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 Merced Nursing & Rehabilitation Ctr during CMS and state inspections, most recent first.
Two residents were involved in a behavioral incident where one resident pushed another’s wheelchair and the other resident kicked the first resident’s wheelchair, leading to yelling and verbal aggression toward peers and staff. Although a nurse intervened, separated the residents, and reported performing an assessment on the second resident, no documentation of this assessment, no care plan updates, and no IDT notes were entered for that resident. For the first resident, documentation and care plan updates focused only on alleged false statements, without addressing the documented aggressive behaviors toward another resident and staff or the wheelchair‑kicking incident. These omissions violated facility policies requiring ongoing assessment and timely, person‑centered care plan revisions after significant changes in condition or behavior and were cited as placing both residents at risk for psychosocial distress and for not being comprehensively reassessed for appropriate individualized services.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not ensure that a registered dietician was available onsite to conduct required sanitation inspections and observe food safety practices, resulting in unaddressed residue and buildup on kitchen equipment and improper garbage disposal. The remote RD was unable to perform these tasks, and no monthly sanitation audits were conducted after the previous onsite RD left. Observations found unsanitary conditions in the kitchen and around dumpsters, and staff confirmed that facility policies and expectations for cleanliness were not met.
Surveyors found that the facility failed to maintain safe food storage and kitchen sanitation, with expired food items present in storage and food residue on equipment such as the stove, oven, and steam table. Staff interviews revealed inconsistent understanding and application of food labeling and disposal policies, and cleaning schedules were not consistently followed. The Registered Dietician was unable to conduct in-person inspections, and previous audits documented ongoing sanitation issues.
The facility failed to ensure proper disposal of garbage and refuse, as observed by uncovered and overflowing dumpsters, piles of cardboard on the ground, and littered areas outside the kitchen. Staff interviews confirmed ongoing issues with garbage accumulation after deliveries, and the inability of the remote RD to conduct required sanitation inspections. Facility policies and job descriptions required proper containment and cleanliness, but these were not followed, resulting in unsanitary conditions and potential cross-contamination risks for residents receiving food from the kitchen.
A resident with multiple medical conditions and a urinary catheter was observed with an uncovered catheter drainage bag, making their urine visible to anyone entering the room. Both a CNA and the Infection Preventionist confirmed that the catheter bag should have been covered to protect the resident's dignity, in accordance with facility policy. The resident was cognitively intact at the time of the incident.
A resident with insomnia, who was cognitively intact, repeatedly requested to receive melatonin later at night to improve sleep but continued to receive it earlier than preferred. Staff acknowledged the request but did not adjust the medication schedule, resulting in the resident's right to participate in healthcare decisions not being honored.
Two residents were unable to sleep and became irritable due to excessively loud televisions and staff shift changes at night. Staff and leadership acknowledged the noise issue, with one television measured at 100 dB in the hallway, but did not take effective action to reduce the noise. Residents affected had complex medical conditions and varying cognitive abilities, and the facility did not follow its own policy or resident council recommendations regarding noise control.
A resident with end stage renal disease, heart failure, and other conditions was placed on a physician-ordered fluid restriction, but the care plan was not updated in a timely manner to reflect the restriction or its distribution between nursing and dietary staff. Staff interviews and record reviews confirmed the omission, and facility policy required such updates within 72 hours of a change in treatment.
An unsecured, unlabeled pill was found on a resident's dresser, and two bottles of Erythromycin Ophthalmic Ointment in a medication cart were labeled with incorrect expiration dates. Staff interviews and policy reviews confirmed that medications should not be left unsecured or mislabeled, and that proper procedures for medication storage and administration were not followed.
A resident was served milk with a meal despite a documented dislike, leading to refusal to eat lunch. Multiple staff confirmed the resident's preference was listed and should have been followed, but the tray was not checked for accuracy. The facility's policy requires food preferences to be assessed and communicated, but this was not adhered to, resulting in the resident missing a meal.
Two rooms in the facility did not meet the minimum required living space of 80 square feet per resident, as observed during a survey. Each of these rooms housed four residents but measured less than the required square footage. Despite this, residents had adequate privacy, storage, and accessibility to care and facilities.
In a Memory Unit, inadequate supervision led to an altercation between two residents when a CNA left the dining room unattended to assist another resident. One resident, with a history of brain disorders, struck another resident with dementia. The facility's policy requires a licensed staff member to be present to ensure safety, but this was not adhered to, resulting in the incident.
The facility failed to follow its policy for garbage disposal, as two outside trash bins were found with open lids, attracting animals. Staff interviews confirmed that bins should be closed to prevent pest infestations, aligning with the facility's policy.
The facility failed to provide a homelike environment for several residents due to improperly hung curtains and chipped paint on walls. Staff acknowledged the issues, which compromised privacy and comfort. Residents involved had various medical conditions, including cognitive impairments and chronic illnesses.
The facility failed to develop and implement comprehensive care plans for five residents, leading to unmet needs and potential risks. Two residents lacked individualized care plans for ADLs, while three others did not have plans to ensure they were regularly out of bed, increasing the risk of pressure ulcers. Staff interviews revealed a lack of communication and planning, with no care plans in place to guide staff in addressing these issues.
The facility failed to meet professional standards by not having physician orders for oxygen for a resident with COPD and not following the prescribed oxygen delivery rate for another. Observations showed one resident receiving oxygen without orders and another receiving a higher rate than ordered. Staff interviews confirmed these discrepancies, which were against facility policies requiring physician orders for oxygen administration.
The facility failed to store and prepare food according to professional standards, affecting 71 residents. Issues included a plastic lid on a pantry shelf, incorrect labeling of food items, and the absence of an air gap under the food preparation sink. These deficiencies were acknowledged by the Certified Dietary Manager and Maintenance Supervisor, posing risks of expired food consumption and contamination.
The facility failed to maintain an effective infection control program, as three residents' oxygen concentrators were improperly maintained. One resident's concentrator operated without a filter, while two others had filters covered in lint and dust. This lack of maintenance was acknowledged by staff and could lead to respiratory infections.
A resident's dignity was compromised when her nephrostomy catheter bag was left uncovered, making the urine visible. The resident, who had a history of urinary tract infection and kidney issues, was observed with the uncovered bag on her lap. Staff, including a CNA, LVN, DSD, and DON, acknowledged the importance of covering catheter bags to maintain privacy and dignity, as per the facility's policy.
The facility did not meet the required square footage per resident in two rooms, with room 14 having 292 square feet for four residents and room 17 having 289 square feet for four residents. Despite this, the facility provided adequate privacy, storage, and accessibility, ensuring the waiver did not adversely affect resident health and safety.
Failure to Reassess and Revise Care Plans After Resident-to-Resident Aggression
Penalty
Summary
The deficiency involves the facility’s failure to timely reassess and revise comprehensive, person‑centered care plans for two residents after a significant behavioral incident involving resident‑to‑resident aggression. On 3/13/26, one resident (Res 1), a female with chronic kidney disease stage 3, hypertension, heart failure, type 2 diabetes, atrial fibrillation, malignant pleural effusion, anxiety disorder, depression, hypothyroidism, generalized muscle weakness, and difficulty walking, was observed yelling at other residents and pushing another resident’s (Res 2’s) wheelchair near the nursing station. Res 2, a 61‑year‑old male with hemiplegia and hemiparesis following cerebral infarction affecting the left side, dysphagia, generalized muscle weakness, difficulty walking, a left rib fracture, benign neoplasm of the meninges, nicotine dependence, a cerebrospinal fluid drainage device, and a history of falling, became upset and kicked Res 1’s wheelchair. Staff, including LVN 1, intervened, separated the residents, and moved Res 2 to the patio area while Res 1 remained near the nurses’ station, continuing to yell at staff. Following the incident, LVN 1 documented in Res 1’s nursing note that Res 1 had an episode of behavior with another resident, pushed Res 2’s wheelchair, and that Res 2 kicked Res 1’s wheelchair. The note indicated that both residents were separated, no physical contact was made between their bodies, and that Res 1 continued yelling at staff and attempted to reach toward the nurse. LVN 1 reported performing a head‑to‑toe assessment and mental‑health check on Res 2 and attempting to assess Res 1, but acknowledged she did not document any assessment or notes in Res 2’s medical record. Interviews with the Social Services Director, MDS coordinator, Director of Staffing Development, and DON confirmed that Res 2’s electronic medical record contained no nursing assessment, no nurses’ notes, no care plan updates, and no IDT documentation related to the 3/13/26 incident, despite the expectation that both residents would be assessed and that care plans and IDT notes would reflect the event and any new interventions. For Res 1, the MDS coordinator and Social Services Director identified that the care plan had been updated only to address behaviors of making false statements toward residents and staff, but not to address the documented aggressive behavior toward another resident and staff, nor the incident of Res 2 kicking Res 1’s wheelchair. There was no IDT documentation discussing the aggressive behavior, the pushing of another resident’s wheelchair, or any planned interventions to ensure safety and manage behaviors after the incident. Social services staff and the Administrator stated they followed up and interviewed staff present during the event, but these actions were not documented. The facility’s policies on comprehensive, person‑centered care planning and on abuse investigation and reporting require ongoing assessments, timely care plan revisions when residents’ conditions or behaviors change, and thorough documentation of investigations and findings. The lack of documented reassessment, care plan revision, and IDT planning for both residents after the 3/13/26 resident‑to‑resident aggression constituted the cited deficiency and was identified as placing both residents at risk for psychosocial distress and for not being comprehensively reassessed for appropriate individualized services to assure their highest practicable physical, mental, and psychosocial well‑being.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Ensure Onsite Dietician Oversight and Kitchen Sanitation
Penalty
Summary
The facility failed to ensure that a registered dietician (RD) consultant was able to conduct required onsite sanitation inspections and observe food safety and handling practices for the majority of residents consuming food prepared in the kitchen. The RD, who worked remotely, stated she was unable to perform these onsite tasks, and since the previous onsite RD left in March 2025, no monthly sanitation audits had been conducted. This resulted in a lack of oversight for kitchen sanitation and food safety practices. Observations revealed multiple sanitation issues in the kitchen, including yellow and gray dried residue with small white particles on the steam table knob, dried food residue on stove knobs and the stainless-steel base, and dried brown residue and food particles inside the oven. The oven door and metal shelves also showed discoloration and residue. Additionally, outside the kitchen, dumpsters were found uncovered and surrounded by litter and cardboard boxes, contrary to facility policy requiring dumpsters to be kept closed and the area free of clutter. Interviews with the Certified Dietary Manager (CDM) and the Administrator confirmed that the facility had not maintained expected sanitation standards and had not followed established policies regarding garbage disposal and kitchen cleanliness. The CDM acknowledged the lack of recent sanitation audits and the presence of residue and buildup on kitchen equipment. The Administrator confirmed that the facility had only remote RD coverage, which did not allow for required onsite inspections, and that the facility was not meeting its own expectations or policies for sanitation and refuse disposal.
Deficient Food Storage and Kitchen Sanitation Practices
Penalty
Summary
The facility failed to maintain safe food storage and handling practices in accordance with professional standards, affecting 73 of 74 residents who consumed food from the kitchen. Surveyors observed expired food items in both the refrigerator and dry storage areas, including open containers of red bell peppers and whole watermelons with use-by dates calculated as one year from the opening date. Staff interviews revealed inconsistent understanding of labeling practices, with some staff stating that foods should be used within seven days of opening, while others indicated a one-year use-by date. The Certified Dietary Manager (CDM) and Registered Dietician (RD) both acknowledged that food should be disposed of when beyond the use-by date, and that serving expired food could result in foodborne illness. Documentation review showed that facility policies required proper labeling and disposal of food by the use-by date, but these policies were not consistently followed. In addition to expired food, the facility did not maintain cleanliness of kitchen equipment and surfaces. Observations revealed food residue and build-up on the stove, oven, and steam table, as well as on the floor and other kitchen surfaces. The CDM stated that cleaning was supposed to occur daily and on a weekly schedule, but records showed that scheduled cleaning tasks were not always completed. The RD, who worked remotely, confirmed that she was unable to conduct sanitation inspections or observe food safety practices in person, and that the kitchen equipment appeared unclean based on photographic evidence. Previous sanitation audits also documented recurring issues with debris and build-up on kitchen equipment and surfaces. Job descriptions and facility policies reviewed by surveyors indicated that dietary staff and management were responsible for adhering to sanitation, safety, and procedural guidelines, including regular cleaning and monitoring of food storage for regulatory compliance. However, the lack of consistent oversight, incomplete cleaning schedules, and failure to follow established food labeling and disposal procedures contributed to the deficiencies observed during the survey.
Improper Garbage Disposal and Overflowing Dumpsters Create Sanitation Deficiency
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as evidenced by observations of an uncovered blue dumpster overflowing with cardboard boxes stacked above the rim, additional piles of cardboard on the ground next to a second dumpster, and two piles of cardboard boxes on the concrete walkway outside the kitchen back door. These conditions were directly observed during a site visit, and photographic evidence confirmed the presence of uncovered and overflowing dumpsters as well as littered areas adjacent to the kitchen. Interviews with facility staff, including the Certified Dietary Manager (CDM), Infection Preventionist (IP) Nurse, Registered Dietician (RD), Director of Nurses (DON), and Administrator (ADM), revealed that the facility routinely experienced issues with garbage accumulation, particularly on Mondays following multiple departmental deliveries. Staff acknowledged that the dumpsters were often too full to accommodate all waste, leading to overflow and improper storage of refuse. The CDM and IP Nurse both noted that the homeless population sometimes rummaged through the dumpsters, leaving them uncovered and contributing to the problem. The RD, who provided services remotely, confirmed that she was unable to conduct required sanitation inspections, and the ADM acknowledged that the facility did not meet its own policy expectations for garbage disposal and area cleanliness. A review of facility policies, job descriptions, and a recent sanitation audit further substantiated the deficiency. The facility's policy required all garbage containers to have tight-fitting lids and to be kept covered, and outside dumpsters to be closed and free of surrounding litter. The sanitation audit and job descriptions for key staff emphasized the importance of maintaining sanitary conditions and conducting regular inspections. Despite these requirements, the facility did not ensure that garbage was properly contained and disposed of, resulting in unsanitary conditions with the potential to attract pests and create cross-contamination risks for the food prepared for nearly all residents.
Failure to Cover Urinary Catheter Bag Compromises Resident Dignity
Penalty
Summary
A deficiency occurred when a resident with a urinary catheter was not provided with a dignity bag to cover the catheter drainage bag, resulting in the resident's urine being visible to anyone entering the room. During an observation, the catheter bag was found hanging at the end of the resident's bed without a dignity bag, and this was confirmed by both a CNA and the Infection Preventionist. Both staff members acknowledged that the catheter bag should be covered at all times to protect the resident's dignity and privacy, and that its visibility could cause embarrassment to the resident. The resident involved had multiple medical conditions, including hydronephrosis, urinary tract infection, muscle weakness, contracture of the left hand, schizophrenia, and type 2 diabetes. The resident was assessed as cognitively intact with a BIMS score of 13. Facility policy requires that urinary catheter bags be covered to maintain resident dignity, and staff are expected to assist residents in keeping catheter bags covered. The failure to follow this policy resulted in a violation of the resident's right to dignity and privacy.
Resident's Right to Medication Timing Not Honored
Penalty
Summary
A deficiency occurred when a resident diagnosed with insomnia, who had no cognitive impairment, was not allowed to receive his melatonin medication at his preferred time of 11:00 p.m. or 12:00 a.m. Despite the resident's repeated requests to nursing staff to adjust the timing of his melatonin to help him sleep through the night, the medication continued to be administered at 9:00 p.m. This led to the resident experiencing ongoing sleep difficulties since admission, as he would awaken during the night due to the early administration of his sleep aid. Interviews with staff confirmed that the resident's request was communicated to a nurse, but no action was taken to change the medication schedule. The facility's policies indicate that residents have the right to participate in decisions about their treatment, and staff acknowledged the importance of honoring the resident's preferences. However, the failure to follow up on the resident's request and adjust the medication timing resulted in the resident's right to make choices about his healthcare services not being honored.
Failure to Maintain Comfortable Noise Levels at Night
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment by not controlling excessive noise levels, particularly from resident televisions and staff shift changes during nighttime hours. Two residents reported being unable to sleep due to loud televisions, with one resident specifically stating that the noise made him irritable and upset. Observations confirmed that television volumes were excessively high, with one measured at 100 decibels in the hallway, and staff interviews acknowledged awareness of the issue but did not take effective action to address it. Staff, including RNs and LVNs, confirmed that televisions were loud and could be heard from the front lobby, and that the noise should have been reduced after 10 p.m. to allow residents to sleep. One resident with hearing impairment required a higher television volume, but staff did not implement measures to balance this need with the comfort of other residents. The Director of Nursing, Social Services Director, and Administrator all acknowledged that staff were responsible for maintaining a comfortable noise level and that the facility did not follow its own policy regarding noise control. The residents affected had significant medical histories, including hypertension, depression, muscle weakness, hemiplegia, cirrhosis of the liver, and restless legs syndrome. Cognitive assessments indicated varying levels of impairment among the residents involved. Resident council meeting minutes and facility policy both emphasized the importance of maintaining a comfortable noise level, but these were not adhered to, resulting in residents experiencing sleep disturbances and irritability.
Failure to Timely Update Care Plan with Fluid Restriction Orders
Penalty
Summary
The facility failed to ensure the timely review and revision of a resident's person-centered, comprehensive care plan when a physician ordered a fluid restriction. Specifically, a resident with diagnoses including end stage renal disease, hypertensive heart disease, heart failure, and a right femur fracture was placed on a fluid restriction of 960 mL per 24-hour period, with specific allocations for nursing and dietary staff. Despite this order, the resident's care plan did not reflect the fluid restriction or the distribution of fluids among the nursing and dietary disciplines for several weeks after the order was written. Record reviews and staff interviews confirmed that the care plan, dated prior to the fluid restriction order, only addressed risks related to renal failure and fluid imbalances but did not include the new fluid restriction or its breakdown by discipline. The Certified Dietary Manager acknowledged that the care plan lacked this information and was unaware of the policy requiring the dietary supervisor to ensure the care plan included fluid distribution. Nursing staff, including a Licensed Vocational Nurse and the Director of Nursing, also confirmed that the care plan was not updated in a timely manner to reflect the new physician order, and that this omission could result in staff not providing individualized care as required. Facility policies and job descriptions reviewed during the investigation indicated that care plans should be updated within 72 hours of changes in a resident's condition or treatment, and that both nursing and dietary staff are responsible for ensuring care plans are accurate and current. However, the care plan for this resident was not revised to include the fluid restriction and its distribution until several weeks after the order was placed, contrary to facility policy and professional standards.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to its medication storage and administration policies in two distinct instances. In the first instance, an unsecured and unlabeled round white pill was found on a resident's dresser during an observation. The resident, who had moderate cognitive impairment as indicated by a BIMS score of 11 and diagnoses including COPD, CHF, dementia, and CVA, was unaware of the pill's presence. Multiple staff interviews confirmed that medications should not be left unsecured or unattended in resident rooms, and that the nurse should observe the resident taking the medication or properly dispose of it if dropped. The facility's own policies and professional references reviewed also emphasized that medications must be secured and not left at the bedside or in resident areas. In the second instance, two bottles of Erythromycin Ophthalmic Ointment were found in a medication cart with incorrect expiration dates. The bottles were labeled to expire 30 days after opening, but the manufacturer's guidelines specified a 28-day expiration period. Staff interviews, including those with the RN, DON, and pharmacy consultant, confirmed that medications should be labeled with the correct expiration date and that expired medications could lose efficacy. The facility's policies and job descriptions for nursing staff and the DON outlined responsibilities for ensuring proper medication storage and administration, including checking for expired medications. Both deficiencies were identified through direct observation, staff interviews, and review of facility policies and professional guidelines. The findings demonstrated lapses in following established procedures for medication security and accurate labeling, as required by both facility policy and accepted professional standards.
Failure to Accommodate Resident Meal Preferences
Penalty
Summary
A deficiency occurred when a resident was served milk with his lunch meal tray despite having a documented dislike of milk. The resident had previously informed staff that he did not want milk served with his meals. During observation and interviews, it was confirmed by the Director of Staff Development, Certified Nursing Assistant, Certified Dietary Manager, and Director of Nursing that the resident's meal ticket clearly listed milk as a dislike, and that the resident should not have been served milk. The staff acknowledged that all CNAs and nurses were responsible for ensuring meal trays matched residents' preferences and that the tray should have been checked for accuracy before being served. As a result of receiving milk, the resident refused to eat lunch and missed out on the nutritional value of the meal. The facility's policy indicated that individual food preferences are to be assessed upon admission and communicated to the interdisciplinary team. The failure to accommodate the resident's documented meal preference led to the resident not eating his meal.
Failure to Meet Minimum Room Size Requirements
Penalty
Summary
The facility failed to provide the minimum required living space of at least 80 square feet per resident in multiple occupancy rooms for two out of 29 rooms, specifically rooms 14 and 17. During an environmental tour with the Maintenance Supervisor, it was observed that these rooms, each housing four residents, measured 292 and 289 square feet respectively, which is below the regulatory requirement. Despite this, the report notes that variations were made according to the particular needs of the residents, and that privacy, storage, bedside stands, space for nursing care, ambulation, and accessibility to wheelchairs and toilet facilities were adequate at the time of the survey.
Inadequate Supervision in Memory Unit Leads to Resident Altercation
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents in the Memory Unit dining room, leading to an altercation between two residents. Certified Nursing Assistant (CNA) 3 left the dining room unattended to assist another resident, leaving Residents 1 and 2 without the required supervision. This resulted in Resident 1 striking Resident 2 in the face, although no injuries were noted. The absence of a licensed staff member in the dining room at the time of the incident was against the facility's standard practice, which mandates that a trained and licensed staff member be present to ensure resident safety. Resident 1, who was admitted with a history of Other Specified Disorders of the Brain, displayed behaviors of agitation and striking out at staff, as noted in their Care Plan Report. Their Minimum Data Set (MDS) indicated a severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 4. Resident 2, admitted with a history of Dementia, required substantial assistance with activities of daily living and had a BIMS score of 0, indicating severe cognitive impairment. Resident 2's Care Plan Report highlighted increased agitation and aggression, with interventions including one-on-one supervision as needed. Interviews with staff, including the Director of Nursing (DON) and the Administrator, confirmed that the facility's policy required a licensed staff member to be present in the Memory Unit dining room to provide supervision. The DON and Administrator acknowledged that housekeeping staff were not trained to work in the Memory Unit and were not required to complete the annual Alzheimer and Dementia in-service. The incident occurred due to CNA 3's decision to leave the dining room without alerting another licensed staff member, resulting in a lack of supervision and the subsequent altercation between the residents.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to adhere to its policy regarding the proper disposal of garbage and refuse, as observed by surveyors. During an observation in the alley behind the facility, two outside trash bins were found with their lids open. A large blue trash bin had its lid hanging on the back, exposing its contents, while a large grey trash bin had its lid propped open with an empty cardboard box. Two cats were seen at the bottom of the bins, indicating the potential for attracting animals and pests. Interviews with the Certified Dietary Manager, Registered Dietitian, and Maintenance staff confirmed that the trash bins should always be closed to prevent pest infestations and the spread of disease. The facility's policy, reviewed during the survey, stated that garbage and refuse containers should be covered, aligning with the staff's statements.
Failure to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for several residents, as observed during a survey. Specifically, the privacy and window curtains in the rooms of four residents were not properly hung on the hooks, which compromised the residents' privacy and the homelike atmosphere of their rooms. Staff members, including a CNA, LVN, Maintenance Supervisor, Housekeeping Supervisor, Director of Staff Development, Director of Nursing, and the Administrator, acknowledged the issue and its impact on the residents' environment. The curtains were described as having missing or damaged hooks, preventing them from functioning correctly and providing adequate privacy. Additionally, the facility did not address the issue of chipped and peeling paint on the walls of a room shared by three residents. The paint was missing in a significant section of the wall, which detracted from the homelike environment that the facility is required to provide. The Maintenance Supervisor and the Administrator both recognized that the condition of the walls did not meet the standards for a homelike setting and should have been addressed. The residents involved in these deficiencies had various medical conditions, including severe cognitive impairments, diabetes, dementia, and other chronic health issues. The failure to maintain a homelike environment, as evidenced by improperly hung curtains and damaged walls, was noted during observations and interviews with staff and residents. The facility's policies and job descriptions emphasize the importance of maintaining a clean, safe, and homelike environment, yet these standards were not met in the instances observed.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for five residents, leading to unmet needs and potential risks. Residents 69 and 127 did not have individualized care plans for Activities of Daily Living (ADL), which could result in their ADL needs not being met. Resident 69, with severe cognitive impairment and multiple health issues, required assistance with transfers, but specific interventions were not documented in the care plan. Similarly, Resident 127, who was bed-bound and required total assistance, lacked a care plan addressing her transfer needs, potentially placing her at risk for falls or injury. Additionally, Residents 1, 16, and 26 did not have care plans to ensure they were regularly out of bed, increasing the risk of developing pressure ulcers. These residents, all with severe cognitive impairments and various health conditions, were observed lying in bed without documented attempts to get them up. Staff interviews revealed a lack of communication and planning to address this issue, with no care plans in place to guide staff in getting these residents out of bed for socialization and pressure sore prevention. The facility's policies and procedures required comprehensive, person-centered care plans with measurable objectives and timetables to meet residents' needs. However, the facility failed to adhere to these policies, as evidenced by the lack of individualized care plans for the sampled residents. This deficiency was acknowledged by the Director of Nursing and other staff members, who recognized the importance of care plans in guiding resident care and preventing potential harm.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to meet professional standards of practice for two residents who required supplemental oxygen due to their chronic obstructive pulmonary disease (COPD). For the first resident, there were no physician orders in place for the administration of oxygen, despite the resident's dependence on supplemental oxygen. Observations and interviews with staff revealed that the resident was receiving oxygen continuously via a nasal cannula, but the necessary physician orders were missing. The facility's policy required a physician's order for oxygen administration, which was not adhered to in this case. For the second resident, the facility did not follow the physician's orders regarding the oxygen delivery rate. The resident was observed receiving three liters of oxygen per minute, while the physician's order specified two liters per minute. Interviews with staff confirmed that the oxygen delivery rate was not in accordance with the doctor's orders, and the care plan also indicated the correct rate of two liters per minute. The facility's policy emphasized the importance of verifying physician orders for oxygen administration, which was not followed in this instance. Both deficiencies highlight the facility's failure to ensure that physician orders for oxygen administration were in place and followed, as required by their policies. The lack of proper documentation and adherence to physician orders had the potential to impact the residents' health, as they were not receiving the prescribed amount of oxygen necessary for their condition.
Food Storage and Preparation Deficiencies
Penalty
Summary
The facility failed to ensure food was stored and prepared in accordance with professional standards for food service safety, affecting 71 of 73 residents. During an observation, a plastic lid was found discarded on a pantry shelf in the dry food storage area, which the Certified Dietary Manager (CDM) acknowledged should not be there. Additionally, a canister of oatmeal in the dry food storage area was found with incorrect labeling regarding its received, use by, and opened dates, which the CDM admitted could cause confusion and result in residents receiving expired food. Furthermore, the facility's kitchen was found to lack an air gap under the food preparation sink, a necessary feature to prevent sewage backup and food contamination. The CDM was unaware of the requirement for an air gap, and the Maintenance Supervisor confirmed the absence of an air gap, acknowledging its importance. Additionally, a box of frozen mixed vegetables in the freezer was mislabeled, with the CDM noting the labeling was confusing and did not match the manufacturer's use by date. The Registered Dietitian also highlighted the risks of mislabeling, which could lead to residents consuming expired food.
Inadequate Maintenance of Oxygen Concentrators
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the improper maintenance of oxygen concentrators for three residents. Resident 4's oxygen concentrator was observed operating without a filter, which is a critical component for ensuring clean air delivery. This deficiency was confirmed during an observation and interview with a registered nurse, who acknowledged that the absence of a filter was unacceptable and could exacerbate the resident's respiratory condition. The Director of Nursing also confirmed that using an oxygen concentrator without a filter could lead to respiratory infections such as pneumonia and bronchitis. Additionally, the oxygen concentrator filters for Residents 12 and 58 were found to be covered with lint and dust, indicating a lack of regular cleaning and maintenance. Both residents expressed concerns about the cleanliness of their oxygen concentrators, and the registered nurse confirmed that the condition of the filters was unacceptable. The facility's policy and procedure documents, as well as the oxygen concentrator manual, emphasize the importance of maintaining clean equipment to prevent infections. The facility's job descriptions for licensed vocational nurses and registered nurses include responsibilities for ensuring equipment is in good operating order and following infection control policies. However, the observations and interviews revealed a failure to adhere to these responsibilities, as well as the facility's infection control policies and procedures. The maintenance department is also responsible for following the manufacturer's recommended maintenance schedule, which was not followed in these cases.
Failure to Maintain Resident Dignity by Not Covering Catheter Bag
Penalty
Summary
The facility failed to ensure the dignity of a resident by not covering her nephrostomy catheter bag, leaving the urine visible. This deficiency was observed during a survey when the resident was seen in her room with the catheter bag uncovered and placed on her lap. The resident's medical history included a urinary tract infection, hydronephrosis, and a ureter stone. The lack of coverage for the catheter bag was noted during multiple observations and interviews with staff members, including a Certified Nursing Assistant (CNA), a Licensed Vocational Nurse (LVN), the Director of Staff Development (DSD), and the Director of Nursing (DON). The staff members acknowledged that the nephrostomy catheter bag should have been covered to maintain the resident's dignity and privacy. The CNA stated that catheter bags need to be covered to prevent embarrassment or discomfort for the resident. The LVN confirmed that both CNAs and LVNs are responsible for applying a privacy bag over catheter bags. The DSD and DON reiterated the expectation that catheter bags should always be covered to protect residents' dignity, as outlined in the facility's policy and procedure on dignity. The policy emphasized that residents should be treated with dignity and respect at all times, and demeaning practices that compromise dignity are prohibited.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to provide the minimum required square footage per resident in two of its rooms, specifically rooms 14 and 17. During an environmental tour with the Maintenance Supervisor and Maintenance Staff, it was observed that these rooms did not meet the regulatory requirement of at least 80 square feet per resident. Room 14 had 292 square feet for four residents, and room 17 had 289 square feet for four residents. Despite this deficiency, the facility ensured that the variations in room size were in accordance with the particular needs of the residents, providing a reasonable amount of privacy, adequate closets and storage space, bedside stands, and sufficient room for nursing care and resident ambulation. Wheelchairs and toilet facilities were accessible, and it was determined that the waiver would not adversely affect the health and safety of the residents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 85 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) |
|---|---|---|---|---|
| La Sierra Care Center | 0.1 mi | ★★★★★ | 16 | 0 |
| Golden Merced Care Center | 0.2 mi | ★★★★★ | 4 | 0 |
| Franciscan Post-acute Care Center | 0.7 mi | ★★★★★ | 3 | 0 |
| Merced Behavioral Center | 1.5 mi | ★★★★★ | 0 | 0 |
| Anberry Post Acute | 3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 August 2026) and official state health department websites.