Normal, IL

Mclean County Nursing Home

2-star overall rating with 2-star inspections with abuse icon flag with 5 recent health deficiencies

901 North Main, Normal, IL

(309) 888-5380

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

148

Certified beds

Average residents

Average occupied residents

Ownership

Government

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1984-06-21

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.81

Registered nurse staffing · state 0.73 · national 0.68

LPN hours / resident day

0.68

Licensed practical nurse staffing · state 0.64 · national 0.87

Aide hours / resident day

2.71

Nurse aide staffing · state 2.13 · national 2.35

Total nurse hours

4.21

All reported nurse hours · state 3.49 · national 3.89

Licensed hours

1.50

RN + LPN hours · state 1.36 · national 1.54

Weekend hours

3.44

Weekend nurse staffing · state 3.09 · national 3.43

Weekend RN hours

0.52

Weekend registered nurse coverage · state 0.56 · national 0.47

Physical therapist

0.00

Reported PT staffing

Adjusted RN hours

0.84

CMS adjusted RN staffing hours

Adjusted total hours

4.36

CMS adjusted total nurse staffing hours

Case-mix index

1.32

Higher values indicate more complex resident acuity

RN turnover

45%

Annual RN turnover · state 44% · national 45%

Total nurse turnover

43%

Annual nurse turnover · state 46% · national 46%

SNF VBP

Value-based purchasing

Program rank

8,255

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

27.34

Composite VBP score used to determine payment impact.

Payment multiplier

0.9845

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 20.16% · Performance 23.26% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

1.61

Baseline 6.13% · Performance 7.35% · Measure score 1.61 · Achievement 1.61 · Improvement 0

Total nurse turnover

5.89

Performance 39.62% · Measure score 5.89 · Achievement 5.89 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

3.43

Baseline 4.24 hours · Performance 4.05 hours · Measure score 3.43 · Achievement 3.43 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.77%	10.72% 1 pts worse	No Different than the National Rate · Eligible stays 106 · Observed rate 13.21% · Lower 95% interval 8.01%
Discharge to community	49.27%	50.57% 1.3 pts worse	No Different than the National Rate · Eligible stays 75 · Observed rate 44% · Lower 95% interval 40.2%
Medicare spending per beneficiary	1.04	1.02 About the same
Drug regimen review with follow-up	96.77%	95.27% 1.5 pts better	Numerator 90 · Denominator 93
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 93
Discharge self-care score	46.77%	53.69% 6.9 pts worse	Numerator 29 · Denominator 62
Discharge mobility score	41.94%	50.94% 9 pts worse	Numerator 26 · Denominator 62
Pressure ulcers or injuries, new or worsened	7.53%	2.29% 5.2 pts worse	Numerator 7 · Denominator 93 · Adjusted rate 6.71%
Healthcare-associated infections requiring hospitalization	7.35%	7.12% 0.2 pts worse	No Different than the National Rate · Eligible stays 63 · Observed rate 7.94% · Lower 95% interval 3.79%
Staff COVID-19 vaccination coverage	7.2%	8.2% 1 pts worse	Numerator 9 · Denominator 125
Staff flu vaccination coverage	16.67%	42% 25.3 pts worse	Numerator 32 · Denominator 192
Discharge function score	41.94%	56.45% 14.5 pts worse	Numerator 26 · Denominator 62
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 34 · Denominator 34
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 31 · Denominator 31
Resident COVID-19 vaccinations up to date	53.06%	25.2% 27.9 pts better	Numerator 26 · Denominator 49

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.5	2.0 0.5 pts worse	1.9 0.6 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.5 · Expected 1.9 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.3	2.3 1 pts better	1.8 0.5 pts better	Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.3 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.7%	89.6% 10.1 pts better	93.4% 6.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.5% · 4Q avg 99.7%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	91.6% 8.4 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	5.0%	3.3% 1.7 pts worse	3.3% 1.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 5.1% · Q3 5.4% · Q4 4.6% · 4Q avg 5.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.2%	50.3% 49.1 pts better	11.4% 10.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.5% · Q4 3.4% · 4Q avg 1.2%
Percentage of long-stay residents who lose too much weight	13.1%	6.5% 6.6 pts worse	5.4% 7.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 12.2% · Q3 14.3% · Q4 16.3% · 4Q avg 13.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	23.1%	18.5% 4.6 pts worse	19.6% 3.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 20.8% · Q3 26.0% · Q4 24.4% · 4Q avg 23.1%
Percentage of long-stay residents who received an antipsychotic medication	23.9%	22.8% 1.1 pts worse	16.7% 7.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 27.0% · Q3 22.5% · Q4 18.9% · 4Q avg 23.9% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	25.8%	17.2% 8.6 pts worse	16.3% 9.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 14.2% · Q3 27.3% · 4Q avg 25.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	21.7%	15.0% 6.7 pts worse	14.9% 6.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 17.0% · Q3 22.9% · Q4 40.0% · 4Q avg 21.7% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	2.6%	1.1% 1.5 pts worse	1.0% 1.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 2.6% · Q3 0.0% · Q4 1.5% · 4Q avg 2.6% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	1.7% 1.7 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	29.5%	21.3% 8.2 pts worse	19.8% 9.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 27.2% · Q2 38.6% · Q3 26.5% · Q4 25.2% · 4Q avg 29.5%
Percentage of long-stay residents with pressure ulcers	5.1%	5.2% 0.1 pts better	5.1% About the same	Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 8.4% · Q3 4.5% · Q4 2.3% · 4Q avg 5.1% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	96.0%	68.8% 27.2 pts better	81.7% 14.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 96.5% · Q2 99.1% · Q3 96.6% · Q4 90.4% · 4Q avg 96.0%
Percentage of short-stay residents who had an outpatient emergency department visit	6.7%	14.0% 7.3 pts better	12.0% 5.3 pts better	Short Stay · 20240701-20250630 · Adjusted 6.7% · Observed 6.6% · Expected 11.0% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.4%	2.3% 1.9 pts better	1.6% 1.2 pts better	Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	97.2%	63.0% 34.2 pts better	79.7% 17.5 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 97.2%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	32.1%	26.2% 5.9 pts worse	23.9% 8.2 pts worse	Short Stay · 20240701-20250630 · Adjusted 32.1% · Observed 31.9% · Expected 23.7% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-08-13 · Fire 2024-08-14

5 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2024-08-14 · Fire 2023-08-30

9 health deficiencies

Top issue: Pharmacy Service (3 deficiencies)

1 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Cycle 3 Health 2023-08-30 · Fire 2022-05-05

17 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2023-08-30

E26 · Emergency Preparedness Deficiencies

Fire Safety

Establish roles under a Waiver declared by secretary.

Corrected 2023-09-19

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-08-13

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-09-03

D · Potential for more than minimal harm 2025-08-13

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from the wrongful use of the resident's belongings or money.

Corrected 2025-08-29

D · Potential for more than minimal harm 2025-08-13

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2025-09-03

D · Potential for more than minimal harm 2025-08-13

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2025-09-03

D · Potential for more than minimal harm 2025-05-12

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-05-30

D · Potential for more than minimal harm 2024-12-23

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2025-01-17

F · Potential for more than minimal harm 2024-08-14

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-09-05

D · Potential for more than minimal harm 2024-08-14

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2024-09-05

D · Potential for more than minimal harm 2024-08-14

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2024-09-05

D · Potential for more than minimal harm 2024-08-14

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2024-09-05

D · Potential for more than minimal harm 2024-08-14

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2024-09-05

D · Potential for more than minimal harm 2024-08-14

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2024-09-05

D · Potential for more than minimal harm 2024-08-14

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2024-09-05

D · Potential for more than minimal harm 2024-06-07

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2024-06-27

F · Potential for more than minimal harm 2023-08-30

F801 · Nutrition and Dietary Deficiencies

Health

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Corrected 2023-09-22

E · Potential for more than minimal harm 2023-08-30

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2023-09-22

E · Potential for more than minimal harm 2023-08-30

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2023-09-22

E · Potential for more than minimal harm 2023-08-30