Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0689
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Level of Harm - Actual harm
Residents Affected - Few
Based on observation, interview, and record review, the facility failed to ensure a resident was propelled
safely in the facility parking lot to avoid a fall. The resident fell forward out of her wheelchair and landed on
the asphalt, sustaining progression of an existing neck fracture, a shoulder dislocation, and a hematoma on
her forehead. This applies to 1 of 5 residents (R1) reviewed for falls in the sample of 5.
The findings include:
The facility incident reported to the Illinois Department of Public Health on 6/27/23 (occurring on 6/26/23)
showed R1's incident occurred at 10:46 AM while R1 and fellow residents were being escorted around
facility property by CNAs [Certified Nursing Assistants]. R1's front wheelchair became stuck in grated
manhole cover causing R1 to lean forward and fall from her wheelchair Resident was admitted (to local
hospital) with a [fracture] of C2 [cervical- second bone in the neck] R1's 6/29/23 Physical Therapy referral
showed R1 was re-admitted with a diagnosis of C2 fracture from a fall in the facility compound while CNAs
were pushing [R1] for a morning walk. Patient fell forward out of her [wheelchair] and no leg rests were in
place .
R1's hospital discharge summary (6/26/23 result date) included her Computerized Tomography (CT) of her
spine and it showed IMPRESSION: Unstable complete transverse base of the dens fracture of C2 [second
bone in neck] this fracture has progressed from the prior CT scan dated 12/11/2022 . The narrative section
in R1's hospital discharge summary also showed a left shoulder Xray from 6/26/23 with probable AC joint
separation [collar bone separating from the shoulder blade] . R1's 6/26/23 brain CT findings showed There
is a small left lateral frontal scalp hematoma, measuring 0.5 centimeters in thickness.
On 7/6/22 at 11:51 AM, V12 (Maintenance Assistant) assessed the area in the parking lot where R1 fell out
of her wheelchair. The area had a round metal manhole cover V12 measured as approximately 22 inches
across and it was painted yellow. The manhole cover was set down three-quarters of an inch below the
surrounding asphalt, and the surrounding asphalt gradually sloped down toward the cover. V12 measured
over 10 feet of clearance on one side between the manhole cover and the parking spaces, and six feet 10
inches of clearance between the manhole cover and the lawn on the other side.
On 7/5/23 at 10:36 AM, R1 was lying in bed wearing a hospital gown and sleeping. R1 was wearing a
cervical collar. R1's July 2023 Physician Order Sheet showed a 7/5/23 order of NURSING REHAB: Cervical
neck brace- keep neck brace in place at all times for at least 12 weeks from date of re-admission OR until
re-evaluated by orthopedics .
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
145433
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145433
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Grove of St Charles
611 Allen Lane
Saint Charles, IL 60174
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Actual harm
Residents Affected - Few
On 7/6/23 at 9:46 AM, R1 was in bed in a hospital gown and had discoloration on her left forehead. R1
stated she recalled falling outside. R1 stated she did not have leg rests on her wheelchair at the time of her
fall and she did not want to get out of bed because it hurts to move.
R1's 6/10/23 Minimum Data Set 6/10/23 showed R1 is cognitively intact and required limited assistance
with locomotion off the unit. R1's 7/5/23 V14 NP (Nurse Practitioner- Hospice/Palliative) note from 1:21 PM
showed R1 suffered a fall last month, with head injury. She was sent to the hospital, and it has been
determined that she has a progression of her dens fracture She had been mobile prior to the fall and had
been able to wheel herself around the hallways but has become primarily bed bound
On 7/5/23 at 11:31 AM, V5 (Restorative Aide) stated on 6/26/23 at about 9:30 AM, she and V4 (Restorative
Aide) were escorting R1 with two other residents on a walk around the building through the parking lot. V5
stated they were all walking side by side, and she was the one pushing R1 in her wheelchair. V5 stated they
were talking to the residents as they were walking. V5 stated R1's back left wheel caught the edge of the
manhole cover and R1 fell forward out of the wheelchair before she could grab her. V5 stated R1 fell on her
left side and a bump formed on R1's left forehead. V5 stated every resident has foot pedals in their room. It
is part of their (staff's) job to assure residents have leg rests available when they go out.
On 7/5/23 at 10:55 AM, V4 (Restorative Aide) confirmed she and V5 were walking outside the facility with
R1 and two other residents. V4 stated she was pushing one resident's wheelchair, and another resident
was walking on her left. V4 stated V5 was on her right, pushing R1 in her wheelchair. V4 stated V5 pushed
R1 over the manhole cover and R1 went forward, falling out of her wheelchair. V4 stated R1 hit her left head
and left side. V4 stated when residents are transported by staff, they should have leg rests in place on their
wheelchairs.
On 7/7/23 at 3:15 PM, V16 (Occupational Therapist- Registered) stated residents should have leg pedals
on if they are in the parking lot because of the uneven surfaces. V16 explained the use of leg pedals on a
wheelchair helps position the hips back if there is a sudden jerk while in motion. V16 stated leg pedals keep
the knees up and keep the person back in their seat. V16 added that when residents go out for
appointments, they must use leg pedals for traveling on the bus for safety. V16 stated, It's a standard. V16
stated since the fall, R1 has primarily been on bedrest except for therapy at the bedside. V16 stated, It's a
big change for her (R1) .it's her preference right now. V16 added R1 does not want to get out of bed and
she says it is too much discomfort and pain, adding R1, knows she fell out of the chair.
On 7/7/23 at 3:10 PM, V6 PT (Physical Therapist / Director of Physical Therapy) stated that on 6/26/23
when R1 fell, she heard a commotion out front and went to the parking lot. V6 stated she saw R1 on her
back and R1 said something like, take me, I'm hurting. V6 stated residents do not need leg pedals on their
wheelchairs if they are just sitting in the front entrance because staff is always there. On 7/5/23 at 2:23 PM,
V6 stated when she saw R1 on the ground in the parking lot, her wheelchair did not have leg rests in place.
V6 stated leg rests are important to prevent falls from the wheelchair.
On 7/5/23 at 3:36 PM, V3 ADON (Assistant Director of Nursing) stated R1 had swelling on her right
forehead and an abrasion on her left knee. V3 stated R1 has a bag on the back of her wheelchair for her leg
rests, but he did not recall if the leg rest or a seat cushion were in use. V3 stated when R1 is being
transported outside of the facility, there should be leg rests in use.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145433
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145433
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Grove of St Charles
611 Allen Lane
Saint Charles, IL 60174
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
On 7/6/23 at 11:31 AM, V11 CNA (Certified Nursing Assistant) stated if she is taking a resident outside,
they need to have their leg rests in place. V11 stated the leg rests provide balance and safety.
Level of Harm - Actual harm
Residents Affected - Few
On 7/7/23 at 10:37 AM, V13 NP (Nurse Practitioner) stated R1's current C2 (cervical) fracture post-fall was
a progression of a previous fracture she sustained at the end of last year. V13 stated there was enough
space outside to avoid pushing R1 over the manhole cover.
On 7/7/23 at 3:05 PM, V15 RN (Registered Nurse) stated she heard about R1's fall and that staff should
have used leg pedals for R1, adding, I think they should have avoided the manhole cover.
On 7/7/23 at 11:58 AM, V2 DON (Director of Nursing) stated the facility does not have a policy for
transporting residents, but it is the facility's practice for residents to have leg rests in use when being
escorted by staff. V2 stated staff should make sure the wheelchair is in working condition, the footrests are
in place, make sure it's not raining or windy, and avoid potholes or any dips in the ground.
R1's fall risk care plan (initiated 10/11/18) showed a 10/11/18 person-centered care plan intervention of: I
would like staff to provide me a safe environment: even floors, free from spills and/or clutter .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145433
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
FAQ · About this visit
Common questions about this visit
What happened during the July 11, 2023 survey of Alpine Care of St. Charles LLC?
This was a inspection survey of Alpine Care of St. Charles LLC on July 11, 2023. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Alpine Care of St. Charles LLC on July 11, 2023?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.