Health inspection·February 4, 2026

F 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to provide Physical Therapy (PT-a health professional trained to evaluate and treat people who have conditions or injuries that limit their ability to move and do physical activities) and Occupational Therapy (OT- a health professional that provides services to increase and/or maintain a person's capability to participate in everyday life activities) for five of five residents (Residents 1, 2, 3, 4 and 5) when Residents 1, 2, 3, 4, and 5 did not receive PT and OT treatments ranging from 1/5/26 to 2/4/26 that had been prescribed by their physician. These failures had the potential to result in a decline in the range of motion, decreased functional status, loss of gains and overall weakness for Residents 1, 2, 3, 4 and 5.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive (the mental processes of perception, thinking, learning, memory, reasoning, and judgment) Assessment, dated 12/30/25, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS -an evaluation of attention, orientation and memory recall) score was 15, indicating Resident 1 had no cognitive impairment.During a review of Resident 1's order summary report titled Medication Review Report for December 2025, the Medication Review Report indicated PT and OT orders were prescribed on 12/26/25.During a review of Resident 1's PT and OT evaluation and plan treatment, dated 12/26/25, the PT and OT plan indicated Resident 1's diagnosis of muscle weakness. PT and OT would work with Resident 1, five times a week for four weeks daily from 12/26/25-1/22/26. Resident 1 did not receive PT and OT for the weeks of 1/5/26, 1/12/26 and 1/19/26 for a total of eight missed PT treatments and eight missed OT treatments.During a review of Resident 2's MDS Assessment, dated 10/20/25, the MDS indicated Resident 2's BIMS score was 15, indicating Resident 2 had no cognitive impairment.During a review of Resident 2's order summary report titled Medication Review Report for January 2026, the Medication Review Report indicated PT and OT orders were prescribed on 1/20/26.During a review of Resident 2's PT evaluation and plan treatment, dated 1/21/26, the PT plan indicated Resident 2's diagnosis of muscle weakness. PT would work with Resident 2, five times a week for four weeks daily from 1/21/25-2/4/26. Resident did not receive PT for the weeks of 1/26/26 and 2/2/26 for a total of 7 missed PT treatments. Resident 2 did not have an OT evaluation or treatments documented.During a review of Resident 3's MDS assessment, dated 12/30/25, the MDS indicated Resident 3's BIMS score was 7, indicating Resident 3 had severe cognitive impairment.During a review of Resident 3's order summary report titled Medication Review Report for December 2025, the Medication Review Report indicated PT and OT orders were prescribed on 12/26/25.During a review of Resident 3's PT and OT evaluation and plan treatment, dated 12/28/25, the PT and OT plan indicated Resident 3's diagnosis of muscle weakness. PT and OT would work with Resident 3, five times a week for four weeks daily from 12/28/25-1/24/26. Resident 3 did not receive PT and OT for the weeks of 1/5/26, 1/12/26 and 1/19/26 for a total of thirteen missed PT treatments and fifteen missed OT treatments.During a review of Resident 4's MDS assessment, dated 12/25/25, the MDS indicated Resident 4's BIMS score was 4, indicating Resident 4 had severe cognitive Residents Affected - Some Page 1 of 3 055475 055475 02/04/2026 Main West Postacute Care 812 West Main Street Turlock, CA 95380

F 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some impairment.During a review of Resident 4's order summary report titled Medication Review Report for December 2025, the Medication Review Report indicated PT and OT orders were prescribed on 12/21/25.During a review of Resident 4's PT evaluation and plan treatment, dated 12/23/25, the PT and OT plan indicated Resident 4's diagnosis of abnormalities of gait and mobility. PT and OT would work with Resident 4, five times a week for four weeks daily from 12/23/25-1/19/26. Resident 4 did not receive PT and OT for the weeks of 1/5/26, 1/12/26 and 1/19/26 for a total of thirteen missed PT treatments and fifteen missed OT treatments.During a review of Resident 5's assessment, dated 10/20/25, the MDS indicated Resident 5's BIMS score was 13, indicating Resident 1 had no cognitive impairment.During a review of Resident 5's order summary report titled Medication Review Report for December 2025, the Medication Review Report indicated PT and OT orders were prescribed on 12/13/25.During a review of Resident 5's PT evaluation and plan treatment, dated 12/15/25, the PT and OT plan indicated Resident 5's diagnoses of a pelvic and other abnormalities of gait and mobility. PT and OT would work with Resident 5, five times a week for four weeks daily from 12/15/25-1/11/26. Resident 5 did not receive PT and OT for the weeks of 1/5/26 for a total of five missed PT treatments and five OT treatments.During an interview on 2/4/26 at 4 p.m., with Consultant Administrator (CA), the CA stated their third-party consultant group is currently assisting the Skilled Care Facility (SNF) transition from contracted therapy services (a strategic arrangement where healthcare facilities hire external, third-party companies or independent therapists to provide specialized, temporary, or ongoing rehabilitation services)to in-house therapy services (direct employment of therapist by the facility without outside contractors or agencies to provide rehabilitation services). CA stated PT and OT services should have continued without disruption after 1/5/26 when the contracted therapy services ended. CA stated the actual PT and OT services did not restart until after 1/22/26. CA stated she could not speak to how no PT and OT services affected the residents in the facility.During an interview on 2/4/26 at 4:07 p.m., with the Director of Nurses, the DON stated therapy services are provided for residents to ensure rehabilitating services are provided as ordered by the physician. The DON stated, during our transition from contracted to in-house therapy services, services were not available for PT and OT from 1/5/26 to 1/22/26. The OT was hired on 1/20/26 and the PT was hired on 1/22/26. The DON stated potential outcomes for residents not receiving or finishing their prescribed therapy services include weakness, loss of gains and potential contractures.During an interview on 2/5/26 at 4 p.m., with the PT, the PT stated he was hired on 1/22/26 to provide therapy services as ordered. The PT stated he previously worked with the contracted therapy services, so he was familiar with the residents in the facility prior to coming on board for in-house therapy services. The PT stated that the residents did not receive therapy services from 1/5/26 to 1/22/26 because there was no one hired to do so. The PT stated it was concerning how the facility went about terminating the contracted services without having staff hired prior to the contract termination to ensure there wasn't any disruption in PT services for the residents. The PT stated potential outcomes for residents not receiving services included loss of strength, decline in functional status and potential risk for falls.During an interview on 2/6/26 at 10:37 a.m., with the ADM, the ADM stated in total there were five residents who did not have continued services or evaluations for PT and OT rehab services from 1/5/26 to 1/22/26.During an interview on 2/6/26 at 10:45 a.m., with the DON, the DON stated PT and OT services should be evaluated and assessed by the PT or OT within 72 hours of orders. The licensed nurses are responsible for ensuring notifications are made to the therapy department for evaluations to be conducted. The DON stated from X to X there was not a PT or OT available to conduct the evaluations or continue the current treatment plans for the five residents in the facility. The DON stated it is important for 055475 Page 2 of 3 055475 02/04/2026 Main West Postacute Care 812 West Main Street Turlock, CA 95380

F 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some PT and OT services to continue or for the residents to be evaluated to ensure a decline does not occur and functional mobility remains.During an interview on 2/6/26 at 10:59 a.m., with the ADM, the ADM stated the plan of care and orders for Residents 1,2,3,4 and 5 were not followed according to the physician orders and treatment plans within the medical record. The ADM stated potentially these residents could have experienced increased weakness due to the lack of therapy services. The ADM stated policy for Therapy services were not followed and it was the expectation that the consulting group would assist the facility with a smoother transition, but this did not occur. ADM stated the primary physician should have been notified of the delays and orders should have been clarified to readjust treatments for Resident's 1,2,3,4 and 5.During an interview on 2/6/26 at 11:18 a.m., with the OT, the OT stated she recently got hired on 1/20/26 and prior to that date, she could not speak about what the facility was doing to ensure services for OT. The OT stated currently she is assisting the facility via telehealth (the provision of healthcare provided remotely by means of technology) as she is in Florida. The OT stated that she instructs the staff to assist her with the telehealth with exactly how to perform the necessary assessments while overseeing the movements online. The OT stated OT services are important to ensure residents become stronger to be more independent with self-care, contracture management, and overall quality of life. The OT stated that without oversight, potential quality of life detriment could occur.During a review of the facility's policy and procedures (P&P) titled, Scheduling Therapy Services, dated Jan. 2018, the P&P indicated, .Therapy services shall be scheduled in accordance with the resident's treatment plan. the therapist shall interview the resident and consult with the attending physician as to the type of treatment to be administered. therapy is scheduled in coordination with nursing service and is documented in the resident medical records. residents receiving therapy is posted at each nurses station. The listing contains: the name of the resident, the room number of the resident, the type of therapy scheduled, the time therapy is scheduled, where the therapy is scheduled,. nursing service shall be responsible for preparing and escorting the resident to the therapy area.During a review of the facility's policy and procedures (P&P) titled, Care Plans, Comprehensive Person-Centered, dated Jan. 2018, the P&P indicated, . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The comprehensive, person centered care plan will.include measures objectives and timeframes, describe the services that are to be furnished to attain or maintain the resident highest practicable physical, mental and psychosocial well-being.incorporate identified problem areas. incorporate risk factors associated with identified problems. reflect treatment goals, timetables and objectives. assessments of residents are ongoing and care plans are revised as information about the residents and the residents condition change. 055475 Page 3 of 3