San Joaquin Nursing Center and Rehabilitation Cent

In the surveyor’s words

From the most serious findings on record at San Joaquin Nursing Center and Rehabilitation Cent, in the surveyor’s own words.

• Actual harm, patternF725Feb 14, 2022

  Based on interview and record review, the facility failed to ensure four of four residents (Resident 1, Resident 2, Resident 3, and Resident 4) were provided nursing care when the nursing care unit they were in (a single, 4-bed isolation room known as the red zone, where Covid-19 positive residents were housed) went unstaffed for a period at least sixty (60) minutes. 1. This failure had the potential to result in Resident 1's fall to the floor, and, 2. The failure had the actual result of no staff responding to Resident 1 as she laid on the floor, for approximately 30 minutes, which required Emergency Medical Services (EMS) to be summoned by her roommate, Resident 2, due to no facility staff being aware of the fall, and, the actual result of untimely incontinent care provided to four of… […]

• Actual harm, isolatedF686Jun 23, 2025

  Based 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. […]

• Actual harm, isolatedF624Aug 24, 2023

  Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was discharged home safely when Resident 1 needed assistance with personal care but was sent home alone without a caregiver or family member in an unsafe living condition and without discharge instructions. This failure resulted in Resident 1 being admitted to the hospital for 12 days with diagnoses of failure to thrive (a state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments), pulmonary edema (too much fluid in the lungs), elevated troponin (type of protein found in the muscles of the heart - indicator for impending heart attack) after only six hours from being discharged from the skilled nursing facility (SNF) and 12… […]

• Actual harm, isolatedF689Jan 6, 2021

  (Note: Mechanical lifts are assistive devices used in healthcare facilities that allow caregivers to lift a resident and transfer them with a minimum of physical effort. Commonly used brands are Arjo, Medline, and Hoyer. Each operate by hooking onto and lifting a sling that is positioned under the resident. In the below deficiency, the brand-name Hoyer is used by facility staff to describe mechanical lifts in general, regardless of the actual manufacturer.) Based on observation, interview, and record review, the facility failed to safely transfer one of one residents (Resident 1) from her bed to her wheelchair, when the wrong sling was used on a mechanical lift. This failure resulted in Resident 1 falling to the floor and fracturing her right hip, leading to pain and surgical repair. […]

• No harm, potential for more than minimal, widespreadF812Mar 12, 2026

  Based 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. […]