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Complaint Investigation

Tracy Nursing And Rehabilitation Center

November 12, 2025 · Tracy, CA · 545 West Beverly Place
Citations 1
CMS Rating 3/5
Beds 62
Provider ID 555080
Healthcare Facility
Tracy Nursing And Rehabilitation Center
Tracy, CA  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

TRACY NURSING AND REHABILITATION CENTER in TRACY, CA — inspection on November 12, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0678
Quality of Life and Care Deficiencies
Potential for More Than Minimal Harm

Review of the facility P&P indicated, .Policy.Properly trained personnel will be available to provide basic life support, including cardiopulmonary resuscitation (CPR), to those requiring emergency care, prior to arrival of emergency medical personnel, and subject to accepted professional guidelines, advance directives, and physician orders.facility staff will provide basic life support, including CPR.if.absence of a valid, Do Not Resuscitate/DNR order.In a cardiopulmonary emergency, immediately initiate, code blue emergency response to facilitate additional assistance in obtaining, implementing, and activating emergency services.

Facility staff should engage in concurrent/coordinated emergency response activities, to include assessing individual (i,e. quickly evaluating responsiveness, breathlessness, pulselessness, etc.), activating 911, positioning individual for CPR, initiating chest compressions and performing rescue efforts as indicated, retrieving crash cart, verifying code status, and preparing records for emergency transfer as indicated.Initiate chest compression when pulse is absent and continue until EMS arrives, patient begins moving, or consciousness is regained.

The DON acknowledged that the facility's P&P was not followed by nursing staff.

The DON stated her expectation was that because Resident 1 was Full Code, CPR should have been initiated immediately.

The DON further stated that the decision to perform CPR was not up to the nursing staff, as Resident 1's representative had already signed the POLST indicating that Resident 1 was Full Code.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in TRACY, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from TRACY NURSING AND REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.