Dr Arthur Clifton McKinley Ctr

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to initiate a baseline care plan and provide a written summary of the baseline care plan and order summary to the resident and/or representative for five of five residents reviewed (Residents R2, R6, R9, R10, and R13). Findings include: Review of facility policy entitled Care Plans - Baseline dated 11/4/25, revealed that A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight hours of admission. The policy further stated The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality of care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: Initial goals based on admission orders and discussion with the resident/representative, physician orders, dietary orders, therapy services, social services, and PASARR…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policy and manufacturer's guidelines, observation, and staff interview, it was determined that the facility failed to appropriately discard outdated medications for one of two medication rooms reviewed (Rehabilitation Unit). Findings include: Review of facility policy entitled Medication Labeling and Storage dated 11/4/25, revealed that Multi-dose vials that have been opened or accessed (example - needle punctured) are dated and discarded within 28-days unless the manufacturer specified a shorter or longer date for the open vial. Review of manufacturer's guidelines revealed that an open vial of Tubersol (a solution used for tuberculosis testing upon admission and employment) should be discarded within 30-days after opening. Observation of drug storage on 12/2/25, at 12:13 p.m. of the Rehabilitation Unit medication storage room refrigerator revealed an open vial of Tubersol with an open date of 10/28/25, making the discard date 11/27/25. During an interview at the time of observation, Licensed Practical Nurse Employee E1 confirmed that the open vial of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure a physician's order was completed to indicate the code status as Full Code (CPR[cardiopulmonary resuscitation]/Attempt Resuscitation) or Do Not Resuscitate (DNR/Do Not Attempt Resuscitation-Allow Natural Death) for one of 18 residents reviewed (Resident R26). Findings include: No facility policy was provided regarding a physician's order in the electronic medical record (EMR) for a resident. Resident R26's clinical record revealed an admission date of [DATE], with diagnoses that included chronic respiratory failure with hypoxia (a condition where the lungs are unable to provide oxygen to the body), cardiac heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), diabetes mellitus type one (a condition where the pancreas makes little or no insulin to carry the blood sugar into the cells of the body resulting in high blood sugars), and constipation.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of a PRN (as needed) psychotropic (affecting the mind) medication for one of five residents reviewed for unnecessary medications (Resident R24). Findings include: A facility policy entitled Behavioral Assessment, Intervention, and Monitoring dated 11/02/24, indicated that non-pharmacological approaches will be used to the extent possible to avoid or reduce the use of antipsychotic medications to manage behavioral symptoms and that other approaches and interventions will be tried prior to the use of antipsychotics medications. Resident R24's clinical record revealed an admission date of 5/07/22, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), Anxiety (a condition that causes a person to be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policy and manufacturer's instructions, observation, and staff interview, it was determined that the facility failed to ensure that medications were discarded in a timely manner for one of two medication rooms observed (1st floor medication room) Findings include: A facility policy entitled Medication Labeling and Storage dated 11/02/24, indicated that multi-dose vials that have been opened or accessed (example - needle punctured) are dated and discarded within 28-days unless the manufacturer specifies a shorter or longer date for the open vial. Manufacturer's recommendations for Tubersol PPD (solution used to test for tuberculosis) indicated that vials which are entered and in use for 30-days should be discarded. Observation of drug storage on 12/18/24, at approximately 10:01 a.m. in 1st floor medication storage room refrigerator revealed an opened vial of Tubersol PPD with and an open date of 11/15/2024, making the discard date 12/15/24. During an interview at the time of observation, Licensed Practical Nurse Employee E1 confirmed that the open Tubersol…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and staff and resident interviews, it was determined that the facility failed to ensure that the resident was offered the opportunity to participate in the development, review, and/or revision of their person-centered care plan for three of 18 residents reviewed (Residents R7, R12, and R26). Findings include: Resident R7's clinical record revealed an admission date of 5/11/22, with diagnoses that included Diabetes (a condition where the body produces insufficient amounts of insulin, causing high blood sugar), peripheral vascular disease (a slow and progressive circulation disorder), and atrial fibrillation (a type of abnormal, rapid heartbeat that is present all the time, causing shortness of breath, heart palpitations, and weakness and can lead to development of blood clots). Review of Resident R7's Quarterly Minimum Data Set (MDS- a federally mandated standardized assessment conducted at specific intervals to plan resident care needs), with an Assessment Reference Date (ARD-a look back period of time for the MDS assessment) of 11/27/23, revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of clinical records and staff interview, it was determined that the facility failed to ensure that a written summary of the baseline care plan was provided to the resident and/or the resident's representative for four of 18 residents reviewed (Residents R30, R25, R34, and R65). Findings include: Resident R30's clinical record revealed an admission date of 5/16/23, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD-a condition that obstructs air flow in the lungs with symptoms of difficulty breathing, coughing and shortness of breath), congestive heart failure (a progressive heart disease that weakens the pumping action of the heart muscles, causing fatigue and shortness of breath in the resident), Diabetes (a condition where the body produces insufficient amounts of insulin, causing high blood sugar). Review of Resident R30's clinical record lacked evidence that a written summary of the baseline care plan was provided to the resident and/or representative. Resident R25's clinical record revealed an admission date of 10/14/23, with diagnoses that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to conduct a complete investigation for an injury of unknown origin in a timely manner for one of 18 residents reviewed (Resident R57). Findings include: Review of the facility policy entitled Resident Incident and Accident Report dated 1/27/23, indicated that, The RN (Registered Nurse) will initiate an investigation for any injury or accident of unknown cause. Review of the clinical record revealed that on 12/12/23, at 10:12 a.m. Resident R57 was having increased leg pain and the physician was notified to obtain an x-ray, an order was received from the physician at 10:38 a.m. to x-ray Resident R57's left hip and leg, the x-ray company was called at 10:52 a.m. and the x-ray was completed at 6:14 p.m. On 12/14/23, at 1:02 a.m. the x-ray results were obtained via telephone which identified an acute left femoral neck fracture and at 9:19 a.m. an order was received to send Resident R57 to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of clinical records and staff interviews, it was determined that the facility failed to develop a wound care plan for one of 18 residents reviewed (Resident R34). Findings include: Resident R34's clinical record revealed an admission date of 8/2/23, with diagnosis of hypertension (high blood pressure), peripheral venous insufficiency (a condition where your veins have trouble sending blood from your limbs back to your heart), open wound right lower leg, and lymphedema (a condition that causes swelling which can cause skin break down). Review of Resident R34's treatment record revealed an order to keep dressings clean, dry and intact to both legs, and to elevate bilateral lower extremities when possible. Review of Resident R34's physician orders revealed Resident R34 follows with the wound clinic for peripheral venous wounds to bilateral legs. Review of Resident R34's care plans revealed no evidence of a care plan for peripheral venous wounds to bilateral legs. During an interview on 1/11/24, at 12:21 p.m. the Director of Nursing confirmed that Resident 34's plan of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policies and clinical records, and resident and staff interviews, it was determined that the facility failed to follow physician's orders for medication administration and oxygen therapy for two of 18 residents reviewed (Residents R65 and R30). Findings include: Review of facility policy entitled Physician Orders dated 1/27/23, revealed Upon receipt of written or verbal orders by the practitioner, the Registered Nurse (RN) will write and or enter the new order into electronic medical record (EMR). and If a new medication has been ordered . the pharmacy should dispense either via omni cell, routine/scheduled run or via emergency run. Review of Resident R65's clinical record revealed an admission date of 10/14/23, with diagnosis that include urinary tract infection (an infection in the urine), diabetes (a condition where the body produces insufficient amounts of insulin, causing high blood sugar), hypertension (high blood pressure), and urinary calculus (kidney stones). Interview with Resident R65 on 1/10/24, at 10:42 a.m. revealed that he/she was told…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policy and clinical records, and resident and staff interview, it was determined that the facility failed to obtain a physician's order for the provision of Bilevel Positive Airway Pressure (BIPAP - a machine that uses pressure to push air into your lungs) and/or CPAP (Continuous Positive Airway Pressure) therapy for one of one residents reviewed for respiratory services (Resident R30). Findings include: Review of a facility policy dated 1/27/23, entitled, AVAPS (Average Volume Assured Pressure Support - a device that provide consistent ventilation support) and BiPAP Therapy indicated Procedure instructions stating, Obtain physician order .). Resident R30's clinical record revealed an admission date of 5/16/23, with diagnoses including respiratory failure with hypercapnia (extreme breathing difficulties demonstrated by increased carbon dioxide levels in the blood), Chronic Obstructive Pulmonary Disease (COPD - a condition involving constriction of the airways and difficulty or discomfort in breathing), and diabetes (a condition where the body produces…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility contract, clinical record, and staff interview, it was determined that the facility failed to maintain records relating to dialysis communication and collaboration for one of one residents reviewed for dialysis (Resident R39). Findings include: Review of dialysis contract dated 11/28/23, indicated Long Term Care Facility (LTCF) shall timely provide all relevant information to Dialysis Clinic Inc (DCI) regarding the condition and needs of each LTCF patient ., DCI shall provide relevant information regarding each patient's dialysis treatment which may require follow up care or observation by LTCF's staff: and This .communication will occur prior to each and every transfer of a patient to DCI . Resident R39's clinical record revealed an admission date of 11/28/23, with diagnoses that included end stage renal disease (a disease that causes the kidneys not to function properly), diabetes, hypercholesterolemia (high cholesterol), and hypothyroidism (a condition where your thyroid gland [a butterfly shaped organ in your neck] makes too little hormone). Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policies, observations, and staff interviews it was determined that the facility failed to appropriately discard outdated medications for two of three medication carts reviewed (Apple Tree and Hickory Lane medication carts). Findings include: Review of facility policy entitled Storage of Medications dated 1/27/23, indicated The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. Review of manufacturer's guidelines revealed open Insulin Lispro pens must be used within 28 days after opening or be discarded, even if the pen still contains insulin. Observation of drug storage on 1/9/24, at 3:46 p.m. of the Hickory Lane medication cart revealed a pen of Insulin Lispro with an open date of 12/10/23, which was beyond the expiration date of 28 days after opening. During an interview at the time of observation, Licensed Practical Nurse (LPN) Employee E1 confirmed that the Insulin Lispro pen should have been discarded as it was beyond the 28 days after opening. Observation of drug storage on 1/9/24, at 4:18 p.m. of the Apple Tree…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.