Charleston Rehab: Infection Control Failures - IL
The September inspection at Charleston Rehab and Nursing found certified nursing assistants V15 and V16 caring for a resident placed on Enhanced Barrier Precautions due to previous multi-drug resistant organism infection and a permanent urinary catheter. Both staff members acknowledged afterward they should have worn gowns during the direct care.
The resident, identified as R8 in the inspection report, requires maximum assistance for toileting and moderate help with dressing and bathing. Her room displayed a sign reading "Enhanced Barrier Precautions" next to the door.
On August 27 at 2:00 PM, inspectors watched as the two nursing assistants provided catheter care and cleaned the resident's genital area without gowns. V16 then emptied the resident's urinary drainage bag, which contained 450 milliliters of dark orange, cloudy urine, still without protective clothing.
The room contained no disposal bins for contaminated protective equipment. The garbage cans showed no evidence that staff had used and discarded any protective gear.
Twenty minutes later, both nursing assistants admitted their error when questioned. V16 told inspectors that failing to wear proper protective equipment "could result in cross contamination to other residents."
The facility's Assistant Director of Nursing, who also serves as the infection prevention specialist, confirmed the violation when interviewed two days later. V21 explained that staff must wear appropriate protective equipment when providing catheter care, genital cleaning, and emptying drainage bags for residents on enhanced precautions.
"The purpose behind a resident being placed on EBP is due to that resident has had a history of a Multi Drug Resistant Organism and/or has an indwelling device," V21 told inspectors. She noted that R8 qualified for enhanced precautions on both counts.
V21 emphasized the resident's vulnerability: "R8 is high risk for obtaining another infection which could be spread if the staff do not wear the proper PPE."
Multi-drug resistant organisms pose serious threats in nursing homes because they resist multiple antibiotics, making infections difficult to treat. Residents with indwelling catheters face additional infection risks because the devices provide pathways for bacteria to enter the body.
The facility's own infection control policy requires gowns and gloves during high-contact care activities for residents with drug-resistant organism histories or indwelling medical devices. The policy specifically lists hygiene care, catheter management, and wound care as situations requiring protective equipment.
Enhanced Barrier Precautions represent an intermediate level of infection control, more restrictive than standard precautions but less intensive than full isolation. The approach aims to prevent transmission of resistant organisms while allowing residents to participate in facility activities.
Federal inspectors reviewed 17 residents for urinary tract infections and examined three residents on enhanced precautions. Only R8's care violated infection control requirements during the inspection period.
The inspection occurred following a complaint to state health officials. The violation received a "minimal harm" rating, indicating the deficiency had limited immediate impact but created potential for more serious consequences.
Nursing homes nationwide have struggled with infection control since the COVID-19 pandemic highlighted the consequences of inadequate protective measures. Federal regulators have increased scrutiny of facilities' compliance with infection prevention protocols.
The Charleston facility must submit a plan detailing how it will correct the infection control deficiency and prevent similar violations. State health officials will verify compliance during future inspections.
R8 remains at the facility with her enhanced barrier precautions in place. The resident's cognitive abilities remain intact, meaning she likely understood the care she received and the staff's failure to follow safety protocols designed to protect her and other residents from dangerous infections.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Charleston Rehab and Nursing from 2025-09-02 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Charleston Rehab and Nursing in CHARLESTON, IL was cited for violations during a health inspection on September 2, 2025.
Both staff members acknowledged afterward they should have worn gowns during the direct care.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.