Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 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.
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.
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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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.
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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 | — | 2 | 0 |
| Garden City Healthcare Center | 1.1 mi | — | 19 | 0 |
| Crestwood Manor | 1.2 mi | — | 11 | 0 |
| River View Post Acute | 1.4 mi | — | 30 | 0 |
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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 August 2026) and official state health department websites.