Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Coulterville Rehab & Hcc during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, dementia, psychiatric diagnoses, and documented exit-seeking behavior, who used a wheelchair and had a daily elopement alarm, was able to leave the building unnoticed and was found alone in the busy parking lot by a visiting family member. The resident’s elopement risk was identified in assessments, but her care plan did not address elopement, and progress notes for the day of the incident did not document her unsupervised departure. Staff, including an LPN and a pulmonary nurse/LPN, reported they did not see the resident exit, did not recall hearing her elopement alarm, and could not state how long she was outside or how far she traveled. Observations on a later date showed the same resident repeatedly attempting to open exit doors and verbally expressing a desire to leave, requiring redirection by the receptionist. The facility’s elopement policy required that at-risk residents have elopement issues addressed in their care plans and defined a missing resident as one who left without signing out, but these measures were not effectively implemented, leading to an Immediate Jeopardy finding.
Multiple cognitively impaired female residents with dementia, mobility limitations, and inability to report events were subjected to unwanted intimate touching by male residents with known or newly identified sexually inappropriate behaviors. In one case, a male resident with dementia and a history of grabbing female staff and residents was seen with his hand on a female resident’s thigh in the dining room and, during separation, reached toward her chest; in another, a wandering, severely impaired female resident was found in his room while he had his hand down her pants. In a separate incident, a cognitively intact male resident was observed by a CNA with his hand up the front of a severely impaired female resident’s shirt, fondling her breast near the dining area. These events occurred despite existing diagnoses, documented behavioral histories, and an abuse prevention policy that prohibits non‑consensual sexual contact, and some involved residents whose care plans did not address abuse or protection from inappropriate resident‑to‑resident contact.
Surveyors observed that multiple residents' rooms and bathrooms were not kept clean, with brown or black substances found on floors and wall trim, and dried blood noted on a handrail. Despite some residents denying concerns, direct inspection confirmed the presence of unclean conditions that were not addressed according to facility cleaning protocols.
The facility failed to maintain proper chemical levels in the dish machine for effective sanitation and improperly stored uncooked animal proteins above other food items, contrary to professional standards. These deficiencies could impact all 70 residents.
A facility failed to follow a prescribed Renal Therapeutic Diet for a resident with End Stage Renal Disease and Type 2 Diabetes Mellitus. The resident's meal card included inappropriate items, and staff lacked understanding of the renal diet requirements. The facility's policy mandates that the physician's diet order match food service terminology, which was not adhered to.
Failure to Supervise Exit-Seeking Resident Resulting in Unnoticed Elopement to Parking Lot
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement for a resident who was known to be at risk for exit-seeking. The resident, who used a wheelchair and required substantial to maximal assistance with most activities of daily living, was able to leave the building without staff knowledge and was later found alone in the parking lot by a visiting family member. The parking lot was described as being off a main city road with cars pulling in and out throughout the day. Staff were unable to state how long the resident had been outside, how far she had gone, or exactly how she exited the building. Multiple staff members, including an LPN and a pulmonary nurse/LPN, reported that they did not see the resident go out and did not recall hearing any alarms at the time of the incident. The resident had multiple documented diagnoses, including Alzheimer’s disease, vascular dementia, unspecified dementia with agitation and other behavioral disturbances, anxiety disorder, unspecified psychotic disorder with delusions, major depressive disorder with psychotic symptoms, and hemiplegia/hemiparesis following a cerebral infarction. Her MDS documented that she was severely cognitively impaired and that she had an elopement alarm used daily. An elopement assessment indicated that she had a desire to leave the facility and was exit-seeking with a purpose, and the facility had identified her as an elopement risk. Despite this, her care plan did not address elopement. Progress notes for the date of the elopement did not document anything related to her leaving the facility unsupervised, and prior and subsequent notes described her as often tearful, agitated, exit-seeking, and focused on leaving to care for her children or find her car in the parking lot. On the day of the surveyor’s observations, the resident was repeatedly observed in her wheelchair at the exit doors, pulling on the doors and verbally expressing a desire to leave the building and go home. The receptionist had to redirect her away from the doors multiple times, and the doors were noted to beep when pushed but not open. A family member visitor reported that on the day of the elopement she frequently saw the resident sitting by the door crying that she wanted to go home and that the resident did not have family who typically took her out. This family member later found the resident outside, alone in her wheelchair, approximately halfway around the circle drive—estimated at about 20 yards—before bringing her back inside. Staff interviews confirmed that no one knew when or how the resident exited, that no one recalled hearing her elopement alarm, and that the incident was not recognized by staff until the family member returned the resident to the building. The facility’s own elopement policy required that residents at risk for elopement be assessed and have these issues addressed in their care plans, and defined a missing resident as one who left the facility grounds without signing out, but these measures were not effectively implemented for this resident. The situation was determined to constitute Immediate Jeopardy beginning on the date the resident left the facility unnoticed and was found in the parking lot. The Medical Director stated that the resident was not of sound mind, had poor safety awareness and poor judgment, and that it would not be good if she got out of the facility unsupervised, as she would not know how to watch for cars or navigate traffic. The DON stated that she expected staff to respond immediately to any door alarms, check for residents, step outside if no resident was seen, and initiate a head count starting with residents at risk for elopement, with appropriate charting, but acknowledged that this was not done because staff did not realize the resident had gotten out. The surveyor confirmed that Immediate Jeopardy was later removed, but non-compliance remained at a lower level because additional time was needed to evaluate the implementation and effectiveness of staff in-service training.
Failure to Prevent Resident-to-Resident Sexual Abuse of Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from sexual abuse and inappropriate sexual contact by other residents. One male resident with dementia and documented behavioral problems (R5) had a history of grabbing female staff and residents and was known by staff to "love to reach for female body parts" and to grab female breasts and buttocks. On one occasion in the dining room, a dietary aide (V15) heard a female resident (R6) yelling and observed R5 with his hand on R6’s right thigh; as R6 was being moved away, R5 reached toward her chest and R6 pushed his hand away. R6, who had multiple medical conditions including depression, muscle weakness, lack of coordination, and a cognitive communication deficit, was moderately cognitively impaired and used a wheelchair. Her care plan addressed ADL self-care deficits but did not address abuse. R5 did not respond when questioned about the incident, and staff and resident interviews did not yield additional witnesses to the breast contact, but the facility was aware of his pattern of sexually inappropriate touching. In a separate incident, another cognitively impaired female resident (R4), diagnosed with Alzheimer’s disease and dementia and identified as an elopement risk and wanderer, was found in R5’s room. A CNA (V10) entered the room and saw R5 with his hand down R4’s pants. R4 was described as severely cognitively impaired, nonverbal, and unable to report what had occurred. She used a wheelchair, had lower extremity impairment, and was known to wander into other residents’ rooms. Although her care plan identified her as an elopement risk and wanderer and noted behavior problems such as physical aggression toward staff, it did not include specific interventions to prevent her from entering high‑risk areas or rooms where she might be vulnerable to abuse. Staff reported they had been instructed to ensure no women were around R5 due to his history of touching staff and residents, yet R4 was able to enter his room and be subjected to inappropriate physical contact. Another male resident (R9), who was cognitively intact with no memory problems and used a wheelchair, was observed by a CNA (V18) with his right hand up the front of a severely cognitively impaired female resident’s (R7) shirt, fondling her breast while she sat in her wheelchair outside the dining area. R7 had diagnoses of unspecified dementia with mood disturbance, major depressive disorder, and anxiety, was severely impaired with memory problems, and required substantial assistance with ADLs. She was unable to answer questions about the incident due to cognitive dysfunction and did not understand a trauma‑informed assessment attempted by social services. Prior to this event, R9 had no documented history of sexually inappropriate behavior, and R7’s care plan did not address abuse or inappropriate resident‑to‑resident behavior. Across these events, cognitively impaired female residents who could not effectively protect themselves or report abuse were subjected to unwanted intimate touching by male residents, despite the facility’s written abuse prevention policy stating that residents must not be subjected to sexual abuse, including unwanted intimate touching of breasts or perineal areas. R5’s behavioral history also included an earlier incident in which he inappropriately touched R6’s thigh and attempted to reach her chest, and staff accounts indicated he had also grabbed another female resident (R7) on a different occasion. The facility’s abuse prevention policy, dated November 2025, states that each resident has the right to be free from abuse, including sexual abuse defined as non‑consensual sexual contact of any type, such as unwanted intimate touching of breasts or perineal areas, and that residents must not be subjected to abuse by anyone, including other residents. Despite this policy and knowledge of certain residents’ sexually inappropriate behaviors and others’ severe cognitive impairments and wandering tendencies, the facility did not prevent these resident‑to‑resident sexual contacts from occurring.
Failure to Maintain Clean and Homelike Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and homelike environment for four residents, as evidenced by observations of unclean conditions in their rooms and bathrooms. Multiple residents, all of whom were cognitively intact and had various medical diagnoses such as anxiety, irritable bowel syndrome, morbid obesity, fractures, diabetes, hypertension, Parkinson's Disease, atrial fibrillation, and dementia, were included in the review. During interviews, some residents expressed concerns about cleanliness, while others denied issues; however, direct observations revealed brown or black substances on the floors and wall trim in the bathrooms and rooms of all four residents. In one instance, a resident reported stains on a bathroom pull cord, but none were observed during the survey. Further inspection with the Housekeeping Director confirmed the presence of dried blood on a handrail and persistent soiling on floors and wall trim, which the director acknowledged should have been cleaned according to facility procedures. The facility's cleaning protocol requires daily cleaning of floors, trim, and high-touch surfaces, as well as cleaning of visibly soiled areas. Despite these procedures, the observed conditions indicated a failure to adhere to established cleaning standards, resulting in an environment that did not meet the residents' rights to a safe, clean, and comfortable living space.
Deficiencies in Dish Machine Sanitization and Food Storage Practices
Penalty
Summary
The facility failed to ensure the dish machine had the appropriate chemical level required for effective sanitation. During an observation, a dietary aid was seen removing a tray of dishes from the dish machine after the cleaning cycle and placing it on the clean side. When testing the sanitizer level during the final rinse cycle, the test strip did not change color, indicating insufficient sanitizer. The dietary manager attempted to use different test strips, which showed a concentration of 100 ppm, below the required 200 ppm. Further attempts with another type of test strip also failed to show the correct sanitizer level, prompting the dietary manager to call for maintenance assistance. Additionally, the facility did not store food in accordance with professional standards for food service safety. Observations revealed that uncooked animal proteins, such as pork loin fritters and beef Philly steak, were stored on shelves directly above cookie dough and pizza dough, respectively. The dietary manager believed it was acceptable to store these items in such a manner because they were frozen. The facility's policies require food to be stored in a clean, dry area, free from contaminants, and at appropriate temperatures to ensure food safety. These deficiencies have the potential to affect all 70 residents residing in the facility.
Failure to Implement Renal Therapeutic Diet
Penalty
Summary
The facility failed to adhere to the prescribed Renal Therapeutic Diet for a resident with End Stage Renal Disease and Type 2 Diabetes Mellitus. The resident's Minimum Data Set indicated cognitive intactness, and the Physician Order Sheet specified a Renal, Consistent Carbohydrate, regular texture, regular liquid, and no added salt diet. However, the resident's meal card did not reflect these dietary restrictions, listing items such as ham and potato casserole, sausage links, oatmeal, fresh cantaloupe, rye toast, garden salad, Italian wedding soup, salami sandwich, potato chips, and a frosted vanilla cupcake, which are not suitable for a renal diet. Interviews with facility staff revealed a lack of understanding and implementation of the renal diet. Two CNAs were unaware of the specific requirements of a renal diet, with one stating they only knew the resident was diabetic. The Assistant Manager/Day Shift mentioned limiting certain foods but admitted to providing what residents ordered, which did not align with the renal diet. The resident herself was aware of some dietary restrictions but was found with a bag of potato puffs, which she stated was a snack for dialysis given by her children. The facility's policy on therapeutic diets requires that the physician's diet order match the terminology used by food services, which was not followed in this case.
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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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Nursing homes near Coulterville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Randolph County Care Center | 6.6 mi | — | 2 | 0 |
| Pinckneyville Nursing & Rehab | 15.3 mi | — | 0 | 0 |
| Axiom Gardens Of Nashville | 16.4 mi | — | 12 | 3 |
| La Bella Of Freeburg | 20.7 mi | — | 2 | 0 |
| Three Springs Sr Living & Rhab | 20.9 mi | — | 8 | 0 |
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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 August 2026) and official state health department websites.