Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Franciscan Post-acute Care Center during CMS and state inspections, most recent first.
A cognitively intact resident with a history of falls, lumbar fracture, and an L1 fracture was observed getting out of bed and walking unassisted to the bathroom without using a walker or TLSO brace, despite requiring supervised ambulation. CNAs and the PTA reported the resident was consistently noncompliant with using the call light, walker, and brace, and was inconsistent with therapy participation. Although an SBAR documented an unwitnessed fall and the fall care plan mentioned a TLSO brace for ambulation, staff were unaware the brace was required and had never seen it used. The DON confirmed there was no comprehensive, person-centered care plan addressing the resident’s known noncompliance and refusal of care, despite facility policies requiring that refused services be described in the care plan.
A resident with a history of falls, multiple comorbidities, and a new L1 vertebral fracture returned from the hospital with discharge instructions to wear a TLSO brace when out of bed and working with therapy, but this order was not entered into the facility’s OSR. Although the fall care plan noted the need for a TLSO brace for ambulation, nursing staff, including an LVN and CNA, were unaware the brace was required when the resident ambulated and reported never seeing it used. Surveyors observed the resident walking unassisted to the bathroom without the brace while it lay on the bedside table, and the DON confirmed the hospital discharge instructions were not transcribed into physician orders on readmission, resulting in staff not monitoring or enforcing brace use as directed.
A CNA performed a mechanical lift transfer alone for a resident who was care-planned as totally dependent on two staff and requiring a mechanical lift with two to three staff assistance. The CNA acknowledged knowing that two staff were required but proceeded without additional help when another CNA was not available. Another resident reported that staff sometimes used the mechanical lift with only one CNA, though usually two were present. Multiple CNAs, a PTA, an LVN, the DSD, and the DON all stated that two staff were required for mechanical lift use, consistent with staff training and competencies. The facility’s accident hazard policy required proper use of assistive devices and staff training, and while there was no specific mechanical lift P&P and the manufacturer’s instructions did not specify staffing numbers, leadership stated it was the facility’s process to always use two staff for mechanical lift transfers.
A resident with Type 2 DM and COPD was admitted with orders for Glipizide and continuous oxygen therapy, but the care plan lacked individualized interventions for blood glucose and oxygen monitoring. Nursing staff did not document blood glucose checks or monitor oxygen saturation as ordered, even as the resident refused meals and showed signs of respiratory distress. This resulted in the resident developing severe hypoglycemia and hypoxemia, leading to altered mental status and emergency hospitalization. Staff interviews confirmed the care plan was incomplete and not followed.
A resident was served sliced tomatoes with lunch despite a documented dislike for tomatoes on their meal tray ticket. Staff interviews and record reviews confirmed that dietary and nursing staff failed to properly check the meal tray contents against the resident's preferences, resulting in the resident receiving and leaving untouched a food item they had previously reported disliking.
The facility did not refer two residents with newly diagnosed serious mental illnesses for a required Level II PASARR evaluation, as mandated by policy. Despite staff awareness that a new PASARR should be completed when a resident receives a new mental illness diagnosis, there was no evidence in the records that this process was followed for either resident.
A resident in a LTC facility, known to be a smoker and on continuous oxygen, suffered second-degree burns after smoking unnoticed in their room. Despite staff awareness of the resident's smoking habits and possession of cigarettes and lighters, effective measures were not implemented to prevent the fire hazard. The incident resulted in the resident being hospitalized in a burn unit.
A facility failed to accurately reflect a resident's smoking status and oxygen use in the MDS assessment. The resident, who was cognitively intact, was known to smoke and bring cigarettes from hemodialysis, despite the facility's smoke-free policy. The MDS Coordinator admitted to coding tobacco use as 'no' for all residents, and the resident's continuous oxygen therapy was not marked in the MDS. This inaccuracy could lead to unmet care needs, particularly concerning smoking and oxygen safety.
A resident known to be a smoker suffered second-degree burns after attempting to smoke while on continuous oxygen in a smoke-free LTC facility. Despite staff awareness of the resident's smoking habits and previous attempts to bring cigarettes and lighters into the facility, effective care plan interventions were not implemented. The care plans in place were not individualized or specific to the resident's needs, leading to the incident and subsequent hospitalization.
A facility failed to prevent abuse between residents, leading to two altercations involving three residents. Despite known histories of conflict and severe cognitive impairments, staff did not adequately separate or supervise the residents, resulting in one resident being scratched and another being bitten. The facility's abuse prevention policy was not effectively implemented, contributing to these incidents.
A resident who had knee surgery did not receive the ordered physical therapy (PT) services for four days due to the absence of the Physical Therapy Assistant (PTA) and lack of backup coverage. The resident was supposed to receive PT and occupational therapy (OT) five days a week to aid in recovery and improve mobility, but missed crucial sessions, risking further decline in physical well-being.
A resident with a history of falls and cognitive impairment was not monitored hourly as required by the facility's 4 P's Rounding Tool policy. Despite being placed on the program after a fall that resulted in a fractured arm, staff failed to perform and document the necessary checks, leading to multiple missing entries in the resident's logs. This oversight was acknowledged by both an LVN and the DON, highlighting a deficiency in the facility's care provision.
Three residents were improperly restrained using wedge pillows placed under their mattresses, restricting their movement and preventing them from getting out of bed. These actions were taken without physician orders or care plan interventions, violating the residents' rights to be free from physical restraints. Staff acknowledged the use of wedge pillows as a fall prevention measure, but the facility's policy prohibits such use without proper authorization.
A resident with hemiplegia and diabetes was injured during transport to a medical appointment due to inadequate supervision. The resident's left foot slipped off the wheelchair and dragged on the pavement, causing abrasions to four toes. The resident was transported without shoes, wearing only socks, and experienced pain requiring daily dressing changes and pain management. Facility staff expected residents to wear shoes and have leg rests during transport, but these measures were not followed.
A resident with dementia and muscle weakness was left unsupervised while drinking hot tea, resulting in second-degree burns. Despite the care plan indicating the need for staff assistance, the resident was not supervised, leading to the accident. The facility's policy on accident prevention was not followed, contributing to the incident.
Failure to Care Plan Resident’s Noncompliance With Safety Devices and TLSO Brace Use
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a resident-centered comprehensive care plan with person-specific interventions for a cognitively intact resident who had known noncompliance with safety measures. The resident was admitted with multiple diagnoses including lumbar vertebra fracture, protein calorie malnutrition, type 2 diabetes mellitus, heart failure, low back pain, and a history of falls. An MDS assessment showed a BIMS score of 15/15, indicating the resident was not cognitively impaired. The resident reported a history of falls and had a TLSO back brace at the bedside for a back fracture. Surveyors observed the resident getting out of bed and ambulating unassisted toward the bathroom without wearing the TLSO brace. CNAs reported that the resident had a recent fall, required supervision for ambulation due to wobbliness, and was consistently noncompliant with using the call light, walker, or asking for help, despite being alert, oriented, and aware of the need for assistance. The PTA stated the resident was inconsistent with therapy participation and refused to use the walker, and that the TLSO brace should be worn when out of bed due to the back fracture. The resident was described as evasive about wearing the brace, stating he would wear it when he needed it. Record review showed an SBAR documenting an unwitnessed fall and subsequent transfer to the hospital, where an L1 fracture was identified. The fall care plan noted an unwitnessed fall and included an intervention for a TLSO brace for ambulation, but the LVN and CNA interviewed were unaware the resident was supposed to wear the brace when ambulating and reported never seeing it used. The DON confirmed the resident’s noncompliance with using the call light, walker, and back brace, and acknowledged there was no care plan addressing the resident’s noncompliance and refusal of care. Facility policies required a person-centered comprehensive care plan with measurable objectives, including services that would have been provided but were refused, and specified that refused services must be described in the comprehensive care plan; however, such individualized, refusal-related interventions were not present for this resident.
Failure to Implement and Communicate TLSO Brace Orders After Hospital Discharge
Penalty
Summary
The deficiency involves the facility’s failure to ensure services met professional standards of quality for one resident who sustained an L1 vertebral fracture after an unwitnessed fall and was later readmitted from an acute care hospital with instructions to use a TLSO brace. The resident had multiple diagnoses including a prior lumbar fracture, protein calorie malnutrition, type 2 diabetes mellitus, heart failure, low back pain, and a history of falls, and was cognitively intact per a BIMS score of 15/15. Hospital discharge instructions dated 3/30/26 directed that the resident wear a TLSO brace when getting out of bed and working with therapy, but this order was not entered into the facility’s Order Summary Report (OSR) upon readmission. Surveyors observed the resident ambulating independently toward the bathroom without wearing the TLSO brace, with a black back brace lying on the bedside table. A CNA stated the resident needed supervision for safety when ambulating and had a recent fall with back injury, but she was unaware he was supposed to wear the brace while ambulating and reported never seeing him use it. The resident’s fall care plan, dated 3/25/26, documented the need for a TLSO brace for ambulation, yet this directive was not translated into a physician order in the OSR, and nursing staff, including an LVN, reported they could not locate a physician order for the brace and were unaware of the requirement for its use when walking. The DON confirmed that the resident had been hospitalized after the fall, was found to have an L1 fracture, and returned with discharge instructions to wear the TLSO brace when out of bed and working with therapy. The DON acknowledged that the TLSO brace order from the hospital discharge instructions was not entered into the OSR at readmission, even though the brace was referenced in the care plan. The DON stated her expectation was that the admission nurse would review the hospital paperwork and notify the physician of the order. A PTA reported the resident had a TLSO brace at bedside but was noncompliant with wearing it and stated the brace should be worn when out of bed due to the back fracture. The report cites a professional reference emphasizing that SNF nursing staff are under strict guidance to follow hospital discharge instructions and that proper communication of follow-up care in discharge paperwork is critical for patient safety.
Failure to Use Required Two-Person Assistance During Mechanical Lift Transfer
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure adequate supervision and use of assistive devices during mechanical lift transfers. During observation, a CNA was seen operating a mobile floor mechanical lift alone while lowering Resident 2, who was in a sling, into a wheelchair, with no other staff present in the room. In a subsequent interview, the CNA acknowledged that facility practice required two staff members for mechanical lift use, admitted she could not find another CNA to help, and stated she should have waited because operating the lift alone placed Resident 2’s safety at risk and at risk for falling. Resident 2’s ADL care plan documented that the resident was totally dependent on two staff for transfers and required a mechanical lift with two to three staff assistance. Additional interviews and record reviews confirmed that the facility’s expectation and staff training required two staff members for mechanical lift transfers. Another resident reported that staff used a mechanical lift whenever she was taken out of bed and that occasionally a CNA would operate the lift alone, though usually two CNAs were present. CNAs, a PTA, an LVN, the DSD, and the DON all stated that two staff were required when using the mechanical lift, describing the roles of one person to operate the lift and another to guide and position the resident. The facility’s Accident Hazards/Supervision/Devices policy required assistive devices and equipment to be used according to manufacturer recommendations and staff to be trained on their use, and the DSD confirmed that staff, including CNA 1, had been trained and competency-checked on mechanical lift use. The facility did not have a specific mechanical lift policy and relied on manufacturer guidelines, which did not specify the number of staff required, while the DON and Administrator stated it was the facility’s process to always use two people for mechanical lift transfers.
Failure to Develop and Implement Individualized Care Plan for Resident with Diabetes and COPD
Penalty
Summary
The facility failed to develop and implement a person-centered, comprehensive care plan for a resident with multiple diagnoses, including Type 2 Diabetes Mellitus (DM) and Chronic Obstructive Pulmonary Disease (COPD). Upon admission, the resident was prescribed Glipizide for diabetes management, but the care plan did not include individualized interventions such as regular blood glucose monitoring or instructions to withhold Glipizide during periods of poor oral intake. Nursing staff did not document blood glucose checks from admission through discharge, despite the resident refusing several meals while continuing to receive Glipizide. This omission led to the resident experiencing severe hypoglycemia, as evidenced by a blood glucose level of 53 mg/dl, altered mental status, and subsequent emergency hospitalization. Additionally, the resident had a physician's order for continuous oxygen therapy and monitoring of oxygen saturation every eight hours or as needed for symptoms of dyspnea or cyanosis. The care plan included interventions to monitor for signs and symptoms of respiratory distress and to check oxygen saturation, but these interventions were not followed. There was no documentation of oxygen saturation checks for extended periods, and the resident's oxygen level was not monitored according to the physician's order or care plan. This failure resulted in the resident being found with an oxygen saturation of 86%, altered mental status, and requiring emergency transport to a higher level of care. Interviews with nursing staff and the Director of Nursing confirmed that the care plans were incomplete and not individualized to the resident's needs. Staff acknowledged that the lack of specific interventions and failure to follow physician orders contributed to the resident's significant change in condition, including hypoglycemia and hypoxemia, which necessitated hospitalization. Facility policy and professional references reviewed during the survey emphasized the requirement for person-centered, comprehensive care plans with measurable objectives and individualized interventions, which were not met in this case.
Resident Served Food Contrary to Documented Preferences
Penalty
Summary
A deficiency occurred when a resident was served sliced tomatoes with lunch, despite a documented dislike for tomatoes on the resident's meal tray ticket. The resident confirmed during an interview that they had previously informed staff of their dislike for tomatoes, yet continued to receive them. Observation showed the tomatoes were left untouched, and the meal tray ticket clearly listed tomatoes as a dislike. Both the Certified Nursing Assistant and Dietary staff acknowledged that the meal tray contents were not properly checked against the resident's documented preferences prior to serving the meal. Further review with the Dietary Manager confirmed that the expectation was for dietary staff to compare meal tray contents with the tray ticket, which was not done in this instance. The facility's policies require that resident preferences be honored and that ongoing communication and coordination occur to meet residents' dietary needs. The failure to follow these procedures resulted in the resident receiving food that did not accommodate their stated preferences.
Failure to Refer Residents for PASARR After New Serious Mental Illness Diagnoses
Penalty
Summary
The facility failed to refer residents with newly diagnosed serious mental illnesses to the appropriate state-designated authority for a Level II Pre-Admission Screening and Resident Review (PASARR), as required by facility policy. Specifically, two residents were identified who received new diagnoses of serious mental illnesses—one with major depressive disorder, anxiety disorder, and bipolar disorder, and another with schizoaffective disorder. Despite these new diagnoses, there was no evidence in the medical records that the facility initiated or completed a new PASARR evaluation for either resident. Interviews with facility staff, including the Quality of Life Director, Director of Nursing, and Administrator, confirmed that the expectation was for a new PASARR to be completed when a resident received a new mental illness diagnosis. However, this process was not followed for the two residents in question, as documented in their records and confirmed by staff interviews. The deficiency was identified through record review and staff interviews, which revealed a lack of compliance with both facility policy and regulatory requirements regarding PASARR referrals for residents with new serious mental illness diagnoses.
Failure to Prevent Smoking-Related Fire Hazard
Penalty
Summary
The facility failed to address the risk of fire while smoking for a resident who was known to be a smoker and required continuous oxygen. Despite being aware of the resident's smoking habits and history of bringing cigarettes and lighters into the facility, staff did not implement effective measures to ensure the resident's safety from fire hazards. This oversight led to an incident where the resident smoked unnoticed while wearing oxygen, resulting in a fire that caused second-degree burns to the resident's face and right forearm. The resident, who was cognitively intact, had a history of smoking at the facility and during hemodialysis sessions. Staff were aware of the resident's non-compliance with the facility's smoke-free policy and had previously found cigarettes and lighters in the resident's possession. Despite this knowledge, the facility's interventions, such as locking up cigarettes and lighters, were not consistently effective, and the resident continued to access smoking materials. On the night of the incident, the resident attempted to smoke in their room while on oxygen, leading to a fire that required emergency intervention and hospitalization in a burn unit. The facility's policies and procedures for maintaining a smoke-free environment and ensuring safety with oxygen therapy were not adequately enforced, contributing to the preventable accident and injury to the resident.
Inaccurate MDS Assessment for Resident's Smoking and Oxygen Use
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the health and functional status of a resident, specifically regarding smoking status and oxygen use. The resident, who was cognitively intact, had a history of smoking and was known to bring cigarettes and lighters back from hemodialysis sessions, despite the facility being smoke-free. The MDS Coordinator admitted to automatically coding tobacco use as 'no' for all residents because the facility was smoke-free, even though the resident was known to smoke while at dialysis. The resident was on continuous oxygen therapy since admission, but the MDS assessment did not reflect this, as the section for oxygen therapy was not marked. The Director of Nursing acknowledged that the MDS did not indicate the resident's tobacco use and that oxygen use was not checked, despite the resident being admitted with oxygen. This inaccuracy in the MDS assessment could lead to unmet care needs for the resident, particularly concerning smoking and oxygen safety. The facility's policy and procedure for resident assessment emphasized the importance of conducting comprehensive and accurate assessments to support the resident's care needs. However, the MDS assessments were not accurately completed, as evidenced by the failure to document the resident's smoking status and oxygen use. This discrepancy was further highlighted by the facility's practice of coding all residents as non-smokers due to the smoke-free policy, despite evidence to the contrary.
Failure to Implement Effective Smoking Prevention Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan to prevent accidents for a resident who was known to be a smoker. Despite the staff's awareness of the resident's smoking status and his attempts to bring cigarettes and lighters into the facility, effective care plan interventions were not established. The resident, who was cognitively intact, had a history of smoking at dialysis and had been caught smoking at the facility, which was smoke-free. The care plans in place did not accurately address the resident's behaviors or provide effective interventions to prevent smoking-related injuries. On a specific date, a Certified Nursing Assistant (CNA) heard a loud noise from the resident's room and discovered that the oxygen tubing and nasal cannula were on fire. The resident had attempted to smoke a cigarette while on continuous oxygen, resulting in second-degree burns to his face. The facility's staff, including the Administrator, Licensed Vocational Nurse (LVN), and Director of Nursing (DON), acknowledged that the care plans were not individualized or specific to the resident's needs and behaviors. The interventions listed, such as using a cigarette holder and smoking apron, were inappropriate given the facility's smoke-free policy. The facility's policy and procedure on comprehensive care plans emphasized the need for person-centered plans that address medical, nursing, physical, mental, and psychosocial needs. However, the care plans for the resident did not meet these requirements, as they failed to address the resident's non-compliance with smoking rules and did not include effective strategies to prevent him from smoking onsite. The lack of appropriate interventions and documentation contributed to the incident, resulting in the resident's injury and hospitalization.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by two incidents involving three residents. In the first incident, two residents with a known history of verbal altercations were not adequately separated after an altercation. Despite staff intervention, one resident was able to sit next to the other and scratch her face while the CNA's back was turned. Both residents had severe cognitive impairments, and the staff was aware of their history of conflicts, yet failed to provide adequate supervision to prevent further altercations. In the second incident, the same resident involved in the first altercation was not adequately supervised after the initial incident, leading to another altercation with a different resident. The resident, who had a history of causing verbal altercations, bit another resident on the shoulder in the dining room. Despite being placed on 15-minute checks after the first incident, the resident was unsupervised in the dining room, allowing the second altercation to occur. The facility's policy on abuse prevention was not followed, as staff failed to separate residents immediately after altercations and did not provide adequate supervision to prevent further incidents. The Director of Nursing and other staff members acknowledged the need for supervision and separation of residents involved in altercations, yet these measures were not effectively implemented, resulting in harm to the residents involved.
Failure to Provide Ordered Physical Therapy Services
Penalty
Summary
The facility failed to provide rehabilitative services as required by the comprehensive plan of care for a resident who had undergone knee surgery. The resident was ordered by a physician to receive physical therapy (PT) and occupational therapy (OT) five days a week to aid in recovery and improve mobility, weight bearing, and transferring abilities. However, the resident did not receive PT from October 19 to October 25 due to the absence of the Physical Therapy Assistant (PTA) who was out sick, and there was no backup coverage available to continue the resident's rehabilitation during this period. Interviews with the Physical Therapy Assistant, Administrator, Director of Nursing, and Regional Director of Rehabilitation confirmed that the resident missed four days of PT during the specified week, which was crucial for the resident's recovery from surgery and to prevent further decline in physical well-being. The resident's medical history included aftercare following joint replacement surgery, muscle weakness, and difficulty in walking, emphasizing the importance of consistent rehabilitative services. The facility's policy required that each resident receive specialized rehabilitative services as determined by their comprehensive plan of care, but this was not adhered to in this case.
Failure to Adhere to Hourly Monitoring Protocol
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice for a resident when staff did not perform hourly monitoring in accordance with the facility's policy and procedure titled, 'Rounding Using the 4 P's Rounding Tool.' The resident, who had a history of falling, difficulty in walking, dementia, and muscle weakness, was admitted with a diagnosis of Type 2 diabetes mellitus with hyperglycemia. The resident's cognitive status was moderately impaired, as indicated by a Brief Interview of Mental Status assessment score of 09 out of 15. Following an unwitnessed fall that resulted in a fractured left humerus, the resident was placed on the 4 P's program as an intervention to prevent further falls. Despite the implementation of the 4 P's program, which required hourly rounds to check on the resident's pain, positioning, personal needs, and personal items, the facility staff failed to adhere to this schedule. The logs for the resident showed multiple missing entries on various dates, indicating that the hourly rounds were not consistently performed. The Licensed Vocational Nurse and the Director of Nursing both acknowledged that the care plan interventions and the 4 P's program were not followed, which was intended to prevent falls. This lack of adherence to the established care plan and monitoring protocol constituted a deficiency in the facility's provision of care.
Improper Use of Wedge Pillows as Restraints
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary physical restraints, as evidenced by the use of wedge pillows placed under the mattresses of three residents. These wedge pillows were positioned in such a way that they restricted the residents' freedom of movement and prevented them from getting out of bed. This action was taken without proper physician orders or care plan interventions, violating the residents' rights to be free from physical restraints. Resident 2 was observed with a wedge pillow under the mattress, causing the mattress to tilt and restrict movement. The resident had a history of falling and was diagnosed with atherosclerotic heart disease, atrial fibrillation, dementia, and unsteadiness on feet. Similarly, Resident 3, diagnosed with epilepsy, contracture, difficulty in walking, and dementia, was found with a wedge pillow under the mattress, restricting his ability to get out of bed. Resident 4, with Parkinson's Disease, abnormalities of gait and mobility, dementia, and difficulty in walking, was also observed with wedge pillows under the mattress, preventing her from moving freely. Interviews with staff, including a CNA, LVN, and the Director of Nursing, revealed that the wedge pillows were used as a fall prevention measure, but they acknowledged that the pillows could be considered restraints if residents were unable to move freely. The facility's policy on physical restraints prohibits the use of such devices for convenience or to inhibit a resident's freedom of movement. The lack of physician orders and care plan interventions for the use of wedge pillows further highlighted the deficiency in ensuring residents' rights to be free from physical restraints.
Resident Injury Due to Inadequate Supervision During Transport
Penalty
Summary
The facility failed to ensure that a resident was free from injury during transportation to a medical appointment. The resident, who had hemiplegia and diabetes, was transported without shoes, wearing only socks, and his left footrest was initially missing. During the transport, the resident's left foot slipped off the wheelchair and dragged on the pavement, resulting in abrasions to four toes on his left foot. This incident occurred because the transport driver did not notice the resident's foot slipping off the wheelchair. Upon returning to the facility, the resident's sock was found to be worn and bloody, and he had skin injuries on his toes. The resident experienced pain and required daily dressing changes by the nursing staff. The resident's cognitive status was intact, as indicated by a score of 14 out of 15 on the Brief Interview for Mental Status. The resident expressed discomfort and pain, which was managed with pain relievers, including acetaminophen and later Norco, a stronger narcotic-based medication. Interviews with facility staff, including the Director of Occupational Therapy and the Director of Nursing, revealed that it was expected for residents to wear shoes and have leg rests when leaving the facility. The staff also expected transportation personnel to be attentive to residents' needs and ensure their safety during transport. However, these expectations were not met, leading to the resident's injury.
Resident Burned Due to Lack of Supervision with Hot Beverage
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident diagnosed with dementia, poor safety awareness, and muscle weakness. The resident, who was totally dependent on staff for eating and drinking, was left unsupervised while drinking hot tea, resulting in the resident spilling the tea and suffering second-degree burns on her chest. This incident occurred despite the resident's comprehensive care plan indicating the need for staff assistance with eating and drinking. The resident's medical history included cerebral infarction, hemiplegia, and contracture of the left hand, which impaired her ability to safely feed herself. The Minimum Data Set assessment indicated severe cognitive impairment, and the resident required one-person physical assistance for eating. The facility's Hot Beverage Safety Evaluation suggested that the resident might require setup assistance but did not explicitly state the need for supervision, which was questioned by the staff given the resident's medical conditions. Interviews with facility staff, including Licensed Vocational Nurses and the Director of Nursing, confirmed that the resident was not safe to handle hot beverages without assistance. The facility's policy on quality of care emphasized the need for individualized, resident-centered interventions to prevent avoidable accidents, which were not followed in this case. The Director of Nursing acknowledged that the resident's care plan was not adhered to, which may have prevented the accident.
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 83 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 Merced
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Golden Merced Care Center | 0.5 mi | ★★★★★ | 4 | 0 |
| Merced Nursing & Rehabilitation Ctr | 0.7 mi | ★★★★★ | 1 | 0 |
| La Sierra Care Center | 0.8 mi | ★★★★★ | 16 | 0 |
| Merced Behavioral Center | 2.1 mi | ★★★★★ | 0 | 0 |
| Anberry Post Acute | 3.7 mi | ★★★★★ | 0 | 0 |
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