Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 County Nursing Home during CMS and state inspections, most recent first.
The facility failed to follow its infection prevention and control program for residents with internal urinary drainage devices. Two residents with urinary catheters had drainage bags that were allowed to rest on the floor while they were in wheelchairs, despite care plans directing staff to keep tubing and drainage systems off the floor and to use Enhanced Barrier Precautions (EBP). Another resident with a long-term indwelling catheter, also on EBP, had a drainage bag hanging from a garbage can without a dignity bag, and a CNA emptied the bag without wearing PPE. The DON later acknowledged that drainage bags should not be on the floor and that PPE should always be used for residents on EBP.
A resident with moderate cognitive impairment and limited ability to perform ADLs, including grooming, had a care plan and facility policy requiring staff to assist with bathing and nail care. Despite documented showers and partial baths, the resident was repeatedly observed with jagged, untrimmed fingernails and brown material under the nails. CNAs and a shower aide confirmed that shower staff are responsible for cleaning and trimming nails with each shower and as needed, and acknowledged that this nail care should have been done but was not.
The facility failed to keep toilet safety frames and commode assistive bars in safe working condition for two residents with normal cognition but significant fall histories and mobility impairments. Both residents reported that the toilet handrails or commode bars were wobbly and made them feel unsafe, and surveyors directly observed that these devices were loose and moved easily when grabbed. Manufacturer manuals required regular and, in one case, weekly inspection and tightening of all components to ensure stability. Therapy records documented that each resident required toilet stabilizer bars or grab bars for safe toileting and transfers, and therapy staff stated that loose or unsecure bars could contribute to falls. Facility leadership and maintenance staff reported that quarterly preventive bathroom checks were done but used no formal documentation process, and they were unable to produce records showing that the affected toilet safety frames and commode had been routinely inspected.
A resident reported to a CNA that a staff member forcibly took a gown from her, causing a scratch and a red spot on her forearm. The CNA relayed this allegation to the administrator, who did not notify the state agency as required by facility policy. Medical records confirmed there was no documentation of state agency notification regarding the abuse allegation.
A resident with a history of psychotic disorder and moderate cognitive impairment struck one resident and threw coffee on another, causing physical harm. Despite increased supervision measures, the facility failed to prevent these incidents, highlighting a lapse in adherence to abuse prevention policies.
The facility did not maintain the juice dispenser in a sanitary condition, with dried juice and green fuzzy material observed on it. Additionally, opened containers of almond milk, juices, thickening agents, and ice cream toppings were not dated when opened. The Dietary Manager confirmed the juice machine should be cleaned daily, and containers should be labeled with the opening date.
A facility failed to maintain a clean and sanitary mechanical wheelchair for a hospice resident with severe protein malnutrition. The resident expressed discomfort with the dirty chair, which was observed to have a chunky brown and white substance on the seat. The DON confirmed that night shift staff were responsible for cleaning wheelchairs, but the facility lacked a specific policy for equipment cleaning.
The facility failed to secure and position catheter tubing properly for two residents, leading to impeded urine flow and tension at the insertion site. One resident's catheter tubing was compressed under the leg, while another experienced pulling due to lack of anchoring, causing redness and swelling. Staff confirmed the absence of securement devices, contrary to care plans and physician orders.
The facility failed to implement dietician recommendations for two residents who experienced significant weight loss. Both residents were at nutritional risk, and the dietician recommended adding a house shake with lunch to maintain their weight. However, these recommendations were not included in the physician's orders, and the residents did not receive the shakes. The Director of Nursing confirmed that the dietary recommendations were missed and not documented in the care plans.
A facility failed to justify the use of an antipsychotic medication for a resident by not identifying or tracking specific behaviors. The resident's record showed orders for psychotropic medications, but only documented self-isolating and refusal of care, with no nonpharmacological interventions attempted. The RN Unit Manager confirmed these behaviors do not justify antipsychotic use, violating the facility's policy on unnecessary medications.
Two residents experienced medication administration errors at the facility. An LPN administered expired insulin to a resident with diabetes, while another resident received only half of the prescribed Vitamin C dosage. These errors resulted in a medication error rate of 6.67%, surpassing the acceptable 5% threshold.
The facility failed to label medications with the date opened for two residents. A resident's Refresh tears and another's Maxitrol eye ointment were found on the medication cart without the required date of opening. An LPN confirmed the omission, noting that the facility's policy did not address this requirement.
A resident with severe cognitive impairment experienced a delay in reporting a change in condition to their physician and power of attorney. The resident complained of knee pain, which was later diagnosed as a fracture. The facility's policy to notify the physician of significant changes was not followed, resulting in a delay of several days before the physician was informed.
Failure to Implement Enhanced Barrier Precautions and Proper Urinary Catheter Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP) and urinary catheter care practices, for residents with internal urinary drainage devices. For one resident with obstructive uropathy requiring an internal urine drainage device, surveyors observed the urinary drainage bag dragging on the floor while the resident propelled in a wheelchair down the hall and later resting on the ground beneath the wheelchair during an activity in the dining room. This occurred despite the resident’s care plan directing staff to avoid allowing tubing or any part of the drainage system to touch the floor and documenting the need for EBP, including teaching the resident and staff about the chain of infection, methods of transmission, and principles of infection control. Another resident with a flaccid neuropathic bladder and an internal urine drainage device was observed in the dining room with the urinary drainage bag hanging beneath the wheelchair and resting on the ground, contrary to the care plan instructions that no part of the drainage system should touch the floor and that EBP would be used to reduce transmission of multidrug-resistant organisms. A third resident, alert and oriented with a long-term indwelling urinary catheter and on EBP, was found in bed with the catheter bag hanging from a garbage can and not in a dignity bag. A CNA emptied this resident’s catheter drainage bag without wearing any personal protective equipment (PPE), even though the resident’s status on EBP required PPE use. The DON later confirmed that urine drainage bags should never rest on the ground and that PPE should always be worn when a resident is on EBP, corroborating that these observed practices were inconsistent with facility policy and the residents’ care plans.
Failure to Provide Required Fingernail Care and Hygiene Assistance
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident’s personal hygiene by not providing routine fingernail care as required by facility policy and the resident’s care plan. The facility’s ADL policy states that residents unable to carry out activities of daily living will receive necessary services to maintain grooming and personal hygiene, including nail care. The resident’s MDS showed moderate cognitive impairment with a BIMS score of 10 and documented limited ability with ADLs, requiring assistance due to impaired cognition, general weakness, and pain related to Alzheimer’s disease, ulcerative colitis, and low back pain. The resident’s care plan required staff assistance with showering twice weekly, partial bathing twice daily, and assistance with hair, lotion, and nail care. On multiple observations, the resident was seen sitting in a wheelchair near the nurses’ station with fingernails that were jagged, untrimmed, and with brown material beneath them, despite documentation that the resident had recently received showers and bathing assistance. Staff interviews confirmed that shower aides are responsible for providing nail care, including cleaning under the nails with every shower and as needed, and that this care should have been provided during the resident’s most recent shower. One CNA acknowledged that the resident’s nails should have been cleaned and trimmed but “it doesn’t look like it was done.” Another CNA stated they documented the shower but did not provide it, and confirmed that nail care should have been done. The shower aide also confirmed the expectation that nail care be provided with each shower, indicating that the resident’s nail care was not completed as required.
Failure to Maintain Safe and Secure Toilet Safety Frames and Commode Bars
Penalty
Summary
The facility failed to maintain toilet safety frames and a bariatric commode in safe operating condition for two residents who required assistive devices for toileting and transfers. For one resident (R70), who had normal cognition, a diagnosis of repeated falls, urinary incontinence, and a care plan requiring staff assistance with toileting, the toilet safety frame in her bathroom was observed to be wobbly and easily moved when grabbed. The manufacturer’s manual for the toilet safety frame required regular checks to ensure it was securely locked onto the toilet before use. R70 reported that the bathroom handrails around her toilet were wobbly and that she had recently fallen off the toilet, which scared her, though she was not injured. Therapy documentation showed that R70 needed grab bars and toilet stabilizer bars for safe toileting with assistance, and both the PT and COTA stated that she definitely needed secure safety handrails and that an unsecure or loose stabilizer bar could contribute to a fall. For another resident (R4), who also had normal cognition, a history of repeated falls, weakness, CVA with left-sided weakness, and impaired mobility, the handrails attached to his bariatric commode were likewise observed to be unsecure and moved easily when grabbed. The bariatric commode manual required periodic visual inspection and weekly checks of all nuts, bolts, and knobs to ensure stability and safe use. R4 reported feeling unsafe on the toilet because the bars moved around too much. His care plan documented difficulty with transfers, risk for falls, and the need for toileting assistance and reminders not to transfer without help, and OT documentation indicated he required adaptive equipment and assistive devices, including a raised toilet seat/3-in-1 commode, for safe toileting. The COTA confirmed that, due to his CVA and left-sided weakness, he most definitely needed toilet stabilizer bars and that a loose stabilizer bar had the potential to contribute to a fall. The Administrator and Maintenance Director stated that quarterly preventive maintenance was done on resident bathrooms and that a checklist existed but was not used for documentation; the Maintenance Director and Mechanic could not provide documentation that the toilet safety frames for these residents had been routinely checked, and only undated “chicken scratch” notes from a prior period were available.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency as required by its own Abuse Prevention Policy. On 4/30/25, a certified nurse's assistant (V7) reported to the administrator (V1) that a resident (R1) alleged a staff member (V3) had snatched a gown from her, resulting in a scratch to her hand and a red spot observed on her forearm. Despite receiving this report, the administrator confirmed that the state agency was not notified of the allegation. Review of the resident's medical record also showed no documentation that the state agency had been informed of the incident.
Failure to Protect Residents from Abuse by Another Resident
Penalty
Summary
The facility failed to protect residents from abuse by another resident, resulting in multiple incidents involving three residents. On the morning of December 8, 2024, in the Main Dining Room, a resident struck another resident on the face after becoming agitated by the latter's singing. This incident was witnessed by dietary staff who responded to the raised voices. Later that day, the same resident threw coffee on another resident, causing redness on the arm and abdomen. This incident was confirmed by a registered nurse and a visitor who witnessed the event. The resident responsible for the abuse has a history of psychotic disorder with delusions and anxiety disorder, and is noted to have moderate cognitive impairment. The resident's care plan documented potential for verbal and physical behaviors directed at staff and others, including hitting and kicking. Despite these documented behaviors, the facility's response to the initial incident was to increase supervision and encourage the resident to stay in her room, but this did not prevent the subsequent incident later that day. The facility's policy affirms the right of residents to be free from abuse, yet the incidents indicate a failure to adequately supervise and protect residents from harm. The Director of Nursing confirmed that increased supervision should have involved staff being close enough to observe the resident as she moved around the facility. However, during the coffee-throwing incident, no staff were present in the dining room, highlighting a lapse in supervision and adherence to the facility's abuse prevention policy.
Unsanitary Juice Dispenser and Undated Perishable Foods
Penalty
Summary
The facility failed to maintain the juice dispenser in a clean and sanitary manner and did not date perishable refrigerated foods when opened. During a walkthrough of the main kitchen, the juice dispenser was observed with dried juice on the nozzles and surrounding flat surfaces, some of which were covered by green fuzzy material. This dispenser is used to pour drinks for all residents in the facility. Additionally, opened containers of almond milk, juices, thickening agents, and ice cream toppings in the refrigerator were not labeled with the date they were opened. The Dietary Manager confirmed that the juice machine should be cleaned daily, and the containers should be labeled with the opening date.
Failure to Maintain Clean Wheelchair for Hospice Resident
Penalty
Summary
The facility failed to maintain a mechanical wheelchair in a clean and sanitary manner for one resident, identified as R16, who was under hospice care due to severe protein malnutrition. R16's care plan indicated a decline in cognitive and physical abilities, with care focused on maintaining comfort through end-of-life. On August 12, 2024, R16 was observed seated in a mechanical wheelchair in her room, which she stated was provided by hospice and was comfortable but dirty. The wheelchair was noted to be caked with a chunky brown and white substance around the padded seat, which R16 expressed dissatisfaction with. On August 13, 2024, the Director of Nursing, identified as V2, confirmed that the night shift staff were responsible for cleaning wheelchairs and that all staff should remove visible debris as soon as it is noticed. However, the facility did not have a specific policy for cleaning wheelchairs or other equipment, contributing to the deficiency in maintaining a clean environment for R16.
Deficiencies in Catheter Care for Two Residents
Penalty
Summary
The facility failed to provide appropriate catheter care for two residents, leading to deficiencies in securing and positioning catheter tubing. For one resident, the care plan indicated the need for an indwelling urinary catheter due to urinary retention, with instructions to avoid obstructions in the drainage. However, during an observation, the catheter tubing was found to be compressed under the resident's leg, impeding urine flow and leaving a red imprint on the thigh. It was confirmed by the CNAs and the LPN that the resident did not have a securement device for the catheter tubing, which should not have been placed under the leg. Another resident with a physician's order for an indwelling urinary catheter experienced tension at the insertion site during catheter care, causing redness and slight swelling of the urinary meatus. The CNAs noted that the catheter should have been anchored to prevent pulling, especially since the resident had difficulty turning due to a previous leg injury. The DON confirmed that an anchoring device was necessary to prevent the catheter tubing from pulling.
Failure to Implement Dietician Recommendations for Weight Loss
Penalty
Summary
The facility failed to implement dietician recommendations for two residents, R39 and R40, who experienced significant weight loss. R39's care plan indicated she was at nutritional risk, and her weight decreased from 117.2 pounds to 106 pounds over three months, a 9.56% loss. The dietician recommended adding a house shake with lunch to maintain her weight, but this recommendation was not included in the physician's orders, and R39 did not receive the shake. The Director of Nursing confirmed that the dietary recommendation was missed and that the significant weight loss was not documented in R39's care plan. Similarly, R40 experienced an 11.4% weight loss over six months, dropping from 164.6 pounds to 149.2 pounds. The dietician also recommended a house shake with lunch for R40, but this was not reflected in the physician's orders, and R40 did not receive the shake. The Director of Nursing acknowledged that the dietary recommendation was overlooked and that the weight loss should have been added to R40's care plan. Both cases highlight a failure to follow through on dietician recommendations and update care plans accordingly.
Failure to Justify Antipsychotic Use and Implement Nonpharmacological Interventions
Penalty
Summary
The facility failed to identify and track specific behaviors to justify the use of an antipsychotic medication for a resident, leading to a deficiency in medication management. The resident's medical record showed current physician's orders for psychotropic medications, including Fluoxetine, Lorazepam, and Quetiapine. However, the Treatment Administration Record for August 2024 only documented episodes of self-isolating and refusal of care, with no documentation of nonpharmacological interventions attempted. The Registered Nurse Unit Manager confirmed that self-isolation and refusing care are not justifications for antipsychotic use. The facility's Psychotropic Medication Policy outlines that an unnecessary medication is one used without adequate indications of its use, among other criteria.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to administer medications in accordance with physician's orders and manufacturer's recommendations for two residents. For one resident, identified as R4, the Licensed Practical Nurse (LPN) administered insulin aspart from a vial that was past its expiration date. The insulin vial had an open date written on it, indicating it should have been discarded after 28 days. However, the LPN misread the date and proceeded to administer 12 units of the expired insulin to the resident, whose blood glucose level was recorded at 406, necessitating the insulin administration. In another instance, a resident identified as R25 was prescribed two 500 mg tablets of Vitamin C for a vitamin deficiency. The LPN responsible for administering the medication only provided one tablet instead of the prescribed two. This error was later confirmed by the Director of Nursing, who acknowledged that the resident should have received the full dosage as per the physician's order. These incidents contributed to a medication error rate of 6.67%, exceeding the acceptable threshold of 5%.
Failure to Label Medications with Date Opened
Penalty
Summary
The facility failed to properly label medications with the date they were opened for two residents, R150 and R151, out of a sample of 35 residents. R150's Medication Administration Record (MAR) included a physician's order for Refresh tears, which were observed on the medication cart without a date of opening. Similarly, R151's MAR included an order for Maxitrol eye ointment, which should be discarded 30 days after opening, but was also found without a date of opening. A Licensed Practical Nurse (LPN) acknowledged that multidose medication containers are supposed to be labeled with the time and date they are opened, but noted that the medications in question were not dated. The facility's medication administration policy did not address the requirement to label medications with the date opened.
Failure to Timely Report Change in Resident's Condition
Penalty
Summary
The facility failed to timely report a change in condition for a resident who was severely cognitively impaired and unable to communicate effectively. On May 31, 2024, a nurse noted that the resident was complaining of pain during care, specifically in the right knee, which was swollen and painful. Despite this observation, the physician and the resident's power of attorney were not notified of the change in condition and new onset pain until June 3, 2024, which was a delay of several days. During this period, the resident's condition was monitored, and Tylenol was administered for pain relief. The resident's care plan indicated a high risk for falls due to impaired mobility and cognition, among other factors. An x-ray ordered on June 3, 2024, revealed a right knee arthroplasty with an acute periprosthetic fracture of the distal femur. The facility's policy required that any significant change in a resident's condition be reported to the attending physician or power of attorney, which was not adhered to in this case. The Director of Nursing confirmed the lapse in communication, acknowledging that the necessary notifications were not made in a timely manner.
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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 Normal
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arc At Normal | 0.7 mi | ★★★★★ | 13 | 0 |
| Loft Rehab & Nursing Of Normal | 1.2 mi | ★★★★★ | 22 | 0 |
| Arcadia Care Bloomington | 2.2 mi | ★★★★★ | 13 | 1 |
| Goldwater Care Bloomington | 2.5 mi | ★★★★★ | 4 | 0 |
| Westminster Village | 4.2 mi | ★★★★★ | 4 | 0 |
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