Other·September 7, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE AMENDED to reflect the deletion of Tag 253 Housekeeping & Maintenance The following reflects the findings of the California Department of Public HealthLicensing and Certification, during a RECERTIFICATION survey. Representing the California Department of Public Health by Federal ID: 36477 HFEN, 29470 HFEN, 37398 HFEN, 29326 HFEN and 36476 HFEN. Capacity: 104 Census: 93 Sample: 19 Random: 3 One complaint and two Entity Reported Incidents (ERI) were investigated during the RECERTIFICATION survey: Complaint CA00545708: Unsubstantiated with no deficiency identified. ERI CA00515040: Substantiated with deficiency identified F 323. ERI CA00545305: Substantiated with no deficiency identified. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CTB411 Facility ID: CA030000055 If continuation sheet 1 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055185 (X3) DATE SURVEY COMPLETED 07/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDEN CITY HEALTHCARE CENTER 1310 W Granger Ave Modesto, CA 95350 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F311 TREATMENT/SERVICES TO IMPROVE/MAINTAIN ADLS CFR(s): 483.24(a)(1)

F311 SS=E PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 08/16/2017 (a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section. This REQUIREMENT is not met as evidenced by: Based on observation, staff and family interviews, and record review, the facility failed to provide Restorative Nursing Aide (RNA) (trained certified nursing assistants who carry out a maintenance program established and ordered by a physician to maximize the resident's existing abilities) therapy to maintain or improve the resident's ability to carry out activities of daily living for two of 19 sampled residents (Resident 2 and Resident 4) when: 1. Resident 2's RNA therapy was not done five times a week as ordered which resulted in five RNA treatments out of 15 ordered treatments completed in a three week period. 2. Resident 4's RNA therapy was not carried out five times a week per physician's order. These failures had the potential to result in a decline of the resident's ability to achieve and maintain the highest practicable level of functioning. Findings: 1. On 7/27/17 at 10:00 a.m., during a resident room observation, Resident 2 laid in bed and visited with a family member (FM). The resident was clean and well groomed. Located at the foot of Resident 2's bed sat a large high FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CTB411 Facility ID: CA030000055 If continuation sheet 2 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055185 (X3) DATE SURVEY COMPLETED 07/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDEN CITY HEALTHCARE CENTER 1310 W Granger Ave Modesto, CA 95350 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE backed wheelchair. On 7/27/17 at 10:10 a.m., during an interview, the FM stated Resident 2 had not received RNA as ordered by the resident's physician. The FM stated the physician ordered the RNA five times a week and the resident received treatments three times a week or less. The FM stated the resident did not tolerate being up in the wheelchair and tired easily by afternoon. The FM stated the resident preferred the RNA be done in the morning when he was up and out of bed. The FM stated Resident 2's RNA consisted of using the stationary bicycle in the therapy room which exercised his upper and lower extremities. The FM stated she was concerned the resident would have a further decline in his physical strength and mobility if the RNA was not done as ordered. The FM stated prior to the resident's stroke, the two of them went on walks almost daily. On 7/27/17 at 1:30 p.m., during an interview, Restorative Nurse Aid (RNA) 1 stated Resident 2 had RNA treatments ordered five times a week. RNA 1 stated Resident 2, "probably gets RNA three time a week." RNA 1 stated Resident 2's RNA treatments needed to be done in the morning. On 7/27/17 at 1:55 p.m., during an interview, the Director of Nursing (DON) stated she had talked to Resident 2's wife and was aware the resident did not receive RNA treatments five times a week. The DON stated Resident 2 and his wife preferred to have the RNA treatments in the morning. The DON stated "That is my responsibility, we (the facility) can do better to accommodate resident preference (and provide therapy)." Resident 2's physician orders dated 7/3/17, indicated, "RNA AROM (Active Range of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CTB411 Facility ID: CA030000055 If continuation sheet 3 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055185 (X3) DATE SURVEY COMPLETED 07/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDEN CITY HEALTHCARE CENTER 1310 W Granger Ave Modesto, CA 95350 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Motion) and AAROM (Assisted AROM) exerc (exercise) program (B [bilateral]) UE/LE (upper extremity/lower extremity), Sci-fit (specific type) muscle strengthening. 5 x (times)/wk (week) for three months..." Resident 2's electronic clinical record titled, "Restorative Nursing- 'Nursing Rehab/RNA Weekly Progress Note" with a completed date of 7/11/17, indicated, "...Section 1 In the last week the resident has been seen by Restorative (indicate number of times) 2 x." Resident 2's electronic clinical record titled, "Restorative Nursing- 'Nursing Rehab/RNA Weekly Progress Note" with a completed date of 7/18/17, indicated, "...Section 1 In the last week the resident has been seen by Restorative (indicate number of times) 2 x." Resident 2's electronic clinical record titled, "Restorative Nursing- 'Nursing Rehab/RNA Weekly Progress Note" with a completed date of 7/25/17, indicated, "...Section 1 In the last week the resident has been seen by Restorative (indicate number of times) 1 x." The facility policy titled, "JOB DESCRIPTION Restorative Nursing Aide (RNA)" revised 3/1/14, indicated "...The Restorative Nursing Aide (RNA) is to continue the maintenance program established and instructed by the Physical Therapist and/or Occupational therapist with a physician's order..." 2. Resident 4's physician's orders dated 3/10/16, indicated, "RNA ROM exerc program as follows: BLE : hip flexion, hip abduction, knee flexion and extension... 5 x /wk..." Resident 4's clinical record titled, "Restorative Nursing- Point of Care History" dated 5/1/17 through 7/27/17, indicated as follows: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CTB411 Facility ID: CA030000055 If continuation sheet 4 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055185 (X3) DATE SURVEY COMPLETED 07/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDEN CITY HEALTHCARE CENTER 1310 W Granger Ave Modesto, CA 95350 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 5/17 = 12 x out of 20 ordered treatments 6/17 = 15 x out of 20 ordered treatments 7/17 = 6 x out of 20 ordered treatments On 7/28/17 at 8:45 a.m., during an interview, RNA 2 stated Resident 4 had RNA treatments ordered five times a week. RNA 2 stated Resident 4's RNA treatments were to be followed and carried out as ordered. On 7/28/17 at 8:55 a.m., during a concurrent interview and record review, LN 2 reviewed Resident 4's Restorative Point of Care History, and was unable to find the RNA treatments were done 5 x a week as ordered by the physician. LN 2 stated Resident 4's RNA treatments should always be carried out by the RNA staff in accordance to physician's order. On 7/28/17 at 9:55 a.m., during an interview, the Assistant DON stated the RNA staff should follow the physician's orders for frequency of treatments for all residents. The facility policy titled, "JOB DESCRIPTION Restorative Nursing Aide (RNA)" revised 3/1/14, indicated "...The Restorative Nursing Aide (RNA) is to continue the maintenance program established and instructed by the Physical Therapist and/or Occupational therapist with a physician's order..."

F323 FREE OF ACCIDENT FORM CMS-2567(02-99) Previous Versions Obsolete

F323 Event ID: CTB411 09/07/2017 Facility ID: CA030000055 If continuation sheet 5 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055185 (X3) DATE SURVEY COMPLETED 07/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDEN CITY HEALTHCARE CENTER 1310 W Granger Ave Modesto, CA 95350 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) SS=G HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide the necessary supervision to prevent accidents for one of three random sampled residents (Resident 20) when nursing staff were aware Resident 20 had multiple elopement (leaving the facility unsupervised and without permission) attempts and failed to monitor Resident 20's location and personal alarm system (wander guard)(item worn by a resident to alert staff and an audible alarm sounds when FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CTB411 Facility ID: CA030000055 If continuation sheet 6 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055185 (X3) DATE SURVEY COMPLETED 07/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDEN CITY HEALTHCARE CENTER 1310 W Granger Ave Modesto, CA 95350 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE they approach an exit door) function as required by facility policy and procedure. These failures resulted in a fall with injuries [right hip fracture, a right arm fracture, and a hand laceration (cut)] during an elopement by Resident 20. Findings: On 12/20/16 at 3:45 p.m., during an interview, the Administrator (Admin) stated Resident 20 had a history of constantly seeking to elope. The Admin stated the facility had been working for the past year on locating a locked facility placement for Resident 20 due to elopement attempts. The Admin stated Resident 20 eloped from the facility on 12/14/16 and had a fall with injuries. The Admin stated Resident 20 required rehabilitation (physical and occupational therapy to help the resident regain strength and functional abilities) after having sustained a fractured hip during the fall. On 12/20/16 at 4:03 p.m., during an observation and concurrent interview at the nurses station, Resident 20 sat in a wheel chair with a soft cast on her right arm. Resident 20 had difficulty staying awake during the interview and stated she had been given pain medication that made her drowsy. Resident 20 stated she knew she had a fall and broke her hip, but did not remember the incident. On 12/20/16 at 4:29 p.m., during an interview, Certified Nursing Assistant (CNA) 4 stated Resident 20 had a history of elopement attempts. CNA 4 stated Resident 20 usually tried to leave the building through the exit door at the end of the "short hallway." CNA 4 stated there was a wander guard alarm sensor (electronic device that senses the approach of the resident wearing the alarm) in the middle of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CTB411 Facility ID: CA030000055 If continuation sheet 7 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055185 (X3) DATE SURVEY COMPLETED 07/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDEN CITY HEALTHCARE CENTER 1310 W Granger Ave Modesto, CA 95350 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the hallway and the exit door was alarmed. CNA 4 stated Resident 20 had to pass those alarms on 12/14/16, the day she eloped from the facility. CNA 4 stated, "I don't know how [Resident 20] passed the wander guard sensor and exit door alarm." On 12/20/16 at 4:35 p.m., during an interview, Licensed Nurse (LN) 3 stated on 12/14/16, she observed Resident 20 walking back and forth down the "short hall" several times pushing her wheelchair. LN 3 stated she heard Resident 20 say repeatedly, "I want to see my kids." LN 3 stated Resident 20 had passed the area where there was a wander guard sensor. LN 3 stated she heard the alarm sound and redirected Resident 20 away from the sensor. LN 3 stated she last saw Resident 20 around 4 p.m. walking toward the employee exit door. LN 3 stated, "All shifts should check the wander guard alarm [for proper function]. Make sure the button [on the alarm sensor] is fully pushed in." LN 3 stated Resident 20 was "very independent prior to elopement." LN 3 stated prior to her fall, Resident 20 was steady on her feet and went around the facility pushing her wheelchair. LN 3 stated Resident 20 required minimal assistance with dressing and showering before her fall on 12/14/16. On 12/20/16 at 4:58 p.m., during an interview, Restorative Nurse Aide (RNA) 1 stated on 12/14/16, she observed Resident 20 to continually walk toward the exit door. RNA 1 stated Resident 20 stated repeatedly she wanted to go home and see her family. RNA 1 stated she walked Resident 20 back from the exit door to the activity room several times on 12/14/16. RNA 1 stated Resident 20 had to pass the wander guard sensor and the exit door alarm to elope from the facility. RNA 1 stated, "For some strange reason, she [Resident 20] got past those alarms." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CTB411 Facility ID: CA030000055 If continuation sheet 8 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055185 (X3) DATE SURVEY COMPLETED 07/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDEN CITY HEALTHCARE CENTER 1310 W Granger Ave Modesto, CA 95350 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 12/20/16 at 5:01 p.m., during an interview, the Facility Maintenance Director (FMD) stated the maintenance department was responsible for testing the wander guard system on a monthly basis. The FMD stated resident wander guards were checked once per week. The FMD produced a written log titled, "WANDER GUARDS" which indicated a notation of "ok" written weekly from 9/5/15 to 12/15/16. There was no documentation of Resident 20's wander guard checked every shift by the staff. On 12/20/16 at 6:10 p.m., during an interview, the Admin stated on 12/14/16, the local police department notified the facility Resident 20 was found by a bystander outside the facility. The Admin stated the bystander had called the police department to report the incident. The Admin stated the facility had not investigated the circumstances that allowed Resident 20 to leave the building unnoticed. The Admin stated there was no (staff) timeframe or guideline of frequency to monitor Resident 20's location for prevention of elopement. On 2/14/17 at 5:11 p.m., during an interview, the Director of Nursing (DON) stated the maintenance department was responsible for checking the wander guard system on a monthly and weekly basis. The DON stated the nursing staff checked to ensure the alarm was placed on the resident appropriately, but nursing staff did not check the function of the alarm. The DON stated the facility did not have a policy or procedure to guide nursing staff regarding who should check the alarms, how to check the alarms or how often to check the alarms. The DON stated there was no system in place directing nursing staff in checking wander guard alarms. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CTB411 Facility ID: CA030000055 If continuation sheet 9 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055185 (X3) DATE SURVEY COMPLETED 07/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDEN CITY HEALTHCARE CENTER 1310 W Granger Ave Modesto, CA 95350 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 4/6/17 at 3:20 p.m., during a telephone interview, the FMD stated, if working properly, the wander guard alarm in the "short hallway" would alarm continually until a staff member put the code into the alarm box to turn it off. The FMD stated, if working properly, all exit door alarms would continue to alarm until disarmed by staff. The FMD stated exit door alarms were tested every week. On 4/6/17 at 3:30 p.m., during a telephone interview, the DON stated nursing staff check placement of the wander guard alarms on residents, but do not document the check. The DON stated Resident 20 did not have a detailed monitoring plan for elopement prevention. The DON stated staff were instructed to keep Resident 20 within their line of sight as much as possible, but prior to 12/14/16, there was no regularly scheduled or documented monitoring of her location. On 4/7/17 at 8:55 a.m., during a telephone interview, the Admin stated on 12/14/16, Resident 20 and her wheelchair (W/C) had been found by a bystander and the local police department about a block away from the facility on a side street. The Admin stated facility staff were unaware Resident 20 was missing until notified by the local police department. The Admin stated he was not certain how long Resident 20 was missing, but he had seen her that afternoon in the facility. The Admin stated facility staff were not able to determine how Resident 20 left the building. The Admin stated the door alarms were functioning when tested upon Resident 20's return. The Admin stated, "The only thing we can think of is she was very fast that day and by the time the staff silenced the alarms she was already out the door and out of sight." Review of Resident 20's clinical record titled, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CTB411 Facility ID: CA030000055 If continuation sheet 10 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055185 (X3) DATE SURVEY COMPLETED 07/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDEN CITY HEALTHCARE CENTER 1310 W Granger Ave Modesto, CA 95350 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE "Face Sheet (document with personal information of the resident)," indicated diagnoses of Dementia (disorder causing impaired memory, reasoning and judgement), Alzheimer's Disease (a type of dementia that results in memory loss, decrease in intellectual abilities and personality changes), Anxiety Disorder (disorder characterized by feelings of apprehension, uneasiness or dread), and a history of falls. Review of Resident 20's clinical record titled, "Minimum Data Set (MDS) (a resident assessment tool) assessment, dated 11/18/16, indicated a Brief Interview for Mental Status score was 5 of 15 possible points. A score of 5 indicated Resident 20 had severe memory impairment. The MDS dated 11/18/16, indicated Resident 20 was able to ambulate [walk] in her room and in the facility corridor with staff supervision. Review of Resident 20's clinical record titled, "Care Plan" dated 9/28/14, indicated Resident 20 was at risk for elopement related to wandering around the facility inside and outside the front door. Resident 20's Care Plan Approach indicated, "Equip resident with a device that alarms when resident wanders. Check for proper functioning of device and alarms q (every) shift... Monitor resident's whereabouts frequently." Review of Resident 20's Care Plan dated 5/29/16, indicated Resident 20 "Elects to go outside of the facility unescorted potentially related to Advanced Alzheimer's Dementia." Resident 20's Care Plan Goal indicated, "Resident [Resident 20] to remain safe within the facility." Review of Resident 20's Care Plan dated 12/8/16, indicated a problem of "Recurrent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CTB411 Facility ID: CA030000055 If continuation sheet 11 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055185 (X3) DATE SURVEY COMPLETED 07/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDEN CITY HEALTHCARE CENTER 1310 W Granger Ave Modesto, CA 95350 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE focus on leaving facility to look for family, her car, or because of delusions [false beliefs] or hallucination [ a false perception], and is increasingly more difficult to re-direct." The Care Plan Approach indicated, "As possible, keep within line of sight." Review of Resident 20's clinical record titled, "Progress Note" dated 2/10/15, indicated, "She [Resident 20] has often tried to leave the facility..." Review of Resident 20's Progress Note dated 10/7/15, indicated, "Concern expressed by NHA [Nursing Home Administrator] and IDT [Interdisciplinary Team (a team composed of health care providers who plan resident care)] team members ... regarding resident [Resident 20] ambulating outside of facility unattended and high risk for injury." Review of Resident 20's Progress Note dated 5/31/16, indicated, "Resident is alert and oriented to family and some staff, otherwise very confused. She went out of facility unescorted. She was promptly brought back to facility." Review of Resident 20's Progress Note dated 8/4/16, indicated, "Patient has strong self determination to ambulate throughout the facility and outside grounds with poor insight to risks. Was found wandering outside of facility." Review of Resident 20's Progress Note dated 10/14/16, indicated, "[Resident 20] walks independently, daily, throughout the facility either pushing her W/C or without. Often looking for the door. She is noted to become verbally irritable when redirection is attempted to guide her." Review of Resident 20's Progress Note dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CTB411 Facility ID: CA030000055 If continuation sheet 12 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055185 (X3) DATE SURVEY COMPLETED 07/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDEN CITY HEALTHCARE CENTER 1310 W Granger Ave Modesto, CA 95350 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 12/8/16, indicated, "IDT Discussion regarding multiple elopement attempts by patient [Resident 20]." Review of Resident 20's Progress Note dated 12/14/16 at 6:04 p.m., indicated, "Call received from [local police department] with information resident was found outside of facility and had sustained a cut on her hand...PD [police department] officer asked what hospital she should be evaluated at...patient will be transported there..." Review of Resident 20's hospital (ACH) clinical record titled, "Note Report" dated 12/16/16, indicated Resident 20 was admitted to the ACH on 12/14/16 following a fall. The "Note Report" indicated, "D/C [discharge] Diagnosis ...right Femur [the large bone of the lower extremity] Fracture FX [fracture], Right Humerus [upper arm bone] FX. Hip Fracture Cephalomedullary Nail [a treatment for fracture that involves insertion of hardware in the operating room to stabilize the bones] Insertion (right) 12/15/16. Distal [closer to the hand than to the shoulder] humerus fracture under conservative [nonsurgical] management." The facility policy and procedure titled, "Wandering, Unsafe Resident" dated 12/08, indicated, "...6. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CTB411 Facility ID: CA030000055 If continuation sheet 13 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055185 (X3) DATE SURVEY COMPLETED 07/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDEN CITY HEALTHCARE CENTER 1310 W Granger Ave Modesto, CA 95350 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: CTB411 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA030000055 (X5) COMPLETE DATE If continuation sheet 14 of 14