Other·October 1, 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 represents the findings of the California Department of Public HealthLicensing and Certification during an Abbreviated Survey for Complaint: CA 00574409. Representing the California Department of Public Health-Licensing and Certification by Federal ID: 36476, RN HFEN. The Abbreviated Survey was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Complaint: CA 00574409: One deficiency was issued.

F624 SS=G Preparation for Safe/Orderly Transfer/Dschrg CFR(s): 483.15(c)(7)

F624 09/07/2018 §483.15(c)(7) Orientation for transfer or discharge. A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure a safe and orderly discharge for one of three sampled residents, Resident 1. Resident 1 was discharged after 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: IJXL11 Facility ID: CA030000107 If continuation sheet 1 of 11 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: _______________ 055849 (X3) DATE SURVEY COMPLETED 08/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MODESTO POST ACUTE CENTER 159 E Orangeburg Ave Modesto, CA 95350 (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 she left the facility with Family Member (FM) 1 on a day pass and did not return. FM 1, who had no training in caring for elderly persons with dementia and was known to the facility to have aggressive and inappropriate behaviors refused to return Resident 1 to the facility. The Facility did not enlist the aid of the local police department or Resident 1's primary physician to ensure Resident 1's safety, but rather abdicated their responsibility and discharged Resident 1 to the care of FM 1. As a result of this failure, Resident 1 was placed at risk for serious harm from lack of medical supervision and did not receive physician prescribed medications from 11 a.m. on 2/14/18 until admission to the General Acute Care Hospital (GACH) on 2/16/18. Resident 1 was admitted to the GACH on 2/16/18 for hypertension (high blood pressure) and bronchitis (infection in the airways of the lungs) and remained in the GACH until 2/26/18 when she was transferred back to the Skilled Nursing Facility (SNF). Findings: Review of Resident 1's clinical record titled, "Face Sheet (document containing resident personal information)" indicated Resident 1 was an 87-year-old female who had resided in the facility since 7/9/15. The Face Sheet indicated Resident 1 had diagnoses that included Dementia (disorder causing impaired memory, reasoning, and judgment), Hypertension (high blood pressure), Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and Chronic Pain (pain lasting more than 12 weeks). The Face Sheet indicated FM 1 was the Responsible Party for making decisions regarding Resident 1's care. The Face Sheet listed a phone number for FM FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IJXL11 Facility ID: CA030000107 If continuation sheet 2 of 11 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: _______________ 055849 (X3) DATE SURVEY COMPLETED 08/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MODESTO POST ACUTE CENTER 159 E Orangeburg Ave Modesto, CA 95350 (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 1, but no physical address. Review of Resident 1's clinical record titled, "Minimum Data Set" (MDS) (a resident assessment tool used to plan resident care) assessment, dated 2/8/18, indicated a Brief Interview for Mental Status (BIMS, an assessment of memory and recall) score of five points out of 15 possible points which indicated severe memory and recall impairment. The MDS indicated Resident 1 was ambulatory (able to walk) with the aid of a walker, required assistance of one person to use the toilet, required extensive assistance to dress and was totally dependent on staff assistance to bathe. Review of Resident 1's "Order Summary Report (Physician's Orders)" dated 2/15/18 indicated Resident 1 was prescribed multiple medications including: "Remeron [medication to treat depression] 15 mg [milligrams, a unit of dosage] Give 1 tablet by mouth at bedtime ...Gabapentin [medication to treat nerve pain] 100 mg 1 capsule by mouth two times a day ...Aspirin [medication to treat mild pain and to prevent heart attack and stroke] 81 mg 1 tablet by mouth at bedtime ...Atorvastatin Calcium [medication to treat high blood fat levels that could lead to stroke] 80 mg daily ...Isosorbide Mononitrate ER (extended release) [medication used to treat heart disease] 30 mg by mouth 1 time a day ...Lisinopril Tablet [medication to treat high blood pressure] 1 time a day ...Metoprolol Tartrate Tablet [medication to treat high blood pressure] 1 tablet by mouth two times per day ...Nitroglycerin Tablet [medication to treat chest pain caused by poor blood supply to the heart] Sublingually [given under the tongue] 0.4 mg. Give 1 tablet sublingually as needed for chest pain every 5 min. [minutes] Repeat X [times] 3 doses, if pain does not relieve call MD [physician]." The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IJXL11 Facility ID: CA030000107 If continuation sheet 3 of 11 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: _______________ 055849 (X3) DATE SURVEY COMPLETED 08/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MODESTO POST ACUTE CENTER 159 E Orangeburg Ave Modesto, CA 95350 (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 "Order Summary Report" indicated "May go out on pass with RP [Responsible Party] if stable ...order dated 2/14/18." On 2/21/18 at 9:35 a.m., during an interview, the Director of Nursing (DON) stated on 2/14/18 FM 1 arrived at the facility and told the receptionist he was taking Resident 1 out to lunch. The DON stated FM 1 had a history of aggressive and hostile behaviors toward staff and visitors and was not permitted in the facility past the lobby. The DON stated Resident 1 had a physician's order to go out on pass and on 2/14/18 staff took Resident 1 to the lobby. The DON stated Resident 1 and FM 1 left the facility at 11:20 a.m. on 2/14/18 to go to lunch. The DON stated Resident 1 did not return to the facility the night of 2/14/18 and the facility Administrator (Admin) made a decision to discharge Resident 1 to the care of FM 1 on the morning of 2/15/18. On 2/21/18 at 10:06 a.m., during an interview, the facility Social Services Director (SSD) stated FM 1 called her on 2/13/18 and asked for a pass to take Resident 1 to lunch on 2/14/18. The SSD stated she checked the physician orders and told FM 1 Resident 1 had a pass to go out for the day, but not overnight. The SSD stated, "[FM 1] said no more than two hours - they would just be gone for lunch." The SSD stated, "Around 11:20 a.m. [FM 1] arrived. He brought documents for a passport. [FM 1] asked if I could help him get a passport for [Resident 1]. I told him I was not the right person to ask ...We had quite a few behavior problems with [FM 1]. He was harassing the staff and residents. In fact one resident got a temporary restraining order on him. Ultimately [FM 1] was not allowed inside the facility." The SSD stated at 4 p.m. on 2/14/18 Resident 1's nurse wondered why she had not yet returned to the facility. The SSD stated the nurse called FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IJXL11 Facility ID: CA030000107 If continuation sheet 4 of 11 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: _______________ 055849 (X3) DATE SURVEY COMPLETED 08/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MODESTO POST ACUTE CENTER 159 E Orangeburg Ave Modesto, CA 95350 (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 FM 1 15 to 20 times and received no answer. The SSD stated the night shift nurse continued to call FM 1 and on 2/15/18 at 12:30 a.m. FM 1 answered his phone. FM 1 told the night nurse he would keep Resident 1 with him for 14 days. The SSD stated the night nurse reminded FM 1 that Resident 1 needed her medication and did not have any medication or clean clothing with her. The SSD stated FM 1 brought Resident 1 back to the facility the afternoon of 2/16/18. The SSD stated, "We told him [Resident 1] was already discharged [from the SNF]. [FM 1] called 911 [emergency response phone number] outside in the parking lot. A fire truck showed up. [FM 1] would not let them take [Resident 1] to the hospital. [Local police department] was called by EMS [emergency medical services]. [Resident 1] was taken to [local GACH] to be evaluated since she had been gone since 2/14/18." The SSD stated Resident 1 was still in the GACH, her room had been reassigned to another resident on 2/15/18 when she did not return from her luncheon outing. The SSD stated, "Knowing what we know now, we would have not allowed [FM 1] to sign [Resident 1] out." On 2/21/18 at 10:40 a.m., during an interview, Licensed Nurse (LN) 1 stated Resident 1 had dementia, had her own routines she followed and seemed to like staying in the facility. LN 1 stated FM 1 was "aggressive, threatening ...he got in staffs' face ...he would talk about shootings, bombings, how he had a black belt ...almost harassing, he was being that to staff, residents and families ..." LN 1 stated she called FM 1 on 2/14/18 at 5 p.m. and left a voice message on his phone that Resident 1 needed to return to the facility for her medications. On 2/21/18 at 11:37 a.m., during an interview, LN 2 stated she was assigned to Resident 1 on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IJXL11 Facility ID: CA030000107 If continuation sheet 5 of 11 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: _______________ 055849 (X3) DATE SURVEY COMPLETED 08/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MODESTO POST ACUTE CENTER 159 E Orangeburg Ave Modesto, CA 95350 (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 2/14/18. LN 2 stated Resident 1 received her medications and was given a shower prior to leaving for lunch with FM 1. LN 2 stated, "[FM 1] can be a problem. We had several bad encounters with him. He made threats to the staff, residents and even family members ...The facility had called the police on him a few times." On 2/21/18 at 12 p.m., during an interview, the DON stated, "We tried to contact [FM 1] on 2/14/18 multiple times and left him messages about [Resident 1's] medications that she needed to take and he did not respond. By doing that - not getting in touch with us, we considered that [leaving the facility] against medical advice." On 2/21/18 at 12:21 p.m., during an interview, the facility Admin stated FM 1 was permitted to take Resident 1 out on a day pass only. The Admin stated when Resident 1 did not return to the facility on 2/15/18 the SSD called Adult Protective Services (APS) do a wellness check on Resident 1. The Admin stated APS was not able to do a wellness check because the facility had no record of a physical address for FM 1, only a post office box because FM 1 refused to give the facility his physical address. The Admin stated FM 1 did not have Resident 1's medications when she left the building and did not have the training to take care of a dementia patient such as Resident 1. The Admin stated he made a decision to discharge Resident 1 "Against Medical Advice [AMA]" on 2/15/18 because she was gone overnight with FM 1 and FM 1 had refused to return Resident 1 to the facility. The Admin stated, "I made the decision to discharge [Resident 1]." The Admin stated he did not consult Resident 1's physician for advice or orders prior to making the decision to discharge Resident 1. The Admin stated he did not contact the local police FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IJXL11 Facility ID: CA030000107 If continuation sheet 6 of 11 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: _______________ 055849 (X3) DATE SURVEY COMPLETED 08/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MODESTO POST ACUTE CENTER 159 E Orangeburg Ave Modesto, CA 95350 (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 department to assist in locating Resident 1 for a wellness check when FM 1 refused to bring her back to the facility. The Admin stated the facility Interdisciplinary Team (IDT, a team of health care providers including nursing, social services, dietary staff and physicians that meet to plan resident care) did not meet to review the situation before he made the decision to discharge Resident 1. The Admin stated it was not a safe discharge; FM 1 was not trained to provide care to Resident 1, who had dementia. On 2/26/18 at 8:17 a.m., during a telephone interview, GACH Medical Social Services (MSS) 1 stated Resident 1 arrived at the GACH on 2/16/18 by ambulance and was sent to the Emergency Department (ED) for a medical clearance to return to the SNF. The MSS stated Resident 1 was cleared medically later that day. The MSS stated ED staff called the SNF regarding sending Resident 1 back but the SNF stated they did not have a bed available. The MSS stated the GACH could not find a SNF for Resident 1 so she was admitted as an inpatient to the GACH. On 5/8/18 at 10:20 a.m., during a telephone interview, the Business Office Manager (BOM) stated Resident 1 was discharged from the SNF on 2/15/18 at 10:51 a.m. On 5/8/18 at 1:30 p.m., during a telephone interview, the DON stated there was no physician discharge order for Resident 1. The DON stated the licensed nursing staff should obtain and document a physician discharge order. The DON stated, "It doesn't look like we have an official order for discharge [for Resident 1]." Review of Resident 1's clinical record titled "Progress Notes" dated 2/15/18 at 6:19 p.m., indicated "Able to reach [FM 1] on his phone FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IJXL11 Facility ID: CA030000107 If continuation sheet 7 of 11 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: _______________ 055849 (X3) DATE SURVEY COMPLETED 08/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MODESTO POST ACUTE CENTER 159 E Orangeburg Ave Modesto, CA 95350 (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 stated he isn't able to bring back [Resident 1]. Writer did let him know that as of this time [Resident 1] is discharged from facility and need to come pick up her medication. Then he goes on and said, "I thought she will be happy and smiling to see me, but she is like a baby. I was looking for her love and affection but she looks indifferent ..." The progress note was electronically signed by LN 4. Review of Resident 1's clinical record titled "Progress Notes" dated 2/16/18 at 1:46 p.m., indicated "[FM 1] in this afternoon with [Resident 1] attempting to bring Resident back. Explained that resident is now discharged from facility and we are unable to accept [Resident 1] back at this time. He stated that he did not sign up for discharge ...continued to say we needed to assist [Resident 1] back into her room and Administrator and writer explained that we were unable to do that. [FM 1] then called 911. Firefighters showed up, resident continued to sit in the car, firefighters unable to convince [FM 1] to allow resident to go to the hospital since she had not had her medications in the last 2 days. [Local PD] showed up and spoke with resident and [FM 1], he was able to convince to allow to go to hospital. 2 EMTs [emergency medical technicians] showed up and resident was assisted to the gurney." The progress note was electronically signed by the SSD. Review of Resident 1's GACH clinical record titled, "ED [Emergency Department] Note" indicated "Time seen: Date and time 2/16/18 12:31 [p.m.]...Arrival mode: Ambulance ...History of Present Illness: The patient [Resident 1] presents with medical screening and Afib [Atrial Fibrillation, a fast, irregular heart beat] ...risk factors consist of no afib medication for 2 days ...Diagnosis: Cough ...Addendum: CXR [Chest X-ray] possible PNA FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IJXL11 Facility ID: CA030000107 If continuation sheet 8 of 11 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: _______________ 055849 (X3) DATE SURVEY COMPLETED 08/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MODESTO POST ACUTE CENTER 159 E Orangeburg Ave Modesto, CA 95350 (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 [pneumonia, a lung infection] ...will treat with doxy [doxycycline, an antibiotic to treat infection]." Review of Resident 1's GACH clinical record titled, "Discharge Plan Update" dated 2/17/18, indicated "Patient [Resident 1] is ready for D/C [discharge]." Review of Resident 1's GACH clinical record titled, "Discharge Plan Update" dated 2/24/18, indicated "Per [SNF Marketing and Admissions Director] they do not have a bed today; possibly Wed. [Wednesday] 2/28/16." Review of Resident 1's GACH clinical record titled, "Discharge Summary" dated 2/26/18 indicated, "Dis [discharge] date: 2/26/18. Discharge Diagnoses: 1. Chronic atrial fibrillation [irregular heart beat] 2. Hypertension 3. Bronchitis ...She was supposed to be discharged back to [SNF] but her bed was given away. Patient was found to have bronchitis and completed the course of doxycycline ...Patient will be discharged back to [SNF]." The facility policy and procedure titled, "Discharging a Resident without a Physician's Approval", dated October 2012, indicated "Policy Statement: A physician's order should be obtained for all discharges unless a resident or representative is discharging himself or herself against medical advice. Policy Interpretation and Implementation: 1. Should a resident or his or her representative (sponsor) request an immediate discharge, the resident's Attending Physician will be promptly notified. 2. The order for an approved discharge must be signed and dated by a physician and recorded in the resident's medical record. 3. If the resident or representative insists upon being FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IJXL11 Facility ID: CA030000107 If continuation sheet 9 of 11 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: _______________ 055849 (X3) DATE SURVEY COMPLETED 08/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MODESTO POST ACUTE CENTER 159 E Orangeburg Ave Modesto, CA 95350 (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 discharged without the approval of the Attending Physician, the resident and/or representative must sign a Release of Responsibility form. Should either party refuse to sign the release, such refusal must be documented in the resident's medical record and witnessed by two staff members." The facility policy and procedure titled, "Discharging the Resident" dated 12/16 indicated, "Preparation ...5. If the resident is being discharged home, ensure that resident and/or responsible party receive teaching and discharge instructions ..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IJXL11 Facility ID: CA030000107 If continuation sheet 10 of 11 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: _______________ 055849 (X3) DATE SURVEY COMPLETED 08/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MODESTO POST ACUTE CENTER 159 E Orangeburg Ave Modesto, CA 95350 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IJXL11 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA030000107 (X5) COMPLETE DATE If continuation sheet 11 of 11