Inspection visit
Inspection
8 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 8 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0644
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Coordinate assessments with the pre-admission screening and resident review program; and referring for
services as needed.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to request a re-evaluation for a PASARR II (Pre-admission
Screening and Resident Review) screening for a resident with a SMI (serious mental illness) diagnosis
within the required timeframe.
This applies to 1 of 1 residents (R59) reviewed for PASARR in the sample of 18.
R59's EMR (Electronic Medical Record) showed R59 was admitted to the facility on [DATE] with diagnoses
that included bipolar disorder, specified anxiety disorder, and PTSD (Post-Traumatic Stress Disorder).
R59's MDS (Minimum Data Set) dated May 24, 2024 showed R59 was cognitively intact.
R59's care plan dated February 23, 2023, showed R59 presents with a troubled past secondary to bipolar
disorder and diagnoses of PTSD and anxiety. Interventions included conduct the appropriate assessments
to promote knowledge and understanding of R59's past, remind and encourage R59 to verbalize her
thoughts and feelings during her 1:1 session with the visiting psychotherapist.
On July 22, 2024 at 3:04 PM, the facility provided R59's PASARR II screening that was dated February 12,
2023. The PASSAR II evaluation showed R59 was at a previous nursing home and became aggressive with
a staff member at the nursing home and bit them. Assessment showed she has a diagnosis of Bipolar, has
aggressive behaviors, has attempted suicide in past, yells at others, has been homeless in the past, has
hard time trusting others, acts without consequences, has a hard time understanding the impact of her
decisions or actions, cannot solve problems without the help from others, scored 36% on WHO-5 (World
Health Organization) test which shows resident has a poor view of her life, periods of confusion and trouble
with memory, angered easily, difficulty concentrating, moods may go from one extreme to another quickly,
and resident has anxious thoughts. R59 has history of refusing medications because she feels she does
not need them .R59 has been hospitalized in the past for mental health symptoms. R59 has a diagnosis of
a severe mental health condition. The least restrictive treatment setting is a nursing home because R59
needs help with bathing, grooming, money, management, medication, and other community tasks. The
PASARR Determination explanation - R59 is diagnosed with bipolar disorder per her medical record which
significantly impacts her daily life. The evaluation was effective February 12, 2023 for short term and the
approval ends on April 13, 2023.
On July 23, 2024 at 11:54 AM, V21 (Vice President of Operations) said that they track the residents
assessment in the Maximus system and should be notified when an assessment is due. V21 provided a list
of events for R59 from the Maximus system and it showed on March 26, 2023 an initial Service
(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 12
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
07/25/2024
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 0644
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Matters Review was completed. V21 said the facility enters this information into Maximus and that lets the
reviewer know there needs to be a follow-up assessment. V21 said she was not sure why no one came to
do a re-evaluation of R59. V21 provided state surveyor with PASARR I done on July 22, 2024 that showed
an onsite PASARR II was required.
Facility policy titled PASARR Screening of Residents with Mental Disorder or Intellectual Disability with
revision date of June 6, 2024 showed, It is the facility's policy to ensure that residents with Mental Disorder
and those with Intellectual Disorder will receive PASARR Screening within the timeframe allowed.
Event ID:
Facility ID:
145433
If continuation sheet
Page 2 of 12
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
07/25/2024
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 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to assist a resident that was assessed to require
assistance with ADLs (Activities of Daily Living).
Residents Affected - Few
This applies to 3 of 4 residents (R76, R79, R86) reviewed for activities of daily living in the sample of 18.
The findings include:
1. R79's EMR (Electronic Medical Record) showed R79 was admitted to the facility on [DATE], with
diagnoses that included hydrocephalus, major depression, unspecified psychosis, anxiety, cognitive
communicative deficit, unspecified focal traumatic brain injury with loss of consciousness, and traumatic
hemorrhage of cerebrum.
R79's MDS (Minimum Data Set) dated April 19, 2024, showed R79 had severe cognitive impairment and
required substantial/maximal assistance for toileting, showering, and personal hygiene.
R79's care plan showed R79 is incontinent of bowel and bladder and requires assistance with perineal care
and interventions include checking R79 for incontinence episodes and anticipate his toileting needs
throughout each shift.
On July 22, 2024, at 12:31 PM, R79 was observed sitting in the same spot in the dining room as he was at
10:10 AM. At this time, there was a brown substance dried onto his right- hand entire thumb, entire first
digit, and the second digit. R79 had been given juice to drink and was sitting at table with another resident.
V2 (DON/Director of Nursing) was asked to visualize R79's hand. V2 agreed it looked like stool dried onto
R79's hand. V2 grabbed the closest CNA (Certified Nursing Assistant) and asked to have R79 taken to his
room. V3 (CNA), who was assigned to R79, was in the hallway and came and took R79 to his room. R79
stood at his sink and washed his hands four times to get the brown dried substance off his hands. CNA
gathered all her supplies and after his hands were clean, V3 told R79 she was going to change his
incontinence brief. When resident was standing and his shirt was pulled up, the dried brown substance,
now clearly identified as bowel movement, had come up and was on his lower back above the top of the
incontinence brief. When incontinence brief was removed there was a large amount of dried bowel
movement in his brief from between his legs, up his buttocks and up to his lower back. As V3 was cleaning
R79, he kept asking are you done yet? V3 kept replying, not yet, there is a lot of poop on you.
2. R76's EMR showed R76 was originally admitted to the facility on [DATE]. R76 was sent to the hospital on
July 12, 2024, and returned to the facility on July 14, 2024. R76's diagnosis included quadriplegia, major
depressive disorder, morbid obesity due to excessive calorie intake, and critical illness myopathy.
R76's MDS dated [DATE], showed R76 was cognitively intact and was dependent on staff for all ADLs
(Activities of Daily Living).
On July 22, 2024, at 10:18 AM, R76 said she would like to take a shower, her hair was greasy and stringy,
she has facial hair under her chin and would like to be shaved. Multiple observations were made throughout
the day and no shower or shaving assistance had been provided.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145433
If continuation sheet
Page 3 of 12
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
07/25/2024
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 0677
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On July 24, 2024, at 8:58 AM, V3 CNA (Certified Nursing Assistant) said in the morning she will get her
residents up and out of bed, wash their face, assist with oral care, give a bed bath if needed, fix bed, and
comb hair.
On July 23, 2024, at 10:57 AM, R76 was in bed, she had flaky skin noted near her eyebrows and on her
cheeks/chin, there was a dried crusty substance on her lower eye lashes, and when talking there was a
white film on her lips and a red area to the right corner of mouth. R76 had several whiskers under her chin
and on her upper neck. R76 said she really wants to be shaved and cannot remember when she was last
given a bed bath. There is a foul musty odor noted when standing next to the bed.
On July 24, 2024, at 9:06 AM, V2 (DON/Director of Nursing) said on a resident's shower day, the
expectation is that the resident is taken to the shower room and given a shower. V2 said if it is not a
resident's shower day, the expectation is that the resident be helped with morning care/grooming. This
includes washing face and hands, assisting with oral care, brushing hair, washing hair in bed if resident
needs it or requests to have hair washed, nail care, shaving facial hair for both men and women, and
resident should he provided with clean clothes.
3. On July 23, 2024, at 1:14 PM, R86 was in his bedroom and was alert and oriented. R86 displayed
unkempt long facial hair on his upper lip and chin and had long fingernails with the nail beds stained with
brownish discoloration. R86 verbalized that he wants his nails clipped and facial hair shaven because it
feels uncomfortable.
R86's MDS dated [DATE], shows R86 is alert and oriented and requires extensive assistance with activities
of daily living care.
Facility provided policy titled, General Care with revision date of June 6, 2024, showed, 1. On admission or
readmission, the facility will evaluate the resident's physical and psychosocial needs. Physical needs would
include but limited to ADL (Activity of Daily Living), wound care, medical needs, etc .2. The facility will assist
the resident to meet those needs
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145433
If continuation sheet
Page 4 of 12
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
07/25/2024
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 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM
and/or mobility, unless a decline is for a medical reason.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to assess and provide appropriate splints and
therapy services to maintain and/or prevent further progression of deformities or reduction in range of
motion.
This applies to 1 of 3 residents (R76) reviewed for range of motion in the sample of 18.
The findings include:
R76's EMR (Electronic Medical Record) showed R76 was originally admitted to the facility on [DATE]. R76
was sent to the hospital on July 12, 2024, and returned to the facility on July 14, 2024. R76's diagnosis
included quadriplegia, major depressive disorder, morbid obesity due to excessive calorie intake, and
critical illness myopathy.
R76's MDS (Minimum Data Set) dated May 28, 2024, showed R76 was cognitively intact and was
dependent on staff for all ADLs (Activities of Daily Living).
R76's restorative care plan-initiated September 28, 2023, showed R76 required assistance with applying
left resting hand splint during the day while patient is out of bed and removed prior to putting patient back in
bed daily, six to seven days a week as tolerated. The goal was for R76 to maintain current level of
functioning and range of motion in left hand/wrist. Interventions included staff applying the left resting hand
splint, encourage/praise R76's efforts throughout the task to promote participation and staff are to explain
to R76, the splint's purpose.
R76's initial OT (Occupational Therapy) Evaluation and Plan of Treatment dated February 23, 2023,
showed R76 did not have any functional limitations due to contractures. The Restorative Nurse assessment
on the same date showed R76 did not wear a splint or brace.
R76's POS (Physician Order Set) dated May 13, 2024, showed Assistance with Splint/Brace - Apply left
resting hand splint during the day while patient is out of bed and remove prior to putting patient back in bed
daily, six to seven days/week as tolerated. Check skin on left hand and wrist for redness and signs of skin
breakdown prior to application and after removal of splint. Monitor for increased pain.
R76 was referred to OT on May 31, 2024. R76's OT Evaluation and Treatment dated June 2, 2024, showed
R76 was referred to OT for self-feeding evaluation. R76 has declined in self-feeding requiring additional
assistance from staff at all meals. R76 presents with decreased AROM (active range of motion) in BUE
(bilateral upper extremities), decreased strength in BUE, and poor coordination .Prior to thus onset, no
equipment was required.
R76's OT Evaluation and Plan of Treatment showed R76 has severe UE (upper extremity) and LE (lower
extremity) motor movement affecting ability to care for self and complete ADLs (Activities of Daily Living).
LUE (left upper extremity) hand has contracture requiring left resting hand splint to maintain functional
positioning .
On July 22, 2024, at 10:18 AM, R76 has a contracture to her left hand and splint is on bedside
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145433
If continuation sheet
Page 5 of 12
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
07/25/2024
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 0688
table.
Level of Harm - Minimal harm
or potential for actual harm
On July 22, at 12:49 PM, R76 said staff helped feed her lunch but still have not put splint on her wrist today.
On July 22, 2024, at 3:57 PM, R76, was not wearing splint.
Residents Affected - Few
On July 23, 2024, at 10:57 AM, R76 was in bed. The resting wrist splint is on the bedside table and not on
R76.
On July 23, 2024, at 12:34 PM, R76 in bed, no splint on her wrist.
On July 23, 2024, at 4:35 PM, R76 in bed, no splint on her wrist.
On July 24, 2024, at 8:42 AM, R76 in bed, no splint on her wrist.
On July 24, 2024, at 2:20 PM, V20 (OT) and state surveyor went to R76's room. R76 was not wearing the
left- hand resting splint. V20 measured flexion and extension to the left wrist and fingers. Before leaving the
room, V20 did not put the left-hand resting splint on R76.
On July 24, 2024, at 9:13 AM, V8 (Restorative Nurse) said when a resident has a splint, it can be applied
by her, the therapy department (physical or occupational therapy), the restorative CNAs (Certified Nursing
Assistant), and she said she believes the CNAs on the floor can also put a splint on a resident. V8 said R76
should be wearing the brace daily. V8 said she recently updated (July 16) the computer to show R76 was to
wear the wrist daily whether she was in bed or not.
The facility was unable to show documentation that R76 was wearing the splint daily or that she was
wearing it for the recommended four to eight hours a day. There was no documentation under the facility
tasks for the last 30 days by facility staff or agency staff.
Facility provided policy titled, Restorative Nursing Program with revision date June 6, 2024, showed 3.
Nursing and Restorative Services may include the following .c. Contracture Prevention and Management i.
PROM/AROM (passive range of motion/active range of motion) exercises, ii. Splint/Orthotic Management
.6. Restorative Programs shall be reflected and indicated in the resident's electronic restorative log in order
to document the provisions of service and the frequency by the nurses, CNAs, and. Restorative aides .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145433
If continuation sheet
Page 6 of 12
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
07/25/2024
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 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review, the facility failed to ensure that there was enough
oxygen in the resident's portable oxygen tank, to promote delivery of oxygen as ordered by the physician.
Residents Affected - Few
This applies to 1 of 1 resident (R3) reviewed for oxygen therapy in the sample of 18.
The findings include:
R3 had multiple diagnoses including metabolic encephalopathy, hemiplegia affecting right dominant side,
chronic respiratory failure with hypoxia and dependence on supplemental oxygen, based on the face sheet.
On July 23, 2024 at 2:10 PM, R3 was sitting in her wheelchair inside the unit dining room attending the
resident group meeting. R3 was observed with on and off coughing and was not participating with the group
discussion. R3 had an oxygen nasal cannula in place attached to a portable oxygen (E tank) located at the
back of the resident's wheelchair. The gauge of the said portable oxygen was observed at the red area with
a mark refill. A facility nurse was immediately called by the State Agency personnel to inform of R3's
condition and the need for the portable oxygen to be refilled or replaced based on the gauge indicator. At
2:13 PM, V11 (Agency LPN/Licensed Practical Nurse) came inside the unit dining room and changed the
portable oxygen tank of R3. After the portable oxygen tank was changed, R3 was observed with less
coughing and was participating more with the group discussion.
R3's active order summary report showed that the resident was on hospice care since June 20, 2024. The
same order summary report showed an order dated June 20, 2024 for, Oxygen 2-5 (liters) via (nasal
cannula) continuously PRN (as needed).
On July 24, 2024 at 9:10 AM, V11 stated that she was the nurse who changed the portable oxygen tank of
R3 on July 23, 2024 while the resident was attending the group meeting. V11 stated that the gauge
indicator on the oxygen tank that was attached to R3's nasal cannula was at the red area. V11 stated, the
oxygen tank definitely needed to be changed. According to V11, when she changed the portable oxygen
tank, she noticed that the oxygen was set at 2 liters per minute. During the same interview, V11 stated that
she was not the assigned nurse for R3 but because she was called by a female visitor to change the
portable oxygen tank, she therefore went in with a full tank of portable oxygen to change the empty tank.
On July 24, 2024 at 10:14 AM, R3 was in bed, alert and verbally responsive. R3 had an ongoing continuous
oxygen via nasal cannula at 3 liters per minute, using the oxygen concentrator. R3 had no shortness of
breath. R3 was asked about the incident that happened on July 23, 2024 during the group meeting. R3
stated that she was coughing on and off and was having slight shortness of breath. According to R3 after
the nurse changed her portable oxygen tank, she felt better, and her breathing was better.
On July 24, 2024 at 1:54 PM, V2 (Director of Nursing) stated that R3's oxygen should be administered
continuously. According to V2 a clarification order was made, and the order was changed to administer the
oxygen continuously.
On July 24, 2024 at 4:31 PM, V2 stated that she expects the nurses to check the resident's oxygen
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145433
If continuation sheet
Page 7 of 12
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
07/25/2024
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 0695
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
tank to ensure that there is enough oxygen inside the tank for resident's comfort and proper delivery of
oxygen.
The facility's policy regarding oxygen therapy and administration last reviewed by the facility on June 6,
2024 showed, Oxygen therapy shall be administered to patients as indicated and upon a physician's order.
The policy showed in-part under purpose, To assure adequate oxygenation to all spontaneously breathing
and ventilator dependent patients.
Event ID:
Facility ID:
145433
If continuation sheet
Page 8 of 12
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
07/25/2024
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 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to administer medications according to
physician's order. There were 25 medication opportunities with 3 errors, resulting in a 12% medication error
rate.
Residents Affected - Few
This applies to 2 of 7 residents (R37, R52) reviewed for medication administration in the sample of 18.
The findings include:
1. R37's Medication Administration Record (MAR) showed that R37 was prescribed multiple medications
which include Heparin Sodium Injection 5,000 units per milliliter (ml). The physician's order showed to inject
1 ml (5,000 units) of Heparin subcutaneously every 8 hours for anticoagulation.
On July 23, 2024, at 1:57 PM, V9 (Registered Nurse/RN) prepared to administer Heparin Sodium to R37.
V9 drew 0.9 ml (4,500 units) from the Heparin vial. As V9 was about to administer the medication, the dose
was verified and when checked, 0.1 ml was still left in the vial. V9 then proceeded to aspirate the remaining
Heparin from the vial, to administer a total of 5000 units.
2. R52's MAR shows multiple medications which include Docusate Sodium 100 mg capsule and Admelog
Solostar 100 units/ml. V13 (RN) stated that R52 has a new order which was to crush all R52's medications.
V13 was unsure what to do with the Docusate Sodium which cannot be crushed nor split or cut. V13
decided to give the Bisacodyl 5 mg Enteric Coated/EC (Dulcolax) instead, without calling the physician. V13
also crushed the medication. V13 stated that it was also a laxative just like the Docusate Sodium.
3. V13 opened a new pen of insulin Admelog Solostar for R52, V13 dialed the dosage selector to the
appropriate dose according to R52's blood glucose level and proceeded to administer it to R52. However,
V13 did not prime the insulin pen prior to the administration.
On July 24, 2024, at 2:43 PM, V2 (Director of Nursing/DON) stated that staff must follow the physician's
order with regards to administration if medication. V2 stated that the staff should follow the 5 rights with
medication administration, such as the right patient, route, medication, time, and dosage. V2 added that if
the insulin is newly opened, the staff must prime the insulin pen with 2 units prior to administering the
appropriate dose.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145433
If continuation sheet
Page 9 of 12
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
07/25/2024
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on observation, interview and record review, the facility failed to label and date medications after
opening to determine expiration dates. In addition, facility also failed to discard a narcotic medication that
has a broken seal.
This applies to 6 of 6 residents (R16, R22, R25, R44, R88, R445) reviewed for labeling, storage, and
expiration of drugs in the sample of 18.
The findings include:
On July 23, 2024, at 3:40 PM, the 600-hallway cart was monitored with V14 LPN (Licensed Practical
Nurse), and the following was observed:
1. R16 has two Wixela inhalers (Fluticasone Propionate and Salmeterol Inhalation Powder) which were
opened and not dated. The pharmacy's recommended expiration date showed to discard 30 days after
opening the foil pouch.
2. R25's Humalog Kwik Pen was opened and not dated. The pharmacy's recommended expiration date
showed to discard 28 days after it was opened.
3. R22's Basaglar Kwik Pen was opened and not dated. The pharmacy's recommended expiration date
shows to discard 28 days after it was opened.
4. R445's Tobramycin 0.3% and Dexamethasone 0.1% Ophthalmic Solution was opened and not dated. On
July 24, 2024, at 2:42 PM, V2 (Director of Nursing/DON) stated that per pharmacy recommendation the
Tobramycin eye drops should be discarded 28 days after it was opened.
On July 24, 2024, from 11:03 AM though 11:19 AM, the 100 hallway's and the 400 hallway's carts were
inspected with V15 (LPN) and V16 (Registered Nurse) respectively. The following were observed:
5. R44's had two Anoro Ellipta inhalers (umeclidinium and vilanterol inhalation powder)
62.5-25mcg(microgram)/inhalation was opened and not dated. The pharmacy's recommended expiration
date shows to discard 6 weeks or 42 days after opening the foil pouch.
6. R88's Diazepam 2 mg (milligram) tablet (#15) was opened and taped over to seal it.
On July 24, 2024, at 11:50 AM, V10 (Nurse Consultant) stated that once the seal of the blister is torn, the
medication should be discarded, and that it shouldn't be taped over to re-seal it.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145433
If continuation sheet
Page 10 of 12
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
07/25/2024
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 0803
Level of Harm - Minimal harm
or potential for actual harm
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be
updated, be reviewed by dietician, and meet the needs of the resident.
Based on observation, interview and record review, the facility failed to follow the menu spreadsheet to
provide the portion serving size of pureed beef top round roast beef.
Residents Affected - Some
This applies to 5 of 5 residents (R6, R20, R38, R42, R75) reviewed for pureed diets in the sample of 18.
The findings include:
Facility Spring/Summer Menu for week 2 Monday included to use #6 scoop for pureed beef top round roast
beef.
On July 22, 2024 at 12:07 PM, the lunch meal service was observed in the facility kitchen with V6 (Cook)
and V7 (Dietary Aide) on the tray line. V6 and V7 used #8 scoop to serve the pureed beef top round roast
and R6, R20, R38, R42 and R75 received the same. R6, R20, R38, R42 and R75's meal tickets also
showed a serving size of #6 scoop of pureed beef top round roast.
On July 22, 2024 at 12:23 PM, when V5 (Dietary Director) was shown the menu spreadsheets, V5 stated
that the facility should have followed the serving size as shown on the meal ticket for the item served.
On July 22, 2024 at 12:26 PM, (Registered Dietitian) stated that the dietary staff should have followed the
menu spreadsheet and used #6 scoop to serve pureed beef top round roast beef to provide adequacy of
nutrition.
Facility Portion Control Chart chart showed that #8=4 ounces and #6=5 1/3 ounces.
Facility Diet Order Listing printed on July 22, 2024 showed that R6, R20, R38, R42 and R75 were on
pureed diets.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145433
If continuation sheet
Page 11 of 12
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
07/25/2024
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to follow standards of infection control
practices with regards to hand hygiene and gloving during provisions of incontinence care.
Residents Affected - Few
This applies to 1 of 5 residents (R13) reviewed for infection control during provisions of care in the sample
of 18.
The findings include:
On July 24, 2024, at 10:26 AM, V17 and V18 (Both Certified Nursing Assistant/CNA) rendered incontinence
care to R13 who was heavily wet with urine and had a large bowel movement. V17 used wet wipes to clean
R13 from front to back. After she cleaned the front perineum, she removed her gloves and washed her
hands, then she continued to clean the back perineum. Due to the large amount of fecal matter, V17
changed her gloves twice without hand hygiene and continued to wipe R13's buttocks. After she completed
wiping the back perineum, V17 applied barrier cream and incontinence brief while wearing the same soiled
gloves.
On July 24, 2024, at 2:35 PM, V2 (Director of Nursing/DON) stated that during incontinence care, the staff
must perform hand hygiene in between glove changes, in between tasks, and before and after completing
the care. V2 added that the staff must also change gloves in between tasks to prevent spread infection.
Facility's Hand Hygiene Policy and Procedure with revision date of June 6, 2024 showed as follows:
Policy Statement: Hand hygiene is important in controlling infections. Hand hygiene consists of either hand
washing or the use of alcohol gel. The facility will comply with the CDC [Centers for Disease Control]
Guidelines regarding hand hygiene.
Procedures:
1. Hand hygiene using alcohol-based hand rub is recommended during the following situations:
g. Before moving from work on soiled body site to a clean body site on the same patient.
h. After contact with blood, body fluids or surfaces contaminated with blood and body fluids.
i. After removing gloves including during wound dressing change.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145433
If continuation sheet
Page 12 of 12
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Back to topCitations
8 citations 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.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the July 25, 2024 survey of Alpine Care of St. Charles LLC?
This was a inspection survey of Alpine Care of St. Charles LLC on July 25, 2024. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Alpine Care of St. Charles LLC on July 25, 2024?
Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure medication error rates are not 5 percent or greater."
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
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.