Turlock Nursing and Rehabilitation Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 1) were safe from physical abuse when Resident 2 struck Resident 1 with a call light (device used to summon staff for assistance, consisting of a long insulated electrical cord with a 1/4 inch metal headphone-type jack on one end, and a bulbous handheld activator button on the other, with a metal clasp to attach to linens or clothing) several times on the head, face, hand, and forearm. This failure resulted in lacerations (cuts in the skin) to the scalp, forehead, cheek, left forearm, and left hand; pain, and bleeding. During a review of Resident 1's admission Record (AR) dated 6/18/26, the AR indicated Resident 1 was a [AGE] year-old male admitted to the facility about three months earlier. [...]

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure Maintenance Director (MAIND) and Dietary [NAME] (DC) were trained to carry out the functions of the food and nutrition services safely and effectively for 136 of 136 residents when:1. MAIND did not sanitize ice bin during cleaning process according to the manufacturer's guidelines.2. DC did not demonstrate correct thermometer calibration during meal preparation. These failures had the potential to place all 136 residents receiving food from the kitchen at risk for cross-contamination (process by which bacteria is transferred from one object or substance to another, with harmful effect) and exposure of foodborne illnesses (a condition where a person becomes sick after consuming contaminated food or beverages. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices were followed for 136 of 136 residents when:1. A bin containing six bags of stew meat was not labeled with pull-out (a date when items were taken out from the freezer to thaw out in the refrigerator) and use-by date.2. Black and brownish substances were found inside the ice machine. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an effective infection prevention and control program to help prevent the development and transmission of infections for 11 of 23 sampled residents (Resident 143, Resident 46, Resident 53, Resident 154, Resident 39, Resident 109, Resident 70, Resident 20, Resident 149, Resident 5 and Resident 111) when:1. Resident 143 had a peripherally inserted central catheter (PICC line- a long, thin, flexible tube inserted into a large vein in the upper arm, with its tip near the heart) dressing that was not changed for nine days, was not labeled accurately during a dressing change, and the insertion site was not visible under the transparent dressing after a dressing change. [...]

Inspectors wroteBased on Observation, interview, and record review, the facility failed to follow policy and procedure (P&P) and professional standards of practice to ensure residents were not prescribed unnecessary medications to treat resident's medical symptoms for three of three sampled residents (Resident 13, Resident 49, and Resident 148), when:1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure professional standards of practice and facility's policies and procedures (P&P) were followed and implemented for two of 13 residents (Residents 78 and 29) when:1. Resident 78 was not assessed by Licensed Nurses for insidious (gradual unintended weight loss) and significant unintentional weight loss of more than five percent from 2/5/26 to 3/2/26. This failure had the potential for Resident 78 to experience unrecognized decline in health conditions and a delay in implementing nutritional interventions and services.2. Resident 29 maintained and self-administered probiotic (live, beneficial bacteria) capsules and probiotic with fiber gummies supplements at bedside with no physician's order. [...]

Inspectors wroteF759 Free of Medication Error Rate of 5% or moreBased on observation, interview and record review, the facility failed to ensure the medication error rate was not five percent or greater for four of eight sampled residents (Resident 136, Resident 143, Resident 40, and Resident 69), when:1. Resident 136 was administered an 800 mg sevelamer tablet, a medication to be taken with meals, before meals were served.2. Staff did not use the measuring stick provided by manufacturer and did not administer the diclofenac gel dose according to prescriber order for Resident 143. 3. Resident 40 was not administered prescribed dose of sennosides when some crushed medication was left in cup unadministered, and Resident 40 was administered docusate sodium gel tablet with a spoon from his crushed medication cup and Resident 40 the chewed medication instead of swallowing the gel tablet whole.4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals (a substance such as vaccines or drugs derived from a living organism used for treatment) were stored and labeled in accordance with currently accepted professional standards and practice when:1. The facility failed to ensure medications for one of one Resident (Resident 69's) Inhaler (medications used to treat respiratory disease with a mist or spray that the patient breathes in through the nose or mouth) dispenser was labeled with Resident 69's name and medication expiration date and Resident 69's insulin aspart (a fast-acting form of insulin used to treat high blood sugar) injectable pen was not labeled with the medication expiration date.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program that ensured the facility was free of pests for three of six sampled residents (Residents 11, 145, and 147) when ants were observed on Resident 11, 145, and 147's nightstands. This failure resulted in the potential for disease transmission, food contamination, and secondary infections due to ant bites. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were stored safely and securely for one of six sampled residents (Resident 29) when Resident 29 had been assessed as not capable of keeping medications at bedside for self-administration and two over the counter (OTC) supplements (probiotic -live, beneficial bacteria) capsules and probiotic with fiber gummies) were found in Resident 29's unlocked bedside table. This failure resulted in Resident 29 self-administering OTC supplements without a physician order, Resident 29's supplements being accessible to residents, visitors and staff and the potential for unintended use. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure respect and dignity for two of 13 sampled residents (Resident 147 and Resident 40) when:1. Resident 147's lunch tray on 3/3/26 was delivered 24 minutes after all other residents received their meals in the Tuolumne dining room due to his dining location on his meal ticket not being updated for 4 days. 2. Resident 40 gave his lunch tray to Resident 58 and staff did not check residents' lunch trays to ensure all residents received their correct lunch tray at the same timeThis failure resulted in Resident 147 and Resident 40 having to observe other residents eating without being able to participate which led to Resident 147 eating his meal alone and could result in a non-dignified social dining experience with the potential to cause feelings of exclusions or isolation. 1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement a comprehensive person-centered care plan for one of seven sampled residents (Resident 149) when Resident 149's care plan for Stage 3 pressure ulcers ( a deep, full-thickness skin loss injury where subcutaneous fat is visible, but muscle, tendon, or bone are not exposed) to coccyx ( the last bone at the bottom [base] of your spine) was not implemented. This failure resulted in Resident 149 not receiving necessary care and treatment in promoting wound healing and placed Resident 149 at increased risk of an avoidable worsening of pressure ulcers (areas of damaged skin caused by staying in one position for too long), developing new pressure ulcers and wound infection (an invasion of the body by bacteria or viruses that cause disease). During a concurrent observation and interview on 3/3/26 at 10:47 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure necessary care and treatment in promoting wound healing, preventing infection (an invasion of the body by bacteria or viruses that cause disease), developing new pressure ulcers (areas of damaged skin caused by staying in one position for too long) and preventing worsening of existing pressure ulcers were implemented for one of seven sampled residents (Resident 149) when Resident 149 had no pressure relieving device when sitting in a wheelchair and was not repositioned by the nursing staff while sitting in a wheelchair for more than two hours. Resident 149 had a Stage 3 pressure ulcers (is a deep, full-thickness skin loss injury where subcutaneous fat is visible, but muscle, tendon, or bone are not exposed) to coccyx (is the last bone at the bottom [base] of your spine). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receive appropriate services to maintain or improve mobility with the maximum practicable independence for one of seven sampled residents (Resident 35) when Resident 35's Restorative Nursing Program (RNP- a formal, planned and organized program of care which is intended to restore a lost ability or maintain a potentially deteriorating function for a particular resident. RNP is initiated when a resident is discharged from formalized physical, occupational, or speech rehabilitation therapy services) was not developed and implemented after completion and discharge from skilled Occupational Therapy services on 1/30/26. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the daily nurse staffing information posted for public viewing accurately identified the actual number of Registered Nurses (RNs), Licensed Vocational Nurses (LVNs) and Certified Nursing Assistants (CNAs) providing direct care for each shift. Review of the facility's posted staffing sheets indicated staffing was reported under the categories of Licensed and Unlicensed staff, which combined RN and LVN hours under licensed staff and combined CNA and Restorative Nursing Assistant (RNA) hours under unlicensed staff. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free of significant medication errors, when one of one resident (Resident 69) was administered the incorrect dose of Dulaglutide (an injectable medication used to improve blood sugar levels in the blood) that was prescribed by the physician from January 27 2026 to March 3 2026, which resulted in continued high blood sugar levels requiring the increase and addition of medications to help regulate Resident 69's blood sugar levels. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure and maintain complete medical records for one of seven sampled residents (Resident 4) when Resident 4's Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) was not signed by the physician. Resident 4's POLST was prepared by qualified staff and signed by Resident 4 on 1/27/26. This failure had the potential for Resident 4 not to receive necessary care and treatment according to her wishes as stated in her POLST during emergency or significant change of conditions. During a concurrent observation and interview on 3/3/26 at 11:50 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled residents (Resident 1's) family member (FM 1) was notified of a significant change of condition when Resident 1 returned to the facility after a seven-day stay in a nearby hospital, and facility staff noted Resident 1 had new areas of skin breakdown, was refusing further skin assessment of this new breakdown, was refusing antibiotics (medication used to treat infections), and refusing to have a blood test as ordered by her physician. This failure resulted in Resident 1's family being unaware of Resident 1's changes in condition upon her return to the facility from the hospital.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy on resident possessions when it failed to return belongings to the family of one of five sampled residents (Resident 1) when a 42-inch television belonging the Resident 1 was not returned to her family when Resident 1 was discharged from the facility. This failure resulted in Resident 1's family not receiving Resident 1's 42-inch television upon Resident 1's discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 2) had bed rails installed as determined by the facility's Bed Rails - Safety Assessment (BRSA) . (The United States Food and Drug Administration's website page, titled, Adult Portable Bed Rail Safety, dated 2/27/23, indicated, Adult portable bed rails are used by many people to help create a supportive and assistive sleeping environment in homes, assisted living facilities and residential care facilities. This type of equipment has many commonly used names, including side rails, bed side rails, half rails, safety rails, bed handles, bed canes, assist bars, grab bars, and adult portable bed rails. [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure the rights of 1 of 3 sampled residents (Resident 11) were respected and honored when one Certified Nursing Assistant (CNA 9) displayed an obscene finger gesture toward Resident 11. This failure had the potential for Resident 11 to experience a negative effect to his psychosocial well-being, and, 2. Honor the rights of an unknown number of resident rights by ensuring staff followed their policy and procedure and spoke only English in the facility. This failure had the potential for resident rights to not be honored when an unknown number of residents heard staff speaking a non-English language, and possibly thinking staff were speaking about them.

Inspectors wroteBased on interview and record review, the facility failed to ensure timely responses to 2 of 5 residents (Resident 6, Resident 7) requests for pain relief when they had to wait over 30 minutes for a nurse to bring them their prescribed pain medication. This failure had the potential for Resident 6 and Resident 7 to have their pain poorly managed, potentially resulting in prolonged pain and discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Interdisciplinary Team (IDT- a group of professional individuals involved in the care of the resident) assessed one of 14 sampled resident (Resident 4) on the resident ' s ability to self-administer medications safely and accurately when Resident 4 did not take her six oral medications left by License Vocational Nurse (LVN) 3 at the bedside table. This failure had the potential to result of Resident 4 not receiving the correct dose of medications necessary to treat her condition or illness.

Inspectors wroteBased on interview and record review, the facility failed to notify the Responsible Party (RP- the person who is responsible for paying the patient ' s account bills) of a change of condition for one of 14 sampled resident (Resident 3) when Resident 3 was diagnosed with Urinary Tract Infection (UTI- a bacterial infection that occurs when bacteria enter the urinary tract) and was started on antibiotics (a medication that kills bacteria). This failure resulted for the RP not aware of Resident 3 ' s UTI diagnosis and was not able to make informed decisions and participate with Resident 3 ' s care and treatment.

Inspectors wroteBased on observation, record review, interview, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to accurately code a Minimum Data Set (MDS) assessment for 1 (Resident #277) of 33 residents for whom MDS assessments were reviewed. Specifically, the facility failed to ensure Resident #277's 08/02/2024 admission MDS assessment reflected the presence of a nephrostomy tube.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to complete Abnormal Involuntary Movement Scale (AIMS) assessments every six months in accordance with a care planned intervention for 1 (Resident #81) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to follow physician's orders requesting psychiatric evaluations for 2 (Residents #81 and Resident #9) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on interview, record review, and review of the National Pressure Ulcer Advisory Panel (NPUAP) document titled Pressure Injury Stages, the facility failed to ensure Nurse Practitioner (NP) #37 followed professional standards of practice for wound staging for 1 (Resident #278) of 5 residents reviewed for pressure ulcers/injury. Specifically, NP #37 reverse staged Resident #278's Stage 4 right heel pressure injury to a Stage 3.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure proper incontinence care was provided for 1 (Resident #58) of 3 residents observed during incontinence care.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to reevaluate the appropriateness of continued use of bed rails after a resident attempted to climb over their bed rails and sustained a fall. This deficient practice affected 1 (Resident #23) of 8 residents reviewed for accidents.

Inspectors wroteBased on observation, interview, record review, facility document review, and facility policy review, the facility failed to ensure enhanced barrier precautions (EBP) were followed while providing direct care for 1 (Resident #91) of 6 residents reviewed for pressure ulcers and 1 (Resident #54) of 1 resident reviewed for dialysis. The facility also failed to ensure staff washed their hands and changed soiled gloves when providing incontinence care, which affected 1 (Resident #58) of 3 residents observed during incontinence care.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure the menu approved by the Registered Dietitian (RD) was followed for 131 of 131 residents when the meatloaf portion served to residents was less than 4 ounces (oz-unit of measurements). This failure had the potential for residents to receive the wrong caloric intake and not meet the nutritional needs of the residents which could compromise their medical status.

Inspectors wroteBased on interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one of three sampled residents (Resident 1) when Resident 1 was admitted in the facility on 10/3/24 for status post left hemiarthroplasty (a surgical procedure where half of the hip is relaced) and scheduled to have a follow-up appointment with Orthopedic Surgeon (OS- a physician who specialized in treating injuries and diseases of the bones) on 10/26/23. The Facility did not know of the appointment and did not perform a hip xray (a test used to create pictures inside of the body) for Resident 1 to bring for the appointment. [...]

Inspectors wroteBased on interview and record review, the facility failed to assist in making transportation arrangements for one of three sampled residents (Resident 1), when Resident 1 was scheduled to have an orthopedic surgeon (OS- a physician who specialized in treating injuries and diseases of the bones) appointment on 10/26/23 and the facility did not know of the appointment and did not make prior transportation arrangements from the facility to the OS appointment. This failure resulted in Resident 1's family member (FM) to transport Resident 1 in her private vehicle at the last minute to the OS appointment.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, and prepare food in accordance with professional standards for food service safety and proper sanitary conditions when: 1. The walk-in refrigerator stored expired (past the storage guidelines) vegetables. 2. The ice machine contained yellow substance on the evaporator (part where the ice cubes were formed). 3. The commercial can opener had black particles on the blade. These failures resulted in unsafe food storage that could potentially lead to contamination and foodborne illnesses for residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice when: 1. One of two sampled Licensed Vocational Nurse (LVN )1 signed Resident 36's electronic medication administration record (e-mar) before administering her medications. This failure had the potential to result in medication errors. 2. The physician order for one of three sampled residents (Resident 8's) insulin (medication to treat high blood sugar) medication was incomplete and did not include the indicated time for the insulin medication administration. This failure had the potential to place Resident 8 at risk for a hypoglycemic (low blood sugar) episodes.

Inspectors wroteBased on observation, interview and record review the facility failed to accommodate the needs for one of 30 sampled residents (Resident 455) when the call light was not within Resident 455's reach. This failure resulted in Resident 455's needs not being met and being unable to reach her call light to ask for help.

Inspectors wroteBased on observation and interview, the facility failed to protect the privacy of personal information for one of three sampled residents (Resident 36) when Licensed Vocational Nurse (LVN) 1 left the protected health information (PHI) exposed for public view. This failure resulted in the potential for unauthorized access to personal resident information and violated Resident 36's rights to confidentiality.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a plan of care to reflect the care needs for one of two sampled residents (Residents 106) with clostridium difficile (c. diff - a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon) when Resident 106 did not have a care plan to direct the care required to address a C-Diff infection of Resident 106. This failure placed Resident 106 at risk of not receiving appropriate, consistent and individualized care to ensure his needs were being met.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services for one of three sampled residents in the dining table (Resident 131) when Resident 131 did not receive the needed feeding assistance during her lunch meal. This failure had the potential to result in Resident 131 not meeting her daily nutritional needs, and the potential to result in unplanned weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer pain medication at the prescribed time for one of three sampled residents (Resident 37) when Resident 37's pain medication was administered an hour and a half after the scheduled prescribed time. This failure resulted in Resident 37 stating she was crying due to being in pain for over one hour.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and implement an effective infection prevention and control program designed to prevent spread of infectious organisms for one of two sampled residents (Resident 509) with known diagnoses of clostridium difficile (C- diff - a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon), when Resident 509 sat in the social dining area, ate next to other residents in the facility and the facility did not implement their infection prevention practices to prevent the potential spread of C-diff infection to other residents in the dining area as indicated on the facility's protocol criteria. This failure had the potential to place other residents at unnecessary risk of exposure to an infectious bacterium (germ).