Inspection Reports for
McKinley Park Care Center

The facility failed to maintain comfortable room temperatures for 14 of 14 sampled residents, with room temperatures above 81 degrees Fahrenheit due to air conditioning failures, potentially causing discomfort and heat exhaustion.

The complaint was substantiated based on interviews with residents and staff, review of medical records, physician orders, medication administration records, and facility policies. The nursing home is disputing the citation.

The facility failed to protect Resident 2 from abuse by Resident 1, who has severe cognitive impairment and behavioral disturbances. Interviews and record reviews confirmed that Resident 1 hit Resident 2 multiple times, causing potential injury, fear, and distress.

The complaint investigation was substantiated based on interviews with Resident 4, family members, Resident 5 (roommate), CNA 2, Licensed Nurses, and review of progress notes and care plans. Resident 4 reported physical roughness and verbal abuse by CNA 2, including being pushed, having his mouth covered and squeezed, and being yelled at. Family members and staff corroborated these findings.

The facility failed to treat Resident 4 with respect and dignity, as CNA 2 was observed and reported to have been rough, aggressive, and raised her voice while providing care, including physically handling Resident 4 in a manner that caused emotional distress and potential psychological harm.

The complaint investigation found that Resident 1 had multiple falls on 12/17/24 and 12/19/24, and the facility did not update the care plan accordingly. The Director of Nursing and Licensed Nurse confirmed the failure to revise the care plan after these incidents.

The facility failed to timely update Resident 1's fall care plan after falls on 12/17/24 and 12/19/24, which potentially increased the risk of further falls and harm. Interviews with staff confirmed the care plan was not revised as required despite policy mandates.

The facility was found deficient in multiple areas including medication order clarification, feeding formula labeling, insufficient staffing, food preparation and storage issues, infection prevention practices, antibiotic stewardship, and pneumococcal vaccination administration. These deficiencies posed potential risks for resident safety, infection, and inadequate care.

The complaint investigation focused on Resident 1's discharge notice which did not contain the discharge location or updated discharge date. Resident 1 was given a 30-day eviction notice for repeated noncompliance with the smoking policy. The notice was issued on 8/7/24 with an original discharge date of 9/7/24, later extended to 9/14/24 after ombudsman involvement. Resident 1 declined multiple placement options. Staff interviews confirmed the noncompliance and discharge planning efforts.

The facility failed to provide a correct discharge notice to Resident 1, omitting the discharge location and updated discharge date, which had the potential to result in an unsafe discharge. Resident 1 was noncompliant with the facility smoking policy, leading to a 30-day discharge notice. The facility provided education, multiple placement options, and discharge planning assistance, but Resident 1 declined placements and extensions were granted. Interviews with staff and Resident 1 confirmed these findings.

The investigation was complaint-driven, focusing on allegations of theft of Resident 2's personal property and inadequate nursing care leading to a fall and delayed assistance. The findings substantiated the complaints with minimal harm to residents.

The facility failed to protect Resident 2's personal property, resulting in loss of a cellphone. Nursing staff failed to follow safe transfer protocols, leading to Resident 2 sustaining a fall during a mechanical lift transfer by a single CNA. Additionally, staff did not respond promptly to call lights, and Resident 4 experienced delayed assistance with toileting hygiene, potentially causing physical and psychosocial harm.

The facility failed to ensure effective pain management for Resident 1, who experienced frequent and severe pain that was not adequately controlled. Licensed staff did not notify the physician about the ineffectiveness of the pain medications, resulting in unnecessary pain, sleep disruption, and potential health decline. Documentation and communication deficiencies were noted regarding pain reassessment and physician notification.

The complaint investigation was substantiated by findings that Resident 1 eloped on 11/17/23 and was found outside the facility due to inadequate alarm coverage and supervision.

The facility failed to provide adequate supervision for Resident 1, who eloped from the facility through unmonitored sliding doors and was found in an adjacent office building. The alarm system was only installed on main exit doors, not sliding doors, allowing the resident to leave unnoticed. Interviews with staff and residents confirmed the facility's loose monitoring and the resident's ability to bypass alarms.

The investigation was complaint-driven, triggered by reports of a resident fall due to delayed assistance and multiple complaints about long call light response times and insufficient staffing. The complaint was substantiated with interviews and observations confirming staffing shortages and delayed care.

The facility failed to provide adequate supervision and timely assistance to residents, resulting in a fall of one resident who attempted to transfer herself without staff help. Multiple residents and staff reported long call light response times and insufficient staffing, which compromised timely care and resident well-being.

The complaint investigation found that Resident 1 missed her neurology appointment scheduled on 9/6/23 due to no transportation being arranged. The Social Services Director stated residents must give two weeks notice for transportation arrangements. The Director of Nursing validated the missed appointment was due to lack of medical transport service.

The facility failed to ensure that transportation was arranged ahead of time for Resident 1's neurology appointment, causing the resident to experience anxiety and miss the appointment. Interviews with staff confirmed the lack of transportation arrangement despite facility policy requiring social services to assist with transportation as needed.

The facility failed to develop a comprehensive care plan for a resident's Wearable Cardioverter Defibrillator (WCD), did not provide adequate nursing care including failure to notify physicians of abnormal vital signs, failed to provide proper nail care for a resident, left a resident unsupervised leading to a fall, failed to maintain essential equipment in safe working condition, and did not ensure staff training on the WCD device.

The facility failed to ensure blood sugar levels were monitored as ordered for one resident, resulting in a potential risk to the resident's health. Blood sugar checks were not performed for several days after admission despite hospital discharge orders.

The facility failed to ensure staff wore isolation gowns when entering resident rooms in the yellow zone, increasing the potential spread of Covid-19 among residents. Multiple Certified Nurse Assistants admitted to not wearing gowns, and interviews with administrative staff confirmed the expectation for full PPE use.

The facility had multiple deficiencies including failure to assist residents with dentures, timely replacement of missing clothing, comprehensive care planning, medication administration errors, infection control lapses, and maintenance issues in the kitchen and facility rooms.

The facility failed to provide ongoing assessments and documentation for oxygen therapy for one resident, failed to ensure proper labeling and dating of food items in storage, and did not provide the required minimum square footage per resident in multiple rooms, resulting in crowded conditions.