Turlock Nursing and Rehabilitation Center

In the surveyor’s words

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

• Actual harm, isolatedF684Aug 23, 2021

  Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one of three sampled residents (Resident 1) when licensed nurses did not notify the physician, did not conduct assessment or monitoring after Resident 1 experienced a hypoglycemic (low blood sugar) event on 10/29/20 at 12:54 p.m., requiring emergency treatment with IV (intravenous- in the vein) medication. Resident 1 remained in the facility after emergency IV treatment and licensed nurses did not conduct change of condition assessments and did not follow facility policy and procedure to monitor the hypoglycemic event resulting in Resident 1 experiencing a second hypoglycemic episode on 10/29/20 at 6:00 p.m. […]

• No harm, potential for more than minimal, widespreadF802Mar 6, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Mar 6, 2026

  Based 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.These failures had the potential risk of cross contamination (process by which bacteria is transferred from one object or substance to another, with harmful effect) and exposure of microorganisms (a microscopic organism, especially a bacterium, virus, or fungus) that harbor foodborne pathogens (a bacterium, virus, or other microorganism that can cause disease) from improperly… […]

• No harm, potential for more than minimal, widespreadF880Mar 6, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF803May 21, 2024

  Based 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. Findings: During a review of the Detailed Census Report, (census), dated 5/21/24, the census indicated there were 134 residents in the facility. During an observation on 5/21/24, at 11:40 AM, in the facility kitchen, [NAME] 1 was cutting a cooked meatloaf into slices for lunch. […]