation was done to determine the need for Resident 89's wheelchair alarm. 3. Resident 42's face sheet indicated Resident 42 was admitted to the facility on 9/9/17 with diagnoses of schizophrenia (mental illness characterized by illogical thoughts, bizarre behavior and speech, and delusions or hallucinations, such as hearing voices) and history of falling. Review of Resident 42's admission MDS assessment dated 3/14/18 indicated a BIMS FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 29 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE score of 12 out of 15 points which indicated resident has moderate cognitive impairment. The MDS also indicated Resident 42 required extensive assistance of one staff member to transfer from one surface to another. On 5/15/18 at 8:00 a.m., during an observation in Resident 42's room, Resident 42 was sitting in her wheelchair and the wheelchair alarm was at the back of Resident 42's wheelchair. On 5/16/18 at 8:42 a.m., during a concurrent observation and interview in Resident 42's room, Resident 42 stated, "I don't like this [wheelchair alarm]. It makes a lot of noise." On 5/15/18 at 3:42 p.m., during an interview, the MDS coordinator stated, "The consultant said that we don't need an order for alarms. It's just a nursing measure." On 5/16/18 at 9:11 a.m., during an interview, LN 1 stated, "I have been working here for a year and a half. The admit [admission] nurse determines if they have a fall, we give them an alarm. I will notify the CNA's [Certified Nursing Assistants] if the resident needs an alarm. The bed alarm and the wheelchair alarm notify us if they want to get up or if they need help. They [the residents] get agitated. I see it limits their movement then it becomes a restraint. The DSD [Director of Staff Development] gives us [facility staff] inservice on bed alarms but she did not tell us it is a restraint." On 5/16/18 at 9:21 a.m., during an interview, LN 9 stated, "The IDT [Interdisciplinary Team] determines if a resident requires a bed alarm. The nurse in the IDT or the nurse assigned to the resident will notify the doctor and get a doctor's order for the alarm. I did not get inserviced by the DSD about alarms [wheelchair and bed alarm]. I don't know about FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 30 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the others [staff]. If it inhibits the resident's movement then it will be considered as a mental restraint." On 5/16/18 at 9:30 a.m., during an interview, RN 1 stated, "Nursing is responsible for notifying the doctor if residents needs alarm [wheelchair and bed alarm]. For the staff, the alarms tell us if the resident is ambulating or out of wheelchair. It tells the resident they are not supposed to stand up. If the resident feels annoyed with the sound [the bed and chair alarms emitting a loud signal] then it's a possible restraint." Review of Resident 42's clinical record indicated no physician's order was obtained prior to placement of the wheelchair alarm. No consent was obtained from the resident or her responsible party and no assessment or evaluation was done to determine the need for Resident 42's wheelchair alarm. 4. Resident 71's face sheet indicated Resident 71 was admitted to the facility on 12/27/16 with diagnoses of difficulty in walking, muscle weakness and anxiety disorder. Review of Resident 71's MDS assessment dated 4/5/18, indicated a BIMS score of 2 out of 15 points which indicated Resident 71 had severe cognitive impairment. The MDS also indicated Resident 71 required extensive assistance of one staff member to transfer from one surface to another. On 5/15/18 at 3:28 p.m., during a concurrent observation and interview in Resident 71's room, Resident 71 was sleeping and a bed alarm was in place and was in the "on" position. Certified Nursing Assistant (CNA) 16 stated, "She [Resident 71] will try to get up before. She [Resident 71] fell before. She FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 31 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE always had an alarm [bed alarm]." On 5/15/18 at 3:24 p.m., during a concurrent interview and record review, LN 5 stated, "She [Resident 71] tries to get up. She [Resident 71] has an alarm in the bed and wheelchair. Usually we do a fall risk assessment and care plan. I could not find an order for a bed alarm. There should be an order for a bed alarm." On 5/15/18 at 3:42 p.m., during an interview, the MDS coordinator stated, "The consultant said that we don't need an order for alarms. It's just a nursing measure." On 5/16/18 at 9:11 a.m., during an interview, LN 1 stated, "I have been working here for a year and a half. The admit [admission] nurse determines if they have a fall, we give them an alarm. I will notify the CNA's [Certified Nursing Assistants] if the resident needs an alarm. The bed alarm and the wheelchair alarm notify us if they want to get up or if they need help. They [the residents] get agitated. I see it limits their movement then it becomes a restraint. The DSD [Director of Staff Development] gives us [facility staff] inservice on bed alarms but she did not tell us it is a restraint." On 5/16/18 at 9:21 a.m., during an interview, LN 9 stated, "The IDT [Interdisciplinary Team] determines if a resident requires a bed alarm. The nurse in the IDT or the nurse assigned to the resident will notify the doctor and get a doctor's order for the alarm. I did not get inserviced by the DSD about alarms [wheelchair and bed alarm]. I don't know about the others [staff]. If it inhibits the resident's movement then it will be considered as a mental restraint." On 5/16/18 at 9:30 a.m., during an interview, RN 1 stated, "Nursing is responsible for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 32 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE notifying the doctor if residents needs alarm [wheelchair and bed alarm]. For the staff, the alarms tell us if the resident is ambulating or out of wheelchair. It tells the resident they are not supposed to stand up. If the resident feels annoyed with the sound [the bed and chair alarms emitting a loud signal] then it's a possible restraint." Review of Resident 71's clinical record indicated no physician's order was obtained prior to placement of the wheelchair alarm. No consent was obtained from the resident or her responsible party and no assessment or evaluation was done to determine the need for Resident 71's bed alarm. Review of Resident 71's progress notes dated 5/16/18, indicated Resident 71 had an unwitnessed fall. The progress notes also indicated, "...The alarm is not reducing her falls nor is it helping her not to fall..." 5. Resident 4's face sheet indicated Resident 4 was admitted to the facility on 11/11/16 with diagnoses of repeated falls and muscle weakness. Review of Resident 4's MDS assessment dated 4/26/18 indicated a BIMS score of 4 out of 15 points which indicated Resident 4 had severe cognitive impairment. The MDS also indicated Resident 4 required extensive assistance of two staff members to transfer from one surface to another. On 5/15/18 at 10:30 a.m., during an observation in Resident 4's room, Resident 4 laid on her bed and the bed alarm was in the "on" position. On 5/15/18 at 3:42 p.m., during an interview, the MDS coordinator stated, "The consultant said that we don't need an order for alarms. It's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 33 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE just a nursing measure." On 5/15/18 at 3:58 p.m., during an interview, the Director of Nursing (DON) stated she did not know alarms could be considered a restraint. The DON was unable to provide documentation of a physician's order, no medical justification, no consent was obtained from the resident or resident's responsible party and no assessment for the alarms. On 5/15/18 at 3:58 p.m., during an interview, the Administrator (ADM) stated, "We don't consider alarms a restraint. We consider it as safety." On 5/16/18 at 3:03 a.m., during a concurrent observation and interview, Resident 4 laid on her bed and a bed alarm was in place and was in the "on" position. Resident 4 stated, "This beeping device [bed alarm] that makes a really loud sound, I know I am gonna get help that's what I know so I try to get up to get their attention. If they don't hear this sound I won't get the help I need. I use the alarm to get help. They don't do rounds." On 5/16/18 at 8:14 a.m., during an interview, CNA 14 stated, "She [Resident 4] yells hey, hey if she needs help. She [Resident 4] never uses the call light. She [Resident 4] tries to stand up then her alarm will sound then we go to her room. She does that to get our attention." Review of Resident 4's clinical record indicated no physician's order was obtained prior to placement of the wheelchair alarm. No consent was obtained from the resident or her responsible party and no assessment or evaluation was done to determine the need for Resident 4's bed alarm. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 34 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 5/16/18 at 9:11 a.m., during an interview, LN 1 stated, "I have been working here for a year and a half. The admit [admission] nurse determines if they have a fall, we give them an alarm. I will notify the CNA's [Certified Nursing Assistants] if the resident needs an alarm. The bed alarm and the wheelchair alarm notify us if they want to get up or if they need help. They [the residents] get agitated. I see it limits their movement then it becomes a restraint. The DSD [Director of Staff Development] gives us [facility staff] inservice on bed alarms but she did not tell us it is a restraint." On 5/16/18 at 9:21 a.m., during an interview, LN 9 stated, "The IDT [Interdisciplinary Team] determines if a resident requires a bed alarm. The nurse in the IDT or the nurse assigned to the resident will notify the doctor and get a doctor's order for the alarm. I did not get inserviced by the DSD about alarms [wheelchair and bed alarm]. I don't know about the others [staff]. If it inhibits the resident's movement then it will be considered as a mental restraint." On 5/16/18 at 9:30 a.m., during an interview, RN 1 stated, "Nursing is responsible for notifying the doctor if residents needs alarm [wheelchair and bed alarm]. For the staff, the alarms tell us if the resident is ambulating or out of wheelchair. It tells the resident they are not supposed to stand up. If the resident feels annoyed with the sound [the bed and chair alarms emitting a loud signal] then it's a possible restraint." On 5/16/18 at 10:00 a.m., during an interview, the DSD stated, "It [bed and chair alarms] reminds them not to get up without assistance. It's for safety. How are we going to make sure residents are safe if we don't put alarms." The DSD was unable to provide documentation of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 35 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ongoing evaluation for the use of the alarms. On 5/16/18 at 11:00 a.m., during an interview, the Regional Nurse Consultant (RNC) stated, "Alarms are not consider restraints ... it could potentially be a restraint. It's not a restraint. It does not need a doctor's orders. It's use for safety." The RNC was unable to find documentaion of a physician's order, no medical justification, no consent was obtained from the resident or resident's responsible party and no assessment for the use of the alarms. The facility policy and procedure titled, "Use of Restraints" dated 10/07, indicated "... 1. Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement... 5. Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention and a restraint is required to: a. Treat the medical symptom... 6. Prior to placing a resident is restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine the possible underlying causes of the problematic medical symptom...9. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: 1. The specific reason for the restraint (as it relates to the resident's medical symptom); b. How the restraint will be used to benefit the resident's medical symptom; and c. The type of restraint, and period of time for the use of restraint... 11. Orders for restraints will not be enforced for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 36 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE longer than twelve (12) hours, unless the resident's condition requires continues treatment..." The facility policy and procedure titled "Resident Rights" dated 12/16, indicated "... 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to...d. be free from...physical...restraints not required to treat the resident's symptoms..."

F641 SS=D Accuracy of Assessments CFR(s): 483.20(g)

F641 06/19/2018 §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS) (a resident assessment tool used to identify resident care needs) assessment accurately reflected the resident's status for one of 31 sampled residents (Resident 89) when the use of a wheelchair alarm was not coded in Section P (section for alarms and restraint use) of Resident 89's admission and quarterly assessment. This failure resulted in an inaccurate assessment of Resident 89's MDS assessment and had the potential to result in Resident 89's care needs to not be met. Findings: Resident 89's face sheet (a document containing resident profile information) indicated Resident 89 was admitted to the facility on 1/12/18 with diagnoses of muscle weakness and difficulty in walking. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 37 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of Resident 89's admission MDS assessment dated 1/19/18, indicated Resident 89's Brief Interview for Mental Status (BIMS) (assessment of cognitive status) score of 15 out of 15, which indicated no cognitive impairment. The admission MDS assessment section P did not indicate any restraints or alarms used for Resident 89. Review of Resident 89's quarterly MDS assessment section P dated 4/16/18, did not indicate any alarms or restraints used for Resident 89. On 5/15/18 at 10:00 a.m., during an observation in the north hallway, Resident 89 was sitting in his wheelchair with a wheelchair alarm in place. On 5/16/18 at 8:43 a.m., during a concurrent observation and interview, Resident 89 was sitting in his wheelchair with a wheelchair alarm in place. Resident 89 stated, "I don't know why I have this machine that beeps. It makes a lot of noise. I feel like I want to get it and take it off. They did not even tell me what it's for. They just put it there. It makes me irritated." On 5/17/18 at 9:10 a.m., during an interview, Certified Nursing Assistant (CNA) 3 stated, "He has been here for quite some time. He always had that chair alarm." On 5/17/18 at 9:14 a.m., during a concurrent interview and record review, Licensed Nurse (LN) 10 stated, "He [Resident 89] always had it since he transferred from the other side. He [Resident 89] gets up by himself and had fallen that's why he has the alarm. Nursing determines if they fall, we talk to the family and the resident that they need an alarm. It should be in the care plan, I don't know why its not and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 38 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the doctor should be notified to get an order for the alarm." On 5/17/18 at 9:35 a.m., during an interview, LNUM stated, "[The alarm] it is not coded in the MDS. I don't know why but it should be [coded] in the MDS. I don't why I did not code it." On 5/17/18 at 11:39 a.m., during an interview, the MDS coordinator stated, "I went back today at the resident's [Resident 89] progress notes. I did see one progress note that there was a chair alarm. I didn't see it [chair alarm]. I didn't heard it went off that's why its not coded." On 5/18/18 at 8:20 a.m., during an interview, the Director of Nursing stated, "I expect her [MDS Coordinator] to see and assess the resident, that's why it's call an assessment not chart review because you are gathering data." The facility policy and procedure titled, "Resident Assessment" dated 11/17, indicated "... 2. The facility will use resident observation and communication as the primary source when completing the RAI [Resident Assessment Instrument, MDS]. Additionally, record review, communication with staff and other sources may include the resident's physician, resident's representative, family members or others, as needed, will be used... 7. The results of the assessment will be used to develop, review and revise the resident's comprehensive care plan..."

F656 SS=E Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 06/19/2018 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 39 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 40 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person centered care plan for two of 31 sampled residents (Resident 33 and Resident 89) when: 1. Resident 33 did not have an individualized activities care plan to identify listening to music as his activity preference. 2. Resident 89's wheelchair alarm was not identified in the care plan. These failures placed Resident 33 at risk of inappropriate activities resulting in possible decreased psychosocial well being and Resident 89's care needs to not be met. Findings: 1. Resident 33's face sheet (a document containing resident profile information) indicated Resident 33 was admitted to the facility on 6/12/17 with diagnoses of major depressive disorder (a mental health disorder characterized by depressed mood or loss of interest in activities), single episode, unspecified and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), unspecified. On 5/16/18 at 8:20 a.m., during an interview, Resident 33 stated he likes to listen to music. Resident 33 stated he did not like to go to activities. On 5/17/18 at 9:34 a.m., during an interview and concurrent record review, the AD stated activities is reviewed during care conferences on 3/7/18. The AD stated she was aware of the music he enjoys, but it was not on the care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 41 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE plan. The AD stated not putting the resident's likes can result in the CNA's (Certified Nursing Assistants) not knowing what to do for the resident when he is in his room. The AD reviewed the activities care plan dated 6/16/17, "The resident is independent/dependent on staff for meeting emotional, intellectual, physical, and social needs r/t Schizophrenia (a mental disorder that affects how a person thinks, feels, and behaves)." The AD stated there was no care plan interventions indicating resident's music preferences for activities. 2. Resident 89's face sheet indicated Resident 89 was admitted to the facility on 1/12/18 with diagnoses of muscle weakness and difficulty in walking. Resident 89's admission Minimum Data Set (MDS- an assessment tool used to identify resident function and needs) assessment dated 1/19/18 indicated Resident 89's Brief Interview for Mental Status (BIMS) (assessment of cognitive status) score of 15 out of 15, which indicated no cognitive impairment. On 5/15/18 at 10:00 a.m., during an observation in the north hallway, Resident 89 was sitting in his wheelchair with a wheelchair alarm in place. On 5/16/18 at 8:43 a.m., during a concurrent observation and interview, Resident 89 was sitting in his wheelchair with a wheelchair alarm in place. Resident 89 stated, "I don't know why I have this machine that beeps. It makes a lot of noise. I feel like I want to get it and take it off. They did not even tell me what it's for. They just put it there. It makes me irritated." On 5/17/18 at 9:10 a.m., during an interview, Certified Nursing Assistant (CNA) 3 stated, "He has been here for quite some time. He always FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 42 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE had that chair alarm." On 5/17/18 at 9:14 a.m., during a concurrent interview and record review, Licensed Nurse (LN) 10 stated, "He [Resident 89] always had it since he transferred from the other side. He [Resident 89] gets up by himself and had fallen that's why he has the alarm. Nursing determines if they fall, we talk to the family and the resident that they need an alarm. It should be in the care plan, I don't know why it's not." On 5/17/18 at 9:35 a.m., during an interview, LNUM stated, "There is no care plan for the alarm. I don't know why but it should be in the care plan." The facility policy and procedure titled, "Comprehensive Care Plans" dated 11/17, indicated "Purpose: To provide each resident with a person-centered, comprehensive care plan to address the resident's medical, nursing, physical, mental and psychosocial needs. Policy: The facility Interdisciplinary Team (IDT) will develop and implement a comprehensive, person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, physical, mental, and psychosocial needs that are identified in the comprehensive assessment. Guidelines: 1. The care plan will be comprehensive and person-centered. It will drive the type of care and services that a resident receives and will describe the resident's medical, nursing, physical, mental and psychosocial needs and preferences; as well as how the facility will assist in meeting these needs and preferences... 3. The comprehensive care plan will be reviewed and revised by the IDT following both comprehensive and quarterly review assessments... 9. The MDS will be used to assess the resident's clinical condition, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 43 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE cognitive and functional status and use of services in developing the comprehensive care plan..."

F657 SS=E Care Plan Timing and Revision CFR(s): 483.21(b)(2)(i)-(iii)

F657 06/19/2018 §483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be(i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-(A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 44 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on observation, interview, and record review, the facility failed to timely revise and implement a person centered comprehensive care plan for two of 31 sampled residents (Resident 71 and Resident 72) when: 1. Resident 72's enteral nutrition (nutrition provided through a feeding tube into the stomach) care plan interventions indicating the feeding times did not match the physician's order. 2. Resident 71 sustained a fall and no new interventions were documented in the care plan. These failures had the potential to result in Resident 72 to receive inaccurate doses of his enteral nutrition and for Resident 71 to sustain reoccurring falls and at risk for not having her care needs met. Findings: 1. On 5/17/18 at 2:27 p.m., during a concurrent interview and record review, Licensed Nurse (LN) 3 stated the enteral nutrition order for Resident 72 was for Fibersource HN 1.2 at 90 cc (cubic centimeter)/hr (hour) x 20 hours. LN 3 stated the enteral feeding is turned off at 8 a.m. and turned on at 12 p.m. LN 3 stated the timing is on her nursing notes she uses during report. LN 3 stated she is not able to find the on and off timings for the enteral nutrition in the order. LN 3 stated she did not know why the timings are not in the order and it should be. On 5/17/18 at 2:39 p.m., during an interview and concurrent record review, LN 4 reviewed the enteral nutrition order. LN 4 stated, "It's not here. It should be on the orders. If it doesn't show on the eMAR (electronic medication FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 45 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE administration record), the nurses wouldn't know." LN 4 stated the care plan was not updated to specify the total amount of hours the enteral nutrition should be given to Resident 72. On 5/17/18 at 3:28 p.m., during an interview and concurrent record review, the Director of Nursing (DON) stated the on and off times for the enteral nutrition was not in the physician's order. The DON reviewed the care plan for the enteral nutrition and stated the care plan was initiated on 1/14/18. The DON stated, "I did that care plan." The care plan intervention dated 1/14/18, indicated "Enteral Nutrition: Fibersource HN 1.2 formula @ 90 mL/Hr. x 20 hrs/day via pump via PEG (Percutaneous Endoscopic Gastrostomy, a flexible feeding tube placed in the stomach for nutrition) to administer 1800mL/2160 kcals in 24 hours. On @ 1400 Off @ 1000 or until daily dosage is met." The DON stated if the nurse had seen the care plan, it would have been done at a wrong time." Review of the MAR dated 5/1/2018-5/31/2018, indicated "Enteral Feed Order every shift Fibersourc[e] HN 1.2 @ 90cc/hr x 20 hours with total volume 1800cc & flush with 100cc H2o Q 4hours " with start date 4/9/18 at 1400. The facility policy and procedure titled "Enteral Tube Feeding via Continuous Pump" dated March 2015, indicated "Preparation 1. Verify that there is a physician's order for this procedure. 2. Review the resident's care plan and provide for any special needs for resident ...General Guidelines 5. Refer to facility procedures for hang times and administration set changes." 2. Resident 71's "Progress Notes" dated 5/17/18, at 3:50 p.m., indicated "Resident [71] FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 46 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE was hollering out and crying and trying to climb out of bed. Resident has been agitated and very confused. Staff was able to calm her down and resident was sleeping in her bed ... staff had left the room for 3-5 minutes and when [staff] returned, resident was on her knees, on the floor next to the bed ...No visible injuries and no complaints of pain." On 05/18/18 at 7:52 a.m., during a concurrent observation and interview, Resident 71 laid in her bed and was asleep. The Hospice Home Health Aide (HHHA) stated, "She always had those [landing pad]. You can call it a landing pad and landing strip. She always had it since she started falling." The HHHA stated she was not aware of a new intervention to help prevent Resident 71 from falling. On 5/18/18 at 7:53 a.m., during a concurrent observation and interview, Certified Nursing Assistant (CNA) 14 stated, "She [Resident 71] always had it. Landing pad and landing strip is the same. She always had it because she keeps falling." CNA 14 stated Resident 71 did not have new interventions to help prevent her from falling. On 5/18/18 at 7:52 a.m., during a concurrent interview and record review, the License Nurse Unit Manager stated, There is no new intervention. The nurse is responsible if the resident falls on her shift to update the care plan. IDT [Interdisciplinary team] will go over the fall the next day but we haven't had a chance to have an IDT meeting." On 5/18/18 at 8:20 a.m., during an interview, the Director of Nursing stated, "The nurses need to do an actual fall care plan, update the fall assessment, update the care plan with new interventions. I don't know why she did not update the care plan." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 47 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The facility policy and procedure titled, "Comprehensive Care Plans" dated 11/17 indicated, Purpose: To provide each resident with a person-centered, comprehensive care plan to address the resident's medical, nursing, physical, mental and psychosocial needs."

F658 SS=E Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i)

F658 06/19/2018 §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide services which met professional standards of quality when Licensed Nurse (LN) 13 did not follow the facility's "Administering Medications" policy and procedure, when LN 13 stored the medication inside the medication cart after Resident 77 refused the medications and documented in the medication administration record that Resident 77 took the medications. This failure had the potential to result in medications being administered to the wrong resident and the medications not being administered in a timely manner. Findings: On 5/15/18 at 11:11 a.m., during a concurrent observation, interview and record review at the facility's south medication cart, Licensed Nurse FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 48 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (LN) 1 opened the medication cart and several pills were in a plastic medication cup with resident's name (Resident 77) written. LN 13 stated, "It's for the Resident [Resident 77]. She refused her meds [medications] this morning. She usually takes it [medications]. She only took the Zofran [a medication to prevent nausea and vomiting] and Buspar [a medication to treat anxiety]." LN 13 opened the medication administration record (MAR) in the computer and indicated that all 8 a.m. medications were signed indicating Resident 77 took it. LN 13 stated Resident 77 did not take her medications and she documented in the MAR that Resident 77 took all her medication which was wrong for her to do. LN 13 stated "I should have discarded it [medications] a while ago." On 5/15/18 at 11:32 a.m., during an interview, the Director of Nursing stated, "That's not the practice. They [Licensed Nurses] should not be keeping meds [medications] in cart [medication cart]. When you sign it, that means you administer it. She [LN 13] has to notify the physician after 9:00 a.m. [that the medications were refused by the resident]." The DON stated the medications ordered to be administered at 8 a.m. and are considered late administration if given after 9 a.m. She stated LN 13 did not follow the facility medication administration policy. The facility policy and procedure titled "Administering Medications" dated 12/12 indicated, "Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed...3. Medications must be administered in accordance with the orders, including any required time frame...18. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 49 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE circle the MAR space provided for that drug and dose...20. As required or indicated for a medication, the individual administering the medication will record in the resident's medical record: a. The date and time the medication was administered..."

F660 SS=G Discharge Planning Process CFR(s): 483.21(c)(1)(i)-(ix)

F660 08/15/2018 §483.21(c)(1) Discharge Planning Process The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to postdischarge care, and the reduction of factors leading to preventable readmissions. The facility's discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and(i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident. (ii) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. (iii) Involve the interdisciplinary team, as defined by §483.21(b)(2)(ii), in the ongoing process of developing the discharge plan. (iv) Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs. (v) Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan. (vi) Address the resident's goals of care and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 50 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE treatment preferences. (vii) Document that a resident has been asked about their interest in receiving information regarding returning to the community. (A) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose. (B) Facilities must update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities. (C) If discharge to the community is determined to not be feasible, the facility must document who made the determination and why. (viii) For residents who are transferred to another SNF or who are discharged to a HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a postacute care provider by using data that includes, but is not limited to SNF, HHA, IRF, or LTCH standardized patient assessment data, data on quality measures, and data on resource use to the extent the data is available. The facility must ensure that the post-acute care standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident's goals of care and treatment preferences. (ix) Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 51 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to identify discharge needs and develop a discharge care plan for one of 31 sampled residents, (Resident 565) when Resident 565 was discharged to a board and care home without ensuring the board and care home was capable of meeting Resident 565's needs. The facility Interdisciplinary Team (IDT, a team of healthcare providers who meet to plan resident care) did not meet to evaluate Resident 565's need for a safe discharge. Resident 565 was discharged to the board and care home which could not provide Resident 565 with required assistance for bathing and grooming. Resident 565 was transferred without adequate discharge planning, discharge teaching or emotional preparation. As a result of these failures, Resident 565 was not provided with necessary assistance to meet her hygiene and bathing needs and suffered from emotional distress from lack of planning and preparation. Findings: Resident 565's clinical record titled, "Face Sheet (record containing resident personal information)" indicated Resident 565 was a 54 year old female who was admitted to the Skilled Nursing Facility (SNF) on 10/18/17. The "Face Sheet" indicated Resident 565 had diagnoses that included Hemiplegia (paralysis of one side of the body) affecting the left side, Pain and Weakness. The "Face Sheet" indicated Resident 565 was discharged on 3/26/18 to "Private home/apt." Resident 565's clinical record titled, "Minimum Data Set (MDS, an assessment tool used to plan resident care) Assessment" dated 3/26/18 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 52 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (date of discharge), indicated Resident 565 had moderate cognitive (pertaining to memory, reasoning and judgement) impairment and required extensive staff assistance for bed mobility (turning side to side and repositioning), dressing, toilet use, personal hygiene (combing hair, brushing teeth) and was totally dependent on staff assistance for bathing. The MDS indicated Resident 565 had not walked in her room in the 7 days prior to discharge. On 4/19/18 at 9:10 a.m., during an interview, the facility Administrator (Adm) stated the facility was notified by Medi-Cal that Resident 565 would no longer be covered [Medi-Cal would no longer pay for Resident 565's stay in the SNF] effective November 2018. The Adm stated the facility used a placement agency (PA) to find a facility that would accept Resident 565 and the PA arranged placement at the board and care home. The Adm stated the maintenance staff and social services staff drove Resident 565 to the board and care home on 3/26/18 in the facility bus. The Adm stated she thought Resident 565 would "do fine" in the board and care home. The Adm stated, "I did not know that she needs help with hygiene and showers." On 4/19/18 at 9:23 a.m., during an interview, the Assistant Social Services Director (ASSD) stated, "Medi-Cal will not renew [Resident 565] benefit so we needed to find her a place. Her coverage ends in November of this year." The ASSD stated shortly after the facility found out Resident 565's Medi-Cal coverage would end, the PA notified the facility that a board and care was available and someone would come out to speak to Resident 565. The ASSD stated, "I guess a guy came in and evaluated [Resident 565]. I didn't get to meet the guy from that board and care place. [Resident 565] and her roommate both said a guy came in." The ASSD FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 53 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE stated, "I didn't have a good feeling about it [the discharge to board and care]. [Resident 565] had a stroke and so I can see why she would need help with her shower. [Resident 565] was surprised she was accepted [by the board and care] with her left sided paralysis. She was low income. She was getting $800 monthly so she didn't have many options for places to go to." On 4/19/18 at 10:13 a.m., during an interview, Certified Nursing Assistant (CNA) 6 stated she was the CNA regularly assigned to provide care to Resident 565 while she was in the SNF. CNA 6 stated Resident 565 was wheelchair bound most of the time, but could walk short distances with assistance wearing a leg brace and using a special walker. CNA 6 stated, "She needs help to fasten her briefs (adult garment for incontinence). She definitely needs help with her shower." On 4/25/18 at 10:04 a.m., during an interview, the PA Senior Care Coordinator (SCC) stated she had worked as an in-home care giver for one year and three months before going to the PA as a care coordinator. The SCC stated the PA usually assesses a resident before they attempt to find placement. The SCC stated she and two other PA employees were at the SNF a few days before Resident 565 was discharged. The SCC stated, "[Resident 565] was in the activity room so we were unable to talk to her or assess her. [The ASSD] told us not to bother [Resident 565] when she was playing bingo. No, we didn't get to talk to [Resident 565] prior to her discharge." On 4/25/18 at 4:18 p.m., during an interview, the ASSD stated she did not see the PA staff go into Resident 565's room, but the Licensed Nurse Care Coordinator (LNCC) with the PA contacted her and said the board and care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 54 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE home was available for Resident 565. The ASSD stated, "In a matter of four days the discharge happened. The nurse called for the discharge order, the Medical Director (MD), and that was that." The ASSD stated the MD ordered home health to follow Resident 565 after discharge. Resident 565's clinical record titled, "Physician's Orders" dated 3/22/18, indicated, "Pt [patient] to D/C [discharge] to [name of facility] board and care on 3/26/18. Will need home health RN [registered nurse] PT [physical therapy] for medication management, progressive strengthening and mobility. D/C with meds [medication]. F/U [follow-up] with PCP [primary care provider] in one week. Will need standard wheelchair for 99 + days." The order was signed by the MD. Resident 565's clinical record titled, "Progress Notes" dated 3/19/18 indicated, "[PA] in today to attempt to find placement for [Resident 565]. Medi-Cal will not pay for her stay. Information provided and [PA] will follow up in finding placement if possible." Resident 565's "Progress Note" dated 3/22/18, indicated, "[PA] a facility Board and Care will accept [Resident 565]." Resident 565's "Progress Note" dated 3/26/18 at 4 p.m., indicated "[Resident 565] was transported to [board and care] today. Transported by the facility bus. Social Service assisted and helped with all personal items. Helped [Resident 565] settle into her new room, helped with clothing." The "Progress Note" was signed by the ASSD. On 4/25/18 at 4:51 p.m., during a telephone interview, board and care staff member (BCSM) stated he lived at the board and care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 55 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE home with his girlfriend. The BCSM stated, "What we do for each person: we cook three meals, clean the bathrooms, wash clothes once a week. This is independent living. We are not caregivers. I went to [the SNF] and talked to [Resident 565]. I told her that our place is for independent living. I asked her to check it out first before she decides. The [facility staff] brought [Resident 565] the same day I came to visit her. I was actually surprised. We are not caregivers here so I like the potential client to check first." The BCSM stated the ASSD accompanied Resident 565 on 3/26/18 when she was transferred to the board and care home. The BCSM stated, "After bringing in [Resident 565]'s belongings, [the ASSD] left when [Resident 565] was busy talking to other residents. Around dinner time [Resident 565] was looking for [the ASSD]. She said she was getting hungry and needed to go back to [the SNF]. I told her [the ASSD] left earlier and she was not coming back, that [Resident 565] would be living here now. She got very upset and teary. She was going on and on saying, "She dumped me. She dumped me." On 4/25/18 at 5:10 p.m., during a telephone interview, Resident 565 stated, "That day [3/26/18] [the ASSD] packed up my belongings, I thought I was going to be moved to a different room or a different part of [the SNF]. The paper that I signed and everything they did and asked me to do were all for the move to a different part [of the SNF]. Later in the day [the ASSD] took me here [board and care home]. I thought we were just checking the place out because [the BCSM] told me that I needed to check this place first because he said it is for independent living. I told him I need help getting cleaned. That's when he said to check it out to see if it would work for me. Before I knew it, [the ASSD] dumped me. I did not get any teachings. She dumped me here. The [ASSD] FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 56 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE told me home health will be coming over to help me; but nobody has come. I've had one shower in three weeks because my son came to visit with his wife so my daughter-in-law helped me. Then I have this powder medication that I don't know anything about. Nobody told me anything about it so I'm not taking it. I am so confused because the bottle has my name on it but there is also the word "pediatric" on it and I know pediatric means children and I am not one. I can't get ahold of my son and it's always like that with him. I can't depend on him to help me. " Resident 565 stated she had a stroke in 1998 and could get up for a short distance wearing a leg brace and using a cane. Resident 565 stated when she resided at the SNF the CNAs would wake her up at 2:15 a.m. every day, help her put on her leg brace and walk her to the bathroom. Resident 565 stated at the board and care home she was unable to get her leg brace on by herself quickly. Resident 565 stated, "By the time I get it [the leg brace] on I already wet myself." Resident 565 stated she did not have any incontinence briefs available the first two days she resided at the board and care. Resident 565 stated, "[The ASSD] didn't tell me that she was going to dump me here. She told me that we were just checking out the place, then she left. I was looking for her around dinner time to go back to [the SNF]. [The BCSM] told me she left and I'm staying. I was so upset. She tricked me. I can't shower by myself. I am not prepared to come here at all yet. I am not even able to wheel myself to the store because it is a dangerous area. [The ASSD] keeps telling me that they will take care of me but that's not what they do here. They can't. They are not caregivers." On 4/25/18 at 5:22 p.m., during a telephone interview, the home health agency account executive (HHA) stated, "We have not started our service with [Resident 565] because we do FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 57 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE not have updated doctor's orders." The HHA stated they could not accept orders from the facility medical director, the order for home health services had to come from the resident's primary physician and those orders were not received. On 4/25/18 at 7:28 p.m., during a telephone interview, the PA Owner (PAO) stated, "Our assessment [for placement of a resident] is basically an interview, not a physical assessment. We sit down with the patient, social worker and discharge planner to come up to a decision what's the best placement for the patient. I remember we were told that [Resident 565] was independent and limited income. That's why she was referred to room and board [board and care]. The final decision is up to the [SNF] administrator." On 4/26/18 at 10:36 a.m., during a telephone interview, the Director of Nursing (DON) stated, "I didn't know that [the PA] did not assess [Resident 565]. I did know after the fact that the [home health agency] had not gone out to visit yet. There was not a lot of teaching needed for [Resident 565]. Placement was set up, transportation was arranged. There was nothing to teach her or nothing else. The nurse went over the medications and made sure she understood. The ASSD did [Resident 565]'s discharge. She did it within seven days. I did not know that the nurse who discharged [Resident 565] did not do a return demonstration when she went over the medications. Return demonstration is necessary to be sure that what you taught the resident or what you were discussing with that resident was understood clearly." On 4/26/18 at 10:50 a.m., during a telephone interview, Licensed Nurse (LN) 6 stated she was the nurse who discharged Resident 565 on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 58 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 3/26/18. LN 6 stated, "I went over her medications...No I did not have her do it [show how to set up her medications]. I should have done a return demonstration." On 4/26/18 at 11:02 a.m., during a telephone interview the Social Services Director (SSD) stated, "I spoke with home health this morning. She said finally they got their paperwork...for [Resident 565]'s in-home support [one month after the discharge]." On 4/26/18 at 2:48 p.m., during a telephone interview, the DON stated the facility IDT did not meet to plan Resident 565's discharge. The DON stated, "It happened pretty quickly, the discharge. I admit we probably didn't do all the necessary steps. I did not check the regulations on discharge." The DON stated the SNF had IDT meetings on a daily basis, but had not met to plan a safe discharge for Resident 565. Resident 565's clinical record titled "Post Discharge Plan" dated 3/26/18, indicated under "Social Services Information: Family/Resident Involved with discharge planning: a box indicating "no" was checked. The Sections of the "Post Discharge Plan" for nutritional notes, immunization information, home exercises, doctor in charge of resident's care after discharge, follow-up doctor's appointments, resident training for home and notification of the Long Term Care Ombudsman (resident advocate who by regulation should be notified of all facility initiated discharges) were all left blank. Review of the facility Policy titled "Care Planning - Interdisciplinary Team" dated Revised September 2013, indicated "Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 59 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE each resident...2. The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team which includes, but is not necessarily limited to the following personnel: a. The resident's Attending Physician; b. The Registered Nurse who has responsibility for the resident; c. The Dietary Manager/Dietitian; d. The Social Services Worker; e. The Activity Director/Coordinator; f. Therapists; g. Consultants; h. The Director of Nursing; i. The Charge Nurse; j. Nursing Assistants; k. Others as appropriate or necessary to meet the needs of the resident. 3. The resident, the resident's family...are encouraged to participate in the development of and revisions to the resident's care plan." The facility policy titled, "Comprehensive Care Plans" dated 11/20/17 indicated, "Purpose: To provide each resident with a person-centered, comprehensive care plan to address the resident's medical, nursing, physical, mental and psychosocial needs. Policy: The facility Interdisciplinary Team (IDT) will develop and implement a comprehensive, person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, physical, mental, and psychosocial needs that are identified in the comprehensive assessment...8. Care plan will include: d. ii. The resident's preference and potential for discharge to the community. NOTE: Facility will document assessments related to return to community and referrals to local agencies. The facility policy titled, "Discharging the Resident" dated December 2016, indicated "...Preparation: 1. The resident should be consulted about the discharge...4. If discharging the resident to another long-term care facility tell the resident: d. Who will be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 60 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE providing the resident's care...f. Why the discharge is necessary...7. Assess and document resident's condition at discharge..."

F661 SS=D Discharge Summary CFR(s): 483.21(c)(2)(i)-(iv)

F661 06/19/2018 §483.21(c)(2) Discharge Summary When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following: (i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. (ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative. (iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-thecounter). (iv) A post-discharge plan of care that is FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 61 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any postdischarge medical and non-medical services. This REQUIREMENT is not met as evidenced by: Based on staff interview and record review, the facility failed to ensure that the resident's Discharge Summary was documented by the attending physician and included in the resident's clinical record after the resident's death for one of 15 sampled residents (Resident 115). The facility failed to provide a recapitulation of Resident 115's stay at the facility and a final summary of Resident 115's status at the time of the discharge in the closed record which had the potential to result in the inavailability of the Discharge Summary information. Findings: Resident 115's clinical record indicated, Resident 115 was admitted to the facility on 1/12/18 with an admitting diagnosis of Hypoxemia (an abnormally low concentration of oxygen in the blood), Congestive Heart Failure (a heart condition that causes symptoms of shortness of breath, weakness, fatigue, and swelling of the legs, ankles, and feet). Resident 115's progress note dated 2/16/18 at 2:50 a.m., indicated the resident was then seen at 1 a.m. in his bed with Bi-level Positive Airway Pressure [Bipap (a type of ventilator-a device that helps with breathing)] in place FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 62 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE connected to Oxygen concentrator at 3 L (liter)/M (minute). Resident 115 was seen at 2 a.m. in his wheelchair, unresponsive, no palpable pulse, not breathing. Emergency services was notified, Cardiopulmonary Resuscitation (CPR) was initiated. Paramedics arrived at approximately 2:10 a.m. and CPR was continued and the resident was sent to hospital at approximately 2:45 a.m. At 3:30 a.m., the facility received a call from the hospital that the resident had expired. On 5/18/18 at 9:30 a.m., during an interview and concurrent record review, the Medical Information Director (MID) reviewed the clinical record and was unable to find a Discharge Summary documentation included in the resident's clinical closed record. On 5/18/18 at 10 a.m., during an interview, the Director of Nursing (DON) stated the expectation would be that a Discharge Summary should have been documented by the resident's attending physician and included in the resident's clinical closed record. On 5/18/18 at 10:43 a.m., during an interview, the Medical Director (MD) stated since he was not informed of the client's change of condition, hospitalization and death, a Discharge Summary was also not documented and included in the resident's clinical closed records. The facility's policy and procedure titled "Transfer or Discharge Documentation", dated 8/2014 "... 2. Should the resident be transferred or discharged for the following reasons, the basis for the transfer or discharge must be documented in the resident's clinical record by the resident's Attending Physician: a. The transfer or discharge is necessary for the resident's welfare, and the resident's needs FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 63 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE cannot be met in the facility; or b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so that the resident no longer needs the services provided by the facility.

F690 SS=D Bowel/Bladder Incontinence, Catheter, UTI CFR(s): 483.25(e)(1)-(3)

F690 06/19/2018 §483.25(e) Incontinence. §483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. §483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. §483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 64 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide care and assistance to maintain continency of urine to one of 31 sampled residents (Resident 417) when there was no staff available timely to assist Resident 417 to use the restroom. This failure resulted to Resident 417 urinating in bed two times in one day. Findngs: On 5/15/18 at 11:32 a.m., during an interview, Resident 417 stated, "I came in on Friday... and I think it was Sunday night... I kept pushing my buzzer [call light] and no one came to my room... I had to pee in my bed, it is very upsetting... I am an independent person, I got so frustrated I wanted to scream." Resident 417's husband stated, "I came in Monday the 14th and she told me she had to pee in bed because no one can answer the call light to take her to the bathroom and it all happened in the same night..." On 5/17/18 at 8:10 a.m., during an interview regarding Resident 417, Licensed Nurse (LN) 6 stated Resident 417 was continent of urine and used the bedpan with assistance. On 5/17/18 at 8:18 a.m., during an interview regarding Resident 417, Certified Nursing Assistant (CNA) 4 stated, "She (Resident 417) had a neck surgery. She is continent and uses the bed pan. If she doesn't call I will go in every two hours because she goes [to the restroom] with help." When asked if she was able to check on Resident 417 every two hours, CNA 4 stated, "Sometimes it can be awhile, we [staff] FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 65 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE get busy answering the call lights." When asked if any residents experience accidents due to waiting, CNA 4 stated, "Yes, and they do get upset." The facility document titled, "Bladder Elimination" dated 5/11/18- 5/17/18, indicated Resident (417) was incontinent on 5/13/18 on two occasions. On 5/18/18 at 10:28 a.m., during a telephone interview regarding Resident 417, CNA 13 stated, "She knows how to use her call light... She is continent and she uses a bedpan." When asked about the charted incontinence on 5/13/18 [a Sunday], CNA 13 stated he did not get to Resident 417 in time. CNA 13 stated, "I may have been answering other call lights... " The facility policy and procedure titled, "Urinary Incontinence" dated 11/2017, indicated, "... POLICY: A resident will receive the necessary care and services to maintain continence..."

F692 SS=E Nutrition/Hydration Status Maintenance CFR(s): 483.25(g)(1)-(3)

F692 06/19/2018 §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a residentFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 66 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; §483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to maintain proper hydration for two of 31 sampled residents (Resident 16 and Resident 29) when: 1. Resident 29 did not have a water pitcher at her bedside table. 2. Resident 16's water pitcher was not within reach. Resident 29 did not have a water pitcher at her bedside table. These failures placed residents at risk of not having sufficient fluid intake to maintain proper hydration and placed Resident 29 and Resident 16 at risk of dehydration. Findings: 1. On 5/16/18 at 8:30 a.m., during a concurrent observation in Resident 29's room and interview, Resident 29 was sitting in a wheelchair facing the window. Resident 29 was eating cheetos chips. Resident 29 stated, "I am thirsty. I don't have water until they bring me one. It has always been like that. That means I don't get to drink. I don't even know where my FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 67 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE light is." Resident 29's call light lay on top of her stripped bed and Resident 29 was unable to see or reach it from where she sat. On 5/16/18 at 8:38 a.m., during a concurrent observation in Resident 29's room and interview, CNA 15 stated, "There is no water here. That's right she can't drink water if there is no water here. Her [Resident 29] call light should not be there [on top of the bedside]. It should be near her." Resident 29's MDS Assessment dated 3/1/18, indicated a BIMS (Brief Interview for Mental Status) score of 6 of 15 which indicated Resident 29 had severe cognitive impairment in memory. The MDS assessment indicated Resident 29 required extensive assistance of one staff member to transfer from one surface to another. On 5/17/18 at 7:57 a.m.,during an interview, the Director of Nursing stated, "The bedside table should be within reach and will have their remote, water and everything they need prior to staff leaving the room. Call light should be within reach. If they are in bed, it should be within easy access or their preference." On 5/18/18 at 11:53 a.m., during an interview, the Director of Staff Development (DSD) stated, "The CNA's [Certified Nursing Assistants] are responsible during their first rounds to make sure resident has everything they need then nurses also check. Everybody is responsible to take care of it [residents having water at their bedside]." On 5/18/18 at 11:57 a.m., during an interview, the License Nurse Unit Manager (LNUM) stated, "The CNA's are responsible during their initial rounds to make sure residents have what they need. The bedside table should be within FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 68 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE reach with resident's water, call light, remote and everything they need. A lot of things could happen if they don't get water. They could get dehydrated or could get something stuck in their throat." 2. On 5/16/18 at 10:54 a.m., during an observation and concurrent interview with Resident 16, the bed side table was next to the middle curtain dividing Resident 16 from roommate. No water pitcher was observed on the bed side table or nightstand table located on the left side of Resident 16. Resident 16 stated, "The water pitcher was over there and gestured with his arm to the center table across the room." Resident 16 stated that was his pitcher. Resident 16 stated he wanted water. On 5/16/18 at 11:04 a.m., during an interview, Licensed Nurse (LN) 1 stated, "The water pitcher should be on the table that rolls, not the center one. The CNA [Certified Nursing Assistant] should replace the entire water pitcher due to not knowing if the water pitcher belongs to which resident. LN 1 stated, The resident could become dehydrated not having the water pitcher in reach. " On 5/16/18 at 11:07 a.m., during an interview, CNA 9 stated Resident 16 could get dehydrated if the water pitcher is not close to the resident. CNA 9 stated the water pitcher was empty when he opened the lid. CNA 9 placed the pitcher back on the bed side table and moved the table over Resident 16 and left the room and did not fill the pitcher. The facility policy and procedure titled, "Hydration- Clinical Protocol" dated 9/12 indicated, "...The staff will provide supportive measures such as providing fluids..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 69 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F800 Provided Diet Meets Needs of Each Resident CFR(s): 483.60

F800 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 06/19/2018 §483.60 Food and nutrition services. The facility must provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure facility staff supported the nutritional well-being for one of 31 sampled residents (Resident 417) when the admitting staff did not fill out and submit a Diet Requisition (meal ticket) for Resident 417. This failure resulted in (Resident 417) not receiving meal trays for five (5) meals which had the potential to compromise her nutritional status and result in weight loss. Findings: On 5/14/17 at 11:32 a.m., during an interview, Resident 417 stated, "When I came in on Friday afternoon, I was served no dinner and my husband had to go to the nurses' station and request one. Saturday morning - no breakfast, Saturday - no lunch, Saturday night yes, received dinner. Sunday morning - no breakfast, Sunday - no lunch, Sunday night yes, received dinner." Resident 417's husband stated, "We met with Food Services and told them about what had happened over the weekend." On 5/16/18 at 8:57 a.m., during an interview, the Registered Dietitian (RD) stated when she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 70 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE received a new admit she screens the resident within 7 days. The RD stated, "... not sure who would handle the weekends, but the dietary manager would see resident within a couple of days." On 5/16/17 at 12:18 p.m., during an interview when asked how new residents are provided meal trays, the Certified Nursing Assistant (CNA) 10 stated, "The charge nurse admits them and passes it along to the kitchen." When asked how new admits are done on weekends, CNA 10 stated, "The same way, but I was here Saturday when the Resident did not receive her breakfast tray, I went and got her one, but this happens sometimes with new people [residents], because they are hand written cards, and sometimes they don't get trays." On 5/17/18 at 8:03 a.m., during an interview, the Dietary Supervisor (DS) stated, "I look in PCC [Point Click Care - Facility Electronic Charting/Documentation] to find the doctor ordered diet and allergies. If they come in late night or weekend admit - it is the nurse on duty's responsibility to order food for the new admit. If they do not get a dietary order the resident does not get a tray 'til (until) there's a diet order. The cook on the weekend, cannot look at PCC to see the diet the doctor placed, the cook relies on the nurse to report new residents." When asked who sets up the meals for the residents that come on Saturday or Sunday, the DS stated, "The AM (morning) cook sets up the meals with the new resident. In order for the weekend cook to know there's a new admit they (cooks) would have to receive a diet order form nursing... If they come in on the weekend, I would follow up on Monday." The DS stated the kitchen did not receive a diet order for Resident 417 and meals were not served to Resident 417. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 71 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 5/17/17 at 3:43 p.m., during an interview regarding Resident 417's Diet Requisition, the DS stated, "She may not have one, if nursing did not do one... " On 5/17/18 at 3:44 p.m., during an interview regarding the new admits process, CNA 11 stated, "The admit nurse fills out all the paperwork... The nurse fills out the diet form and we take it the kitchen and get the tray for the resident." On 5/17/18 at 3:46 p.m., during an interview regarding the new admits process, Licensed Nurse (LN) 2 stated, "The admitting nurse admits residents... she would look at all doctor's orders and she would fill out the form for dietary and then gets it to the kitchen." When asked if there were times when the resident don't get meal trays, LN 2 stated, "Yes it has happened... but when we notice it's missing then we try and fill out the diet paper and fix it." On 5/17/18 at 4:10 p.m., during an interview regarding Resident 417's Diet Requisition, the DS stated, "Nope, I have nothing on that resident (Resident 417) because the nurse did not fill one (Diet Requisition) out on the weekend and give to the kitchen... I told the Resident 417's husband that it's all my fault, and he said no its not. You weren't here." The facility admission record indicated that Resident 417 was admitted on 5/11/18. The facility policy and procedure titled, "Therapeutic Diets" dated 9/2017, indicated "... All residents have a diet order... that is prescribed by the attending physician... 1. The Licensed nurse accepts the diet order from the authorized prescriber. 2. The Licensed Nurse completes and signs the Diet Requisition Form, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 72 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Including the full diet order, food allergies, and specific food preferences requests. 3. Diets are prepared in accordance with the guidelines in the approved Diet Manual and the individualized plan of care."

F801 SS=F Qualified Dietary Staff CFR(s): 483.60(a)(1)(2)

F801 06/19/2018 §483.60(a) Staffing The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e) This includes: §483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who(i) Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose. (ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional. (iii) Is licensed or certified as a dietitian or nutrition professional by the State in which the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 73 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)(i) and (ii) of this section. (iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law. §483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services who(i) For designations prior to November 28, 2016, meets the following requirements no later than 5 years after November 28, 2016, or no later than 1 year after November 28, 2016 for designations after November 28, 2016, is: (A) A certified dietary manager; or (B) A certified food service manager; or (C) Has similar national certification for food service management and safety from a national certifying body; or D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; and (ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and (iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 74 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on observation, interview, and record review, the facility failed to ensure the Registered Dietitian (RD) provided frequently scheduled consultations to the Dietary Supervisor when a lapse in the delivery of food services associated with diet provision (Cross Reference F800), following of menus (Cross Reference F803), meal temperatures (Cross Reference F804), accommodating resident allergies (Cross reference F806) and food safety (Cross Reference F812 and

F925)occurred. This failure to ensure food and nutrition services systems are accurately and effectively delivered have the potential to result in compromising the nutritional status of residents through the potential transmission of foodborne illness, incorrect plating of physician ordered diets, and/or decreased nutritional intake due to residents' poor acceptance of meals. Findings: On 5/15/18 at 10:13 a.m., during an interview regarding consultations with the Dietary Supervisor (DS), the Registered Dietitian (RD) stated, "I leave my recommendations for the DS. I get consults (resident consults) and I address them on my own." On 5/16/18 at 9:00 a.m., during an interview about her role, the RD stated, "I review all residents for malnutrition... I review with DS for appropriate diet for resident... I assess the resident's ability to chew & swallow... try to figure out eating issues... interventions for weight loss. It's centered on resident.... I followup the nutritional assessment quarterly (every 3 months)... The Nutritional assessment is done on admission then 3 months then annual... The Dietary manager does food preferences and makes resident aware of food FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 75 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE options/preferences." When asked if she gets to work with the kitchen staff, the RD stated, "I don't do a whole lot for the staff. I work with the dietary manager [DS]... Not too much contact with staff... I have not observed the cook prepare or serve food." On 5/16/18 at 9:15 a.m, during a follow-up interview regarding consultations with the DS, the RD stated, "I do not do any formal consultations. If we have questions, we have no problem getting in touch with each other. Our consults are separate. I do resident consults, mainly resident consults from the floor, from the staff. She (DS) can ask me questions about the menu. Our communications is very as needed... Nothing written... no formal documentation." When asked when the menu was implemented, the RD stated it was a question for the DS. When asked about the processes (Puree) and functions (dishwasher) in the kitchen, the RD stated she would know if she was actively involved. The RD also stated the drain flies were first noticed four weeks ago. On 5/16/18 at 11:58 a.m., during an observation in the kitchen office and concurrent interview, two pieces of paper were on the table by the computer keyboard, the RD stated, "I put it (2 documents) face down on DS desk and she will see it in the morning. I also give a copy to the unit manager." A copy of the RD documents titled "Registered Dietitian Consultant Report" and "Clinical Recommendations" were provided. On 5/16/18 at 3:34 p.m., during an interview about QAPI (Quality Assurance Program Improvement) involvement, the RD stated, "I do not participate in QAPI." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 76 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 5/16/18 at 3:40 p.m., during an interview, the District Manager (DM - [HSG] Healthcare Services Group) stated, "The DS is the one doing ongoing training for the staff. RD is here to do the clinical part. RD is contracted [parttime]." On 5/18/18 at 8:09 a.m., during an interview about RD role, the DS stated, "I don't know what her role is. She does assessments, skin and weights, recommendations, progress reports, admits, family consultations, assessment with the resident... No formal consultation with RD." The DS stated anything kitchen related is done by DS and DM. The facility document titled, "JOB DESCRIPTION" indicated "TITLE: Registered Dietitian... JOB FUNCTION: Administrative duties... Provides oversight and guidance to the Dining Services Director [DS] regarding dining service operations... Reviews and makes recommendations for an ongoing quality assurance program for the Dining Services Department... Provides consultation to the Director of Dining Services... on federal, state and local regulations pertaining to dining service operations..." The contract document titled, "DIETITIAN SERVICE AGREEMENT" dated 10/15/17, indicated "... 2. DIETARY CONSULTING SERVICES... Consultants shall maintain Facility's dietary functions through Healthcare [HSG] in compliance with applicable laws and regulations... shall provide guidance and training to the Food Service Director [DS] and dietary staff... shall participate, as requested, in meetings of Facility's quality assurance committee... shall inspect all areas of the dietary department, including but not limited to, sanitation, equipment functioning, food service operations, and compliance with pertinent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 77 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE federal, state and local laws. Consultants shall be available at various mealtimes to observe dining operations..."

F803 SS=E Menus Meet Resident Nds/Prep in Adv/Followed CFR(s): 483.60(c)(1)-(7)

F803 06/19/2018 §483.60(c) Menus and nutritional adequacy. Menus must§483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.; §483.60(c)(2) Be prepared in advance; §483.60(c)(3) Be followed; §483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups; §483.60(c)(5) Be updated periodically; §483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and §483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 78 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE review, the facility failed to ensure the menus were followed when the pork loin was cooked for four hours instead of the indicated Cook Time of - 1-1 ½ Hrs (hours) and incorrect portion size was served. These failures had the potential for residents to receive inadequate protein and nutrients in their meals. Findings: On 5/16/18 at 12:00 p.m., during an observation in the kitchen of the lunch meal service, a tray of pork loin contained a row of bigger slices and a row of smaller slices of pork loin. On 5/16/18 at 12:08 p.m., during an observation and concurrent interview with the Dietary Supervisor (DS) and the Dietary Cook (DC) 1, the DS weighed a piece of pork loin served for 3 oz. meal - weighing 2.5 oz. (ounces). The Dietary Cook stated, "That is a small portion." The DS weighed another piece of pork loin weighing 2.8 oz. When asked about the Pork Loin weight, DS stated, "It is really not 3 oz." DC 1 stated, "It shrank in the oven." The Facility document titled, "hcsgwest 2018 Diet Guide Sheet" indicated "... Lunch Day 4 (Week:1 - Wednesday) [serving size] Regular... Pork Loin 3 oz... Small... Pork Loin 2 oz..." On 5/16/18 at 12:35 p.m., during an interview, the Registered Dietitian (RD) stated the protein amount in resident's diet is prescribed to meet the nutritional requirement and caloric requirement of each resident. RD stated, "I calculate their requirements. It should be served according to the therapeutic menu." On 5/16/18 at 12:50 p.m., during an interview regarding the pork loin, DC 1 stated she sliced 65 portions of pork loin. DC 1 stated, "I cooked it [pork loin] then sliced it then put it back in the oven to get it to heat up... The pork loin is long, then the middle part is fat." DC 1 stated that she used the middle part for the regular size, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 79 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the outer part for small size and the end part of the pork loin for purees and mechanicals (ground up food). DC 1 stated, "I weighed it (a slice of pork loin), it was 3 oz. I don't know what happened." The DC 1 stated the portion size of 3 ounces was not served. On 5/17/18 at 8:56 a.m., during an interview on how the pork loin was cooked, DC 1 stated, "It was cooked at 5 a.m. I took it out of the oven at 9 a.m... at 350°F [degrees Fahrenheit temperature scale], cooked for 4 hours. It was 165°F when it was taken out of the oven... I sliced it and put it back in the oven at 10 a.m. When I took it out after heating it up, it was 180°F." The facility document used by DC 1 titled, "Production Counts (Day 4: Wk [Week] 1Wednesday - 5/16/18)" indicated "... Pork Loin 3 oz... Total 61 (servings)" On 5/18/18 at 8:31 a.m., during an interview, the DS stated, "Pork Loin should take about a couple of hours (to cook). When asked about the incorrect portions of the pork loin, DS stated, "I don't really have a problem with that." DS stated 2.8 oz. is not much less than 3 oz. but it did not follow the menu. The facility recipe titled "Pork Loin" indicated "... Cook Time - 1-1 ½ Hrs (hours)... Cook Temp - 325°F... Portion Size: 3 oz..." The Facility document titled, "Menus" dated 9/2017, indicated "... Menus will be planned in advance to meet the nutritional needs of the residents/patients in accordance with established national guidelines... Menu cycles will include standardized recipes... Menus will be served as written..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 80 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

F804 Nutritive Value/Appear, Palatable/Prefer Temp F804 CFR(s): 483.60(d)(1)(2) SS=E ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 06/19/2018 §483.60(d) Food and drink Each resident receives and the facility provides§483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance; §483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure that food is palatable and served at an appetizing temperature when residents complained of food being bland and being served cold. This failure had the potential to result in residents not eating their food which could compromise their nutritional status and result in weight loss. Findings: On 5/15/18 at 8:20 a.m., during an observation in Resident 109's room and concurrent interview, Resident 109's plate was still full of breakfast food. Only half of the slice of coffee cake was eaten. Resident 109 stated, "The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 81 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE food is very bland. I like food with taste... Everyday is the same thing." On 5/15/18 at 11:36 a.m., during an observation in the kitchen, the Dietary Aide (DA) was warming up 2 plate bases (base to keep plate warm) on a base warmer. At 11:40 a.m. tray line (meal service) started staffed with one Dietary Cook (DC) assembling the food on plate and one DA to arrange the food on trays and put them (trays) into the carts. The DC assembled three plates with food and waited for the dietary aide to set-up the food on the trays. The set-up included the base with the plate of food, the dome (cover), the salad, the drinks, the napkin, the utensils and the meal ticket. On 5/15/18 at 11:48 a.m., during an observation in the kitchen, the base on top of the warming machine was not warm to the touch. The facility document titled, "Resident Council Minutes" dated 2/20/18, indicated "... FOOD... Food coming out cold - Social Dining Room & on Floor..." It also indicated that Dietary personnel were approved to attend the meeting. The facility document titled, "Resident Council Minutes" dated 3/27/18, indicated food is cold and hot food not really hot. The facility document titled, "Resident Council Minutes" dated 4/23/18, indicated "... FOOD... poorly seasoned, sandwiches made poorly..." On 5/16/18 at 10:09 a.m., the Resident Council Meeting was held at the Pinions Vinyard with eight residents (Resident 81, 79, 31, 77, 29, 86, 55, 14) in attendance. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 82 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 5/16/18 at 10:20 a.m., during the resident council meeting, when asked if the complaints presented during the last three council meetings were resolved, the group (eight residents in attendance) stated, "No, nothing has changed." When asked if the facility had given them a time frame of when they will start working on the food complaints, the group stated, "No." On 5/17/18 at 7:35 a.m., during an interview, the Dietary Supervisor (DS) stated she knew of the complaints last February and they tried to address the issue. The DS stated if there were still complaints about the food temperature in the past two months their department did not know about it. The DS stated, "I thought there was no more problem about the food temperature." On 5/17/18 at 9:42 a.m., during an observation in the kitchen, a pile of plates on the lowerator (plate warmer) were not warm. The facility document titled, "Service Line Checklist" dated 5/18/18, indicated the initial temperatures of the foods being served for lunch. The temperatures of the regular diet indicated Fish 185°F, Tomato sauce 180°F, Orzo 182°F, Apple juice 32°F and Peach slices 32°F. The temperatures of the puree diet indicated Fish 175°F, Tomato soup 32°F, Mashed Potatoes 181°F, pureed bread 126°F, milk 32°F and pureed peach slices 32°F. On 5/18/18 at 12:45 p.m., during an interview regarding the test tray, the DS stated she has tasted their (facility) food and it was good. The DS stated, "I can never taste pureed food. I just can't do it." On 5/18/18 at 12:55 p.m., during an observation of the test tray going into the cart, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 83 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the DS went into the office (small room in the kitchen) and never came out for the test tray tasting. The RD was also in the office. The last cart arrived in South B area at 1:01 p.m. and the food trays served to residents. On 5/18/18 at 1:05 p.m., during an observation of the test tray testing, the temperatures on the Regular Diet: Fish 147°F, Tomato sauce 130°F, Orzo 140.2°F, Apple juice 52°F, Peach slices 65°F. Puree Diet: Fish 112°F, Tomato soup 66°F, Mashed Potatoes 135°F, pureed bread 126°F, milk 53.8°F, pureed peach slices 68.1°F. No staff from dietary or management participated in tasting the test tray. Tasting revealed poorly seasoned and bland tasting food. On 5/18/18 at 1:26 p.m., Test tray temps (temperature) were presented to the RD. The RD stated, "show it to the Dietary Supervisor." The facility policy and procedure titled, "Meal Distribution" dated 9/2107, indicated "... Meals are transported to the dining locations in a manner that ensures proper temperature maintenance... All food items will be transported promptly for appropriate temperature maintenance... Proper food handling techniques... temperature maintenance controls will be used for point of service dining."

F806 SS=E Resident Allergies, Preferences, Substitutes CFR(s): 483.60(d)(4)(5)

F806 06/19/2018 §483.60(d) Food and drink Each resident receives and the facility provides§483.60(d)(4) Food that accommodates resident allergies, intolerances, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 84 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE preferences; §483.60(d)(5) Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice; This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to accommodate the food allergies for one of 31 sampled residents (Resident 417) when Resident 417 was allergic to tangerines and was served tangerines on her meal tray. This failure had the potential to result in an allergic reaction and negative outcome to Resident 417. Findings: On 5/16/18 at 12:31 p.m., during an observation in Resident 417's room and concurrent interview, Resident 417's husband stated, "My wife is allergic to oranges, orange juice and tangerines... Look at her lunch tray it has a cup of tangerines and I told them she's allergic to them". Resident 417's lunch tray was on the bedside table with a cup of tangerines. There was no allergies noted on the meal ticket. Resident 417's husband stated, "I told the dietary manager Monday the 14th, and they are still getting it wrong." The facility document titled, "Dietary Profile" dated 5/14/18, indicated "... E. Food Allergies/Intolerances - nkfa [No known Food Allergy]... K. Likes/ Dislikes - oranges..." The facility document titled, "Activity Log Report" dated 5/14/2018 3:56 p.m., indicated "... Added Mandarin Oranges to [Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 85 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 417's name]... Dislikes..." The facility document titled, "Activity Log Report" dated 5/16/2018 6:13 p.m., indicated "...Added Mandarin Oranges and Orange Juice to [Resident 417's name]... Allergies..." On 5/17/17 at 3:43 p.m., during an interview regarding Resident 417's Diet Requisition, DS stated, "She may not have one, if nursing did not do one... I will check." On 5/17/18 at 4:10 p.m., during an interview regarding Resident 417's Diet Requisition, DS stated, "Nope, I have nothing on that resident (Resident 417) because the nurse did not fill one (Diet Requisition) out on the weekend and give to the kitchen... I told Resident's 417 husband It's all my fault, and he said no it's not. You weren't here." On 5/18/18 at 7:58 a.m., during an interview regarding resident food allergies, the Certified Nursing Assistant (CNA) 12 stated, "To look for allergies... it's on the meal tag." On 5/18/18 at 8:13 a.m., during an interview regarding the process of admitting patients, the Unit Manager (LNUM) stated, "I would admit into the system admissions orders... The admission nurse hands the diet form to the kitchen staff... allergies would be noted on the form." On 5/18/18 at 8:20 a.m., during an interview regarding weekend admissions, the Director of Nursing (DON) stated, "The admitting nurse is responsible to communicate the diet and allergies to the kitchen... They transcribe the diet from the hospital..." On 5/18/18 at 9:38 a.m., during an interview regarding her reaction to eating oranges, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 86 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE tangerines or orange juice, Resident 417 stated, "My mouth breaks out in canker sores [mouth sores] almost immediately and it's so painful." On 5/18/18 at 11:00 a.m., during an interview regarding resident food allergies, DON stated "If it's a true allergy, they [residents] can have an allergic reaction." The facility policy and procedure titled, "Dining and Food Preferences" dated 9/2017, indicated "... 1.The diet requisition form will notify the dining services department of food allergies upon admission and prior to meals being served... 4. Food allergies, food intolerances... will be entered into the resident profile... 7. The individual tray assembly ticket will identify all food items appropriate for the resident/patient based on diet order, allergies & intolerances..." The facility policy and procedure titled, "Meal Distribution" dated 9/2017, indicated "... All meals will be assembled in accordance with the individualized diet order... and preferences..."

F812 SS=E Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 06/19/2018 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 87 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to store, prepare and serve food safely when: 1. Half a tray of bread got contaminated by a drain fly. 2. There was a 15 day old opened bag of spinach in the walk-in refrigerator. 3. One (8 pounds) and a half of turkey breast was found submerged in a basin of water. 4. Unlabeled sandwiches were laying on two food prep (preparation) tables. 5. Three frozen boxes of dough had the wrong dates (date received) on them. These failures had the potential to result in unsafe food storage and handling practices that could lead to negative outcomes to the residents. Findings: 1. On 5/15/18 at 12:22 p.m., during an observation in the kitchen, there were four flying insects by the steam table. A flying insect landed and roamed on the tray of bread that was half full and was continuously being served in the tray line (meal service). On 5/16/18 at 9:30 a.m., during an interview regarding the flying insects, the Registered Dietitian (RD) stated it had been four weeks that she had noticed the flies. The facility pest control report from Insect IQ FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 88 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE dated "4/26/18' indicated "... Technician Comments: I sprayed... 2 drains in the kitchen by the sink - The drain by the cone is where the phorid flies [drain flies] are coming from... " On 5/17/18 at 9:07 a.m., during an observation in the kitchen and concurrent interview, there were three drain flies observed by the back entrance of the kitchen. The Dietary Cook (DC) 1 stated, "I have no idea what they are. But I noticed them flying around. I noticed it about 2 weeks ago..." On 5/17/18 at 9:20 a.m., during an interview regarding the drain flies, DC 1 stated, "If it lands on cooked food, we have to toss the food. The flies would contaminate the food." On 5/17/18 at 3:47 p.m., during an interview about the flying insects in the kitchen, the District Manager (DM) stated, "They (kitchen staff) have talked to Maintenance about it, to get pest control... It is drain flies. When told about the drain fly landing and roaming on the food, the DM stated, "The food should be tossed." On 5/18/18 at 8:34 a.m., during an observation in the Dietary office in the kitchen and concurrent interview regarding the drain flies, two drain flies were observed flying in the office. The Dietary Supervisor (DS) stated, "I don't know what they are... I have never seen them before... It's been going on about a month... When they first came out they were a lot." The DS stated, "If flies touch the food... what happens is flies carry a lot of diseases... germs... We throw the food away. They (drain flies) contaminate... If they (staff) saw it (drain flies touching the food) they would throw the food away." The facility policy and procedure titled, "Preventing Foodborne Illness - Food Handling" dated July 2014, indicated "... Food will be stored, handled and served so that the risk of foodborne illness is minimized..." The facility policy and procedure titled, "Meal FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 89 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Distribution" dated 9/2017, indicated "... Proper food handling techniques to prevent contamination..." 2. On 5/15/18 at 10:08 a.m., during an observation in the walk-in refrigerator (fridge) in the kitchen, there was a half a bag of spinach dated 5/1/18 (opened/received date). There were two more unopened bags of spinach that were also dated 5/1/18 (received date). On 5/15/18 at 10:15 a.m., during an interview regarding the bags of spinach, DC 2 stated, "We will use it today and then throw it away." On 5/15/18 at 10:20 a.m., during an interview, the DS stated, "For fresh vegetables it's good for 10 days from opening." On 5/17/18 at 9:04 a.m., during an interview, the DC 1 stated, "For spinach, I think it is good for 7 days. Past 7 days we don't use it. We have to toss it." When asked about a bag of spinach that was opened on 5/1/18 that was still in the fridge, DC 1 stated the spinach is not good anymore. On 5/18/18 at 8:17 a.m., during an interview regarding the spinach, the DS stated, "It was in the menu a week ago. I opened. It was an oversight for me. I do the inventory but it was just an oversight... It (spinach) is past our expiration date per policy." The facility document titled, "Storage Periods for Retaining Food Quality and Safety" indicated greens (spinach) stored in the refrigerator at 40°F is good for three to five days." The facility policy and procedure titled, "Preventing Foodborne Illness - Food Handling" dated July 2014, indicated "... Food will be stored, handled and served so that the risk of foodborne illness is minimized..." 3. On 5/16/18 at 11:50 a.m., during an observation in the kitchen and concurrent interview, one and a half turkey breast was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 90 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE being thawed submerged in a basin of water. DC 3 stated, "I put it there a few minutes ago." DC 3 stated the thawing process should be in running water. On 5/17/18 at 9:06 a.m., during an interview about the thawing process, DC 1 stated, "We leave it in the walk-in fridge to thaw for 3 days. If we thaw in the sink, we have to keep the water running." When asked about the turkey breast submerged in a basin of water, DC 1 stated the turkey breast submerged in the basin of water is not how to thaw. The DC 1 stated when DC 3 cut the turkey breast, it was not thawed very well. On 5/18/18 at 8:15 a.m., during an interview about thawing meats, DS stated, "We take it out of the freezer and into the fridge for about 3 days. We also thaw it in the sink under running cool water." When asked what happens if meats were not thawed properly, DS stated, "Bacteria starts setting in if it's not thawed right then we have to throw it out." The facility policy and procedure titled, "Food Preparation" dated 9/2107, indicated "... The Cook(s) thaws frozen items that requires defrosting... using one of the following methods... Completely submerging the item under cold water (at a temperature of 70°F or below) that is running fast enough to agitate and float off loose ice particles; ..." 4. On 5/15/18 at 7:51 a.m., during an observation in the kitchen, three unlabeled and undated sandwiches were on the counter by the steam table. Two unlabeled and undated sandwiches were on the food prep table by the robot coupe (a commercial food processor). On 5/15/18 at 9:47 a.m., during an interview, DC 1 stated, "The peanut butter & jelly sandwiches were made around 7 am." When asked about the process of preparing sandwiches, DC 1 stated, "We have to label and date everything... I make two to three FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 91 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE peanut butter and jelly sandwiches with extra everyday... It (sandwiches) stays on the table... residents come and ask for it." On 5/17/18 at 9:02 a.m., during an interview, DC 1 stated, "We have to label it (sandwiches) before putting it away... I just didn't get to label it right away" On 5/18/18 at 8:10 a.m., during an interview regarding the peanut butter and jelly sandwich, the DS stated, "They (staff) have a certain amount they make per day. They use it for tray line.... She should have put a date on it." The facility policy and procedure titled, "Food Storage: Cold Foods" dated 4/2018, indicated "... All foods will be stored wrapped... covered, labeled and dated ..." 5. On 5/15/18 at 7:59 a.m., during an observation in the walk-in freezer in the kitchen, there were three boxes of Parker House Roll Dough in freezer dated June 11/18. On 5/15/18 at 1030 a.m., during an interview, DS stated, "The sticker date is the date it comes in." On 5/17/18 at 9:20 a.m., during an interview, DC 1 stated, "The sticker date is the "received date" [date item was received]. We write the "opened date" [date the item was opened]. So that we can use whichever one came in first. It is important for the date to be correct. If the date is wrong then we won't be able to follow the first in - first out [process]." On 5/18/18 at 8:20 a.m., during an interview regarding the sticker date on items, the DS stated, "The date received is put on everything. If we don't put a date there will be a product sitting there and you don't know when it came in... So we know how long to keep it... it helps us track [food delivery] first in, first out." The facility policy and procedure titled, "Receiving" dated 9/2017, indicated "... 5. All food items will be appropriately labeled and dated either through manufacturer packaging FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 92 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE or staff notation. 6. All food items will be stored in a manner that ensures appropriate and timely utilization based on the principles of "first in - first out" (FIFO) inventory management..."

F813 SS=F Personal Food Policy CFR(s): 483.60(i)(3)

F813 06/19/2018 §483.60(i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to implement their policy regarding food brought by family and visitors when: 1. Residents, family, and visitors were not provided a copy of the facility policy on food brought by Family/Visitors. 2. Staff was not aware that there was a policy and was not trained in safe food handling practices. This failure resulted in the residents, family, and visitors not being aware of the facility's policy and staff not aware of the process of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 93 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE handling resident's food from home safely which had the potential to result in foodborne illness. Findings: 1. On 5/17/18 at 9:26 a.m., during an interview, the Dietary Cook (DC) 1 stated food from home does not come to the kitchen. The DC 1 stated it goes to the nursing station. On 5/17/18 at 2:31 p.m., during an observation of the refrigerator in the North station medication room (med room) and concurrent interview, there were 2 yogurt cups labeled "35B", 8 Ensure cartons labeled "44A" and 2 Ensure bottles labeled "[Resident 11's last name]." Licensed Nurse (LN) 11 stated, "We verbally say it that it is only good for 3 days. We don't give [family and residents] the policy." On 5/17/18 at 2:38 p.m., during an interview, the Licensed Nurse Unit Manager (LNUM) stated," They [residents] can keep them [food] on bedside. There is a fridge for residents in the med room. They check it with nursing and they give it to us [staff] to keep in fridge." The LNUM stated anything opened, you only keep for 3 days. On 5/17/18 3:36 p.m., the LNUM also stated, "We [staff] inform them [residents] upon receipt of food that it is only good for 3 days. They don't get the policy." On 5/17/18 at 4:01 p.m., during an interview, Resident 43 stated, "It is okay to bring food from outside. I get Ensure. My daughter brings a carton. I didn't get any policy for food brought in. I don't know if my daughter got one." The facility policy and procedure titled, "Foods brought by Family/Visitors" dated July 2017, indicated "... 2. Nursing staff will provide family/visitors who wish to bring foods to the facility with a copy of this policy. Residents will also be provided a copy..." 2. On 5/17/18 at 3:56 p.m., during an interview, Certified Nursing Assistant (CNA) 13 stated, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 94 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE "Residents' food from family should have their name, date and room number. I have been here for 5 years. It has always been like that. There is a fridge in the med room. The stuff [food] they can't finish, they can eat it the next day." CNA 13 stated she was not aware of a policy. On 5/17/18 at 4:27 p.m., during an interview, the LNUM stated, "We label it [food] with name or room number." On 5/18/18 at 9:18 a.m., during an interview regarding the residents' food in the fridge, LN 12 stated, "It's food that the family brought in. If it's closed, we keep it. If opened we throw it after a day or 2." LN 12 stated, "Policy? Not that I know of... You are supposed to put, name and room number... There is no log for the residents' food in the fridge... With just the resident room number, if the resident transfers a room, then it would probably end up being forgotten." On 5/18/18 at 10:02 a.m., during an interview regarding CNA in-services for food handling and food brought by family or visitors, the Director of Staff Development (DSD) stated, "I don't know if we have Safe Food Handling inservice." The DSD also stated there is no inservice for food brought from home. When asked about the process for food brought in by family, DSD stated, "The CNA checks their (resident's) diet with nurse and make sure it is okay for resident to eat... They (staff) put food in the refrigerator in the med room with their (resident's) name and date on it." When asked if there is a policy for food brought from home, the DSD stated, "I don't know if there is a policy but I do know that that is a nursing practice." On 5/18/18 at 11:01 a.m., during an interview, the Admissions Director (AD) stated, "There is FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 95 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE nothing about food from home on the admissions packet. We do let them know verbally that they can bring food from home." On 5/18/18 at 11:06 a.m., during an interview regarding food brought by family or visitors, the Director of Nursing stated, "I am not sure if there is one (policy)... If they bring it hot they give it directly. If it's refrigerated stuff, we keep it 3 days... We put the patient's room #, name and date you received it because if they get a room change then nobody knows whose it is... We try not to hold it for them coz (because) it might get forgotten and lost... I haven't done an in-service for it." The facility policy and procedure titled, "Foods brought by Family/Visitors" dated July 2017, indicated "... 5. All personnel involved in preparing, handling, serving or assisting the resident with meals or snacks will be trained in safe food handling practices... Food brought by family/visitors... will be stored in re-sealable containers with tight-fitting lids... Containers will be labeled with resident's name, the item and the "use by" date."

F842 SS=D Resident Records - Identifiable Information CFR(s): 483.20(f)(5), 483.70(i)(1)-(5)

F842 06/19/2018 §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 96 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for(i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain(i) Sufficient information to identify the resident; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 97 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to accurately document the physician order for life-sustaining treatment (POLST, a medical order for the specific medical treatments for a resident during a medical emergency form) in the medical records for one of 31 sampled residents (Resident 56). This failure had the potential risk for Resident 56's life-sustaining orders not being followed. Findings: On 5/16/18 at 4:02 p.m., during an interview and concurrent record review with Licensed Nurse (LN) 6. Resident 56's POLST, dated 9/20/16, indicated Do Not Resuscitate (DNR) status. LN 6 stated the doctor signed the form on 9/21/16. LN 6 stated there is a binder with the POLST forms at the nurses' station. LN 6 stated the binder was labeled "Master POLST binder." The original POLST form was observed in the binder. LN 6 stated there was an MD (medical doctor) order for the code status. LN 6 located the physician's order in the computer. The physician order indicated a full code status. She stated she was unsure why the order and POLST form were different. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 98 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 5/16/18 at 4:07 p.m., during an interview and concurrent record review, the Director of Nursing (DON) stated the POLST form was only updated when the resident changes his mind. The DON was unable to locate a new POLST form which indicated a full code status. The DON stated the admission nurse would put in the code status upon admission. The DON stated the full code status MD order was dated 9/20/16 and the POLST form was signed by the MD on 9/21/16 for Do Not Resuscitate (DNR). The DON stated medical records was responsible for checking the accuracy of documentation and scanning the POLST form. The DON stated the nurse on the floor should have been reviewing the form. The DON stated the risk of not having accurate documentation for code status was Resident 56 could get Cardio Pulmonary Resusittion (CPR) when he did not want it. The facility policy and procedure titled, "Medical Record Control System Audit Systems-Physician Order Audit" undated, indicated "Purpose: To ensure that the professional staff receiving the Physicians order completed the necessary documentation in each required part of the health record. This will ensure proper coordination of the information from one part of the health record to the other."

F880 SS=E Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 06/19/2018 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 99 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 100 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: 4. On 5/15/18 at 8 a.m., during an observation in Resident 121's room, an uncovered oxygen facial mask was on top of the oxygen machine, the humidifier bottle was undated and oxygen tubing was on the floor. On 5/15/18 at 8:30 a.m., during an interview, RN 1 stated bad things could happen such as "bacteria growth, infections." RN 1 stated, "Its ok the oxygen tubings are on the floor as long as the mask was not." RN 1 stated the oxygen mask, tubings, and humidifier should have been changed by NOC (night) shift on Sunday. The facility policy and procedure titled, "Infection Control Guidelines for all Nursing Procedures" dated 8/2012, indicated "General Guidelines... 2. Transmission-Based Precaution will be used whenever measures more stringent than the Standard Precaution are needed to prevent the spread of infection." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 101 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 5. On 5/15/18 at 8:44 a.m., during an observation, CNA 9 was pushing a soiled linen cart down the hall. CNA 9 went into Room 11 and left the soiled linen cart blocking the doorway. CNA 9 came out of Room 11, lifted the lid of the soiled linen cart, and discarded her soiled gloves. CNA 9 walked to the nurse's station and placed her hands on the counter. CNA 9 then proceeded to Room 23 to help CNA 8 with resident care. On 5/15/18 at 8:50 a.m., during an interview, CNA 9 stated, "We do not wear gloves to push the soiled linen cart and we have to gel or wash our hands after touching or pushing the cart." CNA 9 stated, "No, I didn't gel or wash my hands." CNA 9 stated she should have washed her hands before touching any place after she handled the soiled linen cart. On 5/15/18 at 8:55 a.m., during an interview, CNA 8 stated, "We could not block door ways with the cart [linen], we could not wear gloves in the hall pushing it, and we should wash hands every time we touch the soiled linen cart." The facility policy and procedure titled, "Departmental (Environmental Services)Laundry and Linen" dated 1/2014, indicated "General Guidelines... 3. Consider all soiled linen to be potentially infectious and handle with standard precautions..." The facility policy and procedure titled, "Handwashing/Hand Hygiene" dated 8/2015, indicated "... 7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or nonantimicrobial) and water for the following situations:... b. Before and after direct contact with with residents... i. After contact with a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 102 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident's intact skin..." The document titled, "Infection Control Guidelines for all Nursing Procedures" dated 8/2012, indicated "General Guidelines... 2. Transmission-Based Precaution will be used whenever measures more stringent than the Standard Precaution are needed to prevent the spread of infection." On 5/15/18 at 12:36 p.m., during a lunch observation in the Assisted Dining room, the restorative nursing assistance (RNA) walked into the Assisted Dining room from the outside patio. The RNA walked to table one and sat down next to Resident 103. The RNA started to assist Resident 103 with the meal without performing hand hygiene. On 5/15/18 at 12:59 p.m., during an interview, the RNA stated she did not wash her hands. The RNA stated not washing her hands can spread germs and should have washed her hands before opening the door. On 5/18/18 at 10:26 a.m., during an interview and concurrent record review with the Director of Staff Development (DSD) stated , "CNAs [certified nurse assistants] are expected to perform hand hygiene before assisting with meals and after each tray pass." The DSD stated not doing hand hygiene is an infection control issue. The DSD stated an in-service was done in February on hand hygiene. The DSD provided the in-service list. The facility document titled, "Infection Control Importance of Hand Washing and Proper Technique" dated 2/7/18, indicated RNA was not in attendance during the in-service. The facility policy and procedure titled, "Handwashing/Hand Hygiene" dated 8/2015, indicated "... 7. Use an alcohol-based hand rub FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 103 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE containing at least 62% alcohol; or alternatively, soap (antimicrobial or nonantimicrobial) and water for the following situations:... b. Before and after direct contact with with residents... i. After contact with a resident's intact skin..." Based on observation, interview and record review, the facility failed to ensure facility infection control practices were followed and implemented when: 1. Licensed Nurse (LN)1 did not perform handwashing after resident direct contact. 2. Certified Nursing Assistant (CNA) 5 did not perform proper hand hygiene before, in between, and after resident care and failed to follow transmission-based precaution when handling a resident with a diagnosis of MRSA (Methicillin-resistant staphylococcus aureus) and after disposal of soiled linens for sampled residents (Resident 16 and 56), and one of 15 random residents (Resident 87). 3. Two of 31 sampled residents (Resident 34 and Resident 45) oxygen tubing was not properly stored after use. 4. Resident 121's oxygen tubing was laying on the floor. 5. CNA 9 did not perform hand hygiene after handling and pushing soiled linen carts and before providing resident care. 6. Restorative Nursing Assistant (RNA) did not perfom hand hygiene for one of 15 random residents (Resident 103) during assistive dining for lunch prior to assisting resident with the meal. These failures placed the residents at risk for cross contamination and spread of infectious diseases. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 104 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: 1. On 5/15/18 at 9:02 a.m., during an observation in the south hall, Resident 87 who was sliding down on her wheelchair was wheeled out of her room by a CNA. LN 1 who was doing medication pass, was asked by the CNA to assist in sitting up Resident 87. After the resident was repositioned, LN 1 did not wash hands then, continued working on the medication cart and gathered residents' empty medication bubble packs and bottles for disposal. On 5/15/18 at 9:10 a.m., during an interview, LN 1 stated she should have washed her hands after direct contact with Resident 87 and her bedding before working on the medication cart to prevent cross contamination. On 5/16/18 at 12:06 p.m., during an interview, the Registered Nurse (RN) 1 stated she would have expected the LN to sanitize her hands before resuming her work in the medication cart. The facility's policy and procedure titled, "Handwashing/Hand Hygiene" dated 8/2015, indicated "... Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or nonantimicrobial) and water for the following situations:... Before and after direct contact with with residents;... After contact with a resident's intact skin..." 2. On 5/15/18 at 9:15 a.m., during an observation outside of Room 16, CNA 5 came out of the room with two bags of linens. CNA 5 discarded the bags of soiled linens in a soiled linen cart by using her right hand to open and close the cart lid. CNA 5 proceeded to get an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 105 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Apex (used to transfer residents) from the shower/storage room without washing her hands and entered Room 12. CNA 5 went out of the Room 12 and returned the Apex in the shower/storage room. CNA 5 entered Room 14 without washing hands. Room 14 had a sign of "STOP - Check with the Nurse before entering." CNA 5 came out of Room 14 and did not wash hands. On 5/15/18 at 9:32 a.m., during an interview, CNA 5 stated she helped Resident 56 in Room 12 get dressed. CNA 5 stated she changed Resident 16's brief in Room 14. CNA 5 stated she should have washed her hands before, after and in-between resident's care. CNA 5 stated she did not wash her hands. On 5/15/18 at 12:25 p.m., during an interview, LN 1 stated CNAs were expected to wash hands before, after and in between resident care. LN 1 stated for transmission-based precaution rooms, the CNA should wash hands before and after resident's care. On 5/16/18 at 12:06 p.m., during an interview, RN 1 stated the expectation was CNAs should wash hands, put gloves and gown on, then discard the used protective materials and wash their hands. RN 1 stated CNA 5 should be reeducated on the procedure on infection control. On 5/17/18 at 3:45 p.m., during an interview, the Director of Staff Development (DSD) stated CNA 5 had undergone training in handwashing technique and she should have applied what she had learned. The facility policy and procedure titled, " MRSA - Management of Recurrent Skin and Soft Tissue Infection" dated 7/2013, indicated "... 2. CDC recommends contact precaution...The components of contact precaution... 2. Utilize FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 106 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE standard precaution at all times for all resident care...." The facility document titled, "Infection Control Guidelines for all Nursing Procedures" dated 8/2012, indicated, "General Guidelines...2. Transmission-Based Precaution will be used whenever measures more stringent than the Standard Precaution are needed to prevent the spread of infection." The facility policy and procedure titled, "Handwashing/Hand Hygiene" dated 8/2015, indicated "... Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or nonantimicrobial) and water for the following situations:... Before and after direct contact with with residents... After contact with a resident's intact skin..." The facility policy and procedure titled, "Departmental (Environmental Services)Laundry and Linen" dated 1/2014, indicated "General Guidelines... 3. Consider all soiled linen to be potentially infectious and handle with standard precautions..."3. On 5/15/18 at 09:03 a.m., during an observation and concurent interview in Resident's 34's room, the oxygen canula (tube used to administer oxygen and placed into the nostrils) was wrapped around the small oxygen tank attached to an empty wheelchair unbaged. Licensed Nurse (LN) 5 stated it should be stored in a bag and marked with room number and date. LN 5 stated the cannula could get bacteria on it and the resident could get sick. On 5/15/18 at 11:36 a.m., during an interview in Resident's 34 room, Director of Staff Development (DSD) stated, "The oxygen tubing, nasal cannulas and humidifier tubing masks are changed weekly on Sundays and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 107 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the masks and cannulas should be in a bag that have a date and residents' name so they know who it belongs to." On 5/15/18 at 4:10 p.m., during an observation and interview in Resident 45's room, the oxygen cannula connected to oxygen concentrator was set at 2 L/M (Liters Per Minute). An uncovered cannula was lying on Resident 45's unmade bed. Resident 45 was in a gurney, she had just had a shower. Certified Nursing Assistant (CNA) 1 stated she had to leave in a hurry because the resident was agitated and she had to give her a bath. CNA 1 stated, "...that's why the oxygen had not been turned off or the tubing placed in a bag." On 5/16/18 at 9:40 a.m., during an interview, LN 7 stated. "It [canula] should have been turned off and placed in a bag it could become dirty. It was bad hygiene to be left uncovered. The cannula could grow bacteria. The resident could get a bacterial infection." Resident 45 stated, "I already have pneumonia." The facility document titled, "Infection Control Guidelines for All Nursing Procedures" dated August 2012, indicated "... 2. TransmissionBased Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent the spread of infection..."

F919 SS=E Resident Call System CFR(s): 483.90(g)(2)

F919 06/19/2018 §483.90(g) Resident Call System The facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area. §483.90(g)(2) Toilet and bathing facilities. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 108 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure call lights were within reach for three of 31 sampled residents (Resident 76, Resident 29 and Resident 420) when: 1. Resident 420's call light lay on the floor and was out of reach. 2. Resident 76's call light lay on top of the bed while resident was sitting on her wheelchair and was out of reach. 3. Resident 29's call light lay on top of the bed while resident was sitting on her wheelchair and was out of reach. These failures resulted in the potential harm of Resident 122, Resident 76 and Resident 29 to not be able to call for assistance by using the call light in the event of need or in an emergency. Findings: 1. On 5/17/18 at 8:10 a.m., during a concurrent observation and interview in Resident 420's room, Resident 420 stated Certified Nursing Assistant (CNA) 5 brought her breakfast tray in her room. The lids of the food dishes were wrapped in plastic and she requested CNA 5 to peel off the plastic wrap because she would not be able to do so. Resident 420 showed her contractured hands and stated "I could not use my arthritic hands." Resident 420 stated CNA 5 left in a hurry without helping her. Resident 420 pointed at the call light on the floor and stated, "I could not even use it." Resident 420 stated that she did not eat her breakfast meal. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 109 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 5/7/18 at 8:20 a.m. during a concurrent observation and interview in Resident 420's room, Licensed Nurse (LN) 3 stated the call light should always be within reach of the resident but it was not. On 5/18/18 at 11:57 a.m., during an interview, the License Nurse Unit Manager stated, "The CNA's [Certified Nursing Assistants] are responsible during their initial rounds to make sure residents have what they need. The bedside table should be within reach with resident's water, call light, remote and everything they need." The facility policy and procedure titled, "Answering the Call Light" dated 10/10, indicated "The purpose of this procedure is to respond to the resident's request and needs... 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident..." The facility policy and procedure titled, "Dignity", dated 9/2009, indicated "Each resident would be cared for in a manner that promotes and enhances the quality of life , dignity, respect and individuality... 1. Residents shall be treated with dignity and respect at all times. 2. "Treated with dignity", means the resident will be assisted in maintaining and enhancing his or her self-esteem and self worth..." 2. Resident 76's Minimum Data Set (MDS) (a resident assessment tool used to identify resident function and care needs) dated 5/9/18, indicated a Brief Interview for Mental Status (BIMS) (assessment of cognitive status) score of 6 out of 15 which indicated moderate cognitive impairment. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 110 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 5/15/18 at 8:46 a.m., during a concurrent observation and interview, Resident 76 was sitting on her wheelchair at the front of her bed. Resident 76's bed was elevated. Resident 76 stated, "Ayuda [help]". Resident 76's call light was observed laying on top of her bed and the resident was unable to see and reach it. On 5/15/18 at 8:47 a.m., during an interview, CNA 15 stated, "The call light should not be there [laying on top of the bed]. It should be within reach. On 5/17/18 at 7:57 a.m., during an interview, the Director of Nursing (DON) stated, " Call lights should be within reach. If they are in bed, it should be within easy access and preference." The facility policy and procedure titled, "Answering the Call Light" dated 10/10 indicated, "The purpose of this procedure is to respond to the resident's request and needs...5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident..." 3. Resident 29's MDS assessment dated 3/1/18, indicated a BIMS score of 6 out of 15 which indicated Resident 29 had moderate cognitive impairment. The MDS also indicated, Resident 29 required extensive assistance of one staff member to transfer from one surface to another. On 5/16/18 at 8:30 a.m., during a concurrent observation and interview, Resident 29 was sitting in her wheelchair facing the window. Resident was eating chips. Resident 29 stated, "I am thirsty. I don't have water until they bring me one. It has always been like that. That means I don't get to drink. I don't even know where my light is." Resident 29's call light lay FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 111 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE on top of her stripped bed and Resident 29 was unable to see or reach it. On 5/16/18 at 8:38 a.m., during a concurrent observation and interview, CNA 15 stated, "There is no water here. That's right she can't drink water if there is no water here. Her call light should not be there [on top of the bedside]. It should be near her." On 5/17/18 at 7:57 a.m., during an interview, the Director of Nursing (DON) stated, "Call lights should be within reach. If they are in bed, it should be within easy access and preference." On 5/18/18 at 11:57 a.m., during an interview, the License Nurse Unit Manager stated, "The CNA's [Certified Nursing Assistants] are responsible during their initial rounds to make sure residents have what they need. The bedside table should be within reach with resident's water, call light, remote and everything they need." The facility policy and procedure titled, "Answering the Call Light" dated 10/10 indicated, "The purpose of this procedure is to respond to the resident's request and needs...5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident..."

F925 SS=E Maintains Effective Pest Control Program CFR(s): 483.90(i)(4)

F925 06/19/2018 §483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 112 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE rodents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to maintain an environment free of pest when drain flies were seen flying in the kitchen and landed on a tray of bread. This failure had the potential to result in foodborne illness to the residents from drain flies contaminating the food. Findings: On 5/15/18 at 7:54 a.m., during an observation in the kitchen, an insect was flying by the metal food preparation table. On 5/15/18 at 8:08 a.m., during an observation in the kitchen and concurrent interview, there were seven flying insects that landed on newly washed bowls. When asked what the insects were, The Dietary Aide (DA) 1 stated did not know what kind of insect. The DA stated, "We just sprayed last week, Friday." On 5/15/18 at 12:22 p.m., during an observation in the kitchen, there were four flying insect by the steam table. A flying insect landed and roamed on the tray of bread that was half full and was continuously being served in the tray line during meal service. On 5/16/18 at 9:30 a.m., during an interview regarding the flying insects, the Registered Dietitian (RD) stated it had been four weeks since she had noticed the flies. On 5/16/18 at 12:31 p.m., during an observation in the kitchen, a flying insect was noted roaming on the floor by the sink. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 113 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The facility pest control report dated 4/26/18, indicated "... Technician Comments: I sprayed... 2 drains in the kitchen by the sink The drain by the cone is where the phorid flies [drain flies] are coming from... " On 5/17/18 at 8:55 a.m., during an observation in the kitchen, one drain fly was roaming by the hand washing sink. On 5/17/18 at 9:07 a.m., during an observation in the kitchen and concurrent interview, there were three drain flies observed by the back entrance of the kitchen. The Dietary Cook (DC) 1 stated, "I have no idea what they are. But I noticed them flying around. I noticed it about 2 weeks ago." On 5/17/18 at 9:20 a.m., during an interview regarding the drain flies, DC 1 stated, "If it lands on cooked food, we have to toss the food. The flies would contaminate the food." On 5/17/18 at 9:22 a.m., during an observation of the steam table, one drain fly was flying by the food preparation table close to the steam table. On 5/17/18 at 3:47 p.m., during an interview about the flying insects in the kitchen, the District Manager (DM) stated, "They [kitchen staff] have talked to maintenance about it, to get pest control. It is drain flies. The DM stated, "The food should be tossed." On 5/18/18 at 8:34 a.m., during an observation in the Dietary office in the kitchen and concurrent interview regarding the drain flies, two drain flies were observed flying in the office. The Dietary Supervisor (DS) stated, "I don't know what they are. I have never seen them before. They look like a baby fly. It's been FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 114 of 115 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056301 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VISTA POST-ACUTE 1900 Coffee Rd Modesto, CA 95355 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE going on about a month. When they first came out they were a lot." The DS stated flies carry diseases and germs. The DS stated "If they [staff] saw it [drain flies touching the food] they would throw the food away." The facility policy and procedure titled, "Pest Control" dated 9/2017, indicated "...1. The Dining Services Director coordinates with the Director of Maintenance to arrange pest control services on a monthly basis, or as needed. 2. All food preparation, service, and storage areas will be monitored regularly for any signs of pest/vermin..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J3XY11 Facility ID: CA030000072 If continuation sheet 115 of 115