Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Mclean Health Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment, an indwelling urinary catheter, and a sacral wound experienced multiple medication changes, including several new Acetaminophen pain regimens and later antibiotic and probiotic therapy following an episode of altered level of consciousness. Although the facility’s policy required notifying and documenting contact with the resident’s responsible party for changes in condition and new MD/APRN orders, the clinical record contained no documentation that the responsible parties were notified of medication changes on several distinct occasions. The DNS acknowledged that responsible parties should have been notified and that nurses were expected to document such notifications, but could not produce evidence that this occurred.
A resident dependent on staff for transfers and diagnosed with hemiplegia was transferred using a mechanical lift without all required sling straps secured, as staff were unable to attach the fourth strap due to the resident's pain and possible sling size mismatch. The transfer was attempted with only three straps, and while maneuvering the lift over an obstruction, the resident slid out of the sling and fell, resulting in spinal fractures. Facility policy requiring all straps to be secured and the area cleared was not followed.
A resident who was dependent for transfers and required a mechanical lift with two staff suffered serious injuries after being transferred by two nurse aides, one of whom was an agency hire not skill checked or educated on the facility's lift procedures. Only three of four sling straps were secured, and the resident fell when the lift encountered an obstruction, resulting in spinal fractures. The facility did not enforce its policy requiring staff education and competency assessment for mechanical transfers for agency staff.
Failure to Notify Responsible Party of Multiple Medication Changes
Penalty
Summary
The deficiency involves the facility’s failure to timely notify the resident’s responsible parties of multiple medication changes following a loss of decisional capacity. The resident had diagnoses including pneumonitis, neuropathic bladder, and cognitive communication disorder, with an admission MDS showing a BIMS score of 9/15, indicating moderate cognitive impairment, dependence in ADLs, and an indwelling urinary catheter. The resident was initially self-responsible until 12/20/2025, after which two responsible parties were designated. The facility’s Change of Resident’s Condition policy required staff to notify the physician and family/representative of changes in condition and to clearly document the date, time, and persons notified in the nurse’s notes. On multiple occasions in January 2026, the APRN and physician ordered new or revised medications for the resident, but the clinical record did not show that the responsible parties were notified. On 1/2/2026, the APRN assessed the resident for a sore throat and ordered Acetaminophen 325 mg, two tablets twice daily until 1/5/2026; there was no documentation that the responsible party was informed of this medication change. On 1/7/2026, after a follow-up visit for a non-improving sacral wound and pain, the APRN ordered Acetaminophen 500 mg, two tablets every eight hours for pain, again without documented notification to the responsible party. The APRN note that day also referenced the responsible party calling nursing to request pain medication prior to wound treatment, but there was still no record of notification regarding the new Acetaminophen order. Further medication changes occurred later in the month without documented responsible party notification. On 1/12/2026, an APRN order directed Acetaminophen 325 mg, three tablets every eight hours for pain management, but the record did not show that the responsible party was notified of this new regimen, despite a nursing note documenting a family communication about labs and a catheter change. On 1/22/2026, after a nursing note described a new onset change in level of consciousness and brief non-responsiveness, the APRN was notified and physician orders were obtained for a urinalysis with culture, Doxycycline Hyclate 100 mg twice daily for seven days, and Acidophilus two capsules three times daily for seven days. Record review again failed to identify documentation that the responsible party was notified of these new antibiotic and probiotic orders. During interview, the DNS confirmed that responsible parties should be notified of new physician orders and that nurses on each shift were expected to notify and document, but could not provide documentation that this occurred for the medication changes on 1/2, 1/7, 1/12, and 1/22/2026.
Failure to Safely Transfer Resident Using Mechanical Lift
Penalty
Summary
A deficiency occurred when staff failed to safely transfer a resident with hemiplegia and hemiparesis using a mechanical lift, as required by the resident's care plan and facility policy. The resident, who was cognitively intact but dependent for transfers, was to be transferred with a Maxi Lift (Hoyer lift) using an extra-large blue sling and the assistance of two staff members. During a transfer, staff were unable to secure all four sling straps due to the resident's complaints of pain and suspected the sling might be the wrong size. Despite this, the transfer was attempted with only three straps secured, with one staff member manually supporting the unsupported limb. While the resident was suspended over the bed, the lift's wheel became obstructed by a cord on the floor. Staff attempted to push the lift over the cord, resulting in the resident sliding out of the sling and falling to the floor. The incident led to the resident sustaining fractures to the C6 and C7 spinous processes, as confirmed by a hospitalization summary. Facility policy and the Director of Nursing Services specified that all four straps must be secured and the area cleared prior to transfer, but these procedures were not followed during the incident.
Failure to Ensure Competency of Agency Staff in Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure that new staff, specifically agency nurse aides, were competent to properly and safely administer mechanical lift transfers for a resident with significant mobility and cognitive needs. The resident, who was dependent for transfers and required the use of a mechanical lift with two staff and a specific sling, was transferred by two nurse aides—one of whom was an agency hire on their first day at the facility and had not been skill checked or educated on the facility's mechanical lift procedures. During the transfer, only three out of four sling straps were secured, and when the lift encountered an obstruction, the resident slid out of the sling and fell, resulting in serious injury including fractures to the C6 and C7 spinous processes. Interviews and documentation confirmed that the agency nurse aide had not received facility-specific training or competency assessment for mechanical transfers prior to participating in the transfer. The facility's policy required staff to be educated on safe handling and transfer practices upon hire, but this was not enforced for agency staff, as the expectation was that they were already trained. The incident was witnessed by both aides involved, and the lack of proper skill verification and adherence to transfer protocols directly contributed to the resident's fall and subsequent injuries.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 701 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Simsbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ark Healthcare & Rehabilitation At Governors House | 1.1 mi | ★★★★★ | 13 | 0 |
| Caleb Hitchcock Health Center | 5.2 mi | ★★★★★ | 11 | 0 |
| Civita Care Meadowbrook | 5.8 mi | ★★★★★ | 15 | 0 |
| Cherry Brook Health Care Center | 6.2 mi | ★★★★★ | 5 | 0 |
| Seabury | 7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Mclean Health Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.