McKinley Nursing

Inspectors wroteBased on record review and interview, the facility failed to ensure certified nursing assistants (CNA) had yearly performance evaluations. This had the potential to affect all residents residing in the facility. The facility census was 151.

Inspectors wroteBased on resident interviews, lunch meal observations, staff interview, and review of diet spreadsheets, resident council minutes and facility policy, the facility failed to ensure appropriate portion sizes were served and all components of the meal were served to meet resident needs and preferences. This affected all residents receiving meals from the kitchen. The facility identified no residents with a nothing by mouth (NPO) diet. The facility census was 151.

Inspectors wroteBased on observation, interview, and review of food committee minutes, the facility failed to serve appealing meals at palatable temperatures. This had potential to affect all residents receiving meals from the kitchen. The facility identified no residents with a nothing by mouth (NPO) diet order. The facility census was 151.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure meals were served at regularly scheduled times. This affected all residents receiving meals from the kitchen. The facility identified no residents with a nothing by mouth (NPO) diet order. The facility census was 151.

Inspectors wroteBased on observation, interview and review of facility policy, the facility failed to ensure food was stored, prepared and served under sanitary conditions. This had the potential to affect all residents receiving meals from the kitchen. The facility identified no residents with a nothing by mouth (NPO) diet order. The facility census was 151.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to properly dispose of garbage and refuse. This had the potential to affect all residents residing in the facility. The facility census was 151.

Inspectors wroteBased on observation, record review, review of facility job descriptions and interview the facility failed to ensure effective administration to manage the facility and identify care concerns, implement appropriate and sustainable corrective actions to prevent reoccurrence and attain or maintain the highest practicable physical, mental and psychosocial well-being of all 151 residents residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure the facility assessment was accurately completed. This had the potential to affect all 151 residents residing in the facility. The facility census was 151.

Inspectors wroteBased on personnel record review, review of the job description for social services, and staff interview, the facility failed to employ a full-time Licensed Social Worker (LSW). This had the potential to affect all residents residing in the facility. The facility census was 151.

Inspectors wroteBased on record review, interview, and review of the facility policy and procedure, the facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) committee was in place to identify and address concerns timely and effectively. This had the potential to affect all 151 residents in the facility. The facility census was 151.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure infection control standards were maintained during medication administration for Resident #50 and during incontinence care for Resident #24. The facility failed to ensure contact precautions were in place for Resident #1. The facility failed to ensure the infection control policy was reviewed annually. Additionally, the facility failed to ensure the Legionella water management program comprehensively assessed risk measures for their elderly population. This had the potential to affect all residents residing in the facility. The facility census was 151.

Inspectors wroteBased on personnel file review, review of the facility assessment, and interviews, the facility failed to conduct mandatory training to all staff on the facility's quality assurance and performance improvement (QAPI) program. This affected five out of 11 personnel files reviewed and had the potential to affect all 151 residents residing in the facility. The facility census was 151.

Inspectors wroteBased on record review and interview, the facility failed to ensure Certified Nursing Assistants (CNA) had at least 12 hours of in-service training annually as required. This had the potential to affect all residents residing in the facility. The facility census was 151.

Inspectors wroteBased on record review, interview and review of the facility policy, the facility failed to conduct care conferences at least quarterly as required. This affected nine residents (#6, #62, #65, #66, #74, #75, #119, #138, and #139) of nine residents reviewed for care planning. Facility census was 151.

Inspectors wroteBased on record review, interview and review of the facility policy the facility failed to timely notify the responsible party and physician of changes. This affected four residents (#2, #56, #138 and #153) of five residents reviewed for notification of change. Facility census was 151.

Inspectors wroteBased on record review, interview, review of self-reported incidents (SRI) and review of the facility policy, the facility failed to ensure residents were free of misappropriation of controlled medications. This affected four residents (Residents #1, #3, #47 and #154) of five residents reviewed for controlled substances. The facility census was 151.

Inspectors wroteBased on record review, interview, review of self-reported incidents (SRI) and review of the facility policy, the facility failed to implement and follow their policy for allegations of abuse for residents. This affected four residents (Residents #47, #98, #138, #154) of fifteen residents reviewed for abuse. The facility census was 151.

Inspectors wroteBased on record review, interview, review of self-reported incident (SRI) and review of the facility policy, the facility failed to thoroughly investigate an allegation of abuse, misappropriation and injury of unknown origin for residents. This affected four (Residents #47, #98, #138, #154) of fifteen residents reviewed for abuse. The facility census was 151.

Inspectors wroteBased on record review and interview, the facility failed to ensure assessments were accurately completed. This affected five (Residents #5, #9, #15, #35 and #107) of 48 residents reviewed for Minimum Data Set (MDS) 3.0 assessments. The facility census was 151.

Inspectors wroteBased on record review, interview and review of the facility policy, the facility failed to formulate a complete baseline care plan timely after admission. This affected 22 residents (#2, #3, #4, #9, #12, #15, #48, #50, #53, #56, #62, #81, #91, #95, #98, #100, #107, #113, #117, #139, #154 and #160) of 62 residents reviewed for care plans. Facility census was 151.

Inspectors wroteBased on record review, interview and review of the facility policy, the facility failed to formulate an accurate and comprehensive care plan as required. This affected five residents (#2, #38, #47, #91 and #139) of 62 residents reviewed for care plans. Facility census was 151.

Inspectors wroteBased on observation, interview, record review and review of the facility policy, the facility failed to implement effective fall interventions and post fall assessments including neurological checks to ensure resident safety. This affected four residents (Resident #2, #42, #56 and #91) of six residents reviewed for falls. Facility census was 151.

Inspectors wroteBased on record review and interview, the facility failed to ensure physician visits were provided as required. This affected five residents (#5, #35, #42, #44, and #53) of 62 residents reviewed for physician visits. Facility census was 151.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were free of significant medication errors. This affected four (Residents #1, #4, #47 and #117) of 13 residents reviewed for significant medication errors. The facility census was 151.

Inspectors wroteBased on observation, interview, record review and review of facility policy, the facility failed to ensure a mechanical soft diet texture was prepared in a form to meet individual resident needs. This affected 29 Residents (#5, #11, #12, #19, #21, #22, #31, #38, #44, #46, #54, #58, #68, #79, #81, #82, #95, #100, #105, #109, #110, #122, #123, #132, #135, #137, #140, #141, and #147) identified as receiving a mechanical soft diet. The facility census was 151.

Inspectors wroteBased on record review, interview, and review of the facility policy, the facility failed to ensure medical records were complete and accurate. This affected four residents (#5, #47, #56, and #100) out of 62 records reviewed. The facility census was 151.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed ensure a clean, sanitary and homelike environment. This affected six residents (#20, #24, #29, #62, #65, and #75) out of 23 residents reviewed for physical environment. The facility census was 151.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure consent of psychotropic medications were in place for Resident #2. This affected one Resident (#2) of five reviewed for unnecessary medications. The facility census was 151. Review of the medical record for Resident #2 revealed an admission date of 03/02/26 and diagnoses including dementia, generalized anxiety disorder, recurrent major depressive disorder, restlessness and agitation, and suicidal ideations. Review of the physician's order dated 03/12/26 revealed Resident #2 was ordered 2 milligrams (mg) Alprazolam (Xanax) three times per day for recurrent major depressive disorder and generalized anxiety disorder. This medication order was adjusted on 04/22/26 to 2 mg Xanax two times per day for anxiety and 1 mg Xanax at bedtime for anxiety. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure resident account management authorization's were signed and witnessed when setting up accounts managed by the facility for residents. This affected three (Residents #56, #62 and #154) of five residents reviewed for personal funds. The facility census was 151.

Inspectors wroteBased on record review, interview, review of self-reported incidents (SRI) and review of the facility policy, the facility failed to report an allegation of abuse and/or misappropriation to the State Agency as required. This affected three (Residents #62, #138 and #154) of fifteen residents reviewed for abuse and misappropriation. The facility census was 151.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure a safe and appropriate discharge for Resident #165. This affected one Resident (#165) of five reviewed for discharge. The facility census was 151.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure Resident #16 was provided a written transfer notice and failed to ensure the Long-Term Care Ombudsman was notified of resident discharges for Residents #16 and #165. This affected two Residents (#16 and #165) of five reviewed for discharge. The facility census was 151.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) was completed when residents had a significant change. This affected one (Resident #41) of one resident reviewed for PASARR. The facility census was 151.

Inspectors wroteBased on record review, interview and review of the facility policy, the facility failed to revise care plans as needed. This affected three residents (#1, #56 and #81) of 62 residents reviewed for care plans. Facility census was 151.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure blood pressure medications were monitored for safety and effectiveness. This affected one (Resident #35) of seven residents reviewed for monitoring of medications. The facility also failed to ensure to treat resident skin conditions per the physician's order. This affected two (Residents #75 and #100) of three residents reviewed for general skin conditions. The facility census was 151.

Inspectors wroteBased on record review, observation, interview and policy review, the facility failed to ensure skin was assessed appropriately and pressure ulcers were treated timely for residents. This affected one (Resident #41) of three residents reviewed for wounds. The facility census was 151.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure sufficient interventions were in place to maintain resident nutritional status. This affected three Residents (#2, #41, and #110) of seven reviewed for nutrition services. The facility census was 151.

Inspectors wroteBased on observation, interview, record review and review of the facility policy, the facility failed to maintain oxygen tubing in a hygienic manner and per standards of practice. This affected three residents (Resident #11, #32 and #42) of four residents reviewed for respiratory care. Facility census was 151.

Inspectors wroteBased on record review, interview and review of the facility policy, the facility failed to provide comprehensive pre and post dialysis monitoring. This affected one resident (#160) of one resident receiving dialysis at the facility. Facility census was 151.

Inspectors wroteBased on medical record review, staff interview, review of facility policy and job descriptions, the facility failed to ensure residents received sufficient and appropriate social services to meet the residents psychosocial and emotional needs. This affected one resident (Resident #138) of 21 reviewed for social services needs. The facility census was 151.

Inspectors wroteBased on record review and interview, the facility failed to ensure medications were available to administer to residents per the physicians' orders. This affected one (Resident #35) of 13 residents reviewed for medications. The facility census was 151.

Inspectors wroteBased on record review, interview and observation, the facility failed to ensure dental services were provided timely for residents. This affected one (Resident #12) of six residents reviewed for dental services. The facility census was 151.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure coordination of care with hospice services for residents to ensure safe and person-centered care. This affected one (Resident #1) of two residents reviewed for hospice services. The facility census was 151.

Inspectors wroteBased on record review and interview the facility failed to ensure that medications and showers were accurately documented. This affected two residents (#24, #31) of two residents reviewed for accurate and complete medical records. The facility census was 156.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure call lights were accessible. This affected one resident (#25) of 156 residents residing in the facility. The facility census was 156. Findings Include:Review of the medical record for Resident #25 revealed admission to facility on 09/06/24 with diagnoses including unspecified dementia, anxiety, depression, schizophrenia, morbid obesity, and left lower leg Tri malleolar (ankle) fracture. The most recent Minimum Data Set (MDS) quarterly assessment completed on 09/23/25 revealed Resident #25 had delusional and disorganized thinking, used a walker to navigate facility, and required supervision or light touching with activities of daily living and grooming or bathing. [...]

Inspectors wroteBased on review of the facility menu, review of resident council meeting minutes, observation, staff interview and resident interview, the facility failed to ensure menus were prepared in advance and updated periodically and failed to ensure residents received the correct portion sizes based on the menus. This had the potential to affect all 154 residents who resided in the facility.

Inspectors wroteBased on observation and staff interviews, the facility failed maintain a sanitary kitchen and food storage areas and failed to ensure infection control was maintained while serving the lunch meal. This affected all residents who resided in the facility, as the facility identified all residents as receiving kitchen services. The facility census was 154. Findings Include: 1. Observation of the facility kitchen on 01/13/25 from 9:20 A.M. through 9:40 A.M. revealed the facility kitchen floors were scattered with torn sugar packets, pieces of old discarded food, crumbs, and dark sticky substances were covering parts of the floor. Several walls were noted to have dried up liquids that were previously splashed from food or drinks. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a clean, sanitary, and homelike environment for residents. This affected one resident (Resident #72) out of three residents reviewed for quality of care and treatment. The facility census was 154.

Inspectors wroteBased on observation, resident interview, staff interview, and review of pest control customer service reports, the facility failed to eradicate cockroaches from Resident #72's room. This affected one resident (#72) out of three residents reviewed for pest control. The facility census was 154.

Inspectors wroteBased on observation and staff and resident interviews, the facility failed to ensure cinnamon rolls were properly prepared to ensure palatability and an appetizing appearance. This had the potential to affect all residents residing in the facility. The facility census was 150.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to maintain appropriate infection control precautions when Licensed Practical Nurse (LPN) #320 did not properly dispose of a used insulin syringe with needle. This had the potential to affect 31 residents (#3, #7, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40) of 31 residents residing on [NAME] Hall. The facility census was 150.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure a timely discharge/transfer and failed to provide the resident or resident representative with required documentation upon discharge. This affected one (Resident #1) of three residents reviewed for discharge/transfer. The facility census was 150.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure a discharge summary which included a recapitulation (concise summary) of the resident's stay at the facility, was completed. This affected one (Resident #1) of three residents reviewed for discharge. The facility census was 150.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the services of a registered nurse were used for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 150 residents residing in the facility. Findings Include: Review of facility staffing schedules revealed on 01/01/24 there was no evidence the services of a registered nurse (RN) were used for at least eight consecutive hours on this date. The schedule reflected there was no RN scheduled for, or present in the building during this entire day. Interview with the Administrator on 03/02/24 at 3:10 P.M. confirmed the facility did not have a registered nurse scheduled or working on 01/01/24. The facility was unable to provide any evidence to support a registered nurse worked in the facility on this date. [...]

Inspectors wroteBased on observation, staff interview, review of the facility menu spread sheets, review of the printed tray cards, and medical record review, the facility failed to ensure proper food portions were served to meet the individual needs of Resident #143 who was ordered double portions, and failed to ensure proper food portions were served to all residents receiving meals from the kitchen. This had the potential to affect all residents receiving meals from the kitchen except Resident #37 who the facility identified as receiving nothing by mouth. The facility census was 147.

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to ensure food was served in a sanitary manner when a dietary staff member with artificial nails was observed not wearing gloves during tray line. This had the potential to affect 146 residents who received food from the kitchen. The facility identified one resident (#37) as not receiving anything by mouth. The facility census was 147.

Inspectors wroteBased on closed record review, hospital record review, facility policy review and interview the facility failed to implement comprehensive and individualized fall/safety interventions to prevent falls including a fall with injury for Resident #200. Actual Harm occurred on 09/27/23 when Resident #200, who had moderate cognitive impairment and required extensive two-person assistance for bed mobility and transfers was transferred to the emergency room per family request due to changes in condition. Record review revealed the resident sustained three falls between 09/25/23 and 09/27/23 without evidence of adequate interventions being in place at the time of the falls. Following a second fall on 09/27/23, the resident was picked up off the floor by Central Supply #808, an employee who was not qualified/trained to provide direct resident care. [...]

Inspectors wroteBased on closed record review, facility policy review, and interview the facility failed to notify Resident #200's family and physician of changes in the resident's condition. This affected one resident (#200) of three residents reviewed for change in condition.

Inspectors wroteBased on closed record review, job qualification review, and interview the facility failed to ensure Resident #200 was transferred by an employee who was qualified to do so following a fall. This affected one resident (#200) of three residents reviewed for falls.

Inspectors wroteBased on closed record review, hospital record review, and interview the facility failed to identify and provide the necessary behavioral health care and services to Resident #200 related to a substance abuse disorder to assist the resident to attain or maintain her highest practicable physical, mental and psychosocial well-being following admission for rehabilitation/treatment of a fall with fracture. This affected one resident (#200) of three residents reviewed for safety/falls.

Inspectors wroteBased on review of personnel files, review of schedules and interview, the facility failed to ensure employees who completed a Nurse Aide Training and Competency Evaluation program successfully completed state testing within the appropriate time frames. This had the potential to affect all 148 residents residing in the facility.

Inspectors wroteBased on observation and staff interview the facility failed to ensure the kitchen was maintained in a clean and sanitary condition. This had the potential to affect the 147 residents receiving food from the facility. The facility identified Resident #55 as receiving no food by mouth. The facility census was 148.

Inspectors wroteBased on observation and staff interview the facility failed to ensure the dumpster area was maintained in a clean and sanitary condition. This had the potential to affect all residents. The facility census was 148.

Inspectors wroteBased on observation and interview the facility failed to ensure call lights were within resident reach. This affected one resident (Resident #76) of 32 residents observed for call light accessibility. The facility census was 148.

Inspectors wroteBased on self-reported incident review, medical record review, policy review and staff interview, the facility failed to ensure narcotic medications were not misappropriated by staff members. This affected three residents (Residents #68, #99 and #111) of five residents reviewed for misappropriation. The facility census was 148.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure residents received the assistance needed for activities of daily living (ADLs). This affected two residents (Resident #89 and #143) of three residents reviewed for ADLs. The census was 148. Findings Include: 1. Review of the medical record for Resident #89 revealed an admission date of 09/14/22. Diagnoses included the need for assistance with personal care, vitreous hemorrhage (blood in the space between the eye's lens and retina), bilateral cataracts, bipolar disorder, anxiety disorder, major depressive disorder, and diabetes with neuropathy. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/31/23, revealed the resident had moderately intact cognition, severely impaired vision, and minimally impaired hearing. Behaviors included delusions and verbal behavioral symptoms directed at others. [...]

Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to monitor resident weights as ordered by the physician. This affected one (Resident #138) of three residents reviewed for weight loss. The facility census was 148.

Inspectors wroteBased on observation and interview the facility failed to maintain the kitchen in a sanitary manner. This affected 166 of 167 residents residing in the facility. Resident #78 was identified as ordered nothing by mouth to eat or drink.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the residents on the Taft unit with appropriate water containers. This affected Resident #68 and Resident #316 and affected 25 of 26 other residents on the Taft unit, Residents #10, #29, #30, #33, #42, #43, #52, #61, #83, #85, #86, #88, #89, #95, #96, #104, #105, #117, #126, #135, #136, #146, #160, #162, and #420. Resident #9 received thickened liquids and was not permitted a water pitcher/cup. The facility census was 167.

Inspectors wroteBased on record review and interview the facility failed to ensure all state tested nurse aides (STNAs) completed twelve hours of in-service education annually. This affected one of three STNA's reviewed who had been employed greater than one year. This had the potential to affect all 28 residents residing on the Taft unit, Residents #9, #10, #29, #30, #33, #42, #43, #52, #61, #68, #83, #85, #86, #88, #89, #95, #96, #104, #105, #117, #126, #135, #136, #146, #160, #162, #316 and #420. The facility census was 167.

Inspectors wroteBased on observation, record review and interview the facility failed to assess, monitor and treat Resident #20's left lower leg scar and wounds. This affected one out of three residents reviewed for skin issues.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure Resident #47's and Resident #78's pressure ulcer treatments were provided as ordered by the physician. This affected two out of three residents reviewed for pressure ulcers.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure insulin vials were dated when opened. This affected one Resident (#110) out of five residents reviewed for insulin storage on the [NAME] unit. The facility census was 167.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure Resident #110's medical record included documentation the resident was provided wine per the physician order. This finding affected one (Resident #110) of thirty-five resident records reviewed for documentation.

Inspectors wroteBased on record review and interview, the facility failed to ensure Residents #78 and #167 were notified in writing the reason for the discharge in an easily understood language. This affected two (Residents #78 and #167) of four resident records reviewed for hospitalization and had the potential to affect all 168 residents residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure Residents #78 and #167 were provided written notification of the bed-hold policy upon discharge to the hospital. This affected two of four resident records reviewed for hospitalization and had the potential to affect any of the 168 residents residing in the facility.