McLean County Nursing Home

Inspectors wroteBased on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions by failing to wear Personal Protective Equipment when emptying an internal urinary drainage device and failed to maintain urinary drainage bags off the floor, in a dignity bag, and away from potentially contaminated surfaces. This failure affects three of five residents (R9, R26, R48) reviewed for infection control on a sample list of 38.

Inspectors wroteBased on interview and record review, the facility failed to prevent misappropriation of resident property for one of three residents (R89) reviewed for misappropriation in the sample list of 38.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a resident's personal hygiene by failing to ensure routine fingernail care was completed for one of three residents (R64) reviewed for Activities of Daily Living (ADL) on a sample list of 38. The facility's ADL policy dated February 2025 documents under Policy Explanation and Compliance Guidelines #3.) A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Grooming includes, but is not limited to hair care, shaving and or facial hair care. R64's Minimum Data Set (MDS) dated [DATE] documents R64 scored a ten on her Brief Interview for Mental Status (BIMS). A BIMS score of eight to twelve indicates moderate cognitive impairment with potential need for help with daily tasks. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure essential resident-care equipment (toilet safety frames) was maintained in safe operating condition for two of two (R4, R70) residents reviewed for environment on a sample list of 38. 1.) The Toilet Safety Frame Owner's Manual dated February 2024 documents that the toilet safety frame should be checked regularly to make sure that it is securely locked onto the toilet. This manual also documents that safety precautions should be taken by always making sure that the safety frame is correctly and securely locked in place before use. R70's Minimum Data Set (MDS) dated [DATE] documents R70's Brief Interview for Mental Status (BIMS) score as 15. This score indicates R70 has normal cognitive function. R70's Electronic Medical Record (EMR) documents R70 has a diagnosis of repeated falls. [...]

Inspectors wroteBased on interview and record review the facility failed to report an allegation of abuse to the State Agency for one (R1) of three residents reviewed for abuse in the sample list of 11.

Inspectors wroteBased on interview, and record review the facility failed to protect resident's (R2, R3) right to be free from abuse by another resident (R1). This failure affects three (R1, R2, R3) of four residents reviewed for abuse in the sample list of four.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain the juice dispenser in a clean sanitary manner and failed to date perishable refrigerated foods when opened. This failure has the potential to affect all 100 residents who reside at the facility. Findings Include: The facility's Long Term Care Application for Medicare and Medicaid dated 8/12/24 documents the facility census as 100 residents. On 8/12/24 during the walk through of the main kitchen the juice dispenser was noted to have dried juice on the surface of the nozzles and the surrounding flat surface. Some of these dried juices were covered by green fuzzy material. V8 cook verified the dispenser is used to pour drinks for all residents who reside in the facility. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a mechanical wheelchair in a clean sanitary manner for one resident (R16) of five residents reviewed for wheelchair cleanliness in a sample list of 35 residents. Findings Include: R16's Care Plan reviewed 5/21/24 documents (R16) is under the care of Hospice Services related to diagnosis of severe protein malnutrition. A further decline in Cognitive and Physical Abilities is expected, all care is directed towards maintaining comfort through end of life. On 8/12/24 at 10:15AM R16 was in her room seated in a mechanical wheelchair. R16 stated I got this special chair from hospice. It's pretty comfortable but look it's dirty. The chair was caked around the padded seat with a chunky brown and white substance. R16 stated she doesn't like sitting in a dirty chair. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to secure catheter tubing to prevent tension and failed to position catheter tubing so that the flow was not interrupted for two of four residents (R40, R72) reviewed for catheters in the sample list of 35.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement Dietician recommendations for significant weight loss for two of three residents (R39, R40) reviewed for weight loss in the sample list of 35.

Inspectors wroteBased on interview and record review the facility failed to identify/track resident specific behaviors to justify the use of an antipsychotic and failed to implement nonpharmacological interventions for one resident (R65) of five residents reviewed for unnecessary medication in a sample list of 35 residents. Findings Include: R65's medical record documents current physician's orders for the following psychotropic medications: 1. Fluoxetine (antidepressant) 10 mg (milligram) on Sundays Fluoxetine 20 mg on Monday, Tuesday, Wednesday, Thursday, Friday, Saturday. 2. Lorazepam (antianxiety) 2mg/ml (milliliter) 0.25ml every 2 hours PRN (as needed). 3. Quetiapine (antipsychotic) 37.5 mg at bedtime. R65's Treatment Administration Record (TAR) for August 2024 documents Acknowledgement of Behaviors: Episodes of self-isolating and refusal of care. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to administer medications in accordance with Physician's Orders and manufacturer's recommendations for two of five residents (R4, R25) reviewed for medication administration in the sample list of 35. The facility had 2 medication errors out of 30 opportunities resulting in a 6.67% (percent) medication error rate.

Inspectors wroteBased on observation, record review, and interview the facility failed to label medication with date opened for two residents (R150, R151) of 25 residents reviewed for medication in a sample list of 35 residents Findings Include: 1.) R150's Medication Administration Record (MAR) includes a current physician's order for Refresh tears 0.5% (percent) two drops in each eye as needed every six hours. On 08/14/24 at 11:37 AM an opened bottle of Refresh eye drops with R150's name was observed on the 400 Hall medication cart not labeled with date opened. 2.) R151's Medication Administration Record (MAR) includes a current physician's order for Maxitrol (neomycin-polymyxin b-dexameth) 3.5mg(milligram)/g(gram)-10,000 unit/g-0.1 % ointment apply to right eye, ophthalmic (eye), At Bedtime. The insert for the Maxitrol eye ointment indicates it should be discarded 30 days after opening. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to timely report a resident change of condition to the resident's representative and physician for one (R1) of four residents reviewed for change in condition and injury of unknown origin in the sample list of four.

Inspectors wroteBased on interview and record review, the facility failed to have a certified dietary manager on staff. This failure has the potential to affect all 103 residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to answer call lights in a timely manner for five of 21 residents (R23, R85, R28, R19, R79) reviewed for call lights in the sample list of 49.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent significant medication errors by failing to administer hormone medication to ensure for proper absorption contributing to abnormal lab results for a resident and failing to administer medication for a resident on dialysis. This failure affects two of five residents (R89, R36) reviewed for significant medication errors on the sample list of 49. Findings Include: 1.) R89's ongoing Census documents R89 was admitted to the facility on [DATE]. R89's ongoing TSH laboratory results document, historically from 2017 - 2019, R89's TSH levels ranged between 0.872 - 2.289 (Normal Value is 0.3 - 5.0). This ongoing TSH results do not document any other results until 8/10/23, in which R89's TSH level is 25.271. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Scheduled II medications were locked in a permanently affixed compartment, date insulin and liquid protein when opened, resident medications were properly labeled with a pharmacy label and dispose of discontinued medication for residents. This failure affects 10 of 49 (R89, R16, R23, R13, R40, R12, R81, R28, R14, and R26) residents reviewed for medication storage and labeling on the sample list of 49. Findings Include: The facility's Drug Labeling Policy dated December 2021 documents the label of each individual container shall clearly indicate the resident's full name, physician's name, prescription number, name and strength of drug, directions for administration, date of issue, the initials of the pharmacist filling the prescription, and the amount of medications contained in each individual prescription. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to assess and obtain physician's order for self-administration of medication for two of two (R90, R61) residents reviewed for self-administration of medication in a sample list of 49. Finding Include: The facility's Medication Administration policy with a reviewed date of February 2023 documents, Self-Administration: Residents with appropriate cognitive status will be able to self-administer medication. The facility will complete a self-medication administration assessment to determine if resident is able to give their own medications appropriately. 1. R90's Physician's Order Summary includes a physician's order which was initiated 5/9/23 for albuterol sulfate HFA aerosol inhaler; 90 mcg/actuation; amt: 2 puffs; inhalation Special Instructions: rinse mouth after each use every 6 hours. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to accurately code the Resident Assessment Instrument (Minimum Data Set) for two of 32 residents (R61, R89) reviewed for Minimum Data Set assessments in the sample list of 49.

Inspectors wroteBased on interview and record review the facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) level I screening and a PASARR level II screening was completed for two (R55, R97) of seven residents reviewed for PASARR screenings from a total sample list of 49 residents reviewed. Findings Include: The facility's admission procedure dated 6/13/19 documents that the facility will obtain an Omnibus Budget Reconciliation Act (OBRA), otherwise known as PASARR, level screening upon admission. 1. R55's level I PASARR dated 12/10/21, obtained by the facility on 8/30/23, documents a level II PASARR is not required due to R55 not having an SMI (Severe Mental Illness) Diagnosis upon admission to the facility on [DATE]. R55's diagnosis sheet dated 3/2/22 documents new diagnoses of Psychotic disorder with delusions and Unspecified Dementia with Behavioral Disturbances. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to timely complete a treatment as ordered by the physician for one of one (R4) resident reviewed quality of care on the sample list of 49. Findings Include: R4's August 2023 Physician Orders document an order to apply elastic bandage wraps to bilateral lower extremities between 4:00 am - 7:00 am daily for localized edema and then remove between 8:00 pm - 11:00 pm. R4's Care Plan dated 6/26/23 documents R4 has limited ability with ADLs (Activities of Daily Living) and requires assistance with ADLs due to chronic pain, easily fatigued and impaired mobility related to Osteoarthritis, Heart Failure and Muscle Weakness with an intervention for staff to apply the elastic bandage wraps every morning to R4's bilateral lower extremities and remove them at bedtime. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to perform hand hygiene and prevent cross contamination during catheter care, ensure an indwelling catheter was secured to prevent it being pulled, ensure a dignity cover was covering the catheter drainage bag, ensure the catheter drainage bag was kept off of the floor, and obtain an urological consult for two of three residents (R89, R94) reviewed for indwelling catheters on the sample list of 49. Findings Include: The facility's Catheter Care Policy last reviewed in February 2023 documents do not tug or pull onto the catheter and secure indwelling catheter as needed. 1. On 8/28/23 at 9:25 AM, R89 was in a wheelchair being pushed down the hall by an unidentified staff member. R89's catheter drainage bag did not have a dignity cover on it, and the drainage bag was dragging on the floor under the wheelchair. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to obtain a Physician's Order for the use of a CPAP (Continuous Positive Airway Pressure) machine, failed to obtain an order to clean the CPAP equipment and failed to protect the CPAP mask and tubing from contamination for one of three residents (R61) reviewed for respiratory in the sample list of 49.

Inspectors wroteBased on interview and record review, the facility failed to have ongoing communication and collaboration with the dialysis facility regarding care for one of one resident (R36) reviewed for dialysis on the sample list of 49. Findings Include: On 8/28/23 at 10:00 am, R36 stated R36 goes out to dialysis three times a week. R36's Care Plan dated 6/10/23 documents R36 receives hemodialysis related to ESRD (End Stage Renal Disease) and will at times refuse dialysis with interventions of assessing for fluid excess, monitoring/recording food/fluid intake and output, monitor weights daily and notify the physician and family of significant weight changes, report abnormal labs indicative of fluid volume excess, and educate on the risks of refusing dialysis. R36's medical record did not contain any dialysis communication forms. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications according to Physician's Orders and Manufacture's Recommendations for two of four residents (R4, R89) reviewed for medication administration on the sample list of 49. The facility had three errors out of 32 opportunities for a medication error rate of 9.38%. Findings Include: 1.) R89's August 2023 Physician Orders document orders for Levothyroxine {Thyroid Hormone} 200 mcg (Microgram) one tablet every morning, and Levothyroxine 25 mcg one tablet every morning to be taken with the 200 mcg for a total of 225 mcg every day, both to be given between 5:00 am - 10:00 am. On 8/29/23 at 8:25 AM, V7 RN (Registered Nurse) prepared all of R89's morning medications, including R89's ordered Levothyroxine, while R89 sat at the dining room table eating breakfast. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure medical records contained preadmission screenings for three of four residents (R97, R51, R80, R55) reviewed for preadmission screenings on the sample list of 49.

Inspectors wroteBased on observation, interview, and record review the facility failed to utilize Personal Protective Equipment (PPE) and implement infection control interventions for one (R90) of four residents reviewed for infections in a sample list of 49. Findings Include: R90's Face Sheet printed includes the following diagnoses: Chronic Systolic (Congestive) Heart failure, Cough, Essential (Primary) Hypertension, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Generalized Anxiety Disorder, Venous Insufficiency (Chronic) (Peripheral), and Lymphedema R90's progress note dated 08/26/2023 at 9:36 AM documents (R90), has productive cough, audible wheezing noted. (R90) taking Norco prn (as needed) for rib pain due to coughing. Hospice called and will be out later to see (R90). 08/26/2023 at 11:45AM documents (R90), had COVID test and was negative. [...]

Inspectors wroteBased on interview and record review the facility failed to follow antibiotic stewardship guidelines for one (R300) of four residents reviewed for infections in a sample list of 49. Findings Include: R300's hospital history and Physical dated 8/7/23 documents (R300) was admitted with diagnoses of Sepsis due to Urinary tract Infection, Right Hip Fracture, and Left ankle Fracture. R300's Face Sheet dated 8/18/23 (date of admission) also documents R300 has Metastatic Cancer and was admitted to the facility on hospice care. R300's progress Note dated 08/27/2023 at 7:59 AM documents (R300's) output from (Urinary Catheter) this AM was pink and thick. Called hospice to notify. Also reported edema in AL hand/forearm. Hospice will be calling back with any new orders. [...]