Health inspection·March 19, 2024

F 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide or obtain the required specialized rehabilitative services for 1 of 3 residents (R2) reviewed for therapy services in a sample of 3. Residents Affected - Few The findings include: R2's admission Record documents that R2 was admitted to the facility on [DATE] with a diagnoses of chronic kidney disease, unspecified, chronic obstructive pulmonary disease, unspecified, hyperlipidemia, unspecified, essential (primary) hypertension, unspecified atrial fibrillation, gastro-esophageal reflux disease without esophagitis, depression, unspecified, anemia in chronic kidney disease, hypertensive heart disease without heart failure, edema, unspecified, and other seasonal allergic rhinitis. R2's Minimum Data Set (MDS) dated [DATE], documents Section C, a Brief Interview for Mental Status (BIMS) score of 13, indicating that R2 is cognitively intact. Section GG, Functional Abilities and Goals, of the same MDS documents that R2 requires setup or clean-up assistance with eating, supervision or touching assistance with oral hygiene, dependent with toileting hygiene, lower body dressing, putting on/off footwear, bed mobility, and transfers, and requires partial/moderate assistance with upper body dressing. R2's Physician's orders dated 2/6/2024 documents Physical Therapy (PT)/Occupational Therapy (OT): Skilled PT/OT 5 times/week x 30 days. Therapy to include Therapeutic Exercises, Therapeutic Activities, Neurological Re-Education, Gait Training, Group Therapy, Self-Care Management, Wheelchair assessment and management. R2's PT Treatment Note dated 2/05/2024 documents a medical diagnosis of cerebral infarction, unspecified, a treatment diagnoses of muscle wasting and atrophy, necrotizing enterocolitis (NEC), multiple sites, and unsteadiness on feet. R2's PT Treatment Note dated 1/22/2024 - 1/26/2024 documents medical diagnoses of heart failure, unspecified and personal history of COVID-19 (1/14/2024) and treatment diagnoses of muscle wasting and atrophy, NEC, multiple sites, and unsteadiness on feet. R2's PT Note dated 1/22/2024 documents this [AGE] year-old male hospitalized with COVID-19, 1/14/2024 - 1/19/2024, continues to be on isolation here at skilled nursing facility. (R2) was previously hospitalized secondary to heart failure (stage III to almost IV). (R2) presented today with deficits in overall activity tolerance, functional mobility, functional transfers, bed mobility, sitting and standing balance/tolerance, bilateral upper extremity strength, and increased need for assistance with self-care tasks. (R2) would benefit from skilled PT services to improve above deficits to increase independence and safety to prior level of functioning. R2's OT Treatment Noted dated 2/05/2024 documents this [AGE] year-old male was referred to skilled (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 145964 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145964 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE McLeansboro Rehab & Hlth C Ctr 405 West Carpenter McLeansboro, IL 62859 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)