Mcknight Place Extended Care

In the surveyor’s words

From the most serious findings on record at Mcknight Place Extended Care, in the surveyor’s own words.

• Actual harm, isolatedF689Feb 4, 2021

  Based on observation, interview and record review, the facility failed to ensure the resident received care in a safe environment when Certified Nursing Assistant (CNA) D, by him/herself, inappropriately transferred a resident (Resident #1) who required two person assistance. This resulted in the resident sustaining a fractured leg and large skin tears. The sample size was three. The census was 44. The administrator was notified on 2/4/21 at 9:45 A.M., of the past non-compliance which occurred on 4/23/20. On 4/23/20, the former assistant Director of Nursing (ADON) became aware of the violation of the resident's safe environment. The staff member was suspended and later terminated. The facility in-serviced the staff on ambulation, gait belts and transfers. The investigation was completed. […]

• No harm, potential for more than minimal, patternF755Apr 9, 2025

  Based on interview and record review, the facility failed to establish a system of records for all controlled drugs with sufficient detail to enable an accurate reconciliation, for two out of two medication carts reviewed. This had the potential to affect all residents with controlled substance orders. The census was 58. Review of the facility's Counting Narcotics policy, updated 8/5/11, showed: -At the change of shift, an off-going nurse or Certified Medication Technician (CMT) and an oncoming Nurse or CMT must count all narcotics, routine and as needed (PRN); -The Nurses or CMTs counting must also verify that the count is correct and that the number of items (cards and bottles) is correct, on both green sheet and the count sheet; -Any Nurse or CMT who had access to the medication cart… […]

• No harm, potential for more than minimal, patternF761Apr 9, 2025

  Based on observation, interview and record review, the facility failed to have a system in place to ensure drugs and biologicals in the medication room refrigerator were stored at a proper temperature for one of one medication room observed. The census was 58. Review of the facility's Storage of Medications, revised April, 2007, showed: -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner; -The nursing staff shall be responsible for maintain medication storage and preparation areas in a clean, safe and sanitary manner; -Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location; -Medications must be stored separately from food and must be labeled accordingly. […]

• No harm, potential for more than minimal, patternF812Apr 9, 2025

  Based on observation, interview and record review, the facility failed to ensure floors and the ice cream freezer in the kitchen were clean. In addition, the facility failed to ensure proper hair restraints were worn. The census was 58. Review of the facility's food service hygiene policy, dated 4/2024, showed: -Policy: employees must meet acceptable standards of personal hygiene and appearance. -Facial hair, including overgrown sideburns, mustaches and beards is to be clean and required to be completely covered wearing protective cover gear. 1. […]

• No harm, potential for more than minimal, patternF638Oct 11, 2023

  Based on record review, interviews, and facility policy review, the facility failed to ensure a quarterly Minimum Data Set (MDS) assessment was completed at least every three months for 3 of 3 residents (Residents #27, #46, and #58) reviewed for timely completion of MDS assessments. Findings included: Review of a facility policy titled, Resident Assessment Instrument, revised September 2010, revealed, 1. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conducts timely resident assessments and reviews according to the following schedule: c. […]