Mckinley Nursing

In the surveyor’s words

From the most serious findings on record at Mckinley Nursing, in the surveyor’s own words.

• Actual harm, isolatedF689Nov 3, 2023

  Based 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. […]

• No harm, potential for more than minimal, widespreadF730May 7, 2026

  Based 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. Findings include:Review of the employee files for Certified Nursing Assistant (CNA) #325, CNA #386 and CNA #425 revealed they had not received yearly performance evaluations. CNA #325 was hired on 03/13/25, CNA #386 was hired on 01/15/25 and CNA #425 was hired on 03/04/25. Interview on 04/28/26 at 1:15 P.M. with Human Resources Director (HR) #307 verified yearly performance evaluations had not been completed as required. HR #307 acknowledged the delay and stated they were behind on evaluations but were working to get caught up.

• No harm, potential for more than minimal, widespreadF803May 7, 2026

  Based 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.Findings include:1. Interview on 04/19/26 at 9:30 A.M. with Resident #75 revealed the menus were not always posted in common areas and the aides were not taking down alternate choices to the kitchen. Resident #75 reported the portion sizes are child-like and he was not receiving enough food. Interview on 04/19/26 at 10:09 A.M. […]

• No harm, potential for more than minimal, widespreadF804May 7, 2026

  Based 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.Findings include:Review of the food committee meeting minutes from 11/25/25, 02/24/26, and 03/31/26 revealed residents complaining of cold food.An interview on 04/19/26 at 11:25 A.M. with Resident #12 revealed the food was not served hot enough and was not appealing. An interview on 04/19/26 at 12:26 P.M. with Resident #91 revealed the food was never hot. An interview on 04/19/26 at 1:16 P.M. with Resident #117 revealed the food was not hot. […]

• No harm, potential for more than minimal, widespreadF809May 7, 2026

  Based 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.Findings include:Review of the Resident Meal Times, undated, revealed breakfast was from 8:15 A.M. to 9:20 A.M., lunch was from 12:30 P.M. to 1:35 P.M., and Dinner was from 5:15 P.M. to 6:20 P.M. Service order was [NAME] Unit, Grant Unit, [NAME] Unit, Presidential Unit, Taft Unit, and [NAME] Unit. Review of Food Committee Meeting minutes from 02/24/26 revealed residents complaining of late lunches and trays being left to sit for 15 minutes after arriving to the unit before staff passed them out. […]