Charleston Rehab and Nursing: Wound Care Failures - IL
The Director of Nursing said so herself.
The resident, identified in inspection records as R10, had a urinary catheter. The Director of Nursing told inspectors on August 29 that the wound was directly caused by the catheter being pulled, a condition called tethering, and that the catheter should have been secured to his inner thigh with a leg strap at all times to prevent exactly that kind of friction and movement. It wasn't.
A physician had ordered zinc oxide cream applied to the wound twice daily, starting July 25. That order was documented in R10's records for both July and August. At some point, the facility ran out of zinc oxide. The Director of Nursing told inspectors there was no reason the facility should have been out of a product that common, and that a physician order is supposed to be followed.
It wasn't followed.
When a registered nurse did apply the cream, she did it wrong. On August 27, she told inspectors she had forgotten to wash her hands after cleaning the wound and before applying the treatment. She also acknowledged she should not have used the gloves she had just used on the wound to apply the cream. Her own facility's skills checklist, undated but on file, instructs staff to wash and dry hands thoroughly after cleansing a wound and before putting on new gloves to apply treatment.
She also told inspectors she couldn't see the full extent of the wound because she hadn't fully retracted the foreskin during cleaning. A certified nursing assistant confirmed that the entire area, including underneath the foreskin, should have been cleaned.
The wound the inspection report describes is not a minor abrasion. Inspectors used the word "filleted" repeatedly in their notes, a clinical term indicating the tissue had split open. It was bleeding.
The Director of Nursing confirmed to inspectors that R10 did not arrive at the facility with any penile wound, that the wound was caused by conditions at the facility, that it had worsened during his stay, and that the facility had no documentation of any wound assessment or monitoring at any point.
No records. None.
That absence matters beyond the paperwork. Without documented assessments, there is no way to know when the wound first appeared, how quickly it progressed, whether any staff member flagged it to a physician in a timely way, or whether earlier intervention could have changed the outcome. The Director of Nursing's own statement, that the wound worsened while R10 was a resident, is the only timeline the record contains.
Inspectors rated the deficiency as causing actual harm, affecting a small number of residents.
The inspection was conducted September 2, 2025, following a complaint. Charleston Rehab and Nursing is located at 716 Eighteenth Street in Charleston.
R10 came to the facility without a wound. He left with one that had grown worse, caused by a catheter no one properly secured, treated with cream that ran out, applied by a nurse who forgot to wash her hands, on tissue she couldn't fully see because she didn't complete the cleaning. And somewhere in the facility's files, there is no chart, no note, no assessment form that documents any of it.
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: August 5, 2026 · Our methodology
Charleston Rehab and Nursing in CHARLESTON, IL was cited for violations during a health inspection on September 2, 2025.
The Director of Nursing said so herself.
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.