F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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) .
Residents Affected - Few
(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. [These devices are] intended to
assist individuals who are disabled, injured, or recovering from surgery or hospitalized with transfer in and
out of bed or repositioning, intended to reduce risk of falling or fracture or mitigate the risk of falling due to
the effects of balance disorders or other medical conditions. )
This failure resulted in the potential for injury, including a fall, in the event Resident 2 attempted to get in or
out of bed without the bed rails.
Findings:
During an observation on 12/20/24, at 12:40 p.m., of Resident 2's bed, no side rails or grab bars were
noted attached to his bed. Resident 2 was not present.
During a review of Resident 2's admission Record (AR) , dated 12/20/24, the AR indicated he was admitted
to the facility on [DATE] with diagnoses that included Muscle Weakness.
During a review of Resident 2's Bed Rails – Safety Assessment (BRSA) , dated 12/14/24, the BRSA
indicated, Type of Bed Rail to be Used: Grab/Transfer Assist Bars or rails (i.e. ¼ Rails, 1/8 Rails)[.]
Benefits / Indication(s) for use. Facilitate enhanced bed mobility[,] Provide stability during transfers[,] Assist
to enter and exit bed independently[,] Prevent falling for slipping onto floor.[,] Resident / Responsible Party
request for sense of security (fear of falling from bed)[.]
During a review of Resident 2's Order Summary Report (OSR), dated 12/20/24, the OSR indicated a listing
of his current Physician's Orders. The OSR did not contain an order for side rails.
During a review of Resident 2's Care Plan (CP), dated 12/13/24, the CP indicated a Focus as Self-Care
Deficit As Evidenced by Needs assistance with ADLs Related to. weakness, impaired mobility. The Care
Plan did not contain interventions for Bed Rails.
(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 2
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
12/20/2024
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)
F 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During a review of Resident 2's Verification of Informed Consent ([NAME]) , dated 12/13/24, the [NAME]
indicated, 1/2 Bed Rails were to be used Every Shift for Mobility / Transfer. The [NAME] was signed by
Resident 2.
During a concurrent record review, observation, and interview with the Minimum Data Set Registered Nurse
(MDS RN), on 12/20/24, at 2:03 p.m., Resident 2's bed was observed. The MDS RN verified no bed rails
were in place on Resident 2's bed. The MDS RN stated if the facility's BRSA indicated that bed rails, side
rails, or grab bars are to be used, then there should be a corresponding physician's order to that effect, and
this should also be included in Resident 2's Care Plan. The MDS RN verified Resident 2's physician's
orders did not contain an order for bed rails. The MDS RN stated grab bars were a smaller version of bed
and/or side rails. The MDS RN stated Resident 2's bed should have had ½ side rails installed on his
bed.
During a review of the facility's Policy and Procedure (P&P) titled Side-Rails, Use and Safety Of , undated,
the P&P indicated, It is the policy of this facility to utilize bed side-rails in a safe manner, which prevents
injury, when any type of frail is required to assist with bed mobility or used per resident's request for an
increased sense of security. PURPOSE[:] To meet resident's safety needs. To use side rails safely.
PROCEDURE[:] Side-rail safety assessment will be done by a licensed nurse and/or the IDT on
admission.and when changes to existing bed rail use is deemed indicated. (Side-rail types include: two full
rails, one full rail, and one or two partial rails such as ¼, ¾, or ½ rails). The need for use
of a side-rail will be added to the care plan.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555240
If continuation sheet
Page 2 of 2
