Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Pearl Of St Charles, The during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple comorbidities, fully dependent on staff for personal hygiene, was observed with extensive brown-orange waxy crust covering much of both feet, including between the toes, as well as on the ankles and shins. Despite physician and podiatry orders for regular skin checks, daily betadine to one foot, and daily moisturizing with clean feet, staff had documented no skin concerns, and a CNA reported not washing the resident’s feet or applying lotion during morning care. Nursing staff and the NP found that the thick, dry, waxy buildup had been present for some time and was easily removable with basic washing and moisturizing, demonstrating a failure to provide ordered and necessary daily foot care.
A resident with multiple fractures and other medical conditions, receiving IV antibiotics for a bacterial wound infection, was given the wrong IV medication when an RN administered Zosyn instead of the ordered Vancomycin. The resident, who was cognitively intact, noticed after the infusion that the IV bag bore another resident’s name and reported it immediately. Progress notes and RN interviews confirmed that Piperacillin/Tazobactam was administered in error, contrary to facility policy requiring verification of the five rights of medication administration and use of two resident identifiers.
The facility failed to maintain sanitary practices in the kitchen, affecting 74 residents. A scoop was found in pooled water, breaded items were improperly stored, and spices lacked proper labeling. The reach-in freezer malfunctioned, with temperatures rising to 30°F, causing defrosting of stored items. Facility policies on ice machine maintenance, food labeling, and freezer temperatures were not followed.
The facility failed to maintain a sanitary environment in both the dining room and a resident's room. During meal service, a Restorative Aide served meals on dirty tables, and the dining room floor was littered with debris. A resident's room was also found unclean for several days, with stains and garbage present. The Housekeeping Director cited staffing shortages as a reason for the oversight.
The facility failed to provide adequate grooming and hygiene assistance to residents requiring help with ADLs. Five residents were observed with unmet hygiene needs, including long, jagged fingernails, unkempt hair, and inadequate cleaning after an ileostomy leak. One resident reported not being offered showers as per the facility's policy, resulting in dry, flaky skin and greasy hair. Staff admitted to being overwhelmed and not adhering to the required care schedule.
The facility failed to provide nutritionally comparable meal options and accommodate dietary restrictions for several residents. A resident on a vegetarian diet received a grilled cheese sandwich daily, lacking protein compared to other meals. Two residents with no pork diets also received grilled cheese sandwiches with insufficient protein. Additionally, a resident on a gluten-restricted diet received a meal with gluten-containing items, causing distress and stomachaches. The facility did not adhere to its policy of providing nutritionally comparable and dietary-appropriate meals.
The facility failed to provide prescribed high-calorie nutrition supplements to four residents, despite physician orders. A resident with quadriplegia and dysphagia did not receive the supplement during meals, even though it was present in the room. Another resident with dementia and a third on a pureed diet also missed their supplements due to a recent change in the facility's supplement orders. Additionally, a resident with multiple diagnoses, including diabetes, did not receive a diabetic high-calorie drink due to the facility's lack of the product.
The facility failed to follow infection control policies, including Enhanced Barrier Precautions and hand hygiene. A resident with a history of drug-resistant infection was not placed on EBP, and staff did not wear isolation gowns during high-contact activities. Additionally, a resident on contact isolation for C-Diff received care without proper PPE, and hand hygiene lapses were observed during peri-care and incontinence care. The Director of Nursing acknowledged the need for adherence to PPE and hand hygiene protocols.
The facility failed to offer and provide education on influenza and pneumococcal vaccines to several residents, as required by policy. Documentation showed that only about 38% of residents were offered the influenza vaccine, and there was a lack of evidence that education was provided to those who did not receive it.
The facility failed to provide education and obtain consent or declination for the COVID-19 booster vaccine for the 2024-2025 period for five residents with various medical conditions. Despite a vaccine clinic being held, only 32% of the facility's residents received the vaccine, and there was no documentation of education or declination for the remaining residents, contrary to the facility's policy and CDC guidelines.
A resident with multiple health conditions was offered and assisted into slippers soiled with stool, which had not been cleaned for a week despite the resident's request. The facility's staff, including an LPN and a CNA, failed to address the issue, compromising the resident's dignity. The DON later acknowledged the oversight, recognizing it as a dignity issue.
The facility failed to secure indwelling urinary catheters for three residents, leading to potential risks. One resident's catheter was not anchored, and the urinary bag was on the floor. Another resident's catheter was unsecured, causing pulling during care. A third resident's suprapubic catheter was detached from its anchor. The DON confirmed the importance of securing catheters and keeping bags off the floor, as per facility policy.
A facility failed to adhere to the physician's order for managing a resident's PICC line. A nurse administered an IV antibiotic to a resident with a PICC line, where the dressing was loose and dated from weeks prior. The dressing should have been changed weekly or as needed, per the care plan. Although the nurse changed the dressing, they did not measure the catheter length or arm circumference, which are necessary to check for migration and swelling. The DON confirmed these steps are required to prevent infection.
A facility failed to obtain a physician order and develop a care plan for a resident requiring continuous oxygen due to chronic respiratory conditions. The resident was observed receiving oxygen without a documented order, and their care plan lacked specific settings for oxygen use. The facility's policy mandates a physician's order for oxygen administration, which was not followed in this case.
The facility failed to provide timely access to medical records for two residents. One resident's spouse reported waiting over a month for records after a request was made, while another resident's power of attorney had not received records weeks after a request. The facility's policy and state regulations require records to be available within two working days, but the facility did not follow up on these requests.
A resident with a history of falls and high fall risk was lowered to the floor by a CNA during a transfer. Despite the incident, the facility did not perform a fall assessment or follow-up monitoring, as required by their policy. The DON acknowledged the oversight, noting that the incident was not initially considered a fall.
A resident with hemiplegia and hemiparesis fell out of bed and sustained fractures due to inadequate assistance during care. The resident required two-person assistance for bed mobility, but a new CNA, feeling rushed and untrained, assisted the resident alone. The care plan lacked clarity on the required assistance, and the facility's policies on fall prevention and ADL support were not effectively implemented.
A facility failed to prevent verbal abuse among residents, involving derogatory and racial slurs exchanged during smoking breaks. Despite being identified as vulnerable adults, three residents engaged in ongoing verbal altercations, with staff aware but unable to stop the abuse. The facility's policy defines such interactions as verbal abuse.
A resident with insulin-dependent diabetes and end-stage renal failure was involuntarily discharged to a homeless shelter without prior notification or acceptance, leading to hospitalization. The facility claimed the resident was a danger due to disruptive behavior and alcohol abuse but lacked documentation to support these claims. The discharge violated state and federal regulations, as the facility failed to ensure an appropriate alternative placement and did not involve the resident in the discharge planning process.
A facility failed to administer medications as ordered, affecting multiple residents due to a nurse's late arrival and inadequate documentation in the EMAR. This led to uneven spacing of medication doses, impacting residents' health conditions such as pain management and blood pressure control. The facility did not obtain necessary physician orders for resident-centered medication administration, contributing to the deficiencies.
A resident reported feeling undignified and uncomfortable when a CNA used a cell phone during a shower, violating the facility's policy on cell phone usage during caregiving. Despite the resident's expressed discomfort, the CNA continued the conversation, leading to a grievance being filed.
A resident with multiple severe diagnoses experienced a significant change in condition, but the facility failed to notify the resident's POA for approximately 12 hours. Despite medical interventions, the resident was later sent to the hospital for respiratory failure. Staff interviews confirmed that the notification should have been made promptly as per facility policy.
The facility failed to provide necessary ADLs for a resident dependent on staff for care. The resident, with multiple medical conditions, was not assisted to get dressed, get out of bed, or brush her teeth on a specific weekend due to staffing issues. Staff confirmed the failure to assist the resident as required, despite the facility's policy mandating such care.
The facility failed to use a gait belt while transferring a resident and did not re-evaluate interventions for a resident identified as an elopement risk. The resident, with severe cognitive impairment and dementia, frequently attempted to exit the facility and wandered into other residents' rooms, causing distress. Staff acknowledged the issue but did not implement effective monitoring or electronic alert systems. Additionally, a CNA assisted the resident with toileting without using a gait belt, contrary to facility policy.
Failure to Provide Adequate Daily Foot Care and Hygiene
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate foot care and skin hygiene for a dependent resident with multiple comorbidities, including Type 2 hemiplegia/hemiparesis, epilepsy, and Parkinson’s disease. The resident’s MDS showed severely impaired cognition and dependence on staff for footwear, lower body dressing, bathing, and substantial/maximal assistance for personal hygiene. Physician orders included daily and weekly skin checks, daily betadine application to the right foot, and moisturizing lotion to both lower extremities as needed for dry skin. A podiatry note documented dry, thin skin on both feet and directed that the feet be kept clean with daily lotion use. Despite these orders and the resident’s dependence, staff reported no skin concerns prior to the surveyor’s observation. On observation, when the nurse removed the resident’s pressure-relieving boots and socks, a brownish-orange waxy crust was seen covering most of the bottoms of both feet, with additional crust on the sides, tops, ankles, and shins, and a large amount between all toes. As the nurse wiped the feet with a wet towel, chips of the substance fell off, revealing intact, pink, dry skin underneath, and only a small portion of the buildup was removed at that time. The DON stated the buildup was not typical and that the feet appeared very dry, and acknowledged the feet should not have had that extent of waxy buildup. The wound nurse stated she had applied cream earlier that morning, acknowledged the substance had been present for a long time, and indicated staff were expected to wash the resident’s feet during scheduled bed baths and apply cream/ointment daily. A CNA reported she had not washed the resident’s feet or applied lotion during morning care, and another CNA stated the brown-orange crust appeared intermittently. The nurse practitioner later described approximately 50% of the bottoms of both feet as covered with easily removable waxy, yellow/orange-brown dry skin and stated the condition was preventable with daily cleaning and moisturizing, noting that staff were expected to perform daily foot care to remove such buildup.
Significant IV Medication Error Due to Failure to Follow Five Rights
Penalty
Summary
A resident with multiple traumatic fractures (including left calcaneus with delayed healing, left first metatarsal, left tibia and fibula shafts, left acetabulum, left pubis, and left ileum) related to a motorcycle injury, and additional diagnoses of anemia, intestinal obstruction, and hypertension, had an active order for IV Vancomycin HCl in dextrose solution (1 g/200 ml, 1.75 mg three times daily) for a bacterial wound infection from 10/11/25 through 10/20/25. The resident’s MDS dated 12/28/25 documented intact cognitive function. On one night in October, around midnight, the resident reported that an RN administered an IV medication, and after the infusion was completed, the resident noticed the medication label showed another resident’s name and immediately informed the nurse. Subsequent interviews with two RNs, including a unit manager, confirmed that the nurse administered Zosyn (Piperacillin/Tazobactam 3.375 g/100 ml) instead of the ordered Vancomycin on that date. Progress notes documented that this medication error occurred, specifying that Piperacillin/Tazobactam was given in place of Vancomycin. The DON stated that nurses are expected to follow the facility’s medication administration policy, which requires verification of the “five rights” (right patient, right drug, right dose, right route, right time) and use of two resident identifiers before administering medications. The documented error shows that these required checks were not effectively carried out, resulting in the resident receiving the wrong IV medication.
Sanitary Practices and Freezer Malfunction in Facility Kitchen
Penalty
Summary
The facility failed to adhere to sanitary practices in the kitchen, affecting 74 residents who received food prepared there. During an inspection, a plastic scoop was found inverted in a holder with pooled water and blackish substances touching the scoop. Additionally, several cardboard boxes containing breaded items were improperly stored on a counter, with some hot dog buns showing a whitish substance. The delivery date on the box was January 15, 2025, and the Dietary Manager acknowledged that these products should have been refrigerated. Furthermore, opened containers of spices on the spice rack lacked proper labeling, with some dating back to May 31, 2021, without an open or use-by date. The reach-in freezer in the kitchen was found to be malfunctioning, with the thermometer reading 25 degrees Fahrenheit initially, and later dropping to 20 and then rising to 30 degrees Fahrenheit. This resulted in frozen vegetables, ice cream, gelato, and waffles being soft to the touch, indicating defrosting. The Regional Dietary Director confirmed that the freezer should maintain a temperature of 0 degrees Fahrenheit. The facility's policies on ice machine maintenance, food labeling, and freezer temperatures were not followed, contributing to the observed deficiencies.
Facility Fails to Maintain Sanitary Conditions in Dining Room and Resident Room
Penalty
Summary
The facility failed to maintain a sanitary dining environment during meal service, affecting eight residents. During an observation, a Restorative Aide was seen distributing breakfast trays on tables that were visibly dirty with smears and debris. The floor was also littered with straw covers, paper bits, and food crumbs. Despite being notified of the unsanitary conditions, the aide continued to serve meals. The Housekeeper later admitted that the dining room had not been cleaned the previous night due to a shortage of housekeeping staff. The Maintenance Director confirmed that the cleaning responsibilities were not clearly communicated to the staff. Additionally, the facility failed to maintain cleanliness in a resident's room. The resident, who was cognitively intact and had multiple medical conditions, reported that her room had not been cleaned for several days. Observations confirmed the presence of brown stains on a blanket, garbage, and sticky smears on the floor. Despite assurances from a housekeeper that the room would be cleaned, the conditions remained unchanged. The Housekeeping Director acknowledged the oversight and attributed it to staffing issues, as the housekeepers responsible for mopping were only available during the day shift.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate grooming and hygiene assistance to residents requiring help with Activities of Daily Living (ADL). Five residents were observed with unmet hygiene needs. One resident, who is legally blind and cognitively impaired, was found with long, jagged fingernails and a black/brown substance underneath them. Another resident, also cognitively impaired, was seen with unkempt hair and similar substances under his nails, despite being cooperative during care. A third resident, requiring assistance for grooming, was observed with drool on his beard and unkempt facial hair, yet staff did not offer to trim his beard or clean his nails after providing other care. A resident with multiple medical conditions, including an ileostomy, was not properly cleaned after a leak from her appliance. The staff changed her gown and sheets but did not clean her skin or change her soiled incontinence brief, leaving her visibly wet and uncomfortable. The resident expressed that staff typically do not wash her skin after such incidents, and she had to resort to using a garbage can when no one assisted her to the restroom. Another resident, cognitively intact, reported only being offered a shower once since admission, despite the facility's policy of offering showers twice a week. The resident's skin was dry and flaky, and his hair greasy, indicating a lack of proper hygiene care. Staff admitted to not offering him a shower due to being overwhelmed, and documentation did not support that showers were offered as required. The facility's policy mandates appropriate support for residents unable to perform ADLs independently, which was not adhered to in these cases.
Failure to Provide Nutritionally Comparable and Dietary-Appropriate Meals
Penalty
Summary
The facility failed to provide nutritionally comparable meal options and accommodate dietary restrictions for several residents. On February 24, 2025, a resident on a vegetarian diet received a grilled cheese sandwich with noodles, Brussels sprouts, and cake, which was a daily occurrence according to the cook. On February 25, 2025, two residents with no pork diets also received grilled cheese sandwiches, which contained significantly less protein compared to the pork fried rice served to other residents. The facility's policy requires nutritionally comparable menu items to accommodate resident preferences, but this was not adhered to. Additionally, a resident on a gluten-restricted diet did not receive a meal tray initially and was later given a tray with gluten-containing items such as noodles, dinner roll, and cake. The resident expressed distress and reported frequent stomachaches due to consuming foods not suitable for her diet. The dietary manager acknowledged the error, and the dietitian confirmed that the resident should have been served according to her diet order. This oversight highlights a failure to adhere to dietary restrictions and provide appropriate meal substitutions.
Failure to Provide Prescribed High-Calorie Supplements
Penalty
Summary
The facility failed to provide high-calorie nutrition supplements as ordered by the physician for four residents. Resident 19, who has quadriplegia and dysphagia, was supposed to receive a high-calorie drink four times a day but did not receive it during observed meals. Despite the presence of the supplement in the room, the resident reported not receiving it, and staff confirmed the absence of the supplement during meal times. Similarly, Resident 20, with dementia and other conditions, was ordered a high-calorie drink once a day but did not receive it during observed meals, with staff confirming the lack of the supplement. Resident 27, who was on a pureed diet, was also supposed to receive a high-calorie drink twice a day but did not receive it during observed meals. Staff confirmed the absence of the supplement, citing a recent change in the facility's supplement orders as the reason for the unavailability. Resident 326, with multiple diagnoses including stroke and diabetes, was ordered a diabetic high-calorie protein drink once a day but did not receive it due to the facility's lack of the supplement. The dietitian was aware of the switch in supplements but the facility had not yet acquired the new product, leading to the deficiency.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies, specifically regarding Enhanced Barrier Precautions (EBP), Transmission-Based Precautions (TBP), and hand hygiene. For instance, a resident with a history of Carbapenem-resistant Pseudomonas aeruginosa was not placed on EBP upon admission, and staff did not wear isolation gowns during high-contact activities such as repositioning the resident. Additionally, a resident on contact isolation for C-Diff did not receive care in accordance with the facility's policies, as a registered nurse administered IV antibiotics and performed a PICC line dressing change without wearing an isolation gown. Furthermore, the nurse used a pillow from another bed without sanitizing it afterward. The facility also demonstrated lapses in hand hygiene practices. Two CNAs assisted a resident with peri-care without changing gloves between tasks and failed to perform hand hygiene after removing gloves and handling soiled items. Another incident involved a CNA providing incontinence care to a resident while wearing the same gloves throughout the procedure, despite direct contact with fecal matter. The Director of Nursing acknowledged that staff must perform hand hygiene before, during, and after care, and wear complete PPE when providing care to residents on contact isolation or EBP. The facility's hand hygiene policy mandates the use of soap and water in specific situations, such as after caring for residents with diarrheal infections like C. difficile, but these protocols were not followed in the observed cases.
Failure to Offer and Educate on Vaccinations
Penalty
Summary
The facility failed to offer and provide education regarding the seasonal influenza and pneumococcal vaccines to several residents. Specifically, four residents were identified as not having been offered or provided education about these vaccines. One resident, with a history of cerebral palsy, anemia, and essential hypertension, had no documentation indicating they were offered or educated about the influenza vaccine for the 2024-2025 season. Another resident, with diagnoses including hemiplegia and cardiac arrhythmia, also lacked documentation of being offered or educated about the influenza vaccine for the same season. Additionally, a resident with chronic obstructive pulmonary disease and chronic kidney disease had signed a consent for the pneumococcal vaccine, but there was no documentation of the vaccine being administered. Furthermore, this resident's family refused the pneumonia vaccine, yet no education was documented as being provided. Another resident, with conditions such as congestive heart failure and chronic kidney disease, had no documentation of being offered or educated about the pneumococcal vaccine, nor was there evidence of previous vaccination. The facility's policy requires offering these vaccines, but documentation showed only about 38% of residents were offered the influenza vaccine, indicating a significant gap in compliance with the policy.
Failure to Educate and Document COVID-19 Booster Vaccination
Penalty
Summary
The facility failed to provide education and obtain consent or declination for the COVID-19 booster vaccine for the 2024-2025 period for five residents. These residents, who have various medical conditions such as cerebral palsy, anemia, essential hypertension, HIV, anoxic brain damage, hemiplegia, asthma, cardiac arrhythmia, chronic obstructive pulmonary disease, and chronic kidney disease, were not documented as having been offered the COVID-19 booster vaccine or provided with education about it. This lack of documentation was noted despite the CDC guidelines emphasizing the importance of the COVID-19 vaccine for individuals in long-term care facilities. The facility's Infection Preventionist confirmed that a COVID-19 vaccine clinic was held, and only 25 residents received the vaccine, which is approximately 32% of the facility's census of 76 residents. The facility's policy states that it will encourage residents, staff, and families to stay up to date with COVID-19 vaccinations, including booster doses. However, there was no documentation provided regarding the education or declination of the COVID vaccine for the remaining residents, indicating a deficiency in the facility's adherence to its policy and CDC guidelines.
Failure to Maintain Resident Dignity with Soiled Slippers
Penalty
Summary
The facility failed to treat a resident with dignity by offering and assisting the resident into slippers that were soiled with stool and not ensuring they were cleaned. The resident, who was cognitively intact, had been admitted with multiple diagnoses including chronic obstructive pulmonary disease, abdominal aortic aneurysm, partial intestinal obstruction, ileostomy status, malignant neoplasm of overlapping sites of the colon, and reduced mobility. During an observation, a Licensed Practical Nurse (LPN) changed the resident's ileostomy dressing but left the resident with soiled clothing and bedding, instructing a Certified Nursing Assistant (CNA) to assist further. The CNA later helped the resident into a clean gown and changed the linens but offered the resident slippers that were visibly stained with stool. The resident confirmed that the slippers had been soiled the previous week and had not been cleaned since. Despite the resident's desire to have them washed, the slippers remained at the bedside, uncleaned, until the Director of Nursing (DON) noticed them and acknowledged the oversight. The facility's policy on resident rights emphasizes treating each resident with dignity and respect, which was not upheld in this instance.
Failure to Secure Indwelling Urinary Catheters
Penalty
Summary
The facility failed to ensure proper care for residents with indwelling urinary catheters, as observed in three residents. One resident, who is alert and oriented, had a catheter that was not secured to his thigh, and the urinary bag was resting on the floor. This resident reported that the catheter had been unsecured for an unspecified period. Another resident, who requires assistance for toileting, had a catheter that was not secured, causing the tubing to pull during repositioning and care. This resident has a history of hospitalizations due to urinary tract infections and other complications. A third resident, who has a suprapubic catheter due to sacral wounds and recurrent urinary tract infections, was found with the catheter tube detached from the anchor, leaving it unsecured. The Director of Nursing confirmed that catheters must be secured to prevent dislodgement and that catheter bags should not rest on the floor to prevent infection. The facility's policy mandates that Foley catheters be positioned correctly and secured, and that the bag should be off the floor.
Failure to Follow PICC Line Management Protocol
Penalty
Summary
The facility failed to follow the physician's order for the management of a Peripherally Inserted Central Catheter (PICC) line for a resident. On February 25, 2025, a registered nurse administered an IV antibiotic to a resident with a PICC line on the right upper arm. The dressing on the PICC line, dated February 3, 2025, was observed to be loose and halfway open. According to the Physician Order Summary, the dressing should be changed once a week and as needed to prevent infection. The resident's care plan also indicated that the dressing should be changed weekly or sooner if it became soiled, loose, or damp, using sterile aseptic technique. The registered nurse changed the dressing on February 25, 2025, but did not measure the length of the catheter or the arm circumference, which are necessary to check for catheter migration and swelling. The Director of Nursing confirmed that these measurements are required when changing the PICC line dressing and reiterated the importance of changing the dressing every 7 days and as needed to prevent infection.
Failure to Obtain Physician Order for Oxygen Administration
Penalty
Summary
The facility failed to obtain a physician order and develop a care plan for oxygen administration for a resident with chronic respiratory conditions. The resident, who was admitted with diagnoses including chronic obstructive pulmonary disease, dependence on oxygen, and chronic respiratory failure with hypoxia, was observed receiving oxygen via nasal cannula at 3 liters per minute. Despite the resident's need for continuous oxygen, there was no physician order for oxygen administration documented in the resident's records from February 23 to February 25, 2025. Additionally, the resident's care plan, initiated on February 26, 2025, for shortness of breath, did not specify the settings for oxygen use. The Director of Nursing confirmed that the facility's policy requires a physician's order for oxygen administration, including the amount of liter flow and method of delivery. However, the resident was not listed among those utilizing oxygen in the facility, indicating a lapse in documentation and adherence to the facility's policy on oxygen use.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide medical records to two residents within the required timeframe. The first resident, who was admitted with conditions such as spinal stenosis and low back pain, was discharged in January 2025. Her spouse reported that they had been waiting for over a month to receive her medical records, which were requested on January 25, 2025. The medical records staff member, V8, acknowledged receiving the request and forwarding it to the legal team but did not follow up to ensure the records were provided. The facility's policy allows 30 days for processing requests for discharged residents, but the Illinois Long-Term Care Residents' Right booklet requires records to be available within two working days. The second resident's power of attorney requested medical records on January 27, 2025, but had not received them by February 20, 2025. The request was initially sent to the wrong facility, but the correct facility received it on January 27, 2025. The medical records staff member admitted to not following up on this request either. The facility's failure to provide timely access to medical records for these residents is a violation of both their internal policy and state regulations.
Failure to Perform Fall Assessment and Monitoring
Penalty
Summary
The facility failed to perform a fall assessment and monitor a resident after a fall incident. A resident, identified as R1, was admitted with diagnoses including spinal stenosis, low back pain, history of falling, muscle wasting, urinary retention, abnormalities of gait and mobility, and lack of coordination. R1 was assessed as high risk for falls. On January 13, 2025, R1 was reported to have been lowered to the floor by a CNA during a transfer from a chair to a bed when R1's legs gave out. Despite R1 denying any pain or discomfort, the facility did not complete a fall report, fall assessment, or follow-up assessment. The Director of Nursing acknowledged that a fall assessment, pain assessment, and change in condition forms should have been completed, but were not, as the facility did not consider the incident a fall. The facility's Fall Prevention and Management policy requires a fall risk screening and post-fall management procedures, which were not followed in this case.
Failure to Provide Adequate Assistance Leads to Resident Fall
Penalty
Summary
The facility failed to safely assist and position a resident in bed, resulting in the resident falling out of bed and sustaining left tibial and ankle fractures. The resident, who had multiple diagnoses including hemiplegia and hemiparesis following a cerebral infarction, required substantial to maximal assistance from two staff members for bed mobility. However, the comprehensive care plan did not specify the number of staff required for bed mobility, leading to a lack of clarity in the care provided. On the day of the incident, a CNA, who was new and felt rushed, assisted the resident alone during incontinence care. The CNA was unaware of the resident's specific care needs and did not have another staff member assist her, despite the resident's known requirement for two-person assistance. The CNA noticed a sticker indicating a two-person total mechanical lift transfer but was unsure about the assistance needed for bed mobility, highlighting a gap in training and communication regarding the resident's care plan. Interviews with facility staff, including the LPN, Restorative Nurse, and Therapy Rehab Director, confirmed that the resident required two-person assistance for bed mobility due to chronic left-side weakness. The Director of Nursing acknowledged that new CNAs should be trained on bed mobility during orientation, but the CNA involved in the incident had not received adequate training. The facility's policies on fall prevention and ADL support emphasized the need for appropriate interventions based on assessed risk factors, but these were not effectively implemented in this case.
Failure to Prevent Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to protect residents from verbal abuse, specifically resident-to-resident verbal abuse, involving three residents. Resident 1 reported being verbally abused by Residents 2 and 3, who made derogatory comments about his ethnicity. Resident 1's care plan indicated he is a vulnerable adult with a susceptibility to abuse, yet he was involved in multiple incidents of verbal altercations with other residents. Despite being cognitively intact, Resident 1 exhibited behaviors such as aggression, antagonizing, and using racial slurs, as noted in his progress notes. Resident 2 was not present during the investigation, but his care plan also identified him as a vulnerable adult. Resident 3, who has hemiplegia and hemiparesis, was involved in the verbal exchanges and was also identified as a vulnerable adult in his care plan. Staff members, including a CNA and the Unit Manager, reported ongoing verbal altercations among the residents, particularly during smoking breaks. The CNA stated that she had informed the Administrator and the DON about the incidents, but the verbal abuse persisted. The Unit Manager acknowledged that name-calling among residents constitutes abuse. The DON and Administrator were aware of the situation, with the Administrator noting that Resident 1 often reported being bothered by others but was vague about specifics. The facility's Abuse Prevention Program-Policy defines verbal abuse as the use of disparaging and derogatory language, which was evident in the interactions among the residents.
Unsafe Discharge of Resident with Complex Medical Needs
Penalty
Summary
The facility failed to provide a safe discharge for a resident with insulin-dependent diabetes and end-stage renal failure, requiring hemodialysis. The resident was involuntarily discharged to a homeless shelter without prior notification or acceptance from the shelter. This resulted in the resident being transported to a local hospital, where he remained awaiting placement in another long-term care facility. The resident had multiple diagnoses, including diabetes, end-stage renal disease, acute pulmonary edema, heart failure, acute respiratory failure, anxiety disorder, anemia, alcohol abuse, and glaucoma. The facility's decision to discharge the resident was based on claims that he was a danger to himself and others, citing disruptive behavior and alcohol abuse. However, the facility did not have documentation to support these claims, such as positive alcohol or drug tests. The resident was cognitively intact and able to perform all activities of daily living independently. Despite this, the facility proceeded with the discharge without ensuring an appropriate alternative placement, violating state and federal regulations. The facility's discharge planning policy required the involvement of the resident and their representative in the development of the discharge plan, which was not followed in this case. The facility also failed to coordinate with the receiving facility, resulting in the resident being left without proper care. The facility's actions led to an immediate jeopardy situation, as the resident was left without a safe and appropriate discharge plan.
Removal Plan
- The Social Service Director audited and identified residents with similar challenging behaviors. The residents were assessed via observation and review of clinical documentation, care plan, appropriateness of discharge location related to resident's needs and discharge criteria. All identified residents remain at facility.
- The facility initiated and completed education for the clinical staff and IDT regarding the discharge process which includes discharge address, necessary equipment, medications and/or prescriptions, transportation, community services, physician notification, discharge orders, and reason for discharge. Education of agency staff, PRN and vacationing staff will be completed prior to the start of their next shift.
- New hires will receive discharge education in orientation.
- Education was completed with the Social Service Director on appropriateness of discharge location related to the resident's needs.
- The facility reviewed and updated the policy and procedure regarding involuntary discharge and transfer.
- The facility Administrator and/or designee will monitor all discharges, using the discharge tool, to ensure appropriateness to include accurate discharge address, necessary equipment, medications, transportation, community services, physician notification with orders and reason for discharge, prior to actual discharge.
- The administrator and/or designee will review the discharge tool prior to each discharge to ensure a safe discharge.
- The Administrator and/or designee will bring the discharge tool to Quality Assurance meeting for review and recommendations for the duration of the audit.
- An ad hoc QAPI was completed with the Medical Director to review the removal plan.
Medication Administration Deficiencies Due to Late Nurse Arrival and Inadequate Documentation
Penalty
Summary
The facility failed to administer medications as ordered by physicians, affecting 12 out of 19 residents reviewed. The medications involved included antipsychotic drugs, sleeping pills, nicotine patches, and pain medications. The issue was exacerbated by the late arrival of an agency registered nurse, which led to delays in medication administration. The facility's electronic medication administration record (EMAR) did not document the specific times medications were administered, only indicating general time frames such as morning, afternoon, evening, and night. This lack of precise documentation resulted in uneven spacing of medication doses, which could potentially affect the efficacy of the medications. Several residents reported receiving their medications late, which they felt impacted their health conditions, such as pain management, blood pressure control, and anxiety. For instance, one resident mentioned that their blood pressure became unstable due to the delayed administration of their medication. Another resident expressed frustration over the long gaps between doses, which they believed affected their pain management. The facility's Director of Nursing acknowledged the issue, noting that the EMAR system's lack of specific time documentation allowed for uneven spacing of medication doses. The facility's policy on resident-centered medication administration was not followed, as there were no physician orders obtained for such administration for the affected residents. The Medical Director and a Nurse Practitioner highlighted the importance of timely and evenly spaced medication administration to prevent adverse effects and ensure optimal therapeutic outcomes. The facility's failure to adhere to these standards and obtain necessary physician orders contributed to the medication administration deficiencies observed during the survey.
Failure to Ensure Resident Dignity During Care
Penalty
Summary
The facility failed to ensure a resident was cared for in a dignified manner. A resident, who was dependent on staff for showers and had no cognitive impairment, reported that a CNA assisting her in the shower was using ear buds and having a conversation with a male voice on the phone. The resident felt uncomfortable and worried about her privacy, especially since she was naked and could not be sure if the phone was lying flat or propped up. Despite expressing her discomfort, the CNA continued the conversation, making the resident feel undignified and exposed. The resident filed a grievance about the incident, which was documented in the facility's grievance binder. The facility's policies, as outlined in the employee handbook, explicitly prohibit cell phone usage during caregiving and in resident care areas. Interviews with the facility's administrator, another CNA, and the Restorative Nurse/Nurse Manager confirmed that staff are not allowed to use cell phones while providing care due to privacy and dignity concerns. The facility's failure to enforce this policy led to the resident's experience of indignity and discomfort during a vulnerable moment.
Failure to Notify POA of Change in Resident's Condition
Penalty
Summary
The facility failed to notify a resident's Power of Attorney (POA) of a significant change in the resident's medical condition in a timely manner. The resident, who had diagnoses including acute on chronic congestive heart failure, chronic respiratory failure with hypoxia, end-stage renal disease, and pleural effusion, experienced shortness of breath around 1 AM. Despite receiving medical interventions such as increased oxygen and medication, the resident's POA was not informed of the change in condition until approximately 1:30 PM, about 12 hours later. The resident was eventually sent to the hospital for respiratory failure at approximately 3:45 PM on the same day. Interviews with staff revealed that the Registered Nurse on duty did not notify the POA because they believed the resident was stabilized. However, the facility's policy mandates immediate notification of the resident's representative in the event of any condition or treatment change. The Restorative Nurse-Manager confirmed that the notification should have been made promptly, especially given the severity of the situation. The failure to notify the POA in a timely manner was a clear deviation from the facility's policy and standard practice.
Failure to Provide ADLs for Dependent Resident
Penalty
Summary
The facility failed to ensure activities of daily living (ADLs) were provided for a resident (R6) who was dependent on staff for care. R6, who has diagnoses including epilepsy, malignant neoplasm of the brain, hemiplegia, and hemiparesis following cerebral infarction, was not assisted to get dressed, get out of bed, or brush her teeth on a specific Saturday and was not assisted to get out of bed on the following Sunday. R6 requires a mechanical lift for transfers and is dependent on staff for showers and other ADLs. The resident reported that staff informed her they were short-staffed and could not assist her without two people. Interviews with staff confirmed that there were staffing issues on the mentioned weekend, leading to the resident not receiving the necessary assistance. Certified Nursing Assistants (CNAs) and a Registered Nurse (RN) acknowledged the staffing challenges and the failure to assist R6 as required. One CNA mentioned that an agency CNA left mid-shift, causing a shift in assignments, and another CNA admitted to not getting R6 out of bed due to other tasks. The RN stated that it was brought to his attention that R6 wanted to get out of bed, but it was later in the day, and R6 decided she no longer wanted to get up. The Restorative Nurse emphasized that it is unacceptable to leave R6 in bed and that there is always someone available to help with transfers. The facility's policy mandates that residents unable to carry out ADLs independently will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene, which was not adhered to in this case.
Failure to Prevent Elopement and Use Gait Belt During Transfer
Penalty
Summary
The facility failed to use a gait belt while transferring a resident and did not re-evaluate interventions for a resident identified as an elopement risk. One resident, diagnosed with severe cognitive impairment and dementia, was noted to have multiple instances of attempting to exit the facility and wandering into other residents' rooms. Despite being identified as a high risk for elopement, the only intervention in place was staff redirection, which was inconsistently applied. The resident's family was aware of the situation but was not informed of any additional measures that could be taken to prevent elopement. On multiple occasions, the resident was found in other residents' rooms, causing distress to those residents. Staff members, including CNAs and nurses, acknowledged the resident's frequent wandering and attempts to exit the facility but did not implement more effective monitoring or electronic alert systems as outlined in the facility's policy. The facility's policy on elopement risk reduction was not followed, leading to repeated incidents of the resident being found in unauthorized areas. Additionally, the facility failed to use a gait belt during the transfer of the same resident, who was identified as a moderate fall risk. A CNA assisted the resident with toileting without using a gait belt, contrary to the facility's policy that mandates the use of gait belts for all residents requiring assistance with transfers. The Restorative Nurse confirmed that gait belts should be used to ensure the safety of both residents and staff during transfers.
What surveyors are citing around you — mapped
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What surveyors actually found near you
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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 St Charles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alpine Care Of St. Charles Llc | 1.2 mi | ★★★★★ | 16 | 0 |
| Bria Of Geneva | 2.7 mi | ★★★★★ | 0 | 0 |
| Greenfields Of Geneva | 3 mi | ★★★★★ | 6 | 0 |
| Batavia Rehabilitation And Health Care Center | 4.7 mi | ★★★★★ | 1 | 0 |
| Michaelsen Health Center | 4.7 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.