McLean Care Center

-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. -The facility failed to have an open date on Resident #9's Trelegy inhaler. -The facility failed to discard 1 bottle of Zyrtec with no expiration date on bottle. -The facility failed to store medications appropriately, 7 loose pills were…

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 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. 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 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.

CNA 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. Findings include: During an observation on 07/08/25 at 10:17 AM CNA B and CNA C performed incontinent care for Resident #10. Neither CNA provided privacy for Resident #10. Door and curtain were never closed or pulled at any time during resident care. During an interview on 07/09/25 at 11:08 AM CNA B stated the negative outcome would be that the resident would feel embarrassed, and they do not have privacy. During an interview on 07/09/25 at 11:11 AM CNA C stated the negative…

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 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.Findings Included:Record review of Resident #15's admission record dated 07/08/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited…

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.

-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. These deficient practices could place residents at an increased risk for potentially exposing them to bacterial or viral infections that could lead to the spread of communicable diseases. Findings…

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 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. Findings included: On 6/11/24 beginning at 9:31AM an initial observation of the kitchen was conducted. An observation of the dry panty revealed: (3) 5-ounce cans LaChoy Chow Mein Noodles with expiration date 3/23/24. (1) 5-ounce can LaChoy Chow Mein Noodles with expiration date 12/2/23. (4) 3-ounce cans LaChoy Asian-style Crunchy Noodles with expiration date 12/18/23. (1) 19-ounce can Progresso Chicken and Sausage Gumbo Soup with expiration date 3/23/24. (2) partial 15-ounce bottles of Lime Juice with exp. date of 11/16/23. Refrigerate after opening stamped on both bottles by manufacturer. Both were in dry pantry. (1) 2-pound bag Honey Nut Cereal Rounds-no…

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 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]. Resident #1's diagnoses included but are not limited to Systemic Lupus (autoimmune disease), Rheumatoid Arthritis (chronic inflammatory disorder that can affect more than just your joints), and Diabetes Mellitus (body has high sugar levels for prolonged periods of time) with unspecified complications.…

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.

The 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. Findings included: An observation on 10/31/23 at 11:12 AM revealed a resident sitting in Contact Isolation Room on C Hall that had transmission base precautions posted on door for contact precautions. A plastic, 3 drawer container was beside the door with PPE in each drawer. An observation and interview on 10/31/23 at 2:44 PM showed HK A was cleaning the room with contact precautions sign on the door. HK A did not don PPE while in room with transmission-based precautions posted. HK A indicated that housekeeping was to wear PPE when…

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 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. Findings include: Record Review of Resident #1's facility clinical record revealed: Resident #1 was a [AGE] year-old female with an admission date of 8/16/23. She was admitted to the facility for rehabilitation services after a diagnosis of pneumonia in the community. Resident #1 had diagnoses of pneumonia, unspecified protein calorie malnutrition, chronic pain, unsteadiness on feet, muscle wasting, major depression, single episode. Resident #1…

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 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. Findings included: Observation of the upright refrigerator on 05/08/23 at 09:57 AM revealed the following: -a white plastic tub of chicken base with no date -a resealable plastic bag of what appeared to be slices of ham dated 04/28/23 -a bag of celery with no date -a resealable plastic bag of what appeared to be tortillas dated 02/16/23 -a resealable plastic bag of what appeared to be half a green pepper dated 03/28/23 -mango slices in rectangular plastic package with a use by…

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 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. The facility's failure to ensure the accuracy of a residents advanced directive such as a DNR (Do Not Resuscitate), recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care could place residents a risk for not receiving healthcare as per their or their legal representatives wishes. Findings include: Resident #4 Record review of the face sheet dated 5-9-2023 in the clinical record for Resident…

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 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). Findings included: Record review of Resident #16's face sheet, dated 05/09/23 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, chronic obstructive…

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.