Guardian Care And Rehabilitation Center
GUARDIAN CARE AND REHABILITATION CENTER in MANTECA, CA — inspection on December 23, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
fatigue.Review of Resident 3's current order summary report indicated an active physician order dated 11/24/25 for oxygen therapy at 2 L/min via nasal cannula, to be administered as needed for shortness of breath and/or comfort.During an observation in Resident 3's room on 12/19/25 at 3:14 PM Resident 3 was noted lying in his bed while receiving oxygen therapy at 2 L/min via an oxygen concentrator. No oxygen in use signage was observed posted on Resident 3's doorway.During a concurrent observation and interview on 12/19/25 at 3:16 p.m., in Resident 3's room Licensed Nurse (LN) 3 confirmed that Resident 3 was receiving oxygen at 2 L/min via an oxygen concentrator for shortness of breath.During a subsequent observation on 12/23/25 at 8:40 a.m., no oxygen in use signage was observed posted on Resident 3's doorway.During a concurrent observation and interview at Resident 3's room on 12/23/25 at 8:50 a.m., Certified Nurse Assistant (CNA) 3 confirmed that no Oxygen in Use signage was posted on Resident 3's room doorway. CNA 3 also confirmed that Resident 3 was receiving oxygen via an oxygen concentrator.
CNA 3 explained that Oxygen in Use signage should be posted to alert staff, visitors, and residents that oxygen was in use in the room to maintain safety and prevent potential fire hazards.
During an interview on 12/23/25 at 10:49 a.m., the Director of Staff Development (DSD) confirmed that nurses were responsible for posting oxygen in use signage on residents' doorways when oxygen was being used to prevent fire hazards and to meet residents' needs.During a concurrent interview and record review on 12/23/25 at 2:26 p.m., with the Assistant Director of Nursing (ADON) the facility provided policy and procedure (P&P) titled Oxygen Administration, revised September 2022, was reviewed.
The ADON explained the purpose of oxygen in use signage, stating it was important to post signage on the doorway of rooms where residents were receiving oxygen as a safety precautions.
The ADON stated that when there was an order for oxygen therapy, nurses were responsible to ensure oxygen in use signage was posted on the resident's doorway.
The ADON stated it was necessary to post oxygen in use signage on Resident 2's and Resident 3's doorway to alert staff, residents, and visitors that oxygen was being used in the room to prevent fire hazards.
The ADON further stated she expected nurses to post oxygen in use signage immediately upon receiving and implementing an order for oxygen therapy, and stated this expectation was not met by nursing staff.
Review of the facility's P&P for oxygen administration indicated, .
The purpose of this procedure is to provide guidelines for safe oxygen administration.
Preparation. 3.
Assemble the equipment and supplies as needed.
Equipment and Supplies. 4. No Smoking/Oxygen in Use signs.
Steps in the Procedure. 2.
Place an Oxygen in Use sign on the outside of the room entrance door.
The ADON acknowledged that the facility's P&P was not followed.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/23/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Guardian Care and Rehabilitation Center
410 Eastwood Ave Manteca, CA 95336
SUMMARY STATEMENT OF DEFICIENCIES
Review of the facility provided policy and procedure (P&P) titled, LABELING AND DATING OF FOODS, dated 2023, indicated, POLICY: All food items in the storeroom, refrigerator and freezer need to be labeled and dated. PROCEDURE.
Newly opened food items will need to be closed and labeled with an open date and used by date that flows the.
Freezer Guidelines.
Food items will be dated with receive date, open date and use by date.
The facility P&P was not followed.
Facility ID: