Guardian Care And Rehabilitation Center
Inspection Findings
F-Tag F0610
F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
not reviewed CNA 8's employee file. The SSD further stated she should have partnered with the DSD to
review CNA 8's employee file. The SSD stated the risk to Resident 72 was further abuse. During an
interview on 8/28/25, at 11:19 AM, with the Director of Nursing (DON), the DON stated other staff members
on shift of the day of the alleged abuse should have been interviewed. The DON further stated other residents, in the care of CNA 8, should have been interviewed. The DON explained the importance of interviewing staff on shift from the day of the alleged abuse and other residents was to ensure a complete investigation and to prevent further incidents. The DON explained it was important to look at employee records to help in the investigation and to find out if there were similar complaints.A review of an undated facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, indicated, .All reports of resident abuse (including injuries of unknown origin) .are reported .and thoroughly investigated .The individual conducting the investigation as a minimum .interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .interviews the resident's roommate, family members, and visitors .interviews other residents to whom the accused employee provides care or services .reviews all events leading up to the alleged incident .
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Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/29/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Guardian Care and Rehabilitation Center
410 Eastwood Ave Manteca, CA 95336
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0656
F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
During an interview on 8/26/25, at 2:16 PM, with Resident 102, Resident 102 stated she was not happy with the care she received while being turned by staff. Resident 102 explained there was only one nursing aide who turned her while providing care.
During a phone interview on 8/27/25, at 2:42 PM, with Certified Nursing Assistant (CNA) 3, CNA 3 confirmed that she had turned Resident 102 alone, without the assistance of another staff.
During a concurrent interview and record review on 08/28/25, at 10:55 AM, with the Director of Staff Development (DSD), the DSD confirmed that CNA 3 had turned Resident 102 alone, when there should have been two CNAs providing care. The DSD stated it was important to follow Resident 102's care plan to ensure that the resident was receiving proper care, using the correct interventions, and to achieve goals for health conditions.
Review of an undated facility policy titled, Repositioning, indicated, .Repositioning the Resident in Bed 1.
Check the care plan…to determine resident’s specific positioning needs…and the number of staff required to complete the procedure .
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/29/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Guardian Care and Rehabilitation Center
410 Eastwood Ave Manteca, CA 95336
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0658
Federal health inspectors cited GUARDIAN CARE AND REHABILITATION CENTER in MANTECA, CA for a deficiency under regulatory tag F-F0658 during a standard health inspection conducted on 2025-08-29.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Ensure services provided by the nursing facility meet professional standards of quality.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of GUARDIAN CARE AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
F-Tag F0684
Federal health inspectors cited GUARDIAN CARE AND REHABILITATION CENTER in MANTECA, CA for a deficiency under regulatory tag F-F0684 during a standard health inspection conducted on 2025-08-29.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of GUARDIAN CARE AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
F-Tag F0688
Federal health inspectors cited GUARDIAN CARE AND REHABILITATION CENTER in MANTECA, CA for a deficiency under regulatory tag F-F0688 during a standard health inspection conducted on 2025-08-29.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of GUARDIAN CARE AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
F-Tag F0689
F 0689 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
transportation to the Dialysis clinic. LN 9 stated Resident 103 ‘s skin was warm to touch, and her temperature was 100.2 F (Fahrenheit, a unit of temperature measurement). LN 9 stated she tried to call the doctor, and the doctor did not answer so she called 911 and had the paramedics (highly trained prehospital care providers who assess, stabilize, and treat patients experiencing medical emergencies or traumatic injuries before they reach a hospital) take Resident 103 to the hospital.During a concurrent interview and
record review, on 9/12/25, at 4:28 p.m., Resident 103's hospital electronic medical record was reviewed with the Quality Assurance Director (QAD, employed by the hospital Resident 103 went to after the incident). The QAD confirmed Resident 103 did not have a fall while in the hospital from the date of admittance of 7/3/25 through the discharge date of 7/18/25. The QAD stated Resident 103's emergency room visit notes and ambulance report did not contain documentation regarding Resident 103's fall from the gurney prior to arrival at the emergency room. Review of an undated facility policy titled, Safety and Supervision of Residents, the policy indicated, .Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .Resident supervision is a core component of the systems approach to safety.risk factors and environmental hazards include the following: a. Bed safety.falls.Review of an undated facility policy titled, Fall Risk Assessment, the policy indicated, .The staff will seek to identify factors that may contribute to falling .Review of an undated facility policy titled, Transportation, Diagnostic Services [medical tests, examinations, and procedures used to identify or diagnose a health condition], the policy indicated, .A member of the nursing staff, or social services, will accompany the resident to the diagnostic center when the resident's family is not available. The nursing staff must always monitor and seat next to
the residents .The nursing staff must check if residents are strapped in their seats, safe and secure.Review of the facility staff job descriptions titled, Certified Nursing Assistant, dated 2003, the document indicated, .Make resident comfortable.Assist in transporting residents to/from appointments.Assist with lifting, turning, moving, positioning, and transporting residents into and out of beds, chairs, bathtubs, wheelchairs, lifts etc.Ensure that residents who are unable to call for help are checked frequently.Assist with the application of slings, elastic bandages, binders, etc. [et cetera; and other similar things].Follow established safety precautions in the performance of all duties.
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If continuation sheet
F-Tag F0692
Federal health inspectors cited GUARDIAN CARE AND REHABILITATION CENTER in MANTECA, CA for a deficiency under regulatory tag F-F0692 during a standard health inspection conducted on 2025-08-29.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide enough food/fluids to maintain a resident's health.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of GUARDIAN CARE AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
F-Tag F0740
Federal health inspectors cited GUARDIAN CARE AND REHABILITATION CENTER in MANTECA, CA for a deficiency under regulatory tag F-F0740 during a standard health inspection conducted on 2025-08-29.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of GUARDIAN CARE AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
F-Tag F0755
Federal health inspectors cited GUARDIAN CARE AND REHABILITATION CENTER in MANTECA, CA for a deficiency under regulatory tag F-F0755 during a standard health inspection conducted on 2025-08-29.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of GUARDIAN CARE AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
F-Tag F0757
Federal health inspectors cited GUARDIAN CARE AND REHABILITATION CENTER in MANTECA, CA for a deficiency under regulatory tag F-F0757 during a standard health inspection conducted on 2025-08-29.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure each resident’s drug regimen must be free from unnecessary drugs.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of GUARDIAN CARE AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
F-Tag F0761
Federal health inspectors cited GUARDIAN CARE AND REHABILITATION CENTER in MANTECA, CA for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2025-08-29.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of GUARDIAN CARE AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
F-Tag F0778
Federal health inspectors cited GUARDIAN CARE AND REHABILITATION CENTER in MANTECA, CA for a deficiency under regulatory tag F-F0778 during a standard health inspection conducted on 2025-08-29.
Category: Administration Deficiencies
The facility was found deficient in the following area: Help the resident make transportation arrangements to and from radiology services.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of GUARDIAN CARE AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
F-Tag F0865
Federal health inspectors cited GUARDIAN CARE AND REHABILITATION CENTER in MANTECA, CA for a deficiency under regulatory tag F-F0865 during a standard health inspection conducted on 2025-08-29.
Category: Administration Deficiencies
The facility was found deficient in the following area: Have a plan that describes the process for conducting QAPI and QAA activities.
Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of GUARDIAN CARE AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
F-Tag F0880
Federal health inspectors cited GUARDIAN CARE AND REHABILITATION CENTER in MANTECA, CA for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-08-29.
Category: Infection Control Deficiencies
The facility was found deficient in the following area: Provide and implement an infection prevention and control program.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of GUARDIAN CARE AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
GUARDIAN CARE AND REHABILITATION CENTER in MANTECA, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MANTECA, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from GUARDIAN CARE AND REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.