The Terraces at San Joaquin Gardens Village

In the surveyor’s words

From the most serious findings on record at The Terraces at San Joaquin Gardens Village, in the surveyor’s own words.

• Immediate jeopardy, widespreadF692May 10, 2022

  Based on observation, interview, and record review, the facility failed to implement a comprehensive systemic approach to ensure effective monitoring and systems to maintain acceptable parameters of nutritional status for 10 of 10 sampled Residents (145, 146, 25, 1, 28, 40, 31, 201, 197, and 34) when: 1. Resident 145 experienced a severe unplanned weight gain of 25.2 pounds (lbs-measurement of weight), or 10% of previous weight, in two days. Weights were obtained but were not communicated to the Physician and Registered Dietitian (RD) to determine effective interventions. […]

• No harm, potential for more than minimal, widespreadF921Mar 21, 2025

  Based on observation, interview, and record review, the facility failed to maintain a safe and sanitary environment when the facility's three tumble dryers in the laundry room was not maintained per the manufacturer's recommendations and had a layer of gray and white debris collected on the back of the dryer's vent and pipes. This failure had the potential to create a fire hazard that could have placed 50 of 50 residents at risk for displacement. Findings: During an observation and interview on 3/19/25 at 11:15 a.m. with the Director of Buildings and Grounds (MAIN) and laundry (LAU) in the laundry room, a layer of small gray and white particles covered the back of the three dryer vents and the pipe that lead from the back of the dryer to the wall. […]

• No harm, potential for more than minimal, widespreadF812May 10, 2022

  Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation requirements were met in accordance with professional standards for food service when: 1. A systematic process was not used to ensure meats were thawed properly, 2. Resident dishes were not washed to prevent cross contamination, 3. One of three ice machines was not clean, 4. Hair restraints were not worn during food service activities, 5. Frozen foods were not stored to prevent freezer burn, and 6. Food preparation equipment was not air dried. These failures had the potential for the growth of microorganisms which can result in food borne illnesses in a highly susceptible resident population of 46 facility residents that consumed food prepared in the kitchen. Findings: 1. […]

• No harm, potential for more than minimal, patternF655Mar 21, 2025

  Based on observation, interview and record review, the facility failed to develop and implement a baseline care plan for three of 10 sampled residents (Resident 17, 197, 247) when: 1. Resident 17 had broken teeth and visible signs of tooth decay and no specific care plan interventions were put in place to address Resident 17's dental needs. This failure had the potential to result in Resident 17's dental needs to not be met which placed Resident 17 at an increased to develop dental infection. 2. […]

• No harm, potential for more than minimal, patternF656Mar 21, 2025

  Based on observation, interview, and record review, the facility failed to develop and implement a resident-centered comprehensive care plan for two of five sampled residents (Resident 347 and Resident 24) when: 1. Resident 347 did not have a care plan for the use of sling to left arm and splint to left foot. These failures placed Resident 347 at risk for complication from not having care plan needs planned by licensed nurses to determine if nursing interventions needed to be added, changed or completed. 2. Resident 24 did not have a care plan for the use of antibiotic for clostridium difficile (C-diff-germ that causes diarrhea and colitis [inflammation of the colon]). This failure placed Resident 24 at risk for care needs not met. Findings: 1. […]