Noble Care Center: MD Never Notified of Decline - CA
The incident unfolded across two days in mid-July at the facility on North California Street. On July 16, 2025, a nurse's progress note recorded that the resident had done nothing but lie facing the wall. He refused to eat. He refused a Covid booster. He refused all his medications. The note ended: "Will continue to monitor. Call light in reach."
The next day was worse.
On July 17, a nurse entered the room carefully, according to her own account given to inspectors weeks later, because the resident's behavior had turned aggressive. He took the medications from her hand and pretended he was going to swallow them. Then he leaned forward and threw every pill under the nightstand and under the bed. The progress note from that shift read: "Re-direct the resident. Will continue to monitor."
The doctor was never called. Not on July 16. Not on July 17.
Licensed Nurse 2, who was present for the July 17 incident, told inspectors on August 14 that she had confirmed what the notes described and that she had not notified the medical director. She acknowledged she should have. She said notifying him could have led to a further evaluation, including laboratory tests.
The Director of Nursing reviewed the same progress notes with inspectors that morning and said the licensed nurses should have called the medical director when behavioral changes were occurring. Refusing medications was a reason to call. Refusing to eat was a reason to call. The medical director, she said, would have provided guidance on what steps to take.
The medical director told inspectors he could not recall any nurse contacting him about the resident's refusals or his aggressive behavior. He said he was available around the clock, seven days a week. He said he would have wanted to know. He said he would have discussed medical options with the resident.
What those options might have been, and whether any of them would have helped, is now an open question. The resident came to Noble Care Center in the summer of 2025 carrying a set of diagnoses that made the missed notifications more consequential, not less: he needed assistance with personal care, he had dementia with behavioral disturbances, and he had suicidal ideations. A man with that history, refusing to eat and throwing his medications, lying motionless facing a wall for days, was not a stable patient waiting to be monitored. He was a patient whose condition was signaling something.
The nurse's notes do not record what happened after July 17. The inspection report does not say whether the resident's condition improved, deteriorated, or whether he was ever evaluated for whatever was driving the refusals and the aggression. The report notes only that the medical director was not notified, that the Director of Nursing confirmed the nurses should have called, and that the medical director confirmed he was never reached.
The inspection was a complaint survey, triggered by a concern brought to regulators, not a routine visit. Inspectors arrived on August 14, nearly a month after the two-day episode. By then, the licensed nurse's account of carefully entering the room, of watching the resident lean forward and throw his pills, had become something she was describing in past tense to a federal inspector rather than something she had reported to a physician when it happened.
The medical director said he would have liked the facility to have notified him so he could have discussed some medical options with the resident.
He was not given the chance.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Noble Care Center from 2025-08-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 4, 2026 · Our methodology
NOBLE CARE CENTER in STOCKTON, CA was cited for violations during a health inspection on August 14, 2025.
The incident unfolded across two days in mid-July at the facility on North California Street.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.