Turlock Nursing and Rehabilitation Center

Name: Turlock Nursing and Rehabilitation Center
Address: 1111 E TUOLUMNE ROAD, Turlock, CA, 95380, US
Telephone: 2096327577

1111 E Tuolumne Road, Turlock, CA 95380 · Stanislaus County · 144 certified beds · avg 134 residents/day · certified since Sep 25, 1986

Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)

2/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

3.73

Nurse hours/resident/day (adjusted)

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

Health inspection rating: ★★☆☆☆2/5 · 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.

All citations in the current public record (42)

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
Jun 17, 2026	D · Potential for harm, one-off	The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Mar 6, 2026	F · Potential for harm, facility-wide	The facility did not have enough support staff to safely and effectively run its food and nutrition service.
Mar 6, 2026	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.
Mar 6, 2026	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.
Mar 6, 2026	E · Potential for harm, repeated	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.
Mar 6, 2026	E · Potential for harm, repeated	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Mar 6, 2026	E · Potential for harm, repeated	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Mar 6, 2026	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.
Mar 6, 2026	E · Potential for harm, repeated	The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests.
Mar 6, 2026	D · Potential for harm, one-off	The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate.
Mar 6, 2026	D · Potential for harm, one-off	The facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings.
Mar 6, 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.
Mar 6, 2026	D · Potential for harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Mar 6, 2026	D · Potential for harm, one-off	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.
Mar 6, 2026	D · Potential for harm, one-off	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.
Mar 6, 2026	D · Potential for harm, one-off	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.
Mar 6, 2026	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.
Jun 18, 2025	D · Potential for harm, one-off	The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
Jun 18, 2025	D · Potential for harm, one-off	The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint
Dec 20, 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. · from a complaint
Dec 12, 2024	E · Potential for harm, repeated	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint
Dec 12, 2024	D · Potential for harm, one-off	The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint
Sep 5, 2024	D · Potential for harm, one-off	The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. · from a complaint
Sep 5, 2024	D · Potential for harm, one-off	The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
Aug 15, 2024	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Aug 15, 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 15, 2024	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.
Aug 15, 2024	D · Potential for harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Aug 15, 2024	D · Potential for harm, one-off	The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Aug 15, 2024	D · Potential for harm, one-off	The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly.
Aug 15, 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.
May 21, 2024	F · Potential for harm, facility-wide	The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. · from a complaint
Mar 26, 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. · from a complaint
Mar 26, 2024	D · Potential for harm, one-off	The facility did not help residents with transportation to and from laboratory services outside the facility. · from a complaint
Sep 27, 2019	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.
Sep 27, 2019	E · Potential for harm, repeated	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Sep 27, 2019	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.
Sep 27, 2019	D · Potential for harm, one-off	The facility did not keep residents' personal and medical information private and confidential.
Sep 27, 2019	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.
Sep 27, 2019	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.
Sep 27, 2019	D · Potential for harm, one-off	The facility did not provide safe and appropriate pain management for a resident who needed it.
Sep 27, 2019	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.

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (7 → 16).

Year	Citations	Worst severity that year
2019	8	F
2024	15	F
2025	2	D
2026	17	F

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)	3.73	4.31	3.95	bottom 22% in California; bottom 48% in the U.S.
Registered Nurse hours	0.59	0.61	0.69	top 34% in California; top 49% in the U.S.
Weekend total nurse staffing	3.47	3.90	3.50	bottom 28% in California; top 43% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.47	0.51	0.48	top 34% in California; top 36% in the U.S.
Total nursing staff turnover (%)	34.9	36.7	45.8	top 45% in California; top 24% in the U.S.
RN turnover (%)	45.5	38.1	42.9	bottom 34% in California; bottom 43% 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 3.89, RN 0.62, weekend 3.63. Staffing rating: 3/5.

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: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5

Who owns this facility

For profit - Limited Liability company · changed ownership in the last 12 months

Owner / manager	Type	Role	Stake	Since
Burnam, Soon	Individual	Corporate Officer	NOT APPLICABLE	09/20/2024
Chan, Alexander	Individual	Managing Control - Governing Body	NOT APPLICABLE	08/01/2025
Chan, Alexander	Individual	Operational/Managerial Control	NOT APPLICABLE	08/01/2025
Chan, Alexander	Individual	ADP of the SNF	NOT APPLICABLE	08/01/2025
Ensign Services INC	Organization	ADP of the SNF	NOT APPLICABLE	09/20/2024
Keetch, Chad	Individual	Corporate Officer	NOT APPLICABLE	03/01/2011
Monette, Cory	Individual	Corporate Officer	NOT APPLICABLE	09/20/2024
Port, Barry	Individual	Corporate Director	NOT APPLICABLE	07/26/2018
Rice, Cheryl	Individual	Managing Control - Governing Body	NOT APPLICABLE	08/01/2025
Rice, Cheryl	Individual	Operational/Managerial Control	NOT APPLICABLE	08/01/2025
Rice, Cheryl	Individual	ADP of the SNF	NOT APPLICABLE	08/01/2025
Sato, Ami	Individual	Corporate Officer	NOT APPLICABLE	09/20/2024
Willits, Adam	Individual	Corporate Officer	NOT APPLICABLE	09/20/2024

Questions to ask on your visit

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

"Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
"How is your kitchen staffed, and have meals ever been delayed because of staffing?"
"What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
"Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
"What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
"Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
"What is your current medication error rate, and what have you changed to bring errors down?"
"Can you show me how medications are stored and secured on the units, including controlled drugs?"
"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
Covenant Village Care Center	0.1 mi	Turlock, CA	★★★★☆	4/5
North Starr Postacute Care	1.0 mi	Turlock, CA	★★★★☆	4/5
Main West Postacute Care	1.9 mi	Turlock, CA	★★★☆☆	4/5
Ceres Postacute Care	9.4 mi	Ceres, CA	★★★☆☆	3/5
Grace Home INC.	11.4 mi	Livingston, CA	★★★★★	5/5
River View Post Acute	11.8 mi	Modesto, CA	★★☆☆☆	2/5
Crestwood Manor	13.0 mi	Modesto, CA	★★★★★	5/5
Modesto Post Acute Center	13.2 mi	Modesto, CA	★★★★★	4/5
Valley Skilled Nursing Center	13.2 mi	Modesto, CA	★★★★☆	4/5
Golden Modesto Care Center	13.2 mi	Modesto, CA	★★☆☆☆	2/5
Garden City Healthcare Center	14.1 mi	Modesto, CA	★★☆☆☆	2/5
Almond Vista Healthcare	14.8 mi	Modesto, CA	★☆☆☆☆	1/5

Compare this facility with the 3 closest →

All facilities in Turlock →

Facility data as of CMS processing date 2026-08-01. CCN 555240.

The Care File

Visit checklist — Turlock Nursing and Rehabilitation Center

1111 E Tuolumne Road, Turlock, CA 95380 · 2096327577

Health inspection rating 2/5 · CMS overall 3/5· Fines (3y): $0

Questions for the administrator:

☐ "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
☐ "How is your kitchen staffed, and have meals ever been delayed because of staffing?"
☐ "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
☐ "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
☐ "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
☐ "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
☐ "What is your current medication error rate, and what have you changed to bring errors down?"
☐ "Can you show me how medications are stored and secured on the units, including controlled drugs?"
☐ "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 555240 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)