Complaint Investigation

Franciscan Post-acute Care Center

February 5, 2025 · Merced, CA · 3169 M Street

Citations 4

CMS Rating 4/5

Beds 71

Provider ID 055979

Healthcare Facility

Franciscan Post-acute Care Center

Merced, CA · View full profile →

Source Document

Official CMS Inspection Report (Medicare.gov)

Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.

Inspection Summary

FRANCISCAN POST-ACUTE CARE CENTER in MERCED, CA — inspection on February 5, 2025.

Found 4 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0641

Ensure each resident receives an accurate assessment.

resident ' s status .

Accuracy of Assessments: Why .

Proper care planning . MDS accuracy: How .

(MDS-a resident assessment tool used to identify resident cognitive and physical function) accurately reflected resident's health and functional status for one of three sampled residents (Resident 1) when Resident 1's smoking status and oxygen use were not accurately coded on the MDS assessment.

055979 02/05/2025

Franciscan Post-Acute Care Center 3169 M Street Merced, CA 95348

FF0657

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared,

facility and did not develop and implement effective care plan interventions to prevent smoking

055979 02/05/2025

Franciscan Post-Acute Care Center 3169 M Street Merced, CA 95348

FF0689

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to

Oxygen Therapy: Using Oxygen Safely, dated 12/15/23, the reference indicated, .

Materials burn more

Flame . [NAME] ' t smoke and don ' t allow others to smoke near you .

Keep sources of heat and

fire] nearby .

FF689

Minimal harm or told to make sure Resident 1 was not smoking, have cigarettes or a lighter. CNA 2 stated Resident 1 would Few During a concurrent interview and record review on 2/5/25 at 10:37 a.m. with Licensed Vocational Nurse affected

During a review of Resident 1 ' s Admission Record, undated, the admission record indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis that included atrial fibrillation (an irregular and often very rapid heart rhythm), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), end stage renal disease (ESRD-irreversible kidney failure), shortness of breath and dyspnea (difficulty breathing).

During a review of Residents 1 ' s Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 1 ' s Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 15 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment).

The BIMS assessment indicated Resident 1 was cognitively intact.

During an interview on 2/5/25 at 10:27 a.m. with CNA 2, CNA 2 stated Resident 1 was a known smoker and had been caught smoking at the facility even though the facility was smoke-free. CNA 2 stated the staff was told to make sure Resident 1 was not smoking, have cigarettes or a lighter. CNA 2 stated Resident 1 would go to HD and bring cigarettes and lighters back with him.

055979

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 055979 B.

Wing 02/05/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Franciscan Post-Acute Care Center 3169 M Street Merced, CA 95348

Frequently Asked Questions

What is an F-tag violation?

F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.

Were these violations corrected?

Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.

How often do nursing home inspections happen?

CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.

What should families do about these violations?

Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MERCED, CA, (5) Report new concerns to state authorities.

Where can I see the full inspection report?

Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from FRANCISCAN POST-ACUTE CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.

More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.