Below average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Alpine Care Of St. Charles Llc during CMS and state inspections, most recent first.
Two residents did not receive ordered medications as prescribed. One resident with a history of pulmonary embolism and anticoagulant use missed scheduled Lovenox doses, and the DON confirmed the omissions without explanation. Another resident on dialysis could not receive ordered Hydroxyzine before treatment because the medication was not available in the facility; the resident reported itching and anxiety, and the NP confirmed the medication’s intended use.
A resident reported recurring problems with not receiving all ordered medications, including a fentanyl transdermal patch for pain and Lovenox injections as a blood thinner. Review of the MAR for the month showed multiple missed Lovenox doses, with some entries lacking any documentation of administration and others marked as unavailable, as well as a scheduled fentanyl patch dose documented as unavailable and not given. The DON acknowledged at least one missed blood thinner dose when an agency nurse could not locate the medication, and the ADON confirmed that a fentanyl patch dose was not administered because it was not available despite being ordered from the pharmacy, even though the facility’s policy requires safe medication administration and end-of-pass EMAR review to ensure all medications are given and documented.
The facility failed to implement and update effective fall prevention interventions for several cognitively impaired, high fall‑risk residents who required extensive assistance with transfers and wheelchair mobility. One resident, needing step‑by‑step cues for safety, fell from bed during a transfer when a CNA turned away to obtain clothing, resulting in a laceration above the eye, and the resident’s fall care plan was not revised afterward. Another resident, also severely cognitively impaired and at high fall risk, slid from a wheelchair near the nurses’ station, sustaining multiple skin tears while seated on a non‑specialty cushion without anti‑slip material, and the only documented intervention related to the fall was treatment for chronic anemia rather than specific fall‑prevention measures.
A resident admitted after hip surgery with existing pressure ulcers, a Braden score indicating high risk, and bowel and bladder incontinence was found lying on her back with a heavily soiled brief and a newly developed sacral wound, in addition to known heel and buttock ulcers. CNAs reported the last incontinence care had been provided more than four hours earlier, despite facility expectations and policies that incontinent, cognitively impaired residents be checked and changed at least every 2–3 hours and receive moisture management. The WCN confirmed that earlier skin and wound assessments showed no sacral wound, and later identified a new stage 2 sacral pressure ulcer, demonstrating that required pressure ulcer prevention and incontinence interventions were not consistently implemented.
A resident with severe cognitive impairment experienced an unwitnessed fall from bed that was observed by a CNA and reported to an RN, who assisted in lifting the resident back to bed, did not document the incident, and did not notify the MD. Subsequent shifts, including agency CNAs, an agency RN, a dialysis RN, and an OT, noted new acute right leg/hip pain, inability to bear weight, and a marked increase in assistance needed for transfers, but none were aware of any recent fall. The day-shift RN, also unaware of the fall, reported the hip pain to the MD and obtained a routine rather than STAT x-ray, which later revealed a right femoral neck fracture. The facility’s policy required immediate MD notification of accidents and significant changes in condition, but this did not occur, leading to delayed medical evaluation of the fracture.
A resident with severe cognitive impairment experienced an unwitnessed fall from bed that was observed by a CNA and assessed by an RN, but the RN did not document the event in the EMR, notify the MD, or inform subsequent nursing staff. A separate fall incident report was completed as a QA-only document and not integrated into the clinical record, so oncoming RNs and CNAs were unaware of the fall and did not initiate post-fall or neuro assessments. The resident was repeatedly transferred, including for toileting, dialysis, and therapy, while vocalizing acute right leg/hip pain and showing decreased ability to bear weight, but staff and therapy providers were not told of any recent incident. The day-shift RN, still unaware of the fall, reported hip pain to the MD and obtained a routine rather than STAT x-ray, and the fall coordinator later confirmed there was no EMR documentation or required 72-hour post-fall monitoring despite facility policy.
A resident with a history of AV fistula complications was admitted with orders to use a new permcath for dialysis, but the facility failed to communicate this change to the dialysis team. As a result, the AV fistula was used for treatment, leading to severe arm swelling and pain, and the resident required hospitalization for an acute cephalic vein thrombosis. Documentation and care planning did not reflect the updated orders, and the dialysis nurse lacked access to critical hospital discharge information.
Kitchen staff did not follow sanitary food handling and storage practices, including improper cleaning and use of thermometer probes, inadequate hair restraint use, leaving food uncovered, and storing expired or spoiled food items. These actions were inconsistent with facility policies and affected all residents receiving food from the kitchen.
Four residents with cognitive and physical impairments did not receive needed assistance with personal hygiene tasks such as nail care and shaving, despite requesting help from CNAs. Observations showed untrimmed fingernails and unshaven facial hair, and interviews confirmed that requests for care were not met. Facility policy requires meeting residents' ADL needs, but these were not fulfilled as observed.
The facility did not ensure proper coordination and documentation of hospice care activities for four residents, as hospice staff recorded care notes in their own system and did not provide written documentation to the facility. Facility staff relied on verbal updates, and hospice visit notes were missing from the residents' records, resulting in incomplete documentation of hospice services and care plans.
Two residents were allowed to keep and self-administer medications at their bedside without proper assessment, updated physician orders, or care planning. One resident had multiple medications at bedside with missing or outdated self-administration assessments and no care plan, while another with mild cognitive impairment had an inhaler and nasal sprays without required assessments or orders for all medications. Facility policy requiring regular evaluation and demonstration of self-administration ability was not followed.
A resident who was thin and frail did not receive their ordered nutritional supplement drink at lunch because the supplement was not included on their meal ticket. The dietician had not completed the required nutritional assessment or care plan, and the supplement order was not communicated to dietary staff as required by facility policy, resulting in the supplement not being provided.
Medications, including tablets, eye drops, and powder, were found unsecured on the bedside tables of three residents. One resident reported that a nurse left her refused medications in her room, while the other two had their medications left out as well. The DON confirmed that all medications should be kept secured in the med cart according to facility policy.
Two residents with significant dental needs were not assessed or assisted in obtaining routine dental services. Despite documented oral health issues and assessment forms indicating the need for dental evaluations, staff failed to refer these individuals for dental care due to unclear processes and lack of communication between nursing and social services.
Multiple residents' personal refrigerators were found with excessive ice buildup, expired and unlabeled food, missing temperature logs, and lack of thermometers. Staff interviews revealed confusion over responsibilities for cleaning, temperature monitoring, and food disposal, resulting in inconsistent adherence to facility policies regarding food safety and refrigerator maintenance.
Staff failed to follow infection control protocols by not changing gloves or performing proper hand hygiene between care activities, and by placing urinary catheter drainage bags directly on the floor for multiple residents. Gloves were improperly stored in uniform pockets and hand sanitizer was not used according to policy, leading to lapses in standard precautions during resident care.
A resident with cognitive impairment alleged sexual abuse by a male CNA, but the facility failed to investigate or report the incident promptly. The administrator delayed action due to an unrelated allegation, and the police were notified days later, contrary to the facility's abuse policy.
A resident with severe cognitive impairment and multiple medical conditions experienced a delay in receiving an x-ray for a suspected fracture, resulting in a delay in diagnosis and treatment. Despite an x-ray being ordered on 8/13/2024, it was not performed until 8/16/2024, leading to a delay in the resident being sent to the hospital for appropriate care. The facility's staff failed to follow up on the x-ray order promptly, and the Director of Nursing could not explain the delay.
The facility failed to label and date medications after opening, affecting six residents. Medications such as inhalers, insulin pens, and ophthalmic solutions were not dated, contrary to pharmacy recommendations for expiration. Additionally, a narcotic medication with a broken seal was improperly taped over instead of being discarded, as confirmed by a Nurse Consultant.
The facility did not follow the prescribed menu portion sizes for pureed beef top round roast beef, using a #8 scoop instead of the required #6 scoop for five residents on pureed diets. This resulted in a deficiency as the dietary staff did not adhere to the menu spreadsheet, leading to inadequate nutrition portions being served.
A facility failed to request a timely re-evaluation for a PASARR II screening for a resident with a serious mental illness. The resident, admitted with bipolar disorder, anxiety, and PTSD, did not receive a follow-up assessment after the initial PASARR II evaluation expired. Despite tracking assessments in the Maximus system, the facility did not conduct the required re-evaluation, resulting in a deficiency.
The facility failed to assist three residents with activities of daily living (ADLs), resulting in neglect of personal hygiene and incontinence care. One resident with severe cognitive impairment was found with dried stool on his hand and body, while another dependent resident was not provided with requested grooming and showering. A third resident expressed discomfort due to unkempt facial hair and long fingernails, highlighting a lack of adherence to the facility's policy on meeting residents' physical needs.
A facility failed to provide appropriate splint and therapy services for a resident with quadriplegia and other conditions, leading to a deficiency in maintaining range of motion. The resident's care plan required a left resting hand splint to be applied daily, but observations showed it was not consistently used. Staff acknowledged the requirement, but there was no documentation to confirm adherence to the prescribed schedule.
A resident with chronic respiratory failure was found with an almost empty portable oxygen tank during a group meeting, leading to coughing and reduced participation. A nurse replaced the tank, improving the resident's condition. The facility's policy requires continuous oxygen administration as per physician's orders.
A facility was found to have a 12% medication error rate due to improper administration of medications. An RN initially drew an incorrect dose of Heparin for a resident but corrected it before administration. Another RN administered Bisacodyl instead of Docusate Sodium without consulting a physician and failed to prime a new insulin pen before use. The DON emphasized adherence to physician's orders and proper medication administration protocols.
A facility failed to follow infection control practices during incontinence care for a resident. A CNA did not perform hand hygiene between glove changes while cleaning a heavily soiled resident and applied barrier cream with soiled gloves. The DON confirmed that hand hygiene is required between tasks, aligning with the facility's policy and CDC guidelines.
Medication Omission and Unavailable Ordered Medication
Penalty
Summary
The facility failed to ensure that prescribed medications were available and administered according to physician orders for two residents. One resident had diagnoses including thrombocytopenia, a history of pulmonary embolism, long-term anticoagulant use, radiculopathy, sacrococcygeal disorders, and spondylosis, and was assessed as cognitively intact but needing substantial staff assistance with ADLs. The resident stated that Lovenox had not been given on May 11 and 12, 2026, and also reported a prior episode in April when the medication was not administered. Review of the MAR and nursing documentation confirmed the omission, and the current physician order sheet showed Lovenox 40 mg every 12 hours by subcutaneous injection. The DON later validated that the morning doses were not administered on those dates and had no explanation for why the medication was not given. A second resident had diagnoses including dependence on renal dialysis treatment, PTSD, epilepsy, and metabolic encephalopathy, and was assessed as moderately cognitively impaired with substantial ADL assistance needs. During medication administration, the RN was unable to give Hydroxyzine 50 mg because the medication was not available in the facility. The order was for Hydroxyzine to be given on dialysis days before treatment to help decrease anxiety and lessen urticaria symptoms. The resident reported feeling itchy and said it felt like bugs were in the room; maintenance checked the room and found no bugs. The NP confirmed that Lovenox was a significant medication for clot prevention and that Hydroxyzine was ordered for dialysis days to control anxiety and continuous itchiness.
Failure to Provide Ordered Anticoagulant and Pain Medications Due to Unavailability and Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to ordered anticoagulant and pain medications. The resident reported that she does not receive all her medications and that the facility runs out of them, stating she did not receive her fentanyl pain patch and Lovenox blood thinner injection a few weeks prior. Review of the April 2026 Medication Administration Record (MAR) showed an order for Lovenox 40 mg every 12 hours, with five missed doses. On two dates (4/10 and 4/22), there was no documentation that Lovenox was administered, and on three dates (4/7, 4/8, 4/11) the MAR indicated the medication was unavailable and not given. The MAR also showed an order for a fentanyl 50 mcg/hr transdermal patch to be applied every 72 hours for pain, with documentation that the patch was unavailable and not administered on 4/10/26. During interviews, the DON stated that when medications are running low, nursing staff should reorder at least three days in advance and that some medications can be obtained from emergency supply if not available. The DON acknowledged there was a time when the resident did not receive her blood thinner injection because an agency nurse reported she could not find it, and confirmed that if a medication is not documented on the MAR, it was not administered. The ADON confirmed, upon review of the April MAR, that the resident did not receive her fentanyl patch on 4/4/26 because it had been ordered from the pharmacy but was not available to administer. The ADON also stated that the blood thinner injections are delivered in a box with plenty of supply and was unsure why nursing documented the medication as unavailable. The facility’s Medication Administration Policy dated April 2026 states that medication administration is to be performed safely to prevent errors and that, at completion of med pass, all EMARs are to be reviewed to assure all medications have been administered and documented.
Failure to Implement and Update Fall Prevention Interventions for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement and update fall and safety interventions for multiple residents identified as high fall risk. One resident with severe cognitive impairment and a documented high fall risk required substantial to maximal assistance with transfers and dressing and needed extensive step‑by‑step cues for safety. This resident sustained a partial laceration to the right eyebrow after a witnessed fall from bed during a transfer and bedtime care, when the CNA turned away and walked across the room to obtain a gown, during which time the resident fell and hit her head on furniture. The fall incident report documented the fall and resulting laceration, and the resident’s skin/wound evaluation confirmed the injury. Despite this event, the resident’s fall care plan had not been updated since the prior year, and no new interventions were added following the fall. Another resident, also severely cognitively impaired and assessed as high risk for falls with a history of falls, required partial to moderate assistance with wheelchair mobility and substantial to maximal assistance with transfers. This resident was observed with multiple skin tears on both arms and was unable to explain how the injuries occurred. Staff reported that the resident had fallen and sustained the skin tears after sliding off a wheelchair while at or near the nurses’ station, having propelled away from staff view. The resident was seated on a black cushion that was not a wedge or pommel cushion, and staff verified there was no anti‑slip material in the wheelchair. The unwitnessed fall incident report documented that the resident was found lying on the floor in front of the nurses’ station with skin tears on the arms after reporting that he slid on the floor and hit his head slightly. The fall nurse acknowledged the resident had multiple falls and that the identified intervention related to his fall was treatment for chronic anemia, without additional fall‑specific interventions described in the report.
Failure to Provide Timely Incontinence Care and Pressure Ulcer Prevention
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pressure ulcer prevention and incontinence care for a resident at high risk for pressure injury. The resident was admitted after left hip surgery with two existing pressure ulcers: an unstageable ulcer on the left heel and a deep tissue injury (DTI) on the left buttock. Her care plan and Braden score of 12 identified her as high risk for pressure ulcer development, with known skin breakdown and bowel and bladder incontinence. On the morning in question, the resident was observed in bed on her back, confused, and calling out for assistance before requesting toileting. When two CNAs provided incontinence care, they found her brief heavily soiled with urine and smeared feces, and noted a new open area on the sacrum in addition to the existing DTI on the left buttock. One CNA reported that the last incontinence care had been provided at the beginning of the shift around 6–7 AM, more than four hours before the heavily soiled brief was discovered, and stated that the sacral area had been intact at that earlier time. The Wound Care Nurse confirmed that earlier that morning she had assessed the resident’s skin and performed wound care to the left buttock DTI and left heel unstageable ulcer, and at that time there was no sacral wound. Upon reassessment later that day, the Wound Care Nurse identified a new stage 2 pressure ulcer on the sacrum measuring 5 x 1.8 x 0.1 cm with purple discoloration to the peri-wound area. The Wound Care Nurse and DON both stated that incontinent residents, especially those who are cognitively impaired, should be checked and changed at least every 2–3 hours, and the facility’s incontinence and pressure ulcer prevention policies required incontinence care after each episode and moisture management based on resident needs. Despite these expectations and policies, the resident was not provided timely incontinence care, and a new sacral pressure ulcer developed.
Failure to Notify Physician After Unwitnessed Fall and New Acute Hip Pain
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician of an unwitnessed fall and subsequent acute right hip pain for a cognitively impaired resident, resulting in delayed medical care for a right hip fracture. The resident had a severely impaired cognitive status per a recent MDS and was unable to provide information about the fall. On the evening shift, a CNA found the resident on the floor next to her bed in a sitting position and notified the assigned RN. The RN assessed the resident, assisted in lifting her back to bed by carrying her under the arms with the CNA, determined she had not sustained an injury, and did not document the fall in the EMR or notify the physician of the incident. On the following overnight and day shifts, multiple staff members observed new, acute right leg/hip pain and functional decline without being aware of the prior unwitnessed fall. The overnight agency RN administered acetaminophen for pain but had not been informed of any incident. The agency CNA on that shift was also unaware of any fall and assisted the resident with pivot transfers based on prior instructions that she required only minimal assistance. The next morning, a CNA noted that the resident, who previously required minimal to partial assistance, now required extensive assistance, guarded her right lower extremity, and was unable to bear weight. This CNA reported her concerns to the agency RN and then to the oncoming RN, but was instructed to continue routine care, and subsequently observed the resident vocalizing pain during transfers to dialysis and therapy. Throughout that day, the dialysis RN and the occupational therapist were informed of the resident’s acute right leg pain and observed her vocalizing pain, screaming, and holding her right lower extremity when it was moved, yet neither had been notified of any recent fall. The OT documented that the resident verbalized pain, was unable to grade it, and screamed while holding her right lower extremity during movement. The day-shift RN, who had not been told of the fall, reported the resident’s right hip pain to the physician and obtained an order for a routine, not STAT, hip x-ray, which was completed later that evening. The radiology report, reviewed remotely that night, showed a subcapital fracture of the right femoral neck. The physician later stated she had not been notified of the fall or the acute pain at the time of the incident and that, had she been informed, she would have further assessed the resident and ordered STAT testing or hospital transfer sooner. The facility’s policy required immediate physician notification of accidents with potential for requiring physician intervention and significant changes in condition, but the RN on the evening of the fall did not follow this policy.
Failure to Document and Communicate Unwitnessed Fall Resulting in Delayed Assessment of Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to document, report, and monitor an unwitnessed fall for a severely cognitively impaired resident, which led to delayed medical care for a right hip fracture. On the evening of 3/01/2026, a CNA found the resident on the floor next to her bed in a sitting position and notified the assigned RN. The RN assessed the resident, determined she had no apparent injury, and assisted the CNA in manually lifting the resident back to bed by carrying her under the arms. The RN did not document the fall in the electronic medical record (EMR), did not notify the physician, and did not inform the oncoming nursing staff of the incident. A fall incident report was completed separately, indicating an unwitnessed fall and transfer back to bed, but it was marked as privileged and not part of the clinical record, and it was not integrated into the EMR. Because the fall was not documented in the EMR or communicated in shift report, the night-shift agency RN and CNA were unaware of the incident and did not perform any post-fall assessments or enhanced monitoring. The night CNA was instructed that the resident required only minimal assistance with transfers and proceeded to pivot-transfer her for toileting, without knowledge of a recent fall. Staff who routinely cared for the resident reported that prior to 3/02/2026 she required minimal to partial assistance with transfers. Early on 3/02/2026, a CNA assisting with dressing noted the resident vocalizing acute right leg pain, stopped care, and consulted the agency RN, who had just administered an analgesic. When the CNA asked if there had been a recent incident such as a fall, the agency RN reported there was no such event documented or reported in the EMR, and the CNA proceeded with transfers using a gait belt, observing that the resident now required extensive assistance, guarded her right lower leg, and was unable to bear weight. Throughout 3/02/2026, multiple staff members encountered the resident’s acute right leg and hip pain without knowledge of the prior unwitnessed fall. The CNA transporting the resident to dialysis reported the pain to the dialysis RN, who in turn notified the day-shift RN but was not informed of any recent incident. The dialysis communication form requested information on any change in condition, including recent falls, but no fall was reported. During therapy, the OT was not notified of any recent incident and documented that the resident screamed and held her right lower extremity when it was moved and was unable to safely stand. The day-shift RN, who had not been told of the fall and saw no EMR documentation of it, did not perform post-fall assessments and later reported the resident’s right hip pain to the physician, obtaining an order for a routine, rather than STAT, x-ray. The facility’s fall coordinator confirmed that there was no EMR documentation or 72-hour post-fall assessments for the unwitnessed fall, despite facility policy requiring incident reports to be documented in the medical record and accessible to staff, and requiring post-fall assessments and neurological checks for unwitnessed falls.
Failure to Communicate Updated Dialysis Orders and Assess Post-Dialysis Complications
Penalty
Summary
A deficiency occurred when the facility failed to communicate a resident's updated dialysis access order to the dialysis team and did not adequately assess for post-dialysis complications. The resident, who had a history of severe bleeding complications from his right arm AV fistula, was discharged from the hospital with instructions to use a newly placed permcath for dialysis instead of the AV fistula. Upon admission, the facility did not update the dialysis team with these new orders, and the dialysis Communication Report sheet did not reflect the change or the recent complications. As a result, the dialysis nurse used the resident's AV fistula for treatment, unaware of the updated order to use the permcath. After the treatment, the resident developed severe right arm swelling and pain. The family member notified the nurse on duty, who observed the swelling and contacted the nephrologist. The resident was subsequently transferred to the hospital, where he was diagnosed with an acute cephalic vein thrombosis in the right arm. Record review revealed that the facility's admission and care planning documentation did not include the new permcath access site or the updated dialysis orders. The dialysis nurse did not have access to the hospital discharge documents uploaded into the facility's EMR, and the baseline care plan and order summary did not reflect the required use of the permcath. The facility's policies and service contract required timely and accurate communication of changes in dialysis orders, which was not followed in this case.
Failure to Maintain Sanitary Food Handling and Storage Practices
Penalty
Summary
Facility kitchen staff failed to follow sanitary practices and safe food storage procedures, affecting all residents who receive oral nutrition from the kitchen. Observations included improper handling of thermometer probes, such as dropping a probe cover on the floor and placing it on a prep table without cleaning, using an uncleaned probe to check food temperatures, and using an alcohol wipe to push food off a probe back into a tray. Staff also failed to wear hair restraints properly, leaving hair exposed during food preparation, and left pureed food items uncovered on the steam table before service. Additional deficiencies were noted in food storage and labeling. In the walk-in cooler, a bag of pulled turkey lacked an expiration, use-by, or thaw date, and was fully thawed. Moldy and spoiled produce, including a zucchini with white fuzzy spots and green peppers with black, mushy areas, were found stored with other food. In dry storage, a scoop for thickener was left uncovered and exposed to environmental contaminants, and prune juice bottles past their best-by date were still present. Staff interviews confirmed that these practices did not align with facility policies for food labeling, storage, and sanitation. Facility policies require proper thawing, labeling, and storage of food items, as well as the use of clean, sanitized equipment and utensils. Staff acknowledged that food items past expiration or best-by dates should be removed, vegetables with visible spoilage should not be stored, and hair restraints must cover all hair. The observed failures to follow these procedures resulted in unsanitary conditions and improper food handling in the kitchen.
Failure to Provide Timely ADL Assistance for Residents Needing Personal Hygiene Support
Penalty
Summary
Surveyors observed that the facility failed to provide necessary assistance with activities of daily living (ADLs) for four residents who required help with personal hygiene tasks such as nail care and shaving. Direct observations revealed that one resident had long fingernails with a black substance underneath, despite requesting assistance from CNAs, while another had long yellow fingernails and also expressed a desire for nail care. Two additional residents were noted to have facial hair and stated they wanted to be shaved, but reported that CNAs had been too busy to assist them. These residents had documented diagnoses including major depressive disorder, dementia, anxiety disorders, schizophrenia, and impaired mobility, and their care plans indicated a need for substantial or maximal assistance with personal hygiene. Interviews with the residents confirmed that their requests for assistance with ADLs had not been fulfilled. The Director of Nursing stated that ADL care, including shaving and nail care, is typically provided on shower days or as needed, according to resident preference, and that CNAs are responsible for these tasks. Facility policy requires evaluation and provision of care to meet each resident's physical and psychosocial needs, including ADLs. Despite these policies, the observed lack of assistance resulted in unmet hygiene needs for the affected residents.
Failure to Maintain and Coordinate Hospice Documentation
Penalty
Summary
The facility failed to coordinate and maintain documentation of hospice care activities and the hospice care plan for four residents receiving hospice services. Hospice staff documented care and progress notes in their own electronic system and did not provide copies of this documentation to the facility. Facility staff received verbal updates from hospice staff, but written documentation, such as after-visit notes, was not consistently included in the residents' hospice binders or the facility's medical records. The only documentation provided by hospice to the facility included admission packets, DNR forms, POA forms, admission assessments, history and physicals, and occasionally physician orders. Interviews with facility RNs and the DON confirmed that hospice staff were expected to document in the hospice binder and provide verbal updates, but facility nurses only documented hospice notes when they initiated contact with hospice. Review of the hospice binders for the four residents revealed that essential hospice visit notes and after-visit documentation were missing. The binders typically contained only initial admission documents, consents, and sporadic physician orders, with little to no ongoing documentation of hospice visits or care provided. The facility care plans for each resident receiving hospice services were limited, listing only general goals and interventions related to comfort and pain management, with instructions to contact hospice as needed. The facility's agreement with the hospice provider stated that hospice would coordinate with the facility to ensure documentation of services was completed and that hospice care plans and documentation would be included in the facility medical record. However, this coordination and documentation did not occur as required, resulting in incomplete records of hospice care activities for the affected residents.
Failure to Assess and Care Plan for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure ongoing assessment and care planning for residents who desired to self-administer medications. In one case, a cognitively intact resident had multiple medications, including eye drops, an inhaler, and a topical cream, stored at his bedside. While there were physician orders for self-administration of some medications, there were no orders for others, and the required self-administration assessments were either outdated or missing. The resident reported not being taught how to take the medications, and there was no documentation of a care plan addressing self-administration. The facility's policy required regular assessment and demonstration of self-administration ability, but these procedures were not followed, and the policy did not specify how bedside medications should be secured. Another resident with mildly impaired cognition also kept an inhaler and nasal sprays at his bedside. Although there was a physician order for unsupervised self-administration of the inhaler, there were no such orders for the nasal sprays. The resident stated he was not assessed by nursing staff for his ability to self-administer these medications, and there was no documentation of such assessments or related care planning in his record. These findings indicate a lack of compliance with facility policy and federal regulations regarding the assessment, authorization, and care planning for self-administration of medications.
Failure to Assess and Provide Ordered Nutritional Supplement
Penalty
Summary
A resident who appeared thin and frail was not provided with their ordered nutritional supplement drink during lunch on multiple occasions. Observations showed that the resident's meal tray included juice and Lactaid milk, but not the prescribed supplement. Staff interviews revealed that the resident's meal ticket did not list the supplement, and the dietary staff prepared meals based on these tickets. The dietician confirmed that she was responsible for assessing residents' nutritional needs and that dietary communication slips were used to inform the kitchen of required supplements. However, the resident's dietary evaluation was not completed following both their initial admission and subsequent readmission, resulting in the supplement order not being entered into the dietary system or reflected on the meal ticket. Record review indicated that the resident's dietary evaluation form and nutritional care plan remained incomplete, and there was no documentation of an assessment of the resident's nutritional needs. The order for the supplement drink was present in the medical record, but it was not communicated to the dietary staff via the required forms or the electronic system. Facility policy required a nutritional assessment within 24-72 hours of admission and communication of supplement orders to the kitchen, but these procedures were not followed, leading to the resident not receiving the ordered nutritional supplement.
Failure to Secure Resident Medications
Penalty
Summary
Surveyors observed that medications were not properly secured for three residents. One resident had a medication cup containing six tablets of various shapes and colors left on her bedside table, with a handwritten label and another cup covering it; the resident stated she had refused the medication and that it was left by a nurse from a previous shift. Another resident had a vial of eye drops lubricant on her bedside table, and a third resident had Nystatin powder also left on her bedside table. The Director of Nursing confirmed that all medications should be secured in the medication cart and not left in resident rooms, as per facility policy, which requires medications to be stored safely and in locked storage areas.
Failure to Assess and Assist Residents in Obtaining Dental Services
Penalty
Summary
The facility failed to assess and assist two residents in obtaining routine dental services. Both residents had been living at the facility for an extended period and reported not having seen a dentist, despite visible dental issues such as missing and broken teeth, visible decay, and loose or missing dentures. Documentation showed that oral health assessments indicated the need for dental evaluations for both individuals, but no abnormalities were recorded on the assessment forms. The forms did note that a dental check-up was required as soon as possible. Interviews with staff revealed that the process for identifying and referring residents for dental care was unclear and inconsistently followed. The Social Services Director was unaware of the residents' dental needs and was not familiar with the assessment forms used to identify such needs. Additionally, the residents were not included on the facility's list of those enrolled in the dental program, and there was confusion among staff regarding responsibility for completing assessments and communicating dental care needs.
Failure to Maintain and Monitor Resident Refrigerators and Food Safety
Penalty
Summary
The facility failed to maintain and monitor residents' personal refrigerators, as evidenced by multiple observations and record reviews. One resident's freezer section was completely filled with accumulated ice, rendering the freezer door frozen shut and inaccessible. Temperature logs for this refrigerator were incomplete, with several days missing entries. Another resident's refrigerator contained expired food, significant ice buildup, a melted cup of ice cream, and unidentifiable crumbs at the bottom. The temperature log for this refrigerator was also incomplete for several days. Additionally, a third resident's refrigerator lacked a thermometer and contained undated and unlabeled food items, including a piece of chicken breast wrapped in saran wrap. Interviews with staff revealed confusion and inconsistency regarding responsibilities for cleaning, defrosting, temperature monitoring, and food disposal in resident refrigerators. CNAs, housekeeping, and maintenance staff each described different roles, with some overlap and lack of clarity. Facility policies required proper labeling, dating, and timely disposal of food brought in from outside, as well as regular checks and maintenance of resident refrigerators. However, these policies were not consistently followed, leading to the deficiencies observed.
Failure to Follow Infection Control Practices During Resident Care
Penalty
Summary
Surveyors observed multiple failures in infection prevention and control practices among staff caring for three residents with urinary catheters and incontinence needs. In one instance, a CNA donned gloves and PPE to assist a resident with morning care, including changing an incontinence brief and dressing the resident, but did not change gloves between different care activities. The CNA also placed the resident's full urinary catheter drainage bag directly on the floor, both before and after care. In another case, two CNAs changed a resident's soiled incontinence brief, with one CNA repeatedly obtaining gloves from his uniform pocket and not consistently performing proper hand hygiene between glove changes. The gloves stored in the uniform pocket were not considered clean, and hand sanitizer was not used according to facility policy, as it was wiped off with a washcloth instead of being rubbed until dry. A third resident was observed with a full urinary catheter drainage bag left on the floor for several hours. When two CNAs later assisted with care, one obtained gloves from his uniform pocket and did not change gloves or perform hand hygiene between different care activities, including cleaning the catheter tubing, peri-area, and dressing the resident. Both CNAs failed to change gloves and perform hand hygiene as required. Facility policies reviewed by surveyors specified that gloves should be single-use and not stored in uniforms, hand hygiene should follow CDC guidelines, and catheter drainage bags should always be kept off the floor. The Assistant Director of Nursing confirmed staff expectations for proper glove use, hand hygiene, and catheter care, which were not followed in these instances.
Failure to Investigate and Report Sexual Abuse Allegation
Penalty
Summary
The facility failed to investigate allegations of sexual abuse in a timely manner and did not implement their abuse policy and procedure. A resident with moderate cognitive impairment and multiple medical conditions, including dementia and depression, alleged that a male CNA from a staffing agency sexually abused her. The resident reported the incident to a counselor and hospital staff, but the facility did not initiate an investigation or report the allegation to the police until several days later. The facility's administrator received a call from hospital staff about the allegation but did not act immediately due to an unrelated open allegation of physical abuse. The police were only notified four days after the initial report by the hospital. The facility's policy requires immediate reporting of such allegations, but this was not followed. The resident was not interviewed by facility staff until prompted by a surveyor, and the alleged perpetrator was identified through a review of the staffing schedule.
Delay in Radiological Services for Resident with Fracture
Penalty
Summary
The facility failed to provide timely radiological services for a resident with a change in medical condition, resulting in a delay in diagnosis and treatment. The resident, who had severe cognitive impairment and multiple medical conditions including ESRD, was admitted to the facility and later sent to the hospital with an acute comminuted fracture of the right proximal tibia and fibula. On 8/13/2024, a nurse practitioner ordered an x-ray for the resident's right leg due to reported pain, but the x-ray was not performed until 8/16/2024, more than 48 hours later. This delay in obtaining the x-ray led to a delay in the resident being sent to the hospital for appropriate treatment. The resident's medical records and staff interviews revealed that the x-ray order was not followed up on promptly, despite the resident's continued complaints of pain and the nurse practitioner's follow-up visit on 8/15/2024. The Director of Nursing could not provide an explanation for the delay in obtaining the x-ray. The resident was eventually diagnosed with a fracture and returned to the facility with a leg brace. The delay in radiological services and subsequent treatment was a significant deficiency in the facility's care for the resident.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to properly label and date medications after opening, which is necessary to determine their expiration dates. This deficiency was observed during a survey where multiple residents' medications were found to be improperly managed. For instance, two Wixela inhalers for one resident were opened but not dated, despite the pharmacy's recommendation to discard them 30 days after opening. Similarly, another resident's Humalog Kwik Pen and a third resident's Basaglar Kwik Pen were opened without being dated, even though they should be discarded 28 days after opening. Additionally, Tobramycin and Dexamethasone Ophthalmic Solution for another resident was also opened and not dated, with the pharmacy recommending disposal 28 days post-opening. Furthermore, the facility failed to discard a narcotic medication with a broken seal. During the inspection, it was noted that a resident's Diazepam tablets were opened and taped over to reseal, which is against the proper protocol. The Nurse Consultant confirmed that once the seal of the blister is torn, the medication should be discarded and not taped over. These findings indicate a lack of adherence to proper medication labeling, storage, and expiration protocols, affecting six residents in the sample reviewed.
Failure to Follow Menu Portion Sizes for Pureed Diets
Penalty
Summary
The facility failed to adhere to the prescribed menu spreadsheet for serving pureed beef top round roast beef, resulting in a deficiency. During a lunch meal service, the dietary staff, including a cook and a dietary aide, used a #8 scoop instead of the required #6 scoop to serve the pureed beef to five residents on pureed diets. This discrepancy was observed despite the meal tickets indicating the correct serving size of a #6 scoop. The Registered Dietitian confirmed that the dietary staff should have followed the menu spreadsheet to ensure the adequacy of nutrition. The facility's portion control chart indicated that a #8 scoop equates to 4 ounces, while a #6 scoop equates to 5 1/3 ounces, highlighting the shortfall in the portion size provided to the residents.
Failure to Conduct Timely PASARR II Re-evaluation
Penalty
Summary
The facility failed to request a re-evaluation for a PASARR II screening for a resident with a serious mental illness (SMI) diagnosis within the required timeframe. The resident, identified as R59, was admitted with diagnoses including bipolar disorder, specified anxiety disorder, and PTSD. The resident's care plan indicated a need for appropriate assessments to understand her past and encourage verbalization of thoughts and feelings. However, the PASARR II evaluation, which was effective from February 12, 2023, to April 13, 2023, was not followed up with a re-evaluation as required. The Vice President of Operations (V21) stated that the facility tracks assessments in the Maximus system, which should notify them when an assessment is due. Despite this, no re-evaluation was conducted for R59, and the facility was unable to explain why. The facility's policy mandates PASARR screenings within the allowed timeframe, but this was not adhered to in R59's case. The oversight was identified during a survey, highlighting a deficiency in the facility's compliance with PASARR requirements.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for three residents, leading to deficiencies in their care. One resident, who had severe cognitive impairment and required substantial assistance, was observed with dried stool on his hand and body, indicating a lack of timely incontinence care. Despite being in the dining room for over two hours, the resident was not assisted with toileting needs until the issue was brought to the attention of the Director of Nursing (DON). The resident's care plan specifically required staff to check for incontinence episodes and anticipate toileting needs, which was not adhered to. Another resident, who was dependent on staff for all ADLs, expressed a desire for a shower and grooming, which was not provided over several days. Observations noted greasy hair, facial hair, and a musty odor, indicating neglect in personal hygiene care. A third resident, who required extensive assistance with ADLs, was found with unkempt facial hair and long, discolored fingernails, despite expressing discomfort and a desire for grooming. The facility's policy required evaluation and assistance with physical needs, including ADLs, which was not adequately followed for these residents.
Failure to Provide Appropriate Splint and Therapy Services
Penalty
Summary
The facility failed to assess and provide appropriate splints and therapy services to maintain or prevent further progression of deformities or reduction in range of motion for a resident identified as R76. R76, who was diagnosed with quadriplegia, major depressive disorder, morbid obesity, and critical illness myopathy, was dependent on staff for all activities of daily living. The resident's care plan required the application of a left resting hand splint during the day to maintain functional positioning and prevent contractures. However, observations over several days revealed that the splint was consistently not applied, despite being prescribed to be worn daily for four to eight hours. Interviews and record reviews indicated a lack of documentation and adherence to the prescribed splint application schedule. The restorative nurse and other staff members acknowledged that the splint should be applied daily, but there was no evidence in the facility's records to confirm that this was being done. The facility's policy on restorative nursing programs, which includes contracture prevention and management, was not followed, as there was no documentation in the resident's electronic restorative log to reflect the provision of services and frequency of splint application.
Oxygen Tank Deficiency for Resident
Penalty
Summary
The facility failed to ensure that a resident's portable oxygen tank contained enough oxygen to deliver the prescribed therapy. The resident, who had multiple diagnoses including chronic respiratory failure with hypoxia and was dependent on supplemental oxygen, was observed in a group meeting with an oxygen nasal cannula attached to a portable oxygen tank. The gauge on the tank indicated it needed a refill, as it was in the red area. A nurse was called to replace the tank, and after the replacement, the resident's coughing decreased, and participation in the group discussion improved. The resident's active order summary indicated that oxygen was to be administered continuously as needed. However, during the incident, the oxygen was set at 2 liters per minute, and the tank was nearly empty. The Director of Nursing later clarified that the resident's oxygen should be administered continuously. The facility's policy on oxygen therapy stated that it should be administered as indicated and upon a physician's order, to ensure adequate oxygenation for patients.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer medications according to physician's orders, resulting in a 12% medication error rate. This deficiency was identified through the observation of medication administration for two residents. For one resident, a registered nurse (RN) prepared to administer Heparin Sodium but initially drew an incorrect dose of 0.9 ml instead of the prescribed 1 ml. The error was corrected before administration, but it highlighted a lapse in following the exact dosage as per the physician's order. For another resident, the RN was unsure about how to administer Docusate Sodium, which cannot be crushed, and instead administered Bisacodyl without consulting the physician. Additionally, the RN failed to prime a new insulin pen before administering the insulin, which is a necessary step to ensure accurate dosing. The Director of Nursing (DON) confirmed that staff must adhere to the physician's orders and the five rights of medication administration, emphasizing the importance of priming insulin pens before use.
Infection Control Breach During Incontinence Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during incontinence care for a resident identified as R13. On July 24, 2024, two CNAs, V17 and V18, provided care to R13, who was heavily soiled with urine and feces. During the care, V17 initially performed hand hygiene after cleaning the front perineum but failed to do so after changing gloves twice while cleaning the back perineum. Furthermore, V17 applied barrier cream and an incontinence brief while still wearing the same soiled gloves, which is against the facility's hand hygiene policy. The Director of Nursing (DON), identified as V2, confirmed that staff are required to perform hand hygiene between glove changes, between tasks, and before and after completing care to prevent infection spread. The facility's hand hygiene policy, revised on June 6, 2024, aligns with CDC guidelines and specifies that hand hygiene should be performed before moving from a soiled to a clean body site, after contact with body fluids, and after removing gloves. The failure to follow these procedures during the care of R13 represents a breach in infection control practices.
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.
Illustrative
What surveyors actually found near you
We read the 698 citations issued within 25 miles in the last 12 months — including the 9 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.
Illustrative
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.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Saint Charles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pearl Of St Charles, The | 1.2 mi | ★★★★★ | 2 | 0 |
| Greenfields Of Geneva | 2.6 mi | ★★★★★ | 6 | 0 |
| Bria Of Geneva | 2.8 mi | ★★★★★ | 0 | 0 |
| Batavia Rehabilitation And Health Care Center | 4.2 mi | ★★★★★ | 1 | 0 |
| Michaelsen Health Center | 4.3 mi | ★★★★★ | 3 | 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.