Average — CMS composite of the measures below.
The next survey window likely opens around February 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 Turlock Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Food service staff were not trained to perform key kitchen tasks safely and effectively. A Maintenance Director cleaned the ice machine without sanitizing the ice bin and used methods that did not follow the facility logbook or manufacturer guidance, while a newly hired dietary employee could not correctly demonstrate thermometer calibration and placed the probe improperly in ice water. The RD, DSM, ADM, and Safety Maintenance Resource all stated both staff members needed more training and were not competent in these tasks.
Food storage and sanitation practices were not followed when a bin of thawing stew meat in the walk-in refrigerator was found without pull-out and use-by dates, despite facility policy requiring those labels. In addition, black and brown substances were observed inside the ice machine, and the DMS, DSMA, and RD confirmed the machine was not clean and should have been free of such contamination.
Infection Control Failures With PICC Care, Shared Equipment, Room Placement, and Commode Sanitation: A resident’s PICC dressing was left unchanged beyond the ordered interval and was later dressed so the insertion site was not visible, a dirty commode with urine and stool was left in a shared bathroom, a resident with MRSA was roomed with a roommate without MRSA, and staff reused a BP cuff, pulse ox, and glucometer between residents without proper cleaning/disinfection or required wet time. Staff and the DON acknowledged the infection control lapses and the facility policies called for routine line care, immediate cleaning of contaminated equipment, and disinfection between resident uses.
The facility failed to ensure psychotropic meds were supported by resident-specific NPIs and, for one resident, behavior monitoring and documented diagnoses. One resident with dementia, bipolar disorder, schizophrenia, anxiety, and depression received multiple psychotropic and antipsychotic meds without documented attempted NPIs; another resident received buspirone and escitalopram without specific NPIs; and a third resident received sertraline and lorazepam without NPIs, behavior monitoring, or documented anxiety/depression diagnoses.
A resident with severe cognitive and swallowing impairment had a steady, significant weight loss that licensed nurses did not assess with a change-of-condition SBAR, despite staff noting the decline and the DON stating the loss met the facility’s threshold for significant weight change. In a separate issue, another resident kept probiotic capsules and probiotic with fiber gummies at the bedside and self-administered them without a physician order, even though staff confirmed there were no orders and the self-administration assessment did not allow bedside meds.
Medication Error Rate Exceeded 5 Percent: An RN gave sevelamer before a resident’s meal, another RN used a cup instead of the manufacturer’s measuring stick for diclofenac gel, an LVN mixed crushed meds with whole meds and the resident chewed a gel capsule, and insulin aspart was given nearly 2 hours after a blood sugar check and after the meal. The DON stated the orders and manufacturer instructions were not followed.
A resident’s inhaler dispenser and insulin pen were found without complete labeling, and several discontinued medications remained in active medication and treatment carts for multiple residents, including controlled and topical medications that had already ended or been discontinued. Staff confirmed the items should not have remained with active medications. In addition, the medication refrigerator storing shingles vaccines was monitored only once daily instead of twice daily, and the DON stated the vaccine storage temperatures were not being monitored appropriately.
Pest Control Program Not Effective: Ants were observed on the nightstands of three residents, including one resident with diabetes and liver disease, one resident after spine surgery, and one resident with severe cognitive impairment. Staff and the DON stated ants should not be present in resident rooms, and work orders documented ants and spiders in rooms and ants in a room. The facility’s P&P required an effective pest control program to eradicate and contain common household pests, but ants were still found in resident rooms.
A resident with moderate cognitive impairment was found keeping OTC probiotic supplements in an unlocked bedside table and self-administering them without a physician order. Staff confirmed the supplements were not supposed to be at bedside, the resident was not assessed to keep meds there, and the DON stated the facility’s self-administration policy was not followed.
A resident with severe cognitive impairment received lunch 24 minutes after others in the dining room because his dining location was not updated on the meal ticket, causing him to watch others eat and then dine alone. In a separate incident, another resident gave his lunch tray to a different resident and staff did not verify trays or ensure all residents at the table were served at the same time, despite staff stating residents should be served together and the correct diet confirmed.
A resident with Stage 3 pressure ulcers to the coccyx and other pressure-related skin damage was observed sitting in a wheelchair without a cushion and without documented repositioning while up in the chair. The resident stated she could not reposition herself and depended on nursing staff, while staff confirmed the wheelchair cushion was missing and that she should have been repositioned every two hours and provided a gel cushion. The care plan listed frequent repositioning for the pressure ulcer, and the wound order required offloading and repositioning, but staff interviews and observations showed these interventions were not implemented as described.
A resident with a Stage 3 coccyx pressure ulcer, diabetes, CKD, morbid obesity, and other comorbidities was observed sitting in a wheelchair without a pressure-relieving cushion and on a folded blanket. The resident stated staff were not repositioning her while she sat for more than two to three hours at a time, and staff interviews confirmed she needed a gel cushion and repositioning every two hours to support wound healing and prevent worsening of the ulcer.
A resident who was cognitively intact and wanted to walk was not placed on an RNP after skilled OT discharge, despite therapy recommending a restorative transfer program and staff acknowledging the referral could have been missed. The resident had previously received restorative ambulation services with a FWW, but the current RNP list did not include her, and the DSD stated there was no order or referral received from therapy. The DON and DSD both stated the RNP should have been implemented to maintain functional mobility.
Inaccurate Daily Nurse Staffing Posting: The facility failed to post daily staffing information that clearly identified the actual number of RNs, LVNs, and CNAs providing direct care on each shift. The posted sheet grouped RN and LVN hours under licensed staff and CNA and RNA hours under unlicensed staff, and the SC, PR, and DON acknowledged that the form did not separately show the specific hours or counts for each staff type.
Incorrect Dulaglutide Dose Administered: An LVN gave a resident a 0.75 mg prefilled dulaglutide injector even though the MAR and physician order called for 1.5 mg weekly for DM2. The DON and LVN acknowledged the mismatch, and the pharmacy dispense record showed the lower-strength product was repeatedly supplied while the resident’s blood sugar stayed elevated and additional diabetes meds were later added.
Unsigned POLST in Resident Record: A resident’s POLST was signed by the resident but not by the physician, leaving the form incomplete and not valid per staff. The resident had been admitted after hospital surgery and had multiple diagnoses, including DM2, chronic pulmonary edema, HTN, atherosclerotic heart disease, and a pacemaker. Staff stated the POLST should have been completed shortly after admission, and the facility policy described a fully executed POLST as a legal physician order.
A resident returned from a hospital stay with multiple new wounds, a UTI requiring antibiotics, and was refusing further skin assessments, antibiotics, and a blood test. Facility staff documented these changes and refusals but did not notify the resident's family member, as required by policy. The family member only learned of the situation during a visit the next day, and the DON confirmed there was no documentation of notification.
A resident's 42-inch television, brought in by family and mounted in her room, was not documented on the personal belongings inventory and was not returned to her family upon discharge. The facility's policy requiring inventory and return of personal items was not followed, resulting in the family's loss of the television.
A facility failed to install bed rails for a resident as determined by the Bed Rails - Safety Assessment. The resident's bed lacked side rails or grab bars, despite the assessment indicating their necessity for enhanced mobility and fall prevention. The MDS RN confirmed the absence of bed rails and noted the lack of a corresponding physician's order and care plan interventions. The facility's policy required a side-rail safety assessment and care plan inclusion, which was not followed.
A resident's rights were violated when a CNA made an obscene gesture towards them, leading to the CNA's termination. Additionally, the facility failed to enforce its English-only policy, causing discomfort among residents who believed staff might be speaking about them in a non-English language. These incidents highlight the facility's failure to uphold resident rights and effective communication.
Two residents experienced delays in receiving prescribed pain medication, with one resident waiting up to three hours and another up to an hour. Both residents had physician orders for Norco, but the facility failed to administer it in a timely manner, contrary to their care plans and facility policy. The DON and MD acknowledged the excessive wait times.
A facility failed to assess a resident's ability to self-administer medications safely. An LVN left six oral medications on a resident's bedside table without confirming if they were taken. The resident, diagnosed with Alzheimer's and schizophrenia, was found with the medications unattended. The ADON confirmed the lack of an IDT assessment for self-administration, contrary to facility policy.
A resident with severe cognitive impairment was diagnosed with a UTI and prescribed antibiotics, but the Responsible Party (RP) was not notified of the change in condition. The RP only became aware of the diagnosis and treatment upon visiting the resident and seeing a sign indicating the UTI. The facility's policy requires notifying the RP of such changes, but this was not done.
A resident with intact cognition reported feeling threatened by the Activities Manager after raising concerns about a roommate's care. Despite reporting this to the DSS, no action was taken. The DSS and DSD did not report the resident's concerns as an allegation of abuse, violating the facility's policy requiring immediate reporting.
A facility failed to accurately code an MDS assessment for a resident by not reflecting the presence of a nephrostomy tube. The resident had a medical history of acute kidney failure and other conditions, and their care plan indicated a nephrostomy tube. However, the MDS assessment incorrectly coded the section related to urinary appliances. The error was confirmed by both the MDS Coordinator and the DON.
A resident with a history of psychosis and schizophrenia did not receive Abnormal Involuntary Movement Scale (AIMS) assessments every six months as required by their care plan. Despite receiving antipsychotic medication, the facility failed to adhere to the care plan's directive for regular AIMS assessments, with gaps noted in the assessment schedule. Interviews with staff confirmed the expectation for regular assessments, but the facility lacked a specific policy to ensure compliance.
The facility failed to conduct psychiatric evaluations for two residents as ordered by physicians. One resident with severe cognitive impairment and a history of psychosis did not receive a psychiatric evaluation despite orders and permission from the Power of Attorney. Another resident with depression and anxiety also lacked a scheduled evaluation. The facility lacked a specific policy for following physician's orders, leading to deficiencies in care.
A resident with a Stage 4 pressure ulcer on the right heel was incorrectly reclassified to Stage 3 by an NP, contrary to NPUAP guidelines. The NP based the reclassification on observed improvements, but was unaware that reverse staging is not permitted. Interviews with facility staff revealed a lack of awareness about the prohibition against reverse staging, leading to the deficiency.
A resident with peripheral vascular disease and moderate cognitive impairment did not receive proper incontinence care. During an observation, a CNA failed to clean both sides of the labia from front to back, as required by facility policy. This was confirmed by interviews with the CNA, DSD, IP, and DON.
A resident with severe cognitive impairment fell while attempting to climb over bed rails, but the facility failed to conduct a timely bed rail safety assessment as required by policy. Despite the incident, the next assessment was only completed during a routine quarterly review, indicating a lapse in communication and adherence to safety protocols.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents at high risk of MDRO colonization, including a resident with a dialysis catheter and another with a Stage 4 pressure ulcer. Additionally, staff did not follow proper hand hygiene and glove use during incontinence care for a resident, leading to potential contamination. The Infection Preventionist and Director of Nursing acknowledged these lapses in infection prevention measures.
The facility failed to follow the approved menu and portion sizes, serving meatloaf portions less than the required 4 ounces. This occurred due to a miscommunication by the Dietary Manager regarding the correct food package size and confusion over the recipe instructions. The Registered Dietitian confirmed the error, which could lead to residents not receiving adequate caloric intake.
A resident admitted for status post left hemiarthroplasty was scheduled for a follow-up appointment with an orthopedic surgeon, but the facility was unaware of the appointment and did not perform the necessary hip x-ray. This resulted in the resident arriving at the appointment without the required x-ray, leading to the surgeon being unable to assess the resident's recovery.
A facility failed to arrange transportation for a resident's follow-up appointment with an orthopedic surgeon, resulting in the resident's family member having to transport the resident in her private vehicle. The facility was unaware of the appointment despite it being documented in the resident's physician's orders.
Food Service Staff Not Competent in Ice Machine Cleaning and Thermometer Calibration
Penalty
Summary
The facility failed to ensure that the Maintenance Director and Dietary staff member were trained to carry out food and nutrition service functions safely and effectively for 136 residents. During a concurrent observation and interview in the kitchen, the Maintenance Director cleaned the ice machine by removing the water curtain, squeezing cleaning solution into the water trough, scrubbing the inside with a green scouring pad, and wiping the ice bin with paper towels, but did not use sanitizer to clean the inside of the ice bin. He stated he used hot water to rinse the bin, took apart components to run through the dishwasher, and had been cleaning the machine this way for 18 years. He also stated he had not been trained at the facility. Black and brown substance was observed on the scouring pad after scrubbing the inside of the machine, and he acknowledged that such substances should not have been in the ice machine. The Registered Dietician stated the Maintenance Director was expected to clean and maintain the ice machine monthly and should have followed the manufacturer's guidelines and the facility logbook instructions, which directed staff to sanitize the interior and ice bin using an approved sanitizer. The Administrator and Safety Maintenance Resource also stated the Maintenance Director should have used the manufacturer's directions and sanitizer, and that he needed more training. The report states the black and brown substances could have contaminated the ice and that residents could have gotten sick from consuming cross-contaminated ice. The facility also failed to ensure a newly hired Dietary staff member could correctly calibrate a thermometer during meal preparation. During observation, the staff member placed the thermometer in a cup of ice water with the stem touching the bottom of the cup and stated she should have waited until it reached 32 degrees Fahrenheit, added more ice, and did not know how to calibrate it when it did not read 32 F. She stated she had been hired three months earlier and understood accurate calibration was important for proper food temperatures. The Dietary Services Manager and Registered Dietician stated she was not competent in thermometer calibration and needed more training. The facility policy required the thermometer to read 32 F in ice water or be calibrated or discarded, and the report states inaccurate calibration could have resulted in undercooked food and foodborne illness.
Food Storage and Ice Machine Sanitation Deficiencies
Penalty
Summary
Safe and sanitary food preparation and storage practices were not followed when a bin containing six bags of stew meat in the walk-in refrigerator was observed without a pull-out date and use-by date. During the observation, the Dietary Service Manager Assistant stated the meat should have been labeled with a pull-out date of 3/3/26 and a use-by date of 3/5/26, and that kitchen staff should have labeled the meat when it was removed from the freezer. The facility policy on thawing meats indicated that meat thawed in a refrigerator should be labeled with pull and use-by dates. The facility also had black and brown substances inside the ice machine during a kitchen observation. The Dietary Service Manager, Dietary Service Manager Assistant, and Registered Dietician all confirmed the substances were present and stated the ice machine should have been clean and free of such material. The Dietary Service Manager stated dietary staff were responsible for cleaning the outside of the ice machine and the Maintenance Director was responsible for cleaning the inside, while the logbook indicated monthly deep cleaning of the ice machine interior and exterior.
Infection Control Failures With PICC Care, Shared Equipment, Room Placement, and Commode Sanitation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program in multiple areas involving resident care equipment, shared spaces, and resident placement. One resident with a PICC line had a dressing dated 2/23/26 that remained in place for 9 days, despite an order for weekly dressing changes. When the dressing was changed, the insertion site was covered with gauze under the transparent dressing, and the dressing was dated 3/2/26 even though the change occurred on 3/4/26. The resident’s record showed admission diagnoses including endocarditis and bacteremia, and staff interviews confirmed the dressing was not changed within the ordered timeframe and the insertion site was not visible for daily observation. In a shared bathroom between two resident rooms, a bedside commode was observed containing visible urine, stool, and used toilet paper in a plastic liner. The commode remained in the same condition during a later observation more than an hour afterward and was accessible to residents from both rooms. Staff interviews stated the commode should have been cleaned immediately after use and that leaving a dirty commode in a shared bathroom was not appropriate. The facility policy stated that care should minimize the spread of infection and that equipment and bathing areas should be cleaned and disinfected between each resident use. The facility also placed a resident with a documented MRSA wound infection in a room with another resident who was not identified as having MRSA. The resident with MRSA had a left foot wound and a wound vac, and the roommate’s record did not include MRSA. Staff interviews acknowledged that residents with the same infection may be cohorted, and that it would be inappropriate to place a resident without active MRSA with a resident who had MRSA. In addition, a nurse used the same blood pressure cuff and pulse oximeter on two residents without cleaning and disinfecting the equipment between uses, including one resident on EBP due to wounds. Two nurses also failed to disinfect a glucometer according to the manufacturer’s wet-time instructions after blood glucose checks on two residents, and the glucometer was allowed to dry before the required contact time was met.
Psychotropic Medications Given Without Resident-Specific Interventions or Supporting Diagnoses
Penalty
Summary
The facility failed to follow its policy and procedure and professional standards of practice to ensure residents were not prescribed unnecessary psychotropic medications for three sampled residents. For Resident 13, the record showed diagnoses including dementia, bipolar disorder, schizophrenia, restlessness, anxiety disorder, and depression. The resident’s medication orders included buspirone, divalproex, methadone, aripiprazole, lorazepam, and quetiapine for behaviors such as restlessness, screaming, and interference with care. During review of the MAR, there were no markings showing that the ordered non-pharmacological interventions were initiated before antipsychotic or psychotropic medications were administered, and the LVN stated there was no documentation indicating which interventions were attempted. For Resident 49, the MARs showed psychotropic medications including buspirone and escitalopram oxalate. The DON stated there were no specific non-pharmacological interventions implemented prior to administering these medications. The DON also stated that resident-specific interventions were important because each resident was unique and that the interventions should have been specific to the psychotropic medications and the behavior being treated. For Resident 148, the OSR showed orders for sertraline HCl for depression and lorazepam for anxiety. The MAR showed no non-pharmacological interventions implemented prior to initiating the psychotropic medications, and the DON stated there was no specific behavior monitoring for the resident’s psychotropic medications. The DON also stated the resident should have had specific NPIs and behavior monitoring to determine whether the medications were working. In addition, the DON stated the resident’s record did not list diagnoses of anxiety or depression, and the PC stated the resident should have had diagnoses corresponding to the prescribed anti-anxiety and antidepressant medications. The facility policy stated residents who use psychotropic drugs receive behavioral interventions unless clinically contraindicated and that the specific condition requiring psychotropic medication is diagnosed and documented in the clinical record.
Failure to Assess Significant Weight Loss and Unordered Supplements at Bedside
Penalty
Summary
Licensed nurses failed to assess Resident 78 for insidious and significant unintentional weight loss after the resident’s recorded weights showed a steady decline from 122.8 lbs. to 115.4 lbs. over the course of the month. During observation, Resident 78 was in a wheelchair in the dining room being fed by a CNA and was not opening her mouth when fed, with eye contact but no verbal response. The resident’s daughter stated that Resident 78 was totally dependent on staff for ADLs, could not verbalize needs, did not know how to use the call light, and had declined in oral intake and lost weight since brain surgery. Record review and staff interviews showed that the resident’s weights were reviewed, but the weight loss was not identified by the ADON as requiring a change-of-condition SBAR assessment at the time the weights were recorded. The ADON stated he was waiting for the RD’s list of residents with significant weight changes before completing the assessment, while other licensed nurses stated that a change-of-condition SBAR should have been completed when the weight was recorded and that the resident had a significant weight loss of 6% in a month. The DON stated that a 5% change in weight in one month was significant and required a nursing assessment, and that nursing should not wait for the RD before initiating assessment. The record also showed the resident had diagnoses including surgical aftercare following nervous system surgery, intracerebral hemorrhage, dysphagia, severe protein calorie malnutrition, aphasia, and dysarthria. Resident 29 maintained probiotic capsules and probiotic with fiber gummies at the bedside and self-administered them without a physician’s order. The supplements were observed in the resident’s nightstand, and the resident stated she kept them there and took them when she remembered. A CNA confirmed the supplements had been in the room previously and had not notified the nurse. An LVN stated the supplements were not supposed to be in the room, that there was no physician order for them, and that medications and supplements needed to be kept in the locked medication cart and labeled. The resident’s OSR showed no order for either supplement, and the self-administration assessment indicated the resident may keep meds at bedside: No. The DON stated that any medications or supplements in the resident’s room needed a doctor’s order and secure storage, and that all medications and supplements being self-administered needed physician orders.
Medication Error Rate Exceeded 5 Percent
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent for four sampled residents during observation, interview, and record review. The cited errors involved timing, dose measurement, medication preparation, and administration technique. The residents involved had diagnoses including chronic kidney disease, diabetes mellitus, heart failure, COPD, endocarditis, bacteremia, gait and mobility abnormalities, neuralgia, neuritis, fracture of the left femur, muscle weakness, difficulty walking, atrial fibrillation, and acute kidney failure. For one resident with severe chronic kidney disease, an RN administered sevelamer 800 mg before the meal tray was served. The order was for the medication to be given with meals, and the RN stated the resident had an appointment pickup time later that afternoon. The DON stated the medication should have been given when the meal tray was in front of the resident and that it would not work if not given with meals. For another resident, an RN applied diclofenac sodium gel using a medication cup rather than the measuring stick provided by the manufacturer. The order was for diclofenac sodium external gel 1% to be applied topically to the left forearm in a 2 gram dose. The RN stated she was not aware of using the measuring stick and routinely used a medication cup to dose the gel. The DON stated staff should have followed the pharmacist’s instructions and used the stick provided in the medication box. For a third resident, an LVN administered crushed medications mixed with applesauce and also gave whole medications from the same spoon used for the crushed medications. The resident chewed the docusate sodium gel capsule, and small amounts of applesauce containing powdered medication remained in the cup when the LVN discarded it. The resident’s orders included docusate sodium 100 mg daily and sennosides 2 tablets twice daily for constipation. The LVN stated the resident should not have chewed the docusate capsule or the acetylsalicylic acid tablet and that not all of the crushed medication may have been received. The DON stated whole tablets should not have been placed in the same container with crushed medications and applesauce. For a fourth resident with diabetes, an LVN checked blood sugar in the morning and later administered insulin aspart almost 2 hours after the blood sugar check. The medication was ordered before meals, and the LVN stated it should have been given within 15 to 30 minutes before the meal. The DON stated insulin ordered before meals should have been administered no later than 15 minutes from checking the blood sugar or when meal trays were being delivered, and that it should not have been given after the meal.
Medication Labeling, Discontinued Medications, and Vaccine Refrigerator Monitoring
Penalty
Summary
The facility failed to ensure drugs and biologicals were labeled in accordance with accepted standards when Resident 69’s fluticasone/salmeterol inhaler dispenser and insulin aspart injectable pen were observed without the resident’s name and medication expiration date on the dispenser and without an expiration date on the injectable pen. During the observation, the LVN obtained the inhaler and insulin pen from the medication storage area and entered the resident’s room with them. The resident’s record showed diagnoses including type 2 diabetes mellitus, atrial fibrillation, acute kidney failure, shortness of breath, and cough. The LVN stated the inhaler dispenser and insulin syringe could have been mixed up with another resident’s medication and that the resident could have been given the wrong medication. The DON also stated the insulin pen and inhaler were not labeled appropriately and should have had their own labels to ensure the medication was given to the right resident and was not expired. The facility also failed to remove discontinued medications from active medication and treatment carts for multiple residents. Resident 57’s hydrocodone-acetaminophen blister packet remained in the medication cart even though the order had ended on 3/1/26. Resident 155’s clotrimazole cream remained in the treatment cart after the resident had been discharged and the medication had been discontinued. Resident 45’s nystatin topical powder and clotrimazole cream were found in the treatment cart even though the orders had ended, and Resident 19’s collagenase ointment and silver sulfadiazine cream were observed in the treatment cart, including duplicate tubes with labels showing prior start and end dates and opened dates. Staff interviews confirmed these medications were discontinued, and the DON stated discontinued medications should have been removed from the carts and placed in the medication room to avoid being given to residents. The facility further failed to monitor the temperature of the medication refrigerator containing vaccines two times per day. During observation, the refrigerator in the medication room contained shingles vaccine vials, and RN 1 stated the temperature was monitored once daily. The temperature log showed entries for the refrigerator and room temperatures, but the log did not reflect the twice-daily monitoring described in the facility’s vaccine temperature recording form. The DON stated the refrigerator temperatures for the vaccine storage unit were not monitored appropriately and that staff should have checked and documented the refrigerator temperature twice a day, once in the morning and once before the end of the workday.
Pest Control Program Not Effective
Penalty
Summary
The facility failed to maintain an effective pest control program that kept resident rooms free of pests. During observations and interviews, ants were seen on the nightstands of three sampled residents: Resident 11, Resident 145, and Resident 147. The report states that the presence of ants in these rooms showed the pest control program was not effective, and facility staff acknowledged that ants should not be in resident rooms or in the facility. Resident 11 was admitted with diagnoses including acute posthemorrhagic anemia, type 2 diabetes mellitus with diabetic polyneuropathy, cirrhosis of the liver, and a history of falling. Her MDS showed a BIMS score of 15, indicating she was cognitively intact. During observation, ants were seen on her nightstand on two occasions, including near her denture cup and lipstick. Resident 11 stated she had intermittently seen one or two ants in her room since moving into the facility a couple of months earlier. Resident 145 was admitted with diagnoses including surgical aftercare following nervous system surgery, lumbar spine fusion, neuralgia/neuritis, and depression, and had a BIMS score of 13. Five ants were observed on the resident’s nightstand near the television control, a cup, and food in a zip-locked bag. Resident 145 said she was not aware of the ants. Resident 147 was admitted with diagnoses including UTI, Parkinson’s disease without dyskinesia, generalized muscle weakness, and a history of falling, and had a BIMS score of 6. One ant was observed on the resident’s nightstand, and the resident said he was not aware of it. Facility staff and the DON stated ants should not be present, and work orders documented ants and spiders in rooms and ants in a room.
Unsecured OTC Supplements Kept at Resident Bedside Without Order
Penalty
Summary
The facility failed to ensure medications were stored safely and securely for one resident who had been assessed as not capable of keeping medications at bedside for self-administration. Resident 29 was admitted with diagnoses including paroxysmal atrial fibrillation, aftercare following joint replacement surgery, tremors, and depression. The resident’s MDS showed a BIMS score of 12, indicating moderate cognitive impairment. During observation, two OTC supplements, probiotic capsules and probiotic with fiber gummies, were found in the resident’s unlocked bedside table, and the resident stated she kept them there and self-administered them when she remembered. Staff interviews and record review confirmed there was no physician order for either supplement. A CNA stated she had seen the supplements in the room the prior week but did not notify the nurse because she did not know the nurse and doctor needed to be aware. An LVN stated she was not aware the supplements were stored in the unlocked nightstand and said medications and supplements needed to be kept in the locked medication cart and labeled for safety. The resident’s self-administration assessment indicated the resident may keep meds at bedside: No, and the DON stated the supplements should not have been at the bedside, should have been under lock, and that the facility’s self-administration policy was not followed.
Meal Service Not Coordinated to Preserve Resident Dignity
Penalty
Summary
Resident 147 was observed in the Tuolumne dining room on 3/3/26 without a meal while other residents at the table had already been served. Resident 147 had diagnoses including UTI, Parkinson’s disease, and a right hand fracture, and his MDS showed a BIMS score of 6, indicating severe cognitive impairment. During the observation, CNA 3 stated Resident 147 had been transferred from the Olive room to the Tuolumne room days earlier and that his trays had been late since the transfer. Resident 147 stated he was hungry and tired of his food being late, and Resident 77 stated his meals had been late every day since he transferred. Resident 147’s lunch tray was not delivered until 24 minutes after the other residents in the Tuolumne dining room had received their meals. At the time of delivery, his meal ticket still listed the Olive room, and the dining location had not been updated. The DSD stated the dining room change had been completed on 2/26/26 for a start date of 2/27/26, but the meal ticket had not been processed and updated. The DSD stated the result was that Resident 147’s meals were delivered to the wrong dining room since 2/27/26, causing him to watch others eat before receiving his own meal and to dine alone. Resident 40 was observed in the Olive dining room without his lunch tray while other residents had already been served. Resident 40 had diagnoses including fracture of the neck of the left femur, atherosclerosis, atrial fibrillation, muscle weakness, dementia, and heart failure, and his MDS showed a BIMS score of 8, indicating moderate impairment. CNA 3 stated Resident 40 gave his lunch tray to Resident 58 when Resident 58’s tray was not brought to her, and CNA 3 did not check to ensure Resident 58 had received the correct tray. CNA 3, CNA 1, RNA 1, and the DON all stated residents should have been served at the same time and staff should have checked trays to ensure the correct diet was served to the correct resident.
Failure to Implement Pressure Ulcer Care Plan
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident with Stage 3 pressure ulcers to the coccyx. The resident was admitted from an acute care hospital with diagnoses including COPD, chronic kidney disease, type 2 diabetes mellitus, hypertensive heart disease, morbid obesity, and pressure-induced deep tissue damage of the sacral region and left ankle. The resident was cognitively intact with a BIMS score of 13 and stated she was receiving therapy and treatment for wounds on her bottom. During observations, the resident was repeatedly found sitting in a wheelchair without a cushion. On 3/3/26, she was observed sitting in a wheelchair watching television, then later sitting on a folded facility blanket with a rough texture and stating she had no cushion on her wheelchair. She also stated she had been sitting in her wheelchair since after breakfast, usually remained up in the wheelchair for more than two to three hours, sometimes longer, could not reposition herself while seated, and depended on nursing staff for wheelchair repositioning. On 3/5/26, the resident was observed in bed on a low air loss mattress, and her wheelchair was found parked in her room with a standard pillow on the seat. Staff confirmed there was no wheelchair cushion available in the room. Record review showed the resident’s care plan identified a Stage 3 pressure ulcer to the coccyx with a goal that the pressure ulcer would show signs of healing and remain free from infection, and the listed intervention was frequent repositioning. The wound care report documented Stage 3 pressure injury to the bilateral buttocks with orders to offload the wound and reposition per facility protocol. Staff interviews indicated the resident should have had a gel cushion in the wheelchair and should have been repositioned every two hours when up in the wheelchair. The DON stated the resident should not have been up in the wheelchair for more than two hours and should have been repositioned every two hours and as needed in bed and in chair. The facility policy required residents with pressure injuries to receive necessary treatment and services to promote healing, prevent infection, and prevent new avoidable pressure injuries, including individualized person-centered care planning, repositioning, and use of pressure-relieving devices.
Failure to Provide Pressure Relief and Repositioning for Resident With Stage 3 Coccyx Ulcer
Penalty
Summary
The facility failed to ensure necessary care and treatment were provided to promote wound healing, prevent infection, and prevent worsening of an existing Stage 3 pressure ulcer to the coccyx for one resident. During observation, the resident was sitting in a wheelchair without a pressure-relieving cushion and was seated on a folded facility blanket with a rough texture. The resident stated she had no cushion on the wheelchair, could not reposition herself while sitting, and depended on nursing staff for wheelchair repositioning. The resident had diagnoses including COPD, chronic kidney disease, type 2 diabetes mellitus, hypertensive heart disease, morbid obesity, and pressure-induced deep tissue damage of the sacral region and left ankle. The resident’s MDS showed a BIMS score of 13, indicating cognitive intactness. The resident stated she had been sitting in the wheelchair for more than two to three hours at a time, sometimes longer, and that staff were not repositioning her while she remained in one position. Staff interviews and record review confirmed the resident had a Stage 3 pressure ulcer to the coccyx and was identified as high risk for pressure ulcers. The care plan included frequent repositioning, and the wound care report directed offloading and repositioning per facility protocol. Multiple staff members stated the resident should have had a gel cushion in the wheelchair and should have been repositioned every two hours when up in the wheelchair. The DON stated the resident should not have been up in the wheelchair for more than two hours and should have been repositioned every two hours and as needed in bed and in chair, but the resident was observed without the cushion and without documented repositioning while sitting in the wheelchair.
Restorative nursing program not implemented after OT discharge
Penalty
Summary
The facility failed to ensure that Resident 35 received appropriate restorative nursing services to maintain or improve mobility after discharge from skilled OT. Resident 35 was readmitted with diagnoses including pneumonia, mild dementia, and heart failure, and her MDS dated 1/31/26 showed a BIMS score of 13, indicating she was cognitively intact. During observation on 3/3/26, Resident 35 was in bed awake, stated she wanted to walk, reported she had been walking prior to hospitalization, and said she could stand briefly, take a few steps in her room, and manage toileting and dressing with some assistance. She also stated she used a wheelchair as her primary mode of locomotion and felt she was getting weaker and at risk for falls. Record review and interviews showed Resident 35 had previously been on an RNP for ambulation, with RNA monthly summaries documenting ambulation with a FWW and goals to maintain mobility. The OT discharge summary dated 1/30/26 stated a restorative transfer program was recommended, including sit-to-stand training. The DOR stated Resident 35 was referred for RNP sit-to-stand, and OT 1 stated she remembered completing a restorative nursing referral and that it could have been missed. However, on 3/5/26 RNA 1 reviewed the current RNP list and found Resident 35 was not on it, and the DSD stated there was no order for RNP and that she did not receive a referral from therapy. The facility’s DON stated Resident 35’s RNP should have been implemented when discharged from OT services, and the DSD stated Resident 35 should have been on RNP when skilled therapy ended to prevent decline in functional mobility. The facility policy required restorative nursing care to be developed based on nursing assessment and therapy recommendations, with goals and interventions formulated and re-evaluated. Despite these requirements and the therapy recommendation, Resident 35’s restorative nursing program was not developed and implemented after OT discharge.
Inaccurate Daily Nurse Staffing Posting
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information posted for public viewing accurately identified the actual number of RNs, LVNs, and CNAs providing direct care for each shift. During observation, the posted staffing sheet in a common area showed a resident census of 133 and listed staffing by shift under the categories of licensed and unlicensed staff, combining RN and LVN hours under licensed staff and CNA and RNA hours under unlicensed staff. The posting reflected day, evening, and night shift staffing totals and a handwritten calculation of 3.78 nursing hours per resident day, but it did not separately identify the number of RNs, LVNs, CNAs, or RNAs working each shift. During interview and record review, the SC and PR stated the staffing information was reconciled from the prior day and then posted, but the categories remained grouped together. The SC stated she would need to manually calculate the specific hours worked by CNAs and RNAs, and also separate RN hours from LVN hours, because the posted information combined those categories. The DON stated the RNA primarily performed restorative duties but could also respond to call lights and pass snacks, and acknowledged that the posted form only reflected licensed and unlicensed staff categories and did not clearly show how many nurses and CNAs were working in the facility. Review of staffing sheets for several days showed the same grouping of RN and LVN hours and CNA and RNA hours, without identifying the specific number of each type of staff providing direct care for each shift.
Incorrect Dulaglutide Dose Administered
Penalty
Summary
The facility failed to ensure a resident was free from a significant medication error when the resident was administered the incorrect dose of dulaglutide. The resident had diagnoses of type 2 diabetes mellitus, atrial fibrillation, and acute kidney failure. During observation, an LVN administered dulaglutide from a prefilled single-dose injector that was labeled 0.75 mg/0.5 mL, even though the physician order in the MAR and OSR was for 1.5 mg subcutaneously every Tuesday for diabetes mellitus 2. Record review showed the resident’s dulaglutide order was changed from 0.75 mg to 1.5 mg, but the medication dispensed and administered remained the 0.75 mg strength. The MAR and pharmacy dispense report reflected repeated dispensing of dulaglutide 0.75 mg/0.5 mL while the order called for 1.5 mg. During interview, the DON acknowledged the resident’s dulaglutide was a 0.75 mg single-dose prefilled syringe and not the ordered 1.5 mg dose. The LVN also acknowledged administering the wrong dose and stated the resident should have received 1.5 mg, not 0.75 mg. The resident’s blood sugar remained elevated after the dose discrepancy, and the medical record showed subsequent increases in insulin glargine and the addition of pioglitazone. The MD stated the dulaglutide dose had been increased, but the resident’s blood sugar was still not controlled, so additional diabetes medications were added. The pharmacist consultant stated the facility should have discontinued the 0.75 mg order and placed a new order for the 1.5 mg dose, and that the pharmacist should have checked the label before placing it on the medication. Facility policies reviewed included requirements to follow the six rights of medication administration, verify medication labels against physician orders, and discontinue prior orders when a dose changes.
Unsigned POLST in Resident Record
Penalty
Summary
The facility failed to ensure and maintain a complete medical record for one sampled resident when the resident’s POLST was not signed by a physician. Resident 4’s POLST was prepared by qualified staff and signed by the resident on 1/27/26, but the physician signature was missing from the form. Staff stated the POLST should have been signed by the physician within 48 to 72 hours, and the Medical Records Manager later stated the form was incomplete and not valid without the physician signature. Resident 4 was observed on 3/3/26 lying in bed with oxygen at 2 liters per minute via nasal cannula. During interview, the resident stated she had been admitted from the hospital after surgery. The resident’s record showed diagnoses including UTI, surgical aftercare following digestive system surgery, type 2 diabetes mellitus, chronic pulmonary edema, essential hypertension, atherosclerotic heart disease, and presence of a cardiac pacemaker. The MDS dated 2/2/26 showed a BIMS score of 11, indicating moderately impaired cognition. During record review and interviews, the MRM stated the POLST had not been signed by the physician and was faxed to the physician on 3/5/26. The SSD stated the POLST should be signed by the physician, resident, or legally recognized decision maker to be valid. The DON stated it was her expectation that the POLST be signed by the physician within 48 hours of admission and that it was not acceptable for the form to remain unsigned since admission. The facility policy stated a completed, fully executed POLST is a legal physician order and is immediately actionable.
Failure to Notify Family of Resident's Significant Change in Condition After Hospitalization
Penalty
Summary
The facility failed to notify a resident's family member of significant changes in the resident's condition following her return from a seven-day hospital stay. Upon her return, the resident was found to have multiple new areas of skin breakdown, including bruising, open wounds, and excoriations, as well as a urinary tract infection requiring antibiotics. The resident also refused further skin assessments, antibiotic medication, and a blood test as ordered by her physician. These changes and refusals were documented in the resident's clinical record. Despite these significant developments, there was no documentation that the family member was informed of the resident's return to the facility, the new wounds, or the refusals of treatment. The family member confirmed during an interview that she was not notified of the resident's return, the assessment findings, or the refusals of care, and only became aware of the situation during a visit the following day. The Director of Nursing also confirmed that there was no record of such notifications and stated that staff assumed the family member was already aware due to her visits to the hospital. The facility's policy required staff to observe, record, and report any change in a resident's condition, including notifying the resident's responsible party. However, this policy was not followed in this instance, resulting in the family member being unaware of the resident's significant changes in condition and care refusals after her return from the hospital.
Failure to Return Resident's Personal Belongings Upon Discharge
Penalty
Summary
The facility failed to implement its policy regarding resident possessions when it did not return a 42-inch television to the family of a resident upon her discharge. The resident's admission record indicated she was admitted and later discharged from the facility, but her television, which was brought in by her family and mounted by maintenance staff, was not included on her personal belongings inventory. As a result, the television was not listed on the discharge inventory and was not returned to the family. Interviews with the resident's family member and the Social Services Director confirmed that the television was the resident's personal property and that it was not documented on the inventory list, despite being present in the resident's room and previously noted in the facility's Grievance / Theft & Loss Tracking Log. The facility's policy requires all personal belongings to be inventoried and returned upon discharge, but this process was not followed, leading to the family's loss of the television.
Failure to Install Bed Rails as Assessed
Penalty
Summary
The facility failed to ensure that a resident had bed rails installed as determined by the facility's Bed Rails - Safety Assessment (BRSA). During an observation, it was noted that the resident's bed did not have side rails or grab bars attached, despite the BRSA indicating the need for grab/transfer assist bars or rails to facilitate enhanced bed mobility, provide stability during transfers, assist in entering and exiting the bed independently, and prevent falling. The resident's Admission Record indicated a diagnosis of muscle weakness, and the Verification of Informed Consent signed by the resident specified the use of 1/2 bed rails every shift for mobility and transfer. The Minimum Data Set Registered Nurse (MDS RN) confirmed that there were no bed rails in place and stated that if the BRSA indicated the use of bed rails, there should be a corresponding physician's order and inclusion in the resident's Care Plan. However, the Order Summary Report did not contain an order for side rails, and the Care Plan lacked interventions for bed rails. The facility's policy on side-rails emphasized the need for a side-rail safety assessment and inclusion in the care plan when side-rails are required, which was not adhered to in this case.
Resident Rights and Language Policy Violations
Penalty
Summary
The facility failed to respect and honor the rights of a resident when a Certified Nursing Assistant (CNA) displayed an obscene gesture towards the resident. The incident occurred when the CNA, identified as CNA 9, was preparing another resident for a shower and accidentally bumped into the resident's bed. This led to an exchange of foul language and gestures between the resident and CNA 9. The incident was witnessed by an admissions staff member, who reported it to the Director of Staff Development. The facility's investigation confirmed the incident, and CNA 9 admitted to the gesture, leading to his termination for misconduct. Additionally, the facility failed to ensure that staff adhered to the policy of speaking only English within the facility. This issue was raised by residents who felt uncomfortable and believed that staff might be speaking about them in a non-English language. The facility's policy, which establishes English as the official language, was not consistently followed, as confirmed by interviews with staff and residents. The Director of Nursing acknowledged the ongoing issue and the need for staff to speak English in resident care areas. The deficiencies highlight the facility's failure to uphold resident rights to a dignified existence and effective communication. The incidents involving both the obscene gesture and the language policy breach had the potential to negatively impact the residents' psychosocial well-being and their perception of care within the facility.
Delayed Pain Management for Two Residents
Penalty
Summary
The facility failed to ensure timely responses to requests for pain relief for two residents, resulting in prolonged pain and discomfort. Resident 6, who suffers from bursitis in the right elbow, reported that it sometimes takes two to three hours for staff to respond to his call light for pain medication. His records indicated a physician's order for Norco to be administered every four hours as needed, but there was a significant gap between doses, with no medication given between 2 p.m. on one day and 7:30 a.m. the next day. Resident 6's care plan emphasized the need for immediate response to pain complaints, which was not adhered to. Resident 7, who has a medical diagnosis of pain in the right hip, also experienced delays in receiving pain medication. She reported that it typically takes 30 minutes to receive her medication, but it can take up to an hour. The Director of Nursing and the Medical Director both acknowledged that these wait times were excessive and not in line with their expectations. The facility's policy on pain management requires that pain relief be provided in a timely manner, consistent with professional standards and the residents' care plans, which was not achieved in these cases.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to ensure that the Interdisciplinary Team (IDT) assessed a resident's ability to self-administer medications safely and accurately. This deficiency was observed when a Licensed Vocational Nurse (LVN) left six oral medications on the bedside table of a resident diagnosed with Alzheimer's Disease and schizophrenia, without confirming if the resident took them. The medications were left unattended within the resident's reach, and the resident was found in bed with her eyes closed, indicating she might not have taken the medications. The Assistant Director of Nursing (ADON) confirmed that the medications should not have been left at the bedside and that the medication nurse should have ensured the resident took her medications before leaving the room. Upon reviewing the resident's clinical record, the ADON found no IDT assessment indicating the resident was safe to self-administer medications. The facility's policy requires an assessment and approval process for self-administration, which was not followed in this case.
Failure to Notify Responsible Party of Resident's UTI Diagnosis
Penalty
Summary
The facility failed to notify the Responsible Party (RP) of a change in condition for a resident diagnosed with a urinary tract infection (UTI). The resident, who had severe cognitive impairment due to dementia, was prescribed antibiotics for the UTI. Despite the diagnosis and treatment, there was no documentation indicating that the RP was informed of these changes. This lack of communication was discovered when the RP visited the resident and noticed a sign indicating the UTI and antibiotic treatment. The Assistant Director of Nursing (ADON) confirmed that the family was not notified of the change in condition until the RP's visit, which was a day after the diagnosis. The facility's policy requires licensed nurses to notify the resident's family or RP of any change in condition, but this protocol was not followed. The ADON acknowledged that the RP should have been informed of the UTI diagnosis and treatment as per the facility's policy.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, identified as Resident #15, who had a medical history including Alzheimer's disease, anxiety disorder, somatoform disorder, and depression. The resident, who had intact cognition as indicated by a BIMS score of 15, reported feeling threatened by the Activities Manager after raising concerns about the care of a roommate. The resident claimed the Activities Manager made a threatening statement suggesting harm could be done without evidence. Despite reporting this to the Director of Social Service (DSS), no action was taken. The DSS, along with the Director of Staff Development (DSD), met with the resident but did not report the resident's concerns as an allegation of abuse. The DSS and DSD dismissed the resident's fears of being poisoned as unfounded after a conversation with the resident. Both the Executive Director and the Director of Nursing stated that they expected staff to report any allegations of abuse immediately, but neither received any report regarding Resident #15. The Activities Manager denied making any threatening statements. The facility's failure to report the allegation of abuse violated their policy, which mandates immediate reporting of such allegations.
Inaccurate MDS Assessment for Resident with Nephrostomy Tube
Penalty
Summary
The facility failed to accurately code a Minimum Data Set (MDS) assessment for a resident, specifically not reflecting the presence of a nephrostomy tube. The resident, who was admitted on 07/26/2024, had a medical history including acute kidney failure, hydronephrosis, type two diabetes mellitus, and obstructive and reflux uropathy. The resident's care plan, initiated on 07/29/2024, indicated the presence of a nephrostomy tube. However, the admission MDS assessment dated 08/02/2024 incorrectly coded the section H0100 as 'None of the above' instead of 'indwelling catheter' to reflect the nephrostomy tube. During an observation and interview on 08/05/2024, a urinary drainage bag was noted at the resident's bedside, and the resident's emergency contact confirmed the presence of a nephrostomy tube. The MDS Coordinator acknowledged the error, stating that the nephrostomy tube should have been reflected on the MDS. The Director of Nursing also confirmed that the MDS should have accurately reflected the presence of the nephrostomy tube, indicating a lapse in the facility's assessment process.
Failure to Conduct Timely AIMS Assessments for a Resident
Penalty
Summary
The facility failed to complete Abnormal Involuntary Movement Scale (AIMS) assessments every six months for a resident, as required by the care plan intervention. The resident, who was admitted on 12/07/2021, had a medical history of unspecified psychosis, schizophrenia, and other specified persistent mood disorders. The care plan for this resident included a directive to perform AIMS assessments every six months and with each increase in dose of antipsychotic medication. However, the medical record showed that AIMS assessments were not conducted at the required intervals, with assessments recorded on 12/08/2021, 06/15/2023, 07/31/2024, and 08/11/2024, indicating a lapse in adherence to the care plan. Interviews with facility staff, including the Pharmacy Consultant and the Director of Nursing (DON), confirmed the expectation that AIMS assessments should be completed every six months to monitor for tardive dyskinesia, a potential side effect of the antipsychotic medication quetiapine fumarate. Despite this expectation, the facility did not have a specific policy regarding the completion of AIMS assessments. The DON acknowledged that care plans should be followed, and a Licensed Vocational Nurse (LVN) emphasized the importance of reviewing care plans to ensure interventions are completed as scheduled.
Failure to Conduct Psychiatric Evaluations as Ordered
Penalty
Summary
The facility failed to follow physician's orders for psychiatric evaluations for two residents, leading to deficiencies in care. Resident #81, admitted with a history of unspecified psychosis, schizophrenia, and mood disorders, was ordered a psychiatric evaluation and medication adjustment by the Medical Director in April 2024. Despite the Power of Attorney's permission and the order being noted, there was no documented evidence that the evaluation occurred. Interviews revealed that the facility was unable to secure a psychiatric provider for the evaluation, and the last psychiatric visit for the resident was in October 2023. Resident #9, with a history of depression and anxiety disorder, was also not provided with a psychiatric evaluation as ordered in May 2024. The resident's care plan included interventions for anxiety and depression, but the facility failed to schedule the required psychiatric evaluation. Interviews with the Director of Social Services and the Medical Director indicated that the facility's psychotropic team was responsible for scheduling evaluations, but no evaluation was documented after September 2023. The Director of Nursing confirmed that the facility lacked a specific policy for following physician's orders, relying instead on standard practice. This lack of adherence to physician's orders for psychiatric evaluations resulted in deficiencies in the care provided to both residents, as the necessary evaluations and potential medication adjustments were not conducted.
Improper Wound Staging by Nurse Practitioner
Penalty
Summary
The facility failed to ensure that a Nurse Practitioner (NP) followed professional standards of practice for wound staging for a resident with a pressure ulcer. Specifically, the NP incorrectly reverse staged a Stage 4 pressure injury on the resident's right heel to a Stage 3, contrary to the guidelines set by the National Pressure Ulcer Advisory Panel (NPUAP). The NPUAP guidelines clearly state that pressure injuries should not be reverse staged as it does not accurately reflect the healing process. The resident in question was admitted to the facility with a medical history that included a Stage 4 pressure ulcer on the right heel. The wound was initially assessed by a Wound Physician's Assistant (WPA) and documented as Stage 4, with debridement revealing muscle, tendon, and bone. Despite this, the NP assessed the wound and reclassified it as Stage 3, citing improvements such as the absence of discharge, smell, and raw edges. However, the NP was unaware that wounds could not be down staged, which led to the incorrect classification. Interviews with facility staff, including the Medical Director and Director of Nursing, revealed a lack of awareness regarding the prohibition against reverse staging. The Medical Director deferred to the wound team for staging expertise, while the Director of Nursing expected documentation from the wound team regarding wound progression. The NP's actions were based on her observations of the wound's improvement, but this did not align with the established guidelines, resulting in the deficiency.
Improper Incontinence Care for Resident
Penalty
Summary
The facility failed to provide proper incontinence care for a resident, identified as Resident #58, who was observed during incontinence care. The resident, admitted on 06/12/2024, had a medical history of peripheral vascular disease (PVD) and was receiving palliative care. The resident's Minimum Data Set (MDS) indicated moderate cognitive impairment and complete dependence on staff for toileting and bed mobility, with consistent incontinence of bowel and bladder. The care plan directed staff to check and change the resident during personal care and assist with toileting. During an observation, two CNAs were seen providing incontinence care to the resident. CNA #12 did not follow the facility's perineal care policy, which required cleaning both sides of the labia from front to back. Instead, CNA #12 only wiped down the center of the perineum without spreading the labia to clean the sides. This incorrect procedure was confirmed by interviews with the CNA, the Director of Staff Development, the Infection Preventionist, and the Director of Nursing, all of whom stated that proper cleaning should involve spreading the labia and cleaning both sides from front to back.
Failure to Reassess Bed Rail Safety After Resident Fall
Penalty
Summary
The facility failed to reevaluate the appropriateness of continued use of bed rails for a resident after an incident where the resident attempted to climb over the bed rails and fell. The resident, who had severe cognitive impairment and a history of senile degeneration of the brain, anxiety disorder, restlessness, agitation, and generalized muscle weakness, was admitted with an order for half-length side rails to aid in mobility and transfers. Despite the fall incident, a bed rail safety assessment was not conducted immediately after the fall, and the next assessment was only completed during a routine quarterly review. The facility's policy required that bed rail safety assessments be conducted after any incident involving bed rails, but this was not adhered to in the case of the resident's fall. Interviews with the Assistant Director of Nurses and the Director of Nursing confirmed that a new bed rail safety assessment should have been completed within 24 hours of the incident. However, the responsible staff member, LVN #49, was not aware of the incident and did not complete the necessary assessment, highlighting a lapse in communication and adherence to safety protocols.
Failure to Implement Enhanced Barrier Precautions and Proper Infection Control
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents at high risk of multidrug-resistant organism (MDRO) colonization and transmission. Resident #54, who had a dialysis catheter, did not have EBP signage or a personal protective equipment (PPE) cart at their room. A certified nursing assistant (CNA) provided care without wearing a gown, contrary to the facility's policy and CDC guidelines. The Infection Preventionist (IP) and Director of Nursing (DON) acknowledged that EBP should have been followed for Resident #54 due to the presence of a hemodialysis catheter. In another instance, the facility failed to ensure proper hand hygiene and glove use during incontinence care for Resident #58. Two CNAs were observed handling soiled wipes improperly, with one CNA handing wipes over the resident to the other CNA, who then touched the bed rail with soiled gloves. The CNAs did not change gloves or wash hands before making the resident comfortable, which was against the facility's incontinence care policy. The Director of Staff Development and the IP confirmed that the CNAs should have changed gloves and washed hands between dirty and clean tasks. Additionally, the facility did not maintain EBP for Resident #91, who had a Stage 4 pressure ulcer. The resident's room lacked EBP signage and a PPE cart, and a Licensed Vocational Nurse (LVN) provided wound care without wearing a gown. The IP and DON admitted that Resident #91 should have remained on EBP due to the open wound, but the resident was overlooked when their indwelling catheter was removed. The failure to adhere to EBP protocols was acknowledged by the facility's staff, highlighting a lapse in infection prevention measures.
Failure to Follow Approved Menu and Portion Sizes
Penalty
Summary
The facility failed to ensure that the menu approved by the Registered Dietitian (RD) was followed, specifically regarding the portion size of meatloaf served to residents. The meatloaf portions served were less than the required 4 ounces, with some slices weighing only 3.5 ounces. This discrepancy was observed during a kitchen inspection where the Dietary Manager (DM) and kitchen staff confirmed the incorrect portion sizes. The issue arose because the cook used 30 pounds of ground turkey instead of the required 37.5 pounds of ground beef for 150 servings, leading to insufficient meatloaf portions for the 134 residents, of which three were NPO and receiving nutrition via gastrostomy tube. The DM admitted to miscommunicating the correct food package size to the cooks, resulting in the shortage. Additionally, there was confusion regarding the recipe title, which indicated a 3-ounce portion, while the instructions specified a 4-ounce portion. The RD confirmed that the recipe was not followed correctly and acknowledged that serving smaller portions could lead to residents not receiving the necessary caloric intake. The facility's policy on meal production was reviewed, highlighting the need for accurate meal production and sufficient product forecasting according to resident preferences and physician's diet orders.
Failure to Provide Required X-Ray for Follow-Up Appointment
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident who was admitted for status post left hemiarthroplasty. The resident was scheduled for a follow-up appointment with an orthopedic surgeon, but the facility was unaware of the appointment and did not perform the necessary hip x-ray for the resident to bring to the appointment. This oversight resulted in the resident arriving at the appointment without the required x-ray, leading to the orthopedic surgeon being unable to assess the resident's recovery and detect potential complications. Interviews with the family member, Assistant of Staff Development, and Director of Staff Development revealed that the facility did not follow its usual process of preparing residents for their appointments. The physician's orders indicated a follow-up appointment, but the licensed nurse did not obtain an order for an x-ray. The orthopedic surgeon's clinic supervisor confirmed that x-rays are always required for follow-up appointments, and the facility should have provided the resident with a CD containing the x-ray image. This failure to adhere to professional standards of practice resulted in the resident missing a critical assessment of their surgical recovery.
Failure to Arrange Transportation for Medical Appointment
Penalty
Summary
The facility failed to assist in making transportation arrangements for a resident who was scheduled to have an orthopedic surgeon appointment. The resident had recently undergone hip surgery and was scheduled for a follow-up appointment. On the day of the appointment, the resident's family member arrived at the facility to accompany the resident, only to find that the facility was unaware of the appointment and had not arranged transportation. As a result, the family member had to transport the resident in her private vehicle at the last minute. Interviews with the Assistant of Staff Development and the Director of Staff Development revealed that the usual process for handling residents' appointments and transportation was not followed in this case. The resident's physician's orders, which included the follow-up appointment details, were received and signed by a facility licensed nurse, but this information was not communicated to the staff responsible for arranging transportation. The facility's handbook states that the facility is responsible for arranging transportation for medical appointments when family assistance is not available, but this protocol was not adhered to for this resident.
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Illustrative
What surveyors actually found near you
We read the 210 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
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Illustrative
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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) |
|---|---|---|---|---|
| Covenant Village Care Center | 0.1 mi | ★★★★★ | 0 | 0 |
| Brandel Manor | 0.3 mi | — | 0 | 0 |
| North Starr Postacute Care | 1 mi | ★★★★★ | 15 | 0 |
| Main West Postacute Care | 1.9 mi | ★★★★★ | 1 | 0 |
| Ceres Postacute Care | 9.5 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.