Inspection·May 22, 2023

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 follow its policy to provide incontinent care to dependent residents. Residents Affected - Few This applies to 3 of 3 residents (R1, R4, and R5) reviewed for activities of daily living (ADL) in a sample of 5. Findings include: 1. R1 is a [AGE] year-old female with cognition intact as per Minimum Data Set (MDS) assessment dated [DATE]. Record review on MDS indicates that R1 requires extensive two-person assistance for toilet use. On 5/20/23 at 9:10 AM, R1 was observed on her bed with a urine smell. R1 stated, They changed me at six o'clock in the morning, and nobody changed me after that. On 5/20/23 at 9:13 AM, V3 (Certified Nursing Assistant - CNA / Restorative Aide) checked on R1 and R1was observed with a urine-soaked incontinent brief. On 5/20/23 at 9:13 AM, V3 stated, I am not the assigned CNA for R1. We are supposed to provide incontinent care every two hours and as needed. On 5/21/23 at 11:50 AM, R1 stated, They changed me today at around 9:00 AM. I can't tell now if I am wet or not. On 5/21/23 at 11:55 AM, V7 (CNA) checked on R1 per the surveyor's request and observed her incontinent brief soaked in urine. On 5/21/23 at 11:55 AM, V7 stated, I changed R1 at 9:30 AM. I am going to change her now. 2. R4 is a [AGE] year-old female admitted on [DATE] with severely impaired cognition per MDS dated [DATE]. Record review on MDS indicates that R4 requires extensive one-person assistance for toilet use. On 5/20/23 at 9:17 AM, observed R4 on her bed with speech difficulty. R4 stated, I am wet now. They changed me around 8:00 PM last night. On 5/20/23 at 9:20 AM, V4 (Licensed Practical Nurse - LPN) checked R4 for incontinence, and R4 was observed with a double diaper with the inner one soaked in urine. On 5/20/23 at 9:20 AM, V4 stated, R4 should have been changed earlier. Incontinent care is supposed to be every 2 hours and as needed. 3. R5 is a [AGE] year-old female, morbid obese with a body mass index (BMI) of 65.6, with cognition (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 2 Event ID: 145011 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 145011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Care of Evanston 500 Asbury Street Evanston, IL 60202 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)