San Joaquin Nursing Center and Rehabilitation Cent

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and distribute food in a sanitary manner when: 1. Sheet pans and dry storage bins were stored upside down while wet, with food debris and sticky residue adhered to their surfaces. 2. A dirty dining cart was stored in the walk-in refrigerator, not cleaned and disinfected. 3. Label on a container used to store garlic bread in the walk-in refrigerator had the wrong use-by date. 4. A (Brand) floor mixer had black residue buildup underneath the splash guard and splashes of light brown residue in mixing bowl. 5. A commercial can opener had black residue buildup on the cutting blade. 6. A meal slip (paper ticket that goes onto residents' food tray to ensure the correct food is served based on their needs and preferences) fell and the corner of the slip touched the edge of the gravy pan. 7. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain professional standards for three of 18 sampled residents (Resident 1, 106 and 121) and two unsampled residents (Resident 70 and 118) when: 1. Registered Nurse (RN) 1 did not verify identity before giving intravenous medication (IV, medication administered directly into the vein), did not label IV medication and tubing to Resident 121. This failure had the potential to cause harm to the resident.2. Peripherally inserted central catheter (PICC line, a long, thin flexible tube inserted into upper arm's vein and guided into a large vein above the heart, to administer medication) dressing was not changed for Resident 121. This failure had the potential to cause harm to the residents. 3. Resident 70's Medication Administration Record (MAR) was signed by LVN 5 without the medication being given. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices for two unsampled residents (Residents 22 and 128) when: 1. CNA (Certified Nursing Assistant) 1 did not perform hand hygiene and wore a gown while providing care to Resident 22 who was on Enhanced Barrier Precautions (EBP, infection control intervention designed to reduce the spread of multidrug-resistant organism, MDROs - a germ that is resistant to many antibiotics). 2. CNA 1 did not perform hand hygiene before and after repositioning Resident 128. 3. Licensed Vocational Nurse (LVN) 1 did not perform hand hygiene in accordance with facility policy and procedure and infection prevention and control guidelines for Clostridioides Difficile (C. difficile- contagious bacteria that causes diarrhea and inflammation of the colon). 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Ombudsman (person who represents or protects the interest of another) was notified of resident transfer to the hospital for one of 18 residents (Resident 1) per Federal notification requirements. This failure had the potential to limit advocacy oversight and protection of Resident 1's rights during the transfer process.

Inspectors wroteBased on interview and record review, the facility failed to implement a comprehensive person-centered care plan that included anticoagulation therapy (use of blood thinning medications) for one of 18 sampled residents (Resident 123). This failure had the potential to result in the lack of appropriate monitoring and increased the risk for bleeding complications for Resident 123.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a care plan for Anticoagulant (medication that prevent or reduce the formation of blood clot) was reviewed and updated for one of five sampled residents (Resident 3). This failure had the potential to result in Resident 3 not receiving care that is aligned with his current needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 106), received the necessary respiratory (the process of breathing) care (respiratory treatment/ therapy, oxygen therapy) and services with a current physician's order. This failure had a potential to result in respiratory complications for Resident 106.

Inspectors wroteBased on observation, interview, and record review, the facility failed to document on the daily Census and Nursing Hour Posting the facility name, the total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: registered nurses, licensed practical nurses or licensed vocational nurses, and certified nurse aides. This failure resulted in the public not knowing the correct number of staff working per shift. During a concurrent interview and record review on 3/11/2026 at 2:20 p.m. with Director of Staff Development (DSD), the Census and Nursing Hour Posting, dated Wednesday, March 11, 2026 was reviewed. The census did not have the name of the facility or the correct number of staff or staffing hours for AM (morning shift), PM (afternoon shift), and NOC (night shift) shifts posted. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 12 ointment medications in the treatment cart had pharmacy labels. This failure had the potential to result in the wrong medication ointment to be given to another resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one unsampled resident's (Resident 70), Medication Administration Record (MAR) for Lacosamide (medication used to treat seizures) on 3/8/2026 was accurate. This failure resulted to an inaccurate clinical record and placed Resident 70 at risk for seizures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure environment was free of accident hazards when the pavement in the facility's designated smoking area had a gap that three of three sampled residents (Resident 1, Resident 2 and Resident 3) reported causing their wheelchairs to get stuck. This failure had the potential to place residents at risk for falls and accidents.

Inspectors wroteBased on interview and record review the facility failed to follow its policy and procedure (P&P) titled, Referrals, Social Services, when the facility failed to schedule a follow-up surgeon's (a doctor who removes or repairs a part of the body by operating on the patient) appointment for one of four sampled residents (Resident 1). This failure had the potential for a delay in follow-up care for Resident 1 after surgery (the branch of medical practice that treats injuries, diseases, and deformities by the physical removal, repair, or readjustment of organs and tissues, often involving cutting into the body).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fingernails were kept clean and trimmed for one of four sampled residents (Resident 1). This failure had the potential to result in Resident 1 developing infection and skin injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) on Urinary Catheter (a tube placed in the body to drain and collect urine from the bladder) Care for two of five sampled residents (Resident 1 and Resident 2) when:1. The facility did not monitor placement of urinary catheter for Resident 1.2. The facility did not document urine output according to the plan of care for Resident 2. These failures had the potential for Resident 1 and Resident 2 developing UTI (Urinary Tract Infection - bladder infection).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure:A Certified Nursing Assistant (CNA) 2 was wearing proper personal protective equipment (PPE) when entering one of nine sampled residents' (Resident 6) room on contact precautions (to use PPE before entering residents' room with residents known or suspected to be infected with germs that can be spread by direct contact). This failure had the potential to result in spread of infection to other residents, staff, and visitors.2. A Licensed Vocational Nurse (LVN) performed hand hygiene after removing used gloves during a suprapubic catheter (a tube that drains urine from the bladder through a small opening in the lower abdomen) care for one of five sampled residents (Resident 3). This failure had the potential to result in Resident 3 developing urinary tract infection (bladder infection).

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedures (P&P) titled, Prevention of Pressure Injuries (PI -localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), Wound Care, and admission Assessment and Follow Up: Role of the Nurse, for one of three sampled residents (Resident 1) when the physician was not notified and treatment orders obtained, a care plan was not developed and implemented, wound measurements were not completed, and an individualized turning/repositioning schedule was not determined, when the resident was admitted with a coccyx (tailbone) PI. These failures resulted in Resident 1 not being provided wound care for nine days and the worsening of Resident 1's pressure injury.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Wound Care, for one of three sampled residents (Resident 1) when wound care orders were not obtained and care plan interventions were not developed and implemented for Resident 1's right and left heel wounds. These failures resulted in Resident 1 not being provided wound care for nine days and had the potential for worsening of Resident 1's right and left heel wounds.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and sanitary environment for one of three sampled residents (Resident 2 ) when:1. A low air loss mattress (a specialized medical mattress designed to prevent and treat pressure injuries [PI - localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear and/or friction] by providing a combination of air circulation and pressure redistribution) was improperly installed. This failure resulted in Resident 2 hitting his head.2. The wheelchair was not maintained and could not be properly cleaned and sanitized. This failure had the potential for Resident 2 to be exposed the infection and bacteria.

Inspectors wroteBased on interview and record review, the facility failed to ensure: 1. Wound treatments were completed as ordered by the physician for three of three sampled residents (Resident 1, Resident 2, and Resident 3). 2. Weekly wound assessments were completed for two of three sampled residents (Resident 2 and Resident 3). These failures had the potential for delayed wound healing, worsening of wounds, and infection for Resident 1, Resident 2, and Resident 3.

Inspectors wroteBased on interview and record review, the hospital failed to follow its policy and procedure (P&P) titled, Background Screening Investigations when one of three sampled Licensed Vocational Nurse (LVN) 1's background check was not completed within two days prior to employment. This failure had the potential to expose residents to staff with criminal background.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nationally recognized infection prevention and control practices provided by the Centers for Disease Control and Prevention (CDC-agency responsible for preventing infectious diseases) were followed and implemented when: 1. Certified Nursing Assistant (CNA) 1 entered Resident 96's room with Enhanced Barrier Precaution (reduce transmission of multidrug-resistant organisms [MDRO]- bacteria that resist treatment with more than one antibiotic) posted outside the door, without proper Personal Protective Equipment (PPE-refers to gowns, gloves, masks, face shield, or goggles to protect the individual from injury or infection). 2. Hand hygiene was not provided for two of five sampled residents (Resident 38 and Resident 15) before their food trays were delivered. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders (PO) for six of twelve sampled residents (Resident 10, Resident 26, Resident 352, Resident 351, Resident 96, and Resident 2) when: 1. Resident 10's blood work (labs) were not drawn monthly as ordered. This failure resulted in the physician to be unaware of the medication levels and the potential for Resident to have seizures. 2. Nursing staff did not put compression stockings on Resident 26. This failure had the potential for Resident 26 to develop a Deep Vein Thrombosis (DVT- blood clot). 3. Nursing staff did not administer intravenous (IV- in the vein) medications at the ordered rate for four out of six residents (Resident 352, Resident 351, Resident 96, and Resident 2) on IV medication

Inspectors wroteBased on interview and record review, the facility failed to maintain competency (skills and knowledge to perform a job) for one of one Registered Nurse (RN 1) when RN 1 did not have documented competencies to calculate intravenous (IV-within the vein) medication flow rates. This failure had the potential for the residents to receive incorrect doses of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled,Discarding and Destroying Medications when: 1. Two of two sampled Licensed Vocational Nurses (LVN 5 and LVN 1) did not discard medication in the pharmacy discard bin. 2. One of two sampled medication carts was left unlocked and unattended. 3. Controlled Drug Records (CDR) were not signed by two nurses. These failures had the potential for medications to go unaccounted for and potentially result in drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 96) was determined capable of self-medication administration (the ability of a person to take medication independently) when Resident 96 had eye drops at the bedside to self-administer. This failure had the potential to result in Resident 96 administering medication without the appropriate guidance on how to instill the eye drops in his eyes, possible side-effects, and drug reaction.

Inspectors wroteBased on interview and record review, the facility failed to ensure an advance directive (legal document indicating person's preference for end-of-life treatment decisions) was offered and completed for one of five sampled residents (Resident 16). This failure had the potential for Resident 16's healthcare wishes to not be honored.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Transfer or Discharge, Facility-Initiated, when the facility did not send a notice of transfer to the ombudsman (an advocate for residents of long-term care facilities) for two of two sampled residents (Resident 16 and Resident 38). This failure had the potential to result in Resident 16 and Resident 38 not having an advocate who could inform them of their admission, transfer, and discharge rights and options.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess and document urine output for one of one sampled resident (Resident 3) with a urostomy ( opening in the stomach wall to allow urine to pass). This failure resulted in the physician being unaware of accurate measurements of urine output to meet the individualized needs of Resident 3.

Inspectors wroteBased on interview and record review, the facility failed to ensure the discharge summary for two of two sampled residents (Resident 60 and Resident 84) were completed accurately. This failure had the potential for Resident 60 and Resident 84 to miss their follow-up care, not have details of their ongoing care, and could negatively impact Resident 60 and Resident 84's safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foot care was provided for one of one sampled resident (Resident 84). This failure resulted in Resident 84 to not being referred to podiatry (the medical care and treatment for disorders of the feet and toenails).

Inspectors wroteBased on interview and record review, the facility failed to ensure Performance Evaluations (PE-employee feedback on job performance) for two of eight sampled employees (Certified Nursing Assistant [CNA] 1 and CNA 5) were completed. This failure had the potential for the staff to not be aware of their need for improvement in areas of patient care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than five percent (5%) during the medication pass observation. The facility has a medication error rate of 9.26 % consisting of five medication errors in a sample size of 54 opportunities for error.

Inspectors wroteBased on interview and record review the facility failed to evaluate food preferences for one of one resident (Resident 90). This failure resulted in Resident 90 eating peanut butter and jelly sandwiches every meal, seven days a week, which triggered Resident 90's discontent and anger.

Inspectors wroteBased on interview and record review, the facility failed to maintain a complete and accurate medical records for one of two sampled residents (Resident 40). This failure had the potential for Resident 40's physician to be unaware of Resident 40's edema and therefore not ordering appropriate tests or order medication.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy & procedure (P&P) on Binding Arbitration Agreement (BAA - a way to resolve disputes between healthcare providers and residents) for two of two sampled residents (Resident 15 and Resident 33) when admission staff did not document a verbal acknowledgement of the BAA from Resident 15's Family Representative (RP 15) and Resident 33's Family Representative (RP 33). This failure had the potential for facility staff to be unaware if family representatives fully understood the legal document they were signing.

Inspectors wroteBased on interview and record review, the facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI-takes a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes) Program for all 96 residents residing in the facility. This failure had the potential for residents to not receive an acceptable standards of care, and the facility to not be able to identify areas of improvement.

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan for one of three sampled residents (Resident 1) pressure injury (PI-pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence). This failure had the potential for unmet care needs and Resident 1 ' s wound to worsen.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was provided with appropriate pain management. This failure had the potential for Resident 1 ' s pain to not effectively managed.

Inspectors wroteBased on interview and record review, the facility failed to ensure a baseline care plan was completed within 48 hours of admission for three of three sampled residents (Resident 1, Resident 2, and Resident 3). This failure had the potential for the residents and/or responsible party (RP) to be unaware of the plan of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure behavioral health services were provided for one of three sampled residents (Resident 1). This failure had the potential to result in Resident 1 ' s psychosocial needs not being met.

Inspectors wroteBased on observation, interview, record review the facility failed to ensure one of the four sampled residents ' (Resident 1) rights to receive a telephone call was honored when the facility did not allow Resident 1 to receive a telephone call. This failure resulted in violating Resident 1 rights to communication.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received the necessary services for pressure injuries (PI- pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence) to promote healing. This failure had the potential for unmet care needs for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop an individualized care plan for one of four sampled residents (Resident 1) when Resident 1 was frequently pulling out his Gastrostomy Tube (G-Tube-tube inserted through the wall of the abdomen directly into the stomach for nutrition, hydration, and medication). This failure had the potential to result in Resident 1 frequently going to the general acute care hospital for re-insertion of the frequently pulled G-Tube.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure titled, Abuse, Neglect, Exploitation, or Misappropriation-Reporting Investigating for one of the three sampled residents (Resident 1), when Resident 1 made an allegation of neglect and facility did not investigate and report to the California Department of Public Health (CDPH). This failure had the potential to result in Resident 1 experiencing continued neglect.

Inspectors wroteBased on interview, and record review, the facility failed to provide medically related social services for one of three sampled residents (Resident 1), when the Social Services Designee (SSD) did not follow up and provide psychosocial monitoring for Resident 1 after an allegation of neglect. This failure had the potential for Resident 1 experiencing psychosocial distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided advance notice of a room change during a three-day hospital transfer. This failure resulted in Resident 1 being unaware he was returning to a different room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat one of four sampled resident (Resident 1) with dignity and respect when the facility failed to permit Resident 1 to return to his previous room after three days of being in the hospital. This resulted in Resident 1 moving to a different room without his consent and violation of Resident 1's rights.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician ordered medications were administered for one of five sampled residents (Resident 1). This failure had the potential for Resident 1 to have adverse outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility to: 1. Provide oxygen as ordered by Medical Doctor (MD) for one of three sampled residents (Resident 1). 2. Provide humidified (increase the moisture) oxygen for two of three sampled residents on continuous oxygen (Resident 1, Resident 2). These failures had the potential to negatively impact the residents medical condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards for food service safety and sanitary kitchen conditions. This failure had the potential to cause foodborne illness (illness caused by the ingestion of contaminated food or beverages) for at-risk vulnerable residents when: 1. Cold storage food items were not labeled per facility food service safe storage and guidelines. 2. Dry storage canned products were retained when dented. 3. Persons entering the kitchen and food service area did not adhere to food service safety and sanitary kitchen professional standards.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) for one of 42 sampled residents (Resident 345) when Resident 345's call light was on the floor. This failure had the potential for Resident 345's needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to ensure an Advance Directive (AD Legal documentation consistent with the known requests or desires of the patient's medical preference) was not in the chart for one of 42 sampled residents (Resident 50). This failure had the potential for Resident 50 to not receive the necessary treatment when needed.

Inspectors wroteBased on interview and record review the facility failed to ensure one of 42 sampled residents (Resident 24), had a notification sent to the long-term care ombudsman (Ombudsman are representatives that assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) when Resident 24 was transferred to the hospital. This failure had the potential to result in Resident 24 not being protected from an inappropriate discharge and not having access to an advocate who can inform them of their options and rights.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) when: 1. Resident 5 did not have a smoking assessment completed. This failure had the potential to result in Resident 5 not being assessed and jeopardize his safety. 2. Resident 7 did not have a weekly skin assessment of a pressure ulcer (Injury to skin and underlying tissue resulting from prolonged pressure on the skin). This failure had the potential for Resident 7 to not receive needed care and treatments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 42 sampled residents (Resident 3) had a comprehensive care plan (includes measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs) developed and implemented for his dental concerns. This failure had the potential to negatively impact Patient 3's safety, psychosocial, and care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician ordered anticoagulant (blood thinner medication) was available for administration for one of 42 sampled residents (Resident 65). This failure had the potential for adverse health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error rate was less than 5% for two of eight sampled residents (Resident 65 and Resident 39). This failure had the potential for adverse health outcomes related to incorrect medication administration.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 42 sampled residents (Resident 2) had a TSH (thyroid stimulating hormone; primary stimulus for thyroid hormone production by the thyroid gland) level ordered. This failure had the potential to result in Resident 2 having a continued, unplanned weight gain.

Inspectors wroteBased on observation and interview the facility failed to provide a safe and sanitary environment for two of 42 sampled residents (Resident 39 and Resident 2) when hand hygiene was not provided before the food tray was delivered. This failure had the potential to adversely affect Resident 39 and Resident 2's health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was assessed (evaluated) after an unwitnessed fall. This failure had the potential for injuries due to unsafe movement of Resident 1 by the Certified Nursing Assistant (CNA) from the floor to the wheelchair.