Health inspection·April 25, 2024

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to follow their identified offender policy by not complying with state regulations in performing criminal background checks within 24 hours of the admission of a new resident and failed to schedule a fingerprint-based criminal history record inquiry with 72 hours of receiving the initial criminal background results for 4 (R8, R12, R35, R67) of 5 residents reviewed for identified offenders. This failure has the potential to affect the safety and well-being of all 89 residents that currently reside in the facility. Residents Affected - Few Findings include: Per facility census dated [DATE], total in-house census is 89 residents. Per interviews with V17 (Social Services Director) and V18 (Social Services Designee) on [DATE], there are 5 identified offenders who currently reside at the facility. Per record review, the admission dates, criminal background checks including local and national sex offender registries and fingerprinting for 4 (R67, R35, R8, and R12) of 5 identified offenders revealed the following: R8's admission record indicated resident admitted to the facility on [DATE]. R8's initial criminal history inquiry was conducted on [DATE]. R8 consented to fingerprinting on [DATE] and was fingerprinted on [DATE]. R8's sex offender check was conducted on [DATE]. R8's identified offender care plan was initiated on [DATE]. On [DATE] at 3:00 PM, V18 (Social Services Designee) said when she started the process to have R8 fingerprinted on [DATE], she discovered that his initial criminal background results were expired so a new search was completed on [DATE]. R12's admission record indicated resident admitted to the facility on [DATE]. R8's criminal history inquiry was conducted on [DATE]. No fingerprint documentation was provided for R12. R12's sex offender check was attempted on [DATE] but was incomplete; resident birthdate and results were not listed. No identified offender care plan was found on file. R35's admission record indicated resident admitted to the facility on [DATE]. R35's criminal history inquiry was conducted on [DATE] and repeated on [DATE]. R8 consented to and was also fingerprinted on [DATE]. R35's sex offender check was attempted on [DATE] with no results, system was down. The facility made no other search attempts or provided evidence for the check at a later date. R35's identified offender care plan was initiated on [DATE]. (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 4 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 04/25/2024 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)