Health inspection·January 6, 2026

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 observation, interview, and record review, the facility failed to implement preventative measures to discourage drug seeking behavior/drug use for one of three sampled residents (Resident 1) when Resident 1's urine test results was positive for Cocaine (an addictive drug used as an illegal stimulant) on 7/18/25, and Cannabis (commonly known as marijuana, weed, and pot, which is a psychoactive drug that produces effects, ranging from relaxation to altered perception) on 7/18/25, 8/21/25, 9/25/25 and 12/6/25. These failures posed potential risks to Resident 1's safety, risked potential drug interactions with prescribed medications, and risked changes in level of consciousness for Resident 1 which put Resident 1, and other residents at the facility, at risk for accidents/injuries.Findings:Review of Resident 1 ' s admission RECORD indicated Resident 1 was admitted to the facility in 2013 with diagnoses including paraplegia, chronic pain syndrome, and major depressive disorder (a serious mood illness causing persistent sadness, loss of interest, and significant impairment in daily life, affecting sleep, appetite, energy, and concentration).During an interview on 1/6/26 at 11:03 a.m., in Resident 1's room, Resident 1 stated he got stressed and he made a mistake by sniffing cocaine (inhaling powdered or crushed illicit drugs (like cocaine) through the nose so they are absorbed rapidly which results in quick intoxication). Resident 1 stated he was aware that his urine tested positive for cocaine and cannabis. Resident 1 stated the doctor had decreased his pain medication (methadone) from 60mg (milligram, a unit of measure) to 40mg because he tested positive for marijuana. Resident 1 stated he had used marijuana for the last 12 years while residing at the facility. Resident 1 further stated the doctor notified him that his fourth drug test, which was done in December 2025, tested positive for marijuana. Resident 1 stated he went to the nearby park by himself and that was where he met a friend who supplied him with cocaine and marijuana. Resident 1 stated he had notified the facility staff that a friend had given him cocaine. Resident 1 stated he was never supervised by a facility staff member when he left the facility's premises and was allowed to go to the park by himself. Resident 1 further stated the risk of taking methadone and cocaine was he could have had difficulty breathing and he could have passed out (to become unconscious; faint) and no one would have known. Resident 1 stated he brought one marijuana cartridge (small, pre-filled container holding concentrated cannabis oil designed for use with a compatible vaporizer or vape pen, offering a discreet, portable, and convenient way to inhale cannabis vapor) inside the facility but staff told him he could not smoke marijuana in the facility. Resident 1 stated after his positive drug test in July 2025 he stopped going to the park following a doctor's order not allowing any more day passes. Resident 1 further stated a visitor came into the facility to see him in August 2025, September 2025 and December 2025 and gave him marijuana brownies (brownies a food item made with marijuana or marijuana oils which can be used as an alternative to smoking or vaporizing marijuana). Resident 1 further stated no one at the facility had talked to him about substance use treatment services (such as behavioral health services (treatment for mental health and substance use Page 1 of 4 056216 056216 01/06/2026 Guardian Care and Rehabilitation Center 410 Eastwood Ave Manteca, CA 95336

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few disorders), medication-assisted treatment (MAT- Medications for Addiction Treatment), alcoholic/narcotics anonymous meetings (drug and alcohol addiction treatment )).During an interview on 1/6/26 at 12:53 p.m., CNA 2 stated residents were not allowed to take drugs in the facility. CNA 2 stated Resident 1 was independent and when Resident 1 got up from his bed she did not know where he went. CNA 2 stated residents signed a log before they went outside of the facility. CNA 2 stated being unsupervised, a resident with drug seeking behavior could go outside and consume some bad stuff and visitors could be a bad influence on the resident. CNA 2 stated when a resident had a history of drug seeking behavior, they should be monitored regularly.During a concurrent interview and record review of Resident 1's medical record on 1/6/26 at 1:04 p.m., Licensed Nurse (LN) 1 stated Resident 1 tested positive for cocaine and cannabis on 7/18/25, and positive for cannabis on 7/18/25, 8/20/25, 9/24/25 and 12/5/25. LN 1 stated a care plan was initiated on 7/24/25 for Resident 1's drug seeking behavior. LN 1 further stated after 7/24/25 until 1/6/26 there were no care plan revisions or new interventions for Resident 1's additional positive drug tests. LN 1 stated there was no drug behavior monitoring (a healthcare document for tracking patient behavior) done regularly for Resident 1's continued drug use.During a concurrent interview and record review of Resident 1's medical record on 1/6/26 at 1:45 p.m., LN 2 stated Resident 1 did not attend drug treatment meetings and there were no psychological evaluations of Resident 1 for drug use in his medical record. LN 2 stated Resident 1 did not have a behavioral monitoring log for drug use. LN 2 stated facility staff did not know Resident 1 was using cocaine and cannabis because there were no psychological evaluations and no behavior monitoring log.During a concurrent interview and record review of Resident 1's medical record on 1/6/26 at 2:03 p.m., LN 3 stated when a resident who used drugs took marijuana with other drugs the Resident could have a drug overdose and/or interaction with his prescribed medications. LN 2 stated Resident 1 did not have a behavior monitoring log to track drowsiness, changes in behavior, or if Resident 1 had taken drugs.During an interview on 1/6/26 at 4:32 p.m., LN 4 stated when a Resident with a history of drug use did not have a behavior tracking log, the facility would not have a way of tracking when that resident used drugs. LN 4 stated the risk of not monitoring Resident 1's drug seeking behavior/drug use was Resident 1 could have respiratory distress (trouble breathing) caused by an overdose and interactions between narcotics and illicit drugs. LN 4 further stated drug seeking behavior monitoring should have been done for Resident 1 to avoid the recurrence of positive drug tests and track who brought drugs to the facility for Resident 1.During an interview on 1/6/26 at 4:45 p.m., the Director of Nursing (DON) stated behavior monitoring was documented on Resident 1's progress notes for 72 hours after Resident 1 tested positive for cocaine and cannabis on 7/18/25. The DON stated there was no daily behavior tracking implemented for drug seeking behavior/drug use for Resident. The DON stated the risk of not having a log for Resident 1 was the new staff at the facility would not be aware of Resident 1's drug seeking behavior/drug use. The DON stated a care plan for drug seeking behavior for Resident 1 was implemented on 7/23/25 and the care plan was not revised after Resident 1 tested positive for cannabis on 8/20/25, 9/24/25 and 12/5/25. The DON stated visitor monitoring could have helped stop drugs being brought to Resident 1 in the facility.During a phone interview on 1/7/26 at 2:14 p.m., the Medical Doctor (MD) stated Resident 1 had a diagnosis of paraplegia (paralysis affecting the lower half of the body, typically the legs, due to damage to the spinal cord, leading to loss of motor function, sensation, and sometimes bowel/bladder control) and Resident 1 was prescribed methadone for his pain. The MD stated Resident 1 was offered to go to a pain management clinic and recommended psychiatric evaluation. The MD stated Resident 1 was educated to not use recreational drugs (a loose term that refers to legal and illegal drugs that are used without medical 056216 Page 2 of 4 056216 01/06/2026 Guardian Care and Rehabilitation Center 410 Eastwood Ave Manteca, CA 95336

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few supervision). The MD stated the risk of using recreational drugs with methadone was it could have caused Resident 1 to have a seizure (disruptions in muscle control and movement), QT prolongation (a heart condition causing the heart's electrical recharging cycle to take too long, increasing the risk for dangerous, irregular heart rhythms which can lead to fainting, seizures, or sudden cardiac arrest), and central nervous system depression (the slowing down of brain activity).Review of Resident 1's urine lab test result indicated a positive result for cocaine on 7/18/25 and positive results for cannabis on 7/18/25, 8/21/25, 9/25/25 and 12/6/25.Review of Resident 1's Office Visit, dated 12/26/25, indicated, .Office Visit.Plan of Care.If drug screen is neg [negative] and pain is still present will consider change, Refer to pain management.Monitor behavior.Continue with methadone 10mg 2 tab [tablets] twice daily.Review of Resident 1's Office Visit, dated 12/11/25, indicated, .Office Visit.HPI [history of present illness] at admission.h/o [history of] polysubstance abuse [mixing of different drugs],.per staff [Resident 1] has had severe behavior issues, possibly ongoing drug use.does leave on own when he wants.Has behavior out burst and anger issues.Opiate dependence [the chronic use of opioids [pain medication] that causes clinically significant distress or impairment].Polysubstance abuse.Patient on chronic [long term] methadone use instructed regarding contraindication.Psych [psychiatric] eval.Monitor behavior.No more day pass.Record review of Resident 1's Change in Condition (CIC) evaluation, dated 6/7/25, indicated, .Aggressive behavior.Review of Resident 1's Office Visit, dated 7/16/25, indicated, .Polysubstance abuse.Refer to Psych eval.Monitor behavior.Supportive care.Review of Resident 1's Office Visit, dated 9/17/25, indicated, .Office Visit.Pending Psych eval.Monitor behavior.Drug screen ordered.Review of Resident 1's Office Visit, dated 10/28/25, indicated, .Office Visit.Monitor behavior.Review of Resident 1's Office Visit, dated 11/3/25, indicated, .Office Visit.Opiate dependence.Pending Psych eval.Monitor behavior.Review of Resident 1's Office Visit, dated 11/4/25, indicated, .Office Visit.Monitor behavior.Rash possible allergic reaction.Review of Resident 1's Office Visit, dated 12/4/25, indicated, .Office Visit.Monitor behavior.Monitor Vitals.fall precautions.Record review of Resident 1's IDT Team Investigation, dated 7/21/25, indicated, .Resident tested positive on UDS [urine drug screen] reported on 7/18/2025.attempted to ask resident where he got his illicit drugs, resident immediately became agitated, started yelling for staffs to get out of his room. Resident stated he only did cocaine once and has been taking cannabis for a long time and will not stop taking cannabis.Record review of Resident 1's IDT Team Investigation, dated 8/20/25, indicated, .Resident tested positive again for cannabis on 8/20/25.Per resident he has been taking cannabis for 13 yrs. and will not stop just because a doctor told him to.Record review of Resident 1's IDT Team Investigation, dated 9/26/25, indicated, .resident tested positive for cannabis on 9/24/25.Per resident, he does not want to stop cannabis.Behavior remains the same, agitated at times and yells at the staffs during care.Record review of Resident 1's IDT Team Investigation, dated 12/8/25, indicated, .team started investigation on positive cannabis UDS result on 12/5/25.Resident stated he does not even smoke the cannabis, he only eats it through edibles [edible forms of cannabis].Record review of Resident 1's Progress Notes, dated 7/21/25 at, indicated, .IDT NOTE.Positive lab results for Narcotics (cocaine, cannabinoids) .Resident agreed to follow facility protocol and policy.IDT RECOMMENDATIONS.Drug test as needed upon suspicion of being under the influence. Monitoring of suspicious behavior.Record review of Resident 1's Progress Notes, dated 7/24/25, indicated, .Resident was seen by MD for PRN [as needed] visit following resident & family member's request to see MD regarding pain medication [discontinued due to] positive UDS result for cocaine & cannabis. Patient teaching was done by MD regarding risk of overdose if resident continues to take illicit drugs.Record review of Resident 1's Progress Notes, dated 12/26/25, indicated, .Resident was seen by MD during 056216 Page 3 of 4 056216 01/06/2026 Guardian Care and Rehabilitation Center 410 Eastwood Ave Manteca, CA 95336

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few routine visit following resident's positive UDS for cannabis on 12/5/25.MD explained to resident that taking recreational drugs might impose a risk to resident if taken alongside methadone. MD stated he will refer resident to pain specialist for pain management but before finishing his sentence, resident cut MD off by stating I don't want to hear anything.During a record review of Resident 1's Care Plan, in the section titled focus initiated on 6/7/25, indicated, .The resident has a behavior problem (aggressive). The section titled Interventions, indicated, .Refer to psych services as needed per MD.During a record review of Resident 1's Care Plan, in the section titled focus initiated on 7/21/25, indicated, .Resident is a long-term resident in the facility. The section titled Interventions, indicated, .Possible referral for psychological services to assist in adjustment to change in functional abilities and assist staff with appropriate behavioral intervention.During a record review of Resident 1's Care Plan, in the section titled focus initiated on 7/23/25, indicated, .History of substance use disorder and drug seeking behaviors. The section titled Interventions, indicated, .Discuss the risks of substance misuse and overdose, use a clear consistent approach from all staff, avoid confrontation, remain calm and nonjudgemental, inform MD for any S/S of overdose, perform urine drug screen for suspected use of illegal substances.During a record review of Resident 1's Care Plan, in the section titled focus initiated on 12/27/25, indicated, .Resident has ep. [episode] Of non-compliance w/UDS. The section titled Interventions, indicated, .Document each refusals for urine drug screen.Provide patient teaching about importance of UDS.A review of facility's undated policy titled, Pain Assessment and Management, indicated, .When opioids are used for pain management, the resident is monitored for medication effectiveness.Any resident who uses opioids for long-term management of chronic pain is at risk for opioid overdose.A review of facility's undated policy titled, Visitation, indicated, .Our facility permits residents to receive visitors subject to the resident's wishes and the protection of the rights of other residents in the facility.Some visitation may be subject to reasonable clinical and safety restrictions that protect the health, safety, security and/or rights of the facility's residents such as.denying access or providing supervised visitation to individuals who have a history of bringing illegal substances into the facility which places residents health and safety at risk. 056216 Page 4 of 4