Merced Behavioral Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the policy and procedure (P&P) titled, Weight Assessment and Intervention, to ensure residents with significant unplanned weight changes had updated care plan interventions and that those interventions were carried out and monitored for their effectiveness to avoid further weight changes for one of five sampled residents (Resident 73). This failure resulted in significant, unplanned weight changes for Resident 73 and had the potential to result in malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care plans were created and/or revised for four of 37 sampled residents (Resident 49, 296, 58 and 73), when: 1. Resident 49 and Resident 296 had a change of condition (a change in a person's health or functioning), and their care plans did not reflect the care the residents were currently receiving. 2. Resident 73 lost 20 pounds in 6 months and his care plan for weight loss did not provide current interventions to help the resident maintain his weight. 3. Resident 58 gained unplanned 10 pounds for one month. Interdisciplinary Team (IDT-a group of health care professionals from different fields who work toward a common goal for the resident) did not develop an individualized care plan and implement effective interventions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices for 93 of 93 residents who receive food from the kitchen when: 1. Ice machine was not kept in sanitary condition and put residents at risk for foodborne illness (stomach illness acquired from ingesting contaminated food). 2. The can opener in the kitchen was not kept in sanitary condition which could transfer to residents' foods. Dietary staff did not clean the can opener after use. This had the potential to cause foodborne illness and cross contamination. 3. The walk-in refrigerator had rusting storage shelves and had the potential to harbor bacterial growth. 4. Worn out green cutting board. 5. Hood filter above stove covered with grease and dust. 6. Dust: [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure that dietary staff safely and effectively carried out the functions of food and nutrition services for 93 out of 93 sampled residents when: 1. [NAME] 1, [NAME] 2 and Dietary Supervisor (DSS) did not know they need to do cool down process (is an essential process used in food production to prevent foodborne illness. Bacteria grow best in food in the temperature range 135°F to 41°F, also referred to as the temperature danger zone. Cooked Foods not served immediately must be cooled quickly to minimize bacterial growth. If cooked foods left for improper cool down process, cooked foods can become unsafe to eat in a matter of hours) for cooked bean. (Cross referred 812) 2. Dietary Aide 1 did not follow manufacturer guideline time length to submerse kitchen ware into [NAME] (sanitizer) in the sanitizing sink. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Pest Control, when the facility did not maintain an environment free of pests. This failure had the potential to result in illness related to cross contamination of food.

Inspectors wroteBased on observation, interview and record review, the facility failed to honor a food request for one of one sampled residents (Resident 59), when a Licensed Vocational Nurse (LVN) denied his verbal request for a biscuit and did not offer him an alternative item. This failure resulted in Resident 59's individual preference or choice being devalued (reduce or underestimate the worth of importance of) and not being treated with honor or respect.

Inspectors wroteBased on observation, interview and record review, the facility failed to inventory personal property for one of one sampled residents (Resident 14) when Resident 14's hand-held radio was not inventoried (item entered in to a list). This failure resulted in Resident 14's property being lost or stolen and the facility not replacing it.

Inspectors wroteBased on observation, interview and record review, the facility failed to allow residents to submit grievances (complaints) anonymously (not being named or identified) for one of four sampled residents (Resident 60) when the grievance box was inaccessible (not able to be accessed) for residents to submit grievances anonymously. This failure resulted in Resident 60 not being able to voice concerns without discrimination, or fear of reprisal (retaliation).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS- assessment of healthcare and functional needs) assessment accurately reflected the resident's status for one of five sampled residents (Resident 3) when Resident 3 had an open skin wound and was coded with intact skin in the MDS assessment. This failure resulted in an inaccurate assessment of Resident 3's skin condition and had the potential for Resident 3's needs to go unmet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it was free of accident hazards when they did not use a wet floor sign to identify a hallway floor that was wet from mopping. This failure had the potential to result in residents, staff, and visitors slipping on the wet floor and sustaining a fall or injury.

Inspectors wroteBased on interview and record review, the facility failed to complete a performance evaluation of a nurse aide at least every 12 months for one of two sampled Certified Nurse Assistant (CNA 7), when CNA 7 did not have a performance evaluation review. This failure had the potential to result in residents to not receive the appropriate care and services performed by CNA 7.

Inspectors wroteBased on observation, interview and record review, the facility failed to destroy controlled (drugs that are tightly controlled because of their abuse potential or risk) medications per facility policy for one of two sampled medication storage rooms, when controlled substances were discarded in an unlocked medication destroy bin accessible to all staff members. This failure had the potential to result in the potential diversion (transfer of any legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illegal use) of controlled medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide dental services to meet the needs of each resident and follow its policy titled, Dental Services, for one of eight sampled residents (Resident 34), when Resident 34 broke his dentures in November 2022, informed staff and no dental appointment was made. This caused Resident 34 to miss out on foods that he enjoyed due to not having his dentures to use.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a safe and sanitary environment for two of three sampled pill crushers (device for crushing medications) when the pill crushers were not free of medication residue (white substance). This failure had the potential to result in cross-contamination (process by which bacteria is transferred from one substance or object to another, with harmful effect) of medications and possibly cause serious harm, or death.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Long Term Care Ombudsman (an advocate for residents) was notified of the acute care hospital transfer for nine of nine sampled residents (Resident 3, 18, 28, 47, 73, 87, 89, 443, and 444), when the residents were transferred to a general acute care hospital (GACH) on different days and the transfer of each resident was not communicated to the ombudsman office by the facility. This failure had the potential of not providing Residents 3,18, 28, 47, 73, 87, 89, 443, and 444 with access to the ombudsman and the benefit of an advocate who could inform them of their discharge and transfer rights.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was stored, prepared and served in accordance with professional standards for food service safety when the kitchen dry storage area and walk in-refrigerator stored food items with dates beyond the use-by date and undated, unlabeled food items were available for consumption. These failures had the potential for residents to consume expired food and result in food borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately code one of 17 sampled residents (Resident 19) Minimum Data Set (MDS- assessment of memory and functional needs) assessment when Resident 19's tobacco use was not coded on an annual MDS assessment. This failure had the potential for Resident 19 to not receive an individualized plan of care based on specific needs.