Mckay Healthcare & Rehab CTR

In the surveyor’s words

From the most serious findings on record at Mckay Healthcare & Rehab CTR, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Oct 26, 2022

  Based on observation, interview, and record review, the facility failed to implement key interventions to safeguard, protect and prevent a resident from eloping outside of the facility (an instance where a resident leaves the facility without authorization and/or any necessary supervision to do so) for one of three residents (1), reviewed for accidents/hazards; by the resident having access to an unsecured/unsupervised egress (an exit from the facility) door. This failure resulted in an Immediate Jeopardy (IJ), on 10/21/2022, for Resident 1 who had been unsupervised for six minutes and in that time had eloped from the facility at without a door alarm sounding or staff's knowledge. […]

• Actual harm, isolatedF689Feb 9, 2024

  Based on observation, interview, and record review, the facility failed to identify the risk of hot liquids, adequately supervise, and initiate interventions for the safe use of hot liquids for a resident who required staff assistance with drinking fluids for 1 of 3 residents (Resident 6), reviewed for accidents. Resident 6 experienced harm as they sustained a second degree burn to their right thigh. Additionally, the facility failed to safeguard the residents' environment by securing cleaning chemicals for 2 of 3 common resident bathrooms (bathrooms [ROOM NUMBERS] on hall D ) and 2 of 2 shower rooms (shower rooms [ROOM NUMBERS] on hall D), reviewed for environment. […]

• Actual harm, isolatedF835Oct 26, 2022

  Based on observation, interview and record review, the facility's Administration failed to effectively utilize its multidisciplinary resources to maintain the facility's compliance with federal regulatory requirements related to not implementing key interventions to safeguard, protect and prevent one of three residents (1), reviewed for accidents/hazards who was cognitively impaired and lacked safety awareness. The facility's Administration failed to ensure a functioning wanderguard (WG, a system that safeguards high risk residents by alarming staff of possible resident elopement) system or other effective preventative interventions were in place to prevent residents at risk for elopement (an instance where a resident leaves the facility without authorization and/or any necessary… […]

• Actual harm, isolatedF689Aug 22, 2022

  Based on observation, interview, and record review, the facility failed to ensure one of one resident (1) reviewed for accidents received adequate interventions and supervision to prevent wandering and falls. The failure to evaluate and analyze the risks of multiple unwitnessed falls and wandering, and to ensure interventions were provided, resulted in harm when the resident exited the building (from an area not intended for resident access) and fell from their wheelchair onto the concrete. Findings included . Resident 1. Review of the medical record showed the resident was admitted to the facility on [DATE]. Diagnoses included advanced dementia with disorientation. […]

• No harm, potential for more than minimal, widespreadF806Feb 9, 2024

  Based on observation, interview, and record review, the facility failed to provide dietary information for staff to follow that recognized the resident's diet type, consistency, allergies, intolerances, and preferences for 34 of 34 residents living in the facility reviewed for dining. This failure placed the residents at risk of receiving food or drink that decreased their quality of life and had the potential to cause harm. Findings included . During an observation on 02/04/2024 between 12:20 PM and 1:15 PM, showed residents being served their lunch trays in the dining room from carts sent from the kitchen. […]