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 Mcleansboro Rehab & Hlth C Ctr during CMS and state inspections, most recent first.
The facility failed to ensure RN coverage for 8 consecutive hours daily, affecting 35 residents. Nursing schedules showed no RN coverage on two weekend days. The Corporate Administrator and Administrator confirmed the lack of RN coverage, especially on weekends, acknowledging the challenge of staffing RNs during these times.
The facility did not maintain the required RN coverage for 8 consecutive hours daily, affecting the care of 30 residents. The DON admitted to difficulties in covering weekend shifts with RNs, relying instead on LPNs. Despite efforts to hire more RNs, there were days in May and June when no RN worked the required hours, as shown in the nursing schedules.
A resident with schizophrenia and dementia was inaccurately assessed in the MDS, as the facility failed to recognize the need for a Level II PASRR. The MDS/Care Plan Coordinator initially believed the dementia diagnosis outweighed the schizophrenia, leading to the oversight.
A resident with severe cognitive impairment and multiple medical conditions experienced a fall while attempting to get out of bed without assistance. Despite being identified as high risk for falls, no new interventions were added to the care plan. The DON was unaware of the incident due to unfiled paperwork, and the fall was not communicated to the administration or the MDS Coordinator, resulting in a failure to follow the facility's fall prevention policy.
A resident with severe cognitive impairment experienced burning pain after a CNA applied hand sanitizer to her excoriated skin. The incident was reported late due to staff fears and miscommunication. The facility's investigation confirmed the inappropriate action, highlighting a deficiency in protecting residents from abuse.
The facility failed to report and investigate abuse allegations within the required time frames for two residents. One resident with severe cognitive impairment was allegedly abused by a CNA who applied hand sanitizer to her scratched areas, and the incident was reported four days late. Another resident, who is cognitively intact, reported being jabbed with a washcloth during a shower, but the administrator did not initially consider it abuse and failed to investigate. The facility's policy requires immediate reporting and investigation of abuse, which was not followed in these cases.
A resident reported being jabbed in the stomach with a washcloth by a CNA during a shower, but the facility administrator did not initiate an investigation, despite the Ombudsman categorizing it as abuse. The resident, who is cognitively intact, had reported the incident, but the administrator only changed the resident's shower times without conducting a formal investigation, violating the facility's abuse prevention policy.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to maintain the required Registered Nurse (RN) coverage for 8 consecutive hours a day, 7 days a week, which has the potential to affect all 35 residents residing in the facility. A review of nursing schedules from June 7, 2024, through June 24, 2024, revealed that there was no RN coverage on Saturday, June 15, 2024, and Sunday, June 16, 2024. During an interview on June 24, 2024, the Corporate Administrator acknowledged the lack of continuous RN coverage, particularly on weekends. The facility Administrator also confirmed that there are weekends when the facility does not meet the minimum RN coverage requirement, expressing relief at having any nurses available, even if they are not RNs. The facility's Resident Matrix dated June 24, 2024, documented that 35 residents were residing at the facility at the time of the deficiency.
Failure to Maintain RN Coverage 8 Hours Daily
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for 8 consecutive hours a day, 7 days a week, which is a requirement for the care of the 30 residents residing in the facility. The Director of Nursing (DON) acknowledged that there are weekends when they cannot cover shifts with an RN, and instead, they rely on Licensed Practical Nurses (LPNs) to fill in. The facility does not use a staffing agency but attempts to cover shifts using a PRN float pool and a list of facility-specific PRN RNs. Despite having advertisements out to hire RNs, there were specific days in May and June when no RN worked the required hours, as confirmed by the nursing schedules reviewed for those months.
Inaccurate MDS Assessment for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for a resident, identified as R8, who was part of a sample reviewed for assessment accuracy. R8's admission record indicated multiple diagnoses, including anxiety disorder, schizophrenia, anemia, depression, and unspecified dementia. An OBRA Initial Screen from 2017 confirmed a formal diagnosis of mental illness, excluding organic disorders/dementia, and noted a history of psychiatric hospitalization and outpatient mental health services. Despite this, the MDS assessment dated January 16, 2024, incorrectly marked that the resident was not considered by the state Level II PASRR process to have a serious mental illness, even though schizophrenia was listed as an active diagnosis. The MDS/Care Plan Coordinator, identified as V2, initially stated that no residents in the facility were Level II and believed that R8's dementia diagnosis outweighed the schizophrenia diagnosis, thus negating the need for a Level II PASRR. However, V2 later acknowledged that a new PASARR should have been completed when R8 was diagnosed with dementia. This oversight in the assessment process led to the deficiency noted by the surveyors.
Failure to Implement New Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement new person-centered fall interventions for a resident identified as high risk for falls. The resident, who has severe cognitive impairment and multiple medical conditions including dementia and diabetes, experienced a fall while attempting to get out of bed without assistance. Despite the fall, no new interventions were added to the resident's care plan to prevent further incidents. The resident's care plan had existing interventions such as keeping the call light and personal items within reach, ensuring proper footwear, and requiring staff assistance for transfers, but these were not updated following the fall. The Director of Nursing (DON) was unaware of the fall incident until it was discovered in unfiled paperwork, indicating a lapse in communication and documentation. The facility's policy requires immediate assessment and intervention after a fall, including a fall huddle and documentation of new interventions. However, the MDS Coordinator confirmed that the fall was not communicated to the administration or the DON, and no new interventions were added to the care plan. This oversight highlights a failure to adhere to the facility's fall prevention policy, resulting in inadequate supervision and risk management for the resident.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from staff-to-resident abuse, resulting in the resident experiencing burning pain and irritation. The incident involved a Certified Nurse's Assistant (CNA) applying hand sanitizer to the resident's bottom and legs, which had excoriations. The resident, who has severe cognitive impairment and is dependent on assistance for daily activities, was unable to communicate effectively about the incident. The facility's investigation revealed that the CNA applied the hand sanitizer to stop the resident from scratching, which was inappropriate and caused harm. The incident was reported to the facility administrator by a Licensed Practical Nurse (LPN) after being informed by another CNA. The investigation uncovered that the CNA involved had initially claimed to use a skin prep product but later admitted to using hand sanitizer. Other staff members were aware of the incident but failed to report it immediately, citing personal fears and misunderstandings about reporting procedures. The resident's family member was informed of the incident and expressed concern about the CNA's actions, although they felt the resident was safe in the facility. The facility's policy on abuse prevention emphasizes the residents' right to be free from abuse and neglect. However, the incident highlights a breakdown in communication and reporting among staff members, as well as a failure to adhere to the facility's abuse prevention policy. The investigation documents included interviews with staff and the resident, confirming the inappropriate use of hand sanitizer and the resident's experience of pain. Despite the resident's cognitive impairment, the incident was corroborated by multiple sources, indicating a clear deficiency in the facility's care and protection of its residents.
Failure to Timely Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to implement its abuse policies by not reporting abuse within the designated time frames for two residents. The first resident, who has severe cognitive impairment and multiple diagnoses including Alzheimer's Disease and Dementia, was allegedly abused by a CNA who applied hand sanitizer to her scratched areas. The incident was reported to the administrator four days after it occurred, and the investigation revealed that the CNA had used inappropriate methods to stop the resident from scratching. The abuse was not reported immediately as required by the facility's policy, and the initial notification to the Illinois Department of Public Health was delayed. The second resident, who is cognitively intact and requires assistance with showers, reported being abused during a shower when a CNA allegedly jabbed a washcloth into her abdomen. The resident reported the incident to the administrator, who did not initially consider it abuse and failed to conduct an investigation. The Ombudsman was informed of the incident and reported it to the administrator, but the administrator did not take immediate action to investigate or report the incident as required by the facility's policy. The facility's policy mandates immediate reporting of any potential or alleged mistreatment, exploitation, neglect, and abuse to a supervisor and the administrator, as well as external reporting to appropriate authorities. In both cases, the facility did not adhere to these requirements, resulting in delayed reporting and investigation of the alleged abuse incidents. The failure to follow the established procedures for reporting and investigating abuse allegations constitutes a deficiency in the facility's compliance with its abuse prevention program.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to initiate and thoroughly investigate an allegation of abuse involving a resident who reported being jabbed in the stomach with a washcloth by a CNA during a shower. The resident, who is cognitively intact with a BIMS score of 15, reported the incident to the facility administrator, who did not consider it abuse and did not initiate an investigation. The resident had been admitted with diagnoses including Chronic Obstructive Pulmonary Disease and Anxiety and required assistance with showers. The incident was initially reported to the Ombudsman, who informed the administrator of the resident's complaint. Despite the Ombudsman categorizing the incident as abuse and notifying the administrator, no investigation was conducted at that time. The administrator later stated that the issue was resolved by changing the resident's shower times to avoid the CNA involved, but no formal investigation was documented. The facility's policy on abuse prevention requires a thorough investigation of any allegations of mistreatment, including interviews and documentation reviews. However, the administrator, who is also the Abuse Coordinator, did not follow these procedures upon receiving the report from the Ombudsman. The lack of an investigation was a direct violation of the facility's abuse prevention policy, as no evidence of an investigation was provided until prompted by surveyors.
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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 41 citations issued within 25 miles in the last 12 months — including the 1 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mcleansboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Silver Foxes Sr Living & Rehab | 0.7 mi | ★★★★★ | 2 | 0 |
| Wabash Senior Living & Rehab | 20.1 mi | ★★★★★ | 10 | 1 |
| White County Rehab And Nursing | 20.3 mi | ★★★★★ | 2 | 0 |
| Eldorado Rehab & Healthcare | 20.4 mi | ★★★★★ | 1 | 0 |
| Stonebridge Nursing & Rehab | 21.6 mi | ★★★★★ | 9 | 0 |
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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.