Merced Behavioral Center

In the surveyor’s words

From the most serious findings on record at Merced Behavioral Center, in the surveyor’s own words.

• Actual harm, isolatedF692Jun 5, 2023

  Based 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). […]

• No harm, potential for more than minimal, widespreadF657Jun 5, 2023

  45580 Based 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. […]

• No harm, potential for more than minimal, widespreadF812Jun 5, 2023

  Based 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. […]

• No harm, potential for more than minimal, patternF802Jun 5, 2023

  Based 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. Cook 1, Cook 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. […]

• No harm, potential for more than minimal, patternF925Jun 5, 2023

  Based 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. Findings: During an observation on 5/30/23, at 3:16 p.m., a fly was noted flying above the steam table. During an observation on 5/30/23, at 3:17 p.m., a fly was noted flying near the two-compartment sink. Dietary Supervisor (DSS) saw the fly, attempted to swat it with her hand. During an observation on 5/30/23, at 3:23 p.m., there was a fruit fly inside a box of moldy cucumbers on the counter near the two-compartment sink. […]