Mclean Health Center

In the surveyor’s words

From the most serious findings on record at Mclean Health Center, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 20, 2025

  Based on review of clinical records, interviews, and review of facility documentation and policy for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to ensure a resident was safely transferred using a mechanical lift. The findings included:Resident #1 was admitted to the facility March 2021 with diagnoses of hemiplegia and hemiparesis, major depressive disorder, and anxiety disorder. Review of the Comprehensive Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) score of fifteen (15) and indicated Resident #1 was cognitively intact. […]

• No harm, potential for more than minimal, widespreadF812Sep 15, 2023

  Based on tour of the Dietary Department and staff interview, the facility failed to ensure stored food included an expiration date, was dated when opened and failed to ensure refuse was covered near food items. The findings include: Tour of the Dietary Department on 9/11/23 at 11:30 AM with the Director of Dining Services identified the following in the HC-HC Reach in Refrigerator: a. a 1 gallon container that was 1/3 full of Vinaigrette dressing was dated as opened 8/18/23, but the container or labeling failed to include an expiration date. b. a 1 gallon container that was 3/4 full of Italian dressing was dated as opened on 9/6/23 but failed to identify an expiration date either on the container or labeling. c. […]

• No harm, potential for more than minimal, isolatedF580Jul 7, 2026

  Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for medication errors, the facility failed to ensure the resident and physician/APRN were notified timely when a medication was not administered in accordance with physician orders. The findings include: Resident #1's diagnoses included depressive episodes and anxiety disorder. The Resident Care Plan (RCP) dated 4/8/2026 identified Resident #1 had anxiety and insomnia. Interventions directed to administer antianxiety medications as ordered by the physician, and maintain consistent schedule with daily routine. The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 was alert and oriented. […]

• No harm, potential for more than minimal, isolatedF755Jul 7, 2026

  Based on clinical record review, facility documentation review, facility policy review and interviews for one of three residents (Resident #1) reviewed for medication errors, the facility failed to ensure medications were administered in accordance with physician orders. The findings include: Resident #1's diagnoses included depressive episodes and anxiety disorder. The Resident Care Plan (RCP) dated [DATE] identified Resident #1 had anxiety and insomnia. Interventions directed to administer antianxiety medications as ordered by the physician, and maintain consistent schedule with daily routine. The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 was alert and oriented. […]

• No harm, potential for more than minimal, isolatedF580Mar 16, 2026

  Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for change in condition, the facility failed to ensure responsible party was notified timely of medication changes. The findings included: Resident #1's diagnoses included pneumonitis, neuropathic bladder and cognitive communication disorder. Record review identified Resident #1 was self-responsible until 12/20/2025, and Resident #1 had two (2) designated Responsible Parties. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of nine out of fifteen, indicative of moderate cognitive impairment, was dependent with ADLs, and had indwelling urinary catheter. […]