Alpine Care of St. Charles: Missed Fentanyl, Blood Thinner - IL
"There's medication issues every month," she said.
The inspection, conducted April 23, 2026, confirmed she was right. Her medication administration record for April showed she had missed five doses of Lovenox, a blood thinner injected twice daily to prevent dangerous clots. On April 7, 8, and 11, the record listed the medication as simply "unavailable." On April 10 and April 22, there was no documentation at all, which the facility's own Director of Nursing confirmed means the medication was not given.
She also missed her fentanyl patch, a 50-microgram-per-hour transdermal pain medication applied every 72 hours, on at least two dates in April. The patch was not administered on April 10 because it was unavailable. The Assistant Director of Nursing, reviewing the April record alongside the inspector, confirmed the patch had also not been given on April 4, because it had been ordered through the pharmacy but was not on hand when it was time to apply it.
The resident had told the inspector exactly this. "Nursing said they didn't have the medication."
The Director of Nursing said that when a medication runs low, nurses are supposed to order a replacement at least three days in advance, and that some medications can be pulled from an emergency supply in the meantime. She acknowledged there was one instance when a blood thinner injection was missed because an agency nurse said she could not find it. She said she was not aware of any other missed doses.
The April medication record documented at least five.
The Assistant Director of Nursing had a different explanation for the blood thinner shortage, one that raised its own questions. She told the inspector that Lovenox is delivered in a box supply, meaning there should be plenty on hand at any given time. She said she was not sure why nurses were documenting the medication as unavailable.
Nobody had an answer for why it kept happening.
The facility's own medication administration policy, dated April 2026, the same month the missed doses were occurring, requires nurses to review all electronic medication records at the end of each medication pass to confirm every medication was given and documented. If that review was happening, it did not stop five missed doses of a blood thinner or two missed applications of a fentanyl patch in a single month.
Lovenox is prescribed to prevent blood clots, including deep vein thrombosis and pulmonary embolism. Missing multiple doses is not a minor administrative lapse. Fentanyl patches manage chronic pain and are not medications a patient can simply go without for a day while supply is sorted out.
The resident knew that. She said she had not received her pain patch or her blood thinner injection a few weeks earlier, and she described the pattern plainly: this happens every month.
Federal inspectors rated the violation as causing minimal harm, the lowest level on the harm scale. The citation covered one of three residents reviewed for medication management during the complaint inspection.
She was still in her bed when the inspector arrived that morning, waiting.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alpine Care of St. Charles LLC from 2026-04-24 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Alpine Care of St. Charles LLC in SAINT CHARLES, IL was cited for violations during a health inspection on April 24, 2026.
"There's medication issues every month," she said.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.