Tracy Nursing and Rehabilitation Center

Name: Tracy Nursing and Rehabilitation Center
Address: 545 WEST BEVERLY PLACE, Tracy, CA, 95376, US
Telephone: 2098356034

545 West Beverly Place, Tracy, CA 95376 · San Joaquin County · 62 certified beds · avg 57 residents/day · certified since Feb 1, 1978

Part of chain: ASPEN SKILLED HEALTHCARE (35 facilities, chain avg rating 3.7★)

3/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

4.38

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 3/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Actual harm, one-off · Jan 11, 2024 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Mar 4, 2024 (Deficient, Provider has date of correction)

All citations in the current public record (44)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Jan 20, 2026	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Jan 20, 2026	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Dec 5, 2025	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Dec 5, 2025	F · Potential for harm, facility-wide	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Dec 5, 2025	E · Potential for harm, repeated	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Dec 5, 2025	D · Potential for harm, one-off	The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function.
Dec 5, 2025	D · Potential for harm, one-off	The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services.
Dec 5, 2025	D · Potential for harm, one-off	The facility did not notify the appropriate authorities when a resident with a mental disorder or intellectual disability had a significant change in condition.
Dec 5, 2025	D · Potential for harm, one-off	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Dec 5, 2025	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Dec 5, 2025	C · Minimal risk, facility-wide	The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day.
Dec 5, 2025	B · Minimal risk, repeated	The facility had resident rooms smaller than required — at least 80 square feet per person in shared rooms and 100 square feet in single rooms.
Nov 12, 2025	D · Potential for harm, one-off	The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes. · from a complaint
Aug 30, 2024	E · Potential for harm, repeated	The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
Aug 30, 2024	E · Potential for harm, repeated	The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint
Aug 30, 2024	D · Potential for harm, one-off	The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
Aug 30, 2024	D · Potential for harm, one-off	The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Aug 30, 2024	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Aug 30, 2024	D · Potential for harm, one-off	The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have.
Aug 30, 2024	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Aug 30, 2024	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Aug 30, 2024	D · Potential for harm, one-off	The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them.
Aug 30, 2024	D · Potential for harm, one-off	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Aug 30, 2024	D · Potential for harm, one-off	The facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care.
Aug 30, 2024	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Aug 30, 2024	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Aug 30, 2024	D · Potential for harm, one-off	The facility had resident rooms smaller than required — at least 80 square feet per person in shared rooms and 100 square feet in single rooms.
Feb 6, 2024	D · Potential for harm, one-off	The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. · from a complaint
Jan 24, 2024	D · Potential for harm, one-off	The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. · from a complaint
Jan 11, 2024	▲ G · Actual harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Nov 30, 2023	D · Potential for harm, one-off	The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint
Sep 21, 2023	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Aug 18, 2023	E · Potential for harm, repeated	The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline.
Aug 18, 2023	E · Potential for harm, repeated	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Aug 18, 2023	E · Potential for harm, repeated	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Aug 18, 2023	E · Potential for harm, repeated	The facility had resident rooms smaller than required — at least 80 square feet per person in shared rooms and 100 square feet in single rooms.
Aug 18, 2023	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Aug 18, 2023	D · Potential for harm, one-off	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Aug 18, 2023	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Aug 18, 2023	D · Potential for harm, one-off	The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason.
Aug 18, 2023	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Aug 18, 2023	D · Potential for harm, one-off	The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective.
Aug 18, 2023	D · Potential for harm, one-off	The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices.
Aug 18, 2023	C · Minimal risk, facility-wide	The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day.

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (14 → 10).

Year	Citations	Serious (G–L)	Worst severity that year
2023	14	0	E
2024	17	1	G ▲
2025	11	0	F
2026	2	0	D

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	California avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	4.38	4.31	3.95	top 34% in California; top 27% in the U.S.
Registered Nurse hours	0.87	0.61	0.69	top 14% in California; top 22% in the U.S.
Weekend total nurse staffing	3.79	3.90	3.50	top 47% in California; top 30% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.63	0.51	0.48	top 19% in California; top 21% in the U.S.
Total nursing staff turnover (%)	51.2	36.7	45.8	bottom 12% in California; bottom 34% in the U.S.
RN turnover (%)	63.6	38.1	42.9	bottom 12% in California; bottom 17% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.59, RN 0.92, weekend 3.97. Staffing rating: 4/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 4/5 · long-stay residents: 5/5 · short-stay residents: 4/5

Who owns this facility

For profit - Limited Liability company

Owner / manager	Type	Role	Stake	Since
Aspen Skilled Healthcare INC	Organization	5% or Greater Direct Ownership Interest	—	07/01/2012
Atmc LLC	Organization	5% or Greater Direct Ownership Interest	—	12/07/2012
Bradshaw, Peter	Individual	Indirect Ownership Interest	NOT APPLICABLE	07/07/2023
Elsner, Eric	Individual	Indirect Ownership Interest	NOT APPLICABLE	12/07/2012
Kirkwood, Jared	Individual	Indirect Ownership Interest	NOT APPLICABLE	01/01/2019
Orgill, Craig	Individual	Indirect Ownership Interest	NOT APPLICABLE	01/01/2019
Parti, Rajesh	Individual	Indirect Ownership Interest	NOT APPLICABLE	12/07/2012
Parti, Shruty	Individual	Indirect Ownership Interest	NOT APPLICABLE	12/07/2012
Paxman, Marcus	Individual	Indirect Ownership Interest	NOT APPLICABLE	04/01/2022
Aspen Healthcare Services LLC	Organization	ADP of the SNF	NOT APPLICABLE	01/01/2023
Aspen Skilled Healthcare INC	Organization	5% or Greater Mortgage Interest	NOT APPLICABLE	10/01/2019
Aspen Skilled Healthcare INC	Organization	ADP of the SNF	NOT APPLICABLE	10/01/2019
Atmc LLC	Organization	Operational/Managerial Control	NOT APPLICABLE	12/07/2012
Atmc LLC	Organization	ADP of the SNF	NOT APPLICABLE	12/07/2012
Bradshaw, Jeffrey	Individual	Corporate Officer	NOT APPLICABLE	07/01/2012
Bradshaw, Jeffrey	Individual	Individual Is an Owner, Partner or Trustee of Any ADP of the SNF	NOT APPLICABLE	03/03/2026
Bradshaw, Jeffrey	Individual	ADP of the SNF	NOT APPLICABLE	10/01/2019
Brady, Vern	Individual	Corporate Officer	NOT APPLICABLE	07/01/2012
Brady, Vern	Individual	ADP of the SNF	NOT APPLICABLE	10/01/2019
Case, Ryan	Individual	Corporate Officer	NOT APPLICABLE	07/01/2012

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"Can you show me an example care plan, and how are families included when it's created and updated?"
"Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
"What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
"How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
"What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
"How do you screen new residents for mental health and disability-related needs, and how do you provide the specialized services they require?"
"How do you coordinate with state agencies for residents with mental health conditions or intellectual disabilities?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
North Park Post-Acute	0.7 mi	Tracy, CA	★★★★☆	3/5
Guardian Care and Rehabilitation Center	12.5 mi	Manteca, CA	★★☆☆☆	2/5
Harvest Crossing Post Acute	12.6 mi	Manteca, CA	★★☆☆☆	2/5	abuse
Bethany Home Society San Joaquin County	16.4 mi	Ripon, CA	★★★★☆	4/5
Lincoln Square Post Acute Care	16.6 mi	Stockton, CA	★★★☆☆	2/5
Good Samaritan Rehab and Care Center	16.9 mi	Stockton, CA	★★★☆☆	2/5
Hampton Post Acute	17.6 mi	Stockton, CA	★☆☆☆☆	1/5	abuse
Brookside Care Center	17.8 mi	Stockton, CA	★☆☆☆☆	1/5
Noble Care Center	17.8 mi	Stockton, CA	★☆☆☆☆	1/5	abuse
Crestwood Manor - 104	17.9 mi	Stockton, CA	★★★☆☆	3/5
Fulton Gardens Post Acute, LLC	18.2 mi	Stockton, CA	★★★☆☆	3/5
Oak Grove Post Acute	18.6 mi	Stockton, CA	★☆☆☆☆	1/5	abuse

Compare this facility with the 3 closest →

All facilities in Tracy →

Facility data as of CMS processing date 2026-08-01. CCN 555080.

The Care File

Visit checklist — Tracy Nursing and Rehabilitation Center

545 West Beverly Place, Tracy, CA 95376 · 2098356034

Health inspection rating 3/5 · CMS overall 3/5· Fines (3y): $0

Most serious findings on record:

▲ Jan 11, 2024 (F-0689, Actual harm, one-off): The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Questions for the administrator:

☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "Can you show me an example care plan, and how are families included when it's created and updated?"
☐ "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
☐ "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
☐ "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
☐ "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
☐ "How do you screen new residents for mental health and disability-related needs, and how do you provide the specialized services they require?"
☐ "How do you coordinate with state agencies for residents with mental health conditions or intellectual disabilities?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 555080 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)