A list of the most recent deficiencies for Mcleansboro Rehab and Hlth C Ctr. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-11-13 | 2023-11-16 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-05-04 | 2023-08-02 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-05-16 | 2023-05-26 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-05-16 | 2023-05-26 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-05-16 | 2023-05-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-16 | 2023-05-26 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-05-16 | 2023-05-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-16 | 2023-05-26 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-05-16 | 2023-05-26 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-05-16 | 2023-05-26 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-16 | 2023-05-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-16 | 2023-05-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-04 | 2023-05-19 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-08-09 | 2022-08-18 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-08-09 | 2022-08-18 | Y |
| Install proper backup exit lighting. | Fire Safety | 2022-04-08 | 2022-04-25 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-04-08 | 2022-04-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-04-08 | 2022-04-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-04-08 | 2022-04-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-04-08 | 2022-04-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-08 | 2022-04-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-29 | 2021-08-18 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-07-29 | 2021-08-18 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-05-10 | 2021-05-20 | Y |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2021-02-17 | 2021-03-05 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-02-17 | 2021-03-05 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-02-17 | 2021-03-05 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-02-17 | 2021-03-05 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-02-17 | 2021-03-05 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2021-02-17 | 2021-03-05 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2021-02-17 | 2021-03-05 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2021-02-17 | 2021-03-05 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2021-02-17 | 2021-03-05 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-02-17 | 2021-03-05 | N |
| Develop a communication plan. | Fire Safety | 2021-02-17 | 2021-03-05 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-02-17 | 2021-03-05 | N |
| Establish methods for sharing information. | Fire Safety | 2021-02-17 | 2021-03-05 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-02-17 | 2021-03-05 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-02-17 | 2021-03-05 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-02-17 | 2021-03-05 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-02-17 | 2021-03-05 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-02-17 | 2021-03-05 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-02-17 | 2021-03-05 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-02-17 | 2021-03-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-02-17 | 2021-03-05 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-02-17 | 2021-03-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-02-17 | 2021-03-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-02-17 | 2021-03-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-02-11 | 2021-03-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-02-11 | 2021-03-03 | N |
