Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at North Starr Postacute Care during CMS and state inspections, most recent first.
The facility did not monitor or document the temperature of the medication room and refrigerator on two consecutive days, as required by their policy. This lapse was discovered during an observation with the DON, who confirmed that LNs were responsible for this task. The medication room contained various over-the-counter drugs, while the refrigerator stored critical items like vaccines and insulin. The absence of temperature records could affect the effectiveness of these medications.
The facility failed to ensure that all staff completed mandatory annual in-service training for Abuse Prevention and Fall Prevention. 11 out of 28 staff members missed the Abuse Prevention training, and 16 out of 28 missed the Fall Prevention training. No remedial classes were offered, potentially leaving staff without the necessary knowledge to prevent abuse and falls among residents.
Two residents reported the west hall shower room as unclean and unsafe due to missing and stained tiles. Both residents, who were cognitively intact, expressed reluctance to use the shower. Maintenance and housekeeping staff acknowledged the issues, and the DON confirmed the shower's condition was not acceptable, posing potential risks.
Two residents in a LTC facility experienced safety risks due to malfunctioning wheel locks on their wheelchairs, which were not reported for repair. Despite protocols requiring staff to report such issues, the wheel locks remained loose, posing potential injury risks. The residents, both with significant medical histories, relied on their wheelchairs for mobility.
The facility failed to develop and implement comprehensive care plans for three residents, leading to potential health risks. A resident's care plan lacked interventions for a shoulder sling after a fall, another resident's plan did not address medication refusal, and a third resident was not supervised during meals despite needing assistance. These deficiencies were acknowledged by the Director of Nursing and other staff.
A resident with cognitive impairment and multiple medical conditions experienced an unwitnessed fall resulting in a left arm and shoulder injury. The resident reported being pushed, but the facility failed to investigate the allegation of abuse or report the incident to the California Department of Public Health (CDPH) and the Ombudsman office. The Licensed Vocational Nurse (LVN) and Director of Nursing (DON) did not complete or submit the required documentation, contrary to the facility's policy.
A resident with COPD repeatedly refused a prescribed inhaler, but the refusals were not documented, nor was the physician notified, as required by facility policy. This oversight was acknowledged by an LVN and confirmed by the DON, highlighting a failure to adhere to professional standards of practice.
The facility did not meet the required room size of at least 80 square feet per resident in 15 out of 16 rooms, with rooms measuring only 143 or 144 square feet for two residents each. Despite this, the report notes that residents had reasonable privacy and accessibility, and the waiver does not adversely affect their health and safety.
Failure to Monitor Medication Storage Temperatures
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Medication Storage in the Facility' by not monitoring and documenting the temperature of the medication room and medication refrigerator on 9/8/24 and 9/9/24. This oversight was identified during an observation and interview with the Director of Nursing (DON) on 9/10/24. The medication room contained various over-the-counter medications, while the medication refrigerator stored critical items such as a vial of pneumovax vaccine, tuberculin tests, regular insulin vials, insulin glargine pens, and an emergency kit with insulins. The absence of temperature documentation for these dates was confirmed by reviewing the facility's temperature logs, which showed blank entries for the specified days. The DON acknowledged that the medications could lose their effectiveness if stored at incorrect temperatures, emphasizing that Licensed Nurses (LNs) were responsible for checking and documenting the temperatures. The facility's policy required medications stored at room temperature to be kept between 59 and 86 degrees Fahrenheit, and those requiring refrigeration to be maintained between 36 and 46 degrees Fahrenheit. The failure to document the temperatures as per the policy posed a potential risk to the effectiveness of the stored medications and biologicals.
Failure to Complete Mandatory Abuse and Fall Prevention Training
Penalty
Summary
The facility failed to ensure that all staff, including Licensed Nurses (LNs), Certified Nursing Assistants (CNAs), and ancillary support staff, received and demonstrated competency in preventing and recognizing resident abuse and in caring for residents at high risk for falls. Specifically, 11 out of 28 staff members did not attend the mandatory annual in-service training for Abuse Prevention, and 16 out of 28 staff members did not attend the mandatory annual in-service training for Fall Prevention. The Director of Staff Development (DSD) acknowledged that no remedial classes were offered for those who missed the initial sessions, which could result in staff lacking the necessary knowledge to prevent abuse and falls among residents. The facility's policy and procedure documents, as well as job descriptions for various staff roles, emphasize the importance of mandatory training in areas such as resident rights, abuse prevention, and fall prevention. Despite these requirements, the facility did not ensure compliance with its own policies, potentially placing residents at risk for unsafe and incompetent care. The Director of Nursing (DON) confirmed that these trainings are mandatory and should be completed annually by all relevant staff to ensure proper care for residents.
Facility Fails to Maintain Clean and Safe Shower Environment
Penalty
Summary
The facility failed to provide a clean, safe, and homelike environment for two residents, identified as Residents 16 and 22, due to the condition of the west hall shower room. The shower room was accessible for use despite having missing floor tiles and existing tiles that were black with yellow areas in the grout. This condition was observed during a survey, and both residents expressed their reluctance to use the shower due to its unclean state, opting instead to request access to another shower in a different hallway. Resident 16, who was admitted with serious medical conditions including metabolic encephalopathy, severe sepsis, and Fournier disease, was cognitively intact with a BIMS score of 13. Resident 22, also cognitively intact with a BIMS score of 15, had been admitted with a fracture of the left femur and other health issues. Both residents reported the shower's uncleanliness during interviews, indicating that the environment was not conducive to their comfort and safety. The maintenance staff acknowledged the age and condition of the shower tiles, noting that missing tiles could not be cleaned properly and posed an infection risk. The housekeeping supervisor confirmed that requests had been made to repair the tiles, and the Director of Nursing stated that the shower's condition was not acceptable, as it could cause injury and did not provide a homelike environment. The facility's job descriptions and policies emphasized the importance of maintaining a clean and safe environment, which was not upheld in this instance.
Failure to Maintain Safe Wheelchair Conditions for Residents
Penalty
Summary
The facility failed to maintain a safe environment for two residents, identified as Residents 20 and 22, due to malfunctioning wheel locks on their wheelchairs. Resident 20, who was admitted following joint replacement surgery and had a history of morbid obesity, hypertension, muscle weakness, and anxiety disorder, reported that the right wheel lock on her wheelchair had been loose for two weeks. Similarly, Resident 22, who had a history of a left femur fracture, hypertension, muscle weakness, and difficulty walking, reported that the left wheel lock on her wheelchair had been loose for several weeks. Both residents expressed concerns about the safety of their wheelchairs, which were essential for their mobility. During observations and interviews, it was confirmed by a Certified Nurse Assistant (CNA) and the Maintenance Supervisor (MAINS) that the wheel locks on both residents' wheelchairs were indeed loose and not functioning properly. The CNA acknowledged that loose wheel locks could increase the risk of injury, and the MAINS confirmed that such issues should be reported immediately for repair. However, there were no documented maintenance requests for the wheel locks of Residents 20 and 22, indicating a failure in the reporting process by the staff. The Director of Nursing (DON) stated that both licensed and unlicensed staff were responsible for reporting equipment issues, either through a maintenance log for non-emergent issues or directly to the maintenance supervisor for urgent matters. The facility's job descriptions and policies emphasized the importance of maintaining a safe environment and reporting equipment malfunctions. Despite these protocols, the staff failed to report the malfunctioning wheel locks, which could potentially lead to falls or injuries for the residents involved.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to potential health risks. Resident 1's care plan did not include interventions for the use of a left shoulder sling after an unwitnessed fall, which could have worsened her injury. Despite the presence of a sling and a diagnosis of a humeral fracture, there was no physician order or care plan intervention documented for its use. The Director of Nursing acknowledged that the care plan should have been resident-specific and that the facility did not follow its care planning policy. Resident 10's care plan was incomplete as it did not address her refusal of medications, specifically her Fluticasone-Salmeterol inhaler. The Licensed Vocational Nurse noted that there was no documentation of the physician being notified of the refusals, nor was there a care plan developed to manage this issue. The absence of a care plan for medication refusal could have led to a deterioration of Resident 10's Chronic Obstructive Pulmonary Disease. The facility also failed to implement the care plan for Resident 6, who required monitoring and assistance during meals due to dysphagia. Despite the care plan's recommendation for 1:1 feeding assistance, Resident 6 was observed eating without supervision, which could have led to choking or aspiration. The Infection Preventionist and the Director of Nursing confirmed that the care plan was not followed, which could have resulted in missed care and potential health decline for Resident 6.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse and report the results to the State Survey Agency within the required timeframe. This deficiency involved a resident who had an unwitnessed fall resulting in a left arm and shoulder injury. The resident, who had a history of cognitive impairment and multiple medical conditions, reported being pushed, which led to the injury. However, the facility did not complete an incident report or submit the necessary documentation to the California Department of Public Health (CDPH) and the Ombudsman office. The Licensed Vocational Nurse (LVN) on duty at the time of the incident did not recall completing the required incident report or submitting it to the appropriate authorities. The Director of Nursing (DON) also confirmed that there was no record of the incident being reported, and she did not believe it was a reportable incident. This lack of action was contrary to the facility's policy and procedure, which mandates that all reports of abuse or injuries of unknown sources be promptly reported and thoroughly investigated. The facility's policy requires that findings of abuse investigations be reported to the appropriate agencies within five working days. However, in this case, the facility did not adhere to its policy, potentially placing the resident and other vulnerable residents at increased risk of abuse. The failure to report and investigate the incident as per the policy highlights a significant deficiency in the facility's handling of such events.
Failure to Notify Physician of Medication Refusal
Penalty
Summary
The facility failed to meet professional standards of practice by not notifying the attending physician of a resident's ongoing refusal to take a prescribed inhaler medication, Fluticasone-Salmeterol, which is used to prevent inflammation and narrowing of the airway. The resident, who was admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Hypertension, Muscle Weakness, and Congestive Heart Failure, had a history of refusing the inhaler. Despite this, there was no documentation of the refusals in the Medication Administration Record (MAR) or any notification to the attending physician, as required by the facility's policy. The Licensed Vocational Nurse (LVN) acknowledged the lack of documentation and communication, stating that the inhaler should have been depleted if administered as ordered. The Director of Nursing (DON) confirmed that the facility's policy required nurses to document medication refusals and notify the physician after three or more refusals. The failure to follow these procedures could potentially lead to a worsening of the resident's COPD condition.
Facility Fails to Meet Room Size Requirements
Penalty
Summary
The facility failed to provide the minimum required square footage per resident in 15 out of 16 rooms during a survey conducted from 9/10/24 to 9/13/24. Specifically, rooms 2 through 16 did not meet the regulatory requirement of at least 80 square feet per resident in multiple occupancy rooms. Observations made on 9/12/24 at 4:33 p.m. during an environmental tour with the maintenance supervisor revealed that these rooms, housing two residents each, measured only 143 or 144 square feet, falling short of the required space. Despite these deficiencies, the report notes that variations were made according to the particular needs of the residents, and there was a reasonable amount of privacy, adequate storage, and accessibility for wheelchairs and toilet facilities. The report suggests that the waiver of the square footage requirement does not adversely affect the health and safety of the residents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 179 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Turlock
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brandel Manor | 0.8 mi | — | 0 | 0 |
| Main West Postacute Care | 0.9 mi | — | 1 | 0 |
| Covenant Village Care Center | 0.9 mi | — | 0 | 0 |
| Turlock Nursing & Rehabilitation Center | 1 mi | — | 0 | 0 |
| Ceres Postacute Care | 9.6 mi | — | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for North Starr Postacute Care.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.