Health inspection·December 23, 2025

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete fatigue.Review of Resident 3's current order summary report indicated an active physician order dated 11/24/25 for oxygen therapy at 2 L/min via nasal cannula, to be administered as needed for shortness of breath and/or comfort.During an observation in Resident 3's room on 12/19/25 at 3:14 PM Resident 3 was noted lying in his bed while receiving oxygen therapy at 2 L/min via an oxygen concentrator. No oxygen in use signage was observed posted on Resident 3's doorway.During a concurrent observation and interview on 12/19/25 at 3:16 p.m., in Resident 3's room Licensed Nurse (LN) 3 confirmed that Resident 3 was receiving oxygen at 2 L/min via an oxygen concentrator for shortness of breath.During a subsequent observation on 12/23/25 at 8:40 a.m., no oxygen in use signage was observed posted on Resident 3's doorway.During a concurrent observation and interview at Resident 3's room on 12/23/25 at 8:50 a.m., Certified Nurse Assistant (CNA) 3 confirmed that no Oxygen in Use signage was posted on Resident 3's room doorway. CNA 3 also confirmed that Resident 3 was receiving oxygen via an oxygen concentrator. CNA 3 explained that Oxygen in Use signage should be posted to alert staff, visitors, and residents that oxygen was in use in the room to maintain safety and prevent potential fire hazards.During an interview on 12/23/25 at 10:49 a.m., the Director of Staff Development (DSD) confirmed that nurses were responsible for posting oxygen in use signage on residents' doorways when oxygen was being used to prevent fire hazards and to meet residents' needs.During a concurrent interview and record review on 12/23/25 at 2:26 p.m., with the Assistant Director of Nursing (ADON) the facility provided policy and procedure (P&P) titled Oxygen Administration, revised September 2022, was reviewed. The ADON explained the purpose of oxygen in use signage, stating it was important to post signage on the doorway of rooms where residents were receiving oxygen as a safety precautions. The ADON stated that when there was an order for oxygen therapy, nurses were responsible to ensure oxygen in use signage was posted on the resident's doorway. The ADON stated it was necessary to post oxygen in use signage on Resident 2's and Resident 3's doorway to alert staff, residents, and visitors that oxygen was being used in the room to prevent fire hazards. The ADON further stated she expected nurses to post oxygen in use signage immediately upon receiving and implementing an order for oxygen therapy, and stated this expectation was not met by nursing staff.Review of the facility's P&P for oxygen administration indicated, . The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation. 3. Assemble the equipment and supplies as needed. Equipment and Supplies. 4. No Smoking/Oxygen in Use signs. Steps in the Procedure. 2. Place an Oxygen in Use sign on the outside of the room entrance door. The ADON acknowledged that the facility's P&P was not followed. Event ID: Facility ID: 056216 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 056216 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Guardian Care and Rehabilitation Center 410 Eastwood Ave Manteca, CA 95336 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to provide food storage, as well as maintain kitchen equipment and food contact surfaces in accordance with professional standards for food safety for the 93 residents who ate facility prepared meals when:1. Four sheet pans (sheet pan, a flat, rectangular metal pan with a raised rim on all four sides, used in ovens for baking, roasting, and broiling foods) were found with dark brown build-up; and,2. A food item (pie) in the freezer was not labeled with a use-by date and expiration date.These failures had the potential to expose 93 residents to foodborne illnesses (illnesses caused by the ingestion of contaminated food or beverages).Findings: 1. During a concurrent observation and interview conducted during the initial tour of the kitchen with the Dietary Supervisor (DS) on 12/19/25 at 10:47 a.m., a stack of four large sheet pans was observed stored in the clean rack, stacked on top of one another. Dark brown buildup was noted on the raised rims of all four sheet pans. The DS confirmed the finding. The DS stated that some of the sheet pans were old and required more thorough scrubbing. The DS further stated it was not acceptable when sheet pans were not washed properly, as residents consuming food prepared on those sheet pans could potentially be exposed to foodborne illness. The DS stated that he expected staff to scrub the sheet pans properly; however, his expectations were not met by dietary staff.During an interview on 12/19/25 at 12:16 p.m., the Dietary Aide (DA) stated that if dishes and pans were not completely cleaned, old food particles could come off into food, and residents could become ill from consuming contaminated food.During a concurrent observation and interview of the sheet pans conducted on 12/19/25 at 12:49 PM the Dietary Supervisor Assistant (DSA) stated that bacteria and mold could grow on those sheet pans and that anyone consuming food cooked on those pans could potentially develop foodborne illnesses. The DSA also stated that she checked all dishes, including sheet pans, and she did not know how she missed those items.During an interview on 12/19/25 at 1:07 p.m., the Dietary [NAME] (DC) explained the dishwashing process, and stated that all remaining food items were first removed from dishes, including sheet pans. The DC stated all dishes and pans were then scrubbed thoroughly with soap and water to ensure no food build up remains, rinsed with water, and placed in the dishwasher, and after washing, dishes were air-dried and then placed on the clean racks. The DC stated that when sheet pans were noticed to not be properly clean, the entire process would be repeated to ensure the items were clean and safe for use. The DC further stated that if food particles remain on dishes or pans, it would be unsafe for residents to consume food prepared and cooked in those items and could cause residents to become ill. During an interview on 12/23/25 at 2:26 p.m., the Assistant Director of Nursing (ADON) stated that it was not acceptable for dishes to be inadequately cleaned and that there was a risk of foodborne illness associated with consuming food prepared using improperly cleaned dishes.Review of the facility provided policy and procedure (P&P) titled, Sanitation, dated 2023 indicated, .The Food & Nutrition Services Department shall have equipment of the type and in the amount necessary for the proper preparation, serving, and storing of food. PROCEDURE. 11. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair. The facility's P&P was not followed. According to the Food and Drug Administration (FDA) Food Code 2022, Section 4-601.11, Equipment, Food-Contact Surfaces required, . EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. 2. During a concurrent observation and interview conducted on 12/19/25 at 10:42 a.m., during the initial kitchen tour with the Dietary Supervisor (DS), an opened box of (brand name) pie was observed with an open date of 12/11/25; however, it did not have a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056216 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 056216 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Guardian Care and Rehabilitation Center 410 Eastwood Ave Manteca, CA 95336 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete use-by ( the last day a food is recommended for consumption, meaning you should not eat it after this date) date, or expiration date. The item was located on the left side shelf inside the freezer near the door. The DS confirmed the finding and stated the pie had been left over from Christmas dinner held several days prior. The DS acknowledged that the pie should have been labeled with a use-by date and that the date was missing. The DS further stated that serving food past its use-by date was unsafe and could result in foodborne illness, posing a risk to residents and anyone consuming the product.During an interview on 12/19/25 at 1:07 p.m., the Dietary [NAME] (DC) stated that all food items stored in kitchen storage areas and other food preparation locations were required to be labeled with an open date, preparation date, use-by date, and expiration date to ensure residents' safety.During an interview on 12/23/25 at 2:26 PM, the Assistant Director of Nursing (ADON) stated food items should be labeled properly with all dates. ADON added residents might get foodborne illnesses from eating unlabeled foods. Review of the facility provided policy and procedure (P&P) titled, LABELING AND DATING OF FOODS, dated 2023, indicated, POLICY: All food items in the storeroom, refrigerator and freezer need to be labeled and dated. PROCEDURE. Newly opened food items will need to be closed and labeled with an open date and used by date that flows the. Freezer Guidelines. Food items will be dated with receive date, open date and use by date. The facility P&P was not followed. Event ID: Facility ID: 056216 If continuation sheet Page 4 of 4