Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Anberry Post Acute during CMS and state inspections, most recent first.
Failure to provide timely nail care for two residents. One resident had thick, long fingernails and toenails with jagged edges and said he could not remember the last time his nails were cut, while another resident had thick, long toenails and said they made it hard to wear shoes. Staff said nail care was expected on shower days, CNAs could not trim toenails, and the podiatrist had last visited the facility and did not see these two residents.
An emergency med kit in the med room was found open and had not been replaced by the pharmacy for over two months, despite facility policy requiring replacement within 72 hours. In addition, a resident with epilepsy and severe cognitive impairment had Lamotrigine brought in by family stored in the med cart, and staff could not confirm it had been verified by the facility’s licensed pharmacist. The DON stated family-brought meds should be verified before administration and kept in the med room, not the cart.
A facility failed to properly label and store medications and biologicals on medication carts. An unlabeled topical gel was stored with oral and liquid meds, a resident’s ophthalmic solution lacked open and used-by dates, another resident’s nasal spray was labeled only with a room number, and an LPN administered an expired ondansetron tablet to a resident with multiple chronic conditions, including post-stroke deficits, DM2, HTN, and nausea/vomiting.
Failure to follow EBP during resident care: an LVN accessed a resident’s GT without PPE, a CNA provided brief and linen care to a resident on EBP without wearing PPE, and two CNAs left used gowns at another resident’s bedside after a transfer. The residents involved had a GT, an AKA, and a surgical wound, and staff acknowledged the PPE and disposal lapses.
A resident with ESRD and hemodialysis needs did not have a baseline care plan developed within the required timeframe after admission/readmission. The care plan record initially lacked ESRD/hemodialysis interventions, and staff later confirmed the baseline plan was developed beyond the expected 48- to 72-hour window. The DON stated the baseline care plan should have been individualized and in place when the resident returned to the facility.
A resident admitted with fractures, DM2, depression, PTSD, and anxiety had orders for paroxetine 20 mg and 40 mg daily for depression, but staff could not find a CP for the antidepressant. An LVN stated a medication CP should have been in place to monitor side effects, and the DON said psychotropic and antidepressant CPs should include monitoring for side effects and adverse reactions and be developed within 21 days of admission.
Two residents received apixaban without food despite physician orders directing that it be taken with food. An LVN administered one resident’s meds while breakfast remained untouched and gave another resident’s apixaban via G-tube without connecting the feeding formula. The nurses later acknowledged the orders required food, and the DON stated nurses were expected to verify the MAR, label, and physician orders before giving medications.
A resident who was NPO and dependent on GT feedings for nutrition did not receive a scheduled enteral feeding at the ordered time. The LVN acknowledged the feeding was late because she was behind, and the EMAR documented the feeding as given nearly three hours after the 8:00 a.m. schedule. The resident had diagnoses including dysphagia, gastrostomy status, pneumonia, COPD, hypertension, and severe protein calorie malnutrition, and the DON, UNM, and RN confirmed the feeding was not administered as ordered.
CPAP Order Not Carried Out and Equipment Not Cleaned: A resident with sleep apnea was observed using a CPAP machine that the resident said had not been cleaned for two weeks, with the mask and tubing left at the bedside. The chart lacked a CPAP order in the order summary and the care plan did not address CPAP use, even though a pulmonology note said to continue CPAP. The UNM and DON stated the CPAP order should have been carried out, the use should have been care planned, and the equipment should have been cleaned weekly.
A resident receiving rivaroxaban for DVT prophylaxis and AFib was not monitored per the care plan for anticoagulant side effects, with no EMAR documentation of shift-by-shift checks. Another resident had ticagrelor ordered for an unclear indication, and two residents receiving sertraline for depression did not have non-pharmacological interventions initiated before the psychotropic meds were ordered and given.
Unlabeled and undated food was found in the kitchen walk-in refrigerator and in a nourishment unit refrigerator. A bin of zucchini lacked required labeling, and a box of pizza brought in from outside was not labeled with the resident's name, room number, date brought in or opened, or use-by date. The CDM and RD stated food items should be labeled and dated, and that outside food stored in the nourishment refrigerator required clear identification.
A resident with an ileostomy had no documented bag changes in the TAR/EHR for an extended period despite orders for ostomy care PRN, and the DON could not locate staff signatures showing the care had been provided. In a separate event, an LPN administered a resident’s scheduled meds via G-tube but failed to sign the eMAR afterward, even though staff stated meds should be documented immediately after administration.
Staff COVID-19 Vaccine Education and Offer Not Documented: The facility failed to document education on the benefits and risks of the COVID-19 vaccine and failed to document that the vaccine was offered to three sampled staff members. Record review showed the employee files lacked evidence of vaccine education or an offer of vaccination, and interviews with the IP, DSD, CNA, and DNS confirmed the facility had not continued offering the vaccine or ongoing COVID-19 education after orientation, despite the facility policy requiring staff education and offering the vaccine.
Chemical containers stored in the dirty laundry area were found covered with a thick white foamy substance, with the same substance on the floor below. The LP did not know what the substance was, while the HD, DSM, DM, and ADM all stated they had been aware of the expired sanitizer containers for weeks and had not ensured they were safely removed.
A resident with a pressure ulcer in the sacral region was not turned and repositioned every two hours as required, leading to incomplete documentation and potential worsening of the ulcer. Despite staff awareness of the need for regular repositioning, the care plan did not specify this requirement, and medical records lacked consistent documentation. This deficiency contributed to the resident's death from septic shock.
The facility failed to inform and document information on how to formulate an advance directive for all residents. Staff interviews revealed that residents were referred to external sources for assistance, and no documentation was made in resident charts. The facility's policy required documentation of discussions about advance directives, but this was not followed, violating residents' rights to be informed.
A facility failed to update a resident's care plan after the resident was discharged from hospice services. Despite the discharge, the care plan was not revised to reflect this significant change in condition, as confirmed by interviews with the LVN, MDSN, and ADON. The resident, admitted with multiple diagnoses, was no longer receiving hospice services, but the care plan remained outdated, contrary to the facility's policy requiring updates after changes in condition.
The facility failed to meet professional standards by not labeling oxygen tubing for three residents, not notifying a physician when a resident's hypertension medication was withheld, and administering an incorrect oxygen flow rate to a resident. These actions put residents at risk of infection and adverse health outcomes.
The facility did not post accurate daily nurse staffing information, failing to include specific hours worked by RNs, LVNs, and CNAs. This oversight left residents and families unable to identify care responsibilities and staffing levels. Interviews revealed a lack of awareness about the requirement to post detailed staffing hours.
The facility failed to provide palatable food, with 79 residents receiving bland broccoli and five residents on puree diets receiving unappetizing salads. The DNS acknowledged the lack of seasoning, and the RD was unaware of residents' dissatisfaction. The facility's regular diet exceeded recommended sodium levels, and the RD did not observe plate waste or consult with kitchen staff about the puree salads.
The facility failed to maintain safe storage and sanitation of food and ice, with an ice machine showing black and pink residues, and a refrigerator containing expired apple juice and sticky substances. Maintenance and dietary staff acknowledged these issues, but documentation and oversight were lacking, potentially risking foodborne illness for residents.
The facility failed to provide written notification to residents and their representatives regarding hospital transfers, as confirmed by interviews with an LVN and the ADON. The facility's policy required written notification, but this was not followed, leaving residents and their representatives potentially unaware of the reasons for transfers.
The facility did not provide written notification of the bed hold policy to residents and their representatives upon hospital transfer, affecting several residents. The BOM stated that notifications were only given verbally and at admission, not upon transfer. The ADON confirmed this practice and acknowledged the importance of written notifications for residents to understand their rights.
Two residents in the facility did not have care plans for oxygen administration, despite having conditions requiring oxygen use. One resident, admitted with COPD and other diagnoses, was observed using oxygen without a care plan in place. Another resident, with emphysema and other conditions, had an oxygen flow rate set higher than usual, also without a care plan. Staff interviews confirmed that care plans should have been initiated upon admission to ensure proper monitoring and safety, as emphasized by facility policies.
The facility failed to store and label medications properly, with expired drugs found in medication carts and an antibiotic with an unreadable expiration date in a refrigerator. Additionally, a medication cart was left unlocked, and loose pills were found unsecured in a resident's room, posing risks of unauthorized access and missed doses.
A facility failed to follow the approved menu for 16 residents when gelatin with whipped topping was served instead of the planned ambrosia pudding. This change was made to use leftover gelatin without consulting the registered dietitian, as required by facility policy. The director of nutritional services described the incident as an isolated oversight.
Two LVNs failed to follow infection control practices, with one entering an isolation room without proper PPE and another neglecting hand hygiene and glucometer sanitization. These actions risked spreading infections, contrary to facility policies.
A resident with diabetes and moderate cognitive impairment had long, untrimmed fingernails, which were not addressed by the facility staff. The resident expressed concern about the potential for infection due to his condition. Observations and interviews with staff confirmed the oversight, highlighting a failure to adhere to the facility's policy on personal hygiene and nail care.
Two residents in the facility were not adequately monitored for behaviors while on psychotropic medications, leading to potential unnecessary medication use. One resident, with dementia and depression, was on quetiapine without behavior monitoring, while another, with bipolar disorder and anxiety, lacked monitoring orders for her prescribed medications. Facility policies requiring behavior tracking and interdisciplinary care planning were not followed.
A resident's request for halal meat was not accommodated by the facility, despite discussions with the RD and CDM. The resident, concerned about protein intake, registered as a vegetarian and relied on family to provide halal meat. The facility's policy on accommodating ethnic food preferences was not followed, and the resident's dietary tray card inaccurately indicated a dislike for all meat.
A facility failed to honor a resident's fluid preferences by providing apple juice despite a documented dislike. The resident's dietary tray ticket contained conflicting information, leading to the provision of fluids inconsistent with their preferences. The resident, who was cognitively intact, expressed dissatisfaction with the facility's failure to honor their preferences, which could impact their nutritional intake and quality of life.
A resident's POLST form was found incomplete, with Section B unmarked, failing to document their end-of-life care preferences. Despite being cognitively intact and having serious health conditions, the resident's wishes for medical interventions were not recorded, as confirmed by the Infection Prevention Nurse and Admission Nurse. The facility's medical records policy emphasizes the need for accuracy and completeness, which was not met in this case.
Failure to Provide Timely Nail Care
Penalty
Summary
The facility failed to provide needed nail care in accordance with professional standards of practice for two sampled residents, both of whom had fingernails and toenails that were thick, long, and had jagged edges. During an initial tour, one resident was observed sitting in a wheelchair with thick, long fingernails and toenails with jagged edges and stated he did not remember the last time his nails were cut. He said he wanted his toenails cut because they caught in his socks and he could not wear his shoes or socks, and he wanted his fingernails cut because they were too long and could scratch him. Another resident was observed sitting in a wheelchair wearing open-toed footwear, with toenails that were thick and long. She stated she had not had her toenails trimmed for a while and that it was difficult to wear her new shoes because her toenails were too long. During a later observation, a LVN checked the resident’s fingernails and toenails and stated they were long and needed to be trimmed; the resident stated she wanted her nails trimmed and could not wear her shoes and socks because of her long toenails. Staff interviews indicated nail care was expected on shower days, CNAs were not allowed to trim toenails, and nurses were responsible for resident nail care and for arranging podiatry services. The SSD stated the podiatrist last came to the facility on 5/2/26, saw only 10 residents, and these two residents were not seen.
Emergency Kit Not Replaced and Unverified Family Medication Stored in Cart
Penalty
Summary
Pharmaceutical services were not provided according to facility policy when the refrigerator emergency medication kit in the medication room was found open with a red lock and a slip showing it had been opened on 4/13/26, but it had not been replaced by the pharmacy for more than two months. The Director of Staff Development stated the opened kit should have been replaced by the following day or within 72 hours, and the Director of Nursing stated her expectation was replacement within 48 hours. Facility policy stated opened kits are to be replaced with sealed kits within 72 hours of opening. Resident 75 had a medication bottle of Lamotrigine 200 mg, an antiepileptic medication, stored in the medication cart and available for use. During observation and interview, staff identified that the bottle had been brought in by the family from an outside pharmacy, and Licensed Vocational Nurses stated they could not validate that it had been verified by the facility’s licensed pharmacist. One LVN stated medications brought in by family should be verified before administration, while another stated family-brought medications should not be used and should be returned to the family. Resident 75’s record showed an active order for Lamotrigine 200 mg for seizure disorder, and the admission record listed epilepsy. The Minimum Data Set dated 4/9/26 showed a BIMS score of 7, indicating severe cognitive impairment. Facility policy stated medications brought into the facility are ordinarily not permitted, and if essential, the contents of each container must be verified by a licensed pharmacist before use. The DON stated medications brought by family should be verified by the facility’s licensed pharmacist prior to administration and should be kept in the medication room, not the medication cart.
Medication Labeling, Storage, and Expired Medication Administration
Penalty
Summary
The facility failed to ensure medications and biologicals were labeled and stored according to accepted professional principles. During observation of medication cart 300, a topical gel ointment was found on the bottom shelf with other oral and liquid medications even though it had no medication label and no open date. The RN stated the topical ointment should have been labeled with an open date and used-by date and should have been stored separately from oral and liquid medications to prevent cross-contamination. The DON stated over-the-counter medications were expected to be labeled with the date opened and use-by date, and that oral and topical medications or external medications must be stored separately. Resident 122’s ophthalmic solution was observed on the medication cart with no open date and no used-by date. The RN stated the eye drops should have been labeled with both the date opened and the use-by date, and that these dates were important to determine when the medication was started and when it should be discarded. The DON stated licensed nurses were expected to ensure eye drops were properly labeled with the date opened and the use-by date. Resident 122’s order entry indicated the resident was receiving ophthalmic tears, 1 drop in both eyes three times a day for dry eyes. Resident 19’s nasal spray was labeled only with the resident’s room number. The LVN stated the medication should have been labeled with the resident’s name, room number, date opened, and used-by date. The DON stated licensed nurses should use patient identifiers and verify that medications were properly labeled during administration. Resident 75’s ondansetron HCL 4 mg tablet had an expiration date of 6/9/26 and was still available for use on 6/18/26. The LVN stated she administered the expired medication to Resident 75 and did not check the expiration date before giving it. Resident 75’s EMAR showed ondansetron HCL 4 mg was administered that morning, and the resident’s record showed diagnoses including aftercare following circulatory system surgery, hemiplegia, hemiparesis following cerebral infarction, type 2 diabetes mellitus, essential hypertension, and nausea and vomiting.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program when staff did not follow enhanced barrier precautions during resident care activities for three residents. Resident 21 was on enhanced barrier precautions due to the presence of a gastrostomy tube and had an admission record showing encounter for surgical aftercare following surgery of the digestive system and gastrostomy status. During observation, an LVN prepared and administered the resident’s enteral feeding in the room without wearing PPE. The LVN later stated she did not wear PPE when she accessed the resident’s GT and acknowledged that a gown should have been worn to protect against infection. Resident 97 was also on enhanced barrier precautions related to an above-the-knee amputation. During observation, a CNA entered the resident’s room with linens and a gown to provide brief and linen change without wearing appropriate PPE. The CNA later stated she changed the resident’s brief and linens, did not notice the yellow triangle sign indicating enhanced barrier precautions, and stated she should have worn a gown during the care. The resident was observed lying in bed, awake, alert, and oriented, and stated she had had a bowel movement and was looking for the CNA. Resident 8, who was on enhanced barrier precautions due to a surgical wound and had a BIMS score of 15, was transferred from bed to wheelchair by two CNAs using a sit-to-stand machine. After the transfer, two used gowns were left crumpled at the foot of the resident’s bed. Both CNAs stated the gowns were used during the transfer and should not have been left at the bedside, but should have been bagged and disposed of in the soiled linen room. The facility’s enhanced barrier precaution policy and staff interviews identified gown and glove use for high-contact care activities, including device care, brief changes, linen changes, transferring, and wound care.
Failure to Develop Baseline Care Plan for ESRD and Hemodialysis Needs
Penalty
Summary
The facility failed to develop a baseline care plan for Resident 97 within 48 hours of admission/readmission. Resident 97 was observed lying in bed, awake, alert, and oriented to person, place, and situation, and stated she was receiving dialysis treatment. Record review showed Resident 97’s clinical admission dated 6/12/26 included a diagnosis of end stage renal disease (ESRD) and hemodialysis, but the care plan report did not include a care plan for ESRD and hemodialysis when reviewed on 6/17/26. During interviews, the Unit Nurse Manager stated there was no care plan for ESRD and hemodialysis and said the care plan should have been developed within 72 hours of readmission. The MDS Nurse later confirmed the baseline care plan should be developed within 72 hours from admission or readmission and stated the care plan for hemodialysis related to renal failure and risk for fluid overload was developed beyond 72 hours. The DON stated baseline care plans should be developed within 48 hours of admission or readmission and that Resident 97’s care plan for ESRD and hemodialysis should have been developed when the resident was readmitted to prevent unrecognized complications related to ESRD and hemodialysis treatment.
Missing Care Plan for Antidepressant Medication
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for one sampled resident who was admitted with diagnoses including a displaced intertrochanteric fracture of the right femur, an unspecified fracture of the lower end of the left radius, type 2 diabetes mellitus, depression, PTSD, and anxiety disorder. The resident’s MDS showed a BIMS score of 15, indicating the resident was cognitively intact. The resident’s OSR listed paroxetine HCL 20 mg daily and paroxetine HCL 40 mg daily for depression, with instructions to administer both doses together for a total of 60 mg daily. During interview, an LVN stated that all new admissions should have a care plan, including one for medications, and that she could not find a care plan for the resident’s antidepressant medication. The LVN stated there should have been a care plan to monitor side effects. The DON stated that care plans for medications such as antidepressants should include monitoring for side effects and adverse reactions, and that comprehensive care plans were expected to be created and implemented within 21 days after admission. The facility policy stated that a comprehensive person-centered care plan with measurable objectives and timetables is developed and implemented for each resident and is developed no more than 21 days after admission.
Failure to Follow Apixaban Orders With Food
Penalty
Summary
The facility failed to provide services that met professional standards of quality for two sampled residents when LVN 1 and LVN 3 did not follow physician orders to administer apixaban with food. During a concurrent observation and interview, LVN 1 prepared Resident 25’s medications, including apixaban, and administered them in the resident’s room without food while the breakfast tray remained untouched on the overbed table. Resident 25’s record showed diagnoses including surgical after care following surgery on the digestive system, fracture of the left femur, and muscle weakness, and the order summary directed apixaban 5 mg by mouth twice a day, take with food. During another observation and interview, LVN 3 prepared Resident 9’s medications, including apixaban, and administered them through the resident’s G-tube after flushing with water and without connecting the feeding formula. LVN 3 later reviewed the EMAR and stated the apixaban order indicated to administer with food and that she did not compare the medication directions from the bubble pack. The DNS stated licensed nurses were expected to follow medication administration rights and check the medication label, MAR, and physician orders before administering medications. The facility policy stated medications are administered in accordance with prescriber orders and the individual administering medication checks the label three times to verify the right resident, medication, dosage, time, and method of administration.
Late Administration of Scheduled Tube Feeding
Penalty
Summary
The facility failed to ensure that enteral nutrition was administered according to the physician’s order for one resident who was NPO and dependent on gastrostomy tube feedings for nutrition. The resident had diagnoses including gastrostomy status, dysphagia, pneumonia, COPD, hypertension, and severe protein calorie malnutrition. The resident’s care plan identified nutritional problems related to the gastrostomy tube, dysphagia, pneumonia, and underweight status, with goals to tolerate tube feeding and maintain adequate nutritional and hydration status. During observation, the resident stated she had not received her morning tube feeding and was waiting for her formula, saying her stomach was growling and that she could not eat by mouth. The LVN later stated the resident’s GT feeding was scheduled for 8:00 a.m. and was late because she was behind. The LVN was observed preparing the formula and later stated she administered the enteral feeding. The resident’s EMAR showed the enteral feed order was scheduled every 4 hours, including 8:00 a.m., and the administration was documented at 10:51 a.m., nearly three hours after the scheduled time. The UNM and RN stated licensed nurses were expected to follow the prescribed feeding schedule to ensure the resident received the required calories and protein and to prevent weight loss. The DON and LVN confirmed the feeding was given late, with the LVN stating it was completed almost 11:00 a.m. The resident’s record also showed she had been on NPO status since 5/15/26 and was receiving enteral feeding as her primary source of nutrition.
CPAP Order Not Carried Out and Equipment Not Cleaned
Penalty
Summary
Necessary respiratory care was not provided for Resident 92, who had a diagnosis of sleep apnea and used a CPAP machine. During observation, the resident was in bed, awake, alert, and asking for water while pointing to the CPAP machine at the bedside. The resident stated he applied his own CPAP but was not able to clean it, and said the CPAP machine, mask, and tubing had not been cleaned for two weeks. The resident also stated his wife was coming the next day to clean the equipment. Record review showed the facility did not have a physician's order for CPAP in the order summary report, and the care plan did not include CPAP use. A consultation note from the pulmonology visit stated the resident was doing well with CPAP and to continue use. The Unit Nurse Manager stated the pulmonologist order was not carried out by licensed nurses and that a care plan for CPAP use was not developed and implemented. The Unit Nurse Manager also stated night shift nursing staff were responsible for cleaning the CPAP machine and that it should be cleaned to prevent infection. The resident's admission record listed diagnoses including CHF, chronic atrial fibrillation, hyperlipidemia, and morbid obesity. The facility policy for CPAP/BIPAP support required review of the physician's order, monitoring of oxygen saturation, documentation of therapy, and weekly cleaning of the machine, humidifier, filter, mask, and tubing. The DON stated the physician's order to continue CPAP should have been carried out, the CPAP use should have been care planned, and the mask and tubing should be cleaned weekly to prevent the risk of respiratory infection.
Unmonitored anticoagulant therapy, unclear antiplatelet indication, and missing non-pharmacological interventions
Penalty
Summary
The facility failed to ensure that Resident 8’s anticoagulant regimen was monitored as identified in the resident’s care plan. Resident 8 was admitted with diagnoses including fusion of spine, chronic atrial fibrillation, long-term use of anticoagulants, and essential hypertension, and had a BIMS score of 15, indicating cognitive intactness. The resident was receiving rivaroxaban 10 mg by mouth in the evening for DVT prophylaxis and atrial fibrillation. During record review, the Unit Nurse Manager stated licensed nurses were administering the medication but were not monitoring for possible anticoagulant side effects, and she could not locate documentation of such monitoring in the EMAR. The care plan directed staff to monitor and document side effects every shift, including bleeding, bruising, blood in urine or stool, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, blurred vision, shortness of breath, loss of appetite, and sudden changes in mental status. The facility also failed to have an adequate indication for Resident 2’s ticagrelor order. Resident 2 was admitted with diagnoses including encephalopathy, atherosclerosis of native arteries of the extremities, and depression. The Order Summary Report showed sertraline 100 mg daily for depression and ticagrelor 90 mg twice daily for intermittent claudication. During interview and record review, LVNs stated the indication for ticagrelor was not appropriate and they were not sure what it was. They also stated they did not find documentation that the medical doctor gave the diagnosis or indication, and the resident’s discharge summary from the acute hospital did not provide a diagnosis or indication for the medication. The facility further failed to initiate non-pharmacological interventions before administering psychotropic medications for Resident 2 and Resident 24. Resident 24 was re-admitted with diagnoses including aftercare following joint replacement surgery infection and inflammatory reaction due to internal left knee prosthesis and major depressive disorder, and had an active order for sertraline 50 mg daily for depression. Staff stated that non-pharmacological interventions should be initiated for residents receiving psychotropic medications, including relaxation techniques, activities, redirection, distraction, or someone to talk to. During interview, the DNS stated her expectation was for licensed nurses to start non-pharmacological interventions as soon as they received an order for psychotropic medications. The record review and staff interviews indicated that such interventions were not started before the psychotropic medications were ordered and administered for Resident 2 and Resident 24.
Unlabeled and Undated Food Stored in Kitchen and Nourishment Refrigerator
Penalty
Summary
Food was not stored in accordance with professional standards when an unlabeled and undated plastic bin containing zucchini was observed in the walk-in refrigerator. During observation, kitchen staff acknowledged that food items placed into another container should be labeled with the received date and use-by date, and stated the labeling had been missed. The Certified Dietary Manager later confirmed the zucchini was unlabeled and undated and stated that all food, including produce, should have a received date and use-by date to support quality and determine when it should be discarded. The Registered Dietician also stated that produce received in the kitchen should be properly labeled and dated, and that unlabeled and undated food was thrown away because it could spoil and cause foodborne illness. Food stored in the Station 200 nourishment unit refrigerator was also not properly labeled when a box of pizza brought into the facility was observed with only a date of 6/6/26. The Certified Dietary Manager stated staff were responsible for checking food items in the nourishment unit refrigerator and ensuring foods brought in by residents or family members were labeled with the resident's name, room number, the date the food was brought in or opened, and the use-by date. The Registered Dietician stated outside food stored in the nourishment unit refrigerator should have been clearly labeled with the resident's name, room number, the date brought in or opened, and the use-by date, and stated leftovers were not stored in that refrigerator.
Missing Documentation for Ostomy Care and Medication Administration
Penalty
Summary
Resident 11’s electronic health record did not contain documentation of completed ileostomy bag changes after 7/3/25. The resident’s admission record listed diagnoses including spondylosis with myelopathy-cervical region, anxiety disorder, muscle spasm, morbid obesity due to excess calories, chronic pain syndrome, ileostomy status, and generalized muscle weakness. The MDS dated 4/13/26 showed a BIMS score of 15, indicating the resident was cognitively intact, and the admission record identified the resident as her own responsible party. The resident’s order summary and TAR showed orders for ostomy care and for changing the ileostomy bag as needed if soiled or dislodged, but the TARs for 4/1/26-4/30/26, 5/1/26-5/31/26, and 6/1/26-6/30/26 contained no documentation of completed ileostomy bag dressing changes. During interview and record review, LVN 7 stated the ostomy bag was changed as needed and that such care should be documented on the TAR. LVN 7 reviewed the EHR and stated the last documented ostomy bag change was on 7/3/25. The DNS also stated staff should document ileostomy bag changes in the TAR and was unable to locate staff signatures showing ileostomy care had been provided. Resident 9’s eMAR was not signed after medications were administered during medication pass. During observation and concurrent interview, LVN 1 stated she administered the resident’s 7 a.m. medications and then forgot to sign the eMAR, acknowledging that she should have signed it immediately after administration. Resident 9’s record showed diagnoses including hemiplegia, hemiparesis, dysphagia, and dementia, and the resident had a G-tube. Other nurses stated medication administration practice was to document after giving medications, and the DNS stated licensed nurses were expected to document right away after medication administration.
Staff COVID-19 Vaccine Education and Offer Not Documented
Penalty
Summary
The facility failed to educate and offer COVID-19 vaccination to three of three sampled employees, CNA 5, CNA 7, and LVN 5, and their employee files did not contain documentation that they were provided education about the benefits and potential risks associated with the COVID-19 vaccine or that the vaccine was offered. During record review with the DSD, the employee files for these three staff members were reviewed and found to lack the required documentation. The DSD stated the facility had not offered the COVID-19 vaccine to staff since 2023 because it was no longer required. During interviews, the IP stated the facility did not offer COVID-19 vaccinations for staff because it was no longer mandated for staff to be vaccinated. CNA 8 stated she could not remember the last time she received information or was offered a COVID-19 vaccination at the facility and said COVID-19 had not been brought up in recent years. The DNS reviewed the facility policy titled, Coronavirus Disease (COVID-19)-Vaccination of Staff, dated May 2024, and stated the facility provided COVID-19 education and vaccination only at orientation upon hire and did not continue ongoing education or offer the vaccine after the initial orientation period. The DNS also stated the facility's policy was not being followed.
Chemical Containers Stored With White Foamy Substance in Laundry Area
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary condition when four five-gallon chemical containers stored in the dirty area of the laundry room were found covered with a thick white foamy substance, and the floor directly below the containers also had the same substance. During observation, nine containers were stacked in the corner of the room, and four were visibly covered with the white foamy substance. The Laundry Person stated she had not used the chemicals before, did not notice the substance, and was not sure what it was or whether it was safe. The Housekeeping Director stated the containers held liquid sanitizer used in the kitchen and that he had been aware of the white foamy substance for a few weeks after being told by the Dietary Services Manager. The Dietary Services Manager stated she noticed the containers about four weeks earlier and reported them to the Administrator and Director of Maintenance, and that the chemicals were past expiration and no longer used. The Director of Maintenance stated he remembered being told about the containers, knew some were covered with thick white foamy substance, and said he should have followed up more often until the chemicals were picked up. The Administrator stated he had been aware of the containers for a month or two and thought the Director of Maintenance had taken care of it.
Failure to Document and Implement Repositioning for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to meet professional standards of quality care for a resident who was admitted with a pressure ulcer in the sacral region. The resident required turning and repositioning every two hours, but the care plans did not specify this requirement, and the medical records did not document that the resident was turned and repositioned as needed. This lack of documentation and care plan specification led to incomplete and inaccurate records of the resident's care. The resident had a history of hemiplegia and hemiparesis following a cerebral infarction, affecting the left non-dominant side, and was dependent on assistance for activities of daily living. The resident's condition included a pressure ulcer of the sacral region, which was not properly managed due to the facility's failure to document and implement a consistent turning and repositioning schedule. Interviews with staff, including LVNs, CNAs, and the DON, revealed that while they were aware of the need to turn and reposition the resident every two hours, this was not consistently documented or reflected in the care plan. The deficiency resulted in the potential worsening of the resident's pressure ulcer and the development of new pressure ulcers, contributing to the resident's death from septic shock. The facility's policies and procedures for wound and skin management and turning and repositioning were not adequately followed, as evidenced by the lack of documentation and care plan updates. The facility's failure to adhere to these standards of care and documentation requirements highlights a significant lapse in the quality of care provided to the resident.
Failure to Inform and Document Advance Directive Information
Penalty
Summary
The facility failed to inform and provide written information on how to formulate an advance directive for all 87 residents. This deficiency was identified through interviews and record reviews, which revealed that the facility did not document information on how to obtain an advance directive in resident charts. The Medical Records Director (MRD) stated that the facility referred residents to their primary physician for advance directives and only kept them on file if residents brought them in. The Social Services Director Assistant (SSDA) and the Intake Coordinator (IC) confirmed that no documentation was made in resident charts regarding advance directives, and residents were directed to external sources like the Long Term Care Ombudsman (LTCO) or their primary physician for assistance. The Assistant Director of Nursing (ADON) acknowledged that it was not the facility's practice to document whether education and information on obtaining an advance directive were provided to residents. The facility's policy, dated 4/30/22, required social services to document discussions about advance directives in the resident's medical record, but this was not being followed. The lack of documentation and failure to provide necessary information violated the residents' rights to be informed about advance directives, which are crucial for ensuring their medical wishes are honored if they become unable to make decisions themselves.
Failure to Update Care Plan After Hospice Discharge
Penalty
Summary
The facility failed to revise and implement a person-centered comprehensive care plan for Resident 45 after the resident was discharged from hospice services. Despite the discharge occurring on November 16, 2024, the care plan was not updated to reflect this significant change in condition. Interviews with the License Vocational Nurse (LVN) and the Minimum Data Set Nurse (MDSN) revealed that the care plan should have been updated immediately to ensure proper communication and care for Resident 45. The LVN acknowledged receiving a verbal order from the hospice agency to discharge the resident and documented the conversation, but the care plan was not revised accordingly. Resident 45, who was admitted with diagnoses including hemiplegia, hypertension, anxiety, severe protein-caloric malnutrition, muscle weakness, and pain, was no longer receiving hospice services as of November 16, 2024. The Assistant Director of Nursing (ADON) confirmed that the care plan should have been updated by the licensed nurses to reflect the resident's current needs and condition. The facility's policy requires care plans to be reviewed and revised by the interdisciplinary team after each assessment and when changes in the resident's condition occur, which was not adhered to in this case.
Deficiencies in Oxygen Management and Physician Notification
Penalty
Summary
The facility failed to meet professional standards of practice for four residents due to several deficiencies. For three residents, the oxygen tubing was not labeled with the date it was changed, which is a critical step to prevent infection. Observations and interviews with staff confirmed that the nasal cannula tubing for these residents was not dated, and staff acknowledged the importance of labeling the tubing to track when it was last changed. The facility's policy required that nasal cannulas be changed weekly and marked with the date and nurse's initials, but this was not adhered to, putting the residents at risk of infection. Another deficiency involved a resident whose attending physician was not notified when their hypertension medication was withheld due to low blood pressure levels. The facility's policy required that the physician be informed if medication was not administered as prescribed, but there was no documentation indicating that the physician was notified. This oversight could have led to negative outcomes for the resident, as the physician's guidance was not sought when the medication was not given. Additionally, a resident received an incorrect oxygen flow rate, which was set at 4.5 L/min instead of the prescribed 2 L/min. The resident and staff noted the discrepancy, and it was confirmed that the oxygen rate should have been checked regularly and set according to the physician's orders. The failure to administer oxygen at the correct rate could have resulted in adverse effects for the resident, particularly given their medical conditions. The facility's policy emphasized the importance of following physician orders and documenting the oxygen flow rate, but these procedures were not followed in this instance.
Failure to Post Accurate Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information was posted accurately and comprehensively, as required. During an observation, it was noted that the Census and Direct Care Services Hours Per Patient Day (DHPPD) did not include the total number of actual hours worked by Registered Nurses (RNs), Licensed Vocational Nurses (LVNs), and Certified Nurse Aides (CNAs). This omission meant that residents and their family members could not identify who was responsible for their care, the number of licensed and unlicensed staff on shift, or the total number of hours staff were working. Interviews with the Administrator and Staff Coordinator revealed a lack of awareness and understanding of the requirement to post specific hours for each category of nursing staff. The Administrator admitted that only CNA hours were posted, and there were no posted numbers for RNs and LVNs. The Staff Coordinator confirmed that the hours posted were for the total hours worked by combined staff and not broken down by specific categories. The facility's policy and procedure on Nursing Staffing Ratio Posting, which requires the posting of actual hours worked by each category of nursing staff, was not followed.
Unpalatable Food Served to Residents
Penalty
Summary
The facility failed to provide palatable and flavorful food to its residents, as observed during a survey. The broccoli served to 79 residents on a regular diet was found to be bland, soggy, and lacking in flavor. The Director of Nutritional Services (DNS) acknowledged that the broccoli was bland and watery, attributing the sogginess to excess moisture from cooking and the lack of flavor to limited seasoning in the recipe. The facility's recipe for seasoned broccoli required only a minimal amount of salt, which was insufficient to enhance the taste. Additionally, the puree salad served to five residents on a puree diet was found to be unappetizing. The Dietary Aid (DA 2) had to use a food processor and blender to achieve the desired consistency, as the recipe did not include any liquid. The puree salad tasted sharp and earthy, and the salad dressing packets provided were difficult to open. The DNS noted that the puree salad tasted better with dressing but was still not very palatable. The Certified Nursing Assistant (CNA 1) reported that residents on puree diets often requested salad dressing, and if it was not provided, she would obtain it for them. The Registered Dietitian (RD) was not involved in resident council meetings and was unaware of the residents' dissatisfaction with the food. The RD stated that the facility's regular diet exceeded the recommended sodium intake for a low-sodium diet, and a more liberalized approach to sodium intake could benefit older adults. The RD relied on others to inform her of residents' preferences and did not observe plate waste or consult with kitchen staff about the puree salads. The facility's failure to address these issues resulted in unpalatable meals, which could lead to decreased food intake and potential nutritional deficiencies among residents.
Deficiencies in Food and Ice Storage and Sanitation
Penalty
Summary
The facility failed to ensure the safe storage, distribution, and serving of food and ice, as evidenced by several observations and interviews. The ice machine was found to have black spots above the water trough and pink residue on the ice grate and sensor, indicating inadequate cleaning. The Maintenance staff acknowledged the presence of these substances and stated that the ice machine is cleaned and sanitized every six months, with the last cleaning occurring approximately six months prior. However, the Registered Dietitian could not provide sanitation review logs for the recent months, highlighting a lack of documentation and oversight. Additionally, a pitcher of apple juice in the nourishment room refrigerator was observed to be past its use-by date, and the refrigerator itself contained a dry, sticky substance on the bottom drawers and a door shelf. The Infection Preventionist and Director of Nutritional Services confirmed that expired items should be discarded immediately and that the refrigerator should be cleaned daily. However, the facility's daily log for stocking and cleaning did not have current dates or staff signatures, indicating a failure in maintaining proper records and ensuring cleanliness. These deficiencies could lead to the growth of microorganisms and potential foodborne illness for the residents.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and their representatives regarding transfers to the hospital for four residents. This deficiency was identified during interviews and record reviews, revealing that neither the residents nor their representatives received written notices explaining the reasons for hospital transfers. Licensed Vocational Nurse (LVN) 1 confirmed that notifications were only made via phone calls, and no written documentation was provided. This practice left residents and their representatives potentially unaware of the reasons for the hospital transfers. The Assistant Director of Nursing (ADON) corroborated that the facility's nurses did not provide written notifications for hospital transfers, relying solely on phone calls. The facility's policy required written notification to residents and their representatives 30 days in advance of a transfer or as soon as the discharge date was known, except in emergencies or other specified situations. However, this policy was not followed, as evidenced by the lack of written documentation in the residents' clinical records.
Failure to Provide Written Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to residents and their representatives upon transfer to a hospital, affecting four of eight sampled residents. The Business Office Manager (BOM) admitted that while the business office would call the resident's representative to inform them of the bed hold policy, no written notification was sent. The BOM was unaware that written information was required upon a resident's transfer to the hospital, and written notices were only given at the time of admission. The Assistant Director of Nursing (ADON) confirmed that it was not the facility's practice to provide written bed hold information upon hospital transfer. The ADON acknowledged the importance of written notification, as it allows residents and their representatives to review the information at their own pace and understand their rights to return to their bed in the facility. The facility's policy, dated 1/31/22, indicated that documentation should show how the resident or representative was notified about the transfer and bed hold rights, and a copy of the bed hold consent should be sent with the resident to the hospital and to the resident or their representative.
Failure to Implement Oxygen Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, specifically regarding oxygen administration. Resident 231, who was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, and dementia, did not have a care plan for oxygen use despite being observed with oxygen infusing via a nasal cannula. The Minimum Data Set Nurse (MDSN) and Admission Nurse (AN) acknowledged that a care plan should have been initiated upon admission, as care plans are triggered by physician orders and are essential for assessing and monitoring the resident's condition. Similarly, Resident 235, admitted with conditions such as emphysema, pleural effusion, and atrial fibrillation, also lacked a care plan for oxygen administration. During an observation, Resident 235's oxygen flow rate was set higher than usual, and there was no care plan in place to guide staff on the appropriate administration and monitoring of oxygen. The MDSN and AN confirmed that a care plan should have been established to ensure proper care and safety for the resident. Interviews with Licensed Vocational Nurses (LVNs) further highlighted the importance of care plans in providing specific and appropriate care to residents. The absence of care plans for oxygen use in both residents posed a risk of improper monitoring and administration, potentially leading to negative outcomes. The facility's policies and job descriptions emphasize the necessity of initiating and following care plans to ensure resident-centered care, which was not adhered to in these cases.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled according to professional standards. Observations revealed that the refrigerator in section 300-Medroom contained an antibiotic with an unreadable expiration date. Additionally, medication carts 200-Backside and 300-B contained expired medications, including inhalers, lactulose, ferrous gluconate, and insulin. Licensed Vocational Nurses (LVNs) acknowledged that expired medications should not have been present and could lead to ineffectiveness or adverse reactions. The facility also failed to secure medication carts properly. An LVN was observed leaving a medication cart unlocked while administering medications to residents, despite the facility's policy requiring carts to be locked when not directly supervised. This lapse in security could allow unauthorized access to medications, posing a risk to residents and staff. Furthermore, two loose white pills were found on a resident's bedside table while the resident was out of the room. The LVN acknowledged that the pills should not have been left unsecured, as they could be taken by others or result in the resident missing their prescribed medication. The Assistant Director of Nursing (ADON) emphasized the importance of ensuring all medications are taken as prescribed to avoid missed therapeutic effects and prevent other residents from accessing unsecured medications.
Menu Deviation Leads to Unapproved Dessert Substitution
Penalty
Summary
The facility failed to adhere to the planned and approved menu for 16 residents when a dessert not listed on the menu was served. On December 9, 2024, during lunch, the menu indicated that ambrosia pudding was to be served as dessert. However, an observation revealed that gelatin with whipped topping was served instead. This substitution occurred because the previous night's cook made less ambrosia pudding to use up leftover gelatin, as explained by a dietary aide. This deviation from the menu was not communicated to or approved by the registered dietitian, who stated that staff are expected to follow the menus and consult with her if changes are necessary. The registered dietitian and the director of nutritional services were unaware of any previous instances of menu changes without consultation. The director of nutritional services described the incident as isolated and an oversight. The facility's policy and procedure on menus, dated May 1, 2016, requires that menus be written and posted at least one week in advance and followed as planned. The failure to follow the menu as approved had the potential to affect the nutritional intake and meal satisfaction of the residents involved.
Infection Control Deficiencies in PPE and Hand Hygiene
Penalty
Summary
Two Licensed Vocational Nurses (LVN 4 and LVN 7) failed to adhere to infection control practices, compromising the safety and sanitary environment necessary to prevent the spread of infections. LVN 4 entered an isolation room without donning the required personal protective equipment (PPE), specifically an isolation gown, despite the presence of a notice indicating the necessary PPE. The resident in the isolation room was infected with E. coli, and LVN 4 acknowledged the risk of spreading the infection to other residents due to this oversight. LVN 7 was observed neglecting hand hygiene protocols before and after administering medications to different residents. This failure to perform hand hygiene between resident interactions increased the risk of transmitting infections. Additionally, LVN 7 did not properly sanitize a glucometer after use, failing to adhere to the manufacturer's instructions for the required dwell time of the sanitizing solution. LVN 7 admitted to not being trained in the correct procedure for sanitizing the glucometer, which could lead to the spread of bloodborne infections. The facility's policies and procedures, including those for isolation precautions, PPE usage, hand hygiene, and cleaning of point-of-care equipment, were reviewed. These policies emphasize the importance of using PPE, performing hand hygiene, and following manufacturer instructions for equipment cleaning to prevent infection transmission. However, the observed actions of LVN 4 and LVN 7 were inconsistent with these established protocols, highlighting deficiencies in adherence to infection control practices.
Failure to Provide Adequate Nail Care for a Resident
Penalty
Summary
The facility failed to provide adequate personal hygiene care for a resident, identified as Resident 46, who had long, yellow fingernails that were not cut or filed. During an observation and interview, Resident 46 expressed dissatisfaction with the length of his fingernails and mentioned that as a diabetic, long fingernails could lead to infections if he scratched his skin. The resident could not recall the last time his fingernails were trimmed by the staff. A Certified Nursing Assistant (CNA) acknowledged the issue, noting that the long fingernails were dirty and could harbor bacteria, potentially affecting the resident's ability to eat properly. The CNA admitted that he should have informed the nurse about the resident's request to have his fingernails cut. Further observations and interviews with the Infection Preventionist (IP) and the Assistant Director of Nursing (ADON) confirmed that the resident's fingernails were indeed long and should have been trimmed by the nursing staff. The IP and ADON both recognized the risk of infection and injury due to the long fingernails, especially given the resident's diabetic condition. The facility's policy on Activities of Daily Living (ADL) required staff to assist residents with personal hygiene, including nail care, as needed. However, the staff failed to adhere to this policy, as evidenced by the lack of regular nail care for Resident 46, who was moderately impaired in cognition and had a history of multiple health issues, including diabetes and candidiasis of the skin and nails.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary medications due to inadequate monitoring and lack of non-pharmacological interventions. Resident 236, who was admitted with multiple diagnoses including dementia and depression, was prescribed quetiapine fumarate for behavioral and psychological symptoms of dementia. However, there was no behavior monitoring implemented to assess the effectiveness of the medication or to determine if non-pharmacological interventions could be used instead. Interviews with staff revealed that monitoring for highs and lows was not conducted, which is crucial to ensure the medication's therapeutic value and to adjust treatment if necessary. Similarly, Resident 32, admitted with bipolar disorder and anxiety, was prescribed multiple psychotropic medications including duloxetine, Seroquel, and Lorazepam. Despite this, there were no monitoring orders in place to track her behaviors or assess the effectiveness of the medications upon her admission or during the month of October. Staff interviews confirmed the absence of necessary monitoring orders, which are essential to ensure the intended use of the medications and to prevent potential side effects. The facility's policies and procedures require the interdisciplinary team to care plan individual interventions, including non-pharmacological and pharmacological treatments, and to track behaviors and medication side effects. However, these protocols were not followed for Residents 236 and 32, resulting in a failure to monitor their conditions adequately and to ensure the medications administered were necessary and effective.
Failure to Accommodate Resident's Halal Meat Preference
Penalty
Summary
The facility failed to accommodate the food preferences of a resident who required halal meat due to religious dietary restrictions. Despite the resident's requests and discussions with the Registered Dietitian (RD) and Certified Dietary Manager (CDM), the facility did not provide halal meat, leading the resident to register as a vegetarian and rely on bone broth ordered online for protein intake. The resident expressed concerns about his protein consumption and had to ask his family to bring halal meat from home, which the facility could only warm but not prepare. Interviews with the CDM, Administrator (ADM), and RD revealed that the facility had previously purchased halal meat and acknowledged the importance of honoring food preferences to prevent weight loss and ensure cultural sensitivity. However, the facility's policy on resident food preferences, which includes accommodating ethnic food preferences, was not followed in this case. The resident's dietary tray card inaccurately indicated a dislike for all kinds of meat, contradicting his expressed preference for halal meat.
Failure to Honor Resident's Fluid Preferences
Penalty
Summary
The facility failed to provide a resident with fluids consistent with their needs and preferences, specifically regarding the provision of apple juice. Despite the resident's standing order for apple juice, it was noted that the resident had a documented dislike for it. During an observation, a cup of apple juice was found on the resident's lunch tray, and the resident expressed that their food preferences were not always honored. The Certified Dietary Manager (CDM) confirmed that the resident's dislike for apple juice was noted on their dietary tray ticket, yet the standing order for apple juice was not updated to reflect this preference. The Registered Dietitian (RD) acknowledged that the resident's food preferences should be honored every time food is served and that the dietary tray ticket was confusing due to the conflicting information. The RD also noted that the resident was selective about their fluids, and incorrect fluid provision could impact their nutritional intake and quality of life. The resident was cognitively intact, as indicated by their Minimum Data Set (MDS) score, and had a medical history that included conditions such as Ogilvie syndrome, hypotension, and signs concerning food and fluid intake.
Incomplete POLST Form for Resident
Penalty
Summary
The facility failed to ensure accurate and complete medical records for one of the nine sampled residents, specifically regarding the Physician Orders for Life-Sustaining Treatment (POLST) form for a resident. The POLST form, which is crucial for outlining a resident's end-of-life care preferences, was found to be incomplete as Section B, which details medical interventions, was left unmarked. This section is essential for indicating whether the resident desires full treatment, selective treatment, or comfort-focused treatment. The omission was identified during a review of the resident's records, and it was acknowledged by the Infection Prevention Nurse that the POLST should have been completed to reflect the resident's wishes accurately. The resident in question was admitted to the facility with multiple serious health conditions, including heart failure, kidney failure, hemiplegia, hemiparesis, dysphagia, and pneumonia. Despite these conditions, the resident was assessed as cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 15. The Admission Nurse confirmed the importance of a complete POLST form for guiding care during emergencies and ensuring that the resident's end-of-life care preferences are respected. The facility's job description for medical records emphasizes the need for accuracy and completeness in clinical documentation, which was not upheld in this instance.
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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.
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Nursing homes near Merced
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Merced Behavioral Center | 2.5 mi | ★★★★★ | 0 | 0 |
| La Sierra Care Center | 3 mi | ★★★★★ | 16 | 0 |
| Merced Nursing & Rehabilitation Ctr | 3 mi | ★★★★★ | 4 | 0 |
| Golden Merced Care Center | 3.2 mi | ★★★★★ | 4 | 0 |
| Franciscan Post-acute Care Center | 3.7 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.