Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mckinley Park Care Center during CMS and state inspections, most recent first.
Kitchen staff failed to follow proper food storage, dish handling, and hand hygiene practices. Unlabeled raw squash was found in the refrigerator, wet meal tray lids were stacked before drying, soiled gloves were used while handling clean dishes after dishwashing, and a staff member preparing salad touched a trash can liner multiple times without hand hygiene. The DM acknowledged the improper practices, and facility policy required hand washing after handling soiled equipment, during food prep as needed, and after touching a trash can or lid.
Late Quarterly MDS Assessments: The facility failed to complete quarterly MDS assessments on time for multiple residents. The MDSC confirmed that several assessments were late or still in progress beyond the required completion window, and the DON stated assessments were expected to be completed timely based on the ARD. Facility policy and the RAI Manual both required timely quarterly assessments and transmission.
Late and Incomplete MDS Assessments: The facility failed to complete and transmit MDS assessments within required timeframes for multiple residents. The MDSC confirmed several quarterly, annual, significant change in status, and discharge assessments were late or not completed, and the DON stated assessments were expected to be done timely based on the ARD.
Therapeutic diets were not followed for four residents during tray line. A dietary aide failed to place a fortified item on one resident’s tray, placed a regular dessert with whole fruit on a resident ordered a pureed diet, added a salt packet to a tray marked NAS, and added margarine to a tray marked low fat/low cholesterol. The RD stated all kitchen staff were expected to follow therapeutic diets, and the menu spreadsheet indicated low fat/cholesterol meals should have no margarine.
A resident on EBP was repositioned by the DON and a CNA with gloves but without gowns, despite the resident’s care plan requiring gown and glove use for high-contact care. The resident was cognitively intact and had multiple serious diagnoses, including immunodeficiency due to drugs and autoimmune hepatitis. In addition, the clean side of the laundry room had dusty vents and fan blades, a torn clean linen cart cover, and a dirty cover on the cart holding residents’ clothes; the LS, MS, IP, and DON all confirmed the laundry conditions were dirty or damaged.
A resident’s annual MDS assessment was completed late after the ARD-based deadline had passed. The MDSC acknowledged the assessment was overdue, and the DON stated assessments were expected to be completed timely based on the ARD; the facility policy and RAI Manual both required completion within the specified timeframe.
Late Significant Change in Status Assessment: A resident with a palliative care history was discharged from hospice after stabilizing, and the MDSC stated an SCSA was scheduled but not completed within the required timeframe. The MDSC confirmed the assessment was late, and the DON stated assessments were expected to be completed timely based on the ARD.
A resident received metformin that had been ordered for another resident after an order was transcribed into the wrong chart. The resident, who was cognitively intact and not diabetic, received one dose before refusing a later dose and telling staff she was not a diabetic. RN and DON stated the medication was entered into the wrong resident’s electronic record and the nurse did not verify the correct chart before saving the order.
Failure to Provide Timely Nail Care: A resident with Parkinson’s disease, left-sided hemiplegia, and impaired cognition required max assistance with grooming and personal hygiene, but staff did not maintain his fingernails in a clean, trimmed manner. The resident was observed with long, sharp, uneven nails and stated he did not like them that long and wanted them cut short. CNA acknowledged the nails should have been trimmed, and the DON stated the ADL care plan was broad and did not address fingernail or toenail care.
A resident with right-sided hemiparesis, a left BKA, muscle weakness, and a history of falls was left suspended in a Hoyer sling during a transfer while a CNA left the room to look for help. The resident was cognitively intact, dependent on transfers, and later said he was scared while hanging in the air. The CNA acknowledged the transfer should not have been done alone, another CNA stated 2 to 3 staff were needed for mechanical lift transfers, and the DON confirmed residents must not be left unattended during Hoyer lift use.
Respiratory care was not managed according to standards for three residents. Two residents had nebulizer masks left on bedside dressers instead of being stored in a bag after use, and an LPN and the DON confirmed the facility expected bag storage per infection control practice. Another resident’s BiPAP order was incomplete because the settings were missing, and a third resident with OSA had no CPAP order in the chart and did not receive CPAP until well after admission, despite hospital documentation noting the need for CPAP.
Pain management was not provided in accordance with care plans and nursing standards for two residents. One resident received PRN Tylenol for stomach pain, but the RN did not complete the required pain reassessment within one hour, and the MAR later showed the medication was ineffective. Another resident with RA and spinal stenosis reported ongoing chronic pain, said staff repeatedly offered only Tylenol or Excedrin, and stated non-pharmacological measures were not consistently offered or documented despite care plan directions to assess pain each shift and use comfort measures such as repositioning, heat, cold, massage, and relaxation.
A resident with schizophrenia and PTSD was not assessed for trauma triggers, and the care plan and Annual Social History Assessment did not identify her significant life events or triggers. The resident stated her trauma was related to an eye injury caused by her spouse and that loud voices and hearing her name said loudly were triggers, but staff could not identify those triggers.
A resident received Ferrous Sulfate without food and Carvedilol about two hours before the ordered time, and the LPN did not document the Carvedilol administration at the time it was given. The DON stated meds should be given as ordered and documented immediately, and the facility’s medication error rate was 7.4%, exceeding the allowed threshold.
A controlled medication, Lyrica, was found unsecured on an open shelf in the med room inside a bag of meds brought from home, and an LPN acknowledged it should have been counted and locked. In addition, a resident’s Fluticasone Propionate and Salmeterol inhalation powder was stored in Medication Cart 1 without an open date, even though the label and manufacturer instructions required it to be discarded one month after opening; the DON stated it was unknown when the medication was opened and the resident may have received expired medication.
The facility failed to provide at least 80 sq ft per resident in 8 rooms, with several 2- and 3-resident rooms measuring below the required space. The ADM stated there was no room waiver in place and no waiver letter, and staff and residents reported using mechanical lifts and wheelchairs in the rooms without concerns, though one resident in a bariatric bed said there was not enough space for all of her belongings when the room housed three residents.
The facility did not maintain room temperatures within the required range, with several rooms measured above 81°F due to a malfunctioning air conditioning unit. Multiple residents, including those with heart failure, COPD, ESRD, and respiratory failure, reported discomfort despite the use of fans, and the facility's policy requiring comfortable temperatures was not met.
A resident with severe dementia and a history of behavioral disturbances physically struck another cognitively intact resident multiple times during an activity. Staff and the affected resident confirmed the incident, and facility documentation showed prior episodes of aggression. The facility failed to prevent this abuse, contrary to its policy requiring protection from abuse by anyone, including other residents.
A resident with cognitive and physical impairments reported being treated roughly and disrespectfully by a CNA during care, including having their mouth covered and being yelled at. The incident was corroborated by the resident's family and roommate, and the facility's policy on dignity was not followed.
A resident at high risk for falls experienced two falls within a short period, but the facility failed to update the care plan after the first fall. Despite the resident's conditions of hemiparesis and muscle weakness, the care plan was not revised to include new interventions, as confirmed by staff interviews and facility policy. This oversight decreased the facility's ability to prevent further falls.
The facility exhibited multiple deficiencies in food safety and equipment maintenance, including malfunctioning kitchen equipment, improper sanitation practices by staff, and inadequate food storage. Staff were unable to correctly perform and interpret sanitizer tests, and expired or improperly labeled food items were found. These issues posed a risk to resident safety and violated facility policies and FDA guidelines.
The facility failed to meet professional standards for three residents. An MRI order for a resident was not processed promptly, a medication order for another resident lacked clarification on duration, and a third resident's feeding formula was not properly labeled. These deficiencies were confirmed by facility staff and were contrary to established policies.
The facility failed to provide sufficient staffing, falling short of the 3.5 hours per patient day goal, leading to rushed care and delayed responses to call lights. A resident with a high fall risk experienced five unwitnessed falls in one month due to inadequate supervision. Staff and the DON confirmed that staffing shortages compromised resident care and safety.
A resident was served a burnt cookie, and another resident reported similar issues with burnt food. The Registered Dietician and Certified Dietary Manager confirmed an oven malfunction caused uneven cooking, leading to burnt food being served. The facility conducted an in-service training on food preparation in response to complaints.
A facility failed to maintain infection control practices during wound care and blood glucose monitoring. A TN did not perform hand hygiene between glove changes and improperly returned supplies to the treatment cart. Additionally, an LN did not sanitize a blood glucose machine after use. These actions violated the facility's infection control policies.
A resident was prescribed two antibiotics for osteomyelitis without an infection screening evaluation, violating the facility's antibiotic stewardship program. The resident, admitted with pneumonia and type 2 diabetes, received antibiotics without a timely assessment. The Infection Preventionist confirmed the oversight, which contradicted both facility policy and state guidelines.
A resident admitted with pneumonia and type 2 diabetes consented to a pneumococcal vaccine, but the order was not entered correctly, delaying administration for over a month. The facility's policy requires timely vaccination, but this was not followed, as confirmed by the Infection Preventionist.
A resident with multiple diagnoses and cognitive intactness was issued a discharge notice for violating the smoking policy, but the notice lacked a discharge location and updated date after an extension. Despite being independent in ADLs, the resident refused offered placements due to financial concerns. Facility staff confirmed the omission, which could lead to an unsafe discharge.
A resident was issued a discharge notice for non-compliance with the smoking policy, but the notice lacked the discharge location and updated discharge date after an extension. The resident, who was cognitively intact and independent in ADLs, repeatedly violated the smoking policy. Despite being offered multiple room and board options, the resident declined them, and the facility failed to update the discharge notice as required by policy.
Kitchen Food Storage and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to follow proper food storage, hygienic dish handling, and hand hygiene techniques in the kitchen. During observation and interview, undated and unlabeled raw green squash were found in a stainless steel container in the food refrigerator, with approximately 11 whole squash present and no labels, open date, or use-by date. The Dietary Manager stated she did not see any label or dates, and later told kitchen staff they had to label and date the foods in the refrigerator. The facility also failed to maintain proper hygiene during dishwashing and food preparation. A dietary aide was observed stacking wet meal tray lids on top of one another while water dripped from them, and the Dietary Manager stated the lids were still wet and should not be stacked. Another dietary aide dropped a meal tray lid on the floor while washing soiled dishes, picked it up, and placed it into the dishwasher while still wearing soiled gloves; after the dishwasher cycle, the aide removed clean dishes while still wearing the soiled gloves, and another aide touched the same crate and unloaded clean dishes with bare hands. In a separate observation, a staff member preparing fresh lettuce for a salad touched the trash can liner multiple times while wearing gloves and continued food preparation without performing hand hygiene. The facility policy reviewed stated employees must wash hands after handling soiled equipment or utensils, during food preparation as needed to prevent contamination, and after touching a trash can or lid.
Late Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure quarterly MDS assessments were completed within the required timeframe for 10 of 13 sampled residents out of a census of 77. During interview and record review, the MDS Coordinator confirmed that the quarterly assessments for Residents 22, 35, 36, 5, 45, 48, 49, 4, 83, and 92 were late or still in progress beyond the required completion date based on each resident’s ARD. The assessments were completed and transmitted after the due dates, and one assessment was still in progress when reviewed. The MDS Coordinator stated the facility has 14 days after the ARD to complete the assessment and 14 days after completion to transmit it. The DON stated her expectation was that assessments be completed timely based on the ARD and noted that when assessments are not done timely there is potential for not identifying the problem and this delays interventions. The facility policy stated the resident assessment coordinator is responsible for ensuring the interdisciplinary team conducts timely and appropriate resident assessments, and the RAI Manual stated quarterly MDS assessments must be completed no later than ARD plus 14 calendar days and transmitted no later than 14 days after completion.
Late and Incomplete MDS Assessments
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments were completed and transmitted within the required timeframe for 13 of 13 sampled residents out of a census of 77. During interview and record review, the MDS Coordinator stated the facility believed assessments had 14 days after the Assessment Reference Date to be completed and 14 days to transmit after completion. The survey review identified late or incomplete assessments for quarterly, annual, significant change in status, and discharge assessments for residents including Resident 22, Resident 24, Resident 35, Resident 36, Resident 5, Resident 45, Resident 48, Resident 49, Resident 4, Resident 82, Resident 83, Resident 92, and Resident 6. The MDS Coordinator confirmed multiple assessments were completed and transmitted after the required completion dates, including several quarterly assessments, one annual assessment, one significant change in status assessment, and one discharge assessment that was not completed. The Director of Nursing stated her expectation was that assessments be completed timely based on the ARD and noted that untimely assessments could delay identification of problems and interventions. The facility policy stated the resident assessment coordinator is responsible for ensuring timely and appropriate resident assessments, and the RAI Manual requirements reviewed by surveyors specified completion and transmission timeframes for annual, quarterly, significant change in status, and discharge assessments.
Therapeutic Diet Orders Not Followed During Tray Line
Penalty
Summary
Therapeutic diets were not followed for four residents who received meals from the kitchen. During tray line observation, a dietary aide did not place the fortified diet item of 2 individual packs of margarine on one resident’s lunch tray, and the tray was sent to the cart without the fortified item even though the tray ticket indicated a fortified diet. The dietary manager stated the fortified item for lunch was 2 packets of margarine. During the same tray line observation, a dietary aide placed a regular dessert item, orange blossom parfait with whole pieces of fruit, on another resident’s tray even though the tray ticket indicated a pureed diet; staff stated the pureed dessert for that meal was chocolate pudding. In two additional observations, a dietary aide placed a salt packet on a resident’s tray marked no added salt, and placed a margarine packet on a resident’s tray marked low fat/low cholesterol. The facility’s winter menu spreadsheet indicated low fat/cholesterol meals should have no margarine, and the registered dietitian stated it was her expectation that all kitchen staff follow therapeutic diets for all residents.
EBP Not Followed During Resident Care; Dirty Laundry Area and Damaged Linen Cart Covers
Penalty
Summary
Enhanced Barrier Precautions were not followed during resident care for a resident admitted with multiple diagnoses including metabolic encephalopathy, orthopedic aftercare, multiple rib fractures, fracture of vertebra, systemic lupus erythematosus, immunodeficiency due to drugs, autoimmune hepatitis, and a laceration of the left buttock. The resident’s MDS indicated a BIMS score of 15 out of 15, showing the resident was cognitively intact. The care plan required Enhanced Barrier Precautions during high-contact resident care activities, with gown and glove use for activities such as dressing, bathing, transferring, hygiene, linen changes, brief changes, toileting assistance, device care, and wound care. During an observation, the DON and a CNA entered the resident’s room and put on gloves but did not put on gowns before repositioning the resident in bed using a draw sheet. In an interview, the CNA stated she did not wear a gown when repositioning the resident and acknowledged the resident was on EBP and that a gown should have been worn. The DON also stated she did not wear a gown when repositioning the resident and said a gown was not required because repositioning was not a high-contact activity. An RN later stated that for a resident on EBP, gown and gloves are needed for high-contact activities including changing sheets, changing briefs, transfers, and wound care, and stated repositioning is a high-contact activity requiring gown and gloves. Sanitary conditions in the laundry room were not maintained. On the clean side of the laundry room, two air vents had gray fuzzy material, the fan blades were covered with gray fuzzy material, and the clean linen cart cover had a tear on the sides with clear tape used on the cart handles. The cart containing residents’ clothes had a discolored cover with dust particles on the bottom area. The laundry staff stated dust from the vent could transfer to clean clothes and that he turned off the fan when folding clothes because dust would transfer to the clothes. The maintenance supervisor confirmed the tear in the clean linen cart cover and stated the cover was for infection control. The infection preventionist and DON also confirmed the vents, fan, floor, cart covers, and laundry conditions were dirty or torn, and the DON stated there was a need for aftercare in the laundry and that if the laundry is not clean there is a possibility of contamination of clean clothes and linen.
Late Annual MDS Assessment
Penalty
Summary
The facility failed to complete an annual MDS assessment timely for one sampled resident, Resident 82. During a concurrent interview and record review with the MDS Coordinator on 1/22/26, Resident 82’s annual MDS assessment was reviewed and the ARD was documented as 12/4/25. The MDS Coordinator stated the annual assessment was due 14 days after the ARD, on 12/18/25, but it was not completed until 1/20/26, and acknowledged that the annual assessment was late. During an interview with the DON on 1/23/26, the DON stated her expectation was for assessments to be completed timely based on the ARD. The DON stated that when assessments are not done timely there is potential for high probability of not identifying the problem and this delays the interventions. The facility policy titled, MDS Completion and Submission Timeframes, stated resident assessments would be conducted and submitted in accordance with current federal and state submission timeframes, and the RAI Manual indicated annual assessment completion timing was ARD +14 calendar days.
Late Significant Change in Status Assessment
Penalty
Summary
The facility failed to ensure a significant change in status assessment (SCSA) was completed within 14 days after a resident’s change in condition was identified. Resident 24 had a diagnosis of palliative care in June 2025, and the hospice discharge summary showed the resident was discharged from hospice effective the end of day on 12/4/25 because the resident was stabilized and no longer met criteria. During interview and record review, the MDS Coordinator stated Resident 24 came off hospice on 12/5/25 and that an SCSA was scheduled for 12/12/25, but the assessment was not completed until 1/21/26, which the MDS Coordinator confirmed was late. The DON stated her expectation was that assessments be completed timely based on the ARD and that late assessments could delay identification of problems and interventions. The facility policy stated resident assessments are to be conducted and submitted in accordance with federal and state timeframes, and the RAI Manual stated the SCSA should be completed on the 14th calendar day after the determination that a significant change in status occurred.
Wrong Resident Received Metformin
Penalty
Summary
The facility failed to meet professional standards of care when Resident 9 received metformin that had been ordered for another resident, Resident 40. Resident 9 was admitted in January 2025 and readmitted in December 2025 with diagnoses including cellulitis of the left lower leg, lymphedema, and dyspnea. Resident 40 was admitted in December 2025 with diagnoses including metabolic encephalopathy, a sacral pressure ulcer, and diabetes. Resident 9’s MDS dated 1/6/26 showed a BIMS score of 15 out of 15, indicating she was cognitively intact. A written order for Resident 40 dated 1/14/26 directed metformin 500 mg by mouth twice daily for diabetes. An electronic order for Resident 9 dated 1/14/26 also listed metformin 500 mg by mouth twice daily for DM2. Resident 9’s MAR showed she received one dose of metformin 500 mg on 1/15/26 and refused the medication on 1/16/26. The SBAR form documented a change in condition related to receiving metformin. During interviews, RN 1 stated the medication was ordered by mistake and had been transcribed into the electronic record for the wrong resident, and the DON stated the nurse clicked and saved the order to the wrong chart and did not verify the correct chart. Resident 9 stated staff tried to give her a medication for blood sugar and that she told them she was not diabetic.
Failure to Provide Timely Nail Care
Penalty
Summary
The facility failed to ensure that Resident 7’s fingernails were maintained in a clean and trimmed manner. Resident 7 was admitted in early 2025 with multiple diagnoses, including Parkinson’s disease and left-sided hemiplegia, and the MDS dated 1/9/26 indicated moderately impaired cognition and maximum assistance needed for grooming and personal hygiene. The care plan dated 1/7/25 stated that Resident 7 required assistance with ADLs and included daily assistance with ADL care, but it did not address personal hygiene, fingernail care, or toenail care. During an observation and interview on 1/20/26, Resident 7 was sitting in a wheelchair in his room and was observed with long fingernails with sharp, uneven edges. Resident 7 stated that he did not like his nails to be that long and said it was sometimes hard to find someone to trim them. During a concurrent observation and interview, CNA 3 acknowledged that the fingernails were long and should have been trimmed, then stated the resident wanted to leave them long, which Resident 7 contradicted by stating that his nails caught on his clothes and scratched his skin and that he wanted them cut short. The DON later stated that Resident 7 was dependent on staff for personal hygiene, including nail care, and acknowledged that the ADL care plan was broad and not individualized to address fingernails and toenails.
Unsafe Mechanical Lift Transfer and Lack of Supervision
Penalty
Summary
The facility failed to ensure a resident was safely transferred using a mechanical lift and failed to provide adequate supervision during the transfer. The resident was admitted in the summer of 2025 with diagnoses including right-sided hemiparesis and hemiplegia, left leg below-the-knee amputation, and muscle weakness. The MDS dated 10/27/25 indicated the resident was cognitively intact, required maximum assistance with all ADLs, and was totally dependent on transfers. A physician progress note dated 1/16/26 also documented a history of falls with collarbone and rib fractures. The care plan dated 6/20/25 identified the resident as being at risk for falls related to altered balance while standing and/or walking and unsteady gait, with interventions to anticipate and meet needs, keep the resident within supervised view as much as possible, and keep the call light within reach. A separate care plan addressing mobility and ADLs stated that the resident's needs would be anticipated and met by staff, but it did not address the level of assistance required with ADLs, transfer, or mobility. During observation on 1/21/26 at 6:17 a.m., the resident was seen suspended in a Hoyer lift sling outside the room, unattended by nursing staff and with no staff present in the room. The resident was elevated off the floor and positioned several feet away from the bed without support from the bed or wheelchair. A CNA stated she left the resident in the air and went to look for help in the next room, then closed the door, moved the lift with the resident, and lowered the resident to the bed without another staff member assisting. During interview, the CNA acknowledged it was very wrong to attempt the transfer alone and stated the resident could have fallen and been injured. Another CNA stated that 2 and sometimes 3 staff were required to assist with mechanical lift transfers. The resident later stated that he remembered being suspended in the air while the CNA left the room and said, "I was scared." The DON stated residents should not be left unattended while suspended in the Hoyer lift, that staff are required to remain with residents at all times during transfers, and that the facility's process was to always use 2 staff during mechanical lift transfers.
Respiratory equipment storage and CPAP/BiPAP order documentation failures
Penalty
Summary
Respiratory care was not provided according to professional standards for three residents. For one resident admitted with diagnoses including lobar pneumonia and pleural effusion, a nebulizer mask used for Ipratropium-Albuterol treatments was observed sitting on top of the bedside dresser rather than being stored in a respiratory bag after use. During observation and interview, the resident stated she had received a breathing treatment earlier, and the LN confirmed the mask should have been kept inside a respiratory bag. The LN also stated there was no bag available at the bedside, and the facility’s infection control protocol was to place the mask in a bag when not in use. For another resident with CHF and COPD, the record showed an order for Ipratropium-Albuterol nebulizer treatments as needed, but the nebulizer mask was also observed on top of the bedside dresser instead of being stored in a bag. The LN confirmed the mask was used for nebulizer treatment and stated it should be inside a bag, but could not identify when the mask had been replaced. The DON stated the expectation was for the nebulizer mask to be inside the infection pouch or container when not in use. The facility policy for respiratory therapy equipment stated that after completion of therapy, the nebulizer container should be removed, rinsed, dried, and the circuit stored in a plastic bag marked with the date and resident’s name between uses. For the same resident, the BiPAP order was incomplete because the settings were not included in the body of the order. The record showed BiPAP orders dated 11/9/25 and 1/10/26, but neither order included the inspiratory or expiratory settings. The LN confirmed the order did not include settings, and the DON stated her expectation was for BiPAP orders to include the settings in the body of the order. The facility’s CPAP/BiPAP Support policy stated that mode and settings for CPAP/IPAP/EPAP should be documented. A third resident admitted with heart failure, respiratory failure with hypoxia, acute pulmonary edema, and OSA did not have a CPAP order in the clinical record, and CPAP was not used until over one month after admission. The hospital discharge summaries identified OSA and noted that nocturnal CPAP could be followed at the SNF, but the Order Summary did not show a CPAP order. The resident stated the facility did not provide CPAP on admission and that she had been using CPAP before admission. The LN and DON acknowledged that hospital recommendations for CPAP were not transcribed into the electronic orders, there was no MAR documentation for CPAP use, and the resident did not use CPAP during the periods identified in the record. The facility policy stated that physician orders should be reviewed to determine the oxygen concentration, flow, and pressure settings for CPAP/BiPAP support.
Pain management not reassessed timely and pain assessments/interventions not consistently provided
Penalty
Summary
The facility failed to provide pain management in accordance with professional standards and resident-centered care plans for two residents. For one resident, staff did not complete a pain reassessment within one hour after administering PRN Tylenol. During an observation, the resident was moaning and stated her stomach hurt and that she was constipated. She reported that she had already received pain medicine earlier but was still in pain. The DON stated that pain reassessments were expected within one hour after PRN pain medication administration, and the resident’s MAR showed Tylenol was given at 9:14 a.m. with no pain reassessment documented at that time. RN 1 confirmed she had given the PRN Tylenol at 9:14 a.m. and had not yet reassessed the resident’s pain. The MAR was later updated to indicate the medication was ineffective. The resident’s care plan identified her as at risk for pain and directed staff to administer medications as ordered, monitor for adverse effects, and assess pain every shift and as indicated. The facility’s pain assessment and management policy stated that staff should monitor the resident’s response to interventions and level of comfort over time. At the time of the observation, the resident continued to report significant pain, rating it 9 out of 10 in her stomach area when the DON completed a pain assessment. For the second resident, the facility did not consistently assess pain or offer non-pharmacological interventions. The resident had diagnoses including rheumatoid arthritis, spinal stenosis, and muscle weakness, and the MDS indicated she was cognitively intact. Her care plan identified her as at risk for pain and discomfort and included approaches such as assessing for pain, administering pain medication as ordered, considering pre-medication, and providing alternative comfort measures such as heat, cold applications, massage, relaxation, and positioning. During multiple interviews and observations, the resident stated she was always in pain, rated her pain between 4 and 5 out of 10 at rest, and reported pain of 9 to 10 out of 10 when moved or repositioned. She stated that staff repeatedly offered only Excedrin or Tylenol, which she said were not effective for her chronic pain, and that nobody asked her if she was in pain. Staff interviews and record review showed that pain was not being assessed every shift as expected and that non-pharmacological interventions were not consistently documented or offered. The DON stated nurses were required to assess pain every shift, offer non-pharmacological interventions first, and contact the physician if prescribed medications were not effective. The DON also stated she could not find evidence that the resident’s pain was assessed every shift and noted that the MARs did not show non-pharmacological interventions for pain. Other nursing staff stated they usually asked about pain during morning medication pass or near the end of shift, and one nurse described giving Voltaren ointment to the area that hurt, but did not identify other interventions when asked.
Failure to Identify Trauma Triggers for Resident with PTSD
Penalty
Summary
The facility failed to identify trauma triggers for one of 22 sampled residents, a cognitively intact resident with diagnoses including schizophrenia and PTSD. The resident’s admission record showed she was admitted in May 2022, and her care plan noted impaired visual function and that she had a prosthetic put in resulting in PTSD. During interview, the resident stated she had experienced a traumatic event and explained that her spouse knocked her left eye and detached her retina. She also stated that loud people and having her name said loudly were triggers for her trauma, and she was not sure whether facility staff knew about these triggers. A review of the resident’s Annual Social History Assessment did not indicate significant life events, and the care plan did not identify the resident’s trauma triggers. The SSD stated she was familiar with the resident and acknowledged that it is important to know the cause of the traumatic event and the triggers to provide appropriate help, and that re-traumatization could not be prevented if triggers were not identified. The DON stated her expectation was for the SSD to determine the root cause, triggers, and manifestations for residents with PTSD, and an LN stated she could not say what the resident’s PTSD triggers were.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure that the medication error rate remained below five percent, with a cumulative medication error rate of 7.4% based on two errors in 27 medication opportunities for Resident 42. During a medication pass observation, a licensed nurse prepared Resident 42’s morning medications, including Ferrous Sulfate and Carvedilol, placed them in a small plastic cup with less than one teaspoon of applesauce, and administered them without offering any additional food or snacks. No food was observed on the resident’s bedside table, and no breakfast trays were available in the hallway at the time. Record review showed that Ferrous Sulfate 325 mg was ordered to be given with food, and Carvedilol 3.125 mg was ordered twice daily at 9 a.m. and 7 p.m. The nurse later stated that the resident received the medications at 7 a.m., which was about two hours before the scheduled Carvedilol time, and acknowledged that Ferrous Sulfate was given before the resident would have food available. The nurse also stated that Carvedilol was not documented at the time it was administered because it was too early to document. The DON stated that medications should be given as ordered and documented immediately after administration, and the facility policy required medications to be administered in a safe and timely manner within one hour of the prescribed time unless otherwise specified.
Unsecured controlled medication and undated inhalation medication
Penalty
Summary
The facility failed to ensure safe storage, labeling, and accountability of medications when a bottle of Lyrica tablets was found stored unsecured on an open shelf in the medication room inside a paper bag with other medications brought from home. During observation, Licensed Nurse 4 acknowledged that Lyrica is a controlled substance with a high risk for abuse and stated it was not safe to keep it on the open shelf. The nurse also stated that controlled substances brought from home should be counted, documented, and locked until the resident’s discharge. The Director of Nursing later confirmed that controlled substances should be stored locked and not on the open shelf. The facility also failed to ensure proper dating of a multidose inhalation medication for Resident 73. Fluticasone Propionate and Salmeterol Inhalation Powder was observed in Medication Cart 1 with no open date documented. The medication label showed it had been dispensed over 60 days earlier, while the manufacturer instructions stated it should be discarded one month after opening the foil pouch. The resident’s record showed an order for Fluticasone Salmeterol Inhalation Aerosol Powder twice daily for shortness of breath, and the MAR indicated the resident continued to receive the medication. The DON stated that without an open date, it was not known when the medication was opened and the resident might have been administered expired medication that was not effective.
Insufficient Room Space for Multiple Residents
Penalty
Summary
The facility failed to provide at least 80 square feet per resident in 8 resident rooms. A review of room measurements on 1/20/26 showed multiple rooms housing 2 or 3 residents with per-resident space ranging from 73.3 sq ft to 79.3 sq ft, including rooms measuring 156 sq ft for 2 residents, 154 sq ft for 2 residents, 230 sq ft for 3 residents, 228 sq ft for 3 residents, 238 sq ft for 3 residents, 220 sq ft for 3 residents, and 223 sq ft for 3 residents. The Administrator stated the facility did not have a room waiver in place for rooms with less than 80 sq ft per resident and confirmed there was no waiver letter. He also stated he had contacted the Department after the last survey in 2024 but did not hear back and did not follow up. During interviews and observations, residents and staff described the rooms as usable despite the reduced space. One resident who used a mechanical lift stated there seemed to be enough room to maneuver the lift and that staff had not complained about the room size. Another resident in a bariatric bed stated staff used a mechanical lift to get her out of bed and that there was not enough space for all of her things when the room had three residents, though it had been fine when only two residents were in the room. Staff members assigned to or working in the affected rooms stated they had no concerns about the room sizes and reported that mechanical lifts and wheelchairs could be used in the rooms without issue.
Failure to Maintain Safe and Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain a comfortable environment for all 14 sampled residents when room temperatures exceeded the facility's stated acceptable range of 71 to 81 degrees Fahrenheit. During a facility tour, surveyors measured room temperatures between 82 and 84 degrees Fahrenheit using an infrared temperature gun. The administrator confirmed that the air conditioning unit was not functioning properly, resulting in elevated room temperatures that could negatively affect residents' health. Multiple residents with significant medical conditions, including heart failure, COPD, end stage renal disease, and respiratory failure, reported discomfort due to the heat in their rooms. Residents described the use of fans, both personal and in the hallway, but indicated these measures were insufficient to cool their rooms. The facility's policy on providing a homelike environment specifies maintaining comfortable and safe temperatures, which was not achieved during the survey period.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a diagnosis of vascular dementia exhibited physical aggression towards another resident who was cognitively intact. The aggressive resident, who had a documented history of behavioral disturbances and was being monitored for verbal and physical aggression, struck the other resident multiple times on the thigh during an activity. This incident was witnessed by staff and reported in facility documentation, confirming that the aggressive behavior was not an isolated event. The facility's policy requires protection of residents from abuse by anyone, including other residents. Despite this, the cognitively intact resident was subjected to physical abuse by another resident, as confirmed by interviews with staff and the affected resident. The incident was documented in the Report of Suspected Dependent Adult/Elder Abuse and corroborated by staff interviews, indicating that the facility failed to prevent the abuse as required by its own policies and procedures.
Resident Dignity and Respect Violation by CNA
Penalty
Summary
The facility failed to treat a resident with respect and dignity, as evidenced by an incident involving a Certified Nursing Assistant (CNA) who was reported to have been rough, aggressive, and verbally abusive while providing care. The resident, who had been admitted with diagnoses including left side hemiplegia, hemiparesis, and dysarthria, reported through an interpreter that the CNA raised her voice, handled him roughly, and covered his mouth during care. This incident was corroborated by the resident's family members and roommate, who also reported hearing the CNA yelling and using inappropriate language. The resident's family members reported the incident to the nursing staff, describing how the CNA had physically and verbally mistreated the resident, causing him emotional distress. The resident's roommate confirmed hearing the CNA's loud and disrespectful behavior, which woke him up during the night. The Licensed Nurse on duty at the time also confirmed hearing the CNA's raised voice and intervened to remind her to lower it. The Director of Nursing stated that staff are expected to treat residents with respect and maintain good communication. The facility's policy on dignity emphasizes that residents should be treated with respect at all times. The resident's care plan was updated following the incident to address the psychosocial well-being problem related to the allegation of abuse.
Failure to Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to update and revise the comprehensive care plan for a resident who was at high risk for falls. The resident, admitted with conditions including hemiparesis and muscle weakness, was assessed as high risk for falls. Despite this, after the resident experienced a fall on December 17, 2024, the care plan was not updated to include new interventions to prevent further falls. The resident fell again on December 19, 2024, indicating that the care plan was not revised in a timely manner to address the resident's fall risk. Interviews with facility staff, including a Licensed Nurse and the Director of Nursing, confirmed that the care plan should have been updated following the initial fall to include new goals and interventions. The facility's policy requires that care plans be revised when there is a change in the resident's condition or when initial interventions fail to prevent falls. However, the care plan for the resident was not updated after the first fall, which decreased the facility's ability to prevent further falls and compromised the resident's well-being.
Deficiencies in Food Safety and Equipment Maintenance
Penalty
Summary
The facility failed to maintain food equipment in proper working order, which was evident during a kitchen tour. The dish machine's temperature gauge was malfunctioning, and the sink faucet dish sprayer was leaking, both of which were confirmed by the Certified Dietary Manager (CDM) and the Maintenance Supervisor (MS). Additionally, the meat freezer had significant ice buildup, indicating potential temperature fluctuations that could affect food quality and safety. These equipment issues were not promptly addressed, as evidenced by the lack of regular servicing and maintenance records. The facility's staff demonstrated a lack of knowledge regarding sanitation processes, which was observed during the kitchen tour. Dietary Aides were unable to correctly perform and interpret the Quat sanitizer test, and they were unfamiliar with the facility's manual dishwashing process. This lack of understanding was confirmed by the Registered Dietitian (RD) and the CDM, who acknowledged that there were no documented in-services for kitchen staff related to these procedures. The improper use of sanitizing solutions and the inability to follow proper dishwashing protocols posed a risk to resident safety. Food storage practices in the facility were also found to be inadequate. Expired food, improperly labeled or unlabeled items, and uncovered foods were discovered in various storage areas. The CDM confirmed these findings, noting that such practices could lead to foodborne illnesses. Additionally, dirty and wet containers were found in the ready-to-use storage area, and worn food preparation equipment that could not be sanitized was not discarded. These deficiencies in food storage and equipment maintenance were in violation of the facility's policies and procedures, as well as the FDA Food Code.
Deficiencies in MRI Order Processing, Medication Clarification, and Feeding Formula Labeling
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for three residents. For Resident 25, an MRI order to confirm osteomyelitis was not processed promptly. The order was written by a Nurse Practitioner, but there was no evidence that it was processed or an appointment scheduled. The Infection Preventionist and Social Services Director confirmed the lack of action, and the Director of Nursing noted that follow-up only occurred after the surveyor's inquiry. Resident 73's medication order for Valacyclovir lacked a specified duration, and there was no documented attempt by Licensed Nurses to clarify this with the prescribing physician. The Registered Nurse Consultant confirmed that the medication was administered for 54 days without clarification, contrary to the facility's policy requiring automatic stop orders unless specified otherwise. For Resident 63, the feeding formula was not labeled with necessary information such as the resident's name, date, time, and rate of infusion. The Director of Nursing confirmed the label was incomplete and that there were no policies on labeling enteral feeding, although it was expected that the Licensed Nurse would complete the label with the resident's information.
Insufficient Staffing Leads to Resident Falls
Penalty
Summary
The facility failed to provide sufficient staffing for a census of 80 residents, as evidenced by multiple staff members stating that the facility was understaffed. The Staffing Coordinator admitted that the schedule often fell short of the goal of 3.5 hours per patient day (PPD) of direct nursing care, with 17 out of 29 days in September 2024 being scheduled under this minimum. Staff interviews revealed that the reduction in scheduled CNAs led to rushed care and delays in responding to resident call lights, particularly during the night shift. Resident 55, who was admitted with difficulty walking and muscle weakness, experienced five unwitnessed falls in one month. The resident's care plan indicated a need for supervision due to a high risk of falls, but staff shortages hindered the ability to monitor the resident adequately. Interviews with CNAs and the Director of Nursing confirmed that the facility's failure to meet the 3.5 PPD goal contributed to insufficient supervision and care for residents like Resident 55. The facility's policies on staffing and resident safety emphasized the need for sufficient and competent nursing staff to provide necessary care and supervision. However, the facility's inability to consistently meet its staffing goals compromised its ability to adhere to these policies, as evidenced by the staffing shortfalls and the multiple falls experienced by Resident 55.
Facility Serves Burnt Food to Residents
Penalty
Summary
The facility failed to provide palatable food when a resident was served a burnt cookie. During an observation and interview, the resident expressed dissatisfaction with the food, showing a cookie that was black on the bottom. Another resident also reported that food was sometimes served burnt. The issue was confirmed by a staff member who stated she would not eat a burnt cookie like that. The Registered Dietician acknowledged the problem, attributing it to an oven malfunction that caused uneven cooking. The Director of Nursing and the Certified Dietary Manager both confirmed the expectation that burnt food should not be served to residents. The facility had conducted an in-service training on food preparation in response to complaints about burnt food, attended by five staff members. The facility's policy indicated that poorly prepared food should not be served and should be improved, prepared again, or replaced.
Infection Control Deficiencies in Wound Care and Blood Glucose Monitoring
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during wound care and blood glucose monitoring. In the first instance, a Treatment Nurse (TN) did not perform hand hygiene between glove changes while providing wound care to a resident with a history of orthopedic aftercare following surgical amputation, osteomyelitis, and diabetes. The TN removed the old dressing, changed gloves without hand hygiene, and applied a new dressing. Additionally, the TN improperly returned wound care supplies, such as paper tape and saline cartridges, to the treatment cart after use in the resident's room, despite acknowledging that these items cannot be sanitized and should not be reused. In a separate incident, a Licensed Nurse (LN 1) failed to sanitize a blood glucose machine after performing a capillary blood sugar check on a resident. The LN 1 admitted to not cleaning the machine with an alcohol prep pad or equipment sanitizer after use, which is required to prevent the spread of infection. The facility's policies on hand hygiene, wound care, and blood glucose monitoring were not followed, contributing to these deficiencies.
Failure to Conduct Antibiotic Stewardship for Resident
Penalty
Summary
The facility failed to maintain an antibiotic stewardship program for one of the sampled residents, specifically Resident 25, who was prescribed two antibiotics for osteomyelitis without an infection screening evaluation. Resident 25 was admitted to the facility with diagnoses including pneumonia and type 2 diabetes. On September 30, 2024, Resident 25 was started on Trimethoprim/Sulfamethoxazole and Cefalexin for a right foot infection. However, the latest infection screening evaluation in the resident's medical record was from August 13, 2024, and no assessments were conducted for the current infection. During an interview and record review, the Infection Preventionist (IP) confirmed that no antibiotic use assessments were done for the antibiotics prescribed on September 30, 2024. The IP acknowledged that the assessment should have been completed promptly when the antibiotics were started. The facility's policy required all clinical infections treated with antibiotics to undergo review by the IP or designee, but this was not done. The California Department of Public Health's guidelines also recommend an antibiotic review process at 48-72 hours after initiation, which was not followed in this case.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that a resident received the pneumococcal vaccine, which is intended to prevent or reduce the severity of pneumonia. The resident, who was admitted in August 2024 with diagnoses including pneumonia and type 2 diabetes, had provided informed consent for the pneumococcal vaccination on August 13, 2024. However, the order for the vaccine was not entered correctly into the system, resulting in the vaccine not being administered. The facility's policy requires that assessments of pneumococcal vaccination status be conducted within five working days of admission, and vaccines should be administered unless contraindicated, already given, or refused. Despite these guidelines, the resident's vaccination was delayed for over a month, which was acknowledged as unacceptable by the Infection Preventionist during an interview. The oversight was attributed to a failure in entering the order for the vaccine, as confirmed by the Infection Preventionist.
Incomplete Discharge Notice for Non-Compliant Resident
Penalty
Summary
The facility failed to provide a correct discharge notice to a resident who was being discharged for non-compliance with the facility's smoking policy. The resident, who was admitted in March 2023 with multiple diagnoses including polyneuropathies, paraplegia, and malnutrition, was cognitively intact and independent in activities of daily living. Despite being educated on the smoking policy and acknowledging understanding, the resident repeatedly violated the policy by smoking outside designated areas and times. On August 7, 2024, the resident was issued a 30-day discharge notice due to these violations. However, the discharge notice did not include the discharge location or an updated discharge date after an extension was granted following a meeting with the ombudsman. The facility's policy requires that discharge notices include the effective date and specific location of discharge, which was not adhered to in this case. Interviews with facility staff, including the Administrator, Social Services Director, and Director of Nursing, confirmed the omission of the discharge location in the notice and the resident's refusal to accept offered placements. The facility had been actively seeking placement options for the resident, but the resident declined them due to financial concerns and personal preferences. The failure to provide a complete discharge notice had the potential to result in an unsafe discharge for the resident.
Failure to Provide Correct Discharge Notice
Penalty
Summary
The facility failed to provide a correct discharge notice to a resident who was being discharged for non-compliance with the facility's smoking policy. The discharge notice did not include the discharge location or the updated date of discharge after an extension was granted. This oversight was identified during a review of the resident's records and interviews with facility staff and the resident. The resident, who was admitted to the facility with multiple diagnoses including polyneuropathies, paraplegia, and malnutrition, was cognitively intact and independent in activities of daily living. Despite being educated on the facility's smoking policy, the resident repeatedly violated the policy by smoking outside designated areas and times. As a result, the resident was issued a 30-day discharge notice, which was not updated to reflect an extension granted after discussions with the ombudsman. Interviews with the facility's administrator, social services director, and director of nursing revealed that the resident was provided with multiple room and board options, all of which were declined by the resident. The facility's policy requires that discharge notices include the specific location to which the resident is being discharged, but this was not adhered to in this case. The director of nursing acknowledged that a new discharge notice should have been issued with the correct discharge address.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 676 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sacramento
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Saylor Lane Healthcare Center | 0.4 mi | ★★★★★ | 0 | 0 |
| Mid-town Oaks Post-acute | 0.5 mi | ★★★★★ | 27 | 0 |
| University Post-acute Rehab | 1 mi | ★★★★★ | 0 | 0 |
| Sherwood Healthcare Center | 1.2 mi | ★★★★★ | 0 | 0 |
| Advanced Health Care Of Sacramento | 1.7 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.