Modesto Post Acute Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from a preventable injury when Resident 1 spilled hot coffee onto his lap. This failure resulted in a second-degree burn (involving the first two layers of skin and may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin) to the skin on Resident 1's scrotum (private male area), causing pain and risk for infection. (Exposure of skin to water temperatures of 155 degrees Fahrenheit (F) for as little as 1 second may result in burns as severe as third-degree, which are more severe than second-degree). During a review of Resident 1's admission Record (AR), dated 7/19/26, the AR indicated he was discharged from the facility on 7/5/26. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure garbage storage area was maintained in safe and sanitary conditions when:1. Grayish fluids from the sewer and thick yellowish drainage from the grease trap were draining creating a pool into the driveway on 3/17/26.2. Two of the three garbage bins did not have a lid and were open to air on 3/18/26. These failures had the potential for unwanted pest ((any organism-insect, rodent, or microbe-those damages structures or threatens human health) which could have led to disease transmission causing foodborne illness (results from eating food contaminated with germs [bacteria, viruses, parasites] or toxins) leading to hospitalization for 98 residents, vendors, guests and staff.

Inspectors wroteBased on interview and record review the facility failed to promote and implement an antibiotic (ATB) stewardship and surveillance program (ATBS- designed to reduce unnecessary use of antibiotics and to limit the spread of antibiotic resistance in bacteria) for the use of antibiotics when:Infection screening evaluations (ISE-completed before starting antibiotics to ensure the medication is necessary, effective, and targeted) were not completed before residents started antibiotics. Antibiotics discontinued after initiation, for not meeting infection screening evaluation criteria, were not included in antibiotic stewardship data review or monitoring for 2/2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored and prepared safely in accordance with professional standards of food service safety for 95 out of 98 residents receiving food at the facility when:1. An open bag of potato chips inside a zip lock bag did not have a use by (a crucial safety indicator found on perishable foods like meats and salads, marking when it is no longer safe to eat, even if it appears fine) date.2. The food preparation sink did not have an air gap (space between the end of sink pipe and top of sink to prevent backflow). These failures had the potential to result in the serving of expired, spoiled, or contaminated food and items which could result in foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) to 95 residents receiving food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of 10 sampled residents (Resident 74 and Resident 75) were informed, in advance, by the physician or other practitioner, of the risks and benefits of proposed treatment when:1. Resident 74 did not have a signed physician informed consent (a process in which a healthcare professional educates a patient about the risks, benefits, and alternatives of a given procedure or intervention) prior to receiving psychotropic (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) medications Mirtazapine (a drug used to treat depression) and buspirone (a medication used to treat generalized anxiety disorder).2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a homelike environment was maintained for one of eight sampled residents (Res 2) when the Resident's Clothing and Possession Inventory on admission (RCPIA-a sheet used for inventorying residents' personal items) was not updated to reflect current items in the closet on 3/20/26. This failure resulted in Res 2's personal items being inaccurately inventoried, which could lead to clothing and items being unaccounted for when missing and has the potential to cause upset and inconvenience for residents and their families.

Inspectors wroteBased on interview and record review, the facility failed to revise and implement, in a timely manner, a person-centered comprehensive care plan (CP- a personalized, written document detailing an individual's health needs, goals, and the specific services or support required to manage them) for two of eight residents (Res 2 and Res 70) when:1. Res 2 's had continued CP' for not swallowing and pocketing (the act of holding food in the mouth) food when returned from the hospital with a percutaneous endoscopic gastrostomy (PEG tube-a feeding tube inserted through the abdomen into the stomach) and was NPO (nothing by mouth) on 12/22/24.2. Res 70's had a continued short term care plan to observe for dark amber urine past the 48-to-72-hour timeframe. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure professional standards of practice for two of six sampled residents (Resident 87 and 104) when:1. Resident 87 was administered amiodarone (blood pressure [force of blood pushing against artery walls] medication used to treat irregular heart rhythms), four times, outside of ordered parameters. This failure resulted in Resident 87 receiving amiodarone on 2/3/26, 2/5/26, 2/13/26 and 3/11/26 when it should have been held, according to order parameters, which could lead to decreased blood pressure, cardiac distress and adverse effects. 2. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure vegetables were prepared to conserve appearance and palpability for three of eight sampled residents (Res 25, Res 60 and Res 69) when the Italian blend vegetables with carrots and squashes were soft and mushy, and string beans were split in half with bean pods exposed for lunch served on 3/19/26.,This failure had the potential to result in vegetables not being consumed for Res 25, Res 60 and Res 69 and not meeting their recommended daily allowance (RDA- the average daily dietary intake level sufficient to meet the nutrient requirements of nearly all (97.5 percent) healthy) leading to malnutrition (a dangerous imbalance between the nutrients the body needs and those it receives).

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an effective infection prevention and control program for one of four sampled residents (Resident 103) when Personal Protective Equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) was not worn during care for Resident 103 who was on Enhanced Barrier Precautions (EBP- an infection control intervention designed to reduce transmission of resistant organisms [bacteria that have become resistant to certain antibiotics] that requires gown and glove use during high contact resident care activities). [...]

Inspectors wroteBased on observation, interview, and record review during the survey period of 3/17/26 through 3/20/26, the facility failed to provide the minimum of at least 80 square feet per resident in 27 of 37 multiple resident rooms (rooms 101, 102, 103, 104, 105, 106, 107, 108, 115, 116, 117, 118, 119, 120, 121, 122, 123, 124, 128, 130, 131, 132, 133, 134, 135, 136, and 137). This failure had the potential for residents to not have reasonable accommodations for privacy or adequate space for care to be rendered.

Inspectors wroteBased on interview and record review, the facility failed to report an injury of unknown origin for one of three sampled residents (Resident 1) when Resident 1 was noted to have pain, bruising, and swelling to her right hand and wrist; and discoloration to her left wrist. This failure resulted in Resident 1's injuries of an unknown source to not be investigated, placing Resident 1 at potential risk for harm and/or abuse, and delayed medical intervention.

Inspectors wroteBased on interview and record review, the facility failed to honor six out of six sampled residents ' (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6) rights when they all were given written notices they would have to move into different rooms in the facility with no existing reason to do so, despite some of the residents having resided in their rooms for several years. This failure resulted in: 1. The potential for more than minimal harm for Resident 1, Resident 2, Resident 3, Resident 5, and Resident 6 when their collective right to a respectful and dignified existence was not honored by failing to allow all six residents ' rights to self-determination, affecting their right to a respectful and dignified environment, by not allowing them to remain in their rooms that had been their home for years which the residents strongly objected to, and, 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its transfer and discharge policy and procedure for one of three sampled residents (Resident 1) when the facility failed to comply with the legal requirements to provide Resident 1 with sufficient preparation and orientation to ensure a safe and orderly discharge from the facility. This failure had the potential to result in Resident 1's unsafe discharge and increased likelihood of preventable re-admissions.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a significant medication error did not occur for 1 (Resident #46) of 5 residents reviewed for unnecessary medications. Specifically, facility staff failed to follow a physician's order to hold midodrine hydrochloride (a medication used to treat low blood pressure) when the resident's systolic blood pressure (SBP, the top number in a blood pressure reading) was greater than 130 millimeters of mercury (mmHg) and failed to only administer losartan potassium (a medication used to treat high blood pressure) when the resident's SBP was greater than 130 mmHg.

Inspectors wroteBased on observation, interview, facility document review, and facility policy review, the facility failed to ensure residents rooms measured at least 80 square (sq) feet (ft) per resident in 26 (Rooms 101-108, Rooms 115-124, and Rooms 130-137) of 36 resident rooms in the facility.

Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to provide 1 (Resident #40) of 1 sampled resident reviewed for preadmission screening and resident review (PASARR) with the recommended specialized services identified by the resident's PASAR) Level II. Specifically, the PASARR determination report dated 04/18/2024 for Resident #40 recommended specialized services of psychotherapy/counseling which were not provided by the facility.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure windows on the secure unit were locked and secure for 2 (room [ROOM NUMBER] and room [ROOM NUMBER]) of 9 residents' rooms located on the secure unit. Specifically, room [ROOM NUMBER] and room [ROOM NUMBER] had missing and/or damaged window screens and no locking mechanism to prevent the windows from opening fully.

Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to obtain psychiatric consultation as ordered for 1 (Resident #58) of 19 sampled residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure nursing staff did not document the monitoring of peripheral intravenous (IV) site when the resident no longer had the IV because it had been removed for 1 (Resident #297) of 19 sampled residents.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure facility staff used appropriate hand hygiene during meal service for 1 (Resident #66) of 10 sampled residents observed for dining.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure reasonable accommodation of resident needs was provided for one of three sampled residents (Resident 1) when Resident 1 was scheduled to be out of the facility (4/18/24) for an appointment for four hours during lunchtime and was not provided with food (packed food). This failure resulted in Resident 1 not having eaten any food from 10 a.m. until after 5 p.m. which placed Resident 1 at risk for hypoglycemia (low blood sugar).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff were trained to access emergency water supplies. This failure placed residents, staff and visitors at risk of being without water in the event of an emergency.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a resident centered comprehensive care plan for three of five sampled residents (Resident 49, 70 and 97) when: 1. Resident 49's care plan intervention for the indwelling catheter tubing (tube inserted into the bladder to drain urine) was not implemented and the indwelling catheter tubing was not positioned in a manner that would allow urine to drain into the urine collection bag. This failure had the potential to allow for backflow of urine and increase the risk for a urinary tract infection (infection in the bladder). 2. Residents 70 and 97 were administered blood thinning medications and did not have a care plan developed with interventions that would monitor side effects from the use of blood thinning medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services which meet professional standards of quality for five of six sampled residents (Resident 24, 37, 46, 299 and 300) when: 1. Two of four sampled Licensed Vocational Nurse (LVN) 6 and LVN 2 failed to follow the facility's Policy and Procedure when obtaining a fingerstick blood sample (a procedure in which a finger is pricked with a lancet [a small needle device] to obtain a small quantity of blood for blood sugar testing) for Residents 37, 46, 299, and 300. LVN 6 and LVN 2 used the first drop of blood instead of using a clean blood sample from Resident 37, 46, 299, and 300's fingertips for fingerstick blood sugar level. This practice had the potential for residents on fingerstick blood sugar to have an inaccurate blood sugar level result. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide dialysis services consistent with professional standards of practice for three of three sampled residents (Resident 33, 46 and 349) when the Dialysis (the process of artificial filtering and removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions) coordination of service Assessment Communication Record (DACR - form used to communicate pertinent dialysis resident assessment information from facility nursing staff to dialysis center staff ) form was not fully completed before or after dialysis treatment. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Licensed Nurses (LNs) possessed specific competencies required to accurately perform fingerstick blood sugar testing (a procedure in which a finger is pricked with a lancet [a device with an attached small needle used to prick the skin] to obtain a small quantity of blood for blood sugar testing) and for accurate use of insulin lispro Flex Pens (a dial-a-dose device, pre-filled insulin pen for discreet insulin medication administration) for five of six sampled resident's (Resident 24, 37, 46, 299 and 300) when: 1. Two of four sampled Licensed Vocational Nurse (LVN) LVN 6 and LVN 2 did not possess competencies to perform fingerstick blood sugar testing for Resident 37, 46, 299, and 300. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an effective infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable (contagious) diseases and infections when: 1. Certified Nursing Assistant (CNA) 3 did not perform hand hygiene (hand washing or use of hand sanitizer) while providing feeding assistance for two of 16 sampled residents (Resident 59 and 64) after touching unclean equipment, surfaces and residents during meal service. 2. Licensed Vocational Nurse (LVN) 5 did not wear Personal Protective Equipment (PPE - gloves, gown, and mask) prior to entering a contact isolation (precautions used to prevent the spread of infection) room for one of one sampled resident (Resident 70). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide two of 16 sampled residents (Resident 64 and Resident 80) with a dignified dining experience in accordance with the facility policy and procedure when Certified Nursing Assistant (CNA) 3 assisted residents with their meals in a standing position. This deficient practice violated Resident 64 and 80's right to a dignified dining experience and had the potential to negatively affect their quality of life.

Inspectors wroteBased on observation and interview, the facility failed to provide and maintain a minimum of at least 80 square feet per resident in multiple resident rooms (Rooms 101-108, 115-124, 130-137). This failure had the potential for residents to not have reasonable privacy or adequate living space.