Charleston Rehab: PPE Failures for Drug-Resistant Infection - IL
The resident, identified in inspection records only as R8, is cognitively intact and knows what is happening around her. She needs maximum help getting to the toilet and moderate help with dressing and personal hygiene. She also carries a history of a Multi Drug Resistant Organism and has an indwelling urinary catheter, a combination that her facility's own infection preventionist later described as making her high risk for obtaining another infection.
On August 27, 2025, at 2:00 in the afternoon, two certified nursing assistants entered R8's room and performed indwelling urinary catheter care and perineal care. Neither wore a gown. One of them, identified as V16, then emptied R8's urinary drainage bag, which held 450 milliliters of dark orange, hazy urine. Still no gown.
Inspectors noted the room contained no disposal bins for contaminated protective equipment. The garbage cans inside the room held no used PPE at all, confirming the gowns had not simply been removed and discarded before inspectors arrived. They had never been put on.
Twenty minutes after the care was provided, inspectors spoke with both nursing assistants. V15 and V16 each acknowledged they should have worn gowns. V16 went further, stating directly that not wearing the proper PPE could result in cross contamination to other residents.
That admission is worth sitting with. The nursing assistant understood the risk, articulated it clearly to an inspector, and had not acted on it during the care she had just finished providing.
Two days later, on August 29, the facility's Assistant Director of Nursing, who also serves as the Infection Preventionist and is a registered nurse, told inspectors the same thing. Staff should wear appropriate PPE during catheter care, perineal care, and drainage bag emptying. She explained that Enhanced Barrier Precautions exist precisely because a resident has a history of MDRO or has an indwelling device. R8 has both. The ADON stated plainly that R8 is high risk for obtaining another infection, and that the risk spreads if staff do not wear the proper PPE.
The facility's own written infection control policy, though undated, spells out that gown and glove use is required during high-contact care activities for residents with MDRO history or indwelling medical devices. Catheter care is listed by name as one of those activities.
The inspection was triggered by a complaint and was completed September 2, 2025. Inspectors reviewed three residents flagged for urinary tract infections out of a broader sample of 17. The PPE failure was documented for R8 alone.
CMS rated the harm level as minimal, or potential for actual harm. That classification reflects the regulatory framework, not necessarily what R8 faces going forward. A resident with a drug-resistant organism history and an indwelling catheter, who requires hands-on assistance for her most basic bodily care, depends entirely on the people entering her room to follow the precautions posted on her wall. On the afternoon of August 27, two of those people did not. They knew the sign was there. They knew what it meant. They said so themselves.
The dark orange, hazy urine in that drainage bag suggested R8 may already have been dealing with another infection at the time of the inspection. The report does not say. What it does say is that the staff member who emptied it was not wearing a gown, and that the same staff member told an inspector, minutes later, exactly why that was a problem.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Charleston Rehab and Nursing in CHARLESTON, IL was cited for violations during a health inspection on September 2, 2025.
The resident, identified in inspection records only as R8, is cognitively intact and knows what is happening around her.
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.