Health inspection·July 15, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few Note: The nursing home is disputing this citation. walking or rising from a chair) while supporting Resident 1 under both armpits. The RNA explained, from the wheelchair, they transferred Resident 1 back to the bed using a towel transfer technique. The RNA explained and demonstrated that she placed a towel behind Resident 1's leg, just above the backs of his knees. The RNA stated CNA 1 and herself then positioned themselves on each side of the resident. The RNA further explained, with one arm, each of them supported Resident 1 under his armpits while holding the gait belt; with the other arm, each held one end of the towel. The RNA stated they then lifted and swung Resident 1 back onto the bed. The RNA stated that she taught CNA 1 how to execute the towel transfer on 7/5/25 - at the time of said towel transfer. The RNA stated that she did not document the incident because she had told the nurse in-charge of Resident 1 on that day about what happened. The RNA stated FM 1 went to the facility on 7/6/25 and was able to speak with her regarding what happened.During an interview on 7/15/25 at 4:06 PM, the RNA stated that on 7/5/25, she did not think of using a mechanical lift (a device used to safely transfer individuals who cannot bear weight or have limited mobility, from one place to another) or requesting assistance from a physical therapist (a person qualified to treat disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise) to assist Resident 1 off the ground. RNA 1 stated she used the towel transfer technique and manually transferred Resident 1 from the wheelchair to the bed. The RNA stated that she believed a therapy order was required to use the mechanical lift.During an interview with the Director of Nursing (DON) and Administrator (ADM) on 7/15/25 at 4:50 PM, the DON stated when a resident was heavy or considered dead weight or unable to assist during transfers, the expected practice was to use a mechanical lift. When asked about the use of the towel transfer technique, the DON stated that the facility primarily uses gait belts and mechanical lifts but depending on the situation, the facility would use what was appropriate for a safe resident transfer. During the interview, the Administrator contacted the RNA by phone to confirm how the towel transfer had been performed. The RNA explained that Resident 1 had been sliding off the edge of bed. She asked CNA 1 for help repositioning him, but they were unable to move him back up. As a result, they laid him down on the floor. The RNA stated that she and CNA 1 then used a gait belt - holding Resident 1 by the gait belt and under each armpit, to lift him up from the floor into the wheelchair. From the wheelchair they transferred Resident 1 to the bed by lifting him into the air - ensuring he did not touch the floor - using a towel placed under the back of his legs and holding by each arm, swinging him onto the bed.During an interview on 7/15/25, at 12:42 PM, the Director of Nursing (DON) stated Resident 1 was transferred to the emergency room on 7/5/25 due to an Altered baseline and was admitted to the hospital due to a shattered knee. The DON explained that Resident 1 used to be talkative. The DON explained, on 7/5/25, although Resident 1 was not confused, he was notably quiet. The DON stated Resident 1 complained of left leg pain during repositioning by a Certified Nursing Assistant (CNA) and that his knees were together and staff were unable to separate them due to his pain. The DON stated Resident 1 did not fall on 7/5/25; rather, Resident 1 was assisted by both the Restorative Nursing Assistant (RNA) and CNA 1 to the floor sometime between 1 PM and 1:30PM. The DON stated it was unclear what happened because Resident 1 was a one-person assist with transfers (movement from one place to another) according to the therapy department (a group of healthcare professionals who help residents perform physical movements). During an interview on 7/15/25 at 1:26 PM, Family Member (FM) 1 stated he was notified by a facility staff around 5 PM on 7/5/25 that Resident 1 had been sent to the hospital. FM 1 stated he was told that Resident 1's leg appeared crooked. FM 1 stated, the next day, on 7/6/25, he visited the facility because he wanted to find out what happened to Resident 1. FM 1 stated he spoke with the RNA who informed him that Resident 1 began to fall but facility staff were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055185 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055185 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden City Healthcare Center 1310 West Granger Modesto, CA 95350 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few Note: The nursing home is disputing this citation. able to assist Resident 1 to the floor, facility staff then used a towel to pick up Resident 1, and Resident 1 said, it hurts, and his leg appeared crooked. FM 1 stated he was also told by the RNA that Resident 1 was put back to bed and refused lunch. FM 1 stated the RNA told him that Resident 1 told her, I think you broke my leg. During an interview on 7/15/25 at 1:54 PM, the Director of Staff Development (DSD) stated that Resident 1's RNA program (a range of treatments and approaches aimed at helping residents regain, maintain, or improve their physical functioning) was ordered three times per week, although the specific days were inconsistent. The DSD also stated that Resident 1 had never refused the RNA program and, although he cannot walk, he can stand up and pivot (to turn or rotate on the foot) with the assistance of one person.During an interview on 7/15/25 at 2:25 PM, with Licensed Nurse (LN) 1, LN 1 stated that she was the nurse assigned to Resident 1 on 7/5/25 for the afternoon shift and was also the one who arranged his transfer to the hospital. LN 1 stated, although Resident 1 was alert, she transferred him out to the hospital because, Resident 1 did not seem like himself and was a bit different from his normal. LN 1 further explained that CNA 2 had alerted her to check on Resident 1's left leg. LN 1 stated, upon assessment, LN 1 observed that Resident 1's left knee was swollen, Resident 1 was complaining of pain, and Resident 1's left leg appeared misaligned or not straight. LN 1 stated that she was not aware of any fall involving Resident 1 but had heard that he had been lowered to the floor. During an interview on 7/15/25 at 3:33PM, CNA 2 stated that she was the CNA in charge of Resident 1 on 7/5/25 and that she was very familiar with him. CNA 2 stated she took Resident 1's vital signs and observed that he was non-verbal and appeared as though he was dying, noting that his eyes looked sleepy. CNA 2 stated after reporting her concerns regarding Resident 1 to LN 1, LN 1 decided to transfer Resident 1 to the hospital. CNA 2 stated before the transfer, CNA 2 intended to change Resident 1's briefs to ensure he was clean and dry. CNA 2 stated when she removed Resident 1's blanket, she noticed that his left leg appeared crooked. CNA 2 stated that when she attempted to reposition Resident 1, he screamed in pain. During an interview on 7/15/25 at 4:02 PM, the DSD stated that the facility's protocol for transferring a heavy or non-weight bearing (one who should not put any weight at all on the injured leg, foot or ankle) resident is to use a mechanical lift. The DSD clarified that they do not require an order to use the mechanical lift. The DSD stated that her expectation was for all resident transfers to be conducted safely and without causing pain.During an interview on 7/17/25 at 9:03AM, the RNA explained that the facility did not provide training on the towel transfer technique. The RNA explained she learned the towel transfer method through years of experience and from working at other facilities. The RNA stated the towel should be placed under the resident's leg - not under the buttocks or hips - According to the RNA, she was holding one side of the towel, which was placed on the resident's leg just above the knee. With her other arm, she was supporting one side of the resident's armpit. She added that placing an arm under the armpit also allows you to hold the gait belt. CNA 1 was positioned on the other side of the resident, using the same technique. When asked whether there are any medical conditions that would make the towel transfer inappropriate, the RNA said she did not know. During an interview on 7/17/25 at 9:15AM, the Physical Therapist (PT) stated that the facility does not offer towel transfer technique (also known as, towel lift transfer or towel lift) training. The PT stated the facility recommended the following lifting transfer methods: Stand and Pivot Transfers (Helping one move from seated position to another by assisting them to stand up, turn and then sit down again), slide board transfers (Way to move a person with limited mobility from one sitting surface to another, use of a Hoyer lift (A special machine to help move someone who cannot get up or move on their own, safely and gently), and use of a Stand-up Hoyer Lift (A special machine that helps a person stand up from sitting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055185 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055185 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden City Healthcare Center 1310 West Granger Modesto, CA 95350 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few Note: The nursing home is disputing this citation. FORM CMS-2567 (02/99) Previous Versions Obsolete position when they cannot do it on their own but still have some strength in legs and can hold on). The PT explained that the towel transfer technique was not typically used at the facility, though it may be considered depending on the specific case. The PT explained that she found it safer not to use a towel transfer technique. The PT explained, with the towel transfer technique, the towel was placed around the buttock/low waist to gain control of the pelvis (hips). The PT stated the towel lift technique was not appropriate for certain residents including residents without lower body strength, residents with general weakness, and residents with neurological conditions (a problem with the brain, spinal cord, or nerves that affect how your body moves, feels, or functions) due to lack of lower extremity control and stability. The PT stated that a resident must be stable before considering a towel lift transfer.During a phone interview with the Director of Nursing (DON) and Licensed Nurse (LN) 3 on 7/17/25 at 10:43 a.m., the DON confirmed that LN 3 was the assigned nurse for Resident 1 during the morning shift on 7/5/25. The DON stated that she was unable to find any documentation of the incident involving Resident 1. LN 3 stated she was caring for Resident 1 during her morning shift on 7/5/25. LN 3 explained that she did not document the incident because she only saw the RNA and CNA 1 transferring Resident 1 to a wheelchair and was not informed that Resident 1 had been lowered to the floor. A review of the facility's policy titled, Safe Lifting and Movements of Residents, dated 7/17, the policy indicated, .Resident safety, dignity, comfort and condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents.Manual lifting of residents shall be eliminated when feasible.Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis.assessment shall include.Resident's mobility (degree of dependency).weight-bearing ability. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices.Mechanical lifting devices shall be used for heavy lifting, including lifting and moving of residents when necessary.Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents.Staff will be observed from competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques.Mechanical lifts shall be made readily available and accessible to staff 24 hours a day.A review of the facility's policy titled, Fall and Fall Risk, Managing, dated 3/18, the policy indicated, .A fall is defined as: Unintentional coming to rest on the ground, floor or other level.An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall.Medical factors that contribute to the risk of falls include.neurological disorder; and balance and gait disorders; etc.Monitoring Subsequent Falls and Fall risk.staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. Event ID: Facility ID: 055185 If continuation sheet Page 4 of 4