Charleston Rehab And Nursing

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review the facility failed to ensure the dignity of one (Resident R8) resident out of three residents reviewed for resident rights in a sample list of 17 residents. Findings include: Resident R8's Minimum Data Set (MDS) dated [DATE REDACTED] documents Resident R8 as cognitively intact. Resident R8's Nurse Progress Note dated 8/17/2025 at 12:24 PM documents Resident R8 was crying, stating staff was not listening, laughing at her (Resident R8) and stated she (Resident R8) wanted to leave Against Medical Advice (AMA). On 8/27/25 at 10:00 AM, Resident R8 stated on 8/13/25 she was worried about Resident R9 since Resident R8 heard Resident R9 screaming so loud. Resident R8 stated she got herself up into her motorized wheelchair and went out to the hall. Resident R8 stated V2 Director of Nursing (DON) was yelling and laughing at her (Resident R8) because she was concerned about Resident R9. Resident R8 stated Resident R8 had an abscessed tooth on the upper Left back side in her mouth. Resident R8 stated she woke up one day (8/17/25) and 'the whole Left side of my face was swollen out to here' (pointing to Left cheek area). Resident R8 stated Resident R8 was telling the staff (V2 DON, V14 LPN and V20 LPN) about this and the staff yelled and laughed at her. Resident R8 stated 'They (staff) were all laughing at me. It made me feel so sad.' On 8/27/25 at 1:50 PM, V1 Administrator stated staff should always treat residents with dignity and respect. V1 stated the staff should be more aware of residents. V1 stated Resident R8 was not abused but the staff should be more aware of their conversations when residents are within earshot. The facility policy approved December 2024 documents each resident in this community has

the right and will be afforded the right to a dignified existence, self-determination, and communications with and access to persons and services inside and outside the community without interference, coercion, discrimination or reprisal. No staff member or contracted provider of care will hamper, compel, treat differently or retaliate against a resident for exercising Resident Rights.

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

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Charleston Rehab and Nursing

716 Eighteenth Street Charleston, IL 61920

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)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

cursing and throwing items. V1 Administrator stated on 8/14/25, Resident R9 was upset because his pencil sharpener was missing. V1 Administrator stated Resident R9 yells out regardless of who is around. V1 Administrator stated that morning (8/14/25) Resident R9 intentionally yelled curse words at Resident R13.

The facility policy titled Abuse, Prevention & Prohibition Policy approved December 2024 documents each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. The facility Administrator will be designated as the facility Abuse Coordinator and will be responsible for overseeing the Abuse Prevention and Prohibition Program and directing any abuse investigation. If the Administrator is not available to address this role, the Administrator will designate

a person “in charge” in their absence to fulfill the role. This person would normally be the Director of Nursing. Resident to resident abuse includes the term “willful”. The work “willful” means that the individual's action was deliberate (not inadvertent or accidental), regardless of whether the individual intended to inflict injury or harm. Verbal Abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within the hearing distance regardless of their age, ability to comprehend, or disability.

Mental abuse includes but is not limited to, humiliation, harassment, and threats of punishment or deprivation. Mental abuse includes but is not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate a resident.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Charleston Rehab and Nursing

716 Eighteenth Street Charleston, IL 61920

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)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review the facility failed to report allegations of mental abuse on two separate occasions affecting one (Resident R8) resident from staff interactions to the State Agency timely out of three residents reviewed for Abuse in a sample list of 17 residents. Findings include:Resident R8's Minimum Data Set (MDS) dated [DATE REDACTED] documents Resident R8 as cognitively intact. Resident R8's Nurse Progress Note dated 8/17/2025 at 12:24 PM documents Resident R8 was crying, stating staff was not listening, laughing at her and states she wanted to leave Against Medical Advice (AMA). On 8/26/25 at 12:10 PM, V1 Administrator was informed of an allegation of mental abuse of Resident R8 from staff V2 Director of Nursing (DON), V14 Licensed Practical Nurse (LPN) and V20 LPN on 8/13/25. V1 stated this allegation was never reported to the State Agency. On 8/27/25 at 1:40 PM, V1 Administrator stated she was not made aware of Resident R8's allegation of mental abuse from staff on 8/13/25 nor 8/17/25. V1 stated she was made aware through her own record review of Resident R8 on 8/27/25. V1 Administrator stated staff should always report any allegation of abuse directly to the Administrator. The facility policy titled Abuse, Prevention & Prohibition Policy approved December 2024 documents each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. The facility Administrator will be designated as the facility Abuse Coordinator and will be responsible for overseeing the Abuse Prevention and Prohibition Program and directing any abuse investigation. If the Administrator is not available to address this role, the Administrator will designate a person in charge in their absence to fulfill the role. This person would normally be the Director of Nursing. Resident abuse must be reported immediately to the Administrator. The Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Charleston Rehab and Nursing

716 Eighteenth Street Charleston, IL 61920

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)

F 0684 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Foreskin for cleansing due to Resident R10's filleted Penile wound was bleeding. V16 CNA stated Resident R10's entire area should have been cleansed including underneath Resident R10's Penile Foreskin.On 8/27/25 at 12:15 PM, V17 Registered Nurse (RN) stated she forgot to wash her hands after cleansing Resident R10's fillet Penile wound and prior to applying Resident R10's Zinc treatment. V17 RN stated she should have not used her gloves to apply Resident R10's cream. V17 RN stated she was unable to see Resident R10's entire filleting of Resident R10's Penis due to she did not fully retract Resident R10's Penile Foreskin. On 8/29/25 at 1:40 PM, V2 Director of Nursing (DON) stated Resident R10 did not admit to the facility with any Penile wounds. V2 DON stated Resident R10 should have his catheter secured at all times to prevent tethering. V2 DON stated Resident R10's Penile wound is directly caused by the constant pulling of his urinary catheter. V2 DON stated there is no reason the facility should be out of a commonly product such as Zinc Oxide. V2 DON stated Resident R10's Zinc is a physician order and should be followed. V2 DON stated Resident R10's Penile wound has worsened while Resident R10 as stayed at this facility. V2 DON stated the facility is not able to provide any documentation of Resident R10's Penile wound assessment and/or monitoring. Resident R10's Physician Order Sheet (POS) dated July 2025, and August 2025 documents a physician order starting 7/25/25 to apply Zinc cream to Resident R10's penis twice a day. The facility policy titled Urinary Catheter Care approved December 2024 documents staff are to secure the catheter after providing catheter care. This same policy instructs staff to ensure the catheter remains secured with a leg strap to reduce friction and movement at the insertion site.

Catheter tubing should be strapped to the resident's inner thigh. The undated facility Skills Checklist for Changing Dressing/Treatment instructs staff to wash and dry hands thoroughly after cleansing wound and prior to applying new gloves to apply treatment.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Charleston Rehab and Nursing

716 Eighteenth Street Charleston, IL 61920

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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review, the facility failed to effectively supervise an unalarmed and unlocked facility exit door. This failure resulted in Resident R3, a resident with a diagnosis of Dementia, eloping unnoticed from the facility and exiting through the facility courtyard towards the facility parking lot area. The facility also failed to identify and document any root-cause for Resident R3's elopement in their elopement investigation. Resident R3 is one of three residents reviewed for supervision in the sample of 17. Findings include: Resident R3's Medical Diagnosis sheet (8/27/2025) documents Resident R3's diagnoses including Dementia, Weakness, Muscle Wasting and Atrophy, and Unsteadiness on Feet. Resident R3's Orders sheet (8/27/2025) documents the order May be up ad-lib (at liberty) per plan of care. Resident R3's Elopement Assessment (6/4/2025) documents Resident R3 is cognitively impaired, independently mobile, and has the elopement risk factor of a recent mental status change. Resident R3's Resident Assessment (6/10/2025) documents Resident R3 has severe cognitive impairment.Resident R3's Care Plan (8/27/2025) documents Resident R3 only requires a minimal level of staff assistance as needed for ambulation.The facility incident report (8/8/2025) documents V5 (Certified Nursing Assistant) noticed Resident R3 walking on a sidewalk outside of the facility on 8/2/2025 and retrieved Resident R3 back into the facility and to Resident R3's bedroom. On 8/27/2025 at 1:45PM, V5 reported being in Resident R15's room on 8/2/2025 providing care to Resident R15 and when V5 looked through Resident R15's window, Resident R3 was visible outside of the facility walking down a sidewalk along the side of the building with Resident R3's walker. V5 reported immediately going outside to retrieve Resident R3 back inside of the facility with Resident R3 stating to V5 at the time it's a beautiful day outside and I just got turned around and need to go home. V5 reported turning Resident R3 around to go back into the facility and Resident R3 then stated Oh, there's my home. V5 denied any door alarms were sounding when Resident R3 eloped from the facility. V5 reported Resident R3 must have exited the building through an exit door located in the hallway near Resident R3's room leading to a courtyard and then out of the courtyard to the sidewalk where V5 found Resident R3. V5 reported the courtyard has a swinging gate that leads to a sidewalk located along the exterior building perimeter and the gate was unlocked and open the day Resident R3 eloped due to the facility mowing contractor being in and out of the courtyard area to [NAME] grass. V3 reported Resident R3 ambulates independently and Resident R3's cognition is so-so and hit or miss. V5 reported the hallway exit door to the courtyard was always kept unlocked and unalarmed so residents who smoke independently could access the facility smoking area located inside of the courtyard without staff supervision. On 8/29/2025 at 10:48AM, the swinging gate leading from the above courtyard to

the sidewalk and building exterior was closed but unlocked and easily opened by the surveyor. The facility Elopement policy (June 2025) documents It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible and Should an elopement occur, the facility's QAPI Committee shall determine the root cause of the elopement and review the facility's systems, policies and procedures, and responses to elopements to identify areas of opportunity for improvement.The facility's Elopement investigation related to Resident R3's 8/2/2025 elopement does not identify or document any root cause for Resident R3's elopement occurring on 8/2/2025 and does not document the hallway exit door above was unsupervised, unlocked, and unalarmed when Resident R3 eloped from the facility. The same investigation fails to document the courtyard exit gate was unlocked at the time of Resident R3's elopement.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Charleston Rehab and Nursing

716 Eighteenth Street Charleston, IL 61920

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)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to document a resident (Resident R3) elopement and subsequent investigation in the resident's medical record. This failure affects one resident (Resident R3) of three reviewed for elopement in the sample of 17.Findings include:Resident R3's Medical Diagnosis sheet (8/27/2025) documents Resident R3's diagnoses including Dementia, Weakness, Muscle Wasting and Atrophy, and Unsteadiness on Feet. Resident R3's Orders sheet (8/27/2025) documents the order May be up ad-lib (at liberty) per plan of care. Resident R3's Elopement Assessment (6/4/2025) documents Resident R3 is cognitively impaired, independently mobile, and has

the elopement risk factor of a recent mental status change.Resident R3's Resident Assessment (6/10/2025) documents Resident R3 has severe cognitive impairment.Resident R3's Care Plan (8/27/2025) documents Resident R3 only requires a minimal level of staff assistance as needed for ambulation.The facility incident report (8/8/2025) documents V5 (Certified Nursing Assistant) noticed Resident R3 walking on a sidewalk outside of the facility on 8/2/2025 and retrieved Resident R3 back into the facility and to Resident R3's bedroom. On 8/27/2025 at 1:45PM, V5 reported being in Resident R15's room on 8/2/2025 providing care to Resident R15 and when V5 looked through Resident R15's window, Resident R3 was visible outside of the facility walking down a sidewalk along the side of the building with Resident R3's walker. V5 reported immediately going outside to retrieve Resident R3 back inside of the facility with Resident R3 stating to V5 at the time it's a beautiful day outside and I just got turned around and need to go home. V5 reported turning Resident R3 around to go back into the facility and Resident R3 then stated Oh, there's my home. V5 denied any door alarms were sounding when Resident R3 eloped from the facility. V5 reported Resident R3 must have exited the building through an exit door located

in the hallway near Resident R3's room leading to a courtyard and then out of the courtyard to the sidewalk where V5 found Resident R3. V5 reported the courtyard has a swinging gate that leads to a sidewalk located along the exterior building perimeter and the gate was unlocked and open the day Resident R3 eloped due to the facility mowing contractor being in and out of the courtyard area to [NAME] grass. V3 reported Resident R3 ambulates independently and Resident R3's cognition is so-so and hit or miss. V5 reported the hallway exit door to the courtyard was always kept unlocked and unalarmed so residents who smoke independently could access the facility smoking area located inside of the courtyard without staff supervision. On 8/29/2025 at 10:48AM, the swinging gate leading from the above courtyard to the sidewalk and building exterior was closed but unlocked and easily opened by the surveyor. The facility Elopement policy (June 2025) documents It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible and Should an elopement occur, the facility's QAPI Committee shall determine the root cause of

the elopement and review the facility's systems, policies and procedures, and responses to elopements to identify areas of opportunity for improvement.The facility's Elopement investigation related to Resident R3's 8/2/2025 elopement does not identify or document any root cause for Resident R3's elopement occurring on 8/2/2025 and does not document the hallway exit door above was unsupervised, unlocked, and unalarmed when Resident R3 eloped from the facility. The same investigation fails to document the unlocked courtyard exit gate was unlocked at the time of Resident R3's elopement.On 8/29/2025 at 1:23PM, V2 (Director of Nursing) reported being unsure if Resident R3's medical record in the facility documented Resident R3's elopement occurring on 8/2/2025.Resident R3's nursing progress notes (August 2025) do not document Resident R3's elopement.Resident R3's electronic medical record (undated/accessed 9/2/2025) does not document Resident R3's elopement incident on 8/2/2025.On 9/2/2025 at 1:32PM, V2 reported V2 would look again in Resident R3's medical record for documentation of the elopement and V2 reported being unsure if the elopement was documented anywhere except in the Risk section of Resident R3's electronic medical record (a portion of Resident R3's EMR not normally accessible to medical staff or nursing staff).

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Charleston Rehab and Nursing

716 Eighteenth Street Charleston, IL 61920

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)

F 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview and record review the facility failed to wear the proper Personal Protective Equipment (PPE) for one (Resident R8) resident on Enhanced Barrier Precautions (EBP) out of three residents reviewed for Urinary Tract Infections (UTI) in a sample list of 17 residents. Findings include:Resident R8's Minimum Data Set (MDS) dated [DATE REDACTED] documents Resident R8 as cognitively intact. This same MDS documents Resident R8 as requiring maximum assistance for toileting and moderate assistance for dressing, personal hygiene and bathing.Resident R8's Electronic Medical Record (EMR) documents Resident R8 is on Enhanced Barrier Precautions (EBP) due to Resident R8 having a history of a Multi Drug Resistant Organism (MDRO) and currently has an indwelling urinary catheter. On 8/27/25 at 2:00 PM, V15 and V16 Certified Nurse Assistants (CNA) provided indwelling urinary catheter care and perineal care for Resident R8. Resident R8 had a sign on the wall outside her door next to the floor that read 'Enhanced Barrier Precautions' (EBP). V15 and V16 did not wear gowns when providing direct catheter care and perineal care for Resident R8. V16 CNA emptied Resident R8's urinary drainage bag which contained 450 milliliters (ml) of dark orange, hazy urine without wearing a gown. Resident R8's room did not contain any disposal bins for contaminated Personal Protective Equipment (PPE). Resident R8's garbage cans inside her room did not contain any PPE that had been disposed of. On 8/27/25 at 2:20 PM, V15 and V16 Certified Nurse Assistants (CNA) both stated they should have worn gowns when providing direct cares for Resident R8. V16 CNA stated not wearing the proper PPE could result in cross contamination to other residents. On 8/29/25 at 10:45 AM, V21 Assistant Director of Nursing (ADON)/Infection Preventionist (IP)/Registered Nurse (RN) stated staff should wear the appropriate Personal Protective Equipment (PPE) when providing direct cares such as indwelling urinary catheter care, perineal care and emptying of a resident's urinary drainage bag.

V21 stated the purpose behind a resident being placed on EBP is due to that resident has had a history of

a Multi Drug Resistant Organism (MDRO) and/or has an indwelling device. V21 stated Resident R8 has both a history of MDRO and has an indwelling urinary catheter. V21 stated Resident R8 is high risk for obtaining another infection which could be spread if the staff do not wear the proper PPE. The undated facility policy titled Infection Prevention and Control Manual-Enhanced Barrier Precautions (EBP) documents EBP involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a Multi Drug Resistant Organism (MDRO) as well as those at increased risk for MDRO acquisition (such as residents that have wounds or indwelling medical devices). High-contact resident care activities where a gown and gloves should be used include providing hygiene, caring for or using an indwelling medical device and performing wound care.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Charleston Rehab and Nursing

716 Eighteenth Street Charleston, IL 61920

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)

F 0908

Keep all essential equipment working safely.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review the facility failed to check their medical equipment on a timely basis to ensure

the medical equipment is in good working condition. The failure of maintaining the Automated External Defibrillator (AED) prevented the use of the AED during an episode of Cardiac Failure for one resident (Resident R1) reviewed for Cardiac Failure in a sample of one. Findings include:Progress notes for Resident R1 dated [DATE REDACTED] at 7:01 PM document Resident R1's return from the hospital to the facility with the diagnosis of Acute Respiratory Failure with Hypoxia. On [DATE REDACTED] staff was sent to get V25 Registered Nurse (RN) due to Resident R1 having an episode of not breathing and unresponsive. V25 asked staff to take Resident R1 to his room and place him on the bed with the cardiac board behind Resident R1's back and to obtain the cardiac cart due to Resident R1's medical status. On [DATE REDACTED] at 9:56 AM, return call from V25 RN (Registered Nurse) was received and V25 stated Resident R1 's head was bent over and Resident R1 still had a weak pulse and was breathing slowly. V25 asked the following CNAs to take Resident R1 to his room and put him to bed. V26 and V27 took Resident R1 to his room and put him in bed with the code board behind his bag. I (V25) had called EMS while they (CNAs) were putting Resident R1 into the bed. After Resident R1 was

in bed V26 went to get the code cart and equipment. Upon returning with the code cart compressions were being done by V27 and I (V25) hooked up the AED to Resident R1's chest. The AED would not work I don't know if

the battery was dead or what the problem was. We started doing chest compressions and V26 was using

the Ambu bag. EMS arrived and they took over the situation with Resident R1. Resident R1 was pronounced dead by EMS

after performing compression with Resident R1 for 20 minutes. EMS called the coroner and Resident R1's body was taken to

the local hospital morgue due to not listing a funeral home on his admission papers.On [DATE REDACTED] at 2:04 PM, V2 Director of Nursing stated No I do not believe the AED would have changed the outcome for Resident R1. The girls started doing the CPR procedure immediately. We do not have the AED here anymore and the last time it was checked was last of June. The AED was not checked on [DATE REDACTED]st to [DATE REDACTED]th and on [DATE REDACTED] we found out it was not working. The AED should be checked daily. We have a form we use to check off the equipment was checked.Facility policy titled Automated External Defibrillator, Use and Care Of. This policy is undated. The section titled Maintaining the AED: states 1. Check the device and perform maintenance tasks, as directed in the AED Manual.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet