Other·January 9, 2020

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a Federal Recertification survey. Representing the Department of Public Health: Health Facilities Evaluator Nurse (HFEN), 29421 HFEN, 38628 HFEN, 40726 HFEN, 40911 HFEN, 42432 HFEN, 29825 The facility census was 142. The sample size was 84.

F550 SS=D Resident Rights/Exercise of Rights CFR(s): 483.10(a)(1)(2)(b)(1)(2)

F550 12/20/2019 §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A 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: 5ITG11 Facility ID: CA030000010 If continuation sheet 1 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and review of facility documents, the facility failed to ensure one of 84 sampled residents (Resident 46) was treated with respect when personal information was posted on the wall by his bedside. This failure increased the risk for psychosocial distress, humiliation, and embarrassment. Findings: Resident 46 was admitted to the facility in 2018 with diagnoses which included paralysis (inability to move) of the right side. Review of Resident 46's Minimum Data Set (MDS, an assessment tool), dated 10/15/19, indicated he had severe impairment of his FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 2 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 memory and required limited assistance with most activities of daily living (ADLs). During an observation on 11/5/19, at 9:15 a.m., the personal information, "Please make sure wheelchair is close to his bed. R [right] hemiplegic [paralysis]" was posted at the head of Resident 46's bed, including his name. During a concurrent observation and interview with the director of nursing (DON) on 11/5/19, at 9:16 a.m., she verified the personal information was posted and said it (personal information) should not be posted at the head of the bed. During an interview with the DON on 11/6/19, at 7:13 a.m., she was asked what her expectations were regarding the posting of personal information and she said, "No names or other personal information should be posted in clear sight for everyone to see. We shouldn't put any diagnosis where it can be seen." Review of the undated facility policy and procedure titled "Dignity and Resident's Rights" indicated, "It is the policy of the facility to promote Dignity and respect Resident's right to privacy...Ways to preserve privacy...Assuring privacy of your health...records..."

F582 Medicaid/Medicare Coverage/Liability Notice FORM CMS-2567(02-99) Previous Versions Obsolete

F582 Event ID: 5ITG11 12/20/2019 Facility ID: CA030000010 If continuation sheet 3 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) SS=D CFR(s): 483.10(g)(17)(18)(i)-(v) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.10(g)(17) The facility must-(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; (B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and (ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section. §483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate. (i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible. (ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change. (iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 4 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements. (iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility. (v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations. This REQUIREMENT is not met as evidenced by: Based on interview, record review, and facility policy review, the facility failed to provide a written Notice of Medicare Non-Coverage (NOMNC-a notice that informs the residents and their representatives of the termination of services) and a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN-a notice providing information to residents and their representatives what services Medicare will not pay and what the resident will assume responsibility) to two of 84 sampled residents (Resident 88 and Resident 85) when Resident 88's and Resident 85's Medicare Part A (a government health insurance covering hospitalization) services ended and they remained in the facility with remaining benefit days. This failure placed Resident 88, Resident 85, and their representatives at risk of not being informed of their responsibility to pay for any services received after their Medicare Part A coverage ended, not given the opportunity to exercise their right to make informed decision regarding their financial liability options, and experiencing financial hardship related to noncovered services received. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 5 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 a. Review of Resident 88's clinical record indicated, she was admitted to the facility in 2019 with diagnoses of osteoarthritis (when flexible tissue at the ends of bones wears down) and muscle weakness. The NOMNC form for Resident 88 indicated, "Resident reached maximum rehab [rehabilitation] potential." Resident 88 was no longer qualified for Medicare services beginning 5/30/19. The NOMNC completed by the business office manager (BOM) indicated, she had spoken directly with the resident's representative on 5/27/19. The NOMNC and the SNF ABN did not have a signature of Resident 88's representative acknowledging receipt of the forms. b. Review of Resident 85's clinical record indicated, he was re-admitted to the facility from a hospital stay in 2019. The NOMNC form for Resident 85 indicated, "Resident has no skilled needs (when you require the skill of a health professional to care for you)." Resident 85 was no longer qualified for Medicare services beginning 7/28/19. The NOMNC completed by the BOM indicated, she had spoken directly with the resident's representative on 7/25/19. The NOMNC and the SNF ABN did not have a signature of Resident 85's representative acknowledging receipt of the forms. In a concurrent interview and record review with the BOM on 11/7/19, at 3:53 p.m., she explained, the NOMNC and SNF ABN notices should be provided to residents or their representatives with instructions on how to appeal the facility's decision of ending Medicare services. A number to call to appeal was included in both forms. She could not tell FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 6 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 whether a copy of the notices were mailed to the residents' representatives. She stated, she usually made a note on the form when mailed. She confirmed, there was no documentation that the notices were mailed. She added, "I cannot show you any documentation." Review of the facility's policy titled, "Denial of Medicare Benefits Policy and Procedure" dated August 2018, indicated in pertinent part, "Policy: To complete ...detailed explanation of Medicare Non-Coverage and to notify the resident or resident representative of the denial of Medicare benefits ...Procedure: 7. The Business Office will contact the resident or representative that the "Notice of Medicare Provider Non-Coverage" and "Skilled Nursing Facility Advance Beneficiary Notice ..." requires a signature and a copy will be mailed via certified mail and must be returned."

F609 SS=D Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 12/20/2019 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 7 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure an allegation of verbal abuse was reported for one of 84 sampled residents (Resident 93), when Licensed Nurse (LN) 4 did not report, to facility administration, Resident 93's complaint about Certified Nursing Assistant (CNA) 2's treatment. This failure resulted in a delay of an investigation into alleged abuse and had the potential to affect Resident 93's psychosocial well being. Findings: Resident 93 was admitted to the facility with diagnoses including kidney stones (hard deposits which can block the flow of urine and cause pain) and kidney failure (kidneys filter out waste from the blood). Review of the Minimum Data Set (MDS-an assessment and care screening tool) dated 9/28/19, indicated Resident 93 had a brief interview for cognitive status (BIMS) score of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 8 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 15. This indicated Resident 93's memory was intact. During an interview with Resident 93 on 11/5/19, during the initial screening, Resident 93 spoke of an event which occurred over the previous weekend. Resident 93 explained she waited for CNA 2 to provide care and described what occurred when CNA 2 entered her room. Resident 93 stated, "I asked her name. She said she didn't have to tell me. She was very abrupt ...I reported it to my nurse [LN 4] ...I think it was day before yesterday ...verbally abusive. I cried. She scared me ..." During an interview with the director of nursing (DON) on 11/5/19, at 1:20 p.m., the DON indicated there was no report received regarding Resident 93's allegation and no investigation was initiated into CNA 2's alleged mistreatment of Resident 93. During an interview with Resident 93 on 11/5/19, at 1:44 p.m., Resident 93 indicated the incident with the CNA occurred during the evening shift. She stated, "...[LN 4] came in when the CNA was still here. She asked me why my face was so red. I pointed to the CNA..." During an interview with LN 4 on 11/8/19, at 8:07 a.m., LN 4 stated, " ...She [Resident 93] was a little crying. I asked her what happened. [CNA 2] raised her voice to her ... I did talk to the CNA and told her to please be careful about talking to the [resident] ...I just got my license four months ago. Now I know I have to report to my supervisor ...when you're new there's so much to learn. I didn't really understand. Now I know what the proper protocol is." A review of a report sent to the Department FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 9 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 titled, "Report of Suspected Dependent Adult/Elder Abuse", completed 11/5/19, indicated Resident 93's allegation of verbal abuse occurred on 11/2/19, and was reported to the Department on 11/5/19. A review of the facility policy titled, "Abuse Prohibition and Prevention Policy and Procedure and Reporting Reasonable Suspicion of a Crime in the facility Policy and Procedure", revised 1/2019, indicated, " ...Facility Staff ...are Mandatory Reporters ...The facility will report allegations of abuse, neglect, exploitation, or mistreatment ...even if no reasonable suspicion. When: ...No later than 24 hours-all other conduct (actual, alleged, or potential neglect, mistreatment ...To Whom: 1. Facility Administrator 2. State Survey Agency ..."

F623 SS=D Notice Requirements Before Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8)

F623 12/20/2019 §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State LongTerm Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 10 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 11 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l). This REQUIREMENT is not met as evidenced by: Based on interview, clinical record review, and facility policy review, the facility failed to provide a written notice of transfer/discharge, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 12 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 complete with appeal rights, to two of 84 sampled residents (Resident 76 and Resident 119), the residents' representatives, and the local Long-Term Care Ombudsman (patient advocate) when Resident 76 and Resident 119 were transferred/discharged to the local emergency room (ER). This failure placed Resident 76, Resident 119, and their representatives at potential risk of not knowing their transfer/discharge appeal rights which included contacting the local Long-Term Care (LTC) Ombudsman and to not be protected in the event of an inappropriate transfer or discharge. Findings: Review of Resident 76's clinical record revealed, he was transferred to the local ER on 10/12/19, due to difficulty breathing. There was no documented evidence in Resident 76's clinical record that a written transfer/discharge form was provided to Resident 76 and/or his representative. Review of Resident 119's clinical record revealed, she was transferred to the local ER on 10/14/19, due to lethargy (unresponsiveness). There was no documented evidence in Resident 119's clinical record that a written transfer/discharge form was provided to Resident 119 and/or her representative. In an interview with Licensed Nurse (LN) 5, on 11/7/19, at 8:34 a.m., she confirmed, a copy of the notice was not given to Resident 76 and Resident 119, nor the residents' representatives. She stated, "I inform by phone." In an interview with LN 7, on 11/7/19, at 8:45 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 13 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 a.m., she stated, "We do not give copy of the transfer/discharge notice to the resident and family member." LN 7 confirmed, a copy of the facility's Transfer/Discharge Report was faxed to the local LTC Ombudsman when Resident 76 and Resident 119 were transferred or discharged to the local ER. In a concurrent interview and record review with the director of nursing (DON) and regional consultant (RC), on 11/8/19, at 10:26 a.m., both confirmed, the residents' and the residents' representatives did not receive a copy of the facility's Transfer/Discharge Reports when the residents were transferred or discharged to the local ER. The DON and the RC stated, "Only the Ombudsman receives a notice of transfer/discharge." The DON and the RC confirmed, the Transfer/Discharge report did not include the following information: a) An explanation of the right to appeal to the State; b) The name, address (mail and email), and telephone number of the State entity which receives appeal hearing requests; c) Information on how to request an appeal hearing; d) Information on obtaining assistance in completing and submitting the appeal hearing requests; and e) The name, address, and phone number of the representative of the Office of the State LTC Ombudsman. In a subsequent interview with the DON and the RC, they stated, the facility's Transfer/Discharge Report faxed to the local LTC Ombudsman was incomplete and lacked the important information necessary for the Ombudsman in assisting the residents and residents' representatives to exercise their appeal rights. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 14 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 facility's policy titled, "Transfer or Discharge Notice" revised December 2016, indicated in pertinent part, "...3. The resident and/or representative (sponsor) will be notified in writing of the following information: a. The reason for the transfer or discharge; b. The effective date of the transfer or discharge; c. The location to which the resident is being transferred or discharged; d. A statement of the resident's rights to appeal the transfer or discharge, including ...f. The name, address, and telephone number of the Office of the State Long-Term Care Ombudsman ...4. A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman ..."

F655 SS=D Baseline Care Plan CFR(s): 483.21(a)(1)-(3)

F655 12/20/2019 §483.21 Comprehensive Person-Centered Care Planning §483.21(a) Baseline Care Plans §483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must(i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to(A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 15 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 §483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan(i) Is developed within 48 hours of the resident's admission. (ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section). §483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as necessary. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to develop a resident centered baseline care plan for one of 84 sampled residents (Resident 93) when Resident 93's baseline care plan did not include care of a nephrostomy tube (a tube that is passed through an opening in the skin into the kidney allowing urine drains into a bag) which was present on admission to the facility. This failure had the potential that Resident 93's immediate care needs were not addressed timely. Findings: Resident 93 was admitted to the facility in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 16 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 2019, with diagnoses including kidney stones (hard deposits which can block the flow of urine and cause pain), kidney failure (kidneys filter out waste from the blood), nephrostomy tubes in each kidney and urinary tract infection. Review of the Minimum Data Set (MDS-a resident assessment and care screening tool) dated 3/28/19, indicated Resident 93 was admitted with nephrostomy tubes. During an interview with Resident 93 on 11/5/19, at 2:07 p.m., Resident 93 stated, " ...I've had them [nephrostomies] seven months. That's why they put me in here." A review of Resident 93's baseline care plan completed 3/22/19, indicated, "Bowel and bladder appliances ...None of the above." One of the choices was nephrostomy. During an interview with the director of nursing (DON) on 11/8/19, at 12:08 p.m., the DON indicated Resident 93's nephrostomies should have been included in the baseline care plan. Review of the facility policy titled, "Care PlansBaseline" revised December 2016, indicated, "...To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within 48 hours of the resident's admission."

F658 SS=D Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i) FORM CMS-2567(02-99) Previous Versions Obsolete

F658 Event ID: 5ITG11 12/20/2019 Facility ID: CA030000010 If continuation sheet 17 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on observation, interviews, and review of facility documents, the facility failed to ensure professional standards of quality were followed for 6 of 84 sampled residents when: 1. Resident 485's dressing was not changed as ordered by the physician; 2. Residents 10, 112, and 127 did not receive RNA (Restorative Nursng Assistance) as ordered; and 3. Resident 116's compression stockings (worn to help circulation and decrease swelling) were ordered but not provided. These failures increased the risk for negative outcomes to occur for Residents 10, 112, 116, 127, and 485. Findings: 1. Resident 485 was admitted to the facility in the fall of 2019 with diagnoses which included diabetes (a condition where the cells are unable to use sugar properly) with a foot ulcer and bone infection. Review of Resident 485's Minimum Data Set (MDS, an assessment tool), dated 10/30/19, indicated he was alert and oriented and required limited assistance with most activities of daily daily living (ADLs). Review of Resident 485's physician order, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 18 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 initiated 10/23/19, indicated "LEFT FOOT BIG TOE SURGICAL AMPUTATION [removal of]: CLEANSE WITH NS [normal saline, a salt solution]. PAT DRY, APPLY IODINE COVER WITH [name of loosely woven bandage]. one time a day for 30 Days [sic]." Review of Resident 485's care plan titled, "SKIN IMPAIRMENT: Resident was admitted with the following skin impairment/wound to: 1) Left big toe surgical wound [post amputation]...," dated 10/25/19, indicated "Administer treatment as per Md's [medical doctor] order [sic]." Review of Resident 485's Treatment Administration Record (TAR) for left foot big toe treatment order dated 10/28/19, and 10/31/19, was not initialed as done. During a concurrent observation and interview with Resident 485 on 11/5/19, at 10:45 a.m., his left foot was covered with a dressing and he said, "They've only done it [left foot dressing] every two days. It's supposed to be done every day." During a concurrent record review and interview with Licensed Nurse (LN) 3 on 11/7/19, at 9:59 a.m. she verified the missing dates on the TAR regarding the left foot big toe treatment order and said, "If I'm not doing the dressing, the licensed nurse does it...I communicate with the licensed nurse to make sure it's done..." During a concurrent record review and interview with LN 1 on 11/7/219, at 10:30 a.m., she verified the missing dates on the TAR regarding the left foot big toe treatment order and said, " It wasn't done 10/31/19. [LN 3] usually does it. We try to communicate with each other. It looks like it was missed." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 19 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 During a concurrent record review and interview with LN 2 on 11/7/19, at 10:35 a.m., she verified the missing dates on the TAR regarding the left foot big toe treatment order and said, " [LN 3] was behind that day. I did his dressing and forgot to document it 10/28/19." 2a. Resident 10 was admitted to the facility in 2018 with multiple diagnoses which included dementia (decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities), muscle weakness, arthritis, osteoporosis (thinning of the bones) and abnormality of gait and mobility. Review of Resident 10's Minimum Data Set (MDS, an assessment tool) dated 10/29/19, indicated she had severe cognitive impairment and required extensive assistance with most ADLs. Review of Resident 10's physician orders, dated 10/31/19, indicated "RNA Referral 1)ambulation with rollator walker [four wheels] (3x/wk [times per week] x 12 wks)." Review of Resident 10's care plan titled, "Restorative Nursing Program," dated 10/31, indicated Resident 10 had muscle weakness with a goal to "Improve and/or maintain current level of function" with the approach indicated as ambulation, ambulation with a gait belt, and the four wheel walker assistive device. Review of the "RNA EXERCISES" spreadsheet, dated 11/4 - 11/10/19, did not include Resident 10. During an observation of Resident 10 on 11/5/19, at 9:05 a.m., she was laying in a low bed with her eyes closed with a wheelchair and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 20 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 walker nearby. During a second observation on 11/8/19, at 7 a.m., she was in bed with her eyes closed. During a concurrent record review and interview with RNA 1 on 11/6/19, at 8:10 a.m., he verified Resident 10 was not on the list and said, "We do monthly weights on the first to the fifth. Everybody misses RNA the first week of the month. The doctor is not aware..." 2b. Resident 112 was re-admitted to the facility in the spring of 2019 with multiple diagnoses which included muscle weakness and difficulty walking. Review of Resident 112's MDS, dated 10/16/19, indicated he was alert and oriented. He required limited assistance for most ADLs. Review of Resident 112's care plan titled "Activity of Daily Living Self-care deficit r/t medical condition...Strength...Weakness...," dated 7/24/19, indicated "RNA as ordered..." Review of Resident 112's 'RESTORATIVE NURSING PROGRAM" referral, dated 8/27/19, indicated "Diagnosis/ Condition requiring RNA: Weakness, L [left] above knee amputation." The effective date was 8/27/19 through 11/19/19 and indicated three treatments per week for 12 weeks. Review of Resident 112's physician orders, dated 8/27/19, indicated "Continue RA [RNA] services 3 x week x 12 weeks for BLE exercise..." It indicated an end date of 11/19/19. Review of the facility "RNA EXERCISES" spreadsheet, dated 11/4 - 11/10/19, indicated Resident 112 did not receive RNA. "WEIGHTS" was written across the schedule for Monday FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 21 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 11/4(2019) through Friday 11/8(2019) During a concurrent record review and interview with RNA 1 on 11/6/19, at 8:10 a.m., he verified Resident 112 was on the list and said, "We do monthly weights on the first to the fifth. Everybody misses RNA the first week of the month. The doctor is not aware..." 2c. Resident 127 was admitted to the facility in 2018 with multiple diagnoses which included muscle weakness and abnormalities of gait and mobility. Resident 127's most recent MDS, dated 7/22/19, indicated he was alert and oriented and required extensive assistance with most activities of daily living (ADLs). Review of Resident 127's physician orders, active as of 11/6/19, indicated "NURSING REHAB [rehabilitation] RNA PROGRAM..." with a start date of 10/15/19 and an end date of 1/7/20. Review of Resident 127's care plan titled "Activity of Daily Living, Self-care deficit r/t medical condition...Weakness on BLE...," revised 10/28/19, indicated "NURSING REHAB RNA PROGRAM...3X A WEEK X 12 WEEKS (1/7/20)..." During a concurrent record review and interview with RNA 1 on 11/6/19, at 8:10 a.m., he verified Resident 124 was on the list and said, "We do monthly weights on the first to the fifth. Everybody misses RNA the first week of the month. The doctor is not aware..." A facility policy and procedure for following physician orders was requested but not received. 3. Resident 116 was admitted to the facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 22 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 with diagnoses including hemiplegia (weakness on one side of the body) following cerebral infarction (a stroke, caused by impaired blood flow to the brain). Review of the MDS, dated 10/17/19, indicated Resident 116 had a brief interview for mental status (BIMS) score of 15. A score of 13-15 indicated intact memory. Review of physician orders in Resident 116's clinical record indicated an order for "Compression Stockings ..." dated 10/18/19. During a concurrent observation and interview with Resident 116 on 11/6/19, at 3:12 p.m., Resident 116 was seated in a wheelchair in the activity room. Resident 116 was not wearing any compression stockings. She stated, "I was told the pharmacy doesn't have them [compression stockings] ...[physician] wanted me to wear them for the swelling in my right calf." Resident 116 indicated she had circulation problems as a result of not moving enough and that the swelling was less when she was walking. During a concurrent interview and record review with the central supply manager (CSM) on 11/7/19, at 9:52 a.m., the CSM stated, "I have the compression stockings ...If someone gives me an order, I will get it ...the info [information] is recorded on a clipboard ...I never got an order for [Resident 116's] stockings." The CSM provided the clipboard for review and there was no evidence the stockings were requested. During a concurrent interview and record review with Licensed Nurse (LN) 8 on 11/7/19, at 10:40 a.m., LN 8 indicated Resident 116 was not wearing any compression stockings. The physician order for compression stockings FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 23 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 dated 10/19/19, was reviewed. LN 8 indicated Resident 116 had not refused the compression stockings. She stated, "We [nurses] don't measure the residents [for stockings]." LN 8 indicated the request for compression stockings should have gone to the CSM. During a concurrent interview and record review with the director of nursing (DON) on 11/7/19, at 11:42 a.m., the DON reviewed Resident 116's order for compression stockings and stated, "She [Resident 116] should have had them [compression stockings] 10/19/19. If the nurse didn't know how to measure, they could ask." Review of the professional standard titled "[State] Nursing Practice Act," enacted 1/1/13, indicated "2725 (b) The practice of nursing within the meaning of this chapter means those functions, including basic health care, that help people cope with difficulties in daily living that are associated with their actual or potential health or illness problems or the treatment thereof, and that require a substantial amount of scientific knowledge or technical skill, including all of the following: (1) Direct and indirect patient care services that ensure the safety, comfort, personal hygiene, and protection of patients; and the performance of disease prevention and restorative measures. 2) Direct and indirect patient care services, including, but not limited to, the administration of medications and therapeutic agents, necessary to implement a treatment, disease prevention, or rehabilitative regimen ordered by and within the scope of licensure of a physician, dentist, podiatrist or clinical psychologist, as defined by Section 1316.5 of the Health and Safety Code." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 24 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F688 Increase/Prevent Decrease in ROM/Mobility CFR(s): 483.25(c)(1)-(3)

F688 SS=E PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 12/20/2019 §483.25(c) Mobility. §483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and §483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. §483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. This REQUIREMENT is not met as evidenced by: 2. Resident 73 was admitted to the facility with diagnoses of osteoarthritis (condition affecting the joints resulting in bone pain and joint damage) and low back pain. During the initial tour on 11/5/19, at 8:51 a.m., Resident 73 was observed to be in bed. During an interview with Resident 73, on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 25 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 11/5/19, at 4:17 p.m., she stated, "I don't get out of bed." She continued, "I do want to get up." She also stated, she had not been getting up and had not been receiving restorative nursing assistance (RNA) services while in bed. She added, "I do [exercises] myself in bed." Review of Resident 73's physician order on 11/7/19, revealed, there was no documented evidence RNA services was ordered. Review of Resident 73's care plan on 11/7/19, indicated the following, "Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility...Pt (physical therapy) evaluation and treat as ordered or PRN [as needed]." In an interview with the director of rehabilitation (DOR) on 11/7/19, at 9:28 a.m., he explained, the residents were re-assessed for the need of RNA services during quarterly reviews of residents' condition and Interdisciplinary Team (IDT-all department heads) meetings. He further stated, the residents were re-assessed for RNA needs when residents had a decline in mobility and when he received requests from the nursing staff. In an interview with Certified Nursing Assistant (CNA) 5 on 11/7/19, at 9:48 a.m., she stated, Resident 73 was mostly in bed and she felt Resident 73 would benefit from RNA services. She further stated, she did not report to the DOR or the licensed nurse (LN) the need for RNA services for Resident 73. In an interview with the LN 5 on 11/7/19, at 9:57 a.m., she explained, any residents who needed RNA services would be referred to the DOR for evaluation. Once the evaluation was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 26 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 received from the DOR, she then would call the resident's physician to get an order for RNA services. She stated, she felt Resident 73 would benefit from RNA services. She further stated, she did not receive any referrals from the DOR. In a concurrent interview and review of Resident 73's clinical record on 11/7/19, at 10:34 a.m., the Minimum Data Set (MDS-a comprehensive assessment tool) dated 12/14/18, 3/16/19, 6/14/19, indicated in Section G, Functional Status, "C. Walk in room ...-3 ...D. Walk in corridor ...-3 ..." The number 3 coded, an extensive assistance with walking. Further review of the MDS dated 9/14/19, indicated in Section G, Functional Status, "C. Walk in room ...-8 ...D. Walk in corridor ...-8 ..." The number 8 coded, walking did not occur. The MDS coordinator (MDSC) confirmed, Resident 73 had a decline in her walking ability. When asked if Resident 73 would benefit from RNA services, she stated, "I believe so." In an interview with director of nursing (DON) on 11/7/19, at 11:11 a.m., she stated, she expected the nurses to report a resident with a decline in condition and should be referred to the DOR to evaluate the need of RNA services. She further stated, residents with decline in mobility should have been identified in the MDS assessments during the quarterly reviews so that referrals could have been done sooner. She added, "She [Resident 73] should have been referred to RNA." A Review of the facility's policy titled, "RESTORATIVE AND SUPPORTIVE NURSING CARE" undated, indicated, "It is the policy of this facility that each resident will be provided with an individualized restorative and supportive plan of care to allow the resident the highest degree of independence possible...4. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 27 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 Restorative and supportive care shall include...c. Making every effort to keep residents active and out bed [sic] for reasonable periods of time..." Based on observation, interview, and record review, the facility failed to provide services to maintain mobility for two of 84 sampled residents (Resident 116 and Resident 73) when: 1. Resident 116's need for restorative nursing assistant (RNA, using special knowledge and skills to perform rehabilitative techniques such as guiding an individual in joint mobility exercises) services was not assessed and orders for services were not resumed, when Resident 116 returned from a two day stay at the hospital; 2. Resident 73 was not provided appropriate treatment and services to prevent a decline in mobility and not re-assessed for a need of RNA-services. These failures had the potential for Resident 116 and Resident 73 to experience a decline in mobility which included the ability to walk. Findings: 1. Resident 116 was admitted to the facility with diagnoses including hemiplegia (weakness on one side of the body) following cerebral infarction (a stroke, caused by impaired blood flow to the brain). Review of the Minimum Data Set (MDS-a resident assessment and care screening) tool dated 10/17/19, indicated Resident 116 had a brief interview for mental status (BIMS) score of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 28 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 15. A score of 13-15 indicated intact memory. During an interview with Resident 116 on 11/5/19, at 11:20 a.m., Resident 116 was in her hospital bed. She stated, "...I was supposed to get [therapy] but they [facility] told me [insurance] would not pay. I was supposed to get RNA services ...some of the CNA's [certified nursing assistants] walk me to the bathroom." During an interview with Resident 116 on 11/6/19, at 8:16 a.m., Resident 116 stated, "My only therapy is walking to the bathroom with the CNA. They do it when they have time. I was able to walk around the dining room about three months ago. Then I got sick with [an infection] ...everyone knew I was trying to go home three months ago. I was even walking in the parking lot when my kids were here ...I've asked for RNA services. They were going to see about putting me back on the program." Resident 116 indicated she had a care conference recently and stated, " ...They ask basics. Do you like the food? I asked about RNA, but no one gets back to me ...They never ask what my goals are. I tell them though; my number one priority is I need to walk." During a concurrent observation and interview with Resident 116 on 11/6/19, at 3:12 p.m., Resident 116 was seated in a wheelchair in the activity room. Resident 116 indicated she had circulation problems and that the swelling in her leg was less when she was walking. Review of the MDS dated 4/28/19, for functional status, indicated Resident 116 was able to walk in her room or in the hall with extensive assistance by one person. Review of the MDS dated 7/17/19, for functional status, indicated Resident 116 did FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 29 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 not walk during the seven-day assessment period. Review of the MDS dated 10/17/19, for functional status, indicated Resident 116 did not walk during the seven-day assessment period. Review of physician orders dated 9/2/19, indicated, Resident 116 was to receive RNA services three times a week for 12 weeks. Review of the referral form for RNA services, completed by a therapist in the rehabilitation department titled, "Restorative Nursing Program" dated 8/28/19, indicated Resident 116 was referred for weakness, and walking was included in her plan. The anticipated discharge date from RNA services was 11/25/19. The goal for treatment was to maintain/improve strength and standing/activity tolerance. Review of the report of RNA services provided for Resident 116 in September 2019, indicated Resident 116 received services between 9/2/19 and 9/18/19. Review of the clinical record indicated Resident 116 went to the emergency room on 9/21/19, and returned to the facility on 9/23/19. During an interview with RNA 1 on 11/8/19, at 9:56 a.m., RNA 1 stated, "Services must have been cancelled when [Resident 116] went to the hospital. When [Resident 116] came back it should have been re-instated. Nursing should have made the referral to rehab to be reevaluated." During an interview and concurrent record review with the director of rehabilitation (DOR) on 11/8/19, at 12:53 p.m., the DOR indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 30 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 Resident 116 had an order for RNA services to begin on 9/2/19 and stop on 11/25/19, for ambulation (walking). He indicated the order was cancelled when Resident 116 went to the hospital. He stated, " ...I rely on RNA's to come to me and ask for re-evaluation. Nursing oversees the program [RNA]. We [therapy] provide the referral ...If existing patient on services we rely on RNA's to let us know. I'll have to ask what happened here ..." During an interview with Licensed Nurse (LN)10 on 11/8/19, at 1:13 p.m., LN 10 stated, " ...The order for RNA services should be resumed when they come back from the hospital. [Resident 116] returned on 9/23/19, only two days. I wonder why the order was cancelled ...Nobody followed up on the RNA." LN 10 further indicated there was no order to stop RNA services.

F691 SS=D Colostomy, Urostomy, or Ileostomy Care CFR(s): 483.25(f)

F691 12/20/2019 §483.25(f) Colostomy, urostomy,, or ileostomy care. The facility must ensure that residents who require colostomy, urostomy, or ileostomy services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure nephrostomy (a tube is passed through an opening in the skin, into the kidney, and urine drains into a bag) care was provided according to professional standards for one of 84 sampled residents (Resident 93), when Resident 93's nephrostomy bags were not changed regularly. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 31 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 This failure had the potential to result in a urinary tract infection for Resident 93. Findings: Resident 93 was admitted to the facility in 2019, with diagnoses including kidney stones (hard deposits which can block the flow of urine and cause pain), kidney failure (kidneys filter out waste from the blood), nephrostomy tubes in each kidney, and urinary tract infection. Review of the Minimum Data Set (MDS-a resident assessment and care screening tool) dated 9/20/19, indicated Resident 93 had a brief interview for mental status (BIMS) score of 15. A score of 13-15 indicated intact memory. During an interview with Resident 93 on 11/5/19, at 2:07 p.m., Resident 93 stated, "Sometimes the bags get so full they leak ...and they keep trash bags around them. A month ago, the right [tube] one fell out. [Hospital] put it back in and changed the bag. Other than that no one changes the bags. I've had them seven months. That's why they put me in here." During a concurrent observation and interview with Resident 93 on 11/7/19, at 8:31 a.m., Resident 93 was in bed. A plastic bag was tied to the rail on each side of the bed and contained a nephrostomy bag. Resident 93 indicated she had problems with nephrostomy bags leaking, particularly the bag on her left side. During an interview with Licensed Nurse (LN) 8 on 11/7/19, at 8:40 a.m., LN 8 stated, "[Resident 93] has the bags changed at [physician] appointments. We don't have a way to change the bag." LN 8 indicated that if FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 32 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 Resident 93's nephrostomy bags leaked, they sent her to the physician. During an interview with the central supply manager (CSM) on 11/7/19, at 9:52 a.m., the CSM indicated she did not know of any residents in the facility with nephrostomies. She indicated the nurses needed to tell her when a resident came in who needed these supplies. During an interview with the director of nursing (DON) on 11/7/19, at 11:42 a.m., the DON stated, " ...I don't know about the bags. They [nurses] never ask me for assistance. We've been sending residents to the emergency department if there is a leak." Review of the nursing care plan for Resident 93 initiated 7/31/19, indicated, "The resident has right and left nephrostomy tubes ..." The goal for this plan was, "The resident will show no [signs and symptoms] of urinary infection ..." The interventions in Resident 93's care plan did not include monthly bag changes or any direction to nursing staff that leaking bags could contribute to infection. During an interview with the regional consultant (RC) on 11/7/19, at 3:54 p.m., the RC indicated it was important to maintain a closed system for a resident with nephrostomy, due to possibility of infection. She indicated Resident 93 was seen by a urologist (a specialist for urinary tract problems) often for problems with leaking from her bags and/or the site on the skin where the tube went into the kidney. She stated, "The policy needs to be updated. We never touched them in the past. We had a problem with leaking, we sent her out. She comes back and it leaks again. I have notes every visit. It wasn't actually every month. Sometimes longer, sometimes more often. We don't track it. There are a few months where she did not go out." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 33 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 There was no documented evidence in the clinical record that Resident 93's nephrostomy bags were changed during any of her physician visits or emergency room visits. During an interview with the DON on 11/8/19, at 8:23 a.m., the DON indicated she had not performed any in-service training for nephrostomy care to the nurses. She stated, "I have a lot of education to do. We have a lot of new nurses." A review of the facility policy titled, "Nephrostomy Tube, care of" revised October 2010, indicated nephrostomy bags should be changed monthly.

F692 SS=D Nutrition/Hydration Status Maintenance CFR(s): 483.25(g)(1)-(3)

F692 12/20/2019 §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; §483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 34 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 health care provider orders a therapeutic diet. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and review of facility documents, the facility failed to offer sufficient fluid intake to maintain proper hydration and health for one of 84 sampled residents (Resident 485) when fluids were requested but not provided. This failure place Resident 485 at risk for dehydration. Findings: Resident 485 was admitted to the facility in the fall of 2019 with diagnoses which included diabetes (a condition where the cells are unable to use sugar properly) and a bone infection. Review of Resident 485's Minimum Data Set (MDS, an assessment tool) indicated he was alert and oriented and required limited assistance with most activities of daily daily living (ADLs). Review of Resident 485's physician orders, dated 11/7/19, indicated "MONITOR FOR PROPER DIET: NAS [no added salt], CCHO [low carbohydrate. Carbohydrates are sugars, starches and fibers found in fruits, grains, vegetables and milk products] REGULAR CONSISTENCY DIET..." Review of Resident 485's care plan titled 'RESIDENT TRIGGERED FOR NUTRITIONAL PROBLEMS SECONDARY TO RECEIVES [sic] A THERAPEUTIC DIET...REDUCED PO [oral] INTAKE," dated 10/28/19, indicated 'ENCOURAGE FLUIDS DAILY..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 35 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 Review of Resident 485's care plan titled, "Hydration/Fluid Maintenance Fluid volume deficit potential and or fluid maintenance concerns...Resident makes simple/basic needs known such as able to express thirst...," dated 11/06/19, indicated, "Keep fluids at bedside within reach..." During a concurrent observation and interview with Resident 485 on 11/5/19, at 10:45 a.m., two empty plastic cups were seen on the overbed table. When asked about it, Resident 485 exclaimed, "I asked three staff for water at 8 a.m. and I still don't have it. It's now 10:45 a.m. and has been 2.75 hours since I asked." He commented he was not on fluid restriction and drank a pitcher a day. No pitcher was in sight. During an interview with the director of nursing (DON) on 11/6/19, at 7:25 a.m., she was asked what her expectations were for fluids at the bedside and said, "Our water pitchers should be changed every shift...Staff should bring fluids to the resident as soon as possible upon request." Review of the facility policy and procedure titled "HYDRATION," revised 6/10/07, indicated "3. Each resident is provided a large container of fresh, cool water which is located on the resident's bedside stand, unless contraindicated..."

F693 SS=E Tube Feeding Mgmt/Restore Eating Skills CFR(s): 483.25(g)(4)(5) FORM CMS-2567(02-99) Previous Versions Obsolete

F693 Event ID: 5ITG11 12/20/2019 Facility ID: CA030000010 If continuation sheet 36 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 §483.25(g)(4)-(5) Enteral Nutrition (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident§483.25(g)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and §483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to ensure nutritional products met resident needs for residents requiring tube feeding (a tube is inserted into the stomach or intestine, used to provide liquid nutrition) when: 1. 26 cans of enteral (stomach, intestinal) tube feeding formula were not disposed of by the expiration date, and 2. A dented can of enteral tube feeding was found in the medication storage room. This failure had the potential to result in compromised integrity of the products used to supply nutrition for four residents receiving tube FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 37 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 feeding formula. Findings: 1. During a concurrent observation and interview with Licensed Nurse (LN) 7 in the Station 2 medication storage room on 11/6/19, at 4:12 p.m., there were 12 cans of [brand name tube feeding formula for diabetes-a disease caused by high blood sugar] on a shelf, with an expiration date of 11/1/19. LN 7 stated these cans should have been discarded. During a concurrent observation and interview with the director of nursing (DON) and the central supply manager (CSM) in the Station 2 medication storage room, on 11/6/19, at 4:28 p.m., there were 14 cans of [brand name regular formula for tube feeding] marked with an expiration date of 11/1/19. The CSM indicated she did not monitor the dates of these items. The CSM explained the delivery was brought in and shelves were stocked, but indicated she was unaware of the process used to monitor expiration dates. The CSM monitored other types of supplies in the medication storage room and tracked the inventory needed. The DON stated, "The nurses should get rid of the old supplies." The DON indicated this was not assigned as a task to any specific staff member. A review of the Journal of Parenteral (feeding bypasses the intestinal tract) and Enteral Nutrition dated March/April 2009 indicated the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) recommended, " ...Enteral nutrition ... Direction to staff regarding the nutritional product and meeting the resident's nutritional needs such as: Ensuring that the product has not exceeded the expiration date ... Expiration Date: The date established from scientific studies to meet U.S. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 38 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 Food and Drug Administration (FDA) regulatory requirements for commercially-manufactured products beyond which the product should not be used." 2. During a concurrent observation and interview with Licensed Nurse (LN) 7, in the Station 2 medication storage room on 11/6/19, at 4:12 p.m., there was a can of [brand name tube feeding formula for diabetes] with a large dent on the side, found on a shelf with other cans of formula. LN 7 indicated the facility was supposed to discard dented cans. A review of the food and drug administration (FDA) guidelines dated 2017 indicated," ...critical to monitor food products to ensure that, after ...processing, they do not fall victim to conditions that endanger their safety, make them adulterated, or compromise their honest presentation ... dented cans may also present a serious potential hazard ..."

F695 SS=D Respiratory/Tracheostomy Care and Suctioning F695 CFR(s): 483.25(i) 12/20/2019 § 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart. This REQUIREMENT is not met as evidenced by: Based on observations, interviews, and record review, the facility failed to provide oxygen FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 39 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 therapy according to professional standards for two of four sampled residents, (Resident 93 and Resident 127) when Resident 93 and Resident 127's oxygen was not provided at the rate ordered by the physician and received a higher oxygen concentration than ordered This failure had the potential to result in respiratory complications for Resident 93 and 127. Findings: a. Resident 93 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (COPD-lung disease in which airflow is restricted and causes difficulty breathing). Review of Resident 93's Minimum Data Set (MDS-a resident assessment tool) dated 9/28/19, indicated a brief interview for mental status score (BIMS) of 15. A score of 13-15 indicated Resident 93 had intact memory. During an observation on 11/5/19, at 2:20 p.m., Resident 93 was in bed and wore oxygen tubing attached to a concentrator (a machine that concentrates oxygen from room air). The rate was set at 3 L (liter, a unit to measure volume) per minute. During a concurrent observation and interview with Licensed Nurse (LN) 8 on 11/7/19, at 8:40 a.m., LN 8 observed the flow rate of Resident 93's oxygen concentrator and stated, "It looks like O2 [oxygen] is at 2.5 to 3. Her O2 order ...is 2L per minute." Review of a physician order dated 10/4/19, indicated, "Oxygen @ [at] 2L/min [minute] per nasal cannula [NC, tubing that delivers oxygen into the nose] continuously." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 40 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 Review of the nursing care plan for Resident 93, initiated 7/31/19, titled, "The Resident has COPD" included the intervention, "Oxygen 2L/min via NC as ordered." During an interview with the director of nursing (DON) on 11/7/19, at 11:42 a.m., the DON indicated staff were not authorized to change a flow rate of oxygen without a physician's order. There was no documented evidence Resident 93 had a recent need for an increase of her oxygen flow rate. b. Resident 127 was admitted to the facility in 2018 with multiple diagnoses which included respiratory failure. His most recent Minimum Data Set (MDS, an assessment tool), dated 7/22/19, indicated he was alert and oriented and required extensive assistance with most activities of daily living (ADLs). Review of Resident 127's physician order, dated 7/14/18, indicated "OXYGEN AT 2 L/MIN [liters per minute] PER NASAL CANNULA [tubing leading from the oxygen source to the resident's nostrils] CONTINUOUSLY..." Review of Resident 127's care plan titled, "The resident has altered respiratory status/difficulty breathing r/t [related to] COPD [Chronic Obstructive Pulmonary Disease, a lung disease made worse by higher concentrations of oxygen], respiratory failure, and CHF [Congestive Heart Failure]", revised 10/30/18, indicated "O2 [oxygen] 2L/min via NC [nasal cannula] continuously." During a concurrent observation and interview with Resident 127 on 11/5/19, at 8:36 a.m., his oxygen concentrator was on at 3.5 liters per minute and led to his nostrils by nasal cannula. He said it was supposed to be on 2 liters and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 41 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 he did not increase it. During a subsequent observation and interview with Licensed Nurse (LN) 1 on 11/5/19, at 8:50 a.m., she verified Resident 127's oxygen was set at 3.5 liters per minute and said, "I'm not sure who increased it. The CNAs [certified nursing assistants] aren't supposed to touch it [oxygen concentrator valve]." During an interview on 11/5/19, at 9:08 a.m. with CNA 1, Resident 127's assigned CNA, he denied that he increased the oxygen level. During an interview with the director of nursing (DON) on 11/6/19, at 6:48 a.m., she was asked what her expectations were regarding the adjustment of oxygen and said, "Only the licensed nurse should adjust the oxygen." A review of the facility policy titled, "Oxygen Therapy" undated, indicated "...It is the policy of this facility that oxygen therapy is administered as ordered by the physician or as an emergency measure until a physician order can be obtained...Read physician orders...Set oxygen flow rate as ordered...Monitor oxygen usage frequently..."

F755 Pharmacy FORM CMS-2567(02-99) Previous Versions Obsolete

F755 Event ID: 5ITG11 12/20/2019 Facility ID: CA030000010 If continuation sheet 42 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) SS=D Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on observations, interviews, and record reviews, the facility failed to safely handle and control medications for a census of 142, when: 1. The controlled drugs (substances with a high potential for abuse) destruction container FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 43 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 contained undestroyed whole tablets in an unsecured container, was stored in an office with access to staff and residents; 2. There was not a secure method for removal and disposal of used fentanyl (treats severe pain) patches in a way that prevented diversion (the transfer of a legally prescribed controlled substance, from the individual for whom it was prescribed to another person for illicit use); and, 3. One of 84 sampled residents (Resident 479) had a bottle of prescription narcotics (used to relieve pain but may cause stupor, coma or convulsions in excessive doses), at his bedside. These failures had the potential to allow for the diversion of controlled substances, and/or accidental exposure and increased risk for an overdose of a narcotic for a census of 139. Findings: 1. During a concurrent observation and interview with the director of nursing (DON) on 11/6/19, at 5:19 p.m., the container used for the destruction of controlled substances was observed in the DON's office, on the floor, between a filing cabinet and a bookshelf. The container was white plastic with a blue plastic lid. There was no locking device and the lid was easily opened. The container was approximately ¼ full and contained insulin (treats high blood sugar) bottles, eye drop bottles, breathing inhalers (device to deliver medication to the lungs), and assorted tablets. There was liquid observed but the level was not high enough to cover the top of the contents. There were intact loose tablets which were not in contact with any liquid. The DON indicated, they used water to destroy controlled FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 44 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 substances. She verified the water did not cover all medications in the container. She further indicated the pharmacist was here recently and observed the transfer of controlled medication for destruction into this container. The DON stated she kept her door locked when she or her staff were not in the room. During an interview with the consultant pharmacist (CP) on 11/7/19, at 4:25 p.m., the CP indicated the facility had a contract with a company to incinerate the destroyed medications. She stated, " ...I have nothing to do with the incineration. I've only seen them put narcotics in [the container] ...water is OK, enough to soak the meds [medications]..." the CP indicated liquid narcotics could be used as a dissolving method, and the container should only be used for narcotics, not other medications. She further stated, " ...Normally they [controlled medications] get picked up soon. They [facility] should call the company soon after we destroy. I'm pretty sure the narcotics dissolved. I don't know what happened after I left." During an observation on 11/8/19, at 7:34 a.m., the DON's office door was open and there was no one in the office. The controlled substance destruction bin was visible on the floor next to the filing cabinet. During an interview with the DON on 11/8/19, at 12:08 p.m., the DON stated, " ...They are not supposed to be mixed in the same bin [narcotics with other medications]. I have ordered a smaller bin. This one came from Station 1 and had other items in it already. It's a big bin, so expensive ...I plan to have it discarded when ½ full ...the destroyed narcotics should be locked up." Review of the facility policy titled, "Discarding FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 45 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 and Destroying Medications" revised October 2014, indicated, " ...All unused controlled substances shall be retained in a securely locked area with restricted access until disposed of ...Destruction of a controlled substance must render it 'non retrievable,' meaning that the process permanently alters the physical or chemical properties of the substance so that it is no longer available or usable, and cannot be illegally diverted." 2. During a concurrent observation and interview on 11/8/19, at 1:35 p.m., with Licensed Nurse (LN) 9, an inspection of medication cart 2A was conducted. There was a container with a lid, labeled "Drug Buster" (neutralizes the active chemicals in pills and patches). LN 9 indicated used fentanyl patches (a narcotic used for pain, in patch form, intended to be placed on the skin) were disposed into the container. There was no log or tracking system to account for the patches removed from the resident. Review of the centers for disease control (CDC) information about fentanyl at the following address, www.cdc.gov/drugoverdose/opioids/fentanyl.ht ml, indicated, fentanyl is 50 to 100 times more potent than morphine. It is prescribed in the form of transdermal (medication delivered through skin) patches or lozenges and can be diverted for misuse and abuse in the United States. During an interview with the DON and the regional consultant (RC) on 11/8/19, at 2:05 p.m., the DON stated, "We don't have to log them. Only when you use it [the fentanyl patch]." The DON indicated the patch removed from a resident did not have much medication remaining and could be disposed of in the regular medication disposal. The RC stated, "I FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 46 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 have never seen anyone account for them [fentanyl patch] once removed." During an interview with LN 11 on 11/8/19, at 2:53 p.m., LN 11 stated he disposed of fentanyl patches into a sharps container (a container used to store items which could cause injury such as needles). Placement of the patch into the sharps container was not witnessed by other staff, or recorded as disposed of. Review of guidelines from the National Institutes of Health (NIH) updated February 2018 at the following address, dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl. cfm?setid=e15a7e9b-8025-49dd-9a6dbafcccf1959f&type=display, indicated, " ...5.3 Accidental exposure ... A considerable amount of active fentanyl remains in fentanyl transdermal system even after use as directed. Death and other serious medical problems have occurred when children and adults were accidentally exposed to fentanyl transdermal system." According to the NIH, " ...Disposal methods for controlled medications must involve a secure and safe method to prevent diversion and/or accidental exposure. Fentanyl transdermal patches present a unique situation given the multiple boxed warnings, and the substantial amount of fentanyl remaining in the patch after removal, creating a potential for abuse, misuse, diversion, or accidental exposure." Information is located at the following address: dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl. cfm?setid=e15a7e9b-8025-49dd9a6dbafcccf1959f&type=display. Review of the facility policy titled, Controlled Medications", undated, indicated, "Medications included in the Drug Enforcement Administration (DEA) classification as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 47 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 controlled substances shall be subject to special handling, storage, disposal and record keeping in the facility, in accordance with federal and state laws and regulations." Review of the facility policy, "Discarding and Destroying Medications", revised October 2014, indicated, "...Document the disposal on the medication disposal record...Include the signature(s) of at least two witnesses." 3. Resident 479 was readmitted to the facility in the fall of 2019 with multiple diagnoses which included hypertension and kidney disease. Review of Resident 479's Minimum Data Set (MDS, an assessment tool), dated 11/5/19, indicated he was alert and oriented and required supervision to limited assistance for most activities of daily living (ADLs). Review of Resident 479's Baseline Care Plan, dated 10/23/19, indicated "Medications resident is taking...Opioids...Self Administer medications...No." Review of Resident 479's physician orders, dated 10/23/19, indicated "[trade name for hydrocodone bitartrate 5 mg and acetaminophen 325 mg, a narcotic pain medication] Give 1 tablet by mouth every 6 hours as needed for Pain." Review of Resident 479's Medication Administration Record (MAR), dated 11/1/19 11/30/19, indicated "hydrocodone bitartrate 5 mg and acetaminophen 325 mg" was given once a day from 11/1/19 through 11/4/19 with a pain level of 6 to 7 out of 10 (10 being the most severe pain) indicated and "E" entered which indicated effective. Review of Resident 479's care plan titled "Pain...Chronic...," dated 11/2/19, indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 48 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 "Administer analgesic timely as/if ordered...Evaluate resident's verbal and non verbal cues...Obtain modifications as needed in pain medication orders..." During an observation on 11/5/19, at 10:25 a.m., Resident 479 had a personal prescription bottle of 43 tablets of hydrocodone bitartrate 5 mg and acetaminophen 325 mg (a narcotic pain medication) at his bedside in clear view. When Resident 479 was asked about the medication, he said, "I had my [family member] bring them in because I was having difficulty getting some [for pain]...Everybody [facility staff] knows about it." During a concurrent observation and interview with Licensed Nurse (LN) 1 on 11/5/19, at 10:25 a.m., she verified the medication found at the bedside and said, "We don't usually allow their medications at the bedside..." During an interview with the director of nursing (DON) on 11/6/19, at 7:13 a.m., she was asked what her expectations were regarding personal medications kept at the bedside and said, "We don't allow prescription medications at the bedside..." Review of the undated facility policy and procedure titled "MEDICATIONS, BROUGHT IN BY RESIDENT/FAMILY" indicated "Drugs brought into the facility will not be administered until the following conditions have been met...The contents of each container will be positively identified by a licensed physician or pharmacist prior to being administered to the resident..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 49 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F761 Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 12/20/2019 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview, review of facility documents, and facility policy review, the facility failed to implement their medication storage and labeling policies and procedures when: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 50 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 1. Expired hydrocodone-acetaminophen 5-325 (a narcotic-a medication used to treat pain) tablets and a bottle of gatifloxacin 0.5% (an antibiotic- a medication to treat eye infection such as pinkeye) eye drop solution were stored in the medication cart; 2. A medication cart was unlocked; and 3. Items used for resident medication administration and treatment were not safely labeled and stored when: a. Influenza vaccine was not labeled with an open date; b. Syringes with needles were not discarded by their expiration date; and, c. Glucometer (a machine used to test blood sugar) control solution (used to determine if glucometer is accurate) was not labeled with an open date. These failures placed residents and Resident 119 at risk for adverse consequences related to the use of expired narcotics and eye drop solution, increased the risk for diversion of medications and a potential for adverse reactions to expired medications, sterility (free from germs) of influenza vaccine and equipment used to administer injections, and reliability of results obtained from glucometers. Findings: 1. During an inspection of Station 2 medication cart on 11/8/19, at 2 p.m., a pack of twenty-one hydrocodone-acetaminophen 5-325 tablets were found in the narcotic box with an expiration date of 10/29/19. Upon further inspection of the medication cart, a bottle of gatifloxacin 0.5% eye drop solution for Resident 119 was found in the third drawer with an original expiration date of 4/30/16 on the label. This expiration date was marked off with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 51 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 a red ink pen and replaced with an expiration date "10/19." All expiration dates indicated, the narcotic tablets and the eye solution were expired. During a concurrent observation and interview with Licensed Nurse (LN) 5, on 11/8/19, at 2:19 p.m., she confirmed both medications, the narcotic tablets and the eye solution, were expired and should be removed from the medication cart. She stated, the expired narcotic tablets should have been given to the director of nursing (DON) for destruction. She further stated, the expired eye drop solution should have been discarded. LN 5 further confirmed, the eye drop solution was administered 4 times "yesterday" from the same bottle of expired eye solution to Resident 119. In an interview with director of nursing (DON), on 11/8/19, at 2:36 p.m., she expected the licensed nurses to be checking the expiration dates prior to administering the medications to the residents. She stated, checking the expiration date is part of the medication administration procedure. She further stated, "No expired meds [medications] anywhere in the cart." Review of the facility policy titled, "Storage of Medications" revised April 2007, indicated, "Policy Interpretation and Implementation...4. The facility shall not use discontinued, outdated, or deteriorated drugs and biologicals. All such drugs shall be...destroyed." 2. During an observation on 11/6/19, at 4:06 a.m., a treatment and medication cart were found unlocked and accessible to all staff and residents. During a concurrent observation and interview with Licensed Nurse (LN) 6 on 11/6/19, at 4:07 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 52 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 a.m., he verified the treatment cart was unlocked and contained multiple creams, ointments and dressings which included nystatin (anti-fungal medication), triminoclone (anti-fungal medication), menthol and zinc oxide ointment (a cream used to treat diaper rash), diclofenac (a medication for pain and inflammation), and collagenase (prescription medicine that removes dead tissue from wounds so they can start to heal). During a concurrent observation and interview with LN 6 on 11/6/19, at 4:10 a.m., he verified the medication cart was unlocked with all medications available except narcotics (a drug that, in moderate doses, dulls the senses, relieves pain, and induces profound sleep but in excessive doses causes stupor, coma, or convulsions) and said, "We're supposed to lock it." During an interview with the director of nursing (DON) on 11/6/19, at 7:25 a.m., she was asked what her expectations were for the securing of medication and treatment carts and said, "The medication and treatment carts should be locked at all times unless in use." Review of the facility policy and procedure titled "Storage of Medications," dated 2001, indicated "7. Compartments (including, but not limited to, drawers...carts...) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others." 3a. During a concurrent observation and interview with Licensed Nurse (LN) 7 at the Station 2 medication storage room on 11/6/19, at 4:12 p.m., there was a bottle of influenza vaccine in the medication refrigerator. The cap had been removed and there was no open date marked on the bottle. LN 7 indicated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 53 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 vaccine should have been labeled with a date when it was opened. During an interview with the director of nursing (DON) on 11/8/19, at 2:05 p.m., the DON indicated influenza vaccine bottles needed to be dated when opened and discarded after 28 days. A review of the CDC (Centers for Disease Control and Prevention) guidelines dated June 2019 at the following address: https://www.cdc.gov/injectionsafety/providers/pr ovider indicated, "Medication vials should always be discarded whenever sterility is compromised or cannot be confirmed ...If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days ..." 3b. During a concurrent observation and interview with Licensed Nurse (LN) 7 and the central supply manager (CSM), at the Station 2 medication storage room on 11/6/19, at 4:12 p.m., there were 22 syringes with needles found on a shelf. The syringes were 3ml (milliliter-a unit to measure volume) with a 1 and ½ inch needle. This type of syringe and needle combination was intended for injection into a muscle. They were marked with an expiration date of February 2019. The CSM indicated the syringes should have been discarded. During an interview with the director of nursing (DON) on 11/8/19, at 2:05 p.m., the DON indicated the syringes could have been compromised and should have been discarded by the expiration date. 3c. During a concurrent observation and interview with LN 9 of Medication Cart 2A, on 11/8/19, at 1:35 p.m., there was a container of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 54 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 glucose control solution, partially full. There was no open date on the solution. LN 9 was unsure how long the solution was good once opened. During an interview with the regional consultant (RC) on 11/8/19, at 2:05 p.m., the RC stated, "The glucose control solution is supposed to be dated when opened."

F812 SS=E Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 12/20/2019 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 55 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 by: Based on observation, interview, and review of facility documents, the facility failed to ensure proper sanitation and food handling practices were followed for a census of 142 to prevent the outbreak of foodborne illness when: 1. A bucket of sanitation solution was out of potency range, and 2. Warm milk was left at Resident 483's bedside without a name, date or time. These failures increased the risk for food borne illness. Findings: 1. During a kitchen observation on 11/7/19, at 11 a.m., a red bucket of solution, used for sanitizing, was sitting in the kitchen sink with cleaning cloths submerged. A request was made of the dietary supervisor (DS) to check the potency level of the solution. The test strip read "0 [ppm, parts per million]." She verified the observation and said, " It can't be below 150 [ppm]." Review of the facility document titled "QUATERNARY [quat] AMMONIUM [a sanitizer] LOG," dated 11/7/19, indicated "Ammonium reading should be at least 200 ppm, or manufacturer's recommendation." The log indicated the "Test Strip" read 400 (ppm) but did not indicate a time. During a concurrent record review and interview with Cook 1 on 11/7/19, at 11:15 a.m., he said, "The quat log shows 400 [ppm] at about 5 a.m. on 11/7/19." Both the DS and Cook 1 verified the quat strip indicated "0" in the only red bucket filled with solution and the DS said, "I don't know how long it's been there. It's used for stainless steel counters to wipe FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 56 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 them down..." Review of the facility policy and procedure titled "QUATERNARY AMMONIUM LOG POLICY," dated 2018, indicated "The solution will be replaced when reading is below 200 ppm." 2. Resident 483 was admitted to the facility in the fall of 2019 with diagnoses which included diabetes (a disease where the body is unable to use sugar) and acid reflux disease. Review of Resident 483's care plan titled "RESIDENT PRESENTS AT RISK FOR NUTRITIONAL PROBLEMS SECONDARY TO RECEIVES (sic) A THERAPEUTIC MECHANICALLY ALTERED [chopped] DIET...," dated 10/29/19, indicated "ENCOURAGE FLUIDS DAILY." Review of Resident 483's Minimum Data Set, (MDS, an assessment tool), dated 10/30/19, indicated he was alert and oriented and required no assistance with eating and drinking. During an observation by two surveyors on 11/5/19, at 10:40 a.m., a glass of milk was covered and sitting on the bedside table of Resident 483. It was room temperature to touch and labeled "NF". The resident was not in his room. During a concurrent observation and interview on 11/5/19, at 10:45 a.m., CNA 4 verified the milk was warm and unlabeled and said, "I don't think it should be there...I do not see a date." During an interview with Resident 483 on 11/5/19 at 10:45 a.m., he stated, "I think that milk is sour." Review of the undated facility document titled FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 57 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 "Meal and nourishment hours" indicated breakfast was served at 7 a.m. During an interview with the director of nursing (DON) on 11/6/19, at 7:13 a.m., she was asked what her expectations were regarding milk left at the bedside and said, "It should be labeled with the date. It should be discarded by the end of the shift." Review of the undated facility policy and procedure titled "FEEDING, FOOD INTAKES: RECORDING PERCENTAGE/NUTRITIONAL ASSESSMENT" indicated "All nourishments are given by the aide and are not left at the bedside..."

F880 SS=E Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 12/20/2019 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 58 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 59 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: 4. Resident 41 was admitted to the facility in 2019 with diagnoses including cerebral infarction (stroke caused by impaired blood flow in the brain). Review of the minimum data set (MDS-a resident assessment tool) dated 8/22/19, indicated Resident 41 had a brief interview for mental status (BIMS) score of 15. A BIMS score of 13-15 indicated intact memory. During a concurrent observation and interview with Resident 41 on 11/5/91, at 10:38 a.m., Resident 41 was coughing. She stated, "I've had it [cough] about a week. I get cough syrup ...this cough is out of control ..." During an interview with the director of staff development (DSD) on 11/7/19, at 8:44 a.m., the DSD indicated the facility had not had any FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 60 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 PPD solution for five to six months. She further indicated the facility used chest x-rays or QuantiFERON testing (a blood test to detect TB infection). During a concurrent interview and record review with the director of nursing (DON) on 11/7/19, at 11:42 a.m., the DON indicated Resident 41 refused a chest x-ray three times. The DON indicated Resident 41 may have had a chest x-ray prior to her admission to the facility in August. She stated, "We've been calling the discharging hospital to give us the chest x-ray. They can bill insurance. We have to pay for them." There was no documented evidence a blood test was ordered to screen for TB in the absence of an x-ray. During an interview and record review with the DSD on 11/7/19, at 12:31 p.m., the DSD indicated the facility told the physician Resident 41 refused chest x-rays. Resident 41's last chest x-ray was done in 2017, and according to their policy for TB screening, a chest x-ray to rule out TB infection was acceptable for three months. She explained the physician instructed staff to watch for any signs of infection. The DSD stated she was unaware Resident 41 had developed a cough. During a subsequent interview with the DSD on 11/7/19, at 1:06 p.m., the DSD stated, "It's my fault. I didn't even ask for the QuantiFERON order. They're very expensive." Review of the facility policy titled, "Resident Screening for Tuberculosis" undated, indicated, " ...All residents admitted should be tested for TB infection and disease either prior to or within 72 hours following the admission date ...When these tests are not available, use of QuantiFERON summary ...The CDC [centers for disease control] guidelines state that QFT-G FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 61 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 [QuantiFERON] can be used in place of ...the [tuberculin skin test]." Based on observations, interviews, and review of facility documents, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for a census of 142 when: 1. There was no hamper with a lid and foot pedal for discarded isolation supplies in Resident 482's room; 2. Oxygen tubing was not covered for Resident 126; 3. Incentive spirometers (IS, device to help take deep breaths and expand the lungs) were not labeled for Resident 479 and Resident 480; and 4. Tuberculosis (TB-a dangerous infection that mainly affects the lungs and is spread with coughing or sneezing) screening was to be performed for Resident 41 and the PPD (purified protein derivative-a solution used to inject into the skin to diagnose TB) was unavailable and an alternate screening of Resident 41 was not performed. These failures increased the risk for transmission of communicable diseases and infections. Findings: 1. Resident 482 was admitted to the facility in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 62 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 fall of 2019 with multiple diagnosis which included pneumonia and resistance to multiple antibiotics. Review of Resident 482's Minimum Data Set (MDS, an assessment tool), dated 10/31/19, indicated he had severe memory impairment and required extensive assistance with his activities of daily living (ADLs). Review of Resident 482's physician's order, dated 10/24/19, indicated "ON DROPLETCONTACT PRECAUTIONS FOR ESBL [ Extended Spectrum Beta-Lactamase, enzymes produced by some bacteria that may make them resistant to some antibiotics] IN LUNGS" Review of Resident 482's care plan titled, "The resident has a Respiratory Infection/ESBL in lungs," dated 10/29/19, indicated "contact isolation precaution strict handwashing before and after each contact..." During an observation on 11/5/19, at 10:02 a.m., Resident 482 was laying on his bed with his sweat pants dropped down to near his knees and there was bowel movement (BM) on the seat of his wheelchair. Inside Resident 482's bathroom was a small, plastic lined garbage can without a lid or foot pedal with an overflow of items that had fallen to the floor, which included gowns, gloves and masks. During a concurrent observation and interview with the director of nursing (DON) on 11/5/19, at 10:05 a.m., she verified there was a moderate amount of BM on the seat of the wheelchair and there was no barrel for discarded isolation gowns, gloves and mask, and said "There should be a garbage can with a foot pedal inside the room." During a subsequent interview with the DON on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 63 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 11/6/19, at 7:13 a.m., she was asked what her expectations were for disposal of isolation supplies and said, "There should be red bags inside the room to use for contaminated items." She verified there was a regular small garbage can in use and said, "There should be a receptacle with a foot pedal. There's not." Review of the facility policy and procedure titled "Equipment and Supplies Used during Isolation," revised 2009, indicated "All equipment and supplies needed to implement isolation precautions will be obtained from Central Supply or an approved vendor..." 2. Resident 126 was readmitted to the facility in the fall of 2019 with multiple diagnoses which included heart and lung disease. Review of Resident 126's MDS, dated 10/7/19, indicated he was alert and oriented and required extensive assistance with most ADLs. Review of Resident 126's physician orders, dated 11/6/19, indicated "OXYGEN AT 2L/MIN [liters per minute] VIA NASAL CANNULA AS NEEDED." Review of Resident 126's care plan titled "The resident has asthma," dated 10/2/19, indicated "Give...oxygen therapy as ordered. OXYGEN SETTINGS: 02 [oxygen] via (nasal cannula)@ [at] (2)L (prn [as needed])." During an observation on 11/5/19, at 9:35 a.m., Resident 126's oxygen tubing was not covered. During a concurrent observation and interview with Licensed Nurse 1 (LN) 1 on 11/5/19, at 9:46 a.m., she verified the nasal cannula was uncovered and said, "It should be put in the bag. If he's on oxygen, physical therapy should put the nasal cannula in the bag before he FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 64 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 goes to therapy." 3a. Resident 479 was readmitted to the facility in the fall of 2019 with multiple diagnoses which included hypertension and kidney disease. Review of Resident 479's physician orders, dated 10/23/19, indicated no order for an IS. Review of Resident 479's MDS, dated 11/5/19, indicated he was alert and oriented and required supervision to limited assistance for most ADLs. Review of Resident 479's Baseline Care Plan, dated 10/23/19, had no documented evidence of an IS. During an observation on 11/5/19, at 10:25 a.m., an IS was on the bedside table uncovered and unlabeled. During a concurrent observation and interview with certified nursing assistant (CNA) 3 on 11/5/19, she verified the IS was not covered or labeled. During an interview with the director of nursing (DON) on 11/6/19, at 7:03 a.m., she was asked what her expectations were regarding storage of the IS and said, "The incentive spirometer comes from the hospital. It should be labeled with the room number." 3b. Resident 480 was admitted to the facility in the fall of 2019 with diagnoses which included asthma and low blood pressure. Review of Resident 480's MDS, dated 10/23/19, indicated he was alert and oriented and required extensive assistance with his ADLs. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 65 of 66 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: _______________ 056216 (X3) DATE SURVEY COMPLETED 11/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GUARDIAN CARE AND REHAB CENTER 410 Eastwood Avenue Manteca, CA 95336 (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 Review of Resident 480's physician orders, not dated until 11/6/19, indicated, "INCENTIVE SPIROMETER 10 x [times] every shift WHILE AWAKE." Review of Resident 480's care plan titled "The resident has asthma...," dated 11/1/19, indicated "incentive spirometer x 10 q [every] shift while awake..." During an observation on 11/5/19, at 9:30 a.m., Resident 480's IS was sitting on the bedside table unlabeled. During a concurrent observation and interview with Licensed Nurse (LN) 1 on 11/5/19, at 9:46 a.m., she verified the IS was unlabeled and said, "It [IS] should be labeled with the date, room number and name of the resident. He's been here two weeks. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ITG11 Facility ID: CA030000010 If continuation sheet 66 of 66