Merced Nursing & Rehabilitation Ctr

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident's medications regimen must be free from unnecessary medications and entire medication regimen was monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being (refers to the state of mental, emotional, and social health of an individual) for one of three sampled residents (Resident 1), when Resident 1's target behaviors were not accurately monitored and documented for the use of psychotropic medications (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all staff were aware of reporting all alleged violations of mistreatment, exploitation (taking advantage of a resident for personal gain, through the use of manipulation, intimidation, threats, or coercion), neglect, or abuse, including injuries of unknown source, and misappropriation of resident property (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent) for one of three sampled residents (Resident 3), when the Activity Director (AD) did not report Resident 3's allegation of abuse to the facility's Administrator on 7/7/26. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to maintain the resident's highest practicable physical, mental, and psychosocial well-being (refers to the state of mental, emotional, and social health of an individual) for one of three sampled residents (Resident 1), when Resident 1's care plan for the indications for use of psychotropic medications (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) did not include measurable and objective goals to meet Resident 1's mental and psychosocial needs. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to timely review and revise residents' comprehensive, person centered care plans after significant changes in condition and or behavior following a resident to resident aggression on 3/13/2026 for two of four sampled residents ((Res) 1, and Res 2), when Res 1 was verbally aggressive towards Res 2 and LVN 1, Res 1 moved Res 2 while he was in his wheel chair, and Res 2 kicked Res 1's wheel chair. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five residents (Resident 1), was free from physical and verbal abuse when on [DATE] Certified Nursing Assistant (CNA) 1 was witnessed grabbing Residents 1's left arm forcefully and escorting Resident 1 back to her room. Resident 1 was instructed by CNA 1 to then remain in her room with the door closed. This failure resulted in Resident 1 experiencing witnessed physical abuse by CNA 1 and isolation. During a concurrent observation and interview on [DATE] at 10:53 a.m. with Resident 1, Resident 1 was sitting on a chair in the lobby with a staff member. Resident 1 was pleasant, easily redirected, compliant and cooperative. The Registered Nurse Supervisor (RNS) escorted Resident 1 to her room for an interview. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a registered dietician consultant was able to conduct sanitation inspections and observe food safety and handling practices for 73 of 74 residents who consumed food prepped from the kitchen, when the consultant stated she worked remotely and would not be able to perform onsite tasks. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain safe food storage and food handling in accordance with professional standards for food service safety for 73 of 74 residents who consumed food from the kitchen when: 1. Expired food was found in the refrigerator and in dry storage (storing/maintaining dry foods). 2. Food residue was stuck to the stove, oven, and steam table. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the garbage was disposed of properly when the blue dumpster was found uncovered with carboard boxes stacked higher than the rim of the dumpster, a pile of cardboard was lying on the ground next to a second dumpster and two piles of cardboard boxes were on the concrete walkway outside of the kitchen back door. This failure had the potential to attract or harbor pests which could increase the risk of cross contamination (the unintentional transfer of harmful bacteria or other contaminants from one food, surface, or object to another, often leading to foodborne illnesses and the growth of microorganisms) and could affect the food prepared in the kitchen for 73 of 74 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 3) was treated with dignity and respect when Resident 3's urinary catheter (a tube placed in the body to drain and collect urine from the bladder [a hollow, muscular organ located in the lower abdomen that stores urine]) bag was not placed in a dignity bag (a bag the catheter drainage bag is placed into, to shield the resident's urine from view). This failure violated Resident 3's dignity, respect, and need for urinary catheterization to remain private which could negatively impact Resident 3's psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to honor a resident's right to make choices about his healthcare services for one of six sampled residents (Resident 175) when Resident 175's request to receive his melatonin (medication which helps promote sleep) at 11:00 p.m. was not honored. This failure caused Resident 175 to not be able to get a full night's sleep since he was admitted on [DATE].

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a comfortable sound level for two of six sampled residents (Resident 31 and Resident 65) when televisions were heard in the lobby from residents' rooms. This failure resulted in Resident 31 and Resident 65 to feel irritable, upset, and was unable to sleep.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the timeliness of each resident's person-centered, comprehensive care plan was reviewed and revised when fluid restriction (limit the amount of liquid you have each day) was ordered by the physician for one of six sampled residents (Resident 9) and Resident 9's care plan did not indicate the fluid restriction or the total number of fluid distribution among nursing and dietary disciplines. This failure placed Resident 9 at risk for not receiving person-centered nursing care which could have led to drinking too much fluid causing fluid overload (too much fluid in the body leading to swelling, shortness of breath), heart failure (HF-the heart is not able to pump enough blood for the kidneys to remove fluid) or kidney failure (when the kidneys are not able to work well to remove fluid).

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's medication regimen was free from unnecessary psychotropic medications for one of three sampled residents (Resident 12) when Resident 12 did not have an informed consent signed prior to receiving her duloxetine (psychotropic medication used to treat sadness) medication. This failure resulted in Resident 12 to not be informed of the risks and benefits of duloxetine and had the potential for Resident 12 to experience the side effects of duloxetine such as nausea, constipation, and drowsiness.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their policy for medication storage when: 1. An unsecured unlabeled single round white pill was found laying on a resident's dresser for one of six sampled residents (Resident 11). This failure had the potential to result in other residents having access to ingest the unidentified medication which could cause adverse side effects (side effect, bad reaction, unwanted response) or an allergic reaction. 2. Two bottles of Erythromycin Ophthalmic Ointment (eye medication) were labeled with an incorrect expiration date which were located in one of two sampled medication carts. This failure had the potential to result in the administration of expired medication to residents that may have lost their potency and effectiveness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate resident meal preferences for one of six sampled residents (Resident 43) when Resident 43 received his documented dislike of milk on 4/14/25. This failure resulted in Resident 43 refusing to eat lunch and missing out on the nutritional value of the meal which had the potential to cause Resident 43 to experience weight loss as a result of not eating.

Inspectors wroteBased on observation and interview during the survey period of 4/14/25 to 4/18/25, the facility failed to provide the minimum of at least 80 square feet per resident for rooms occupied by residents for two of 29 rooms (rooms [ROOM NUMBERS]), when the amount of usable living space was not adequate for residents. This failure had the potential for residents in rooms [ROOM NUMBERS] to not have reasonable privacy or adequate space to move around and for personal belongings.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for two of four residents (Residents 1 and 2) when Certified Nursing Assistant (CNA) 3 left Residents 1 and 2 unattended in the dining room of the Memory Unit (a specialized care facility designed specifically for individuals experiencing memory loss due to conditions like Alzheimer's disease; a brain disorder that gradually destroys memory and thinking skills or Dementia; a loss of brain function that affects thinking, memory, and reasoning, providing a secure environment with tailored activities and 24/7; 24 hours/seven days a week supervision to support their needs) on [DATE]. This failure resulted in Resident 1 striking Resident 2 in the face and the potential for Resident 2 to be injured.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy for garbage and refuse containers when the lids on two of two outside trash bins were left open. This failure had the potential to attracts animals, insects and pests which could lead to infestations, unsanitary conditions and the spread of disease.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement a clean, comfortable, homelike environment for 7 of 29 sampled residents (Residents 1, 9,16, 18, 26, 27, 47) when: 1. Residents 1, 16, 26, and 47's room and privacy curtains were not properly hung on the hooks. This failure had the potential to result in Residents 1, 16, 26, and 47 not being provided their right to have privacy or a comfortable homelike environment. 2. The facility failed to honor the right of three of 23 sampled residents (9, 18, and 27), when the wall of residents 9,18 and 23's room had paint that missing, chipped and peeling.

Inspectors wrote2. During a review of Resident 1's admission record (AR), dated 7/11/24, the AR indicated Resident 1 was admitted on [DATE]. Resident 1's diagnoses included: Alzheimer's (a brain disorder that slowly destroys memory and thinking skills), dysphagia (difficulty swallowing), and bipolar disorder (condition which causes extreme mood swings) During a review of Resident 16's AR, dated 7/11/24, the AR indicated Resident 16 was admitted on [DATE]. Resident 16's diagnoses included: chronic obstructive pulmonary disease (condition which makes it difficult to breathe), dementia (condition characterized by loss of memory, language, problem-solving and other thinking abilities), dysphagia, and bipolar disorder. During a review of Resident 26's AR dated 7/11/24, the AR indicated Resident 26 was admitted on [DATE]. Resident 26's diagnoses included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of practice for two of 26 sampled residents (Residents 4 and 16) when: 1. No physician orders for oxygen were in place for Resident 4 2. The physician orders for oxygen delivery rate were not followed for Resident 16 These failures had the potential to cause Residents 4 and 16 to receive the incorrect amount of oxygen required for their individual needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored and/or prepared in accordance with professional standards for food services safety for 71of 73 residents when: 1. A plastic lid was discarded on the pantry shelf in the dry food storage area. 2. No air gap (an unobstructed vertical space between the water outlet and the flood level of a fixture), under the food preparation sink. 3. One canister of food in the dry food storage area and one box of food in the freezer had incorrect opened, use by and expiration dates. These failures put the residents at risk for food borne illness that could have eventually led to death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection control program when: 1. One of 23 sampled residents' (Resident 4) oxygen concentrator (a device that concentrates the oxygen from the ambient air) was being used without a filter. 2. Two of 23 sampled residents' (Residents 12 and 58) oxygen concentrator filters were found covered with lint and dust. These failures placed Residents 4, 12, and 58 at an increased risk to develop respiratory and healthcare-associated infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignity was provided for one of 26 sampled residents (Resident 4) when Resident 4's nephrostomy catheter (a tube that is inserted into the kidneys, allowing the urine to drain freely into a connected bag) bag was uncovered leaving the urine visible. This failure resulted in Resident 4 not being provided her right to have a dignified existence while in the facility.

Inspectors wroteBased on observation and interview during the survey period of 7/9/24 to 7/12/24, the facility failed to provide the minimum of at least 80 square feet per resident for rooms occupied by residents for two of 29 rooms (rooms [ROOM NUMBERS]), when the amount of usable living space was not adequate for residents. This failure had the potential for residents in rooms [ROOM NUMBERS] to not have reasonable privacy or adequate space.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their infection prevention and control policy and procedures and hand washing standards for one of 13 sampled residents (Resident 19) when Certified Nurse Assistant (CNA) 1 touched Resident 19's bread with her bare hands while assisting Resident 19 with the lunch meal. This failure had the potential to place Resident 19 at risk for food borne illness and cross contamination.

Inspectors wroteBased on observation and interview the facility failed to provide and maintain minimum square footage of at least 80 square feet per resident for rooms occupied by four residents for two of 28 rooms. This failure had the potential risk to result in lack of sufficient space for the provision of care by facility staff and increase risk of not having enough room for their belongings and the potential to diminish visitation privacy for eight of eight sampled residents who resided in those rooms.