Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at North Starr Postacute Care during CMS and state inspections, most recent first.
A resident with ESRD and DM was hospitalized for suspected infected dialysis access, received IV antibiotics, and had the dialysis catheter removed and replaced, but the facility did not revise the comprehensive care plan to address the significant change in condition. Surveyors found no care plan for the hospitalization, physician notification, follow-up care, discharge planning, or IDT review, despite staff and facility policy stating that significant changes require assessment, physician notification, and care plan revision.
A resident with end stage renal disorder, bipolar disorder, anxiety disorder, and schizophrenia had a PASRR Level I screen completed after a significant change in condition when hospice services began. The Level I screen was positive for SMI and required a Level II evaluation, but the facility did not ensure the Level II PASRR was completed after the state agency’s attempted contact, and the DON stated policy and procedure were not followed.
Missing Oxygen Use Signage: A resident was observed in bed with the O2 concentrator running at 5 LPM, but no oxygen-in-use signage was posted in or outside the room and the nasal cannula was on the floor. An LVN confirmed the resident had an O2 order and that signage was required for safety, and the DON stated signage was required whenever O2 therapy was ordered or the concentrator was on.
A resident with embolism/thrombosis diagnoses and severe cognitive impairment was receiving rivaroxaban, but the anticoagulant bleeding-monitoring order was discontinued after hospital return and not restarted for about two days. The EHR showed the resident’s care plan called for each-shift monitoring for bleeding and other adverse effects, and the DON stated nursing staff were expected to follow hospital discharge orders and keep anticoagulant monitoring in place.
Failure to Post Actual Daily Staffing Hours: The facility posted projected DHPPD staffing information instead of the actual direct care staffing hours worked for public review. In the lobby, the Daily Nursing Shift Staffing sheet showed projected staffing, and the DON acknowledged that the posting did not allow residents, family members, or visitors to determine the actual hours worked for the prior day. The DON also reviewed the applicable regulation and the facility policy, which required recording the actual time worked for each nursing staff category.
Unsecured Ice Machine Allowed Improper Access and Handling: The facility failed to keep the ice machine secured and accessible only to staff. A family member was observed placing an empty pitcher inside the machine and scooping ice directly from the interior, while a dietary aide also collected ice from the same machine for kitchen use. The KS stated the machine had no door or lock and had been accessible to residents, visitors, and staff, and the DON stated ice is food and only staff were allowed to access it.
A resident with a midline catheter had a dressing that was left in place for 8 days instead of being changed per order and facility policy. The DON later stated she changed the dressing but documented the wrong date on the dressing and TAR. The IP and DON both stated weekly dressing changes and accurate documentation were required to help prevent catheter-related infections.
The facility did not monitor or document the temperature of the medication room and refrigerator on two consecutive days, as required by their policy. This lapse was discovered during an observation with the DON, who confirmed that LNs were responsible for this task. The medication room contained various over-the-counter drugs, while the refrigerator stored critical items like vaccines and insulin. The absence of temperature records could affect the effectiveness of these medications.
The facility failed to ensure that all staff completed mandatory annual in-service training for Abuse Prevention and Fall Prevention. 11 out of 28 staff members missed the Abuse Prevention training, and 16 out of 28 missed the Fall Prevention training. No remedial classes were offered, potentially leaving staff without the necessary knowledge to prevent abuse and falls among residents.
Two residents reported the west hall shower room as unclean and unsafe due to missing and stained tiles. Both residents, who were cognitively intact, expressed reluctance to use the shower. Maintenance and housekeeping staff acknowledged the issues, and the DON confirmed the shower's condition was not acceptable, posing potential risks.
Two residents in a LTC facility experienced safety risks due to malfunctioning wheel locks on their wheelchairs, which were not reported for repair. Despite protocols requiring staff to report such issues, the wheel locks remained loose, posing potential injury risks. The residents, both with significant medical histories, relied on their wheelchairs for mobility.
The facility failed to develop and implement comprehensive care plans for three residents, leading to potential health risks. A resident's care plan lacked interventions for a shoulder sling after a fall, another resident's plan did not address medication refusal, and a third resident was not supervised during meals despite needing assistance. These deficiencies were acknowledged by the Director of Nursing and other staff.
A resident with cognitive impairment and multiple medical conditions experienced an unwitnessed fall resulting in a left arm and shoulder injury. The resident reported being pushed, but the facility failed to investigate the allegation of abuse or report the incident to the California Department of Public Health (CDPH) and the Ombudsman office. The Licensed Vocational Nurse (LVN) and Director of Nursing (DON) did not complete or submit the required documentation, contrary to the facility's policy.
A resident with COPD repeatedly refused a prescribed inhaler, but the refusals were not documented, nor was the physician notified, as required by facility policy. This oversight was acknowledged by an LVN and confirmed by the DON, highlighting a failure to adhere to professional standards of practice.
The facility did not meet the required room size of at least 80 square feet per resident in 15 out of 16 rooms, with rooms measuring only 143 or 144 square feet for two residents each. Despite this, the report notes that residents had reasonable privacy and accessibility, and the waiver does not adversely affect their health and safety.
Failure to Update Care Plan After Dialysis Access Hospitalization
Penalty
Summary
The facility failed to revise Resident 11’s comprehensive care plan after a significant change in condition related to hospitalization for suspected infected dialysis access. Resident 11 was admitted with end stage renal disease and type 2 diabetes mellitus, and the MDS showed a BIMS score of 12, indicating moderate cognitive impairment. During the survey, staff confirmed the resident had been hospitalized after being sent from dialysis for possible dialysis catheter infection, and that the dialysis catheter was removed and replaced during the hospitalization while the resident received IV antibiotics. Review of the electronic health record did not reveal a care plan addressing the hospitalization, physician notification, follow-up care, or discharge planning after the resident returned to the facility. Surveyors also found no documentation of physician notification or an interdisciplinary team meeting related to the resident’s change in condition. Progress notes showed the resident’s RP notified the facility that the resident had been sent to the hospital by dialysis staff because of drainage from the dialysis catheter site, and the hospital discharge instructions identified cutaneous hypersensitivity, cellulitis at the port site, and a portacath line problem. During interviews, an LVN stated that when a resident experienced a change in condition, staff were expected to assess the resident, notify the physician, follow physician recommendations, notify the RP, document the event, initiate or create a care plan, and discuss the resident’s status in an IDT meeting. The DON stated that nursing staff were expected to follow up with the hospital, document the event, notify the physician, and care plan the hospitalization to support care planning upon the resident’s return. Facility policies also stated that care plans are revised when there has been a significant change in condition, that the nurse must notify the physician for a significant change or transfer to a hospital, and that a significant change requires interdisciplinary review and/or revision to the care plan.
Failure to Complete PASRR Level II Evaluation After Positive Level I Screen
Penalty
Summary
The facility failed to ensure that Resident 3 received a PASRR Level II evaluation after a PASRR Level I screening was positive for serious mental illness. During a concurrent interview and record review, the DON stated she was responsible for completing, reviewing, and following up on all PASRRs, and that all positive Level I PASRRs required a Level II evaluation. Resident 3 had a significant change in condition when she transferred to hospice services, and a Level I PASRR was completed that identified a positive screen for SMI and required a Level II screening by the designated state agency. Records reviewed for Resident 3 showed diagnoses including end stage renal disorder, bipolar disorder, anxiety disorder, and schizophrenia. The facility received a Notice of Attempted Evaluation stating the designated state agency could not reach the facility after two or more attempts to complete the Level II evaluation, and the case was closed without a completed individualized determination. The DON stated the facility did not follow policy and procedure because the Level II PASRR was not completed after the positive Level I result, and that Resident 3 was placed at risk for delayed treatment and identification of care or services.
Missing Oxygen Use Signage
Penalty
Summary
The facility failed to ensure professional standards of practice were followed for oxygen therapy for one resident. During an observation on 5/5/26 at 10:01 a.m., Resident 20 was lying in bed with the oxygen concentrator on at 5 LPM, and the nasal cannula was observed on the floor. During a concurrent observation and interview at 10:30 a.m., LVN 1 confirmed the resident had an order for oxygen therapy, the concentrator was on, and there was no signage indicating oxygen therapy was in use. LVN 1 stated all residents on oxygen therapy required oxygen therapy signage for safety and explained the signage notified residents, staff, and visitors to avoid flames and flammable material due to fire, injury, and hazard risk. During an interview on 5/8/26 at 12:06 p.m., the DON stated that when oxygen therapy was ordered or an oxygen concentrator was turned on, oxygen therapy signage was required to be posted. The DON stated the signage alerted residents, staff, and visitors to the use of oxygen and safety requirements to avoid smoking and open flames. Record review showed Resident 20 had an order for nasal cannula oxygen therapy since 4/22/26. The facility policy titled "Oxygen Administration" stated to place an "Oxygen in Use" sign on the outside of the room entrance door and in a designated place on or over the resident's bed. A professional reference also stated to post No Smoking and No Open Flames signs and turn off oxygen when not in use.
Failure to Maintain Anticoagulant Bleeding Monitoring After Readmission
Penalty
Summary
The facility failed to ensure monitoring for anticoagulant adverse effects remained in place for one resident receiving rivaroxaban 20 mg by mouth once daily after readmission. The resident had diagnoses including embolism and thrombosis of an unspecified artery and venous thrombosis and embolism, and the MDS assessment showed a BIMS score of 5, indicating severe cognitive impairment. During review of the electronic health record with the Infection Preventionist, it was found that the resident had no current monitoring in place for anticoagulant adverse effects even though the physician order for rivaroxaban remained active and the care plan included monitoring for medication side effects. The resident had been hospitalized and returned to the facility, and the anticoagulant side effect monitoring order was discontinued on 5/4/26 and not renewed or reordered until 5/6/26. Review of the MAR showed rivaroxaban was discontinued on 5/4/26 and restarted on 5/5/26, while monitoring for signs and symptoms of bleeding was not restarted until 5/6/26 at 11:00 p.m. The care plan directed staff to monitor each shift for adverse reactions and effectiveness, including signs of bleeding, bruising, blurred vision, shortness of breath, changes in appetite, and sudden changes in vital signs or mental status. The DON stated it was her expectation that nursing staff follow all hospital discharge orders upon readmission and that anticoagulant monitoring remain in place.
Failure to Post Actual Daily Staffing Hours
Penalty
Summary
The facility failed to post actual direct care staffing hours worked for public review for 21 of 21 residents, instead posting projected DHPPD staffing information. During an observation in the facility lobby, the publicly posted Daily Nursing Shift Staffing sheet dated 5/6/26 was reviewed and identified Projected DHPPD of 4.2 at the bottom of the posting. During interviews with the DON, she stated she was responsible for posting the daily DHPPD staffing sheet each day and that the facility used the staff schedule and daily census to determine staffing needs. She also stated the staffing posting was completed in the morning and again before leaving for the day, but acknowledged that a resident, family member, or visitor reviewing the sheet would not be able to determine the actual hours worked for the prior day because the facility did not post actual hours worked. The DON reviewed Appendix PP, Tag F732, and verbalized understanding that the regulation required posting actual hours worked rather than projected staffing hours. The facility policy titled Posting Direct Care Daily Staffing Numbers stated that shift staffing information recorded on the form shall include the actual time worked during that shift for each category and type of nursing staff.
Unsecured Ice Machine Allowed Improper Access and Handling
Penalty
Summary
The facility failed to ensure food was stored, handled, and served in accordance with professional standards for food service safety when the ice machine was left unsecured and accessible to residents, visitors, and staff. During observation, the ice machine was seen in a closet with no door, no lock, and no signage, with a designated ice scoop on the wall beside it. A family member was observed exiting a resident’s room with an empty water pitcher, opening the ice machine, placing the pitcher inside, and scooping ice directly from the interior of the machine into the pitcher before returning to the room. A dietary aide was later observed collecting ice from the same machine for kitchen preparation tasks, and stated the machine had no lock or door and had always been located in the open closet area. The kitchen supervisor stated the ice machine was accessible to all residents, visitors, and staff, that family members had been observed accessing it improperly, and that only facility staff were expected and allowed to access it. The DON stated ice was food and that only staff were allowed to access the ice machine, but the facility had no barriers in place to prevent unauthorized access. The facility policy titled Ice Procedures stated ice is to be handled properly to prevent infection.
Midline catheter dressing not changed on schedule and inaccurately documented
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for one resident with a midline catheter. Resident 30’s midline catheter dressing was observed on 5/5/26 dated 4/27/26, showing it had not been changed for eight days. A record review the same day showed the TAR had no documented midline catheter dressing changes since admission. The resident’s OSR indicated the order for the midline dressing change was every 7 days and as needed if soiled or dislodged. On 5/6/26, the resident’s midline catheter dressing was observed dated 5/4/26, and the TAR documented a dressing change on 5/4/26. During interview, the DON stated she changed the dressing on 5/5/26 but documented the incorrect date of 5/4/26 on both the dressing and the TAR. The DON stated only RNs changed midline catheter dressings in the facility, that the dressing was required to be changed every 7 days per physician orders and facility policy, and that accurate labeling and documentation were important to show when the next dressing change was due. The facility policy titled Midline Dressing Changes stated the purpose was to prevent catheter-related infections and required the dressing change every 5-7 days, with the date and time of the change recorded in the resident’s medical record.
Failure to Monitor Medication Storage Temperatures
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Medication Storage in the Facility' by not monitoring and documenting the temperature of the medication room and medication refrigerator on 9/8/24 and 9/9/24. This oversight was identified during an observation and interview with the Director of Nursing (DON) on 9/10/24. The medication room contained various over-the-counter medications, while the medication refrigerator stored critical items such as a vial of pneumovax vaccine, tuberculin tests, regular insulin vials, insulin glargine pens, and an emergency kit with insulins. The absence of temperature documentation for these dates was confirmed by reviewing the facility's temperature logs, which showed blank entries for the specified days. The DON acknowledged that the medications could lose their effectiveness if stored at incorrect temperatures, emphasizing that Licensed Nurses (LNs) were responsible for checking and documenting the temperatures. The facility's policy required medications stored at room temperature to be kept between 59 and 86 degrees Fahrenheit, and those requiring refrigeration to be maintained between 36 and 46 degrees Fahrenheit. The failure to document the temperatures as per the policy posed a potential risk to the effectiveness of the stored medications and biologicals.
Failure to Complete Mandatory Abuse and Fall Prevention Training
Penalty
Summary
The facility failed to ensure that all staff, including Licensed Nurses (LNs), Certified Nursing Assistants (CNAs), and ancillary support staff, received and demonstrated competency in preventing and recognizing resident abuse and in caring for residents at high risk for falls. Specifically, 11 out of 28 staff members did not attend the mandatory annual in-service training for Abuse Prevention, and 16 out of 28 staff members did not attend the mandatory annual in-service training for Fall Prevention. The Director of Staff Development (DSD) acknowledged that no remedial classes were offered for those who missed the initial sessions, which could result in staff lacking the necessary knowledge to prevent abuse and falls among residents. The facility's policy and procedure documents, as well as job descriptions for various staff roles, emphasize the importance of mandatory training in areas such as resident rights, abuse prevention, and fall prevention. Despite these requirements, the facility did not ensure compliance with its own policies, potentially placing residents at risk for unsafe and incompetent care. The Director of Nursing (DON) confirmed that these trainings are mandatory and should be completed annually by all relevant staff to ensure proper care for residents.
Facility Fails to Maintain Clean and Safe Shower Environment
Penalty
Summary
The facility failed to provide a clean, safe, and homelike environment for two residents, identified as Residents 16 and 22, due to the condition of the west hall shower room. The shower room was accessible for use despite having missing floor tiles and existing tiles that were black with yellow areas in the grout. This condition was observed during a survey, and both residents expressed their reluctance to use the shower due to its unclean state, opting instead to request access to another shower in a different hallway. Resident 16, who was admitted with serious medical conditions including metabolic encephalopathy, severe sepsis, and Fournier disease, was cognitively intact with a BIMS score of 13. Resident 22, also cognitively intact with a BIMS score of 15, had been admitted with a fracture of the left femur and other health issues. Both residents reported the shower's uncleanliness during interviews, indicating that the environment was not conducive to their comfort and safety. The maintenance staff acknowledged the age and condition of the shower tiles, noting that missing tiles could not be cleaned properly and posed an infection risk. The housekeeping supervisor confirmed that requests had been made to repair the tiles, and the Director of Nursing stated that the shower's condition was not acceptable, as it could cause injury and did not provide a homelike environment. The facility's job descriptions and policies emphasized the importance of maintaining a clean and safe environment, which was not upheld in this instance.
Failure to Maintain Safe Wheelchair Conditions for Residents
Penalty
Summary
The facility failed to maintain a safe environment for two residents, identified as Residents 20 and 22, due to malfunctioning wheel locks on their wheelchairs. Resident 20, who was admitted following joint replacement surgery and had a history of morbid obesity, hypertension, muscle weakness, and anxiety disorder, reported that the right wheel lock on her wheelchair had been loose for two weeks. Similarly, Resident 22, who had a history of a left femur fracture, hypertension, muscle weakness, and difficulty walking, reported that the left wheel lock on her wheelchair had been loose for several weeks. Both residents expressed concerns about the safety of their wheelchairs, which were essential for their mobility. During observations and interviews, it was confirmed by a Certified Nurse Assistant (CNA) and the Maintenance Supervisor (MAINS) that the wheel locks on both residents' wheelchairs were indeed loose and not functioning properly. The CNA acknowledged that loose wheel locks could increase the risk of injury, and the MAINS confirmed that such issues should be reported immediately for repair. However, there were no documented maintenance requests for the wheel locks of Residents 20 and 22, indicating a failure in the reporting process by the staff. The Director of Nursing (DON) stated that both licensed and unlicensed staff were responsible for reporting equipment issues, either through a maintenance log for non-emergent issues or directly to the maintenance supervisor for urgent matters. The facility's job descriptions and policies emphasized the importance of maintaining a safe environment and reporting equipment malfunctions. Despite these protocols, the staff failed to report the malfunctioning wheel locks, which could potentially lead to falls or injuries for the residents involved.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to potential health risks. Resident 1's care plan did not include interventions for the use of a left shoulder sling after an unwitnessed fall, which could have worsened her injury. Despite the presence of a sling and a diagnosis of a humeral fracture, there was no physician order or care plan intervention documented for its use. The Director of Nursing acknowledged that the care plan should have been resident-specific and that the facility did not follow its care planning policy. Resident 10's care plan was incomplete as it did not address her refusal of medications, specifically her Fluticasone-Salmeterol inhaler. The Licensed Vocational Nurse noted that there was no documentation of the physician being notified of the refusals, nor was there a care plan developed to manage this issue. The absence of a care plan for medication refusal could have led to a deterioration of Resident 10's Chronic Obstructive Pulmonary Disease. The facility also failed to implement the care plan for Resident 6, who required monitoring and assistance during meals due to dysphagia. Despite the care plan's recommendation for 1:1 feeding assistance, Resident 6 was observed eating without supervision, which could have led to choking or aspiration. The Infection Preventionist and the Director of Nursing confirmed that the care plan was not followed, which could have resulted in missed care and potential health decline for Resident 6.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse and report the results to the State Survey Agency within the required timeframe. This deficiency involved a resident who had an unwitnessed fall resulting in a left arm and shoulder injury. The resident, who had a history of cognitive impairment and multiple medical conditions, reported being pushed, which led to the injury. However, the facility did not complete an incident report or submit the necessary documentation to the California Department of Public Health (CDPH) and the Ombudsman office. The Licensed Vocational Nurse (LVN) on duty at the time of the incident did not recall completing the required incident report or submitting it to the appropriate authorities. The Director of Nursing (DON) also confirmed that there was no record of the incident being reported, and she did not believe it was a reportable incident. This lack of action was contrary to the facility's policy and procedure, which mandates that all reports of abuse or injuries of unknown sources be promptly reported and thoroughly investigated. The facility's policy requires that findings of abuse investigations be reported to the appropriate agencies within five working days. However, in this case, the facility did not adhere to its policy, potentially placing the resident and other vulnerable residents at increased risk of abuse. The failure to report and investigate the incident as per the policy highlights a significant deficiency in the facility's handling of such events.
Failure to Notify Physician of Medication Refusal
Penalty
Summary
The facility failed to meet professional standards of practice by not notifying the attending physician of a resident's ongoing refusal to take a prescribed inhaler medication, Fluticasone-Salmeterol, which is used to prevent inflammation and narrowing of the airway. The resident, who was admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Hypertension, Muscle Weakness, and Congestive Heart Failure, had a history of refusing the inhaler. Despite this, there was no documentation of the refusals in the Medication Administration Record (MAR) or any notification to the attending physician, as required by the facility's policy. The Licensed Vocational Nurse (LVN) acknowledged the lack of documentation and communication, stating that the inhaler should have been depleted if administered as ordered. The Director of Nursing (DON) confirmed that the facility's policy required nurses to document medication refusals and notify the physician after three or more refusals. The failure to follow these procedures could potentially lead to a worsening of the resident's COPD condition.
Facility Fails to Meet Room Size Requirements
Penalty
Summary
The facility failed to provide the minimum required square footage per resident in 15 out of 16 rooms during a survey conducted from 9/10/24 to 9/13/24. Specifically, rooms 2 through 16 did not meet the regulatory requirement of at least 80 square feet per resident in multiple occupancy rooms. Observations made on 9/12/24 at 4:33 p.m. during an environmental tour with the maintenance supervisor revealed that these rooms, housing two residents each, measured only 143 or 144 square feet, falling short of the required space. Despite these deficiencies, the report notes that variations were made according to the particular needs of the residents, and there was a reasonable amount of privacy, adequate storage, and accessibility for wheelchairs and toilet facilities. The report suggests that the waiver of the square footage requirement does not adversely affect the health and safety of the residents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Turlock
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brandel Manor | 0.8 mi | — | 0 | 0 |
| Main West Postacute Care | 0.9 mi | ★★★★★ | 1 | 0 |
| Covenant Village Care Center | 0.9 mi | ★★★★★ | 0 | 0 |
| Turlock Nursing And Rehabilitation Center | 1 mi | ★★★★★ | 24 | 0 |
| Ceres Postacute Care | 9.6 mi | ★★★★★ | 2 | 0 |
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