Health inspection·February 6, 2026

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure professional standards of quality care were met for one of three sampled residents ( Resident 1) when Resident 1 did not receive care for her urinary incontinence (lack of bladder control) in a timely manner. This failure placed Resident 1 at risk for skin breakdown and infection.Findings: A review of Resident 1's admission RECORD, indicated, Resident 1 was admitted to the facility with diagnoses which included paraplegia (inability to voluntarily move the lower half of the body). During a concurrent observation and interview on 2/6/26 at 11:48 AM in Resident 1's bedroom, Resident 1 stated she had not received care since 6:30 AM. Resident 1 further stated she had asked to be cleaned and dressed at 11 AM. Resident 1 pulled down her blanket and asked the department to observe her incontinence brief. The brief indicated a blue line which signified wetness and appeared to be heavily saturated with urine. Resident 1 stated it was almost noon, and she would not be able to go to the dining room for lunch since she had not been cleaned up yet. Resident 1 further stated she was at risk of a urinary tract infection (UTI, infection of kidneys and/or bladder) if she was not changed when she needed to be. During an interview on 2/6/26 at 11:52 AM with Certified Nurse Assistant (CNA) 1, CNA 1 stated she attempted to provide care to Resident 1 at 7 AM, but Resident 1 told her to come back at 11 AM. CNA 1 stated she did not provide care to Resident 1 at 11 AM because she had to go to lunch. CNA 1 further stated CNA 2 had changed Resident 1 instead. CNA 1 stated it was important not to leave residents when they had been incontinent because they were at risk for infections and bed sores, especially Resident 1 as she had a history of infections. During an interview on 2/6/26 at 12:33 PM with CNA 2, CNA 2 stated he did not provide care to Resident 1 at 11 AM or at any other time during the shift. During an interview on 2/6/26 at 12:25 PM with Licensed Nurse (LN) 2, LN 2 stated it was her expectation that Resident 1 would have received incontinence care in a timely manner, or the CNAs should have informed her if they were unable to provide care. LN 2 further stated if Resident 1 had to wait a long period of time to be changed, she was at risk of skin issues or infection. During a concurrent interview and record review, on 2/6/26 at 1:49 PM, Resident 1's care plans were reviewed with the Director of Nursing (DON). The DON stated residents were usually changed every 2 hours and the facility would care plan frequent refusals by residents. The DON stated the CNA should continue to try to change the resident and let nurse know if the resident continued to refuse. The DON reviewed Resident 1's care plans and confirmed the risk to Resident 1 for untimely incontinence care was skin breakdown and the potential for a UTI, per the care plan. During a review of Resident 1's clinical document titled, Care Plan [a working document that indicates a person's health conditions, specific care needs, and current treatments] Report, revised on 6/23/25, the document indicated, .Focus.Bladder/Bowel Incontinence.The resident is always bowel and bladder incontinence [sic].Goal.The resident will remain free from skin breakdown due to incontinence and brief use.Interventions.Clean peri area [area between legs] with each incontinence episode.Check q2-3 H [every 2-3 hours] and as required for Residents Affected - Few Page 1 of 2 056216 056216 02/06/2026 Guardian Care and Rehabilitation Center 410 Eastwood Ave Manteca, CA 95336

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few incontinence.Monitor/document for s/sx [signs and symptoms] UTI. During a review of an undated facility policy titled, Incontinence Care, the policy indicated, .Residents will be provided with timely, appropriate, and individualized incontinent care in accordance with each residents' assessed needs, care plan, and current standards of nursing practice.Incontinent care will be provided.In a timely manner or as needed.At routine intervals per care plan.As requested by the resident.Staff will monitor skin for redness, breakdown, rashes or pressure injuries during care. 056216 Page 2 of 2