Health inspection·December 10, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on interview and record review the facility failed to ensure one of four sampled residents (Resident 1) environment was free of accident hazards when Resident 1's right wrist remained in an arm positioning device (a medical tool that holds a patient's arm in a specific, stable, and extended position during the procedure and does not allow for movement) following a mid-line insertion (medical procedure of placing a thin, flexible tube (catheter) into a large vein in the upper arm, with the tip terminating just below the armpit).This failure had the potential for injury related to the arm positioning device being secured to Resident 1's bedframe, potentially negatively affecting Resident 1's health, safety, and emotional well-being.A review of Resident 1's clinical document titled, admission RECORD, (contains clinical and demographic data) indicated Resident 1 had been admitted to the facility with diagnoses which included a fall, abnormal gait, and impaired mobility (any unusual walking pattern that deviates from a normal, smooth, and coordinated stride).A review of Resident 1's clinical document titled, Order Details, dated 8/31/25, indicated, . May insert midline ., During an interview with certified nursing assistant (CNA) 1 on 11/14/25 at 4:34 p.m., CNA 1 stated she received a shift report from CNA 2 regarding Resident 1's current health condition. CNA 1 explained that when she and CNA 2 went into Resident 1's room, CNA 1 stated she saw the Resident 1's arm in a positioning device. CNA 1 further explained she informed licensed nurse (LN) 1 about the arm positioning device. CNA 1 stated the arm positioning device was still on Resident 1 when she changed his brief (adult diaper) in the morning. CNA 1 explained she removed the arm positioning device to change Resident 1 and when she was done changing him, she put the arm positioning device back on Resident 1.During an interview with LN 1 on 11/14/25 at 4:39 p.m., LN 1 stated she first became aware of the arm positioning device at approximately on 9/1/25 at 6:00 a.m. when she passed medications. LN 1 explained she did not remove the arm positioning device. LN 1 further explained she informed the oncoming day shift nurse (LN 3) of the device.During an interview with CNA 2 on 11/14/25 at 5:26 p.m., CNA 2 confirmed that during shift change (a set of nurses are done working and a new set of nurses start working) he discussed the arm positioning device with CNA 1 and stated he asked CNA 1 if she would inform the nurse. CNA 2 explained CNA 1 told her he would inform the nurse. CNA 2 further stated CNA 1 had informed LN 1 about the arm positioning device.During an interview with LN 2 on 11/18/25 at 10:53 a.m., LN 2 stated she was aware of the arm positioning device when LN 4 (from an outside agency) requested assistance from LN 2. LN 2 explained she saw the arm positioning device on Resident 1's right wrist as she held Resident 1's left arm to assist LN 4. LN 2 further explained LN 4 required assistance due to Resident 1's agitation and aggression. LN 2 stated she had not realized the arm positioning device had still been in place because Resident 1's right wrist was covered.During an interview with LN 3 on 11/21/25 at 11:49 a.m., LN 3 stated that at change of shift on 9/1/25, LN 1 informed her that the arm positioning device on Resident 1's right wrist was still in place. LN 3 explained she informed LN 1 the arm positioning device should not still be on and told LN 1 to remove the device. LN 3 further explained that around 9 a.m., CNA 3 asked her why Resident 1's right arm was secured to the bedframe, LN 3 informed CNA 3 Resident 1's right arm should not be secured to the bedframe. LN 3 stated she went to take a picture of Resident 1's right arm in the arm positioning device so she could inform the administrator. LN 3 stated LN 1 tried to prevent her from taking the picture and managed to unsecure the arm positioning device before she could take the picture. LN 3 further stated she informed the administrator regarding the arm positioning device.During an interview with CNA 3 on 12/2/25 at 1:47 p.m., CNA 3 confirmed she informed LN 3 about the arm positioning device. CNA 3 stated Resident 1's right arm was secured to the bedframe, and he could not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055185 If continuation sheet Page 2 of 3 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 12/10/2025 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 - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete move his right arm freely.A record review of Resident 1's clinical document titled, Progress Notes, dated 9/2/25, indicated, . During report on 9/1/25 this write was informed by [night nurse] [Resident 1's] arm was [in an arm positioning device] . Informed [night nurse] [Resident 1] can not be in [arm positioning device] . Informed [night] nurse she needed to [remove arm positioning device] . At 0900 [9 a.m.,] CNA asked this writer why [Resident 1's] arm was [in arm positioning device] . Informed CNA [night] nurse was supposed to [remove arm positioning device] . This writer went to room. [Resident 1's] right arm was in [arm positioning device secured to his bed] .During an interview with an outside Clinical Nurse Officer (CNO) on 12/2/25 at 10:41 a.m., the CNO stated the arm positioning device should not have been left on a Resident 1. The CNO explained an arm positioning device was used for a limited amount of time during mid-line insertion to help keep the arm in place. The CNO further explained that once the mid-line was inserted and secured the arm positioning device should have been removed, its use documented and reported to the LN on duty. The CNO confirmed the arm positioning device was not removed, its use was not documented, and its use was not reported to the LN on duty by LN 4.During an interview with the Administrator (ADM) on 11/21/25 at 12:30 p.m., the ADM stated Resident 1's right arm remaining in the arm positioning device had the potential to cause Resident 1 emotional distress.During a follow-up interview with the ADM on 12/5/25 at 10:34 a.m., the ADM stated when the mid-line insertion procedure was completed the arm positioning device should have been removed and it had not been. The ADM explained Resident 1 would have been unable to move his arm beyond the arm positioning device and could have caused Resident 1 discomfort.A review of the facility policy titled, Hazardous Areas, Devices and Equipment, revised July 2017, indicated, . All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible . Identification of Hazards . A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include, but are not limited to the following . Equipment and devices that are left unattended . Assessment and Analysis of Hazards . Any element of the resident environment that has the potential to cause injury and that is accessible to a vulnerable resident is considered hazardous . Improper or inappropriate use of equipment and devices . Event ID: Facility ID: 055185 If continuation sheet Page 3 of 3