Health inspection·September 5, 2024

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm Based 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. Residents Affected - Few This failure had the potential to result of Resident 4 not receiving the correct dose of medications necessary to treat her condition or illness. Findings: During a review of Resident 4 ' s admission Record (AR-documents that contained the resident ' s demographics and medical diagnosis), dated 9/6/24, the AR indicated Resident 4 was admitted to the facility in 2020, with diagnoses which included Alzheimer ' s Disease (a progressive disease affecting the brain, altering mood, judgement, and memory); and schizophrenia (mental disorder affecting perceptions of reality). During an observation on 9/5/24, at 12:02 p.m., in Resident 4 ' s room, Resident 4 was in bed with her eyes closed and six oral medications inside a small medication cup was on Resident 4 ' s bedside table. The medications were within Resident 4 ' s reached and there was no facility staff in the room. During a concurrent observation and interview on 9/5/24, at 12:05 p.m., with the Assistant Director of Nursing (ADON), in Resident 4 ' s room. Resident 4 was in bed with her eyes closed. The ADON confirmed the six oral medications inside a medicine cup on Resident 4 ' s bedside table. The ADON stated the medications should not have been left at the bedside table. The ADON stated the medication nurse should have ensured Resident 4 took her medications before leaving the room. During a concurrent observation and interview on 9/5/24, at 12:10 p.m., with the Assistant Director of Nursing (ADON), and Licensed Vocational Nurse (LVN) 3, LVN 3 was preparing medications for residents. LVN 3 stated she was the medication nurse assigned to Resident 4. The ADON showed LVN 3 the medication cup with the six medications found in Resident 4 ' s bedside table. LVN 3 stated she recalled entering Resident 4 ' s room around 9 a.m. to give Resident 4 a total of ten prescribed medications, divided into two separate medication cups. LVN 3 stated she observed Resident 4 take the first medication cup and left the second cup at the bedside table and had no idea if Resident 4 took the second medication cup after she left the room. LVN 3 stated she should have not left the medications at Resident 4 ' s bedside table and should have ensure Resident 4 took the medications before she left the room. LVN 3 stated she did not follow the facility ' s policy and procedure for medication (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 555240 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Turlock Nursing & Rehabilitation Center 1111 E Tuolumne Road Turlock, CA 95380 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)