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Inspection visit

Inspection

COULTERVILLE REHAB & HCCCMS #1459938 citations on this visit
8 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 8 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to ensure residents were free from verbal abuse for 1 of 3 residents (R45) reviewed for abuse in the sample of 44. Findings include: R45's Minimum Data Set (MDS), dated [DATE], documents R45 is cognitively intact and requires extensive to total assistance with most Activities of Daily Living. R45's Progress Note by V1, Administrator, on 5/14/23 at 11:22 AM documents, Resident reported an agency CNA had been rude with her and threw a grabber on her bed and it landed on the resident's legs. This writer assessed bilateral lower legs and saw (no) injuries or discolored areas. The Facility's Initial Report sent to the Illinois Department of Public Health by V1 on 5/14/23 documents, At 10:30 AM on 5/14/2023, I was notified by (V12, CNA, Certified Nurse Aide), and (V13, CNA) that resident (R45) had told them a night shift CNA had thrown a grabber at her. Administrator went and immediately spoke with (R45) about allegation. (R45) states she was in bed and (V14, CNA) responded to call light and when asked to apply lotion to residents back she stated she couldn't reach the lotion and needed a grabber, (R45) handed (V14) her grabber at which point (V14) left room for 20 minutes. When (V14), CNA, returned to room she threw the grabber on the bed, and it landed on (R45)'s lower legs. (R45) states (V14) CNA was rude with her both times she came in room telling her she could do things herself. Roommate (R57) interviewed, and states (V14) was rude to (R45) but not her. (R45) states (V14) did not return to room after that. This writer examined legs and found no injuries or discoloration, (R45) states legs did not hurt when it (hit) by grabber. The Facility's Final Report sent to Illinois Department of Public Health by V1on 5/19/23 documents, At 10:30am on 5/14/23 I was notified by (V12), CNA and (V13), CNA that resident (R45) had told them a night shift CNA had thrown a grabber at her. Administrator went immediately to speak to (R45) about allegation. Resident states she was in bed at approximately 1830 (6:30 PM) on 5/13/23and (V14), CNA, responded to call light and when (R45) asked her to apply lotion to her back (V14) stated she couldn't reach the lotion and needed a grabber, (R45) handed (V14) her grabber to use and (V14) then left room returning 20 minutes later. Upon re-entering resident's room (V14) threw the grabber on the bed and it landed on (R45)'s lower legs and told (R45) to apply the lotion herself. (R45) states she only had those 2 encounters with the CNA (V14) then another (another) CNA took over her care. (R45) denies telling any staff about the episode until the next morning when she spoke to CNAs (V12) and (V13). Roommate (R57) was interviewed and states that she heard (V14) being rude to (R45) but she wasn't rude to her. (V14) is an agency and did not return calls for interview about episode. (V14) (continued on next page) 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 Page 1 of 14 Event ID: 145993 Printed: 05/15/2026 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 145993 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coulterville Rehab & Hcc 13138 State Route 13 Coulterville, IL 62237 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 has been marked as a do not return on the agency portal. (R45) during interview stated she found the way care was refused and the way she was spoken to by (V14) was abusive. On 7/20/23 at 9:50 AM, V13 stated, (R45) told me that (V14) came in and was rude and nasty to her and got upset with her because she wanted things, then (V14) took the grabber and threw it at (R45). (R45) was upset, but said her leg wasn't hurt. On 7/20/23 at 11:28 AM, R57, R45's roommate, stated, (V14) was not very nice to (R45). She was very ugly to her. (R45) told (V14) she was going to turn her in, then (V14) made a remark that was not very nice. Then (V14) threw her hands up and broke my little flower (decoration). It was a gift from my old roommate who passed away. (V14) is in the wrong profession. R57's MDS, dated [DATE], documented R57 was cognitively intact. On 7/20/23 at 1:47 PM, V1 stated she would not expect staff to throw items on resident beds. The Facility's Abuse, Prevention and Prohibition Policy revised 10/2022 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 Policy documents This facility prohibits mistreatment, neglect or abuse of residents. The Policy documents The residents must not be subjected to abuse by anyone. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145993 If continuation sheet Page 2 of 14 Printed: 05/15/2026 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 145993 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coulterville Rehab & Hcc 13138 State Route 13 Coulterville, IL 62237 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide adequate supervision to prevent falls for 1 of 3 residents (R13) reviewed for supervision to prevent falls in a sample of 44. This failure resulted in R13 falling twice in one day and sustaining a right inferior orbital blowout fracture and minimally displaced left nasal bone fracture. Findings include: R13's admission Record, printed on 7/21/23, documents R13 had history of falling, unspecified dementia, unspecified severity, with agitation, unspecified abnormalities of gait and mobility and abnormal posture. R13's Minimum Data Set (MDS), dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 11 indicating moderate cognitive impairment. The MDS documents that R13 requires limited assistance of one person for bed mobility, transfer, dressing, toilet use, and personal hygiene. The MDS documents that R13 requires supervision of one person for locomotion on unit and locomotion off unit. The MDS documents that R13 is not steady, only able to stabilize with staff assistance. R13's Care Plan Focus, dated 2/22/2022 documents, (R13) has impaired cognitive function/dementia or impaired thought processes. R13's Care Plan, dated 05/17/23 documents (R13) remains at risk for falls with injury r/t (related to) her impaired cognition, new admission and hx (history) of actual falls with need for monitoring. Care Plan goal revised on 5/3/23, documented continues with repeated falls, with all interventions reviewed. Care Plan intervention, dated 6/24/22, documented Re-educated resident on safety and using call light to summon staff to give her stand-by assistance with transfers and toileting. R13's Health Status Note dated 04/28/23 at 5:52 AM documents CNA (Certified Nursing Aide) reported to this nurse that resident was found on floor between bed and wheelchair. This nurse went to resident's room to assess her and on assessment found no injuries. Resident states 'I fell when I was trying to get in bed.' Resident denies hitting her head. MD (V16) notified via fax, POA (Power of Attorney) also notified. Vitals 97.4 (temperature) 107 (pulse) 20 (respiration) 143/80 (blood pressure) 94%RA (room air). R13's Fall Investigation dated 04/28/23 documents CNA reported that resident was found on the floor between bed and wheelchair. No injuries found during assessment. Conclusion: Elder frequently attempts to complete task without assistance. Staff educated elder to use call light for assistance. Root cause: No fault. R13's Health Status Note dated 04/28/23 at 9:00 AM documents CNA reported to this writer that R13 was having a slight left sided droop and some slurred speech after a fall this morning. This nurse went to assess resident and resident's vitals were 142/80 BP (blood pressure), 91 BPM (beats per minute), 93 o2 (oxygen saturation), 18 resp (respiration), 98.1 temp. This writer then notified DON (Director of Nursing) of resident's condition and DON advised this writer to call (V16). (V16) was notified and advised this writer to keep an eye on the resident and call back if residents condition worsens. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145993 If continuation sheet Page 3 of 14 Printed: 05/15/2026 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 145993 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coulterville Rehab & Hcc 13138 State Route 13 Coulterville, IL 62237 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 - Actual harm Residents Affected - Few R13's Health Status Note dated 04/28/23 at 9:45 AM documents CNA reported to this writer that resident was on the floor. This writer assessed resident and resident had swelling and a hematoma to her right eye. Resident had and an episode of emesis. This nurse helped CNA get resident up into wheelchair this writer took residents vitals which were 166/82 BP, 124 BPM, 100.2 temp, 92 o2. This nurse then notified DON and was advised to send resident to the hospital. This writer then called 911 and asked for transport. this nurse then notified MD of resident being sent out. POA notified of transport. Resident transported to (local hospital) via EMS (Emergency Medical System). R13's Fall Investigation dated 04/28/23 documents CNA reported that resident was on the floor. Swelling and hematoma noted to right eye. CNA and nurse assisted resident into wheelchair and vitals obtained. Conclusion: Elder was immediately sent to ED for evaluation and 1-hour visual checks initiated upon return from the hospital. Root cause: No fault. R13's Hospital Report dated 04/28/23 documents Right inferior orbital blowout fracture and minimally displaced left nasal bone fracture. On 07/20/23 at 12:32 PM, V16, Medical Director stated that he feels the facility did everything that they could do to prevent R13 from falling. He stated that R13 has tendency of getting up without any help. On 07/21/23 at 10:47 AM, V2, Director of Nursing (DON) stated that R13 fell and then they had her up at the nurses' station. The nurse did not realize she wheeled herself back to her room, by the time they figured it out, she was on the floor. Facility's Fall Policy revised 09/17/19 documents The purpose of the Fall Management Program is to develop, implement, monitor, and evaluate an interdisciplinary team falls prevention approach and manage strategies and interventions that foster resident independence and quality of life. The Fall Management Program promotes safety, prevention and education of both staff and residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145993 If continuation sheet Page 4 of 14 Printed: 05/15/2026 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 145993 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coulterville Rehab & Hcc 13138 State Route 13 Coulterville, IL 62237 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 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review the facility failed to have a Registered Nurse (RN) in the facility for 8 hours daily. This has the potential to affect all 70 residents living in the facility. Residents Affected - Many Findings include: The Facility Nursing Schedule dated July 4th through July 18 was reviewed, and on July 14, 2023, the facility did not have a Registered Nurse (RN) for eight consecutive hours. On 7/20/23 at 3:30 PM, V2, Director of Nursing stated, that was an oversight, and it has been corrected. On 7/21/23 at 10:25 AM V1 Administrator stated, we use the state regulations for our policy for staffing. The facility's Resident Census and Conditions of Residents Form, CMS 672, dated 7/18/23 documents the facility has a census of 70 residents. The CMS 672 documents 5 residents have indwelling or external catheters, 1 resident is restrained, 5 residents have pressure ulcers, 33 residents have dementia, 7 residents are receiving Hospice, 2 residents are receiving dialysis, 2 residents are receiving intravenous therapy/IV nutrition, and or/ blood transfusions, and 10 are residents are receiving antibiotics. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145993 If continuation sheet Page 5 of 14 Printed: 05/15/2026 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 145993 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coulterville Rehab & Hcc 13138 State Route 13 Coulterville, IL 62237 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the Facility failed to store, prepare, and distribute food in a manner that prevents foodborne illness. This has the potential to affect all 70 residents living in the Facility. Findings include: On 7/18/23 at 12:18 PM, V6, Cook, removed a bowl of tomato soup from the microwave and placed it on R65's tray. V6 did not test the temperature of the soup before tray was passed to R65. On 7/18/23 at 12:37 PM, V6, Cook, removed a bowl of tomato soup from the microwave and placed it on R30's tray. V6 did not test the temperature of the soup before the tray was passed to R30. On 7/18/23 at 12:47 PM, V6, Cook, removed a pan of hash brown casserole from the oven and placed it on the steamtable. V6 did not test the temperature of the casserole and plated the casserole on both R45's and R57's trays. The trays were then passed to R45 and R57. On 7/19/23 at 9:54 AM, the Nourishment room freezer had a half empty container of ice cream from a fast-food restaurant that was not labeled or dated. In the Nourishment refrigerator, there was a sealed plastic bag of watermelon cubes that was not labeled or dated. There was a half empty jar of pickled jalapenos with no date and a half empty jug of lemonade with no date. On 7/18/23 at 1:00 PM, V5, Food Service Director, stated she expects her staff to check temperatures before serving. On 7/20/23 at 8:37 AM in the dining room refrigerator there was a container labeled Italian chicken that was not dated. There was a plastic bag with four pieces of an unknown breaded meat that was not labeled or dated. There was an opened jar of cherries and an opened jar of jelly that were not dated. There were two opened containers of snow cone syrup that were not dated. On 7/20/23 at 1:47 PM, V1, Administrator, stated she expects staff to follow the Facility's food service policies. The Facility's Food Storage (Dry, Refrigerated, and Frozen) Policy, undated, Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. The Policy documents General storage guidelines to be followed: All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. The Policy documents Keep potentially hazardous foods out of the temperature danger zone (41 °F - 135°F, or per state specific regulations). The Facility's Monitoring Food Temperatures for Meal Service Policy, undated, documents, Food temperatures will be monitored daily to prevent food borne illness and ensure foods are served at palatable temperatures. Procedure: Prior to serving a meal, food temperatures will be taken and documented for all hot and cold foods to ensure proper serving temperatures. The Policy documents If the serving/holding temperature of a hot food item is not at 135° F (Fahrenheit) or higher (check your state specific regulations: some states require 140°F minimum hot holding temperature) when checked prior to meal service, the item will be reheated to at least 165° F for a minimum of 15 seconds. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145993 If continuation sheet Page 6 of 14 Printed: 05/15/2026 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 145993 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coulterville Rehab & Hcc 13138 State Route 13 Coulterville, IL 62237 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 0812 The Resident Census and Condition of Residents Form, CMS 672 dated 7/18/23 documents there are 70 residents living in the Facility. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145993 If continuation sheet Page 7 of 14 Printed: 05/15/2026 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 145993 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coulterville Rehab & Hcc 13138 State Route 13 Coulterville, IL 62237 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** A. Based on interview and record review, the facility failed to identify causative organisms to assist with identification of patterns to prevent infections. This has the potential to affect all 70 residents living in the facility. Residents Affected - Many Findings include: 1. Facility's Line Listing, Monthly Infection Report for Individual Nursing Units dated February 2023 documents Sections for infection site, symptoms, date of culture/x-ray and organism/results. The Line Listing documented on 02/27/23: R55 had symptoms of dysuria and was started on Keflex with no causative organism/results listed. 2. The facility Infection Control Log for March 2023 documents 5 cultures with no organisms listed on the log. There was a total of 24 infections documented on the log. Facility's Line Listing, Monthly Infection Report for Individual Nursing Units dated March 2023 documents on 03/20/23 R19 had symptoms dysuria. The Line Listing documented R19 was started on Bactrim DS with no organism/results listed. The Line Listing documented 03/05/23 R59 had symptoms of lethargy and was started on Keflex with no causative organism/results listed. The Line Listing documented on 3/6/23, R49 had symptoms of urinary symptoms and was started on Levaquin with no causative organism/results listed. 3. The facility Infection Control Log for April 2023 documents one culture with no organism listed on the log. There was a total of 11 infections documented on the log. Facility's Line Listing, Monthly Infection Report for Individual Nursing Units dated 04/17/23 documents R4 had symptoms of dysuria. The Line Listing documented she had no growth but was started on Keflex for UTI. 4. The facility Infection Control Log for May 2023 documents 4 cultures with no organisms listed on the log. There was a total of 22 infections documented on the log. Facility's Line Listing, Monthly Infection Report for Individual Nursing Units dated May 2023 documents on 05/03/23 R13 had symptoms of abnormal UA results. The Line Listing documents R13 was started on Macrobid with no causative organism/results listed. The Line Listing documents on 05/08/23 R13 had symptoms of lethargy and was started on Macrobid with no causative organism/results listed. The Line listing documents on 05/05/23 R32 had symptoms of lethargy and was started on Bactrim with no causative organism/results listed. 5. The facility Infection Control Log for June 2023 documents 3 cultures with no organisms listed on the log. There was a total of 9 infections documented on the log. Facility's Line Listing, Monthly Infection Report for Individual Nursing Units dated June 23 documents on 06/08/23 R30 had dysuria and was started Bactrim DS with no causative organism/results listed. 6. The facility Infection Control Log for July 2023 documents 2 cultures with no organisms listed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145993 If continuation sheet Page 8 of 14 Printed: 05/15/2026 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 145993 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coulterville Rehab & Hcc 13138 State Route 13 Coulterville, IL 62237 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 on the log. There was a total of 5 infections documented on the log. Level of Harm - Minimal harm or potential for actual harm Facility's Line Listing, Monthly Infection Report for Individual Nursing Units dated July 23 documents on 07/12/23 R32 had symptoms of malodorous dysuria and was started Keflex with no organism/results listed. Residents Affected - Many On 07/21/23 at 10:47 AM, V2, Director of Nursing (DON), stated that the infection control log is missing organisms because sometime hospice will not order antibiotic but will not do a culture and sometimes the doctor will order antibiotics before the culture comes back. Facility's Infection Prevention and Control Program Manual Surveillance dated 2019 documents Infection prevention begins with routine and ongoing surveillance to identify possible communicable diseases or infections before they can spread to other persons in the facility or have the potential to cause, an outbreak. The facility closely monitors all residents who exhibit signs/symptoms of infection through ongoing surveillance and has a systematic method for collecting, consolidating, analyzing, and interpretation of data concerning the frequency and cause of a given disease or event, followed by dissemination of that information to those who can improve the outcomes. The intent of surveillance is to identify possible communicable diseases or infections before they can spread to other persons in the facility. In addition, surveillance is crucial in the identification of possible clusters, changes in prevalent organisms, or increases in the rate of infection promptly. The results should be used to plan infection control activities, direct in-service education, and identify individual resident problems in need of intervention. The Resident Census and Condition of Residents Form, CMS 672 dated 7/18/23 documents there are 70 residents living in the Facility. B. Based on observation and record review, the facility failed to perform hand hygiene to prevent the spread of infection for 3 of 11 residents (R11, R47, R58) reviewed for infection control in the sample of 44. Findings include: 1.R11's Minimum Data Set, dated [DATE] documents R11 requires extensive assistance of two plus persons for toilet use and is always incontinent of urine. R11's Physician Order, dated 6/5/23, documented R11 was receiving Cefuroxime Axetil for a Urinary Tract Infection (UTI) On 07/20/23 at 1:58 PM, V20, CNA, assisted R11 with incontinent care. V20 washed hands with soap and water in bathroom. V20 donned gloves and removed blanket from R11. V20 washed R11's peri-area and vagina with wet wash cloth. V20 dried R11's peri-area and vagina with a towel. V20 rolled R11 toward wall and washed R11's buttocks and gluteal cleft with a new wet washcloth and dried with a towel. V20 placed a new bed pad under R11. R11 was rolled toward V20. Bed pad was straightened out and R11 was rolled onto back. V20 doffed gloves and covered resident with blanket. V20 donned new gloves without hand hygiene and cleaned up supplies. 2. R47's Nursing Note dated 05/03/23 at 9:50 AM documents UA WAS OBTAINED LAST NIGHT AND SENT TO LAB. AWAITING RESULTS. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145993 If continuation sheet Page 9 of 14 Printed: 05/15/2026 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 145993 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coulterville Rehab & Hcc 13138 State Route 13 Coulterville, IL 62237 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 Level of Harm - Minimal harm or potential for actual harm R47's Physician Order dated 05/06/23 documents Cephalexin Capsule 500 MG; Give 1 capsule by mouth three times a day for infection for 7 Days. R47's Nursing Note dated 05/06/23 at 2:49 PM documents UA results. E. Coli detected. New order for Keflex 500mg 1 po BID x7 days. Resident and POA aware and voices understanding. Residents Affected - Many On 07/20/23 at 1:43 PM, V20, CNA assisted R47 with incontinent care. V20 washed hands with soap and water in bathroom. V20 donned gloves, pulled down covers, and open trash bags. V20 doffed gloves and donned new gloves without hand hygiene. V20 washed R47's peri-area and vagina with wet wash cloth. V20 then dried R47's peri-area and vagina with a towel. V20 doffed and donned new gloves without hand hygiene. V20 washed R47's buttocks and gluteal cleft with wet wash cloth, dried R47's buttocks with a towel and rolled a bed pad under R47. V20 doffed and donned new gloves without hand hygiene. Bed pad was straightened out and R47 was covered up. V20 doffed gloves and lowered bed. V20 donned new gloves without hand hygiene and clean up trash bags and supplies. 3.R58's MDS dated [DATE] documents a BIMS score of 4 out of 15. Resident is total dependence of two plus persons for toilet use. Resident is always incontinent of urine. R58's Physician's Order, dated 7/15/23, documented he was receiving Ciprofloxacin HCL for a UTI. On 07/20/23 1:12 PM, V4, CNA and V13, CNA assisted R58's with incontinent care. Both CNAs washed their hands with soap and water in the bathroom prior to starting. V4 washed R58's buttocks and gluteal cleft with wash cloth. V4 doffed gloves and donned new gloves without any hand hygiene. V4 then washed R58's peri-area and penis with a washcloth. V4 doffed gloves and donned new gloves without any hand hygiene. V4 dried R58's peri-area with a towel. V4 doffed gloves and donned new gloves without hand hygiene. V13 rolled R58's toward her. V4 placed incontinent brief under R58. R58 was then rolled toward V4. R58 was rolled on his back and incontinent was pulled up in front and secured. R58 covered up. V4 doffed gloves and donned new gloves without hand hygiene. The Facility's Infection Prevention and Control Program, dated 2019, documents that written standards, policies and procedures for the program will include f. The hand hygiene procedures to be followed by staff involved in direct resident contact. The Program documents that the facility will develop and implement written policies and procedures for infection control that, at a minimum Require staff to follow hand hygiene practices consistent with accepted standards of practice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145993 If continuation sheet Page 10 of 14 Printed: 05/15/2026 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 145993 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coulterville Rehab & Hcc 13138 State Route 13 Coulterville, IL 62237 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review the facility failed to ensure that residents who require antibiotics are prescribed the appropriate antibiotics to treat infections for 4 of 4 residents (R11, R41, R47, R58) reviewed for antibiotic stewardship in a sample of 44. Residents Affected - Some Finding include: The Facility's Infection Prevention and Control Manual Antibiotic Stewardship and MDROs dated 2019 documents It is the policy of this facility to provide systematic efforts to optimize the use of antibiotics in order to maximize their benefits to residents, while minimizing both the rise of antibiotic resistance as well as adverse effects to patients from unnecessary antibiotic therapy. Antibiotic Stewardship will include an assessment process, use of evidence-based criteria, efforts to identify the microbe responsible for disease, selecting the appropriate antibiotic along with documentation indicating the rationale for use, appropriate dosing, route, and duration of antibiotic therapy; and to ensure discontinuation of antibiotics when they are no longer needed. 1. R11's Urinalysis report, dated 5/29/23, documents R11 had 2+ blood, 1+ protein, 3+ leukocytes and greater than 50 white blood cells. There was no culture and sensitivity attached to these results. R11's Health Status Note dated 05/29/23 at 3:40 PM documents Partial UA (urinalysis) rec'd (received) and reported to (V22, Physician), on call for (V21, Physician). (V22) would like to order Bactrim DS but this nurse informed him that resident's POA refuses Bactrim as it upsets her stomach. New order rec'd for Macrobid 100 mg (milligrams) PO (by mouth) BID (twice daily) for 5 days. POA (Power of Attorney) notified. At this time, there was no Culture and Sensitivity (C&S) results to ensure that Macrobid was sensitive to the organism causing R11's UTI. R11's Physician Order dated 05/31/23 documents Macrobid Oral Capsule 100 MG (Nitrofurantoin Monohydrate Macro); Give 1 capsule by mouth two times a day for UTI (urinary tract infection) for 11 Administrations 7 days total. R11's C&S report, dated 6/2/23, documented Bactrim had intermediate sensitivity to the urinary bacteria. R11's Health Status Note dated 06/05/23 at 9:59 AM documents Final urine culture rec'd with intermediate sensitivity noted to Macrobid, (V21) notified, awaiting any new orders. R11's Physician Order dated 06/05/23 documents Cefuroxime Axetil Oral Tablet 500 MG (Cefuroxime Axetil); Give 1 tablet by mouth two times a day for UTI for 5 Days. 2. R41's Health Status Note dated 03/04/23 at 11:04 AM documents UA (urinalysis) from 03/01/23 rec'd, cx (culture) pending, (V16) notified, awaiting any new orders. R41's Health Status Note dated 03/04/23 at 2:10 PM documents (V23), NP (Nurse Practitioner) here, new order rec'd for Keflex 500 mg PO TID (three times daily) x 5 days. Resident aware and agrees with plan. This was ordered prior to identifying if the organism causing R41's UTI was sensitive to Keflex. R41's Physician Order dated 04/12/23 documents Amoxicillin-Pot Clavulanate Tablet 875-125 MG; Give (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145993 If continuation sheet Page 11 of 14 Printed: 05/15/2026 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 145993 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coulterville Rehab & Hcc 13138 State Route 13 Coulterville, IL 62237 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 0881 Level of Harm - Minimal harm or potential for actual harm 1 tablet by mouth two times a day for UTI for 7 Days to start 04/12/23 after UA collection. This antibiotic was started prior to getting a UA or C&S. R41's Health Status Order dated 05/29/23 at 11:43 AM documents Partial UA result rec'd and reported to (V16), cx (culture) pending, awaiting any new orders. Residents Affected - Some R41's Health Status Note dated 05/29/23 at 1:18 PM documents New order rec'd per (V16) for Keflex 500mg PO TID for 7 days. Resident aware and agrees with plan. R41's Physician Order dated 05/29/23 documents Cephalexin Capsule 500 MG; Give 1 capsule by mouth three times a day for UTI for 7 Day. This antibiotic was started prior to getting C&S results to determine if the antibiotic used was sensitive to the organism causing R41's UTI. 3. R47's Nursing Note dated 05/03/23 at 9:50 AM documents UA WAS OBTAINED LAST NIGHT AND SENT TO LAB. AWAITING RESULTS. R47's Physician Order dated 05/06/23 documents Cephalexin Capsule 500 MG; Give 1 capsule by mouth three times a day for infection for 7 Days. R47's Nursing Note dated 05/06/23 at 2:49 PM documents UA results. E. Coli detected. New order for Keflex 500mg 1 po BID x7 days. Resident and POA aware and voices understanding. R47's Urine Culture dated 05/06/23 documents Escherichia Coli. No sensitivity report noted. Unknown if E. Coli is susceptible to Keflex antibiotic. 4. R58's Health Status Note dated 07/10/23 at 6:07 PM documents R58's UA results were received and a new order from Bactrim DS 800/160, 1 tablet po twice daily for 7 days for UTI. R58's Urinalysis dated 07/10/23 documents Culture, urine microbiology tests to follow on separate report. R58 was started on Bactrim prior to receiving the C&S report to determine if the antibiotic given was sensitive to the organism causing R58's UTI. R58's Physician Order dated 07/15/23 documents Ciprofloxacin HCl Oral Tablet 500 MG (Ciprofloxacin HCl); Give 1 tablet by mouth two times a day for UTI for 10 Days. On 07/21/23 at 10:47 AM, V2, Director of Nursing, DON, stated that the facility's medical director, V16, is old school. V2 stated that V16 does not wait for the culture and sensitivity prior to ordering antibiotics. V2 stated V16 orders antibiotics for symptoms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145993 If continuation sheet Page 12 of 14 Printed: 05/15/2026 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 145993 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coulterville Rehab & Hcc 13138 State Route 13 Coulterville, IL 62237 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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 provide residents and/or resident's representatives education on the risks and benefits of influenza and pneumococcal immunizations, and document education and refusals in the residents' medical records for 4 of 5 residents (R31, R35, R61 and R70) reviewed for influenza and pneumococcal immunization in the sample of 44. Residents Affected - Some Findings include: 1. R31's Face Sheet documents R31 was admitted to the facility on [DATE] with diagnosis of Pneumonia, unspecified organism, abnormal sputum, Shortness of Breath, Cardiomyopathy and Chronic Kidney Disease. R31's Minimum Data Set, MDS, dated [DATE] documents R31 has severe cognitive impairment. The MDS documents R31 received the Influenza immunization 10/24/22. R31's MDS documented the pneumococcal vaccine was offered and declined. R31's medical records do not document R31 received education of the risks or benefits of the pneumococcal vaccination and there was no documentation R31 and/or R31's representative signed a refusal or declination form. 2. R35's Face Sheet undated documents was admitted to the facility on [DATE] with a diagnosis of Hemiplegia, Cerebral Infarction, Mild Cognitive Impairment of Uncertain or Unknown etiology and COVID-19. R35's MDS, dated [DATE], documents R35 has severe cognitive impairment. R35's MDS documents R35 received the Influenza vaccine on 10/24/22 and that R35 received the Pneumococcal immunization. R35's medical records do not document that R35 received education of the risks or benefits of the pneumococcal vaccination. 3. R61 Face Sheet undated documents R61's was admitted to the facility 5/2/22 with medical diagnosis of Atrioventricular Block, First degree, Type 2 Diabetes, Nondisplaced comminuted fracture of right patella, Initial encounter for closed fracture and Unilateral Primary Osteoarthritis left knee. R61's MDS, dated [DATE], documents R61 is cognitively intact. The MDS documents R61 received the Influenza immunization 10/25/22 the pneumococcal immunization was offered and declined. There was no documentation in R61's medical records that R61 and/or R61's responsible party received education of the risks or benefits of the pneumococcal vaccination and did not sign a refusal or declination form. On 7/20/23 3:00 PM R61 stated she R61 did not know anything about a pneumonia shot. 4. R70's Face Sheet documents R70 was admitted to the facility on [DATE] and discharged [DATE]. R70's diagnosis was documented as Chronic Kidney Disease, Unspecified B-Cell Lymphoma, and fracture of Unspecified part of neck of right Femur, Subsequent encounter for closed Fracture. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145993 If continuation sheet Page 13 of 14 Printed: 05/15/2026 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 145993 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coulterville Rehab & Hcc 13138 State Route 13 Coulterville, IL 62237 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 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R70's MDS dated [DATE] documents R70 is cognitively intact. The MDS documents R70 received the Influenza immunization 10/25/22, the pneumococcal immunization was offered and declined. R70 medical records did not document he received any immunizations during his stay in the facility. R70's medical record did not document that R70 received education of the risks or benefits of the pneumococcal vaccination and did not sign a refusal or declination form. On 7/19/23 at 3:05 PM V2 Director of Nursing (DON) stated she had only been in the job a couple of months and was uncertain what procedure the previous DON had in place. But she (V2) did not have any refusal forms signed. On 7/20/23 at 1:35 PM V1, Administrator, stated, We have something we need to get straighten out and hence forth we will have documentation of refusals. The facility Policy Pneumococcal Vaccine revised August 2008 documents Residents/representatives have the right to refuse vaccination. Refusal will be documented on the Pneumococcal Immunization Informed Consent form and will include the date, reason for refusal and signature. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145993 If continuation sheet Page 14 of 14

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Citations

8 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0600GeneralS&S Dpotential for harm

    F600 - Freedom from Abuse, Neglect, and Exploitation

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

  • 0689SeriousS&S Gactual harm

    F689 - Accidents

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0727GeneralS&S Fpotential for harm

    F727 - Except when waived under paragraph (f) or (g) of this section, the

    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

  • 0812GeneralS&S Fpotential for harm

    F812 - Food safety requirements

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

  • 0880GeneralS&S Fpotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

  • 0881GeneralS&S Epotential for harm

    F881 - Infection prevention and control program

    Implement a program that monitors antibiotic use.

  • 0883GeneralS&S Epotential for harm

    F883 - Influenza and pneumococcal immunizations

    Develop and implement policies and procedures for flu and pneumonia vaccinations.

  • 0222GeneralS&S Epotential for harm

    Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

FAQ · About this visit

Common questions about this visit

What happened during the July 21, 2023 survey of COULTERVILLE REHAB & HCC?

This was a inspection survey of COULTERVILLE REHAB & HCC on July 21, 2023. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at COULTERVILLE REHAB & HCC on July 21, 2023?

Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect b..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.