Inspection Reports for
Stockton Nursing Center

The facility failed to develop and implement a complete care plan addressing the use of low air loss mattresses for residents with a history of pressure injuries. Additionally, the mattresses were not adjusted according to residents' current weights, increasing the risk of pressure ulcer development or recurrence.

The complaint investigation substantiated that Resident 1 and Resident 4 engaged in physical altercations with Resident 6 and Resident 3 respectively, resulting in injuries. Resident 1 pushed Resident 6 causing a fall from his wheelchair, and Resident 4 struck Resident 3 in the face causing bleeding. Both incidents occurred despite some residents being on one-on-one supervision, which was not adequately maintained at the time.

The facility failed to protect two of four sampled residents from physical abuse by other residents, resulting in injuries including a fall from a wheelchair and facial injury. The incidents involved residents with histories of aggressive behavior and inadequate supervision at the time of altercations.

The facility failed to develop a comprehensive care plan for a resident with new skin issues and scratching behavior, and failed to maintain complete and accurate medical records and treatment documentation for two residents, placing them at risk for worsening conditions and complications.

The complaint investigation found that Resident 1's routine morphine sulfate pain medication order was not carried out for 35 days, despite hospice orders and family member reports of the resident being in pain. Interviews with staff and hospice representatives confirmed miscommunication and failure to implement the routine pain medication order.

The facility failed to provide adequate pain management for one out of three sampled residents when a new routine pain medication order was not carried out for 35 days, causing the resident to experience pain and potential psychosocial distress.

The facility failed to provide adequate pain management for one resident by not carrying out a routine morphine sulfate order for 35 days, resulting in the resident experiencing pain and potential psychosocial distress. The issue was attributed to miscommunication between hospice and the facility staff.

The complaint investigation was substantiated. Resident 1 was involuntarily secluded by a CNA who blocked her from leaving her room. The facility delayed reporting the abuse to the proper authorities beyond the required two-hour timeframe. Resident 1 had known wandering behaviors and was inadequately supervised, placing her at risk of injury and elopement.

The facility failed to prevent involuntary seclusion of Resident 1 by a Certified Nursing Assistant who blocked the resident from leaving her room. The facility also failed to timely report the suspected abuse to proper authorities and did not provide adequate supervision for Resident 1, who exhibited wandering behaviors, placing her at risk for injury and elopement.

The complaint investigation substantiated that Resident 2, who required one-on-one supervision due to aggressive behaviors, was left unattended on 8/20/25 and physically attacked Resident 1. The facility also failed to consistently document safety checks for Resident 2 on multiple dates, compromising resident safety and care communication.

The facility failed to protect a resident from abuse when a resident on one-on-one supervision was left unattended and physically attacked another resident. Additionally, the facility failed to consistently document every 15-minute safety checks for the resident on one-on-one supervision, risking inadequate monitoring and communication.

The facility failed to ensure proper physician orders and monitoring for a pressure ulcer intervention device for one resident, and failed to provide appropriate behavioral health treatment and follow-up psychiatric services for another resident, resulting in potential harm and unmet psychosocial needs.

The facility failed to ensure proper physician orders and monitoring for a Low Air Loss mattress for Resident 4, risking further skin breakdown. Additionally, the facility failed to provide appropriate behavioral health treatment and follow-up psychiatric services for Resident 1, resulting in unmet mental health needs and ongoing resident-to-resident altercations.

The facility failed to protect a resident's privacy when two CNAs live streamed on social media during care activities. Additionally, the facility did not properly label a resident's enteral feeding bag, risking infection due to lack of date and time identification.

The complaint involved CNAs recording and live streaming a TikTok video in Resident 4's room during care, violating privacy. The incident was reported by a Licensed Nurse. The CNAs involved were terminated. The complaint was substantiated with findings of privacy violation and improper feeding tube care.

The facility failed to respect Resident 4's privacy when two CNAs live streamed on TikTok during care activities in the resident's room, resulting in staff termination. Additionally, the facility failed to properly label Resident 4's enteral feeding bag with date and time, risking infection.

The complaint investigation substantiated that the facility did not provide one-to-one supervision to Resident 2 on the night shift, which led to a physical altercation with Resident 1 on 6/7/25. Resident 2 had a history of aggressive behaviors and was supposed to have one-to-one supervision on all shifts. The altercation caused injuries to both residents.

The facility failed to provide one-to-one supervision to Resident 2 during the night shift, which resulted in a physical altercation between Resident 1 and Resident 2 causing injuries to both residents. Resident 2 suffered multiple bruises and a laceration, and Resident 1 sustained two fractures in his left hand.

The facility failed to ensure the environment was free of accident hazards for one of five sampled residents due to remnants of a broken rail with splintered wood and protruding screws near Resident 4's bed. This condition posed a potential risk of injury to Resident 4, staff, and visitors.

The facility failed to maintain acceptable nutrition monitoring for four sampled residents by not carrying out physician-ordered weight checks as required. This failure posed risks of undetected weight loss or gain, potentially delaying treatment and negatively affecting residents' health.

The complaint investigation found that the facility did not implement physician orders for weight monitoring for Resident 1 and failed to conduct weekly weight checks for Residents 2, 3, and 4 during their initial month of admission. The Assistant Director of Nursing and nursing staff confirmed these failures and acknowledged the risks associated with lack of weight monitoring.

The facility failed to carry out physician-ordered weight monitoring for Resident 1 and did not complete weekly weight checks during the first month of admission for Residents 2, 3, and 4. These failures could result in undetected weight changes, delaying treatment and negatively affecting residents' health and functional status.

The complaint investigation found that Resident 1 was not assessed for substance abuse risk and no nursing plan of care was created upon admission despite a documented history of methamphetamine use. The resident tested positive for methamphetamine during an emergency room visit following a sudden change in vital signs and mental status. The facility acknowledged non-compliance with smoking hazards and lack of care plan prior to the positive drug test.

The facility failed to ensure that Resident 1 was assessed for substance abuse risk and that a nursing care plan was initiated upon admission despite documented history of methamphetamine use. This failure potentially contributed to health hazards, including a positive drug test and hospital emergency admission due to altered mental status and other symptoms.

The complaint investigation found substantiated incidents of abuse involving Resident 1 striking Resident 2, slapping Resident 3, hitting Resident 3's ear, and Resident 4 kicking Resident 1. Staff failed to maintain proper supervision during one-to-one care, contributing to these incidents.

The facility failed to protect four of nine sampled residents from abuse, including physical and verbal altercations involving Resident 1 and others. Staff failed to adequately supervise Resident 1 despite one-to-one care interventions, resulting in multiple incidents of resident-to-resident abuse.

The complaint was substantiated. CNA 1 was found to have neglected Resident 1 by leaving her in a soiled brief for two hours and neglected Resident 2 by leaving her care incomplete and slapping her leg. CNA 1 was terminated following the investigation.

The facility failed to ensure residents remained free from neglect when CNA 1 left Resident 1 in a soiled incontinent brief for two hours and left Resident 2 without completing incontinent care, also slapping Resident 2's leg after being asked not to touch due to pain. These failures caused potential for skin breakdown, psychosocial distress, and unnecessary pain.

The complaint investigation substantiated that the Activity Assistant gave cannabis edibles and marijuana to two residents voluntarily and for recreational purposes. Urine tests confirmed presence of cannabinoids. The Activity Assistant's employment was terminated.

The facility failed to ensure the safety of two residents when an Activity Assistant gave them cannabis edibles and marijuana. Both residents voluntarily received the substances, which posed potential risks including drug interactions, increased falls, and impaired cognition. The Activity Assistant was terminated.

The complaint investigation found substantiated incidents where Resident 2 splashed water on Resident 1 and spat on Resident 5. Resident 1 reported feeling unsafe and emotionally uncomfortable due to repeated aggressive behaviors by Resident 2. The facility failed to provide adequate supervision or psychological evaluation as recommended.

The facility failed to protect residents from physical abuse by another resident, resulting in emotional distress and safety concerns. Additionally, the facility failed to implement recommended psychological evaluations for Resident 1 following the abuse incidents. The facility also did not provide adequate monitoring or one-to-one support for the aggressive resident (Resident 2).

The complaint was substantiated as the investigation confirmed that CNA 7 tied the door shut with a garbage bag to prevent Resident 5 from leaving the room, with Resident 6 also present. Multiple staff acknowledged the incident and stated it was unacceptable and a form of abuse.

The facility failed to protect the rights of two residents by tying the room door shut with a garbage bag, constituting involuntary seclusion and abuse. The incident was confirmed by multiple staff interviews and was found to negatively impact the residents' dignity and well-being.

The facility failed to maintain two shared resident bathrooms in a sanitary and homelike condition, with peeling paint, missing baseboards, open gaps, and damaged trim, posing potential safety and psychosocial risks. Additionally, the facility failed to implement and revise a person-centered care plan for Resident 1, specifically regarding fall prevention interventions such as bedrails, call light accessibility, and bed position.

The complaint investigation involved allegations of sexual abuse by Resident 82 towards Unsampled Resident 2, unauthorized videotaping and disparaging comments about Unsampled Resident 2 by Licensed Nurse (LN) 2, and diversion of narcotic pain medications by LN 20 affecting Unsampled Resident 1 and Resident 17. The investigation found psychosocial distress and potential for unmanaged pain among affected residents.

The facility failed to protect residents from mental and sexual abuse, misappropriation of property, and medication diversion involving multiple residents and staff. Additionally, care plans were not developed for certain residents to address safety, hospice care, and medication side effects.

The facility had multiple deficiencies including failure to provide dignity during meal assistance, inaccurate medical record maintenance, unsafe environment issues, failure to address resident grievances, delayed abuse investigation reporting, incomplete care plans, inadequate assistance with activities of daily living, lack of mobility aids, pressure ulcer care deficiencies, respiratory safety issues, pain management delays, behavioral health service gaps, medication administration errors, improper medication storage and labeling, infection control lapses, vaccine education and offering failures, non-functioning call light systems, and ineffective pest control.

The facility failed to ensure appropriate infection prevention measures for one of four sampled residents when a staff member did not wear the required gown while providing care to a resident on Enhanced Barrier Precautions. This failure posed a risk of infection spread within the facility.

The complaint investigation found that the facility failed to obtain and review hospital discharge paperwork and lab results for Resident 1, including urine culture tests, and delayed follow-up on a gastroenterology referral. The lack of timely medical information and referral follow-up placed Resident 1 at risk for substandard care and prolonged pain.

The facility failed to ensure staff received and reviewed Resident 1's hospital discharge summaries and lab results, including urine culture and sensitivity tests, which led to ineffective antibiotic treatment. Additionally, the facility did not follow up timely on a gastroenterology referral, resulting in prolonged pain and risk of substandard care for Resident 1.

The facility failed to develop a timely COVID-19 and isolation care plan for Resident 3 after testing positive, delayed placing Resident 3 in isolation, admitted a COVID-negative resident into the same room, and did not ensure proper COVID-19 testing for exposed roommates. These failures placed residents and staff at risk of infection.

The investigation was complaint-driven, focusing on infection control and care planning failures related to COVID-19 exposure and management within the facility. Substantiation status is not explicitly stated.

The facility failed to develop a timely COVID-19 and isolation care plan for Resident 3 after testing positive on 8/17/24, delayed placing Resident 3 in isolation until 8/19/24, admitted a COVID-negative resident into the same room as Resident 3, and did not ensure proper COVID-19 testing for exposed residents. These failures placed residents and staff at risk of infection and potential disease spread.

The visit was complaint-related due to allegations that the facility did not provide written notification to residents or their responsible parties before room changes during a scabies outbreak. The complaint was substantiated with findings confirming the lack of written notification and late verbal notifications.

The facility failed to provide written notice of room changes to eleven sampled residents and/or their responsible parties prior to moving them on 7/29/2024, violating residents' rights and potentially causing psychosocial distress. The facility staff provided only verbal or late notifications, and documentation of notification was lacking in medical records.

The complaint investigation found that Resident 2 did not receive an ordered antiseptic medication for five days due to failure in medication ordering and supply processes. Resident 1 experienced delayed speech therapy evaluation and missed therapy sessions, increasing risk for health decline.

The facility failed to provide pharmaceutical services to Resident 2 when a prescribed antiseptic medication was not ordered or administered for five days, potentially worsening the resident's rash. Additionally, the facility failed to provide timely speech therapy evaluation and treatment for Resident 1, resulting in delayed services and increased risk of decline.

The investigation was complaint-driven, triggered by family complaints about lack of therapy and RNA services for residents. The facility acknowledged insufficient RNA staffing and lack of documented services for residents. Families reported increased weakness, discomfort, and decreased use of limbs due to lack of therapy and RNA services.

The facility failed to ensure that restorative nursing assistant services were provided as ordered to three residents, resulting in limited or no documented evidence of services and insufficient RNA staff. This failure had the potential to cause a decline in physical functioning and negatively impact residents' health and well-being.

The facility failed to provide restorative nursing assistant services as ordered for Resident 3, resulting in a potential decline in the resident's range of motion. The RNA staff were unaware of the order and did not document providing the services.

The complaint was substantiated based on interviews and record reviews. CNA 6 made inappropriate comments and threatened Resident 1 not to report the incident. The incident was witnessed by CNA 4 and reported to the Administrator.

The facility failed to ensure that Resident 1 was treated with dignity and respect when CNA 6 sat on the lap of Resident 1's family member and made inappropriate remarks. The incident was witnessed by another CNA and reported to the facility administrator.

The complaint investigation found that Resident 2 waited 47 minutes for assistance after pressing the call light multiple times. The RNA answered the call light but did not notify the nurse. Resident 2 reported feeling neglected and emotionally abused. The Administrator confirmed expectation for immediate response to call lights.

The facility failed to ensure timely response to Resident 2's call light requests, resulting in a total wait time of 47 minutes before the nurse attended to her needs. The Restorative Nurse Assistant did not communicate the resident's needs to the nurse, causing potential negative impact on the resident's psychosocial well-being and physical health.

The facility failed to ensure proper infection control practices for residents with urinary catheters and antibiotic-resistant infections, lacked a full-time dedicated Infection Preventionist, and had environmental safety issues including cracked flooring, broken shower tiles, lack of hot water in a resident's bathroom, and malfunctioning bed controls. These deficiencies posed minimal harm or potential for actual harm to residents.

Complaint received on 2023-11-06 reported electrical sparks and smoke near Resident 1's bed. The complaint was substantiated by observations and staff interviews confirming the electrical issue was not repaired until the following day.

The facility failed to timely repair an electrical breakdown causing sparks and smoke near Resident 1's bed, which was not fixed until 13 hours later. This posed a risk of electrical fire and caused Resident 1's bed to remain non-functional and uncomfortable. Multiple staff interviews confirmed delays in maintenance response.

The facility failed to provide a full-time Director of Nursing since mid-October 2023, which decreased the potential to provide accurate and safe nursing care for 109 residents. Multiple staff interviews confirmed the absence of a DON during the inspection.

The investigation was complaint-related, focusing on the absence of a full-time Director of Nursing. The deficiency was substantiated with multiple staff interviews and record reviews confirming the lack of a DON since October 2023.

The facility failed to have a full-time Director of Nursing since mid-October 2023, which decreased the potential to provide accurate and safe nursing care for 109 residents. Multiple staff interviews confirmed the absence of a DON and the importance of this role in resident care.

The facility failed to provide requested resident medical records in a timely manner for one resident, resulting in a delay and denial of the resident's right to timely access. Additionally, the facility failed to ensure that POLST documents for two residents contained required signatures, potentially risking treatment against resident wishes.

The complaint investigation was triggered by Resident 1 eloping from the facility on 9/16/2023. The investigation found the Wandering Assessment was inaccurately completed and the door alarm system failed, allowing the resident to leave undetected. The complaint was substantiated with findings of minimal harm or potential for actual harm.

The facility failed to accurately complete Resident 1's Wandering Assessment after the elopement event, resulting in an inaccurate risk score. Additionally, the facility failed to ensure adequate supervision and maintain a functioning door alarm system, which allowed Resident 1 to leave the facility undetected, jeopardizing the resident's safety.

The complaint investigation was substantiated. Resident 1 eloped from the facility on 9/16/23 through a nonfunctioning alarmed door without staff knowledge. The facility acknowledged system errors and failure to follow policies, placing Resident 1 at risk of injury or death.

The facility failed to accurately complete Resident 1's Wandering Assessment after the elopement event, resulting in an inaccurate risk score. Additionally, the facility failed to ensure adequate supervision and maintain a functioning door alarm system, allowing Resident 1 to leave the facility unnoticed, which jeopardized the resident's safety.

The complaint investigation found that Resident 1, who was at moderate risk for wandering, eloped from the facility unsupervised and was found by a bystander who called the police. The resident was taken to the hospital. Staff reported being too busy to supervise wandering residents adequately, and the facility lacked wanderguard testers. The main entrance door alarm was set at low volume and not heard by staff.

The facility failed to ensure the safety of Resident 1, who had a history of wandering and was found outside the facility unsupervised. The wanderguard alarm was set at low volume and staff were unable to hear it. Staffing and supervision were insufficient to monitor residents at risk for wandering, and the facility lacked proper equipment to test wanderguard functionality.

The complaint alleged the facility was short-staffed daily and unable to provide showers as scheduled. The complaint was substantiated based on interviews, observations, and staffing record reviews.

The facility failed to provide showers as scheduled to 4 of 5 sampled residents due to acute CNA staffing shortages. Staffing ratios did not meet state requirements for a census of 104 residents, impacting the quality of care.

The facility failed to provide a sanitary environment as staff did not perform hand hygiene after contact with residents' belongings while passing lunch trays to four of seven sampled residents. This failure had the potential to spread infections.

The facility failed to serve a therapeutic diabetic diet to Resident 2 on 7/19/23, serving a non-diabetic dessert instead, and failed to honor Resident 1's documented dislike of fish by serving fish on 7/13/23. Both failures had the potential to negatively impact resident health and dining experience.

The complaint investigation found that Resident 7 was left alone in the locked bus for about 40 minutes on a warm day, which could have caused serious physical and emotional harm. The Social Service Director confirmed no changes in Resident 7's mood or behavior post-incident. The Nursing Unit Manager stated the bus driver was responsible for Resident 7's supervision and failed to ensure the resident was off the bus before leaving.

The facility failed to provide adequate supervision for Resident 7, who was left alone in the locked bus by the bus driver, exposing the resident to potential overheating and serious health complications. Resident 7 was assessed and sent to the hospital for evaluation but returned with no new orders or treatments.

The complaint investigation was substantiated as the incident was witnessed by a CNA and confirmed by the resident and nursing staff. Resident 2 exhibited behaviors including agitation, combative actions, and interference with Resident 1's personal belongings and oxygen supply.

The facility failed to provide adequate supervision for Resident 1, who was dependent on supplemental oxygen, when Resident 2 removed her oxygen cannula and hit her with a stuffed toy. The incident was witnessed by staff and confirmed by interviews, revealing Resident 2's behavioral issues and the facility's failure to monitor her adequately.

The facility failed to ensure staff performed proper hand hygiene after contact with residents' belongings while passing lunch trays to four sampled residents, posing a potential risk for spreading infections.

The visit was complaint-related due to the air conditioning failure causing unsafe temperature conditions. The complaint was substantiated as Resident 5 was hospitalized for possible dehydration.

The facility failed to maintain the temperature between 71 and 81 degrees Fahrenheit in the South Station, causing Resident 5 to be hospitalized for possible dehydration and creating potential risk of dehydration and hyperthermia for other residents. The air conditioner was not working, and temperatures in resident rooms ranged from 81.3 to 86.7 degrees Fahrenheit. The maintenance manager could not provide records of air conditioning maintenance.

The facility failed to maintain a clean and sanitary environment for one resident, as Resident 1's window curtain was dirty with large brown stains on both sides. This condition had the potential to negatively impact Resident 1's psychosocial well-being.

The facility failed to maintain a clean and sanitary environment for Resident 1, as the window curtain in the resident's room was dirty with large brown stains on both sides. This condition had the potential to negatively impact Resident 1's psychosocial well-being.

The complaint investigation was substantiated as the resident eloped from the facility and was found outside by a community member. The resident was scared and reported the incident to staff. Staff reported challenges in supervising wandering residents at night due to staffing assignments.

The facility failed to ensure safety for one resident who eloped and was found outside the facility by a community member. The resident was assessed as low risk for elopement and did not have a wander guard device. Exit door alarms were noted to sound only for residents wearing alarmed devices but not when doors were opened otherwise.

Complaint investigation focused on Resident 1's discharge process and transition of care failures, including medication supply, discharge documentation, and notification procedures. The complaint was substantiated with findings of minimal harm.

The facility failed to provide a complete discharge summary including wound care instructions, assistive devices, physician and home healthcare contact information. Resident 1 was discharged without all prescribed medications and without proper documentation of discharge reason. The facility also failed to provide timely and accurate transfer/discharge notices to the responsible party and ombudsman, resulting in lack of awareness of appeal rights.

The complaint investigation focused on Resident 2, who developed a wound on 4/25/23 that was not reported to the wound nurse as required. Licensed nurses failed to monitor the wound per physician orders and facility policy, resulting in the wound progressing to a stage 4 pressure ulcer by 5/10/23. Documentation was found to be inaccurate and falsified, with nurses signing off on monitoring tasks they did not perform. Interviews with staff including the wound nurse, licensed nurses, unit manager, administrator, and medical director confirmed these failures.

The facility failed to notify the wound nurse and properly monitor Resident 2's lower back/coccyx wound according to physician orders and facility policy, resulting in delayed identification and treatment of a pressure ulcer that progressed to a stage 4 pressure ulcer. Licensed nurses documented monitoring tasks that were not completed, leading to inadequate treatment and worsening of the wound.

The investigation was complaint-related, focusing on incidents where Resident 2 physically assaulted Resident 1 and exhibited aggressive and inappropriate behaviors. The complaint was substantiated with findings of inadequate supervision and failure to implement proper interventions.

The facility failed to provide adequate supervision to ensure safety for Resident 1 when Resident 2 hit him on the back of his head and both residents started fighting. Resident 2 exhibited verbal and physical aggressive behaviors, including sexually inappropriate behavior, which were not properly documented or managed in care plans. Staffing shortages contributed to inadequate supervision.

The investigation was complaint-related, focusing on infection control failures regarding residents with suspected scabies treated with permethrin but not placed on isolation precautions or reported to public health. The complaint was substantiated with findings of minimal harm and risk to other residents and staff.

The facility failed to implement adequate infection prevention and control measures for three residents treated with permethrin for skin rashes suspected to be scabies. Residents were not placed on isolation precautions, and the potential scabies cases were not reported to local public health authorities, posing a risk of infection spread to staff and other residents.

The facility failed to maintain a homelike and comfortable environment for one resident due to the room thermostat being set above the recommended temperature range, causing discomfort to the resident, staff, and visitors.

The investigation was complaint-driven, focusing on allegations that restorative nursing assistant services were not provided as ordered. The complaint was substantiated as RNA services were not provided to any of the 23 residents referenced.

The facility failed to provide restorative nursing assistant services to 23 residents as recommended in their restorative referrals, resulting in risk of decline in physical functioning and worsening contractures. Interviews and record reviews confirmed RNA services were not provided or documented from mid-2022 through the inspection date.

The facility failed to provide restorative nursing services to 23 residents as recommended, resulting in potential decline in residents' mobility and physical functioning. RNA services were not implemented or documented, and no current RNA schedules were in place to provide these services.

The investigation was complaint-related, focusing on infection control failures for residents with suspected scabies. The complaint was substantiated as the facility did not isolate affected residents or report the condition to public health.

The facility failed to provide adequate infection prevention and control for three residents treated with permethrin for skin rashes suspected to be scabies. The residents were not placed on isolation precautions, and the potential scabies cases were not reported to local public health authorities, risking spread of infection.

The facility had multiple deficiencies including failure to maintain resident dignity, incomplete care conferences, inaccurate psychiatric diagnoses, inadequate treatment and monitoring of residents, unsafe medication handling, infection control lapses, and facility-wide assessment gaps.

The facility was found deficient in multiple areas including resident dignity and care, care plan conferences, medication management, restorative nursing services, resident safety, nutrition, infection control, medication storage, and facility-wide assessments.

The facility was found deficient in multiple areas including failure to maintain resident dignity during feeding, failure to provide adaptive dining devices, failure to notify physicians timely of residents' weight changes, failure to implement complete care plans, medication regimen review deficiencies, improper medication monitoring, unsafe medication storage practices, food service inaccuracies, unsanitary food preparation conditions, and failure to ensure call light accessibility for residents.