Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Carlinville Rehab & Hcc during CMS and state inspections, most recent first.
Two residents were involved in separate resident-to-resident altercations in which one cognitively intact resident with a history of CVA and bipolar disorder reported that another cognitively intact resident with PTSD and depression pulled her hair and hit her on the head during a verbal dispute, and another cognitively intact resident reported that a confused-appearing roommate with malignant neoplasm swung a TV remote and struck her multiple times on the hand, forearm, and head, causing pain and redness. In both cases, staff later confirmed through observation and investigation that the aggressor residents had physically struck the victims, despite a facility policy stating that each resident has the right to be free from abuse.
A resident with multiple health conditions reported verbal abuse by two CNAs, but the facility failed to properly identify the staff involved during its investigation, initially suspending the wrong CNA and later expressing confusion about the incident's details. The resident experienced fear of retaliation and inconsistent responses from facility leadership, with the investigation process not aligning with the facility's abuse prevention policy.
A resident with multiple complex conditions was admitted with an order for a specialized IV antibiotic that the facility was unable to provide due to pharmacy limitations. The medication was repeatedly held, and there was a delay in contacting the prescribing physician. Attempts to transport the resident for continued treatment were unsuccessful due to bariatric transport challenges, resulting in an interruption of therapy and the need for additional hospital care.
Several residents did not receive their physician-ordered medications as prescribed, including pain medications, anti-seizure drugs, Parkinson's therapy, and hormone replacement, due to delays in obtaining prescriptions, pharmacy refills, and communication issues among staff, pharmacy, and prescribers. Missed doses were documented, and residents reported experiencing pain and discomfort as a result.
A resident's debit card was misused by a CNA, who saved the card information on her phone and made unauthorized transactions. The resident, who is cognitively intact, reported the issue to her bank, leading to an investigation that identified the CNA as the unauthorized user. The resident did not consent to these transactions and felt unsafe and targeted.
A resident experienced severe pain that was not promptly assessed or treated by the facility staff. Despite reporting significant pain, the resident waited 44 minutes before receiving any pain management, which was limited to medication for mild pain. The facility lacked a comprehensive pain management policy, contributing to the deficiency.
A resident with morbid obesity and panniculitis did not receive physician-ordered InterDry sheets for abdominal folds, leading to redness and irritation. Despite documentation indicating treatment was given, observations confirmed the absence of the sheets. The ADON acknowledged the discrepancy, and the facility's wound assessment policy lacked guidance on following physician orders.
The facility failed to respond to call lights promptly for four residents, causing feelings of neglect and degradation. One resident reported waiting hours for assistance, while another experienced accidents due to long waits. The facility lacks a policy on call light response times, although the expectation is 3 to 5 minutes. Insufficient staffing, particularly on weekends and night shifts, contributed to the delays.
The facility failed to provide complete incontinent care for several residents, as observed during the survey. A CNA inadequately cleansed a resident's labia and inner thighs, while another CNA failed to change gloves between tasks, leading to incomplete cleaning of a resident's catheter tubing and groin area. Additional deficiencies included inadequate cleansing of buttocks and inner thighs for other residents, despite care plans specifying thorough cleaning. These observations highlight a pattern of incomplete and inconsistent incontinent care provided by the facility staff.
The facility failed to follow infection control protocols, including hand hygiene and PPE use, for several residents. A CNA and a wound nurse did not change gloves or perform hand hygiene while providing care to a resident with open wounds and a catheter. An RN administered IV medication without wearing a gown or performing hand hygiene, and an LPN was observed administering medications without hand hygiene. These actions violated the facility's infection prevention policies.
The facility failed to provide adequate nursing staff, resulting in significant delays in responding to residents' call lights. Several residents reported waiting hours for assistance, particularly at night and on weekends, due to insufficient staffing levels. The CNA scheduler confirmed that the night shift staffing is inadequate, contributing to the prolonged wait times for residents requiring care.
A facility failed to notify a resident or their representative of the bed hold policy upon hospital transfer. The resident, diagnosed with COPD and pneumonia, had no documentation of bed-hold notification in their records. Staff interviews indicated that while some documents are sent during transfers, the bed-hold policy was not documented. The administrator expects staff to adhere to the policy.
Two residents in a facility had non-occlusive dressings on their PICC lines, which were not changed as required. A nurse administered IV medication without addressing the issue, and records failed to document necessary dressing changes. Facility policy on maintaining infusion equipment was not followed.
A resident with depression did not receive her prescribed Effexor due to the facility's failure to reorder the medication in a timely manner. The resident missed doses over two days, leading to withdrawal symptoms. The ADON was aware of the shortage but did not ensure the medication was available until later. The facility's pharmacy procedures for urgent medication needs were not effectively followed.
The facility failed to properly label and store medications for three residents. An outdated Cephalexin suspension was not discarded, a Humalog Kwik Pen lacked an open date, and two medications were missing pharmacy labels. Staff acknowledged these oversights, which contravened facility policies.
A resident with a mental disorder was verbally abused by two LPNs during a shift change. The resident, who was confused and repeatedly expressed a desire to leave the facility, was told to 'shut up' by the LPNs. Multiple staff members witnessed the incident, but there was a delay in reporting it to the Administrator. The facility's policy on abuse prevention was not followed, leading to the substantiation of the abuse.
The facility failed to properly implement its abuse prevention policies, leading to incidents where a resident was verbally abused by staff. Despite reports from other residents and staff, the facility did not immediately suspend the alleged perpetrators or protect the residents during the investigation. The facility's policy requires immediate reporting and removal of staff involved in abuse allegations, which was not followed in these cases.
The facility failed to report allegations of abuse involving two residents in a timely manner. A CNA was accused of making inappropriate comments to a resident, and two LPNs were reported for verbally mistreating another resident. Both incidents were not immediately reported to the appropriate authorities, violating the facility's policy.
The facility failed to protect residents and conduct thorough abuse investigations. In one case, a CNA allegedly verbally abused a resident, but was not suspended during the investigation. In another case, two LPNs were reported to have verbally abused a resident, with a delay in reporting and removal from the floor. The investigation process was flawed, contributing to the deficiency.
The facility failed to identify, assess, and treat pressure ulcers for two residents. One resident had untreated pressure sores on both heels, contrary to physician orders, while another had an undocumented pressure ulcer on the left gluteal fold. The facility's policy required daily skin observations and treatment to prevent and heal pressure ulcers, which was not followed.
A facility failed to change nebulizer therapy tubing weekly for a resident with COPD and sleep apnea. The resident's nebulizer tubing was observed to be dated several weeks prior, despite the resident's statement that it used to be changed weekly. The facility's MDS coordinator confirmed the absence of a specific policy for nebulization tubing, although it should be changed weekly like oxygen tubing.
A resident with Type 2 Diabetes Mellitus was hospitalized with uncontrolled diabetes due to the facility's failure to monitor blood glucose levels and notify the physician of critical lab results. Despite having a care plan, the resident's blood glucose was not routinely checked, and an A1C level of 9.4 was not communicated to the physician. The resident's condition deteriorated, leading to hospitalization with a blood glucose level of 614.
A resident's medications, Morphine Sulfate and Lorazepam, were misappropriated in an LTC facility. Discrepancies were found during audits, revealing tampering with the Morphine's color and substitution of Lorazepam with an OTC medication. Despite investigations and staff interviews, the responsible party was not identified. The LPN involved was suspended and later terminated.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to prevent resident-to-resident abuse in multiple incidents. In the first incident, one cognitively intact resident with hemiplegia/hemiparesis following CVA, bipolar disorder, weakness, and cognitive communication deficit reported that another cognitively intact resident with cerebral infarction, PTSD, depression, and bipolar disorder pulled her hair and hit her on the back of the head because she was moving too slowly when entering the building from smoking. The aggressor resident stated she was trying to get to her table, asked the other resident to move, and admitted she "barely" hit her on the head and pulled her hair after an exchange of name-calling, acknowledging she should not have done it. The victim resident reported no physical injury but stated that the other resident should not have pulled her hair or hit her. In the second incident, another cognitively intact resident reported that her former roommate, who was described as confused by the victim and later identified as cognitively intact with a diagnosis of malignant neoplasm, told her she should not be in the room and that the room was hers, then grabbed a TV remote, swung it around, and hit her on the right hand and head, causing bruising and pain to her hand. A nurse heard yelling from the room and observed the roommate swinging the bedside remote at the resident, who stated she was hit three times on the hand, forearm, and head. Redness was noted on the resident’s left forearm. The roommate continued to swing the remote when the nurse attempted to intervene, requiring assistance to remove her from the room. In both incidents, the facility’s own abuse investigation reports substantiated that one resident pulled another resident’s hair and hit her lightly on the head in the first case, and that another resident most likely hit her roommate with a TV remote in the second case, with the latter behavior associated with an altered state due to a UTI. Despite the facility’s abuse prevention and prohibition policy stating that each resident has the right to be free from abuse and must not be subjected to abuse by anyone, these resident-to-resident altercations occurred, resulting in physical contact, pain, and observable redness, demonstrating a failure to protect residents from abuse.
Failure to Properly Investigate Alleged Abuse and Identify Involved Staff
Penalty
Summary
The facility failed to follow its own policy for conducting a thorough investigation of alleged abuse, specifically by not properly identifying the staff involved in an incident reported by a resident. The resident, who had multiple diagnoses including major depressive disorder, morbid obesity, and chronic obstructive pulmonary disease, reported that two CNAs entered his room and one made a derogatory and abusive remark. Initial investigation led to the suspension of the wrong CNA due to misidentification, and only after further interviews and review of schedules were the correct staff members identified. The confusion over which staff were involved was compounded by inconsistent statements and uncertainty from both the resident and facility leadership. The resident described feeling fearful of retaliation from one of the CNAs involved, particularly after observing her continue to work on his hall and walk past his room, sometimes laughing. The resident reported that after the incident, he was left without assistance to use the bathroom for an extended period and that the staff involved did not respond to his needs. Interviews with other staff and residents revealed varying accounts, with some staff denying knowledge of the incident and others reporting that the resident had used inappropriate language toward the CNAs. The administrator admitted to confusion and panic during the investigation process, acknowledging that the wrong CNA may have been suspended initially and that the timeline of the incident was unclear. The facility's own abuse prevention and investigation policy required immediate reporting and a thorough investigation of alleged violations of residents' rights. However, the investigation was hampered by misidentification of staff, inconsistent documentation, and uncertainty about the sequence of events. The resident did not have a care plan addressing abuse, and the administrator expressed uncertainty about the details of the incident and the actions taken. This failure to properly identify the alleged staff involved and to conduct a clear, thorough investigation resulted in the resident experiencing ongoing fear of retaliation.
Failure to Administer Ordered IV Antibiotic and Ensure Timely Physician Communication
Penalty
Summary
A deficiency occurred when the facility failed to administer an ordered intravenous (IV) antibiotic to a resident as prescribed, did not ensure timely transport for continued treatment, and did not promptly contact the prescribing physician. The resident was admitted with multiple complex diagnoses, including Fournier Gangrene, chronic kidney disease, urinary tract infection, and a colostomy. Upon admission, the resident had an order for Ceftazidime-Avibactam IV antibiotic to be administered twice daily. However, the facility's pharmacy was unable to supply the medication due to its instability, high cost, and the need for immediate use, and this information was not communicated prior to the resident's admission. The medication administration records show that the IV antibiotic doses were repeatedly marked as "Hold" over several days. Progress notes indicate that the facility staff attempted to contact the prescribing infectious disease physician and the hospital, but there was a delay in communication and obtaining alternative orders. The nurse practitioner at the facility gave an order to hold the antibiotic until the prescribing physician could be reached, but the physician was not notified of the issue until several days later. During this period, the resident remained stable and continued on oral antibiotics, but the prescribed IV antibiotic therapy was interrupted. Efforts to transport the resident back to the hospital for the required IV antibiotic were unsuccessful for several days due to the resident's bariatric status and the inability to secure appropriate ambulance services. The resident ultimately required readmission to the hospital and an additional six days of IV antibiotic therapy due to the interruption in treatment. Interviews with facility staff and the pharmacist confirmed that the facility was not equipped to provide the ordered medication and that there was a breakdown in communication regarding the resident's needs and the facility's capabilities.
Failure to Administer Physician-Ordered Medications as Prescribed
Penalty
Summary
The facility failed to administer physician-ordered medications as prescribed for four residents, resulting in multiple missed doses of critical medications. For one resident with diagnoses including end-stage renal disease, COPD, and diabetic neuropathy, there were several days where a prescribed pain medication (Pregabalin) was not administered due to delays in obtaining a new prescription and pharmacy refill. Documentation showed that both nursing staff and the pharmacy attempted to contact the physician for a new script, but the medication was not available for several days, during which the resident reported experiencing pain. Another resident with a history of diabetes, obesity, and neuropathy also experienced repeated interruptions in receiving Pregabalin, with missed doses documented and the resident reporting frequent shortages of the medication. The DON acknowledged ongoing issues with the medication ordering system, particularly for controlled substances, and noted that the facility was transitioning to a new medical director and system, which contributed to the delays. Nursing staff were sometimes unaware of the missed doses, and the facility's policy required timely reordering of medications before supplies were exhausted, which was not consistently followed. Additional residents were affected by similar issues. One resident with Parkinson's disease missed several doses of Gocovri (amantadine), with progress notes indicating the medication was on order or awaiting delivery from the pharmacy. Another resident missed multiple doses of prescribed estrogen cream, with no documentation in the progress notes explaining the missed doses. Interviews with staff and family confirmed that medication administration was inconsistent due to delays in obtaining medications and communication issues between the facility, pharmacy, and prescribers.
Unauthorized Use of Resident's Debit Card by Staff
Penalty
Summary
The facility failed to protect a resident from misappropriation of property, specifically involving the unauthorized use of the resident's debit card by a staff member. The incident involved a cognitively intact resident, who noticed inconsistencies in her bank account and reported them to her bank. The bank's investigation revealed that two staff members had made unauthorized transactions using the resident's mobile payment application, leading to the involvement of the local police department. The investigation found that a Certified Nursing Assistant (CNA) had saved the resident's debit card information on her phone to order pizza, but subsequently used the card for personal transactions, including transferring money to herself and another former employee. The resident did not give permission for these transactions and felt unsafe and targeted as a result. The CNA admitted to using the resident's money but claimed she was unaware she was doing so until later. The police report confirmed the unauthorized transactions and identified the CNA as the unauthorized user. The facility's policy prohibits misappropriation of resident property, and the incident was determined to be substantiated abuse due to the evidence provided. The resident expressed feelings of sadness and betrayal, highlighting the emotional impact of the incident.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a resident, identified as R129, who was experiencing significant pain. On the morning of June 24, 2024, R129 reported stomach pain to the Assistant Director of Nursing, who promised to inform the nurse but did not follow up. Despite continued complaints of severe pain, including groaning and expressing a desire to die, the resident was not assessed or treated for 44 minutes. A Certified Nursing Assistant (CNA) informed the Registered Nurse (RN) about the resident's pain, but the RN continued with medication rounds without addressing the issue immediately. The resident's pain was eventually assessed as a 10 on a scale of 1-10, indicating the worst possible pain, yet the RN did not contact the doctor or provide immediate relief. The resident's care plan indicated a risk for pain related to depression and required monitoring and reporting of pain complaints. However, the facility did not have a pain policy in place, and the Medication Administration Record (MAR) only included orders for mild pain management, with no provisions for severe pain. The resident was eventually given acetaminophen for mild pain, which was not appropriate for the level of pain reported. The lack of a comprehensive pain management policy and the failure to assess and address the resident's pain in a timely manner contributed to the deficiency identified by the surveyors.
Failure to Administer Physician-Ordered Wound Treatment
Penalty
Summary
The facility failed to provide the physician-prescribed skin and wound treatments for a resident diagnosed with morbid obesity and panniculitis. The resident, who is cognitively intact, reported that he often experiences cellulitis in his abdomen and used to receive InterDry moisture-wicking sheets for his abdominal folds, but had not received them for some time. During an observation, the resident's abdominal fold was found to be red and irritated, and no InterDry sheet was present, despite physician orders specifying its use. The Assistant Director of Nurses confirmed that the InterDry sheets should have been applied as per the physician's orders and acknowledged that documentation falsely indicated the treatment was being administered. The Treatment Administration Record inaccurately documented that the resident received the treatment on specific dates. The facility's policy on wound assessment did not include instructions to follow physician orders for treatment, contributing to the oversight.
Delayed Call Light Response Leads to Resident Distress
Penalty
Summary
The facility failed to answer call lights in a timely manner for four residents, leading to feelings of neglect and degradation among the residents. Resident 38 reported that it sometimes takes hours for staff to respond to call lights, making her feel abandoned. She is cognitively intact and dependent on staff for toileting and bed mobility. Resident 22 also expressed that at night, the response time can exceed an hour, resulting in accidents and feelings of worthlessness. She is cognitively intact, uses a wheelchair, and requires assistance for toileting and hygiene. Resident 50 mentioned that on weekends, the staff response can take hours due to insufficient staffing, leading to feelings of neglect. She is cognitively intact, uses a wheelchair, and is frequently incontinent. Resident 5 reported waiting for over an hour on a bedside commode due to inadequate staffing, with one aide refusing to work due to pregnancy. He is cognitively intact, uses a wheelchair, and requires assistance for toileting and transfers. The facility lacks a policy on call light response times, although the expectation is 3 to 5 minutes. The Resident Council meeting minutes and the Illinois Long Term Care Ombudsman also documented issues with delayed call light responses.
Inadequate Incontinent Care Provided to Residents
Penalty
Summary
The facility failed to provide complete incontinent care for several residents, as observed during the survey. In one instance, a CNA provided care to a resident with a saturated brief but did not adequately cleanse the labia and inner thighs. This resident was documented as severely cognitively impaired and required substantial assistance with personal hygiene. The facility lacked a specific incontinent care policy, relying instead on staff to follow general standards of practice. Another resident, who was cognitively intact and had a catheter, reported needing incontinent care. A CNA provided care without proper gowning and failed to change gloves between tasks, leading to inadequate cleaning of the resident's catheter tubing and groin area. The wound nurse later found feces remaining in the resident's gluteal fold, indicating incomplete care. Additional deficiencies were noted with other residents. One resident received care where the CNA did not cleanse the buttocks or inner thighs adequately, despite the care plan specifying thorough washing, rinsing, and drying of the perineum. Another resident, who was incontinent and had impaired mobility, did not receive proper cleaning of the scrotum or peri area during care. The care plan for this resident also required thorough cleaning after incontinent episodes. These observations highlight a pattern of incomplete and inconsistent incontinent care provided by the facility staff.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, particularly in hand hygiene and the use of Personal Protective Equipment (PPE), for several residents. One resident, who was cognitively intact and required contact isolation due to open wounds and a urinary catheter, did not have appropriate signage or PPE available at her door. A Certified Nursing Assistant (CNA) provided incontinent care without donning a gown and failed to change gloves or perform hand hygiene between tasks, leading to potential cross-contamination. Similarly, a wound nurse did not use a gown and neglected hand hygiene between glove changes while treating the resident's wounds. Another incident involved a Registered Nurse (RN) who entered a resident's room, which had an enhanced barrier precaution sign, without wearing a gown or performing hand hygiene. The RN administered intravenous medication through a PICC line without following proper protocols. Additionally, a Licensed Practical Nurse (LPN) was observed administering medications without performing hand hygiene. These actions were contrary to the facility's infection prevention and control policies, which require enhanced barrier precautions, including the use of gowns and gloves, during high-contact resident care activities.
Insufficient Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple reports of delayed response times to call lights. Resident 38 reported that it sometimes takes hours for staff to respond, attributing the delay to staff being backed up. Resident 22 also experienced significant delays, particularly at night, with call light responses taking over an hour. Both residents are cognitively intact and require assistance with toileting and mobility, highlighting the critical need for timely staff support. Resident 50 noted that on weekends, the response time can be hours due to insufficient staffing. Similarly, Resident 5 experienced a delay of over an hour while on a bedside commode, with only two CNAs available for two halls, one of whom was unwilling to work due to pregnancy. The CNA scheduler confirmed that the night shift staffing levels are inadequate, with only three CNAs available, which is insufficient to meet the needs of the residents, especially those requiring one-to-one supervision. This staffing shortage has led to prolonged wait times for residents needing assistance.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide a notice of bed hold policy to a resident and/or their representative upon transfer to a hospital. This deficiency was identified for one resident, who was readmitted from the hospital with diagnoses of COPD and pneumonia. The resident's records did not document any bed-hold notification provided to the resident or their Power of Attorney. Interviews with facility staff, including an LPN and a social worker, revealed that while certain documents are sent with residents during hospital transfers, the bed-hold policy was not documented as being provided. The facility administrator stated that staff should follow the policy regarding documentation and transfer paperwork.
Failure to Maintain Occlusive PICC Line Dressings
Penalty
Summary
The facility failed to maintain an occlusive dressing for a Peripherally Inserted Central Catheter (PICC) for two residents receiving intravenous therapy. For one resident, a registered nurse observed that the dressing on the PICC line was not adhered to the skin at the bottom and right side, yet proceeded to hang an IV medication without changing the dressing. The dressing was dated five days prior, and the nurse later admitted to not changing it until after the IV was finished. The resident's medication administration record did not document a weekly or as-needed dressing change, as required. Similarly, another resident was observed with a PICC line dressing that was not attached at the bottom or right side, with the dressing dated thirteen days prior. This resident received daily IV medication, but the treatment administration record did not document a dressing change on the day shift. A health status note later indicated that the dressing was changed, and the area appeared intact with no signs of infection. The facility's policy on IV therapy care, which includes maintaining infusion equipment and catheters, was not adhered to in these instances.
Failure to Provide Timely Medication Refill for Resident
Penalty
Summary
The facility failed to ensure that physician-ordered medication was readily available for a resident, leading to a deficiency in pharmaceutical services. A resident, who is cognitively intact and diagnosed with depression, reported that she had run out of her prescribed antidepressant, Effexor, and missed doses on two consecutive days. The resident expressed experiencing withdrawal symptoms due to the missed doses, which were not administered as prescribed. The resident's care plan and physician's orders documented the need for the medication to be administered twice daily, but the medication administration record indicated missed doses with a note to see the progress note. The Assistant Director of Nursing (ADON) acknowledged awareness of the situation and stated that the medication should have been reordered when the medication card indicated a low supply. Despite the resident informing the ADON about the shortage, the medication was not available until after lunch on the day it was reordered. The facility's pharmacy procedures outlined the process for obtaining medications that cannot wait for the next scheduled delivery, but this process was not effectively utilized. Additionally, there was no entry in the resident's progress notes on the day the medication was missed, and subsequent notes indicated the medication was not available.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication labeling and storage protocols for three residents. During an inspection, it was found that a resident's Cephalexin oral suspension was not discarded after the recommended 14 days, as confirmed by the Assistant Director of Nursing. Additionally, a Humalog Kwik Pen used by another resident was not dated upon opening, which is against the facility's policy that requires medications to be dated after opening. The LPN acknowledged the oversight and decided to replace the pen due to the lack of an open date. Further deficiencies were observed with the labeling of medications. A resident's fluticasone propionate nasal spray was found in the medication cart without a pharmacy label, contrary to the facility's policy that requires all medications to be properly labeled. Similarly, a tube of wound debridement ointment used for another resident was missing a pharmacy label, with only the resident's name handwritten on it. The wound nurse was unable to explain the absence of the original labeled box, acknowledging that the medication should have had a pharmacy label.
Verbal Abuse of Resident by LPNs
Penalty
Summary
The facility failed to prevent verbal abuse of a resident by two Licensed Practical Nurses (LPNs), which was substantiated through interviews and records. The incident involved a resident with a mental disorder and altered mental status, who repeatedly expressed a desire to leave the facility to see her son. During a shift change, the resident was at the nurses' station, and two LPNs, identified as V13 and V14, were reported to have told the resident to 'shut up' in response to her repetitive statements. This interaction was witnessed by multiple staff members, including a Registered Nurse (RN) and a Medical Records staff member, who corroborated the verbal abuse. The incident occurred in the early morning, and the facility's Administrator was notified about an hour later. The LPNs involved were suspended following the report of the incident. Witnesses reported that the LPNs used inappropriate language and tone, with one LPN wheeling the resident into the dining room while continuing to use abusive language. Despite the presence of other staff members, the incident was not immediately reported to the Administrator, indicating a delay in addressing the abuse. The facility's policy on abuse prevention and prohibition clearly states that residents must not be subjected to abuse by anyone, including facility staff. However, in this case, the policy was not adhered to, as evidenced by the verbal mistreatment of the resident. The failure to immediately report the incident by some staff members further contributed to the deficiency, highlighting a lapse in the facility's adherence to its own abuse prevention protocols.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to operationalize their abuse policies and procedures, resulting in a deficiency related to the handling of abuse allegations. Specifically, the facility did not conduct a thorough investigation of allegations of abuse, failed to protect residents during the investigation, and did not report allegations to the administrator immediately. This was evident in the cases of two residents, R5 and R41, who were involved in incidents where staff members allegedly verbally abused R41. R5 reported that a CNA, V11, got in R41's face and made inappropriate comments, which R5 perceived as mental abuse. Despite R5's report to the Social Service Director and the Administrator, the response was inadequate, as V11 was not suspended during the investigation and continued to work on the floor. In another incident, two nurses, V13 and V14, were reported to have verbally abused R41 by telling her to shut up during a shift change. Multiple staff members, including a Registered Nurse and a Medical Records staff, witnessed the incident but did not report it immediately. The delay in reporting and the failure to remove the alleged perpetrators from resident contact during the investigation were significant lapses in the facility's abuse prevention and response protocols. The facility's policy mandates immediate reporting and removal of staff involved in abuse allegations, which was not adhered to in this case. The facility's final investigation confirmed the inappropriate verbal interaction between the nurses and R41, leading to the suspension and eventual termination of the involved staff. However, the initial handling of the situation, including the delay in reporting and the failure to protect residents from potential further abuse, highlights deficiencies in the facility's implementation of its abuse prevention and prohibition policy. The facility's policy clearly outlines the steps to be taken in such situations, but these were not followed, resulting in a failure to protect the residents and ensure a safe environment.
Failure to Report Allegations of Abuse in a Timely Manner
Penalty
Summary
The facility failed to immediately report an allegation of abuse involving two residents. One resident reported that a Certified Nurse Aide (CNA) got in the face of another resident and made inappropriate comments about her son being in prison. This incident was reported to the Social Service Director and the Administrator, who decided that the CNA needed retraining. However, there was no documentation that this allegation was reported to the Illinois Department of Public Health (IDPH). Another incident involved two Licensed Practical Nurses (LPNs) who were reported to have verbally mistreated a resident by telling her to shut up during a shift change. This incident was initially reported to the Business Office Manager, who then informed the Administrator. There was a delay in reporting the incident, as it occurred at 6:15 AM, but the Administrator was not notified until 7:30 AM. Despite the report, one of the LPNs continued to work on the floor until the Director of Nursing arrived. The facility's policy requires immediate reporting of abuse allegations to the Administrator or a designated representative and to the mandated state agency. However, in both cases, there was a failure to report the allegations in a timely manner, and the incidents were not immediately communicated to the appropriate authorities as required by the facility's policy.
Failure to Protect Residents and Conduct Thorough Abuse Investigations
Penalty
Summary
The facility failed to protect residents and prevent further potential abuse during abuse investigations and did not conduct thorough abuse investigations for two residents. One incident involved a Certified Nurse Aide (CNA) allegedly getting in the face of a resident, R41, and telling her she would never go home to see her son because he was in prison. This was reported by another resident, R5, to the Social Service Director and the Administrator, who decided that the CNA needed retraining. However, the CNA was not suspended during the investigation, and there was a lack of thorough interviews with other residents or staff about the incident. Another incident involved two Licensed Practical Nurses (LPNs) who were reported to have told a resident, R41, to shut up during a shift change. The incident was reported to the Administrator by the Business Office Manager after a delay. The LPNs were suspended after the investigation substantiated the abuse, and they were eventually terminated. However, there was a delay in removing one of the LPNs from the floor, and the incident was not reported immediately by a CNA who witnessed it. The facility's investigation process was flawed, as evidenced by the Administrator not reviewing collected interviews promptly and the CNA involved in the first incident being allowed to continue working without suspension. Additionally, there was a lack of immediate reporting and action taken in the second incident, which contributed to the deficiency in protecting residents from potential abuse.
Failure to Identify and Treat Pressure Ulcers
Penalty
Summary
The facility failed to properly identify, assess, and treat pressure ulcers for two residents. One resident was observed with pressure sores on both heels without any dressings, contrary to the physician's orders which required specific treatments and dressings. The wound nurse confirmed that the treatments were not being administered as ordered, and the resident's care plan indicated multiple areas of potential skin integrity impairment. The facility's policy on pressure ulcer prevention required treatment to heal existing ulcers and prevent new ones, which was not adhered to in this case. Another resident was found to have a pressure ulcer on the left gluteal fold, which was not documented in the medical record. The resident and a CNA confirmed the presence of the ulcer, but the wound nurse was unaware of it until later. The facility's policy required daily skin observations by CNAs, but there was a lack of documentation, assessment, and notification to the doctor regarding the pressure ulcer. This oversight led to a delay in obtaining necessary treatment orders.
Failure to Change Nebulizer Tubing Weekly
Penalty
Summary
The facility failed to change nebulizer therapy tubing on a weekly basis for a resident, identified as R65, who was reviewed for respiratory therapy. On June 26, 2024, it was observed that R65's nebulizer machine and tubing were on the nightstand beside the bed, with the tubing dated June 2, 2024. R65, who is cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15, stated that the oxygen and nebulizer tubing used to be changed weekly. R65's medical records indicate a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and sleep apnea, with a physician's order for Ipratropium-Albuterol Solution to be inhaled every six hours as needed for shortness of breath. The physician's order also specified that oxygen tubing should be changed weekly, every Sunday during the night shift. On July 1, 2024, the MDS coordinator confirmed that the facility does not have a specific policy for nebulization tubing but stated that it should be changed weekly, similar to the oxygen tubing.
Failure to Monitor and Treat Diabetes Leads to Hospitalization
Penalty
Summary
The facility failed to adequately monitor and treat a resident with Type 2 Diabetes Mellitus, leading to the resident's hospitalization with uncontrolled diabetes and acute on chronic renal failure. The resident, who was moderately cognitively impaired and dependent on staff for activities of daily living, had a history of insulin-dependent diabetes and was admitted to the hospital with a blood glucose level of 614. Despite having a care plan that included diabetes management, the plan did not address monitoring blood glucose levels or recognizing signs and symptoms of hyper or hypoglycemia. The resident's medical records revealed that there was no routine blood glucose monitoring order after the resident returned from a previous hospitalization. The resident's A1C level was recorded as 9.4, which is significantly higher than the target level for diabetics, but there was no documentation that the physician was notified of this abnormal result. Additionally, the resident's blood glucose level was recorded as 374 on a lab result, but no follow-up action was documented. The facility's failure to ensure routine blood glucose monitoring and to notify the physician of critical lab results contributed to the resident's deteriorating condition. Interviews with facility staff and the resident's primary care physician's office indicated a lack of communication and follow-up regarding the resident's diabetes management. The resident's nurse did not perform an accucheck despite observing a change in the resident's condition, and the physician's office did not receive notification of the resident's high A1C result. The hospitalist who treated the resident during the hospitalization stated that routine blood glucose monitoring could have prevented the resident's hospitalization and associated complications.
Misappropriation of Resident Medications
Penalty
Summary
The facility failed to protect a resident from the misappropriation of their medications, specifically Morphine Sulfate and Lorazepam. The incident was identified during an audit conducted by a pharmacy representative on January 3, 2024, when a discrepancy was noted with the color of the Morphine Sulfate, which was supposed to be blue but appeared light green. This indicated potential tampering. The resident involved, who had a history of acute respiratory failure, pulmonary embolism, and cancer, was moderately cognitively impaired and on pain medication therapy related to cancer. Further investigation revealed another discrepancy on January 8, 2024, during a random audit of the medication carts. It was found that the Lorazepam 1 mg medication card for the same resident had been tampered with, as the pill slot contained an over-the-counter medication instead of the prescribed Lorazepam. The facility's Director of Nursing and Administrator conducted interviews with staff members who had access to the medication cart, but they were unable to identify the person responsible for the drug diversion. The facility reported the incidents to the local police department, the medical doctor, the ombudsman, and the responsible party. Despite the investigation and interviews conducted, the facility could not substantiate a perpetrator responsible for the medication diversion. The LPN involved was suspended pending the investigation's outcome and was eventually terminated for improperly handling narcotics. The facility continued to work with law enforcement to gather additional information related to the investigation.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 31 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Carlinville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hallmark Hc Of Carlinville | 0.4 mi | ★★★★★ | 0 | 0 |
| Lakeside Health & Rehab Center | 0.7 mi | ★★★★★ | 9 | 1 |
| Gillespie Health & Rehab Ctr | 12.9 mi | ★★★★★ | 3 | 0 |
| Litchfield Health & Rehab Center | 15 mi | ★★★★★ | 0 | 0 |
| Avenues At Litchfield | 15.3 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.