Guardian Care And Rehabilitation Center

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.

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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

12/23/2025

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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

use-by ( the last day a food is recommended for consumption, meaning you should not eat it after this date) date, or expiration date. The item was located on the left side shelf inside the freezer near the door. The DS confirmed the finding and stated the pie had been left over from Christmas dinner held several days prior.

The DS acknowledged that the pie should have been labeled with a use-by date and that the date was missing. The DS further stated that serving food past its use-by date was unsafe and could result in foodborne illness, posing a risk to residents and anyone consuming the product.During an interview on 12/19/25 at 1:07 p.m., the Dietary [NAME] (DC) stated that all food items stored in kitchen storage areas and other food preparation locations were required to be labeled with an open date, preparation date, use-by date, and expiration date to ensure residents' safety.During an interview on 12/23/25 at 2:26 PM, the Assistant Director of Nursing (ADON) stated food items should be labeled properly with all dates. ADON added residents might get foodborne illnesses from eating unlabeled foods. 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.

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