McLean Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's environment remained free from accidents as was possible and each resident received adequate supervision and assistance devised to prevent accidents for 1 of 5 residents (Resident #2) reviewed for accidents, hazards, and supervision. The facility failed to ensure the TA securely fastened Resident #2's seat to the floor of the facility van when taking him to dialysis. Resident #2's seat tipped sideways, causing Resident #2 to strike the van door with his right shoulder and side, resulting in a fractured right collarbone and rib when the TA made a left turn. The noncompliance was identified as PNC. The IJ began on 3/18/26 when Resident #2 fell in the facility van and ended on 3/19/26. The facility had corrected the noncompliance before the surveyor entered the facility. [...]

Inspectors wrote-Medication cart for the facility revealed the following:-The facility failed to discard Resident #19's Novolog 100units/ml with an open date of 06/06/2025. -The facility failed to have an open date on Resident #19's Novolog 100units/ml. -The facility failed to discard Resident #16's Lantus 100units/ml with open date of 06/03/2025. -The facility failed to discard Resident #16's Novolog 100units/ml with an open date of 06/04/2025.-The facility failed to have an open date on Resident #3's Novolog 100units/ml. -The facility failed to have an open date on Resident #3's Glargin-YFGN Injection pen. -The facility failed to have an open date on Resident #24's Novolog FlexPen. -The facility failed to discard Resident #22's Glargin-YFGN Injection pen with an open date of 06/04/2025. -The facility failed to have an open date on Resident #22's Novolog FlexPen. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. A. The facility failed to ensure kitchen staff used proper hand washing and sanitation procedures when handling food. B. The facility failed to ensure personal items were not in the kitchen prep area. *This tag was written by [NAME]. However, she is out of the office at this time, so I am placing it here to get it turned into Enforcement timely. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. A. [...]

Inspectors wroteCNA B and CNA C did not provide privacy to Resident #10 during incontinent care. Based on observation, interview, and record review, the facility failed to provide each resident personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups for 1 (Resident #10) of 13 residents reviewed for privacy. CNA B and CNA C did not provide privacy to Resident #10 during incontinent care. This failure could place residents at risk of a lack of dignified existence, lowered self-esteem, or a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to, in accordance with professional standards and practices, maintain medical records on each resident that are accurately documented for 1 (Resident #15) of 13 residents reviewed for accuracy of medical records. The facility failed to ensure Resident #15 had orders for his catheter. Based on observation, interview, and record review the facility failed to, in accordance with professional standards and practices, maintain medical records on each resident that are accurately documented for 1 (Resident #15) of 13 residents reviewed for accuracy of medical records. The facility failed to ensure Resident #15 had orders for his catheter. These failures could place residents at risk of not receiving necessary care/treatment due to inaccurate medical records. [...]

Inspectors wrote-ADON did not use PPE to perform a glucose check on Resident #1, who was on contact precautions for MRSA. -ADON did not clean glucose strip container after coming out of Resident #1's room. -ADON did not use PPE to administer IV medications via PICC line for Resident #1. Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communication diseases and infections for 1 of 13 residents (Resident #1) reviewed for infection control. -ADON did not use PPE to perform a glucose check on Resident #1, who was on contact precautions for MRSA. -ADON did not clean glucose strip container after coming out of Resident #1's room. -ADON did not use PPE to administer IV medications via PICC line for Resident #1. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, and distribute food in accordance with professional standards for food safety for 1 of 1 kitchen reviewed for food safety. The facility failed to ensure that all food items being served to residents, were within their expiration or best by dates. This failure could place residents at risk of food-borne illness and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 5 Residents (Resident #1) reviewed. The facility failed to complete a baseline care plan within 48 hours of admission for Resident #1. This failure could place all newly admitted patients at risk for lack of care, needs not being met, and goals not targeted towards the individual needs of the resident. Findings Included: Record review of Resident #1's face sheet, undated, revealed an [AGE] year-old female admitted to the facility on [DATE]. [...]

Inspectors wroteThe facility failed to establish and maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections for one of one room observed for infection control precautions. HK A did not follow transmission-based precautions for a resident under contact precautions by not utilizing PPE while in the room. This failure could place all residents in the facility by exposing them to care that could lead to infection, communicable diseases, and feelings of isolation related to poor hygiene.

Inspectors wroteBased on interview and record review; the facility failed to ensure residents remained free of any significant medication errors for 1 of 6 residents reviewed for medication errors (Resident #1). RN A incorrectly administered another resident's Metoprolol Tartrate Oral tablet 25mg to Resident #1. The significant medication error caused Resident #1 to have an altered blood pressure requiring transfer to the local hospital for further evaluation. The facility's failure could place residents at risk for adverse reactions, health complications and hospitalization and death.

Inspectors wroteBased on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety in one of one kitchen reviewed for proper food storage. 1. The facility failed to ensure refrigerated foods were properly labelled and dated. 2. The facility failed to ensure pantry foods were properly labelled, dated, and stored in airtight containers. 3. The facility failed to ensure expired foods and leftovers past the use by date were removed from the refrigerator, pantry, and spice shelf. These failures could place residents at risk for food-borne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 3 (Resident #4, #11 and #13) of 16 residents reviewed for advanced directives. Resident #4 had a DNR is her record that had no information in the Physicians Statement Section and no second signature for the physician. Resident #11 had a DNR in her record with no information in the Two Witnesses Section. Resident #13 was listed in her chart as a full code with a correctly completed DNR present in her medical records. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 (Resident #16) of 16 residents reviewed for respiratory care. Resident #16 had orders for oxygen at 5 liters per minute and was receiving oxygen at lower concentrations. This failure could place residents who receive oxygen at an increased risk for receiving oxygen at the wrong rate which could lead to hypoxemia (low levels of oxygen in the blood, decreasing the oxygen supply to vital organ), shortness of breath, and hypoxia (insufficient levels of oxygen in the tissues of the body for normal life functions).