Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mcclure Post Acute during CMS and state inspections, most recent first.
The facility failed to transmit MDS assessments for four sampled residents within the required 14-day timeframe. The MDSRN confirmed the assessments were held so they could be sent in a batch with other residents' MDSs, and the DON acknowledged the facility was responsible for timely submission. The MDS Final Validation Report showed the assessments were submitted late and marked as "Record Submitted Late."
Late Quarterly MDS Assessments: The facility failed to complete required MDS assessments within CMS timeframes for two residents. One resident with schizophrenia had a quarterly MDS completed 23 days after the ARD, and another resident with anxiety and HTN had the next MDS completed 94 days after the prior assessment. The MDS RN and DON confirmed the assessments were late under the RAI Manual requirements.
Failure to Provide Ordered 1:1 Dining Supervision: A resident with a stroke, dysphagia, and a history of pocketing food was observed in bed with breakfast cereal and a full drink left at the bedside while sleeping. The LVN and CNA confirmed the resident required 1:1 supervision during meals, but the CNA left the food and drink in the room for the resident to finish alone while she attended to other residents. Records showed physician orders for 1:1 eating/assistance and SLP notes for frequent swallowing cues and monitoring for choking.
Staff were not adequately trained or competent in monitoring and documenting a resident’s self-administered albuterol inhaler kept at bedside. The resident, who had acute and chronic respiratory failure with hypoxia, said he kept the inhaler in a locked box, used it as needed, and recorded use on paper, but staff did not ask him to report each use. Two LVNs were unsure of the process, and the DON said staff had not been educated on how to monitor or document bedside self-administered meds on the MAR.
A resident with acute and chronic respiratory failure with hypoxia had an albuterol sulfate inhaler left on his tray table/bedside instead of being secured. The resident said it was kept there because it was annoying to keep asking for his puffer, and an LVN and the DON both confirmed the inhaler should not have been left unsecured. The facility policy stated drugs and biologicals must be stored in locked compartments.
Surveyors found that the facility failed to provide timely written discharge notices, including appeal rights and bed-hold information, to two residents. One cognitively intact resident with vertigo, CKD, muscle weakness, gait difficulty, and cognitive symptoms received a Notice of Proposed Transfer/Discharge on the same day progress notes and the discharge summary showed the resident left the facility. Another resident with necrosis of the femur, depression, toe cellulitis, and mild cognitive impairment also received a proposed transfer/discharge notice on the same day the SSN documented discharge. The SSD reported that residents are routinely given the Notice of Proposed Transfer/Discharge only on the actual day of discharge and acknowledged there was no established policy or procedure for providing a 30-day discharge notice.
Two residents experienced incomplete and inaccurate clinical documentation when one resident with multiple medical conditions eloped without staff knowledge and was later documented as having left AMA without the required AMA documentation, and the same resident’s request for a room change and the facility’s response were not recorded. Another resident’s record lacked documentation of communication between the SSD and an external case manager regarding discharge planning to an independent living facility, despite the resident being discharged there and both parties reporting prior verbal contact about the placement.
A resident who was cognitively able to communicate and whose assessment documented that private phone use was very important to her was routinely required to use a corded phone at the nurse’s station, an area with constant staff presence, for personal calls. Staff reported that residents without personal cell phones received calls at the front desk or nurse’s station, and one CNA stated she remained with the resident during a phone call. The resident reported that staff overheard and repeated her phone conversations, and an LVN and OT acknowledged that the resident was not afforded privacy during calls. The facility’s own resident rights policy states that residents have the right to use a telephone in privacy.
Two residents were discharged to an ILF without complete discharge planning and documentation. One resident with cognitive and renal conditions was released without assistance in obtaining a needed government ID and bank card, and without documented establishment of a PCP or pharmacy, despite physician orders for home health and follow-up care; the discharge paperwork given to the resident had blank fields for PCP and pharmacy information. Another resident with multiple chronic conditions was discharged with a summary that omitted the discharge location and transportation method, and the post-discharge care instructions also lacked PCP and pharmacy details. In both cases, the facility’s own policy requiring assistance in securing a PCP and documenting those efforts was not followed, and discharge planning was either incomplete or only documented on the day of discharge.
The facility failed to store and prepare food safely, with unlabeled, undated, and expired items found in refrigerators, and a staff member not wearing a beard restraint while preparing food. These actions risked food contamination and illness for 55 residents.
A resident with protein-calorie malnutrition and depression was not provided with an additional large portion of vegetables as per their dietary preferences, leading to feelings of upset and disrespect. The Registered Dietician confirmed the oversight, which was contrary to the facility's policies on food preferences and resident rights.
A resident with Crohn's Disease experienced a decline in health due to the nursing staff's failure to notify the physician of low food intake, pain, and low blood pressure. The resident was at high risk for malnutrition and was found unresponsive with low blood sugar, leading to hospitalization and eventual death. The DON confirmed the lack of documentation and communication with the doctor.
A resident with a cataract diagnosis did not receive assistance from the facility in arranging a cataract evaluation, despite recommendations from the facility's ophthalmologist. The resident, who valued reading and staying informed, experienced blurry vision and had been assured by the Social Services Director that a surgeon would be found, but no follow-up occurred. The facility's policy required eye care services to be provided based on clinical need, but the recommendation for a specialist referral was overlooked.
A resident with a traumatic amputation and osteomyelitis experienced severe pain, but the facility administered medication intended for moderate pain. Despite the resident's reports of severe pain, the staff did not obtain a physician's order for appropriate medication, and the existing policy on pain management was not followed.
The facility was found to have a room occupied by five residents, exceeding the federal regulation limit of four residents per room. This was observed during a survey and confirmed by the facility's daily census, potentially affecting the residents' care, comfort, and privacy.
A resident with a stage 4 pressure ulcer did not have complete medical records due to missing entries in the Treatment Administration Record (TAR) for several dates. The treatment nurse admitted to forgetting to document the wound care provided. The facility's policy requires detailed documentation of wound care, which was not followed, potentially leading to uncoordinated care.
A resident with a femoral shaft fracture and mildly impaired cognition alleged that a CNA pushed and slapped their arm during a linen change. Despite the report to an LVN and a call to the police, the CNA continued to work with other patients. The facility's policy requiring accused employees to be placed on leave was not followed, leading to a deficiency.
Late MDS Submission for Four Residents
Penalty
Summary
The facility failed to ensure MDS assessments were transmitted within the required 14-day timeframe for four of 19 sampled residents: Residents 12, 29, 46, and 64. The MDS completion dates for these residents were 3/13/26 for Residents 12, 29, and 64, and 3/12/26 for Resident 46, but the assessments were not submitted until 4/1/26. The MDS Final Validation Report showed each of these assessments was submitted late and returned a message of "Record Submitted Late." During interview and record review, the MDSRN stated the facility followed the RAI and confirmed that Residents 12, 29, and 64 should have been submitted by 3/27/26 and Resident 46 by 3/26/26. The MDSRN stated the facility waited to submit these assessments so they could be transmitted in a batch with other residents' MDS assessments on 4/1/26. The DON confirmed the facility was responsible for ensuring MDS assessments were submitted within 14 days of completion, and the RAI Manual dated October 2025 stated MDS assessments must be submitted within 14 days of the MDS Completion Date.
Late Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure that Quarterly MDS assessments were completed within the required timeframes for two sampled residents. Resident 40 had diagnoses including schizophrenia. During interview and record review, the MDS RN stated the resident’s most recent MDS had an ARD of 2/23/26 but was completed on 4/1/26, which was 23 days late. The MDS Final Validation Report identified the assessment as late because the completion date was more than 14 days after the ARD, and the DON confirmed the facility was responsible for ensuring the completion date was within 14 days after the ARD. Resident 46 had diagnoses including anxiety and hypertension. The MDS RN stated the resident’s admission MDS was completed on 12/1/25 and the next MDS was not done until 3/5/26, which was late. The clinical record showed the admission MDS had an ARD of 12/1/25 and the following MDS had an ARD of 3/5/26, making it 94 days after the prior assessment. The MDS Final Validation Report identified the assessment as completed late, and the DON confirmed the facility was responsible for ensuring the next MDS was completed within 92 days after the previous assessment.
Failure to Provide Ordered 1:1 Dining Supervision
Penalty
Summary
The facility failed to ensure supervision was provided during dining per physician’s orders for Resident 23, a resident with a stroke, difficulty swallowing and speaking, and a history of pocketing food. During observation, Resident 23 was found in bed with a bowl of cooked breakfast cereal and a full glass of red liquid on the bedside table while she was sleeping, with her fingers in the cereal. LVN 1 confirmed the resident required direct one-on-one supervision during dining because of the recent stroke, history of pocketing food, and swallowing difficulty. CNA 1 also confirmed the resident needed one-on-one supervision during meals and stated she had removed the tray after the resident ate some breakfast but left the uneaten cereal and juice in the room for the resident to finish alone while she picked up other residents’ trays. Record review showed physician orders for one-to-one eating and one-to-one assistance when eating, and speech therapy documentation noted the resident needed cues to double swallow, frequent cues to swallow, and not hold food in her mouth. The speech language pathologist verified the resident had a history of choking on 3/8/26 and stated food should not have been left in the resident’s room unobserved. The care plan identified coughing while eating and the need for assistance while eating, and the facility’s meal assistance policy stated residents shall receive assistance with meals in a manner that meets their individual needs.
Staff Unaware of Self-Administered Medication Monitoring Process
Penalty
Summary
The facility failed to ensure nursing staff were adequately trained and competent in the management of self-administered medications kept at bedside for one resident with acute and chronic respiratory failure with hypoxia. During observation and interview, the resident stated he kept his albuterol sulfate inhaler in a locked box in his room, self-administered it as needed, and last used it on 4/7/26 at 7:00 p.m., recording it on paper. The resident also stated staff did not ask him to notify them when he self-administered the medication. Interviews with two LVNs showed they were unsure how staff would know when the resident self-administered the inhaler or what the process was for bedside self-administered medications. The DON stated the facility had not provided education and training to nursing staff regarding monitoring and documentation of self-administered medications kept at bedside. The DON further stated staff were expected to ask the resident at the end of each shift how many times the medication was self-administered and when it was given, then document that information on the MAR. Review of the MAR showed no albuterol administration on 4/7/26, and the last documented administration was 3/22/26 at 2:47 p.m. The facility policy stated nursing staff review the self-administered medication record each shift and transfer pertinent information to the MAR, noting the doses were self-administered.
Unsecured inhaler left at bedside
Penalty
Summary
The facility failed to ensure medications were stored in a safe and secure manner for one of 19 sampled residents, Resident 76, when his albuterol sulfate inhaler was found lying on his tray table. Resident 76’s face sheet dated 4/9/26 showed diagnoses of acute and chronic respiratory failure with hypoxia. During a concurrent observation and interview on 4/6/26 at 4:33 p.m., the inhaler was observed on the resident’s tray table, and Resident 76 stated it had been kept at his bedside because it was annoying to keep asking the nurse when he needed his puffer. During a concurrent observation and interview later that day, LVN 2 confirmed the albuterol inhaler was left on the bedside table and stated medication should not be left unsecured at bedside. The DON also confirmed on 4/9/26 that the inhaler should not have been left unsecured at Resident 76’s bedside. The facility’s policy titled, Storage of Medications, dated November 2020, stated that all drugs and biologicals are to be stored in a safe, secure, and orderly manner in locked compartments.
Failure to Provide Timely Discharge Notices and Appeal Information
Penalty
Summary
The deficiency involves the facility’s failure to provide required discharge notices in a timely manner, including appeal rights and bed-hold information, for two residents. For one resident admitted with peripheral vertigo, chronic kidney disease, muscle weakness, difficulty walking, and cognitive symptoms, the Admission Record showed admission in November and an MDS dated late January documented a BIMS score of 15, indicating intact cognition. The Notice of Proposed Transfer/Discharge, also dated and signed in late January, included appeal rights and contact information, and stated that if the resident believed the proposed discharge was inappropriate, the resident had the right to appeal to the state long-term care agency. Progress notes and the Discharge Summary and Post-Care Instructions for that same date showed the resident was discharged that day, indicating the proposed discharge notice was given on the actual day of discharge rather than in advance. For a second resident admitted with necrosis of the right femur, depression, toe cellulitis, and mild cognitive impairment, the Notice of Proposed Transfer/Discharge was dated mid-February and indicated it was provided to the resident and signed by facility staff the following day. A Social Service Note dated mid-February documented that this resident was discharged that same following day, again showing that the proposed discharge notice was provided on the day of discharge. In an interview, the Social Services Director stated that residents receive several documents at discharge, including a Discharge Summary and Post-Care Instructions, Inventory of Personal Items, a medications list, and a Notice of Proposed Transfer/Discharge, and acknowledged that the notice provides the proposed discharge date but is only given on the actual day of discharge. The Social Services Director further stated that the 30-day discharge notice requirement is a recent development and that the facility does not yet have an established policy and procedure for it.
Incomplete and Inaccurate Clinical Documentation for Resident Elopement, Room Requests, and Discharge Planning
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for two residents in accordance with professional standards. For one resident with severe sepsis, pneumonia, anxiety disorder, depression, heart failure, and a BIMS score indicating moderate cognitive impairment, the resident left the facility without staff knowledge or permission. Nursing progress notes documented that the resident had left the facility and had not returned, and later that the resident returned from the hospital with a clavicle fracture, swollen eye, and arm sling. However, the event was documented as a departure Against Medical Advice (AMA) in an IDT note, even though staff were unaware of the resident’s departure at the time and there was no documentation of the required AMA elements such as the resident’s request to discontinue care, explanation of clinical risks, or the resident’s consent and post-discharge arrangements, as required by the facility’s AMA discharge policy. The same resident had also requested a room change due to a bathroom issue with a roommate. The case manager stated that the resident had complained about the bathroom issue and had been offered a room change, which the resident then declined. Despite this, there was no documentation in the clinical record of the resident’s request, the offer of a room change, or the resident’s decision, resulting in an incomplete record of the resident’s concerns and the facility’s response. For another resident admitted with peripheral vertigo, chronic kidney disease, muscle weakness, difficulty walking, and cognitive symptoms, the clinical record lacked documentation of communication between the Social Services Director and an external case manager regarding discharge planning to an independent living facility. The Social Services Director reported calling the case manager about finding an independent living facility but could not recall the exact date. The external case manager reported being informed that an independent living facility had been found and requested the name and address to arrange a tour, expecting the information via text message, but later learned the resident had already been discharged that afternoon. The resident’s discharge summary documented discharge to an independent living facility, but the clinical record did not contain documentation of the communication and coordination between the facility and the external case manager related to this discharge.
Failure to Ensure Resident Privacy During Telephone Use
Penalty
Summary
The deficiency involves the facility’s failure to provide privacy for residents using the telephone, resulting in staff overhearing a resident’s personal phone conversations. Resident 1’s admission record showed she was admitted on the specified date, and her MDS dated 1/20/26 documented that she had clear speech, could make herself understood, could understand others, and that it was very important to her to be able to use a phone in private. Resident 1 reported that there was no privacy when she was on the phone, stating that staff or nurses would turn around and tell other nurses what she had just said, and that staff did not seem aware that she needed privacy during calls. Observation on 3/17/26 at 2:07 p.m. showed Resident 1 in her wheelchair in the hallway using a corded phone at the nurse’s station, with multiple staff present, including an LVN sitting at the nurse’s station and an OT standing behind her while she was on the phone. Interviews with staff confirmed that residents received phone calls at the front desk or nurse’s station, areas that always had staff present. CNA 1 stated that residents received calls at these locations and that she had assisted Resident 1 to the nurse’s station phone two days prior and remained with her the entire time. The Activity Director stated that at least four residents did not have personal cell phones and needed to use the facility phone, and that Resident 1 and another resident frequently used the nurse’s station phone. LVN 1 acknowledged that Resident 1 was not provided privacy during her phone conversations and stated she needed to be in a place where no one was around or have a wireless phone in her room. OT 1 stated residents had a right to privacy while using the phone and acknowledged that being in the area while Resident 1 made a personal call invaded her privacy. The ADON stated that if privacy is invaded during a phone call, any reasonable person would be upset. The facility’s Resident Rights policy, dated August 2009, stated that residents have the right to use a telephone in privacy and to exercise their rights and privileges to the fullest extent possible.
Failure to Complete and Implement Effective Discharge Planning for Two Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s discharge planning process for two residents who were discharged to an independent living facility (ILF). Resident 2, admitted with cognitive communication deficit, depression, and stage 3 chronic kidney disease, was discharged without assistance in obtaining a government ID and debit card that were known to be missing. The Social Services Director acknowledged that Resident 2 did not have these items and that she did not assist him in acquiring them before discharge, despite knowing he needed them to pay rent at the ILF. The Social Service Note documented that discharge instructions, including follow-up appointments and a medication plan, were reviewed, but there was no evidence that the facility ensured Resident 2 had the financial and identification resources necessary for his planned living arrangement. Record review for Resident 2 showed a physician’s order for home health services and a primary care physician appointment after discharge, but the Discharge Summary and Post-Care Instructions form had blank fields for the primary care physician’s name, appointment details, phone number, address, and pharmacy information. A copy of this incomplete document was given to the resident at discharge. The Independent Living Facility owner reported being unaware that Resident 2 lacked an ID or debit card and stated that the resident left the ILF and did not return. The home health RN reported that Resident 2 did not have a medication list at the ILF and that there was no established pharmacy or primary care physician. The case manager confirmed that the medical record lacked documentation of a pharmacy for medication pick-up, did not indicate that a primary care physician was established, and contained no discharge planning documentation until the day of discharge. For Resident 3, who had diagnoses including myopathy, COPD, epilepsy, anxiety disorder, and spinal stenosis, the discharge documentation was also incomplete. The Discharge Summary recorded the discharge date but did not include the discharge location or transportation method, although the Social Services Director later stated that the resident was discharged to an ILF. The Discharge Summary and Post-Care Instructions for Resident 3 similarly had incomplete information in the Post-Discharge Plan of Care Services, Referrals, and Equipment section, with blank fields for primary care physician name and appointment details, phone number, address, and pharmacy information, even though a copy was provided to the resident at discharge. Review of the facility’s policy on Discharge Summary and Plan showed that staff were required to assist in finding a primary care provider if the resident had none and to document their efforts, but the records for both residents lacked this documentation and complete discharge planning details.
Food Safety and Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food safety, as evidenced by several observations and interviews. Unlabeled and undated food items, including onions, peas, and turkey burgers, were found in the kitchen refrigerator, which could lead to the use of expired or spoiled food. Additionally, the resident refrigerator contained expired and moldy food items, such as milk, garlic, blueberries, and strawberries, which were not discarded as per the facility's policy. These practices pose a risk of food contamination and potential foodborne illness for the 55 residents who rely on the facility's food services. Furthermore, a staff member identified as CK 1 was observed preparing resident food without wearing a proper beard restraint, which is a violation of the facility's hygiene and sanitary practices policy. The Registered Dietician confirmed the importance of labeling, dating, and discarding expired or moldy food to prevent cross-contamination and foodborne illness. The facility's policies, including those on food receiving and storage, sanitation, and infection control, were not followed, contributing to the identified deficiencies.
Failure to Honor Resident's Dietary Preferences
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not providing nutrition in accordance with their preferences. Resident 42, who was admitted in December 2024 with a diagnosis of protein-calorie malnutrition and depression, was not given an additional large portion of vegetables as per their dietary preferences. This was observed on two separate occasions, where the resident expressed feeling upset and disrespected due to the staff's failure to follow their food preferences. The Registered Dietician confirmed that Resident 42 should have received an additional large portion of vegetables, as indicated on the lunch tray tickets for both days. The facility's policy and procedure on Resident Food Preferences, dated 2001, states that individual food preferences should be assessed upon admission and communicated to the interdisciplinary team. Additionally, the facility's policy on Resident Rights guarantees the right to self-determination, which was not upheld in this instance.
Failure to Notify Physician of Resident's Decline
Penalty
Summary
Licensed nursing staff failed to notify the doctor of significant changes in condition for Resident 49, who was admitted with Crohn's Disease. The staff did not report continued low food intake, pain, and low blood pressures, which are critical indicators of the resident's declining health. The Director of Nursing (DON) confirmed that there was no documentation showing that the doctor had been notified about these issues, despite the expectation that staff should monitor and report such changes. Resident 49's clinical records showed a high risk for malnutrition, with food intake percentages ranging from zero to 26% over several meals. Additionally, the resident was reported to be in pain and experiencing changes in mental status, yet there was no documentation that these concerns were communicated to the doctor. The DON acknowledged that staff should have been monitoring the resident's blood sugar levels due to the risk of hypoglycemia from low food intake. The situation escalated when Resident 49 was found unresponsive with a low blood sugar level and was subsequently sent to the hospital emergency department. The resident was diagnosed with septic shock and a gastrointestinal bleed, conditions that were not addressed in a timely manner due to the lack of communication with the physician. The resident ultimately went into cardiac arrest and died. Interviews with medical staff indicated that earlier intervention, such as a feeding tube, might have been beneficial, but these measures were not taken due to the failure in communication and documentation.
Failure to Facilitate Cataract Evaluation for Resident
Penalty
Summary
The facility failed to assist a resident, identified as Resident 20, in making necessary appointments for a cataract evaluation, which was recommended by the facility's ophthalmologist. Resident 20, who was admitted to the facility in July 2021 with diagnoses including major depressive disorder and hypertension, had a Minimum Data Set (MDS) indicating intact cognitive status. The resident expressed the importance of having access to reading materials and keeping up with the news, which was hindered by her vision impairment. During an observation and interview, Resident 20 reported blurry vision while watching television and stated that she had been diagnosed with a cataract by an eye doctor the previous year. The Social Services Director (SSD) had informed her that the facility would arrange for a surgeon to perform the necessary surgery, but no follow-up had occurred. The SSD confirmed that Resident 20 was seen by the facility's ophthalmologist in December 2024, who recommended a referral to a specialist for cataract extraction. However, the SSD admitted to not seeing the recommendation for the referral and had not referred Resident 20 to an eye surgeon. The facility's policy on Eye Care Services indicated that eye care should be provided upon request, referral, or when a clinical need is identified, including follow-up care based on examination results. Despite this policy, the SSD only considered the six-month follow-up and did not act on the ophthalmologist's recommendation, resulting in a lack of necessary care for Resident 20's cataract condition.
Inadequate Pain Management for Resident with Severe Pain
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as Resident 24, who was admitted with a complete traumatic amputation and osteomyelitis. Despite having a cognitive status indicating intact mental faculties, Resident 24 reported experiencing severe pain, particularly headaches and pain in the amputated leg, with an intensity of 10 out of 10. However, the facility administered pain medication intended for moderate pain, not severe pain, on multiple occasions across January, February, and March 2025. The Medication Administration Records (MARs) showed that the resident was consistently given oxycodone-acetaminophen for moderate pain, despite documentation of severe pain levels. The Director of Nursing (DON) acknowledged that there was no physician's order for medication to address severe pain and that the licensed staff should have contacted the physician to request appropriate medication. The Consultant Pharmacist's Medication Regimen Review also noted that the medication was administered outside of the prescribed parameters, recommending a review and reinforcement of proper procedures. The Assistant Director of Nursing (ADON) provided in-service education to the staff but did not contact the physician to adjust the medication regimen. The facility's policy on pain management emphasized interventions consistent with the resident's treatment goals and the severity of pain, which were not adhered to in this case.
Resident Room Over-Occupancy
Penalty
Summary
The facility failed to comply with federal regulations by allowing a resident room to be occupied by more than the maximum of four residents. During an observation on March 11, 2025, it was noted that room [ROOM NUMBER] was occupied by five residents. This was corroborated by a review of the Facility's Daily Census dated March 10, 2025, which also indicated that the room was occupied by five residents. This failure to adhere to the regulation potentially compromised the provision of adequate nursing care, comfort, and privacy for the residents, as well as sufficient space for the storage of their belongings.
Incomplete Medical Records for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to maintain complete medical records for a resident, identified as Resident 1, who was admitted with multiple diagnoses including malnutrition, kidney cancer, anemia, and diabetes mellitus. The resident also had a stage 4 pressure ulcer on the sacrum, requiring daily wound care treatment as per the care plan. However, the Treatment Administration Record (TAR) for October 2024 was missing entries for several dates, indicating that the nursing staff did not document the wound care treatments provided on those days. During an interview, the treatment nurse responsible for the missing entries admitted to forgetting to record the date, time, and her initials after administering the treatment. The facility's policy and procedure for wound care and documentation require detailed recording of the care provided, including the type of wound care, date and time, and the name and title of the individual performing the care. The lack of documentation in the TAR had the potential to result in uncoordinated care and unnecessary, painful duplicate wound care for the resident.
Failure to Follow Abuse Policy After Allegation
Penalty
Summary
The facility failed to adhere to its abuse policy and procedure, resulting in a deficiency when a Certified Nursing Assistant (CNA) was allowed to continue providing direct patient care after an abuse allegation was made by a resident. The incident involved a resident with a diagnosis of a femoral shaft fracture and mildly impaired cognition, who alleged that the CNA pushed and slapped their arm during a linen change. Despite the resident's report to a Licensed Vocational Nurse (LVN) and a call to the police, the CNA was only removed from caring for the resident but continued to work with other patients for the remainder of the shift. The Director of Nursing (DON) was informed of the incident and instructed the LVN to remove the CNA from the resident's care but allowed the CNA to continue working with other residents. The facility's policy, which mandates that any employee accused of resident abuse be placed on leave with no resident contact until the investigation is complete, was not followed. The investigation into the incident was completed three days later, and the report was faxed to the Department the following day.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Oakland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medical Hill Healthcare Center | 0 mi | ★★★★★ | 6 | 0 |
| Oakland Healthcare & Wellness Center | 0.5 mi | ★★★★★ | 12 | 0 |
| St Paul's Towers | 0.7 mi | ★★★★★ | 0 | 0 |
| The Rehabilitation Center Of Oakland | 0.8 mi | ★★★★★ | 2 | 0 |
| Lake Park Healthcare Center | 1 mi | ★★★★★ | 3 | 0 |
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