4 Reports
Inspection Report — Aug 14, 2025
Complaint Investigation CMS
Date: Aug 14, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide required documentation or notification related to a resident's bed-hold policy and transfer rights.
Complaint Details
The complaint was substantiated as the facility failed to provide written notification and documentation regarding bed hold and transfer rights for Resident 39.
Findings
The facility failed to provide a written bed hold policy and did not issue a written notification as soon as practicable for the transfer of Resident 39, placing the resident at risk for impaired rights related to returning to the facility.
Deficiencies (1)
F 0628: The facility failed to provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Resident 39 was transferred to the hospital without a completed bed hold form or written notification to the resident or representative.
Report Facts
Residents present: 32
Residents in sample: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse (LN) H | Reported on bed hold form completion practices | |
| Social Service Designee (SSD) X | Reported on bed hold form completion by Business Office Manager | |
| Administrative Staff B, Business Office Manager (BOM) | Reported on verbal bed hold practices and lack of completed bed hold for Resident 39 | |
| Administrative Staff A | Reported expectations for bed hold completion and communication practices |
Inspection Report — Aug 14, 2025
Routine CMS
Date: Aug 14, 2025
Visit Reason
Routine inspection of Ascension Living via Christi Village McLean nursing home to assess compliance with regulatory standards including resident rights, medication use, care quality, and infection control.
Findings
The facility had multiple deficiencies including incomplete advanced directives, failure to issue required Medicare notices, improper use and monitoring of psychotropic medications, lack of written bed hold policy, incomplete wound care, inadequate assistance with activities of daily living, failure to monitor bowel movements, and lapses in infection prevention and control practices.
Deficiencies (8)
F578: The facility failed to ensure one resident's advanced directives were thoroughly completed as a DNR order lacked a physician's signature, rendering it invalid.
F582: The facility failed to issue correct and complete Beneficiary Protection Notification forms to a resident, risking uninformed decisions.
F605: The facility failed to ensure a resident's as-needed antianxiety medication had a stop date or specified duration and physician rationale for extended use.
F628: The facility failed to provide a written bed hold policy and failed to issue written notification for a resident's hospital transfer.
F658: The facility failed to provide professional standard care when a nurse signed off on wound treatment as completed but did not complete it.
F677: The facility failed to provide adequate ADL care including grooming of facial hair for a resident, risking impaired dignity and hygiene.
F684: The facility failed to monitor and respond to residents' lack of bowel movements, risking complications such as constipation and bowel obstruction.
F880: The facility failed to implement infection prevention and control practices including proper use of Enhanced Barrier Precautions, hand hygiene, and sanitary storage of respiratory equipment.
Report Facts
Residents present: 32
Residents sampled: 12
Days without bowel movement: 7
Days without bowel movement: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Named in findings related to advanced directives and wound care treatment |
| Social Service Designee X | Social Service Designee | Responsible for obtaining advanced directives |
| Administrative Nurse D | Administrative Nurse | Provided information on advanced directives, psychotropic medication, and bowel movement monitoring |
| Certified Nurse Aide M | Certified Nurse Aide | Reported on resident behaviors and ADL care |
| Certified Nurse Aide N | Certified Nurse Aide | Observed hand hygiene lapses during peri-care |
| Administrative Nurse E | Infection Preventionist Nurse | Provided infection control expectations and policies |
| Administrative Nurse F | Administrative Nurse | Discussed bowel movement monitoring and psychotropic medication policies |
Inspection Report — Nov 15, 2023
Annual Inspection CMS
Date: Nov 15, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements and ensure resident safety and quality of care.
Findings
The facility failed to ensure safe resident transfers, proper medication storage, sanitary food preparation, effective infection control, safe catheter care, and maintenance of the environment including ventilation and cleanliness.
Deficiencies (6)
F 0689: The facility failed to properly transfer two residents, resulting in a non-injury fall and fractures due to failure to use a gait belt and mechanical lift as required.
F 0761: The facility failed to ensure appropriate storage of one resident's inhaler, which was found in an unsanitary location.
F 0812: The facility failed to prepare and serve food under sanitary conditions, including food debris in the freezer and unsanitary equipment.
F 0880: The facility failed to maintain an effective infection control program, including improper storage of clean linens, expired sanitizing wipes, and unsanitary catheter care.
F 0921: The facility failed to provide a safe, functional, sanitary, and comfortable environment due to trash and debris on the kitchen floor.
F 0923: The facility failed to ensure the beauty shop exhaust ventilation was maintained in good working order.
Report Facts
Residents selected for review: 15
Residents observed for medication administration: 6
Fractures: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA MM | Certified Nurse Aide | Named in finding for transferring resident without required mechanical lift causing fractures |
| CNA O | Certified Nurse Aide | Named in finding for failure to use gait belt during resident transfer resulting in fall |
| Administrative Nurse E | Administrative Nurse | Provided statements confirming transfer protocols and injury details |
| Administrative Nurse D | Administrative Nurse | Provided statements on transfer safety and infection control expectations |
| Dietary staff BB | Dietary Staff | Confirmed kitchen floor cleanliness issues |
Inspection Report — May 31, 2022
CMS
Date: May 31, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for Ascension Living via Christi Village McLean, related to a regulatory survey completed on 05/31/2022.
Findings
No health deficiencies were found during the survey.
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