Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Care Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities, including CHF, ESRD on dialysis, mild dementia, and atrial fibrillation, was transported in a facility van while seated in a removable high-back chair that had been recently repositioned and installed on floor rails. The activities director noticed one front leg of the chair did not appear properly on the track and told the transport aide (TA) to reattach it; after reattachment, both believed the chair felt sturdy. The TA, who had been trained on wheelchair tie-downs but not on installing or securing removable seats, had installed this extra seat herself. During a low-speed left turn from a stop sign, the chair tipped sideways, and the belted resident fell against the van door, reporting right shoulder pain. An initial x-ray was negative, but a later CT scan showed an acute, mildly comminuted distal clavicle fracture and a right 2nd rib fracture. Facility investigation found the seat’s safety bar had not fully engaged in the floor track and that the latch handle and red securing pin were difficult to manipulate, leading to the seat not being properly secured and resulting in the in-van fall and injuries.
The facility failed to store and manage food items according to professional standards, with expired and improperly stored items found in the kitchen. Expired LaChoy Chow Mein Noodles, Progresso Soup, and lime juice were discovered in the pantry, while the freezer and refrigerator contained unlabeled and expired items. The Dietary Manager acknowledged the risks of serving expired food, and the facility's policies were not followed, resulting in this deficiency.
Improperly Secured Van Seat Causes Resident Injury During Transport
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s environment remained as free from accident hazards as possible and to provide adequate supervision and assistance to prevent accidents during van transport. A male resident with multiple serious medical diagnoses, including CHF, mild dementia, ESRD requiring dialysis, atrial fibrillation, prior cerebral infarction, hypertension, and severe protein-calorie malnutrition, was being transported by a transport aide (TA) to a dialysis center. The resident, who was ambulatory with a walker and had moderate cognitive impairment (BIMS 10/15), was seated in a high-back chair in the facility van rather than in a wheelchair. The chair had been added to the van to accommodate additional riders and was attached to floor rails intended to secure it in place. On the day of the incident, the activities director (AD) accompanied the TA and observed that one of the front legs of the added chair did not appear to be on the track properly. The AD told the TA that the chair was not right and instructed her to check it; the TA then reattached the chair to the floor railing. The AD reported that she checked the chair again before the resident sat in it and believed it was sturdy and solid. The TA stated she had been trained on wheelchair security in the van but had not been trained on how to install and secure the removable seats, and that this was the only time she had ever put a seat in the van. Despite this, she installed the seat that morning and used it for the resident’s transport. While the van was in traffic at a stop sign in a local community, the TA made a low-speed left turn. At that point, the chair tipped sideways, and the resident, who was belted into the chair, fell over and struck the van door with his right shoulder and side. The TA and AD heard a thud and found the resident leaning over while still strapped to the tipped chair. The TA pulled the van over, assisted the resident up, and transferred him to a different chair. The resident reported right shoulder pain but initially had no visible injuries and could move his shoulder. A same-day x-ray of the right shoulder was read as negative for fracture; however, a later CT scan of the right upper extremity showed an acute, mildly comminuted and minimally displaced fracture of the right distal clavicle and an acute, nondisplaced right anterior 2nd rib fracture. The incident was determined to have resulted from the van seat not being properly secured to the floor track, with subsequent inspection revealing that the safety bar had not fully engaged or seated properly within the groove intended to prevent the latch from loosening and that the handle was difficult to manipulate into the fully secured position. Additional documentation and interviews showed that the facility had a Daily Vehicle Pre-Trip/Post-Trip Inspection Checklist, which on the day of the incident noted only windshield chips and did not identify any issues with seats or restraints. The Weekly Vehicle Inspection Report included checks of seats, seat belts, and wheelchair tie-downs, and the Employee Auto Training Handbook required drivers to ensure the vehicle was in safe operating condition and to correct any unsafe conditions before use. However, the TA reported she was not trained on installing or securing the removable seats, and the Administrator later stated that the TA should not have been responsible for putting seats in or out of the van, indicating that this task should have been assigned to maintenance staff. The combination of an improperly secured removable seat, incomplete staff training on seat installation, and reliance on a pre-trip inspection that did not detect the hazard led directly to the resident’s fall inside the van and subsequent fractures. The resident’s account during interviews was consistent with the documented events: he stated that the seat in the van was not latched well, that when the driver turned, the chair tipped, and he fell against the van door, injuring his shoulder and hitting his head. He reported ongoing shoulder pain until the CT scan identified the fractures. Dialysis center documentation confirmed that on arrival he complained of right shoulder pain from a fall in the van, had no swelling noted, and received PRN acetaminophen. The facility’s own investigation concluded that the incident occurred when the van seat/chair tipped sideways during a low-speed left turn from a stop sign, causing the resident to strike the van door, and that the safety bar on the seat had not fully engaged in the floor track, allowing the latch mechanism to loosen and the seat to tip during normal vehicle operation. The facility’s investigation also identified that the van seat had been repositioned over the weekend to accommodate additional residents for a community parade, and that the latch hardware on the seats was stiff, requiring lubrication. The Maintenance Supervisor and Administrator later found that the red pin at the bottom of the chair was hard to push down to properly secure the chair, and that the handle was difficult to manipulate into the fully locked position. Despite these mechanical issues and the lack of specific training for the TA on seat installation, the seat was used for resident transport. This sequence of events—repositioning and reinstalling a removable seat with a stiff and difficult-to-secure latch, incomplete staff training on seat installation, failure to detect the improperly engaged safety bar before transport, and subsequent tipping of the seat during a routine turn—constituted the failure to maintain a hazard-free transport environment and to provide adequate supervision and assistance to prevent the resident’s accident and injuries.
Improper Food Storage and Expired Items Found in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food safety, as evidenced by the improper storage, preparation, and distribution of food items in the kitchen. During an inspection, several expired food items were found in the dry pantry, including cans of LaChoy Chow Mein Noodles, Progresso Chicken and Sausage Gumbo Soup, and bottles of lime juice that were not refrigerated as required. Additionally, there were items with no received date, such as a bag of Honey Nut Cereal Rounds and loaves of white bread, which had surpassed their best by dates. In the freezer, a partial bag of frozen fruit was left open to air, and a bag of tortilla quarters lacked labeling and dating. The refrigerator contained eggs without a received or use by date and a bottle of brown mustard past its expiration date. The Dietary Manager acknowledged the potential negative outcomes of serving expired food, including sickness, medication interactions, and food aversions. The facility's policies from 2012 on Sanitation and Food Handling, as well as Food Safety, were reviewed and found to require that all unused food be securely covered, labeled, and dated, with stock rotated on a first in, first out basis. The policies also specified that potentially hazardous foods should not be kept past their expiration dates. Despite these policies, the facility did not comply, leading to the deficiency noted in the report.
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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 Mclean
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wheeler Nursing & Rehabilitation | 22.7 mi | ★★★★★ | 6 | 0 |
| Clarendon Nursing Home | 26.6 mi | ★★★★★ | 5 | 0 |
| Avir At Pampa | 30.2 mi | ★★★★★ | 12 | 0 |
| Pampa Nursing Center | 30.2 mi | ★★★★★ | 1 | 0 |
| Wellington Care Center | 34.5 mi | ★★★★★ | 9 | 1 |
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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.