Alpine Care of St. Charles LLC

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure significant medications were available and administered in accordance with physician orders. This applies to 2 of 9 residents (R3 and R8) reviewed for medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was free from significant medication errors. This applies to 1 of 3 residents (R1) reviewed for medications in the sample of 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement fall and safety interventions for residents identified at a high risk for falls. This applies to 4 of 5 (R3, R4, R5, and R6) residents reviewed for falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pressure ulcer prevention interventions for a resident with known risk for pressure ulcer development. This failure applies to 1 of 4 (R5) residents reviewed for pressure ulcers.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of a resident's (R8) unwitnessed fall incident, who was then experiencing acute right hip pain. This failure resulted in R8 receiving delayed medical care for her right hip fracture. This applies to 1 of 7 residents (R8) reviewed for fall incidents in the sample 10.

Inspectors wroteBased on interview and record review, the facility failed to document, report, and monitor a resident (R8) after she sustained an unwitnessed fall and was then experiencing acute right hip pain. This failure resulted in R8 not being properly assessed for post-fall complications and receiving delayed medical care for her right hip fracture. This applies to 1 of 7 residents (R8) reviewed for falls in the sample of 10.

Inspectors wroteBased on observation, interview, and record review, the facility failed to communicate a resident's new dialysis site order to the dialysis team and assess for post-dialysis complications. This failure resulted in the resident developing acute right arm pain and swelling from his AV (Arteriovenous) fistula site and requiring hospitalization for management of an acute cephalic vein thrombosis. This applies to 1 of 3 residents (R93) reviewed for hemodialysis in a sample of 23.

Inspectors wroteBased on observation, interview, and record review, the facility kitchen staff failed to follow sanitary practices and safely store food items in the kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) cares for residents who needs assistance. This failure effects to 4 of 4 residents (R12, R13, R22, R44) reviewed for ADLs in a sample of 23.

Inspectors wroteBased on interview and record review the facility failed to coordinate and maintain documentation of hospice care activities and the hospice care plan. This applies to 4 of 4 residents (R10, R13, R34, and R62) reviewed for hospice care in a sample of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure ongoing assessment and care planning for residents desiring to self-administer medications. This applies to 2 of 2 residents (R11, R55) reviewed for medications in a sample of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess a resident's nutritional needs and provide their ordered supplement. This applies to 1 of 3 residents (R93) reviewed for nutrition in a sample of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to secure resident medications. This applies to 3 of 3 residents (R15, R78, R95) reviewed for medications in a sample of 23.

Inspectors wroteBased on interview and record review, the facility failed to assess and assist residents in obtaining routine dental services. This applies to 2 of 3 residents (R57 and R58) reviewed for dental services in a sample of 23.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain and monitor residents' personal refrigerators. This applies to 3 of 3 residents (R6, R40 and R74) reviewed for personal refrigerators in a sample of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform hand hygiene and change gloves when rendering care, and ensure urinary drainage bags were kept off the floor. This applies to 3 of 3 residents (R44, R58, and R63) reviewed for infection control in a sample of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to investigate allegations of sexual abuse in a timely manner. The facility also failed to implement their Abuse policy and procedure and conduct a comprehensive investigation of the alleged sexual abuse and report the abuse to the state health department and police department. This applies to 1 of 5 residents (R5) reviewed for sexual abuse in a sample of 12.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure radiological services were provided timely, and to meet the needs of the residents' with a change in medical condition. This applies to 1 of 3 residents (R1) reviewed for injury of unknown origin.

Inspectors wroteBased 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.

Inspectors wroteBased 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. This applies to 5 of 5 residents (R6, R20, R38, R42, R75) reviewed for pureed diets in the sample of 18.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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). This applies to 3 of 4 residents (R76, R79, R86) reviewed for activities of daily living in the sample of 18.

Inspectors wroteBased 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.

Inspectors wroteBased 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. This applies to 1 of 1 resident (R3) reviewed for oxygen therapy in the sample of 18.

Inspectors wroteBased 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. This applies to 2 of 7 residents (R37, R52) reviewed for medication administration in the sample of 18.

Inspectors wroteBased 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. This applies to 1 of 5 residents (R13) reviewed for infection control during provisions of care in the sample of 18.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to notify the physician and POA (Power of Attorney) for change in residents' condition. This applies to 1 of 5 residents (R1) reviewed for delay in notification in resident's condition.

Inspectors wroteBased on interview and record review, the facility failed to provide residents toileting assistance and assistance with weekly showers per facility policy. This applies to 6 of 6 residents (R2, R3, R4, R5, R8, R11) reviewed for ADL (Activities of Daily Living) assistance in a sample of 13.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a staff had reported immediately an allegation of sexual abuse. This applies to 1 of 2 (R1) residents reviewed for abuse in the sample of 5.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was prepared and served in a manner to prevent cross-contamination and food-borne illness. The facility also failed to ensure the chemical sanitation level testing for the chemical dishwasher was performed and documented. These failures have the potential to affect all the residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure an employee treated a resident in a dignified manner for 1 of 1 residents (R83) reviewed for resident rights in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to offer and provide activities of daily living (ADL) care for a dependent resident (R17), and failed to provide showers for a resident (R395). These failures apply to 2 of 3 residents reviewed for ADL care in the sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain accurate weights as ordered by the doctor for residents at high risk for nutritional decline for 2 of 3 residents (R23, R75) reviewed for weights in the sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pressure injury prevention interventions were in place for a resident with a history of pressure injuries. This applies to 1 of 5 (R40) residents reviewed for pressure injuries in the sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility failed to apply an arm splint, enter an order for a splint, and initiate a restorative program for R83's arm splint for 1 of 2 residents (R83) reviewed for limited range of motion in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fall prevention measures were in place for a resident (R17), failed to supervise a resident (R17) on aspiration precautions during meal times, and failed to transfer a resident (R395) with a gait belt. These failures apply to 2 of 11 residents reviewed for safety in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide catheter care in a manner to prevent infections for 1 of 2 residents (R395) reviewed for urinary catheters in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to wear personal protective equipment per their policy for 2 residents (R17, R395) on enhanced barrier precautions, failed to disinfect an insulin pen prior to needle application and insulin administration for a resident (R53). These failures apply to 3 of 3 residents reviewed for infection control in the sample of 18.