Tracy Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Tracy Nursing and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 11, 2024

  Based on interview, and record review, the facility failed to provide required supervision for one of three sampled residents, Resident 1, who was dependent on staff for toileting and was left unattended while using the toilet. This failure resulted in Resident 1 attempting to get off the toilet independently without staff supervision which led to a fall and a head injury that resulted in Resident 1's hospitalization on [DATE] and death on [DATE]. Findings: A review of Resident 1's clinical record titled, Admission Record, (a document that contains the resident's personal information) indicated Resident 1 was admitted to the facility on [DATE] with a history that included weakness to the right side of the body following cerebrovascular disease (also called cerebrovascular accident or… […]

• No harm, potential for more than minimal, widespreadF812Dec 5, 2025

  Based on observation, interview, and record review the facility failed to store, prepare, and serve food in accordance with professional standards for food safety when:1. Items past their use by dates and spoiled food items were stored in the dry storage pantry,2. There was no air gap or back flow prevention device installed for the food prep sink or the three compartment sink (a commercial kitchen essential with three basins for washing, rinsing, and sanitizing dishes),3. The dishwasher chlorine level was below the proper level for sanitizing dishes, and4. […]

• No harm, potential for more than minimal, widespreadF880Dec 5, 2025

  Based on observation, interview, and record review, the facility failed to implement a comprehensive water safety management program based on nationally accepted standards to minimize the risk of Legionella (bacteria spreads via inhaling contaminated water and can lead to a serious lung infection) and other waterborne pathogens (a microorganism [bacteria] that exists in water sources or plumbing [pipes required for the water supply, heating and sanitation in a building] systems that can cause serious illness in people over [AGE] years of age and those with weakened immune systems) for a census of 52 residents when:a. The facility did not complete and document a facility wide assessment of potential Legionella growth areas to include flow charts;b. […]

• No harm, potential for more than minimal, patternF677Dec 5, 2025

  Based on observation, interview, and record review the facility failed to ensure four (4) of 20 sampled residents' (Resident 3, Resident 9, Resident 42, and Resident 53) basic grooming needs were met when:Resident 3's fingernails nails were long, jagged, and unclean;Resident 9's fingernails nails were long, jagged, and unclean;Resident 42's fingernails nails were long, jagged, unclean and Resident 42 had an odor coming from her clenched right hand;Resident 53's fingernails nails were long, jagged, and unclean. These failures had the potential for Resident 3, Resident 9, Resident 42, and Resident 53 to sustain injury and/or acquire an infection.Findings:1. […]

• No harm, potential for more than minimal, patternF578Aug 30, 2024

  Based on interview and record review, the facility failed to ensure preferences for end of life or emergency care would be honored for 3 of 22 sampled residents (Residents 12, 43, 49) when, 1. The facility failed to determine upon admission whether Resident 43 and Resident 49 had an Advance Directive (specific instructions about one's own health care) and, if not, determine whether they wished to formulate an Advance Directive; and, 2. The facility failed to ensure a copy of Resident 12's Advance Directive was available at the facility. These failures could have resulted in the residents' end of life wishes not being honored. Findings: 1a. […]