Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Modesto Post Acute Center during CMS and state inspections, most recent first.
Improper Garbage Storage and Sewage Drainage in Waste Area: The facility failed to maintain the garbage storage area in safe and sanitary conditions when grayish sewer fluids and thick yellow drainage from the grease trap pooled in the driveway near the garbage bins, creating a foul sewage odor. The facility also left one garbage bin open and allowed another to be overfilled so the lid could not close properly. The MND, CDM, RD, and ADM all acknowledged the conditions did not follow the facility’s waste management policy.
Antibiotic stewardship and surveillance were not properly implemented when an ISE was not completed before a resident started an antibiotic, and the antibiotic was later stopped after the resident did not meet infection criteria. The resident’s antibiotic use was not included in the monthly ATBS data review, and the CP could not locate a pharmacy review for the antibiotic. The IP stated she had no designee to complete ISEs in her absence, which resulted in residents starting antibiotics before screening was completed and incomplete ATBS reporting.
Food storage and prep practices were not maintained when an open bag of potato chips in a zip lock bag was found without a use by date, and the CDM and RD stated all opened items should be labeled to prevent spoilage and expired food from being served. In addition, the food prep sink was observed draining into the ground without an air gap; the CDM, RD, and ADM acknowledged the need for an air gap to prevent backflow and cross-contamination.
Incomplete informed consent for psychotropic medications: Two residents had psychotropic medication orders without valid provider-signed consent documentation. One resident had buspirone and mirtazapine ordered with no signed physician consent in the chart, and another resident had a PRN lorazepam order with an informed consent form missing the provider signature. Staff interviews confirmed the consents were incomplete and that the residents or their RPs were not documented as being fully informed in advance of the risks, benefits, and alternatives.
A resident with severe cognitive impairment and diagnoses including dysphagia, AKI, DM, anemia, and gastrotomy had an outdated clothing and possession inventory that did not match items found in the closet. The family reported prior missing blankets and a cell phone, and staff confirmed the inventory should have been updated when new items were brought in. The RN, SSD, and ADM acknowledged the resident's belongings were not properly inventoried and that the facility did not follow its policy.
Care plans were not timely revised for two residents when their conditions changed. One resident returned from the hospital with a PEG tube and NPO status, but the care plan still addressed not swallowing and pocketing food. Another resident’s short-term care plan for dark amber urine remained active beyond the 48-to-72-hour timeframe. Staff, including the CN and MDS nurse, stated the plans should have been updated to reflect the residents’ current needs.
A resident with AFib, heart failure, and hypotension received amiodarone outside ordered BP parameters on multiple occasions, even though the order said to hold it if SBP was below 100 or HR was below 60. Staff acknowledged the resident’s BP was low and that the medication could further lower BP and affect therapy participation. In a separate issue, a resident recovering from back surgery was using an incentive spirometer, but the EMR had no order for it; the RN and DON both confirmed there was no order in place when the device was provided.
Vegetables Served Soft and Mushy at Lunch A resident with Alzheimer’s disease, a resident with hemiplegia and DM2, and a resident with anemia were all ordered regular-texture meals, and each reported that the Italian blend vegetables were soft and overcooked. During meal observation, the carrots were mushy, the squash was disintegrating, and the green beans were split open and lacked crunch. The CDM, DC, and RD all acknowledged the vegetables did not hold their texture or match resident preferences, and the facility menu policy stated meals are to meet resident choices and nutritional needs.
Failure to Use PPE During EBP Care: A resident on EBP with a surgical wound, Stage 2 sacral pressure ulcer, and multiple diagnoses including COPD and peripheral vascular disease was observed receiving repositioning care without gowns. Staff identified the resident as requiring gown and glove use for high-contact care such as transfers and linen changes, and the facility’s policy required targeted PPE use during these activities.
Insufficient square footage was identified in 27 of 37 multiple-occupancy rooms, including rooms 101 through 108, 115 through 124, and 128, 130 through 137. During an environmental tour, the MND measured rooms and confirmed they did not meet the minimum square footage per resident required by regulation. A review of the facility’s Client Accommodations Analysis showed multiple 3-bed rooms with square footage below the required standard.
A resident with multiple medical conditions developed pain, swelling, and discoloration in both wrists, but staff did not report or investigate these injuries of unknown origin as required. Despite documentation of severe pain and changes in condition, the DON and nursing staff did not initiate an investigation or notify authorities, contrary to facility policy.
A facility issued mandatory room transfer notices to six residents, moving them from 2-bed to 3-bed rooms to prepare for potential future isolation needs, despite no current outbreak. The residents, who had been in their rooms for years, opposed the move, leading to potential harm for five and actual harm for one resident, who experienced increased depression and suicidal ideation. The facility's actions were based on preemptive measures rather than immediate needs, disregarding the residents' rights and preferences.
A resident with multiple medical conditions was given a 30-day discharge notice due to non-compliance with the smoking policy, but the notice was delayed for the responsible party. The discharge plan was inadequate, lacking placement at an accepting skilled nursing facility, and the resident's safety was at risk. The facility's policy for a 30-day notice and post-discharge plan was not followed, leading to an appeal that allowed the resident to remain.
A resident with hypertension and atrial fibrillation received midodrine and losartan against physician orders, as staff failed to adhere to blood pressure parameters. The MAR showed multiple instances of incorrect administration, confirmed by interviews with RNs who acknowledged the errors. The Medical Director and DON stressed the importance of following medication parameters to prevent adverse effects.
The facility failed to provide adequate room sizes, with 26 out of 36 rooms not meeting the required 80 square feet per resident in shared rooms. Staff reported difficulties in performing mechanical lift transfers due to limited space, and some residents complained about the cramped conditions. The Director of Nursing acknowledged these issues, but the Administrator was unaware of the deficiencies and resident complaints.
A resident with a history of major depressive disorder and PTSD did not receive the psychotherapy/counseling services recommended by their PASARR Level II determination. The Social Services Supervisor acknowledged the oversight in obtaining a psychological referral, and the DON noted a delay in psychiatric services. The Administrator admitted to a lack of clarity regarding PASARR requirements.
The facility failed to secure windows on the secure unit, with two rooms having missing or damaged screens and no locking mechanisms, posing a potential risk. The Maintenance Supervisor was unaware of these issues despite regular checks, and staff were not informed of the problem. The Administrator acknowledged the oversight as a facility mistake.
A resident with vascular dementia and depression did not receive a psychiatric consultation as ordered, despite a recommendation to re-evaluate the necessity of their psychotropic medication. The facility staff, including the Social Services Supervisor, LVN, MD, DON, and Administrator, were unaware or not informed of the need for the consultation, indicating a breakdown in communication and process management.
A resident's IV was removed, yet staff continued to document monitoring of the IV site on the MAR for several shifts. Interviews with RNs revealed awareness of the IV's removal, but documentation errors persisted. The Medical Director and Administrator expected accurate charting.
A CNA failed to follow hand hygiene protocols during meal service by wiping her nose and then handling a resident's food tray without sanitizing her hands. Interviews with facility staff confirmed the expectation of hand sanitation before handling food trays and after touching one's face.
Improper Garbage Storage and Sewage Drainage in Waste Area
Penalty
Summary
The facility failed to ensure the garbage storage area was maintained in safe and sanitary conditions when grayish fluids from the sewer and thick yellowish drainage from the grease trap were observed draining into the driveway and pooling in front of the garbage bins. During the observation, a musty, rotten, foul odor resembling sewage was noted coming from the fluids. The Maintenance Director confirmed that both the grayish fluids and yellow discharge originated from the kitchen area and stated the fluids had been present for two days, though the exact source or location of the clog was unknown at that time. The facility also failed to keep garbage bins properly covered. One garbage bin lid was left open, and another bin was filled to the top with garbage bags so the lid could not close properly. The Certified Dietary Manager stated the garbage bins were used by every department and should always be closed, and the Registered Dietician stated the bins should be covered at all times and there should be no trash spilled over preventing the lids from closing. The Administrator reviewed the facility policy, which stated garbage and refuse containers shall be maintained in good condition, dumpsters and compactors shall be equipped with lids or otherwise adequately covered at all times, and garbage disposal areas shall be kept clean and free from offensive odors, grease, and waste fats.
Antibiotic Stewardship Data Missing ISE Review
Penalty
Summary
The facility failed to promote and implement an antibiotic stewardship and surveillance program because infection screening evaluations (ISEs) were not completed before residents started antibiotics, and antibiotics discontinued after initiation for not meeting ISE criteria were not included in the February 2026 antibiotic stewardship data review or monitoring. During interview and record review, the Infection Preventionist stated she completed ISEs on residents before antibiotics were started, but also stated there was no other designee to complete ISEs in her absence, which meant not all residents received an ISE before starting an antibiotic until she returned to work. The Infection Preventionist identified that Resident 10 did not receive an ISE before antibiotic treatment began and was given an antibiotic for two days before the ISE was completed. The ISE showed the resident did not meet infection criteria, and the antibiotic was discontinued with provider approval. The Infection Preventionist stated Resident 10 was not included in the February 2026 Surveillance Log or Monthly Infection Prevention and Control Report, even though those reports had sections for residents who met and did not meet ISE criteria. She stated accurate documentation and reporting were needed to monitor antibiotic prescribing and use. The Consultant Pharmacist stated pharmacy completed independent monthly antibiotic reviews, including residents whose antibiotics were discontinued early for not meeting ISE criteria, and that the Infection Preventionist also completed antibiotic review reports. He could not locate a pharmacy report for Resident 10’s antibiotic and could not state why it had not been reviewed. The Nurse Consultant stated Resident 10’s antibiotic initiation without an ISE and early discontinuation for not meeting ISE should have been included in the Infection Preventionist’s and pharmacy’s antibiotic stewardship review, and that missing data prevented accurate tracking, trending, and monitoring of antibiotic use.
Food Storage Labeling and Food Prep Sink Backflow Deficiency
Penalty
Summary
Food storage and preparation practices were not maintained in accordance with professional standards when an open bag of potato chips placed inside a zip lock bag in the storage room was observed without a use by date. During interview, the Certified Dietary Manager stated products should have a use by date, that labeling was needed to ensure there was no spoilage, and that all dietary staff should label all items when they are opened with a use by date. The Registered Dietician also stated all food items should have been labeled to prevent residents from consuming expired items and that the facility's policy and procedure were not followed. A separate observation in the food prep area found the food prep sink draining into the ground with no air gap between the pipe and the drainage area. The Certified Dietary Manager stated the sink should have an air gap to prevent cross-contamination and that backflow from dirty water from the sewer could have gotten into the sink and contaminated vegetables prepared there. The Registered Dietician stated there should be a one-inch air gap between the pipe and the drainage, and the Administrator stated she was not aware the food prep sink needed an air gap and that she had one for the ice machine but not the food prep sink.
Incomplete informed consent for psychotropic medications
Penalty
Summary
The facility failed to ensure that two residents were fully informed, in advance, of the risks and benefits of psychotropic medications before treatment was initiated. For one resident, the record showed orders for buspirone 7.5 mg twice daily for anxiety and mirtazapine 7.5 mg at bedtime for depression, but no signed physician informed consent was present in the chart for either medication. The resident’s admission record listed diagnoses including hemiplegia, hemiparesis, cellulitis of the back, infection of intervertebral disc, bed confinement status, anxiety disorder, and depression. The resident’s MDS showed a BIMS score of 15, indicating cognitive intactness. During record review and interviews, Charge Nurse 1 stated the orders indicated informed consent had been obtained by the MD from the RP, but no consents were found in the resident’s record for buspirone or mirtazapine. The Nurse Consultant stated the resident should have had a signed consent before receiving psychotropic medications and that consents were important so residents knew the risks and benefits of taking the medication and could decide whether to take them. The facility’s Resident Rights policy stated residents have the right to be informed of and participate in care planning and treatment, and the Psychotropic Medication Use policy stated staff and the physician would review with the resident or representative the risks related to not taking the medication and appropriate alternatives. For the second resident, the record showed an order for lorazepam 1 mg every 6 hours as needed for anxiety for 14 days, with behaviors described as yelling, restlessness, and agitation. The resident was on hospice, had diagnoses of Alzheimer’s disease, vascular dementia, and anxiety disorder, and his daughter was the RP. The informed consent form for the lorazepam order did not include a provider signature, and staff stated the consent was therefore not complete or valid. Charge Nurse 1, Medical Records, and the Nurse Consultant all stated that without the provider’s signature, it could not be ensured that the resident and RP were informed in advance of the medication’s risks, benefits, and side effects. The resident had not yet received the lorazepam, but staff noted it remained available as a PRN medication.
Resident belongings inventory not updated
Penalty
Summary
The facility failed to maintain a homelike environment for one resident when the Resident's Clothing and Possession Inventory on Admission was not updated to reflect the items currently in the resident's closet. The resident had been admitted with diagnoses including dysphagia, acute kidney failure, diabetes mellitus, anemia, and gastrotomy, and the Minimum Data Set showed a BIMS score of 1, indicating severe cognitive impairment. During interview, the resident's family member stated that blankets and other personal items had gone missing in the past and that she had stopped bringing items to the facility because of items disappearing. She also stated the resident's cellular phone had been missing for one year and that the resident used the phone to play games and was attached to personal items. Staff interviews reflected that resident belongings should be inventoried and updated when family brought in items, and that staff were responsible for safeguarding personal property. A review of the resident's inventory sheet showed only a few clothing items listed, while observation of the resident's closet revealed additional items including shorts, pajama pants, tops, underwear, a baby doll, a plushie, and hair products that were not on the inventory list. The RN stated there should have been another sheet with a new inventory update and confirmed the inventory was not updated. The Social Services Director and Administrator stated that items brought in by family should be inventoried and kept in the chart, and that the facility did not follow its policy and procedure.
Care plans not revised for changed resident needs
Penalty
Summary
The facility failed to revise and implement person-centered comprehensive care plans for two residents in a timely manner. One resident returned from the hospital with a PEG tube and an order for NPO on 12/22/24, but the care plan still continued to address not swallowing and pocketing food. A charge nurse stated the care plan should have been updated when the resident stopped eating by mouth, and the MDS nurse stated the care plan should have been revised when the NPO order was entered. The resident’s record showed diagnoses including dysphagia, acute kidney failure, diabetes mellitus, anemia, and gastrotomy. A second resident had a short-term care plan for dark amber urine that remained in place beyond the 48-to-72-hour timeframe. The care plan directed staff to observe for dark amber urine, with a goal for improved hydration evidenced by urine changing from dark amber to pale yellow within 48 to 72 hours, along with interventions including collecting a UA, notifying the MD and RP, and monitoring for pain and discomfort. The charge nurse stated this short-term care plan should have been updated and discontinued, and that care plans should be specific to residents’ needs. During interview, the nurse consultant stated care plans should be updated quarterly and as needed to reflect resident care, and that the facility did not follow its policy and procedure. The facility policy stated a comprehensive, person-centered care plan with measurable objectives and timetables is developed and implemented for each resident, and that care plans are revised as residents’ conditions change and at least quarterly in conjunction with the required quarterly MDS assessment.
Medication Given Outside BP Parameters and Incentive Spirometer Used Without an Order
Penalty
Summary
Resident 87 had an active order for amiodarone 100 mg by mouth twice daily for AFib, with instructions to hold the medication if systolic blood pressure was less than 100 or heart rate was less than 60. The resident also had diagnoses of AFib, heart failure, and hypotension, and was admitted with low blood pressure that was noted to worsen when standing or participating in therapy. Review of the MAR and order summary showed that the 4:00 p.m. amiodarone dose was administered despite systolic blood pressure readings below the ordered parameter on four occasions: 2/3/26, 2/5/26, 2/13/26, and 3/11/26. During interviews, the Charge Nurse stated the resident’s blood pressure was low on those dates and that amiodarone lowers blood pressure and heart rate. The Charge Nurse stated administering the medication outside the ordered parameters placed the resident at risk for further lowering blood pressure, cardiac distress, and inability to participate in therapy sessions. The Director of Rehabilitation stated the resident’s therapy sessions were modified when blood pressure was low and resumed when it improved, and that the resident met therapy goals but was at risk of not meeting them if amiodarone was given when blood pressure was low. Resident 104 was observed wanting to use an incentive spirometer after back surgery to help prevent lung and breathing problems, and stated she had received and used the device in the acute care hospital. Review of the EMR showed there was no order for the resident to use an incentive spirometer. The RN stated there was not an order for the device and that there should be an order for everything the resident uses. The DON stated she provided the resident with a new incentive spirometer without checking for an order or care plan, and stated the facility did not have a policy regarding its use.
Vegetables Served Overcooked and Lost Texture
Penalty
Summary
The facility failed to ensure vegetables were prepared to conserve appearance and palatability for three residents who were served Italian blend vegetables with carrots, green beans, and squash at lunch. The vegetables were observed to be soft and mushy, with carrots that melted in the mouth without requiring chewing, squash that was disintegrating and did not hold its form, and green beans that were split in half with the pods exposed. The deficiency was identified during observation and interview with the CDM, RD, and another nurse evaluator during the lunch meal service. Resident records showed that one resident had Alzheimer’s disease, low back pain, and falls, with a BIMS score of 15 and a regular diet with regular texture and Italian blend vegetables ordered. A second resident had hemiplegia, DM2, HTN, and muscle weakness, with a BIMS score of 15 and a CC diet with regular texture and Italian blend vegetables ordered. A third resident had anemia, muscle weakness, and shortness of breath, with a BIMS score of 12 and a regular diet with regular texture and Italian blend vegetables ordered. During resident council, the three residents stated the vegetables were soft and overcooked, and one resident said she preferred crunchy vegetables and had already notified kitchen staff without any change. The CDM stated the squash and carrots were too soft, the vegetables should have held their texture, and residents on regular diets would not have wanted them served that way. The DC stated the vegetables were steamed and transferred to the warmer and should have followed the recipes, while the RD stated each vegetable should have maintained its own bite and that residents would not consume vegetables not served to their preferences. The facility policy stated menus are developed and prepared to meet resident choices and nutritional needs in accordance with RDA.
Failure to Use PPE During EBP Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for one of four sampled residents, Resident 103, when PPE was not worn during care for a resident on Enhanced Barrier Precautions (EBP). On 3/17/26 at 11:19 a.m., an EBP sign was observed on Resident 103’s door and a green sticker was observed next to the resident’s name. During a concurrent observation and interview at 11:20 a.m., Resident 103 was observed in bed, dressed, wearing an O2 nasal cannula, with pillows supporting her legs, and she grimaced in pain when moving. She stated her back and leg hurt and that pain medication had helped. Resident 103’s admission record dated 3/20/26 indicated she was admitted from an acute care hospital on 2/24/26 with diagnoses including acquired loss of the left leg above the knee, peripheral vascular disease, COPD, a Stage 2 sacral pressure ulcer, resistance to multiple antibiotics, and anxiety disorder. Her MDS dated 3/2/26 showed a BIMS score of 15, indicating she was cognitively intact. Her care plan, dated 2/25/26, indicated she required EBP related to a surgical wound and directed staff to use gown and gloves during high contact resident care activities including dressing, bathing, transfers, hygiene, toileting, brief changes, changing linens, device care, and wound care. During an observation on 3/18/2026 at 10:20 a.m., CNA 1 and another staff member repositioned Resident 103 by moving linens off the resident, grabbing the sheet underneath her, and pulling her up toward the head of the bed, and neither staff member wore gowns. During interview, CNA 1 stated residents on EBP had a sign on the door and a green dot by their name, and that EBP meant staff needed to wear a gown and gloves for resident care, including repositioning. CNA 1 stated she should have worn a gown when repositioning Resident 103. The DSD stated staff were expected to wear appropriate PPE when providing personal care, transferring, positioning residents in bed, or handling linens. Facility policy stated EBP required targeted gown and glove use during high contact resident care activities, including transferring and changing linens, for residents with wounds and/or indwelling medical devices regardless of MDRO colonization.
Insufficient Square Footage in Multiple Resident Rooms
Penalty
Summary
The facility failed to provide the minimum of at least 80 square feet per resident in 27 of 37 multiple resident rooms, including rooms 101 through 108, 115 through 124, and 128, 130 through 137. During a concurrent observation and interview on 3/20/2026 at 9:16 a.m., the Maintenance Director measured two rooms and stated the rooms did not meet the minimum square footage per resident as required by regulation. A review of the facility document titled Client Accommodations Analysis showed the listed room sizes and bed counts for the affected rooms, including multiple rooms with 3 beds and square footage below the required standard. The report also states that variations were in accordance with the particular needs of the residents, that there was sufficient room for nursing care and resident ambulation, that wheelchairs and toilet facilities were accessible, that closets and storage space were adequate, and that bedside stands were available.
Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report and investigate an injury of unknown origin for a resident who was noted to have pain, bruising, and swelling to her right hand and wrist, as well as discoloration to her left wrist. The resident had a complex medical history, including dementia, schizophrenia, bone disorders, and muscle weakness, and required assistance with personal care. Documentation in the resident's care plan and progress notes indicated new skin discoloration, complaints of severe pain, and swelling, but there was no evidence that these findings were reported as required. Multiple staff members, including the DON, RNs, and the treatment nurse, reviewed the clinical record and confirmed that no investigation was conducted into the source of the injuries, nor was the incident reported to the appropriate authorities as an injury of unknown source. The DON stated she was unaware of the resident's issues and could not provide documentation of an investigation or report. The treatment nurse also indicated she was unaware that such injuries needed to be reported and investigated. The facility's policy required prompt reporting and thorough investigation of all injuries of unknown source, but this was not followed in the case of this resident. The lack of investigation and reporting resulted in the resident's injuries not being addressed according to regulatory requirements, and delayed medical intervention for the resident's condition.
Facility's Preemptive Room Changes Violate Residents' Rights
Penalty
Summary
The facility failed to honor the rights of six residents by issuing mandatory room transfer notices without a current need for such changes. The residents, who had been residing in their rooms for several years, were informed they would be moved to different rooms to potentially accommodate future isolation needs for infectious diseases, despite no current outbreak in the facility. This decision was made to free up the facility's only three 2-bed rooms, which were deemed more suitable for cohorting in the event of an infectious disease outbreak. The residents expressed strong opposition to the move, citing their long-term residence and comfort in their current rooms. The deficiency resulted in potential harm to five residents and actual harm to one resident, who experienced significant mood and behavior changes due to the proposed room change. This resident, who had a history of depression and anxiety, exhibited increased irritability, depression, and suicidal ideation, leading to a significant increase in her anti-depressant medications. The increase in medication dosage raised her risk of side effects, including falls and fractures, due to her advanced age and the number of medications she was already taking. Interviews with the facility's staff, including the Administrator and Infection Prevention Nurse, confirmed that the room changes were preemptive measures for potential future needs rather than immediate requirements. The facility's policy on infection precautions was cited, but the lack of a current infectious disease outbreak made the room changes unnecessary at the time. The Social Services Director and other staff members acknowledged the residents' distress and the lack of immediate need for the room changes, indicating that the situation could have been handled differently to respect the residents' rights and preferences.
Improper Discharge Planning for Resident
Penalty
Summary
The facility failed to adhere to its transfer and discharge policy for a resident, resulting in a deficiency. The resident, who was diagnosed with anoxic brain damage, muscle spasm, generalized anxiety disorder, unspecified psychosis, and major depressive disorder, was given a 30-day notice for discharge due to non-compliance with the smoking policy. However, the notice was not provided to the resident's responsible party until a month later. The resident was wheelchair-dependent and required care from a skilled nursing facility, but the discharge plan lacked placement at an accepting facility. Interviews with the Social Services Director (SSD) and Director of Nursing (DON) revealed that the resident's discharge plan was inadequate. The SSD stated that the resident's mother was contacted for discharge planning, but the plan to discharge the resident home was not feasible due to the small size of the apartment and the disabilities of both parents. The DON confirmed that there was no documentation of referrals to other skilled nursing facilities and that the resident's safety was at risk due to insufficient discharge planning. The facility's Administrator admitted to assuming the resident could return home without verifying the feasibility. The facility's policy required a 30-day advance notice and a post-discharge plan, which were not properly executed. The Department of Health Care Services Office of Administrative Hearings and Appeals granted an appeal, allowing the resident to remain in the facility due to the improper discharge process.
Failure to Adhere to Medication Administration Parameters
Penalty
Summary
The facility failed to prevent a significant medication error for a resident with a history of hypertension and atrial fibrillation. The resident was prescribed midodrine hydrochloride to be held if their systolic blood pressure (SBP) exceeded 130 mmHg, and losartan potassium to be administered only if the SBP was greater than 130 mmHg. However, the facility staff did not adhere to these physician orders, resulting in the administration of midodrine when the resident's SBP was above the specified threshold and losartan when the SBP was below the threshold. The medication administration records (MAR) for June, July, and August 2024 showed multiple instances where midodrine was given despite the resident's SBP being greater than 130 mmHg. Similarly, losartan was administered when the SBP was not greater than 130 mmHg. Interviews with registered nurses confirmed that they failed to follow the prescribed parameters, acknowledging that they should have held the medication and documented the reasons for doing so, as well as notified the physician. The Medical Director emphasized the importance of adhering to blood pressure medication parameters to avoid adverse effects, while the Director of Nursing and the Administrator reiterated the necessity of following physician orders and checking medication labels. The deficiency was identified through interviews and record reviews, highlighting a lapse in the facility's medication administration process for this resident.
Inadequate Room Sizes Affecting Resident Care
Penalty
Summary
The facility failed to ensure that resident rooms met the required minimum square footage per resident, as outlined in their policy. Specifically, 26 out of 36 rooms did not meet the standard of at least 80 square feet per resident in shared rooms. The facility's policy, revised in May 2017, mandates that bedrooms accommodate no more than two residents and measure at least 80 square feet per resident in double rooms. However, the Client Accommodations Analysis revealed that several rooms were occupied by three residents, resulting in insufficient space per resident, with measurements ranging from 72 to 76.66 square feet per resident. Interviews with staff members, including registered nurses and certified nurse assistants, highlighted the challenges posed by the inadequate room sizes. Staff reported difficulties in performing mechanical lift transfers due to the limited space, which hindered their ability to provide adequate care. The cramped conditions also required staff to move other residents' beds to perform necessary care tasks. Additionally, some residents expressed dissatisfaction with the room sizes, indicating that the space was insufficient for three residents. The Director of Nursing acknowledged that residents had complained about the small room sizes and confirmed the issues with staff completing transfers using mechanical lifts. Despite these concerns, the facility's Administrator was unaware of the room size deficiencies and any related resident complaints. This lack of awareness suggests a communication gap within the facility's management, contributing to the ongoing deficiency in meeting room size requirements.
Failure to Provide Recommended Specialized Services
Penalty
Summary
The facility failed to provide a resident with the specialized services recommended by the Preadmission Screening and Resident Review (PASARR) Level II determination. The resident, who was admitted to the facility in 2017, had a medical history that included major depressive disorder and post-traumatic stress disorder. The PASARR determination report dated April 18, 2024, recommended psychotherapy/counseling services for the resident, which were not provided by the facility. Interviews with facility staff revealed that the Social Services Supervisor acknowledged that a psychological referral should have been obtained but was not, due to an oversight. The Director of Nursing expected the Social Services Supervisor to ensure appropriate referrals were in place, but there was a delay in psychiatric services. The Administrator admitted to a lack of clarity regarding PASARR but recognized that recommended services should have been completed.
Deficiency in Window Security on Secure Unit
Penalty
Summary
The facility failed to ensure that windows on the secure unit were locked and secure, leading to a deficiency in maintaining a safe environment free from accident hazards. Specifically, two rooms on the secure unit had windows that were either missing screens or had damaged screens, and lacked locking mechanisms to prevent them from opening fully. These windows opened into the parking lot, posing a potential risk for residents. The facility's policy emphasized the importance of resident safety and supervision, yet the necessary precautions were not in place. During observations, it was noted that the Maintenance Supervisor was unaware of the missing screens and locking mechanisms, despite monthly visual checks being conducted. The Maintenance Supervisor mentioned that devices to prevent windows from opening completely had been purchased but not yet installed. Interviews with staff, including a CNA and an LVN, revealed a lack of awareness regarding the window issues, and the Director of Nursing and Administrator acknowledged the oversight. The Administrator admitted that the failure to replace the window locking mechanisms and screens was a mistake by the facility.
Failure to Obtain Psychiatric Consultation for Resident
Penalty
Summary
The facility failed to obtain a psychiatric consultation as ordered for a resident with a history of vascular dementia and depression. The resident was readmitted to the facility and had a significant change in status, as indicated by a Minimum Data Set (MDS) assessment, which revealed severely impaired cognitive skills and behavioral symptoms. The resident's care plan included the use of psychotropic medication, Olanzapine, for behavior management, with a recommendation from the consultant pharmacist to re-evaluate the necessity of the medication. An order for a psychiatric evaluation was documented, but there was no evidence that the evaluation was conducted. Interviews with facility staff, including the Social Services Supervisor, Licensed Vocational Nurse, Medical Director, Director of Nursing, and Administrator, revealed a lack of awareness and communication regarding the psychiatric consultation order. The Social Services Supervisor was unaware of the need for the evaluation until the day before the interviews, and the Medical Director was not informed that the consultation had not been scheduled. The Director of Nursing and Administrator both expressed expectations that staff should follow physician orders and ensure consultations are scheduled, highlighting a breakdown in the facility's process for managing and executing physician orders.
Inaccurate Documentation of IV Monitoring
Penalty
Summary
The facility failed to ensure accurate documentation of the monitoring of a peripheral intravenous (IV) site for a resident who no longer had an IV. Resident #297, who was admitted with a medical history of adult failure to thrive and liver disease, had an order to monitor the IV site on the right hand dorsum for signs of infection or infiltration every shift. Despite the IV being removed on the night shift of 08/11/2024, staff continued to document monitoring of the IV site on the Medication Administration Record (MAR) for several shifts thereafter. Interviews with nursing staff revealed that they were aware the IV had been removed but continued to chart as if the IV was still present. Registered Nurses #5, #3, and #7 all acknowledged that they should not have documented monitoring of the IV site after its removal. The Medical Director and the Administrator both expressed expectations for accurate documentation on the MAR, highlighting the discrepancy between expected and actual practice.
Inadequate Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to ensure proper hand hygiene during meal service, as observed with Certified Nurse Assistant (CNA) #8. During a lunch meal service, CNA #8 was seen using her left finger to wipe her nose and then proceeded to handle a resident's food tray and unwrap food items without sanitizing her hands. This action was in direct violation of the facility's hand hygiene policy, which mandates hand sanitation before touching a resident or handling food trays, especially after contact with one's face. Interviews with CNA #8, the Infection Preventionist, the Director of Nursing (DON), and the Administrator confirmed the expectation that staff should sanitize their hands before passing out meal trays and after touching their face. CNA #8 admitted to not following the protocol due to her allergies, which led her to wipe her nose without subsequent hand sanitation. The DON and Administrator reiterated the importance of using soap and water or hand sanitizer during meal service to prevent the spread of infections.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Modesto
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Valley Skilled Nursing Center | 0 mi | ★★★★★ | 3 | 0 |
| Golden Modesto Care Center | 0.7 mi | ★★★★★ | 5 | 0 |
| Garden City Healthcare Center | 1.1 mi | ★★★★★ | 20 | 0 |
| Crestwood Manor | 1.2 mi | ★★★★★ | 11 | 0 |
| River View Post Acute | 1.4 mi | ★★★★★ | 35 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.