Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 Alton Memorial Rehab & Therapy during CMS and state inspections, most recent first.
A resident on apixaban with known fall risk was being transferred from a shower chair to a wheelchair when a CNA and an RN assisted her without using a gait belt, despite noted weakness and buckling knees. The resident’s knees gave way, and staff lowered her to the floor; her face contacted a handrail, resulting in broken dentures, mouth bleeding, and later-identified bruising. The RN did not consider this a fall, did not notify the provider, did not obtain vitals or neuro checks, and did not complete any post-fall documentation, despite facility policies requiring a post-fall evaluation and neuro checks when the head is struck. About 12 hours later, an LPN assessed the resident’s mouth pain and dried blood, notified the NP, and the resident was sent to the ER, where facial contusion and other findings were documented after EKG, labs, head CT, and chest x-ray.
A resident with a documented fall risk and on Apixaban experienced a fall in the shower when their knees buckled, causing their face to strike a handrail, breaking dentures and resulting in bleeding and significant mouth pain. The nurse on duty at the time did not notify the provider or document the incident in the electronic record in a timely manner. The oncoming LPN the next morning learned of the fall in report, assessed the resident, and noted dried blood and pain, after which the NP was notified and the resident was sent to the ED. The NP later documented that the fall and suspected head/mouth injury had not been reported when it occurred, despite the resident’s anticoagulant use and a facility policy requiring immediate physician notification of serious incidents such as head injuries using SBAR and documenting provider notification in the chart.
Food Not Served Palatable or at Appetizing Temperature: Multiple residents with regular diet orders reported that meals were not good, tasteless, hard, gummy, and often cold. One cognitively intact resident said the issue had been raised repeatedly in resident council and to the chef without change, while resident council minutes also documented ongoing complaints about food quality and temperature. The facility policy required food and drinks to be palatable, attractive, and served at a safe and appetizing temperature.
Missing Resident Clothing: The facility failed to safeguard the personal clothing of two residents, who reported missing items for months. A family member said one resident’s clothes had been lost and that it was an ongoing issue, while the other resident said she had told the Administrator and nothing had been found. The Laundry/Housekeeping Supervisor said the facility has a lost and found, but was unaware the residents were missing clothing. Resident council notes also documented ongoing missing clothing concerns.
Failure to update a resident's care plan was identified after repeated falls and a change in condition. The resident had a high Morse fall risk score, moderate cognitive impairment, and diagnoses including HTN, osteoporosis, and seizures. The care plan still listed fall interventions such as transfer assistance, a wheelchair brake handle extension, and a "Please Call, Don't Fall" sign, but surveyors observed the extension and signs were not in place. The DON stated the interventions were no longer appropriate and the care plan had not been updated due to human error.
Failure to Maintain Fall Prevention Interventions: A resident with HTN, osteoporosis, seizures, and moderate cognitive impairment had repeated falls and a high Morse fall risk score, yet the care plan interventions were not in place as documented. Surveyors observed no wheelchair brake handle extension and no "Please Call, Don't Fall" sign in the resident's room or bathroom, while the resident had recently fallen during attempted self-transfers.
A resident with protein calorie malnutrition and ESRD had orders for a renal diet and Ensure High Protein TID, which were also reflected in the RD evaluation and care plan. During breakfast observation, the supplement was not on the tray, and staff were unsure whether it had been given; the resident stated she receives the protein shakes only some of the time. The administrator stated the facility does not have a policy regarding following physician orders.
The facility failed to adequately staff the dietary department, resulting in late meal service, particularly during dinner. A resident reported receiving dinner as late as 6:30 PM, despite the scheduled time being 5:30-6:00 PM. Staff confirmed that meal service is slower in the evenings, especially when only one person is working in the kitchen. The issue was previously discussed in a Resident Council Meeting, and the facility's dietary schedule showed understaffing during several dinner services.
A facility failed to report and investigate an alleged abuse incident involving a resident and a CNA. The resident felt abused after being handled roughly and left on a wet bed. Despite a family member's report and written statement, the facility administrator did not initiate an investigation or report the incident to authorities, allowing the CNA to continue working on the resident's floor.
A facility failed to investigate an abuse allegation involving a resident who reported being handled roughly by a CNA, resulting in spilled water and a wet bed. Despite the resident's and family's concerns, the facility's administrator did not initiate an investigation or implement protective measures. The facility's policy requires immediate investigation and reporting of abuse allegations, but this protocol was not followed, leading to a significant deficiency.
The facility failed to provide timely and complete incontinent care for several residents, leading to discomfort and embarrassment. One resident reported being left in a urine-soaked state all night, while others confirmed inadequate care and staffing issues during a Resident Council meeting. Observations revealed incomplete cleaning during care, contrary to the facility's perineal care policy.
A resident experienced a significant medication error when a six-day delay in starting an antibiotic for a UTI occurred due to miscommunication between nursing staff and a Physician Assistant. This delay led to increased confusion, pain, and missed therapy sessions, impacting the resident's recovery and therapy participation.
The facility failed to properly store and discard expired medications, potentially affecting all 45 residents. Expired medications, including Dulcolax and Acetaminophen suppositories, were found in the East Wing Medication Storage Room. LPNs confirmed these were stock medications for all residents, but expired medications should be destroyed. Staff interviews revealed inconsistencies in checking and discarding expired medications, despite procedures requiring their separation and destruction.
A resident was left in a soiled state overnight, compromising their dignity and comfort. The resident, who requires assistance for toileting, was found with soaked clothing and bedding, and not all areas were cleansed by the CNA. The resident expressed feelings of embarrassment and discomfort, and staff confirmed the resident's account of inadequate care and insufficient staffing.
The facility failed to submit MDS assessments for three residents within the required 14-day period. The assessments were submitted late, as confirmed by the Corporate Director of Reimbursement. The facility's protocol requires timely electronic transmission of assessments, which was not followed in these cases.
A resident was left in a soiled state overnight due to inadequate staffing, impacting their dignity and well-being. The resident, who requires assistance with daily living activities, reported feeling dirty and embarrassed after being left wet all night without being changed. This issue was corroborated by multiple residents during a Resident Council meeting, highlighting a systemic problem with staffing and care timeliness in the facility.
A resident sustained a significant injury during a transfer when a CNA failed to use a gait belt, as required by facility policy. The resident's fragile skin condition and low body weight contributed to the severity of the injury, which resulted in a large abrasion and laceration on her right calf. Multiple staff members documented the incident, confirming that the improper transfer technique led to the injury.
Failure to Follow Fall Policy, Use Gait Belt, and Perform Post-Fall Assessment After Shower Transfer Incident
Penalty
Summary
The deficiency involves the facility’s failure to follow its fall management and gait belt policies for a cognitively impaired resident identified as being at risk for falls and receiving apixaban for atrial fibrillation. The resident’s care plan required assistance with transfers and ambulation and specified maintaining appropriate bed height and call light access, but did not document whether a gait belt should be used, the number of staff required, or the mode of transfer. On the evening in question, a CNA requested assistance from an RN to transfer the resident from a shower chair to a wheelchair because the resident’s knees were buckling and she was weak. During the transfer, the CNA stood the resident up to hold the grab bar, moved the shower chair away, and the resident’s knees buckled; the CNA and RN then lowered the resident to the floor without a gait belt in use, despite the RN later acknowledging that a gait belt probably should have been used due to the resident’s weakness. Following this event, the RN observed a small amount of blood on the resident’s mouth and noted that the resident’s dentures were broken, but reported she did not see or hear the resident hit her mouth or head on the rail and therefore did not consider the incident a fall. The CNA later told the RN, about an hour afterward, that the resident’s face had hit the handrail, but the RN still did not notify the provider, did not complete a post-fall assessment, did not obtain vital signs, and did not perform neurological checks, despite facility policy requiring a post-fall evaluation and neuro checks for any fall in which the head was struck. There was no documentation in the electronic medical record on the date of the shower incident regarding a fall, being lowered to the floor, or the resident’s injuries, and no SBAR or post-fall assessment was completed at that time. Approximately 12 hours after the incident, an LPN coming on day shift received report that the resident had fallen in the shower, assessed the resident, and noted dried blood on the lip and complaints of significant mouth pain. The LPN immediately notified the nurse practitioner, who ordered transfer to the ER for evaluation and treatment. Emergency department records documented that the resident presented for evaluation of a fall the previous day with head and facial impact, jaw tenderness and pain on movement, lip abrasion, and bruising to the right upper extremity, and underwent EKG, blood work, head CT, and chest x-ray. The administrator and nurse practitioner both stated there was no documentation of the shower fall or post-fall assessments in the medical record, that the resident was not promptly sent to the ER despite being on a blood thinner, and that staff were expected to follow the facility’s fall and gait belt policies, including treating being lowered to the floor as a fall and using gait belts during transfers.
Failure to Notify Provider of Fall With Head/Mouth Injury for Anticoagulated Resident
Penalty
Summary
The deficiency involves the facility’s failure to notify the provider immediately after a resident experienced a fall with injury. The resident’s care plan dated 11/26/2025 documented that the resident was at risk for falls and required assistance with transfers and ambulation, with interventions including maintaining the bed at an appropriate height and ensuring the call light was within reach. According to an SBAR dated 12/22/2025 at 8:05 AM, an LPN documented that approximately 12 hours earlier the resident’s knees buckled in the shower room, causing the resident’s face to come into contact with a handrail and resulting in broken dentures, bleeding, and mouth pain rated 8/10. The resident was prescribed Apixaban (Eliquis), an anticoagulant, 5 mg BID. The LPN who worked the following day stated she received report that the resident had fallen in the shower, then assessed the resident and noted dried blood on the lip and complaints of mouth pain. She stated it was her understanding that the nurse on the prior shift had not notified the provider when the resident fell and hit her head. The nurse practitioner’s progress note dated 12/23/2025 documented that the fall was not reported to the provider until the oncoming nurse received report the following morning, and that the incident was not documented in the electronic medical record in a timely manner, with no nursing notes available for review. The NP noted that the resident was on Eliquis and that any reported or suspected head strike while on anticoagulation warrants immediate transfer to the emergency department and at minimum a STAT head CT. The NP stated she was not notified of the fall and head/mouth injury when it occurred and that she would have expected staff to notify her because of the resident’s anticoagulant use and need for physician assessment. The facility’s Reporting of Injuries Policy, revised 12/2025, states that serious incidents such as head injuries are to be reported to the physician at the time of occurrence, using SBAR to convey assessment findings and pertinent medication information, and that all charting should include notification of the doctor. These policy requirements were not followed for this resident’s fall with head/mouth injury.
Food Not Served Palatable or at Appetizing Temperature
Penalty
Summary
The facility failed to ensure food was palatable for 4 of 4 residents reviewed for nutritional services. R4, who was cognitively intact and independent with eating, had a regular diet order and stated on 12/2/2025 that the food in the facility was terrible, tasted bad, and was served cold in every meal tray. R4 also reported that the pasta was gummy, everything was tasteless, and food was well done and hard. R4 stated residents had raised concerns about taste and temperature at resident council meetings every month, that a letter had been written to the head chef, and that no changes had been made. R12, R32, and R44 also had regular diet orders, and their MDS assessments documented that R12 and R32 were cognitively intact while R44 was moderately cognitively impaired. On 12/2/2025, R12 stated the food was her only complaint and was not good, R32 stated the food was not good and usually cold, and R44 stated the food was always cold. Facility resident council minutes documented repeated complaints about food, including that milk was made up ahead of time and served not cold, that good food was needed, and that the food was terrible. The Administrator stated on 12/4/2025 that R4 always complained about the food but was not aware of other residents having these complaints. The facility policy stated food and drinks are to be palatable, attractive, and served at a safe and appetizing temperature.
Missing Resident Clothing
Penalty
Summary
The facility failed to ensure respectful handling and safeguarding of 2 residents’ personal clothing, with R3 and R4 both reporting that clothing had been missing for months. R3’s family member stated that the resident’s clothes had been lost by the facility and that this had been an ongoing issue. R4 stated that she had told the Administrator about missing clothes and nothing had been found. The Laundry/Housekeeping Supervisor stated she only washes clothes for long-term residents, that short-term residents’ clothes are washed by families, that the laundry is located in the basement, and that the facility has a lost and found for clothes, but she was unaware that R3 and R4 were missing clothing. Resident council records documented ongoing missing clothing concerns, including missing white v-neck T-shirts, missing clothing, and a resident asking when she would be paid for lost clothing. The facility policy stated that laundry items can be misplaced and staff should be notified immediately if a clothing item cannot be found.
Failure to Update Fall Care Plan After Change in Resident Condition
Penalty
Summary
Failure to evaluate and revise the care plan for a resident with a history of falls was identified for one resident in a sample of 25. The resident had diagnoses including hypertensive disorder, osteoporosis, and focal to bilateral tonic-clonic epileptic seizures, and the MDS documented moderate cognitive impairment with partial/moderate assistance needed for transfers. The care plan, last reviewed on 10/17/25, included fall-related interventions such as assistance with transfers and ambulation, keeping the bed at an appropriate height, keeping the call light within reach, a "Please Call, Don't Fall" sign, frequent observations, and a wheelchair brake handle extension. The resident had a Morse Fall Risk Score of 50 and a history of falls in the last 3 months. Post-fall evaluations documented a fall on 8/5/25 after the resident attempted to self-transfer and the wheelchair brake became loose, and another fall on 8/28/25 when the resident tried to transfer self and slid down the wall to the floor. During survey observations on 12/4/25, no brake handle extension was noted on the wheelchair, no "Call Don't Fall" sign was observed in the bathroom or room, and the administrator stated the fall interventions on the care plan were no longer appropriate and should have been resolved, but the care plan had not been updated due to human error.
Failure to Maintain Fall Prevention Interventions
Penalty
Summary
The facility failed to implement current progressive interventions to prevent falls for one resident who was reviewed for falls. The resident had diagnoses including hypertensive disorder, osteoporosis, and focal to bilateral tonic-clonic epileptic seizures, and the MDS documented moderate cognitive impairment with partial/moderate assistance needed for transfers. The care plan identified the resident as at risk for falls and included interventions such as assistance with transfers and ambulation, keeping the bed at an appropriate height, ensuring the call light was within reach, and use of a "Please Call, Don't Fall" sign and a wheelchair brake handle extension. The resident had multiple fall risk assessments showing scores above 45 and a history of falls in the prior 3 months. Post-fall evaluations documented a fall on 8/5/25 when the resident attempted to self-transfer and the wheelchair brake became loose, and another fall on 8/28/25 when the resident tried to transfer self and slid down the wall to the floor. During survey observation, the wheelchair brake handle extension was not present, and no "Call Don't Fall" sign was observed in the resident's room or bathroom. The Administrator stated the resident previously had the brake handle extension and the sign, but these interventions were no longer appropriate and had not been resolved from the care plan due to human error.
Failure to Follow Ordered Therapeutic Supplement
Penalty
Summary
The facility failed to follow a physician-prescribed therapeutic supplement order for one resident with protein calorie malnutrition and end stage renal disease. The resident’s record showed a renal diet order and an order for Ensure High Protein three times daily, which was also reflected in the registered dietitian’s nutrition evaluation and the care plan. On observation, the resident was sitting in the dining room eating breakfast, and there was no Ensure High Protein on the tray. The resident stated she receives the protein shakes with meals some of the time. During interviews, the dietary aide stated she was unsure whether the resident received Ensure High Protein with breakfast, and the CNA also stated she was unsure whether the supplement was given that morning, adding that the resident will often request it if she does not receive it. The administrator stated the facility does not have a policy regarding following physician orders and that they just follow them, and she stated she would address the supplements not being given.
Inadequate Dietary Staffing Leads to Late Meal Service
Penalty
Summary
The facility failed to adequately staff the dietary department, resulting in meals being served late, particularly during dinner service. This deficiency was observed in the case of a resident who reported receiving dinner as late as 6:30 PM and 6:35 PM, despite the scheduled dinner time being from 5:30 to 6:00 PM. The resident, who was cognitively intact and independent with eating, had a care plan goal to improve nutritional status and was on a carbohydrate-controlled diet. Interviews with staff, including a CNA, a dietary aid, and the dietary manager, confirmed that meal service tends to run slower in the evenings, especially when only one staff member is working in the kitchen. The issue of late meal service was previously discussed in a Resident Council Meeting, and the facility's dietary schedule showed that only one staff member was working during several dinner services. The facility administrator was unaware of the late meal service and stated that there was no policy regarding acceptable meal time frames, although meal times were posted. The deficiency was further supported by the facility's Resident Council Meeting Minutes, which documented the need for food to be served on time.
Failure to Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to report and investigate an alleged abuse incident involving a resident, identified as R2, in accordance with state law and facility policy. The incident involved a certified nursing assistant (CNA), V7, who allegedly handled R2 roughly, resulting in R2 feeling abused and frightened. R2 reported the incident to her family member, V5, who then informed the facility's licensed practical nurse (LPN), V6. Despite the family member's written statement and verbal communication of the incident, the facility administrator, V1, did not initiate an investigation or report the incident to the appropriate authorities. The report details that R2 was left on a wet bed after V7 allegedly mishandled her, causing distress and fear. R2's family member, V5, arrived at the facility to find R2 upset and the bed soaked with water. V5 cleaned the water and reported the incident to V6, who instructed V5 to write a statement and assured that V7 would not provide further care to R2. However, V7 continued to work on R2's floor the following day, indicating a lack of immediate action to protect R2 from further contact with V7. The facility's policy mandates immediate investigation and reporting of any abuse allegations, but V1 did not follow these procedures. V1 claimed not to have received any statements or allegations of abuse, despite V6's report and the statement placed under V1's door. The facility's failure to document and investigate the incident, as well as to report it to the state agency, constitutes a deficiency in ensuring resident safety and compliance with abuse reporting regulations.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to ensure that all abuse allegations were thoroughly investigated for one of the residents reviewed. The incident involved a resident, R2, who reported feeling abused by a male CNA, V7. R2 described an incident where V7 allegedly handled her roughly, causing water to spill on her and leaving her in a wet bed. R2 expressed fear and discomfort due to V7's actions, which she reported to her family member, V5. V5 corroborated R2's account, stating that upon arrival at the facility, they found R2 upset and the bed soaked with water. Despite V5's report to the LPN, V6, and the assurance that V7 would not provide further care to R2, V7 continued to work on R2's floor the following day. The facility's administrator, V1, did not initiate an investigation into the alleged abuse, nor were any protective measures put in place for R2. V1 claimed to be unaware of any abuse allegations, despite V6 stating that they had informed V1 and V2, the DON, about the family's concerns. The facility's policy mandates immediate investigation and reporting of any abuse allegations, but this protocol was not followed in R2's case. No documentation of the incident or any investigation was found in R2's medical records. The facility's failure to investigate the abuse allegation and implement protective measures for R2 represents a significant deficiency in adhering to their abuse prevention policy. The lack of communication and action from the facility's management, including the administrator and DON, contributed to the oversight. This deficiency highlights a breakdown in the facility's procedures for handling and investigating abuse allegations, leaving residents vulnerable to potential harm.
Inadequate Incontinent Care and Staffing Issues
Penalty
Summary
The facility failed to provide timely and complete incontinent care for five residents, resulting in significant discomfort and embarrassment for the residents involved. One resident, who is alert and oriented, reported being left in a urine-soaked state all night, leading to feelings of dirtiness, anger, and embarrassment. The resident expressed that there was insufficient staff to provide necessary care, and that only one CNA consistently provided proper cleaning. The resident's care plan required frequent toileting and peri care after each incontinent episode, but this was not adhered to, as evidenced by the resident's condition and statements. Another resident, who is moderately cognitively impaired and requires extensive assistance with ADLs, was observed receiving incomplete incontinent care. The staff failed to clean all wet areas, which is contrary to the facility's perineal care policy. The policy mandates cleaning from the cleanest to the dirtiest area to prevent infection and promote hygiene, but this was not followed during the observed care. Additional residents also reported inadequate care during a Resident Council meeting, citing insufficient staffing and delayed responses to call lights. One resident, who is cognitively intact and requires substantial assistance, stated that they often remained in soiled conditions due to staff not responding promptly. Another resident, who is also cognitively intact, confirmed assisting a roommate with toileting needs due to staff unavailability. These accounts highlight a systemic issue with staffing and care provision during night shifts, leading to unmet care needs and compromised resident dignity.
Medication Error Leads to Delay in Antibiotic Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of antibiotics for a urinary tract infection (UTI). The resident, who was admitted with multiple diagnoses including a displaced intertrochanteric fracture, Parkinson's disease, and rheumatoid arthritis, was ordered a course of ciprofloxacin by a Physician Assistant on 9/27/24. However, due to a miscommunication between the nurse and the Physician Assistant, the antibiotic was not administered until 10/2/24, resulting in a six-day delay. During this period, the resident experienced increased confusion, abdominal pain, and leg pain, which affected their ability to participate in therapy sessions. The resident's therapy progress notes indicated a decline in performance, with increased assistance required for tasks and decreased mobility. The resident's wife expressed concerns about the delay in treatment and its impact on the resident's therapy and overall condition. The facility's Director of Nursing acknowledged the medication error and attributed it to miscommunication. The incident was documented in a medication error report, and the delay in starting the antibiotic was noted. The resident's wife also reported that the resident was administered oxycodone for pain during the delay, which contributed to the resident being 'zoned out' and unable to participate in therapy effectively.
Improper Storage and Handling of Expired Medications
Penalty
Summary
The facility failed to properly store medications and ensure expired medications were discarded appropriately, which could potentially affect all 45 residents. During an inspection of the East Wing Medication Storage Room, surveyors found expired medications, including a Dulcolax suppository with an expiration date of January 2023, two Acetaminophen 650mg suppositories with an expiration date of April 2024, and a large bottle of stool softener with an expiration date of March 2022. Licensed Practical Nurses (LPNs) confirmed that these medications were stock medications intended for use by all residents, provided there was an order and no allergies. They also acknowledged that expired medications should not be used and must be destroyed. Interviews with staff revealed inconsistencies in the process of checking and discarding expired medications. The Nurse Supervisor and Central Supply person were unsure why expired medications were present, despite procedures stating that expired medications should be separated and destroyed. The facility's Pharmacy Services and Procedure Manual outlines that medications with expired dates should be stored separately until destroyed or returned. However, the staff's statements indicated a lack of clarity and adherence to these procedures, as expired medications were found in the storage room, and there was confusion about the responsibility for checking and removing them.
Resident's Dignity Compromised Due to Inadequate Incontinent Care
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and had their needs met in a timely manner. The resident, identified as R23, was observed to be incontinent of urine and required assistance from staff for toileting. On the morning of October 7, 2024, a CNA, identified as V5, was observed providing incontinent care to R23. The resident's gown, incontinent brief, pad, and sheets were soaked with urine, indicating that the resident had been left in a soiled state for an extended period. V5 did not cleanse all areas of incontinence, leaving R23's inner thighs and back uncleaned. R23 expressed feelings of embarrassment, anger, and discomfort due to being left wet all night and not being properly cleaned by the staff. Interviews with the resident and staff confirmed the resident's account of the events. R23 stated that she had been wet all night and that there was insufficient staff to attend to her needs. The resident reported feeling dirty, angry, and embarrassed, and mentioned that she had to rely on her roommate for assistance at times. Staff members, including a Nurse Supervisor and an LPN, corroborated the resident's statements, acknowledging that R23 was alert and oriented and that her account of the situation was accurate. The facility's Resident Handbook emphasizes the right of residents to be treated with dignity and respect, which was not upheld in this instance.
Late Submission of MDS Assessments
Penalty
Summary
The facility failed to complete and transmit the comprehensive Minimum Data Set (MDS) assessments within the required time frame for three residents. The assessments for these residents were not submitted within the 14-day period following the MDS completion date, as required by the facility's protocol. Specifically, the assessments for residents R28, R23, and R16 were all submitted late, with submission and processing dates recorded as October 8, 2024, which is more than 14 days after the respective completion dates. The MDS Coordinator, V29, was unsure why the assessments were overdue, while the Corporate Director of Reimbursement, V30, acknowledged that the assessments were submitted late. The facility's protocol mandates that comprehensive assessments be transmitted electronically within 14 days of the Care Plan Completion Date, and all other MDS assessments within 14 days of the MDS Completion Date. The failure to adhere to these timelines resulted in the deficiency noted in the report.
Inadequate Staffing Leads to Resident Neglect
Penalty
Summary
The facility failed to ensure sufficient nursing staff to provide necessary care for residents, impacting their physical, mental, and psychosocial well-being. This deficiency was observed through the experience of a resident, R23, who was left in a soiled state overnight due to inadequate staffing. R23, who is occasionally incontinent of urine and requires assistance with activities of daily living, reported feeling dirty, angry, and embarrassed after being left wet all night without being changed. The resident's care plan required frequent toileting and peri care, which was not adhered to, leading to discomfort and a loss of dignity. During an observation, a CNA, V5, was seen providing care to R23, who was found heavily soiled with urine. The CNA did not fully cleanse all areas of incontinence, leaving R23's inner thighs and back uncleaned. R23 expressed dissatisfaction with the care received, stating that only one CNA consistently provided proper care, while others failed to clean her adequately. The resident also mentioned that her roommate had to assist her with toileting needs due to the lack of staff response to call lights. The issue of insufficient staffing was further corroborated during a Resident Council meeting, where multiple residents, including R23, R24, R31, and R33, voiced concerns about the lack of staff and the timeliness of incontinent care. These residents reported similar experiences of being left in soiled conditions for extended periods due to staff not answering call lights or failing to return after promising assistance. The facility's policy on staffing was not effectively implemented, as evidenced by the residents' complaints and the observations made by the surveyors.
Failure to Ensure Safe Transfer Results in Resident Injury
Penalty
Summary
The facility failed to ensure a safe transfer for one resident, resulting in a significant injury. The resident, who had a history of abnormal weight loss, severe protein-calorie malnutrition, and other health issues, sustained a large abrasion and laceration on her right calf during a transfer. The incident occurred when a CNA attempted to transfer the resident from a wheelchair to a bed without using a gait belt, as required by the facility's policy. The resident began to slide out of the wheelchair, and in the process of preventing her from falling, the CNA caused the resident's leg to hit the footboard, resulting in a severe skin tear and bleeding. The resident's fragile skin condition and low body weight contributed to the severity of the injury. The incident was documented by multiple staff members, including the DON and a nurse practitioner, who confirmed that the resident's injury was due to the improper transfer technique. The facility's policy mandates the use of gait belts for all transfers unless there is a medical contraindication, which was not the case for this resident. The CNA admitted to not using a gait belt during the transfer, which directly led to the resident's injury. The facility's Director of Nursing stated that she expected staff to follow the policy and use gait belts for all transfers to ensure resident safety. The failure to adhere to this policy resulted in the resident sustaining a significant wound that required ongoing wound care.
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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 Alton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| La Bella Of Alton | 1.6 mi | ★★★★★ | 3 | 0 |
| Nexus At Alton | 1.9 mi | ★★★★★ | 19 | 0 |
| Bria Of Woodriver | 4.4 mi | ★★★★★ | 21 | 7 |
| Bria Of Godfrey | 5.2 mi | ★★★★★ | 5 | 0 |
| Stonebridge Florissant | 7.2 mi | ★★★★★ | 14 | 0 |
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