Alpine Care of St. Charles LLC

In the surveyor’s words

From the most serious findings on record at Alpine Care of St. Charles LLC, in the surveyor’s own words.

• Immediate jeopardy, patternF600May 19, 2022

  Based on observation, interview, and record review, the facility failed to supervise R1, a male resident with known history of sexually inappropriate behaviors. The facility also failed to develop and implement a comprehensive care plan with specific interventions and instructions regarding 1:1 monitoring to prevent R1 from touching and fondling female residents' breasts who were unable to give consent due to cognitive impairment after an incident involving R6 and R7 on [DATE]. R1 was noted with another incident on [DATE], involving R5. […]

• Actual harm, isolatedF580Mar 21, 2026

  Based 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. The Findings include:On 3/19/2026 at 3:00 PM, R8 was in bed, lying on a mechanical lift sling. R8 was unable to provide information regarding her fall incident on 3/01/2026 due to her cognitive impairment and communication barrier.R8's MDS (Minimum Data Set) dated 1/30/2026 said she was severely cognitively impaired.On 3/20/2026 at 9:50 AM, V11 (Certified Nurse Assistant/CNA) said she routinely took care of R8, and prior to 3/02/2026, she required… […]

• Actual harm, isolatedF684Mar 21, 2026

  Based 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. The findings include:On 3/19/2026 at 3:00 PM, R8 was in bed, lying on a mechanical lift sling. […]

• Actual harm, isolatedF698Sep 26, 2025

  Based 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.Findings include:On 9/23/2025 at 3:20 PM, V9 (R93's Family Member) said R93 required hemodialysis treatments. R93 was in bed with his right arm elevated on a pillow. R93's right arm had purplish discoloration throughout. […]

• Actual harm, isolatedF689Jul 11, 2023

  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 fell ow residents were being escorted around facility property by CNAs [Certified Nursing Assistants]. […]