Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Tracy Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with chronic kidney disease and type 2 DM repeatedly refused skilled services, morning medications, blood draws, and participation in a care conference, and experienced significant weight loss over several weeks. Although the admission record identified a family member as the responsible party and care conference contact, staff did not notify this representative of the refusals of care, the request not to be disturbed, the significant weight loss, or the scheduled care conference, and did not invite the representative to participate. The DON acknowledged that the responsible party had the right to be informed of such changes, and facility policies required notification of the representative and involvement of family in person-centered care planning, but these policies were not followed.
A resident with multiple chronic conditions, including CKD stage 3B, asthma, post-stroke hemiplegia, HTN, PTSD, and type 2 DM, repeatedly refused skilled services, morning medications, a blood draw, and participation in a care conference. Despite these ongoing refusals, staff confirmed that no comprehensive, person-centered care plan was developed to address the refusals or to guide interventions to encourage acceptance of care and involvement in care planning. This was inconsistent with facility policies requiring the IDT to assess residents who refuse care, offer alternative treatments when appropriate, and create measurable, time-bound care plan objectives to direct daily care and prevent decline.
Staff failed to follow hand hygiene requirements for a resident on Enhanced Barrier Precautions (EBP) who had multiple infections, including UTI, E. coli, cellulitis, a stage 4 pressure ulcer, and C. perfringens. An EBP sign was posted at the room door, yet the DSD entered and exited the room to respond to a call light without performing hand hygiene. In a separate instance, a CNA handled a meal tray from the hallway cart, entered the room, assisted with meal preparation, then exited and returned to the meal cart without performing hand hygiene. Both staff later acknowledged the lapse, while the IP and DON confirmed that facility policy and standard precautions require hand hygiene before entering and after exiting rooms and after contact with the resident’s environment.
Food items were found in dry storage past their use-by dates and in spoiled condition, including sauces, spices, baking soda, onions, and potatoes. The kitchen also lacked an air gap or backflow prevention device for the food prep sink and 3-compartment sink, the low-temp dishwasher chlorine level tested below the level the FSD said was needed to sanitize dishes, and dietary staff were observed failing to perform proper hand hygiene after nose wiping and while moving through food prep areas with gloves on.
Incomplete Legionella Water Management Program: The facility failed to maintain a comprehensive water safety management program to reduce Legionella and other waterborne pathogens. The ADM acknowledged the water system lacked a flow chart or diagram, the MS could not produce water testing documentation and did not know the control limits, risk areas, or decontamination process, and the IP was not familiar with the water management program or aware of a completed risk assessment or control measures.
Failure to provide nail care and basic grooming for four residents was identified when a resident with Alzheimer’s disease and three residents with hemiplegia/hemiparesis were observed with long, jagged, soiled fingernails; one resident also had an odor from a clenched hand. A CNA confirmed the nails needed cleaning and trimming, the RP for one resident reported trimming the nails himself, and the DSD and DON stated nail care should be provided by staff during ADL care.
Unnecessary psychotropic medication use was identified for a resident who was receiving quetiapine 100 mg BID and had a schizophrenia diagnosis in the chart. The resident and RP said they did not know the basis for the diagnosis, the DON could not find supporting documentation, and the MHNP stated she did not know the resident well enough to confirm schizophrenia and would need to reassess for other causes of psychosis.
Incomplete PASRR Did Not Reflect Mental Health Diagnoses: A resident with documented bipolar disorder, anxiety disorder, major depressive disorder, and schizophrenia had a level I PASRR that did not include those diagnoses, and no level II PASRR was completed. Records also showed behavioral health care plans for anxiety, depression, and bipolar disorder, while the MDS Coordinator and DON confirmed the PASRR was incorrect and that schizophrenia was not captured.
PASRR Not Updated After New Schizophrenia Diagnosis: A resident’s PASRR remained a negative Level I screening even after a psychiatry note documented depression, anxiety, visual hallucinations, and a diagnosis of schizophrenia. The MDS later listed schizophrenia as an active diagnosis, and the DON stated the PASRR should have been updated when the new diagnosis was received so the resident could be evaluated for appropriate care and services.
Failure to monitor a resident after suicidal ideation was identified. The resident had Alzheimer’s disease, major depressive disorder, vascular dementia, and delusional disorders, and a behavioral health note documented visual hallucinations and suicidal thoughts with a specific plan. The DON confirmed there was no documented change of condition, no care plan update, and no record that staff monitored the resident for suicidal ideation, despite the facility policy requiring suicide threats to be reported, assessed, and communicated to the MD, RP, and staff.
Expired oral meds were found in a med cart, including Senokot labeled for one resident and Meclizine labeled for another resident. In the med room, a discontinued IV Daptomycin bag for a discharged resident was stored in the locked refrigerator, and expired Juven nutrition powder was kept in active storage. The DON and LNs acknowledged the items were expired or discontinued and should not have been stored with active meds.
Failure to post actual daily staffing hours on the DHPPD form. The DSD/IP and DON observed that the staffing sheet posted on the bulletin board did not include Actual Direct Care Service hours and had no staff signature. The DON confirmed the posted information did not show the actual staff-to-resident ratio for the day, and the facility policy required posting the actual time worked for RN, LPN/LVN, and CNA staff within two hours of each shift.
Shared resident bedrooms did not meet the required 80 sq. ft. per resident. The MS and ADM confirmed that several 3-resident rooms were below the minimum, with documented space per resident ranging from about 76.3 to 79.3 sq. ft. A CNA showed that beds and furniture had to be moved to provide care and transfers, including lift use and 2-person assists, while a resident stated the room size was not a concern.
A resident with multiple serious diagnoses and a documented Full Code status was found unresponsive and without vital signs. Despite clear documentation and the representative's wishes for full resuscitation, licensed staff did not initiate CPR or call a Code Blue, and no life-saving measures were attempted prior to hospice arrival. Staff interviews confirmed a lack of protocol adherence and understanding, and the facility's policy requiring basic life support in the absence of a DNR order was not followed.
The facility failed to honor the end-of-life preferences for three residents by not verifying or obtaining Advance Directives upon admission. For two residents, the facility did not determine if they had or wished to formulate an Advance Directive, and for another resident, the facility did not have a copy of the existing Advance Directive on file. Interviews with staff revealed a lack of adherence to policies and procedures regarding Advance Directives and POLST forms.
A resident was admitted with incorrect discharging documents from an acute hospital, leading to significant medication errors for three days. The facility staff failed to thoroughly check the interfacility transfer documents, resulting in the resident receiving medications not prescribed for them. The error was discovered during an unannounced survey after the acute hospital reported the mistake.
A resident with an amputation and Type 2 diabetes was not provided with a prosthetic leg despite being motivated and having an order for evaluation. The facility failed to document and follow up on the prosthetic evaluation, leaving the resident without the necessary adaptive device. The facility's policy on evaluating and accommodating residents' needs was not adhered to, as acknowledged by the DON and Administrator.
A resident was unable to store personal belongings due to inadequate space and previous resident's items left in drawers. Staff confirmed the issue, and the DON acknowledged it was against policy, impacting the homelike environment.
A resident with an indwelling catheter did not have a specific care plan developed upon admission, despite having diagnoses that required catheter care. The facility's procedures and policies were not followed, as confirmed by interviews with staff, including the DON, who acknowledged the oversight.
A resident did not receive scheduled showers over a nine-day period, as confirmed by the facility's Director of Staff Development and Director of Nursing. The resident, with a history of diabetes and heart disease, was supposed to receive showers twice a week, but documentation showed missed showers. This failure to provide basic hygiene care was against the facility's policy, which emphasizes the importance of bathing for cleanliness and skin assessment.
A resident was administered incorrect medications and care for three days due to an error in interfacility transfer documents, which had a different name despite correct stickers. The error was discovered when the acute hospital contacted the facility. Staff interviews revealed reliance on stickers without verifying document names, leading to the deficiency.
A resident with multiple diagnoses, including a history of falls and disorientation, was found outside the facility due to inadequate supervision and failure to implement care-planned interventions. The care plan required a wheelchair alarm and bed alarm checks, which were not fully executed. The facility's policy emphasized individualized safety measures, but these were not effectively applied, leading to the resident's unsupervised wandering.
A resident's IV saline lock was not managed according to professional standards, with the dressing undated, no care plan, and lack of documentation for site care and flushing. The IV was left in place for eight days, exceeding the recommended duration, despite the resident having a PICC line in place.
A facility failed to properly handle controlled medications for a deceased resident. After the resident's death, controlled medications were not removed from the medication cart or counted at shift change by the LNs. The facility's policies require that controlled medications be counted by two LNs at each shift change and stored securely until destruction. The DON confirmed that these procedures were not followed, which could have led to medication errors or diversion.
A resident experienced dental pain for two months without receiving recommended dental services, including a full mouth x-ray for a broken tooth. Despite reporting the issue to staff, no follow-up care was provided. The facility lacked a system to ensure follow-up on treatment recommendations, leading to a significant delay in addressing the resident's dental needs.
A resident with a left leg amputation and Type 2 diabetes was waiting for a prosthetic leg for a year due to missing evaluation notes in her medical record. Despite being highly motivated and having an order for a prosthetic evaluation, the facility failed to obtain and include the necessary documentation. Interviews with staff confirmed the absence of these notes, which were crucial for medical providers to review recommendations. The facility's policy on documentation was not followed, as acknowledged by the DON and Administrator.
The facility failed to maintain infection control measures when a CNA entered a Contact Isolation Precautions room without PPE and did not perform hand hygiene. Additionally, clean water pitchers were distributed from a cart with dirty items, risking cross-contamination. A resident's urinary catheter bag was found on the floor, contrary to policy, posing an infection risk. These actions did not adhere to the facility's infection control policies.
The facility did not meet the minimum space requirement of 80 square feet per resident in seven shared rooms, affecting rooms 1, 3, 5, 6, 8, 10, and 11. Despite this, staff and residents reported no complaints about room sizes, and the Department recommended continuing the room size waiver.
Failure to Notify Responsible Party of Significant Changes and Care Refusals
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party (RP) of significant changes in the resident’s condition and refusals of care, despite the RP being identified in the admission record as the contact person for care conferences. The resident was admitted with chronic kidney disease stage 3B and type 2 diabetes mellitus, and the care plan indicated a preference for having family involved in discussions about care. The resident’s physical therapy evaluation documented refusal of any skilled services and identified a risk for falls. Progress notes showed that over a period of several weeks the resident repeatedly refused morning medications, requested not to be disturbed for care, refused a blood draw, and refused to attend a care conference. The interdisciplinary team also discussed the resident’s significant weight loss during this time. During interviews, a licensed nurse confirmed that the RP was not notified of the resident’s refusals of prescribed morning medications, refusal of a blood draw, request not to be disturbed, refusal to participate in a care conference, or the significant weight loss, and that the RP was not invited to the care conference. The DON stated that the RP had the right to be informed of changes in the resident’s condition, such as significant weight loss or refusal of care or treatment, and acknowledged that the RP was not given the opportunity to participate in care planning and decision-making. Review of facility policies showed requirements to inform the resident/representative regarding refusal or discontinuation of treatment, to notify the physician and RP of significant weight changes, and to develop a comprehensive person-centered care plan in conjunction with the resident and family or legal representative. These documented policies were not followed in this case.
Failure to Care Plan for Ongoing Refusals of Care and Treatment
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address one resident's repeated refusals of care, treatment, and participation in a care conference. The resident was admitted with multiple significant diagnoses, including chronic kidney disease stage 3B, asthma, hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, essential hypertension, PTSD, and type 2 diabetes mellitus. A PT evaluation dated 11/25/25 documented that the patient was refusing any skilled services and identified a risk for falls due to physical impairments and functional deficits. Progress notes from 11/25/25 through 12/20/25 showed ongoing refusals of morning medications, a request not to be disturbed, refusal of a blood draw, and refusal to participate in a care conference. During interviews and concurrent record reviews, an LN confirmed that these refusals required a care plan with effective interventions to encourage acceptance of care, treatment, and participation in care planning, but acknowledged that no such care plan existed for this resident. The DON stated that nursing staff were expected to assess residents who refused care and treatment and initiate a care plan to address refusals and implement appropriate interventions to prevent potential health decline. Facility policies on refusing care and on comprehensive, person-centered care plans required the interdisciplinary team to assess needs, offer alternative treatments when appropriate, and develop measurable objectives and timetables to meet residents' physical, psychosocial, and functional needs, with care plans used to guide daily care routines. Despite these policies, the resident's refusals were not incorporated into a written care plan, which, according to staff, placed the resident at risk for worsening underlying conditions, overall health decline, and preventable complications.
Failure to Perform Hand Hygiene for Resident on Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently performed hand hygiene as part of its infection prevention and control program for a resident on Enhanced Barrier Precautions (EBP). The resident had multiple serious infections and conditions, including a urinary tract infection, unspecified Escherichia coli as the cause of disease, cellulitis of the buttock, local skin and subcutaneous tissue infection, resistance to multiple antimicrobial drugs, a stage 4 pressure ulcer of the right buttock, and Clostridium perfringens as the cause of disease. An EBP sign was posted outside the resident’s room. During observation, the Director of Staff Development (DSD) entered the resident’s room in response to a call light without performing hand hygiene, turned off the call light, and exited the room without performing hand hygiene. The DSD acknowledged not performing hand hygiene upon exiting the EBP room and stated that hand hygiene was supposed to be performed to prevent the spread of infections in the facility. In a separate observation, a Certified Nurse Assistant (CNA) picked up a meal tray from the meal cart in the hallway, entered the same resident’s room, delivered the tray, placed it on the over-bed table, and assisted with meal preparation, then exited the room and approached the meal cart without performing hand hygiene. The CNA stated she forgot to perform hand hygiene after exiting the room and before handling another resident’s meal tray, and acknowledged that this failure placed other residents at risk for infection. The Infection Prevention Nurse stated that staff were required to perform hand hygiene before entering and after exiting a resident’s room and before and after performing any task for residents, and that failure to do so placed other residents at risk for infection. The DON stated that staff were required to perform hand hygiene as part of standard precautions to break the infection cycle and prevent the spread of infection. Facility policies on Enhanced Barrier Precautions and Infection Control Guidelines for All Nursing Procedures required visual alerts for high-contact care and hand hygiene after contact with objects in the immediate vicinity of the resident.
Food Storage, Sink Backflow, Dish Sanitizing, and Hand Hygiene Deficiencies
Penalty
Summary
Food items were stored in the dry storage pantry past their use-by dates and in spoiled condition. During observation, the Food Service Director confirmed a bottle of Worcestershire sauce, several spice containers, and a box of baking soda were available for use beyond their dated shelf life. The same observation also identified a soft, discolored onion and potatoes that were spongy and sprouted. The Food Service Director stated these items should not be available for use beyond their use-by dates and confirmed spoiled food items should not be kept in the storage area. The kitchen sinks did not have an air gap or backflow prevention device in use for the food prep sink or the three-compartment sink. During the observation, the Maintenance Supervisor confirmed the absence of these devices, and the Maintenance Consultant stated the purpose of a backflow prevention system was to prevent contaminated water from backing up into the clean sinks. The Registered Dietitian stated the lack of an air gap or backflow device under the kitchen sinks had the potential for contamination of food and dishes that could have led to food borne illnesses. The low-temperature dishwasher was not sanitizing dishes at the proper chlorine level, and dietary staff did not consistently perform hand hygiene. One dietary staff member tested the dishwasher and the chlorine level measured 25 ppm, while the Food Service Director stated it should be 100 ppm to sanitize dishes. In separate observations, one dietary staff member wiped her nose, left and returned to the kitchen still holding a tissue, then disposed of it and went to the steam table without washing hands, and another staff member wore gloves into the food storage closet and back into the kitchen before touching a food prep cart until instructed to perform hand hygiene. The Registered Dietitian stated staff were expected to wash hands after blowing their noses or touching anything that could contaminate their hands.
Incomplete Legionella Water Management Program
Penalty
Summary
The facility failed to implement a comprehensive water safety management program based on nationally accepted standards to minimize the risk of Legionella and other waterborne pathogens for a census of 52 residents. Surveyors found that the facility did not complete and document a facility-wide assessment of potential Legionella growth areas, did not include a flow chart or diagram of the water distribution system, did not implement adequate control measures, did not establish sufficient monitoring protocols, and did not create an intervention plan for when control limits were not met. During interviews and record review, the Administrator stated the facility managed its own water system and acknowledged the current water management plan lacked a flow chart or diagram showing water distribution throughout the building. The Maintenance Supervisor stated he checked water temperatures and tested for Legionella annually, but could not produce documentation of water testing, did not have a flow chart or diagram, lacked knowledge of control limits and measures, and was unaware of other risk areas. The Infection Preventionist stated she was not highly familiar with the facility’s water management, relied on the Maintenance Supervisor for testing and maintenance, and was unaware whether a facility risk assessment or control measures had been completed. Review of the facility policy titled Legionella Water Management Program showed requirements for identifying areas that could encourage Legionella growth, a diagram of where control measures are applied, a system to monitor control limits and effectiveness, and a plan for when control limits are not met.
Failure to Provide Nail Care and Basic Grooming
Penalty
Summary
The facility failed to ensure basic grooming needs were met for four sampled residents who were unable to perform activities of daily living independently. Resident 3, who had Alzheimer’s disease, was observed with long fingernails and brown material underneath the nails. Resident 3 stated she preferred her fingernails to be clean and short and said she no longer had nail clippers and relied on staff to trim her nails. A CNA confirmed Resident 3’s nails needed to be cleaned and trimmed and stated they should not have been soiled and should have been cared for when the resident received a shower or bed bath. Resident 9, who had hemiplegia and hemiparesis affecting the left side, was observed with long, jagged fingernails and a dark brown substance underneath them. Resident 9 stated he did not know when his fingernails were last cleaned and trimmed. Resident 42, who also had hemiplegia and hemiparesis affecting the left side, was observed with long, jagged fingernails with dark material underneath. Her RP stated he trimmed her fingernails when he visited and noticed they were long and dirty, and he was not aware facility staff trimmed fingernails. During a later observation, the DSD confirmed Resident 42 had long, soiled fingernails and an odor from her clenched right hand, and stated her hands should be washed and dried daily to prevent infection. Resident 53, who had hemiplegia and hemiparesis affecting the right dominant side, stated she had asked staff to trim her fingernails and they did not. She was observed with long, jagged fingernails and dark brown material underneath the nails. Resident 53 stated she preferred her nails to be short and clean and said it was unsanitary to have long, dirty fingernails. A CNA confirmed Resident 53 needed her nails cleaned and trimmed and stated the nails should have been cared for when she received a shower or bed bath. The DSD stated every CNA should have been able to trim residents’ fingernails, that fingernails should have been trimmed whenever they appeared soiled, and that long nails could scratch residents and cause an open area that could lead to infection. The DON stated nail care was expected to be performed by the appropriate staff when residents received showers.
Unnecessary Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure one of twenty sampled residents was free from unnecessary psychotropic medication use. Resident 9, who was originally admitted in mid-2017, had a BIMS score of 14 on 11/10/25 and told the surveyor on 12/5/25 that he did not have any mental illness diagnoses and was not prescribed any psychotropic medications. His RP also stated he did not know where the schizophrenia diagnosis came from and was unsure whether the resident’s hallucinations were related to dehydration or another medical condition. The resident’s record showed active diagnoses over time including psychiatric/mood disorder, anxiety disorder, depression, psychotic disorder, and later schizophrenia. A psychiatry follow-up note dated 6/3/21 documented depression, anxiety, visual hallucinations, and a diagnosis of schizophrenia, unspecified. The MAR for 11/1/25 through 11/30/25 showed quetiapine fumarate 100 mg twice daily and monitoring for visual hallucinations, with one episode documented on 11/22/25 and no other hallucinations recorded that month. The current MHNP stated she had seen the resident twice, did not know him well enough to determine whether he met criteria for schizophrenia, and would need to reassess him to rule out other causes of psychosis. The DON stated she could not find documentation in the record supporting the schizophrenia diagnosis, and the physician stated he was not sure who determined that diagnosis.
Incomplete PASRR Did Not Reflect Mental Health Diagnoses
Penalty
Summary
The facility failed to accurately complete PASRR for one sampled resident, Resident 8, whose level I PASRR did not reflect documented diagnoses of bipolar disorder, anxiety disorder, major depressive disorder, and schizophrenia. The report states that this resulted in a level II PASRR never being completed, despite the resident having mental health diagnoses that were documented in the record. Resident 8’s admission record showed diagnoses including bipolar disorder, major depressive disorder, and anxiety disorder. Additional records reviewed included a hospital history and physical noting bipolar disorder, schizophrenia, seizure disorder, and cerebral palsy, as well as emergency department documentation describing the resident as having cerebral palsy, bipolar disorder, and seizure disorder with altered mental status. A hospice document also listed schizophrenia and bipolar disorder among the resident’s past medical history. The resident’s care plans reflected behavioral health concerns, including anxiety, depression, and bipolar disorder, with interventions such as monitoring mood, suicidal thinking, and medication administration. During interview and record review, the MDS Coordinator confirmed the PASRR should have captured all active diagnoses and stated the schizophrenia diagnosis was not captured. The DON also confirmed the PASRR was wrong and stated the IDT should have reviewed it, noticed it was incorrect, and resubmitted it.
PASRR Not Updated After New Schizophrenia Diagnosis
Penalty
Summary
The facility failed to ensure that Resident 9’s PASRR was updated after a significant change in mental illness diagnosis. Resident 9 was originally admitted in mid-2017, and the MDS dated 2/8/21 listed psychiatric/mood disorder, anxiety disorder, depression, and psychotic disorder. A PASRR Level I Screening Document dated 5/3/21 showed a negative Level I result with case status closed and reason code indicating no mental illness. A psychiatry follow-up note dated 6/3/21 documented that Resident 9 reported depression, anxiety, and visual hallucinations, and the diagnosis was schizophrenia, unspecified. The MDS dated 11/24/21 then listed schizophrenia among the active diagnoses. During interview, the DON stated the PASRR should have been updated when the schizophrenia diagnosis was received so residents could be evaluated for the appropriate care and services. The facility policy stated that residents with newly evident or possible serious mental disorder are to be referred promptly for a Level II resident review upon a significant change in status assessment.
Failure to Monitor Resident After Suicidal Ideation
Penalty
Summary
The facility failed to provide services that met professional standards of quality care for one resident who expressed suicidal ideation and did not have interventions put in place to monitor psychosocial needs. The resident was admitted in 2019 with diagnoses including Alzheimer's disease, major depressive disorder, vascular dementia, and delusional disorders. A behavioral health document dated 6/12/25 stated the resident reported visual hallucinations and suicidal ideation with a specific plan to stab herself and jump off a bridge, and noted that the facility had initiated a safety plan including increased monitoring and environmental precautions. A progress note dated 6/13/25 documented that psychiatry recommended increasing the psychiatric medication for dementia, and another note the same day stated nursing contacted the responsible party to increase the medication and was awaiting consent. During interview and record review, the DON stated that if staff were aware of the resident's suicidal ideation, a change of condition should have been documented, an IDT meeting held, the resident's needs determined, the care plan updated, social services should have followed up for 72 hours, and continual staff monitoring should have been assigned if indicated. The DON confirmed there was no change of condition documented, the care plans were not updated, and there was no documentation in the clinical record showing staff monitored the resident for suicidal ideation during the month of 6/25. The facility policy titled Suicide Threats stated resident suicide threats shall be taken seriously, reported immediately to the Nurse Supervisor/Charge Nurse, assessed in more detail, and communicated to the attending physician, responsible party, and staff involved in care.
Expired and Discontinued Medications Stored in Medication Cart, Refrigerator, and Medication Room
Penalty
Summary
Expired medications were found stored in medication cart 2 during a concurrent observation and interview with LN 1. Two bottles of Senokot 8.6 mg labeled for Resident 35 had an expiration date of 7/31/2025, and one bottle of Meclizine 25 mg labeled for Resident 33 had an expiration date of 8/30/2025. LN 1 confirmed the medications were expired and stated expired medications should not be left in the medication cart because they could lose effectiveness. Expired and discontinued items were also found in the main medication room and refrigerator during a concurrent observation and interview with LN 2. A discontinued IV Daptomycin 700 mg/NS 50 mL bag for discharged Resident 99 was stored in the locked refrigerator, and three boxes of Juven therapeutic nutrition powder had expiration dates of 8/25, 5/25, and 9/25. LN 2 acknowledged the IV antibiotic was stored in the refrigerator and stated she was unsure how long it remained good after being reconstituted by the pharmacy. The DON later confirmed Resident 99's IV Daptomycin expired on 11/8/25 at 4:25 p.m. and that the resident had been discharged from the facility. The DON stated discharged residents' medications should not remain in the medication refrigerator and acknowledged the Juven boxes were expired and should not have been kept in the medication room. Facility policy stated outdated, contaminated, or deteriorated medications and biologicals are to be immediately removed from stock and disposed of according to medication disposal procedures.
Failure to Post Actual Daily Staffing Hours
Penalty
Summary
The facility failed to post the total actual staffing hours worked Per Patient Day (PPD) on the daily staffing information displayed for residents, visitors, and families. During a concurrent observation and interview on 12/4/25 at 11:43 a.m. with the DSD/IP, the facility's posted document titled, Census and Direct Care Services Hours Per Patient Day (DHPPD), was observed on the staff bulletin board without Actual Direct Care Service hours and without a staff signature. The DSD/IP stated she completed the actual direct care services hours on the DHPPD form either on the following work day during the day shift or before leaving the facility at 4:30 p.m. During a concurrent interview and observation on 12/5/25 at 08:11 a.m. with the DON, the DON confirmed the posted DHPPD on the bulletin board did not include actual direct care service hours. The DON stated the facility should have visibly posted the actual PPD so visitors and residents could see the facility's actual staff-to-resident ratio for the day, and stated that when actual PPD hours were entered late or on the following day, the facility may have had inaccurate data posted. The facility policy titled, Posting Direct Care Daily Staffing Numbers, dated 7/16, stated that within two hours of the beginning of each shift, the number of licensed and unlicensed nursing personnel directly responsible for resident care would be posted in a prominent location and that the information recorded would include the actual time worked during that shift for each category and type of nursing staff.
Shared Resident Bedrooms Did Not Meet Minimum Space Requirements
Penalty
Summary
The facility failed to ensure that seven shared resident bedrooms met the minimum space requirement of 80 square feet per resident. During observation and interview, the Maintenance Supervisor confirmed that several shared rooms did not meet the required square footage, and room measurements were taken with a tape measure. The Administrator also reviewed the Client Accommodation Analysis and confirmed the documented room measurements for the affected resident rooms. The report identified shared bedrooms 1, 3, 5, 6, 8, 10, and 11 as not meeting the minimum space requirement, with three residents occupying each room. The documented measurements showed that the rooms provided between 76.3 and 79.3 square feet per resident, below the required 80 square feet. During observation, a CNA demonstrated that beds, bedside tables, and nightstands had to be moved to provide care, including use of a lift machine and two-person transfers, and stated the rooms were tight but usable. A resident interviewed stated there was no concern with room size and that staff had enough space for ADL care and equipment.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
Licensed staff failed to provide basic life support, including CPR, to a resident who was found unresponsive and without vital signs. The resident had a documented code status of Full Code, as indicated in the medical record, hospice documentation, and a POLST form signed by the resident's representative. Despite this, when the resident was discovered unresponsive, nursing staff did not initiate CPR or call a Code Blue, and no resuscitation efforts were made prior to the arrival of hospice personnel, who subsequently pronounced the resident deceased. The resident had multiple significant diagnoses, including chronic obstructive pulmonary disease, dementia, hypertensive heart disease with heart failure, and was under hospice care. The code status was discussed and confirmed with the resident's representative, who wished for all life-saving interventions to be performed. The facility's own policy required staff to provide basic life support in the absence of a valid DNR order, and the staff were aware of the resident's Full Code status. Interviews with the Director of Staff Development, a licensed nurse, and certified nursing assistants confirmed that no CPR was attempted, and the facility's emergency response protocol was not followed. Staff interviews revealed a lack of clarity and adherence to protocol, with the nurse on duty stating she did not know the facility's procedures and had concerns about reviving the resident. The Director of Nursing confirmed that the facility's policy was not followed and that the decision to perform CPR was not up to the nursing staff, as the representative's wishes were clearly documented. The failure to initiate CPR resulted in the resident's representative's wishes not being honored and potentially contributed to the resident's death.
Failure to Honor Residents' End-of-Life Preferences
Penalty
Summary
The facility failed to ensure that the preferences for end-of-life or emergency care were honored for three residents. For Resident 43, the facility did not determine upon admission whether the resident had an Advance Directive or wished to formulate one. The clinical records, including the Physician Orders for Life-Sustaining Treatment (POLST), did not indicate if an Advance Directive was discussed or if the resident had the capacity to make decisions. Interviews with the Director of Nursing (DON) and Medical Records staff revealed that the facility did not verify or obtain a copy of an Advance Directive for Resident 43. Similarly, for Resident 49, the facility did not ascertain if the resident had an Advance Directive or wished to create one during the admission process. The POLST form did not reflect any discussion about an Advance Directive. Interviews with the Social Services Director and the DON confirmed that the facility did not explain or assist the resident in formulating an Advance Directive. The Medical Records staff acknowledged the absence of an Advance Directive on file for Resident 49. For Resident 12, although the clinical record indicated the presence of an Advance Directive, the facility failed to have a copy available. The Preferred Intensity of Care form noted that a copy should be attached, but it was not. Interviews with the Licensed Nurse, Social Services Director, and Medical Records staff confirmed that the facility did not follow up to obtain a copy of the Advance Directive, despite being informed by the resident's responsible party that it had been provided. The facility's policies and procedures were not adhered to, as acknowledged by the DON and the Administrator.
Medication Error Due to Incorrect Transfer Documents
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when they were admitted with incorrect discharging documents from an acute hospital. This error was not identified for three days, resulting in the resident receiving medications that were not prescribed for them. The error was discovered during an unannounced annual recertification survey after the acute hospital contacted the facility to report the mistake. The resident, who was admitted with diagnoses including the presence of a left artificial hip joint, diabetes mellitus, and heart disease, received medications intended for another patient. These medications included antibiotics, anticoagulants, blood pressure medications, and others not prescribed for the resident. The facility's staff, including the Admissions Coordinator and the Director of Nursing, confirmed that the interfacility transfer documents had the correct sticker with the resident's name but contained a different name in smaller print on each page. Interviews with facility staff revealed that the nursing staff did not thoroughly check the interfacility transfer documents, relying instead on the stickers attached to the documents. The facility's procedure required reconciliation of medication lists and communication with the attending physician, but these steps were not adequately followed, leading to the medication errors.
Failure to Follow Up on Prosthetic Leg Request
Penalty
Summary
The facility failed to meet the needs of a resident, identified as Resident 12, by not adequately following up on her request for a prosthetic leg. Resident 12, who has Type 2 diabetes and an amputation above the knee, expressed her desire to regain independence and mobility through the use of a prosthetic leg. Despite having an order for a prosthetic evaluation from her physician, the facility did not ensure the completion and documentation of this evaluation. Interviews with the Medical Director and Director of Rehab revealed that although referrals for a prosthetic evaluation were made, the evaluation notes were missing from Resident 12's clinical record, leaving the physician unaware of the recommendations. The Prosthetic Representative confirmed that Resident 12 was assessed for a prosthetic leg and was highly motivated to receive one, but the evaluation notes were not provided to the facility. The facility's policy on Quality of Life, which mandates the evaluation of residents' needs for adaptive devices, was not followed. The Director of Nursing and the Administrator acknowledged this oversight, admitting that the facility did not adhere to its policy and procedure, resulting in Resident 12's needs not being met.
Inadequate Storage Space for Resident's Belongings
Penalty
Summary
The facility failed to provide a homelike environment for Resident 55, as evidenced by the lack of adequate space for storing personal belongings. Upon admission in July 2024, Resident 55 was assigned to bed A, but the space allocated for personal items was insufficient. During an observation and interview, a family member expressed frustration over the narrow closet space and the inability to use the drawers, which were labeled with a previous resident's name and contained their belongings. This situation prevented Resident 55 from utilizing the space for personal items, compromising the homelike environment. Further observations and interviews with facility staff, including a CNA and LN, confirmed the presence of a discharged resident's name and belongings in the drawers meant for Resident 55. The staff acknowledged that the drawers should have been cleared and relabeled for the new resident. The DON stated that the facility's policy does not include labeling drawers with resident names and emphasized that all belongings should be removed upon discharge. The failure to adhere to these policies resulted in Resident 55 being unable to use the designated space for personal belongings, thus not ensuring a homelike environment.
Failure to Develop Care Plan for Catheter Care
Penalty
Summary
The facility failed to develop and implement a resident-specific care plan for Resident 317, who was admitted with diagnoses including a urinary tract infection and artificial openings of the urinary tract. The Minimum Data Set (MDS) assessment indicated that Resident 317 had an indwelling catheter, which required specific care. However, upon review, it was found that there was no care plan created for the use of the indwelling catheter, despite the Order Summary Report specifying catheter care every shift and monitoring for signs and symptoms of urinary tract infection. During interviews, both Licensed Nurse 8 and the Director of Nursing acknowledged the absence of a care plan for catheter care. The Director of Nursing stated that a care plan should have been created upon admission to ensure all necessary care was provided. The facility's procedures and policies emphasized the importance of a comprehensive, person-centered care plan to meet the resident's needs, which was not adhered to in this case.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to provide adequate care and services for activities of daily living (ADLs) for one resident, identified as Resident 22, by not ensuring that the resident received scheduled showers. Resident 22, who was admitted to the facility with diagnoses including the presence of a left artificial hip joint, diabetes mellitus, and heart disease, did not have documented evidence of receiving a shower from August 6 through August 15, 2024. This lapse was confirmed through interviews and record reviews with the Director of Staff Development (DSD) and the Director of Nursing (DON), who acknowledged the absence of shower documentation and confirmed that the showers were missed. The facility's policy on ADLs, revised in March 2018, mandates appropriate support and assistance with hygiene, including bathing, for residents unable to perform these tasks independently. The DSD and DON both emphasized the importance of showers for maintaining hygiene, preventing infections, and conducting thorough skin assessments. The lack of showers not only compromised Resident 22's hygiene but also potentially affected their psychosocial well-being, as noted by the DSD. The facility's failure to adhere to its own procedures for bathing and showering, as outlined in their policy, resulted in this deficiency.
Medication and Care Plan Error Due to Incorrect Transfer Documents
Penalty
Summary
The facility failed to ensure that correct medications were administered and the correct plan of care was followed for a resident due to an error in the interfacility transfer (IFT) documents. Upon admission, the resident was given incorrect medications and care for three days because the IFT documents from the acute hospital contained a different name, although a sticker with the resident's name was attached to each page. This discrepancy was not identified until the acute hospital contacted the facility three days after the resident's admission. The resident, who was admitted with diagnoses including the presence of a left artificial hip joint, diabetes mellitus, and heart disease, received medications that were not prescribed for her. These included antibiotics, anticoagulants, and medications for conditions such as high blood pressure and Alzheimer's disease. The error was discovered when the acute hospital called to inform the facility that the IFT documents did not belong to the resident. Interviews with facility staff, including the Admissions Coordinator, Director of Nursing, and Licensed Nurses, revealed that the error occurred because the staff relied on the stickers attached to the IFT documents without verifying the names on the documents themselves. The facility's procedure required reconciliation of medication lists and communication with the attending physician, but these steps were not adequately followed, leading to the administration of incorrect medications and care for the resident.
Failure to Implement Care-Planned Interventions and Supervision
Penalty
Summary
The facility failed to provide adequate supervision and implement care-planned interventions for a resident, identified as Resident 62, which led to a deficiency. Resident 62, who was admitted in the spring of 2024, had multiple diagnoses including benign prostatic hyperplasia, a history of falling, anxiety disorder, major depressive disorder, and disorientation. The resident was found on his knees in the facility's front parking lot, indicating a lapse in supervision and monitoring. The care plan for Resident 62 included the use of a wheelchair alarm and a bed alarm to alert staff if the resident attempted to get up unassisted, but these interventions were not fully implemented. Interviews and record reviews revealed that the facility did not have a physician's order for a wheelchair alarm for Resident 62, despite the care plan indicating its necessity. Additionally, the bed alarm checks were not documented during the night shift on a specific date, which was a part of the facility's protocol. The Director of Nursing (DON) confirmed the absence of a wheelchair alarm order and expressed concern over the missing documentation of bed alarm checks. The DON also acknowledged that Resident 62 was at risk for falls due to psychiatric diagnoses and unsteady gait, and that closer supervision was warranted. The facility's policy on safety and supervision emphasized individualized, resident-centered approaches to address safety and accident hazards. However, the failure to implement the care-planned interventions and adequately supervise Resident 62 resulted in the resident being found outside the facility, which could have been prevented with proper monitoring. The DON and Administrator admitted that Resident 62's behaviors, such as wandering and removing the mattress from the bed, required more vigilant supervision and possibly the use of a Wander Guard, which was not in place at the time of the incident.
Failure to Adhere to IV Therapy Protocols
Penalty
Summary
The facility failed to provide services consistent with professional standards of practice for a resident receiving parenteral medication. Specifically, the resident's peripheral IV saline lock dressing was not dated, and there was no care plan developed for the IV saline lock. Additionally, there was no documentation of IV site care and flushing in the resident's medical record, and the IV saline lock was left in place for eight days, exceeding the recommended duration of seven days. The resident, who was admitted in Spring 2024, had diagnoses including a wedge compression fracture, low back pain, and osteoarthritis. During an observation, it was noted that the IV saline lock in the resident's left hand was covered with a transparent dressing without a date or nurse's initials. The facility's policy required transparent dressings to be changed every seven days and labeled with the date and nurse's initials. The Director of Staff Development confirmed the lack of documentation and adherence to policy, and the Director of Nursing stated that the policy should have been followed.
Failure to Properly Handle Controlled Medications for Deceased Resident
Penalty
Summary
The facility failed to ensure the proper handling and accounting of controlled medications for a deceased resident, identified as Resident 58. After the resident's death, the controlled medications, which included hydrocodone and lorazepam, were not removed from the medication cart, nor were they counted at shift change by the licensed nurses, LN 1 and LN 6. During an observation and interview, both nurses acknowledged that they forgot to count the controlled medications, which is a critical step to prevent medication errors or drug diversion. The facility's policies and procedures require that controlled medications be counted by two licensed nurses at each shift change and stored securely until they are destroyed or picked up by a hospice nurse. The Director of Nursing (DON) confirmed that the facility's policies and procedures were not followed in this instance. The policies stipulate that discontinued medications should be marked and stored in a designated secure area until they are destroyed. The DON stated that the controlled medications should have been given to her for destruction with the pharmacist, and that the ongoing and off-going nurses were responsible for counting the medications until they were properly disposed of. This oversight in following established protocols could have led to medication being administered incorrectly or diverted for unauthorized use.
Failure to Provide Recommended Dental Services
Penalty
Summary
The facility failed to ensure that a resident received recommended dental services, specifically a full mouth x-ray for a broken tooth identified months earlier. The resident, who experienced dental pain for about two months, reported the issue to multiple staff members but did not receive the necessary follow-up care. During interviews, the resident expressed frustration over not being heard and feeling neglected. The Social Services Director (SSD) confirmed that there were no referrals or notices for service from the nurses regarding the resident's complaint of tooth pain. The SSD also noted that the facility lacked a follow-up process for treatment recommendations, which contributed to the oversight. The Director of Nursing (DON) reviewed the resident's dental notes and confirmed the absence of follow-up orders for the recommended treatment. The DON acknowledged that the facility should have a system in place to ensure follow-up with outside dental services and that the four-month delay was excessive. The lack of follow-up posed a risk to the resident, as untreated dental issues could lead to further complications. The facility's policy on dental services indicated that routine and emergency dental services should be available to meet residents' oral health needs, but this was not adhered to in this case.
Missing Prosthetic Evaluation Notes in Resident's Medical Record
Penalty
Summary
The facility failed to ensure that copies of evaluations for a prosthetic leg were included in the medical records of a resident, identified as Resident 12. This deficiency was identified during a review of Resident 12's clinical records, which revealed that the resident had been waiting for a prosthetic leg for a year. Despite having an order for a prosthetic evaluation, the facility did not have access to the evaluation notes, which were crucial for medical providers to review recommendations regarding the prosthetic leg. Interviews with the Medical Director, Director of Rehab, and Licensed Nurse confirmed that the evaluation notes were missing from the clinical record, and attempts to obtain them from the prosthetic company were unsuccessful. Resident 12, who had a left leg amputation and a diagnosis of Type 2 diabetes, expressed a strong desire to receive a prosthetic leg to improve her mobility and independence. The Prosthetic Representative confirmed that Resident 12 was highly motivated to have a prosthetic leg and had been assessed multiple times the previous year. However, the representative did not provide the facility with copies of the evaluation notes, stating it was not her practice to do so. The facility's policy on documentation required such information to be included in the resident's medical record, but this policy was not followed, as acknowledged by the Director of Nursing and the Administrator.
Infection Control Deficiencies in PPE Use, Water Distribution, and Catheter Care
Penalty
Summary
The facility failed to maintain proper infection control measures in several instances. A Certified Nurse Assistant (CNA) entered a room designated for Contact Isolation Precautions without wearing the necessary personal protective equipment (PPE) and exited without performing hand hygiene. The CNA was unaware of the isolation status of the room, which was confirmed by a Licensed Nurse who informed the CNA of the requirement for PPE. The Director of Staff Development and the Director of Nursing confirmed that the facility's policy required PPE and hand hygiene for such rooms, but these protocols were not followed. Another deficiency was observed when a CNA distributed clean water pitchers from a cart that also contained dirty water pitchers, a dirty cup, and a partially eaten food tray. This practice posed a risk of cross-contamination, as acknowledged by the CNA and the Director of Staff Development. The Director of Nursing confirmed that the procedure for distributing clean water pitchers was not adhered to, which increased the risk of infection. Additionally, a resident's urinary catheter bag was found resting on the floor, contrary to the facility's policy that requires catheter bags to be kept off the floor to prevent contamination. Both a CNA and a Licensed Nurse confirmed the improper placement of the catheter bag, and the Infection Preventionist and Director of Nursing acknowledged the infection risk associated with the bag being on the floor. The facility's policy on urinary catheter care was not followed, leading to potential cross-contamination and infection risk.
Deficiency in Resident Room Size Requirements
Penalty
Summary
The facility failed to ensure that resident bedrooms met the minimum space requirement of at least 80 square feet per resident in seven shared rooms. This deficiency was identified during a recertification survey, where it was observed that rooms 1, 3, 5, 6, 8, 10, and 11, each housing three residents, did not meet the required space per resident. The room sizes ranged from 229 to 238 square feet, which is below the required 240 square feet for three residents. Interviews with the Administrator and Maintenance Director confirmed the measurements of these rooms. Despite the deficiency, interviews with staff and residents revealed that there were no complaints regarding the room sizes. Licensed nurses and the Director of Nursing stated that they had not received any complaints from residents about the room sizes affecting their ability to perform their duties safely. Residents interviewed expressed that they had enough space for their personal belongings and were comfortable, although one resident mentioned a preference for sharing the room with only one other resident. The Department recommended the continuation of the room size waiver for the affected rooms.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 517 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Tracy
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| North Park Post-acute | 0.7 mi | ★★★★★ | 30 | 0 |
| Guardian Care And Rehabilitation Center | 12.5 mi | ★★★★★ | 11 | 0 |
| Harvest Crossing Post Acute | 12.6 mi | ★★★★★ | 3 | 0 |
| Bethany Home Society San Joaquin County | 16.4 mi | ★★★★★ | 3 | 0 |
| Lincoln Square Post Acute Care | 16.6 mi | ★★★★★ | 24 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Tracy Nursing And Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.