Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 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.
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.
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.
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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.
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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 | — | 25 | 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 | — | 0 | 0 |
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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 August 2026) and official state health department websites.