Mclean County Nursing Home

In the surveyor’s words

From the most serious findings on record at Mclean County Nursing Home, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 4, 2023

  Failures at this level required more than one deficient practice statement. A. Based on observation, interview and record review, the facility failed to complete a safe transfer from the wheelchair to the recliner by ensuring proper foot placement during the transfer for one of three residents (R1) reviewed for falls on the sample list of three. This failure resulted in R1's foot getting caught on an unidentified object during the transfer and sustaining a spiral fracture of the left tibia. B. […]

• Actual harm, isolatedF689Jan 26, 2022

  Based on observation, interview, and record review the facility failed to implement fall prevention interventions as outlined in residents' plans of care. This failure affects two residents (R1 and R3) of three reviewed for fall prevention in the sample of three. This failure resulted in R1 experiencing a fall with pubic bone fractures and R3 experiencing a fall with a laceration requiring sutures in the forehead. Findings include: 1.) R1's Face Sheet dated 1/25/22 documents R1 was admitted to the facility 12/15/21 with medical diagnoses including [CONDITION(S)], Convulsions/ Seizures, Dementia with Behavior Disturbance, Repeated Falls, [CONDITION(S)], and Urge Incontinence. […]

• No harm, potential for more than minimal, widespreadF812Aug 14, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF801Aug 30, 2023

  Based 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. Findings include: The facility resident census and condition report dated 8/29/23 documents 103 residents in the facility. On 8/28/23 at 9:20 AM, V5 Dietary Manager attempted to test the low temperature dishwasher with high temperature heat strip. When this did not change for heat, V5 Dietary Manager stated that he did not realize that he needed to test the machine with a chlorine strip, but that his staff know how to test the machine. On 8/29/23 at 11:40 AM, residents were observed being served lunch at the same tables, at different times, leaving some to wait and watch others eat for long periods of time. […]

• No harm, potential for more than minimal, widespreadF812Apr 8, 2021

  Based on record review, observation and interview the facility failed to prevent the potential for food borne illness by failing to properly label opened package of deli meat and storing unwholesome foods in walk in cooler. These failures have the potential to affect all 60 residents in the facility. Findings include: 1.) On 4/6/21 at 9:15 AM a large open topped cardboard box filled with raw whole sweet potatoes was sitting on the bottom shelf of the walk in cooler. The top layer of sweet potatoes had numerous dime and nickel sized areas of green and white fuzzy substance that appeared to be mold. […]