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]. Page 1 of 4 145011 145011 04/25/2024 Alpine Care of Evanston 500 Asbury Street Evanston, IL 60202

F 0607 Level of Harm - Minimal harm or potential for actual harm R67's admission record indicated resident admitted to the facility on [DATE]. R67's criminal history inquiry was conducted on [DATE] and issued on [DATE]. R67 consented to fingerprinting on [DATE] and was fingerprinted on [DATE]. R67's sex offender check was attempted on [DATE] with no results listed, system was down. No other evidence of search attempts were provided at a later time. R67's identified offender care plan was initiated on [DATE]. Residents Affected - Few R8, R12, R35, and R67 were all previously convicted with criminal offenses. On [DATE], interviews with V17 (Social Services Director) and V18 (Social Services Designee) from 02:26 PM through 03:13 PM revealed that identified offender reviews for new residents upon admission were delayed due to the lack of an admissions director so the facility performed an audit towards end of year in 2023 to initiate these reviews. V17 then said the criminal history information response process (CHIRP) should be done within 24 hours of admission, and she believed fingerprinting should be completed within 30 days if applicable. On [DATE] at 3:30 PM, V1 (Administrator) said that around [DATE], the facility identified that uniform conviction information act (UCIA) checks were not being conducted by the previous admission director. As a result, the admission director was terminated, and the facility then conducted an audit and conducted the UCIA background checks and completed this audit by January of 2024. Identified Offender Policy last revised [DATE] reads as follows: Policy Statement: The facility will comply with the state regulations in addressing residents who are identified offenders. Procedures: 1. The facility shall review the results of the criminal history background checks immediately upon receipt of these checks. 2. The facility shall be responsible for taking all steps necessary to ensure the safety of residents while the results of a name-based background check is pending, while the Identified Offender Report and Recommendation is pending. 3. If the results of a resident's criminal history background check reveal that the resident is an identified offender the facility will: a. Immediately notify the Department of State Police that the resident is an identified offender. 145011 Page 2 of 4 145011 04/25/2024 Alpine Care of Evanston 500 Asbury Street Evanston, IL 60202

F 0607 b. Level of Harm - Minimal harm or potential for actual harm Within 72 hours, arrange for a fingerprint-based criminal history record inquiry to be requested on the identified offender resident. Residents Affected - Few 4. All name-based and fingerprint-based criminal history record inquires shall be submitted to the Department of State Police electronically in the form and manner prescribed by the Department of State Police. 5. If the identified offender is on probation, parole, or mandatory supervised release, the facility shall contact the resident's probation or parole officer, acknowledge the terms of release, update contact information with the probation or parole office, and maintain updated contact information in the resident's record. The record must also include the resident's criminal history record. 6. A written notice confirming whether identified offenders are residing in the facility shall be posted prominently in the facility. It should include a statement indicating that information regarding sex offenders may be obtained from Illinois State Police website (www.isp.state.il.us) and information regarding persons serving terms of parole or mandatory supervised release may be obtained from the Illinois Department of Corrections website (www.idoc.state.il.us). 7. For current residents who are identified offenders, the facility shall review the security measures listed in the Identified Offender Report and Recommendation provided by the Department of the State Police. 8. The facility shall incorporate the Identified Offender Report and Recommendation into the identified offender's care plan. 9. If the identified offender is a convicted or registered sex offender or if the Identified Offender Report and Recommendation prepared pursuant to Section 2-201.6(a) of the Act reveals that the identified offender poses a significant risk of harm to others within the facility, the offender shall be required to have his or her own room within the facility. 10. The facility shall evaluate care plans at least quarterly for identified offenders for appropriateness and effectiveness of the portions specific to the identified offense and shall document such review. The facility shall modify the care plan, if necessary, in response to this evaluation. The 145011 Page 3 of 4 145011 04/25/2024 Alpine Care of Evanston 500 Asbury Street Evanston, IL 60202

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility remains responsible for continuously evaluating the identified offender and for making any changes in the care plan that are necessary to ensure the safety of residents. 11. Incident reports shall be submitted to the IDPH Division of Long-Term Car Field Operations in the Department's Office of Health Care Regulation in compliance with Section 300.690 of this Part. The facility shall review its placement determination of identified offenders based on incident reports involving the identified offender. In incident reports involving identified offenders, the facility shall identify whether the incident involves substance abuse, aggressive behavior, or inappropriate sexual behavior, as well as any other behavior or activity that would be reasonably likely to cause harm to the identified offender or others. If the facility cannot protect the other residents from misconduct by the identified offender, then the facility shall transfer or discharge the identified offender in accordance with Section 300.3300 of this Part. 12. The facility shall notify the appropriate local law enforcement agency, the Illinois Prisoner Review Board, or the Department of Corrections of the incident and whether it involved substance abuse, aggressive behavior, or inappropriate sexual behavior that would necessitate relocation of that resident. 145011 Page 4 of 4