McClure Post Acute

Inspectors wroteBased on an interview and record review, the facility failed to ensure the Minimum Data Set (MDS, standardized assessment used in nursing homes to evaluate a resident's physical, psychological, and functional status) assessments were transmitted (electronically submitted to the national database) within the required 14 day timeframe for four of 19 sampled residents (Resident 12, 29, 46, and 64). This failure resulted in the delayed reporting of the residents' condition, which may negatively impact care planning, oversight, and delivery of appropriate services to meet the residents' needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quarterly Minimum Data Set (MDS, standardized assessment used in nursing homes to evaluate a resident's physical, psychological, and functional status) assessments were completed in a timely manner for two of 19 sampled residents (Resident 40 and 46) when: 1. Resident 40's Quarterly MDS was not completed within the required timeframe of 14 days from the Assessment Reference Date (ARD, specific date selected for an MDS assessment that determines the end of the observation) 2. Resident 46's Quarterly MDS was not within the required timeframe of 92 days from the prior MDS assessment. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure supervision was provided during dining per physician's orders for one of 19 sampled residents (Resident 23). This failure resulted in an increased risk of choking, aspiration (entry of food or liquid into the airway or lungs), and potential respiratory complications such as death for Resident 23. During a review of Resident 23's Face Sheet (FS, demographics), dated 4/9/26, the FS indicated Resident 23 was originally admitted to the facility on [DATE] and then was readmitted after a change of condition on 2/16/26. The FS further indicated Resident 23's diagnosis was a stroke (blood flow blocked to the brain) with difficulty swallowing and speaking. During a concurrent observation and interview on 4/9/26 at 8:16 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff were adequately trained and competent regarding medication management of self-administered medications that were stored at bedside for one of 19 sampled residents (Resident 76). This failure resulted in Resident 76's medications being administered without appropriate oversight or documentation, placing the resident at risk for medication errors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored in a safe and secure manner for one of 19 sampled residents (Resident 76) when his albuterol sulfate inhaler (medication inhaled into the lungs that helps make breathing easier) was found lying on his tray table. This failure had the potential to result in unsafe or unauthorized medication use, drug diversion, and accidental ingestion by Resident 76 or other medically vulnerable residents.

Inspectors wroteBased on interview and record review, for two of three sampled residents (Resident 1 and 2), the facility failed to provide required discharge notice in a timely manner when notice of proposed discharge were provided on the day of discharge. This failure had the potential to prevent residents from understanding their rights or available appeal options. During a review of Resident 1's admission Record(AR) dated 3/17/26, the AR indicated Resident 1 was admitted to the facility 11/12/25 with diagnoses that included peripheral vertigo (severe sensation of spinning), chronic kidney disease (long-term, progressive loss of kidney function), muscle weakness, difficulty walking and other symptoms and signs involving cognitive functions and awareness. [...]

Inspectors wroteBased on interview and record review, for two of three sampled residents (Resident 1 and 3), the facility failed to maintain complete and accurate medical records in accordance with professional standards when:1.a. Resident 3 left the faciity on 3/9/26 without staff knowledge or permission (elopement, when a resident leaves the facility without staff knowledge or permission), and this was documented in the medical record as leaving Against Medical Advice (AMA, a situation in which a resident chooses to leave a healthcare facility or discontinue recommended care despite the facility's clinical advice to remain).1.b. Resident 3's request for room changes, as well as the facility's corresponding response, were not documented in the clinical record. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not provide privacy to one (1) out of four (4) sampled residents during phone conversations. This failure resulted in facility staff overhearing Resident 1's phone conversations, violation of rights to privacy and placed her at risk of being upset. During a record review of Resident 1's admission record, indicated that Resident 1 was admitted to the facility on [DATE]. During a record review of Resident 1's Minimum Data Set (MDS, a resident assessment tool used in identifying problems to be addressed in plan of care), dated 1/20/26, the record indicated that Resident 1 had clear speech, was able to make herself understood, and was able to understand others. MDS also indicated that it was very important for Resident 1 to be able to use a phone in private. During a phone interview on 3/16/26 at 9:10 a.m. [...]

Inspectors wroteBased on interview and record review, for two of two residents (Resident 2 and Resident 3) who were discharged , the facility failed to develop and implement an effective discharge planning process for their transition to post-discharge care when:1. For Resident 2, the facility failed to assist in obtaining a government ID and bank card before discharge. The facility did not arrange primary care or pharmacy services for medication follow-up. This had the potential to result in Resident 2 lacking funds for his ILF (Independent Living Facility) stay and potentially facing homelessness.2. For Resident 3, the facility failed to establish a primary care provider and pharmacy for medication refills after discharge. This failure had the potential to result in unnecessary re-admissions.1. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to store and prepare food in accordance with professional standards for safety when: 1. Unlabeled, undated food items were stored in the kitchen refrigerator. 2. [NAME] (CK) 1 did not wear a beard restraint while preparing resident food. 3. Expired and moldy food items were stored in the resident refrigerator. These failures had the potential for contamination of food resulting in food borne illness for the 55 residents who received food from the kitchen and used the resident refrigerator.

Inspectors wroteBased on observation, interview, and record review, the facility failed to allow one out of 15 Residents (Resident 42) to exercise their right to self-determination when Resident 42 was not provided nutrition in accordance with their preferences. This failure had the potential to result in Residents 42 feeling upset and disrespected.

Inspectors wroteBased on interview and record review, licensed nursing staff did not notify the doctor for changes in condition for one of 15 sampled residents (Resident 49). Staff did not report continued low food intake, pain, and low blood pressures. This failure resulted in Resident 49 becoming unresponsive with a low blood sugar and sent to the hospital emergency department where she experienced a cardiac arrest (condition when heart suddenly and unexpectedly stops beating) and died.

Inspectors wroteBased on interview and record review, for one of one sampled resident (Resident 20) reviewed for vision impairment, the facility did not assist Resident 20 in making appointments for cataract evaluation. This failure had the potential to result in worsening of visual function without treatment. Definition: Cataract, a clouding of the normally clear lens of the eye, leading to blurry and hazy vision. Cataract Evaluation, a comprehensive eye exam to assess the presence, severity, and potential impact of cataracts, as well as overall eye health, to determine the best course of treatment, which may include surgery. Ophthalmology, the branch of medicine focused on the eyes and vision, encompassing the diagnosis, treatment, and prevention of eye diseases and disorders, including surgical procedures and vision correction.

Inspectors wroteBased on interview and record review, for one of two sampled residents (Resident 24) reviewed for pain management, the facility failed to ensure pain management was provided consistent with professional standards of practice when facility did not administer pain medication to address Resident 24's severe pain. This failure had the potential to result in severe discomfort.

Inspectors wroteBased on observation and record review, the facility failed to ensure that resident bedrooms were limited to a maximum of four residents for one out of 24 rooms. This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff, affect resident's right to privacy, dignity and lack of sufficient space for storage of resident belongings.

Inspectors wroteBased on interview and record review, for one of three sampled residents (Resident 1), the facility failed to ensure a complete medical records when Resident 1's Treatment Administration Record (TAR) had missing signatures. This failure had the potential to result in uncoordinated care, and unnecessary, painful duplicate wound care.

Inspectors wroteBased on interview and record review, the facility failed to follow the facility abuse policy and procedure to protect and prevent further potential abuse for one of four sampled residents (Resident 1) when the facility allowed Certified Nursing Assistant (CNA) 1 to continue to provide direct patient care after Resident 1 made an abuse allegation. The failure to complete a thorough investigation of CNA 1 had pushed and slapped Resident 1 ' s arm during linen change resulted in psychosocial harm for Resident 1 and the potential for physical abuse for other residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food safely when the low-temperature dishwasher did not have sanitizer running through it. This failure increased the residents' risk for foodborne illness. Findings During a concurrent observation and interview on 2/20/24 at 9:48 a.m. with Dietary Aide (DA) 1 and Dietary Supervisor (DS), in the kitchen, DA 1 used a test strip to check the sanitizer level in the dishwasher. The test strip did not change color. DA 1 stated, the test strip showed no sanitizer was present. During a concurrent observation and interview on 2/20/24 at 9:55 a.m. with Registered Dietician (RD), in the kitchen, RD used a test strip to check the sanitizer level in the dishwasher. The test strip did not change color. RD stated, the test strip showed no sanitizer was present. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of five sampled residents received treatment to maintain vision. This failure resulted in Resident 32 not being referred to an ophthalmologist for cataracts. Findings Resident 32's facesheet, dated 2/22/24, indicated he was admitted to the facility in January of 2022. Resident 32's Multi Data Set (MDS - an assessment tool used to plan care), dated 1/25/24, indicated his Brief Interview for Mental Status (an assessment tool measuring cognitive function) score was 12, which indicated he was moderately cognitively impaired. During an interview on 2/21/24 at 10:20 a.m. with Resident 32, Resident 32 stated, he had cataracts, which were supposed to have been operated on and removed. Resident 32 stated, he did not know why it was taking so long for the cataracts to be removed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one out of two medication carts (medication cart #2), the medications stored in the medication cart had all their necessary labeling identifying medication stocks on hand. Resident 21's had one medication bottle without any identifying label and another bottle had no pharmacy label and torn out manufacturer's label. This failure had a potential to affect Resident 21's health and safety when unlabeled medications were in stored in the medication cart with current medications on hand for administration.