Inspection·July 19, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to R457. During cares, R457 vomited a moderate amount of emesis onto her pillowcase and fitted bed sheet. V11 and V12 provided incontinence care and changed R457's pillowcase. V11 then stated, We will have to get the sheet changed later where she threw up. V11 and V12 then exited the room without changing R457's fitted sheet. On 7/17/24 at 10:48AM, V4 (Wound care nurse) and V13 (Wound care CNA) provided wound care for R457. Surveyor notified both staff members that R457 had vomited on her sheet and pillowcase during previous observation. V13 looked at the sheet and stated the CNA's will clean it up later. V4 and V13 left the room without changing R457's sheet. On 7/17/24 at 11:49AM, V21 (CNA) stated if a resident soils their linens they should be changed as soon as staff discover or are notified about it. V21 stated it would make her feel gross and any reasonable person would want their sheets changed when soiled. On 7/18/24 at 1:36PM, V2 (Director of Nursing) stated, Sheets should be changed at the time staff are notified or see that they are soiled. This would be a concern due to dignity, infection control, and a general feeling of uncleanliness. The facility's undated booklet titled Residents' Rights for People in Long-term Care Facilities showed, Your facility must provide services to keep you physical and mental health, and sense of satisfaction. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145665 If continuation sheet Page 2 of 18 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 145665 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Care of Zion 2534 Elim Avenue Zion, IL 60099 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)

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to address and follow-up with resident concerns brought forward in resident council. This applies to 1 of 1 residents (R71) reviewed for resident council grievances in the sample of 30 and 5 residents (R48, R75, R105, R74, and R24) outside the sample. Residents Affected - Some The findings include: The facility's 6/20/24 Resident Council Minutes showed 25 residents attended. The minutes showed, Old Business-Treasures Report: The balance last month was $911.09. The balance this month is $356.33. The difference was the special Happy Hour sponsored by the Resident Council. (No follow up was documented regarding any complaints from previous resident councils.) The minutes continued, New BusinessAlternative menu changes. Residents were asked to vote on which 3 items they wanted on the alternative menu. The Residents voted for Hamburger/Cheeseburger, chicken tacos, and peanut butter and jelly sandwich. The alternative menu will switch in September to the second alternative menu of chef salad, grilled ham and cheese, and hot dog. The meal of the month for July will be a gyro with potato salad and apple pie. The next resident council meeting will be Thursday, July 18, 2024. Time meeting Adjourned: 3:03 PM (During this resident council, a meeting with 25 residents in attendance and a facility housing 150 residents, a single complaint or concern was not documented.) The facility's 5/9/24 Resident Council Meeting minutes showed 16 residents attended. The minutes showed, New Business: The Resident Council voted to change the alternative menu removing beef tacos and replacing them with chicken tacos. Old Business: the may meal of the month will be served for lunch on May 30th. Yogurt will return on 5/14. Residents would like to see a BLT sandwich offered every once in a while on the menu. The meal of the Month for June will be a combo BBQ ribs with BBQ chicken, corn on the cop, potato wedges, dinner roll, and banana cream pie. The next resident council meeting will be 6/20 at 2:00 pm in the penthouse. Time adjourned: 2:34 PM. On 7/17/24 at 9:50 AM, a resident council meeting was held as a part of the facility's Annual Certification Survey process. R71, R48, R75, R105, R74, and R24 attended this meeting. All residents, except R71, stated they attended meetings regularly, R105 stated she is the resident council president, R48 stated she is the vice president. All residents stated they voice numerous complaints at resident council meetings. R105 stated she had voiced concerns at the June 2024 resident council meeting regarding late medications, missing medications, and long wait times for call lights. R105 stated she has never been shown the resident council minutes following a meeting for her approval. All residents stated, when concerns are brought forward at resident council meetings, there is little or no follow-up at the next meeting regarding their concerns. All residents stated another issue that has been brought forward, with no resolution, is the downgraded television service. Resident stated the number of television channels has been cut in half and the residents were told there was nothing they could do as it was a corporate decision. R105 said, That never come back to us and tell us what they are doing about the concerns we bring up at the meeting. We never hear anything. I wish they would let us know so we know we are being heard. We all feel like it is very important that they come back to us with our concerns and they never do. R105 said, V26 Activities Director attends the meetings and takes the minutes. (The May and June 2024 resident council minutes do not show any of these concerns.) On 7/17/24 at 12:07 PM, V26 said, I set the agenda [for resident council meetings] and they follow that. I take the minutes at the meeting, no one wants to be secretary at the meeting. V26 stated she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145665 If continuation sheet Page 3 of 18 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 145665 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Care of Zion 2534 Elim Avenue Zion, IL 60099 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)

F 0565 Level of Harm - Minimal harm or potential for actual harm could not recall any specific concerns from the June 2024 meeting other than some possible dietary concerns. V26 said, The grievance process is important in acknowledging their concerns. It is important to follow up so the residents know we heard their concerns. I don't keep track if they follow up with the grievances from the meeting. If there was follow up from concerns, it should be on the minutes. If they have a concern about call lights it should be documented. Residents Affected - Some On 7/18/24 at 7:25 AM, V1 Administrator stated The [grievance] process is important for me so I know what is going on. It's important for the residents so they know they are being heard. Part of the process is going back to the residents and how we fixed the issue and so they know they were heard. The residents do have complaints at resident council. I don't know if their concerns at resident council should go through the grievance process but there should be follow up with the complaints and concerns. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145665 If continuation sheet Page 4 of 18 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 145665 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Care of Zion 2534 Elim Avenue Zion, IL 60099 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)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to ensure a resident's heels were off-loaded for 1 of 1 residents (R204) reviewed for wounds in the sample of 30. Residents Affected - Few The findings include: On 7/16/24 at 10:58 AM, R204 was laying in bed with gauze dressings intact to his bilateral feet and heels. R204 did not have any off-loading devices in place. On 7/16/24 at 11:15 AM, V5 CNA (Certified Nursing Assistant), V7 CNA, and V8 RN (Registered Nurse/MDS care plan coordinator) went into R204's room to provide care. R204's heels were resting on the bed; no off-loading boots or pillow in place to off-load heels. V5 CNA stated R204 had heel wounds and his heels should be off the bed. V5 told V7 they needed a pillow to get his heels up. V5 and V7 provided incontinence care for R204. When they were finished providing care they covered him with a sheet and put his bed in a low position. V5 and V7 did not off-load R204's heels. On 7/16/24 at 11:54 AM, V8 LPN (Licensed Practical Nurse) stated, R204's heels should be offloaded. V8 stated R204 has diabetic sores to his toes and heels but his heels should still be offloaded. On 7/17/24 at 9:44 AM, R204 was laying in bed on his back with his heels resting on the bed. R204 did not have any off-loading devices in place. The Point of Care Task documentation for R204 with a look back period of 14 days from 7/18/24 showed, Monitor - heel protectors (both feet) with no data found for applied, removed, resident not available, resident refused, or not applicable. The Wound Care Physician's Note dated 7/10/24 for R204 showed he had the following wounds: left first toe full thickness wound, left second toe full thickness wound, left foot full thickness wound, left heel full thickness wound, right first toe full thickness wound, right second toe full thickness wound, right toe (doesn't say what toe) full thickness wound, right heel full thickness wound, and left third toe full thickness wound. The recommendations for these wounds included pressure off-loading boot; off-load wound; reposition per facility protocol. All of the wounds were classified as diabetic wounds. The facility's Wound Care Guidelines policy (1/24/24) showed, resident may be properly positioned in bed using pillows or other supportive devices to help protect boney prominence areas susceptible to pressure. Off-load elbows and heels as needed. Elevate resident heels off the bed as indicated (e.g., place pillows under calf: not under ankles or use heel protector that offloads the heel from the bed surface) to raise heels off the bed, unless contraindicated due to medical condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145665 If continuation sheet Page 5 of 18 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 145665 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Care of Zion 2534 Elim Avenue Zion, IL 60099 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure nectar thick liquids were provided to a resident for 1 of 9 residents (R4) reviewed for safety in the sample of 30. The findings include: R4's face sheet printed on 7/18/24 showed diagnoses including but not limited to dementia with behaviors, schizoaffective disorder, kidney disease, and heart disease. R4's facility assessment dated [DATE] showed severe cognitive impairment and staff supervision for eating. R4's July 2024 order review report showed an active order for a regular diet, mechanical soft texture foods and nectar thick liquids. The same report showed active orders for aspiration precautions (potential to swallow or breath food, liquids, or stomach contents into the lungs). On 7/17/24 at 9:53 AM, R4 was lying in bed and alone in her room. R4's bedside table was over her and she was drinking a bottle of liquid nutritional supplement from a straw. A half empty cup of water was on the bedside table. A yellow dietary ticket was on the bedside table and showed aspiration precautions, general mechanical soft, nectar thick liquids. At 10:03 AM, V5 and V10 (Certified Nurse Aides) entered the room and preformed pericare for R4. V5 stated R4 eats all meals in her room and needs supervision. She has low cognition and needs cueing. V5 was questioned regarding the consistency of the drinks and stated neither were nectar thickened. V5 said R4 needs thickened liquids to keep her from aspirating. She has swallow issues and has been on the altered consistency for a long time. V5 stated she should not be drinking either one without staff supervision. On 7/17/24 at 10:18 AM, V9 (Registered Nurse) stated R4 is confused, has behaviors, and can be resistive to care. She needs mechanical soft foods and nectar thickened liquids to prevent swallow problems. V9 said R4 should never be drinking regular consistency liquids alone. On 7/18/24 at 9:45 AM, V2 (Director of Nurses) said any resident with aspiration precautions should be supervised with foods and liquids. Staff should be watching for coughing, pocketing foods, ensure the head of the bed is up, and assessing for changes in lung sounds. Residents with swallow problems have a high risk of choking, aspirating into the lungs, and developing breathing problems. V2 said it is not appropriate for R4 to be drinking regular water and bottled liquid nutritional drinks without supervision. R4's care plan showed a focus area related to: ASPIRATION PRECAUTIONS demonstrates some risk to potentially choke or aspirate food or liquids. This problem is related to general problems with chewing and/or swallowing . On 7/18/24 at 10:32 AM, V2 stated there was no facility policy related to aspiration precautions or swallowing problems available. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145665 If continuation sheet Page 6 of 18 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 145665 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Care of Zion 2534 Elim Avenue Zion, IL 60099 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on interview and record review the facility failed to ensure a resident's catheter drainage bag was kept below the level of the bladder, catheter tubing was free of obstruction, and catheter securement device was in place for 1 of 1 residents (R204) reviewed for catheters in the sample of 30. The findings include: On 7/16/24 at 10:58 AM, R204 was laying in bed on his back on top of the indwelling urinary catheter tubing. R204 did not have a sheet covering him and his hospital type gown was over to his left side. R204's incontinence brief was open on one side; his bilateral thighs were exposed and no catheter tubing securement device was in place. V7 LPN (Licensed Practical Nurse/MDS Care Plan Coordinator)was in the hallway outside R204's room and was asked to come into his room. V7 confirmed R204 did not have a device in place to secure R204's catheter. V7 stated they use the sticky devices and that the ones they use here are square. V7 stated the catheter secure devices they use at the facility don't stick as sell as the ones in the hospital. V7 checked R204's bed to see if the device had come off in his bed and it wasn't located. V7 stated she had seen a secure device on R204 a few days ago. V7 observed R204 laying on his catheter tubing. V7 stated R204 should not be laying on his catheter tubing because it should be free of any kinks so there is not any back flow of urine which can cause an infection. On 7/16/24 at 11:15 AM, V5 CNA (Certified Nursing Assistant), V6 CNA, and V7 LPN (Licensed Practical Nurse) went into R204's room to provide care. V7 went over to R204's right side of the bed, lifted the catheter drainage bag up, above the level of his bladder and placed it on the left side of his bed. V5 removed R204's soiled gown, had R204 turn to his left side while she rolled up the soiled linen under him and then placed clean sheet under half of the bed. V5 asked R204 to roll onto his back. V5 took some disposable wipes and wiped R204's groin; his catheter tubing was not cleaned. V5 had R204 turn onto his left side, took disposable wipes and cleaned his buttocks. R204 was incontinent of a large bowel movement. On 7/16/24 at 11:54 AM, V8 LPN (Licensed Practical Nurse) stated, a resident's catheter drainage bag should be lower that the bladder so the urine doesn't back flow which is painful and cause infection. The catheter tubing should be cleaned every shirt or when changing a resident. V8 stated if a resident was incontinent of stool then the catheter tubing should be cleaned. V8 stated a resident should not be laying on the catheter tubing because they don't want it to get plugged up or have back flow of urine which could cause an infection. V8 stated a secure device is used to hold catheter tubing in place so it doesn't get pulled out. On 7/17/24 at 9:57 AM, V3 RN (Registered Nurse/Infection Control Preventionist) stated, catheter drainage bags should be below the resident's waist so there isn't any backflow of urine. V3 stated the backflow of urine can cause a UTI (urinary tract infection) and/or urine retention. Catheter tubing should not have any kinks or obstruction. If that is present then it can cause backflow of urine and a UTI. V3 stated they use a secure catheter device to secure the tubing to prevent the tubing from getting pulled out. Staff know to put a new one on if the the old one has come off. The CNA's (Certified Nursing Assistants) provide catheter care every shift and empty the drainage bag every shift. If the resident has a bowel movement the CNA should do catheter care. The catheter tubing should be cleaned by taking an alcohol pad and wipe from the urinary meatus. They should wipe down and way from the urinary meatus. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145665 If continuation sheet Page 7 of 18 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 145665 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Care of Zion 2534 Elim Avenue Zion, IL 60099 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The MDS (Minimum Data Set) dated 6/16/24 for R204 showed he has moderate cognitive impairment; dependent for toileting hygiene. Urinary continence not rated; resident had a catheter. R204's Care Plan dated 6/28/24 showed, R204 is at risk for alteration of bowel and bladder functioning related to catheter use. Resident will show no signs and symptoms of urinary infection. Resident will remain free from catheter related trauma. Catheter care every shift and as needed. R204 has an indwelling urinary catheter. Please position catheter bag and tubing below the level of the bladder and away from entrance room door. Staff to check tubing for kinks and leaks. The Face Sheet dated 6/17/24 for R204 showed diagnoses including peripheral vascular disease, muscle wasting and atrophy, dysphagia, type 2 diabetes mellitus, hypertension, gout, generalized anxiety disorder, hypothyroidism, hyperlipidemia, paroxysmal atrial fibrillation, chronic kidney disease, and benign prostatic hyperplasia with lower urinary tract symptoms. The facility's Indwelling Catheter Policy (6/6/24) showed, a care plan for the use of the indwelling catheter will be made per policy. Indwelling catheter bag will always be positioned below the bladder region to prevent backflow if the catheter bag has no anti-backflow valve. The policy did not state to keep the catheter tubing free of kinks and/or obstruction. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145665 If continuation sheet Page 8 of 18 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 145665 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Care of Zion 2534 Elim Avenue Zion, IL 60099 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)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure an accurate weight was obtained on a resident (R92) showing a significant weight loss, failed to identify a significant weight gain for a resident (R46). These failures apply to 2 of 7 residents reviewed for nutrition in the sample of 30. Residents Affected - Few The findings include: 1) R92's electronic face sheet printed on 7/19/24 showed R92 has diagnoses including but not limited to Parkinson's disease, displaced fracture of left femur, hypertension, insomnia, major depressive disorder, personality disorder, alcohol abuse, and bipolar disorder. R92's weight log showed, 2/14/24 190.4lbs (pounds) 3/14/24 196lbs 4/5/24 194.8lbs 4/24/24 183.6lbs 6/11/24 169lbs 7/18/24 178.5lbs. R92's progress note dated 6/30/24 showed, RD (Registered Dietician) note secondary to weight. Resident receives a NAS (no added salt), regular diet with thin liquids. In addition resident receives Ensure TID (three times a day) for additional calories and protein. No reported issues tolerating the diet. PO (oral) intake is documented to be good/adequate with the resident eating 75% or more of most meals. Weight on 6/11 recorded at 169lbs. Weight on 4/24 recorded at 183lbs, a weight loss of 7.65% in 2 months and weight on 3/14/2024 recorded at 196lbs, a significant weight loss of 13.7% in 3 months. Question reasoning for weight loss with good PO intake and supplements TID. This writer will be in the facility tomorrow and will follow-up with the resident regarding weight loss. Will also discuss with staff getting another weight to determine accuracy of the current weight. Will follow-up. R92's care plan dated 2/16/24 showed, COMPROMISED NUTRITIONAL STATUS: (R92's) nutritional status is compromised due to: Malnourished, possible weight loss, need for mechanically altered diet related to wound healing .He had possible 9.6 lbs recent weight loss per his reported usual body weight compared to admit weight. Hospital weight is 2 lbs decreased compared to stated usual body weight; Resident claims he feels he had recent weight loss related to decreased PO intake; PO intake 50-75%, at meals, per nursing documentation; admitted on Mechanical soft diet with HTL (honey thickened liquids); Resident is edentulous .with recent weight loss, decreased mobility, decreased intake. 4/24/24: 6.3%, 12.4 lbs significant weight loss x 1 month and 5.7%, 11.2 lbs weight loss x 19 days . On 7/18/24 at 12:23PM, V17 (Dietician) and V18 (Dietary Consultant) stated, (R92) was reviewed on 6/30/24 by V17. V17 stated, The additional weight that I wanted completed during the week of 6/30/24 was not obtained from what it looks like. Usually, I will send my recommendations via e-mail to the administrative nursing staff so they can follow up on any reweights or new orders. I would assume that I sent the e-mail because I typically send it right after I'm done so I'm not sure why it was never obtained. I guess I forgot to follow up on it because I really thought it was a mistake with the weights. It wasn't a normal person who puts in weights, it's definitely not consistent with who is putting in the weights. The restorative manager is typically the one to oversee the restorative aides who are entering the weights. Sometimes the aides on the floor are entering them so it's kind of a team effort. It should trigger for the staff when they enter the weights that it's a significant change. We would automatically provide interventions while the reweigh is happening. I'm really not sure what happened in this case and why nothing was followed up on or implemented in the meantime. When residents have a significant weight gain, I would expect the staff to obtain a re-weigh as soon as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145665 If continuation sheet Page 9 of 18 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 145665 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Care of Zion 2534 Elim Avenue Zion, IL 60099 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)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few possible and then if it's still reading the same weight then the nurse should be assessing the resident for any edema or other possible reason for a significant weight gain. (R92) and (R46) should have both been re-weighed immediately to ensure accuracy of the weights and that was not done. We have a problem with the process of obtaining and entering weights that needs to be fixed. On 7/18/24 at 1:12PM, V2 (Director of Nursing) stated, Monthly weights are done by the restorative aides. The restorative aide is able to document the weights but if they are not able to then the restorative nurse will do the documentation. If the weight is being put in and it's out of the usual the restorative nurse should catch those but if they don't then the dietitian should be catching that. We typically have them reweigh if it's a significant change. Sometimes they will weight in the wheelchair one day and possibly standing or via lift scale so there is a difference there. There are a couple of staff members that sometimes get an email from the dietitian regarding weights. Most of the time, if I see one of those, I would ask the restorative nurse to do the weight. I typically like to go through restorative. The purpose of monthly weights is to give us a trend of weight loss or weight gain and to determine if there is a steady decline to catch the weight loss and see if the dietitian needs to assess. The facility's policy titled, Weights reviewed on 6/6/24 showed, It is the facility's policy to obtain resident's monthly weight unless otherwise ordered differently by the physician .3. The significant weight changes will be assessed and addressed by the IDT (Interdisciplinary Team) . 2) R46's electronic face sheet printed on 7/18/24 showed R46 has diagnoses including but not limited to schizophrenia, hypothyroidism, anemia, anxiety disorders, insomnia, dementia without behaviors, major depressive disorder, seizures, and osteomyelitis. R46's weight log showed, 5/4/24 151.4lbs 6/5/24 149.6lbs 6/10/24 169.6lbs. R46's progress notes dated 6/29/24 showed, .Current weight on 6/10/24 recorded at 169.6lbs but weight recorded on 6/5 recorded at 149.6lbs, a 20lbs weight gain in 5 days. Will ask staff to obtain a re-weight. Resident does have lymphedema to the left medial foot, and right thigh, may cause alteration in weight . No additional re-weight was present in R46's electronic medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145665 If continuation sheet Page 10 of 18 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 145665 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Care of Zion 2534 Elim Avenue Zion, IL 60099 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)

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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 obtain orders and assess a resident's dialysis site for 1 of 2 residents (R56) reviewed for dialysis. Residents Affected - Few The findings include: R56's electronic face sheet printed on 7/19/24 showed R56 has diagnoses including but not limited to hypertensive heart and chronic kidney disease, brief psychotic disorder, morbid obesity, congestive heart failure, end stage renal disease, dependence on renal dialysis, small b-cell lymphoma, non-Hodgkin's lymphoma, and malignant neoplasm of right eye. R56's facility assessment dated [DATE] showed R56 has no cognitive impairment. R56's physician's orders dated 6/21/24 showed, Permacath on right chest for hemodialysis. R56's physician's orders for July 2024 showed no orders for assessment of R56's permacath site. On 7/18/24 at 1:05PM, V15 (Registered Nurse) stated, We assess (R56's) dialysis site before and after dialysis. We should be checking it on non-dialysis days as well but there is no order for that so it's probably not getting done. We would assess per our policy but I don't see any orders or anything for consistent site assessments in (R56's) records. On 7/18/24 at 1:10PM, V16 (Licensed Practical Nurse) stated, We would assess a dialysis site every shift for a resident with a permacath & it would be documented like a physician's order under the area where we monitor for behaviors and things like that. R56's monitoring documentation was reviewed and showed no area for staff to be documenting or aware that they are to be assessing R56's permacath site. On 7/18/24 at 1:36PM, V2 (Director of Nursing) stated, Nurses should be checking to ensure the dressing is in place and the dialysis site is covered when a resident is coming back from dialysis. I don't know that there is a specific order for that in R56's chart but there should be otherwise the nurses will not know to do it. The facility's policy titled, Hemodialysis Policy reviewed 6/6/24 showed, It is the policy of the facility to ensure that appropriate care for residents on hemodialysis is provided by facility staff .1. The nurse must assess and record the condition of the hemodialysis site daily on the TAR (treatment administration record) or on any part of the resident's medical record . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145665 If continuation sheet Page 11 of 18 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 145665 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Care of Zion 2534 Elim Avenue Zion, IL 60099 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review the facility failed to administer medications in a timely manner leading to a missed dose of medication, and failed to follow manufacturer instructions for an inhaler medication. This applies to two residents (R143, and R146) outside the sample. The findings include: 1. R143's admission Record shows her diagnoses to include nontraumatic intracerebral hemorrhage, acute respiratory failure with hypoxia, dependence on respirator (ventilator) status, hypertension, and nonverbal. R143's MAR (Medication Administration Record) shows she has an order for Hydralazine 100 mg (milligrams) at 9:00 AM, 1:00 PM, and 5:00 PM, for hypertension. On 7/17/24 at 11:06 AM, V3 Nurse manager/ADON (Assistant Director of Nursing) approached V24 LPN (Licensed Practical Nurse) and asked what she could do to help her. V24 named R143's medications needed to be passed. V3 then called R143's doctor to inform her that Moore's first dose of hydralazine for the day had not yet been given and her second dose was soon due to be given and either the first or second dose would have to be missed. On 7/18/24 at 10:45 AM, V3 said, On 7/17/24 at about 9:00 AM, she asked V24 if she needed help and she said she did not, but later at 11:00 AM came to me and said she did need help. V3 said at that point AM medications are late so she called the NP (Nurse Practitioner) for orders on what to do. V3 said the NP said to give the Hydralazine 100 mg now and to skip the 1:00 PM dose. V3 said V24 should have contact her (V3) before the medications were late. V3 said the floor nurse should contact NP or Physician for orders on what to do. V3 said, she should have made a progress note about her calling the NP but she didn't, and will do a late entry note. V3 said R143 should have received her Hydralazine as ordered by the Physician. On 07/18/24 at 11:22 AM, V23 RN (Registered Nurse) said, if medications are running late she would ask the nurse manager to assist in passing. If meds (medications) are late then she would have to call a NP or Physician to see what they want to do especially if the medication is TID (3 times a day) or QID (4 Times a day). V23 said, never double up on meds automatically, and make sure to would report the issue to the next shift nurse. R143's MDS (Minimum Data Set) shows she is totally dependent on staff for all of her care. The facility's Medication Pass (Reviewed 6/6/24) Policy and Procedure shows the facility will adhere to all Federal and State regulations with medication pass procedures. 2. On 7/19/24 at 8:00 AM, V25 prepared and administered medications for R146. V25 provided R146 his fluticasone/salmeterol inhaler (an inhaled combination steroid/airway dilator medication for the treatment of asthma and/or chronic obstructive pulmonary disorder.) After R146 inhaled the medication, V25 did not instruct R146 to rinse out his mouth with water. V25 then exited the room and proceeded on to the next resident's medication. The facility provided instructions for the combination inhaler show after the medication is inhaled (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145665 If continuation sheet Page 12 of 18 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 145665 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Care of Zion 2534 Elim Avenue Zion, IL 60099 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)

F 0755 the patient should rinse out their mouth. Level of Harm - Minimal harm or potential for actual harm On 7/17/24 at 3:56 PM, V3 Assistant Director of Nursing stated steroids, including inhaled steroids can reduce the body's ability to fight of the infection. V3 stated the purpose of rinse and spit following an inhaled steroid is to prevent thrush, a fungal infection of the mouth. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145665 If continuation sheet Page 13 of 18 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 145665 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Care of Zion 2534 Elim Avenue Zion, IL 60099 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)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to offer a resident a dietary substitution for 1 of 1 resident (R147) reviewed for dietary preferences outside of the sample of 30. The findings include: 1. R147's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include malignant neoplasm of esophagus, dysphagia, malignant neoplasm of pharnyx, malignant neoplasm of head, face, and neck, anxiety disorder, and severe protein calorie malnutrition. R147's undated care plan showed, . ADL (Activities of Daily Living) Self Care Performance Deficit and Impaired mobility related to history malignant neoplasm of esophagus . Eating: I require supervision with set up with staff participation to eat . R147's undated care plan showed, Compromised nutritional status due to increased risk for dehydration and/or malnutrition . On 7/18/24 at 12:12 PM, V19 CNA (Certified Nursing Assistant) was sitting in a chair against the wall across from R147's end of bed. V19 was heard by this surveyor speaking to R147. V19 said, [R147] are you going to eat or not? . R147 was heard replying to V19 stating he was not hungry. V19 then said, It's because you don't like carrots, I know that's the issue. This surveyor went into R147's room and asked him why he was not eating, R147 said the food was stone cold and he did not like it. R147 said, They used to have gravy and potatoes which weren't too bad, but this is horrible. R147 pointed at his plate. This surveyor asked V19 CNA if the facility had substitutes they could be offering R147. V19 stated, No, he is on a pureed diet, there are no substitutions . He gets what is on the menu. On 7/18/24 at 1:12 PM, V2 DON (Director of Nursing) said, . I know he dislikes the puree food and sometimes he gets annoyed with that . I don't know him that well, but I know he is undergoing chemotherapy for cancer, so I know he has a lot of nausea. I know they do have some alternative foods but since he is on a pureed diet, I would probably have to reach out to the dietary manger and see. They should offer something that he can find palatable. Food is what they have to look forward to. It could be detrimental to him not to offer substitutes because he won't be getting the amount [of nutrients] he needs for the condition he is in. The facility's policy and procedure with revision date of 6/6/24 showed, . It is the facility's policy to comply with federal regulations in terms of food substitutes being offered to the resident . Food substitute will be offered and should be equivalent to the nutritional properties of the main meal . Last minute food substitutes will be accommodated and will be served promptly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145665 If continuation sheet Page 14 of 18 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 145665 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Care of Zion 2534 Elim Avenue Zion, IL 60099 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 7/16/24 at 10:58 AM, R204's door did not have any signage or container with PPE (personal protective equipment) outside of his room. R204 was laying on his back in bed. R204's bilateral feet had gauze dressings in place. R204 had an indwelling urinary catheter. V7 RN (Registered Nurse/MDS Care Plan Coordinator) was out in the hall and was asked what EBP (enhanced barrier precautions) were and when they were used. V7 stated EBP was for people with feeding tubes, wounds, and peripherally inserted central catheters. V7 was asked if EBP was put in place for residents with indwelling urinary catheters. V7 stated it would make sense to have them on EBP. V7 stated EBP is put in place to protect the resident from getting infected; it is more precautions when handling a resident. V7 stated R204 should have a sign for EBP on his door. Residents Affected - Some On 7/16/24 at 11:15 AM, V5 CNA, V6 CNA, and V7 RN went into R204's room to provide care. V5, V6, and V7 had gloves on but did not put any gowns on. V7 stated she was going to put a secure device on R204's leg and catheter tubing. V7 went over to his right side of the bed, lifted the catheter drainage bag up, and placed it on the left side of his bed. V7 put a catheter secure device on R204's left leg and around his catheter tubing. V5 removed R204's soiled gown, had him turn to his left side while she rolled up the soiled linen under him and then placed clean sheet under half of the bed. V5 then asked R204 to roll onto his back. V5 took some disposable wipes and wiped R204's groin. V5 had R204 turn onto his left side, took disposable wipes and cleaned his buttocks. R204 was incontinent of bowel movement. V5 changed her gloves. V5 put a clean sheet, chuck , and incontinence brief on R204 with V6 assisting her. R204 turned on his right side and V6 washed his back with a disposable wipe. They fastened R204's incontinence brief, put his gown on, and covered him with a sheet. V5 stated R204 should be on enhanced barrier precautions because he has a catheter. V5 stated EBP is put in place to prevent infection to R204 and us. V5 stated they should wear gowns and gloves when doing care. V6 stated there wasn't a sign on the door and that is how she knows if someone is on EBP. On 7/16/24 at 11:54 AM, V8 LPN (Licensed Practical Nurse) stated R204 was supposed to be on enhanced barrier precautions because he has a catheter and wounds. V8 stated when staff provide care for R204 they should wear gloves and gown. V8 stated R204 should have a sign on his door for EBP. On 7/17/24 at 9:57 AM, V3 RN (Registered Nurse)/Infection Control Preventionist) stated, enhanced barrier precautions (EBP) are precautions that are put in place for people with invasive devices like feeding tubes, catheters, dialysis access, and wounds, etc. EBP is put in place as a barrier to prevent them from getting an infection or transmitting an infection to someone else. Staff are educated on EBP as needed, daily, 1:1 and in monthly in-services. There should be a sign on the door for EBP rooms; 95 precent of our signs are in English and Spanish. Staff must wear a gown and gloves and use hand sanitizer before putting on PPE. The sign says what invasive and/or high contact activities that PPE should be worn for. If there is more than one resident in the room, an orange circle sticker is placed next to the resident's name to distinguish who needs EBP. I usually put-up signs or staff can put them up as well. The banner in the computer charting will tell if a resident is on contact or EHB and the reason for it. R204's Care Plan dated 6/28/24 showed he is on enhanced barrier precautions. Ensure that gown and gloves are used during high-contact resident care activities .that provide opportunities for transfer of MDROs (multidrug-resistant organism) to staff hands and clothing. The Physicians Orders for July 2017 for R204 showed orders for indwelling catheter change/care, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145665 If continuation sheet Page 15 of 18 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 145665 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Care of Zion 2534 Elim Avenue Zion, IL 60099 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some wound care to his right first toes, right second toe, right fifth toe, right heel, left first toe, left second toe, left third toe and left heel. The Face Sheet dated 6/17/24 for R204 showed diagnoses including peripheral vascular disease, muscle wasting and atrophy, dysphagia, type 2 diabetes mellitus, hypertension, gout, generalized anxiety disorder, hypothyroidism, hyperlipidemia, paroxysmal atrial fibrillation, chronic kidney disease, and benign prostatic hyperplasia with lower urinary tract symptoms. The facility's Enhanced Barrier Precaution policy (6/6/24) showed, The facility will use enhanced barrier precautions (EBP) to reduce transmission of multi-drug resistant organisms in the nursing home. EBP involves the use of gowns and gloves to reduce transmission of resistant organisms during high-contact resident care activities for residents known to be colonized or infected with XDROs (extensively drug resistant organisms) as well as residents with wounds and/or indwelling medical devices. EBP will be used for any resident in the facility with open wound/s (pressure ulcer, diabetic ulcer, venous ulcer, arterial ulcer, unhealed surgical wounds, etc.) whose drainage can be contained by dressing. Has indwelling medical devices .regardless of XDRO colonization status. EBP requires the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of XDRO's to staff hands and clothing. Examples of high-contact resident care activities requiring gown and glove use among residents that trigger EBP use include . d) providing hygiene, e) changing linens, f) changing briefs .g) device care or use .h) wound care. An EBP sign should be posted on the doors of each resident on EBP. 4. R45's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include chronic metabolic acidosis, end stage renal disease, restlessness and agitation, seizures, and acquired absence of right leg below the knee. R45's facility assessment dated [DATE] showed he has severe cognitive impairment and is dependent upon staff for all cares. On 7/17/24 at 10:25 AM, V19 CNA (Certified Nursing Assistant) put on a gown and gloves before entering R45's room. V19 entered R45's room pushing the mechanical lift into the room. V19 and V21 CNA transferred R45 from his broda chair into his bed. V19 wearing the same gloves she put on outside of the room began providing incontinence care for R45. V19 removed R45's soiled incontinence brief and set it on the end of his bed. V19 then wiped R45's buttocks with incontinence wipes. R45 was rolled back over and V19 used wipes to clean R45's perineal area. V19 placed the used wipes into the soiled brief and then using her gloved hands she wrapped the soiled incontinence brief up and placed it in the trash can. V19 then without changing her gloves applied a clean brief, removed R45's shirt and then removed her gloves. V19 did not perform hand hygiene and placed a clean gown on R45. V19 then touched R45's sheets, blankets, the remote to the bed, and the call light prior touching the bars of the mechanical lift and pushing it out of the room. The first hand hygiene done by V19 occurred after she left the room. On 7/18/24 at 1:12 PM, V2 DON (Director of Nursing) said hand hygiene should be done prior to entering the resident's room to provide care, after dealing with soiled items, and anytime moving from dirty to clean. V2 said she expects hands to be sanitized when removing gloves and prior to putting on new gloves. 5. On 7/17/24 at 8:48 AM, V24 Licensed Practical Nurse (LPN) entered R136's room for a blood sugar check. Posted on R136's door was a sign stating, Contact Isolation. V24 entered R136's room and she did not don a gown. V24 then touched R136's bed with her scrub pants then exited the room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145665 If continuation sheet Page 16 of 18 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 145665 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Care of Zion 2534 Elim Avenue Zion, IL 60099 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 7/17/24 at 3:56 PM, V3 Assistant Director of Nursing stated V24 should have donned a gown prior to entering R136's room. V3 stated R136 in contact isolation due to history of being colonized with drug resistant organisms. V3 said the purpose of wearing a gown is to prevent cross contamination of herself and other residents. The facility's Infection Prevention and Control policy (Revision 6/6/24) showed, Contact Precaution .Use of gown and gloves is necessary prior to room entry . Based on observation, interview, and record review the facility failed to wear appropriate personal protective equipment (PPE) for residents in isolation precautions, failed to remove PPE prior to exiting an isolation room, and failed to use gloves in a manner to prevent cross-contamination. This applies to 5 of 5 residents (R457, R98, R45, R204, R136) reviewed for isolation precautions in the total sample of 30. The findings include: 1) R457's electronic face sheet printed on 7/19/24 showed R457 has diagnoses including but not limited to anoxic brain damage, dependence on ventilator, chronic respiratory failure, and gastrostomy status. R457's facility assessment dated [DATE] showed R457 has severe cognitive impairment and is always incontinent of bowel and bladder. R457's physician's orders showed, 7/15/24 collect stool sample to rule out C-diff (Clostridium Difficile). R457's care plan dated 4/25/24 showed, Resident is on Enhanced Barrier Precautions due to tracheostomy and g-tube . Ensure that gown and gloves are used during high-contact resident care activities (like dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, Device care or use for those with central line, urinary catheter, feeding tube, tracheostomy/ventilator, and Wound care for any skin opening requiring a dressing) that provide opportunities for transfer of MDROs (Multi-Drug Resistant Organisms) to staff hands and clothing. On 7/17/24 at 10:26AM, Surveyor noted a sign on R457's door stating Enhanced Barrier Precautions. Everyone must clean their hands, including before entering and leaving the room. Providers and staff must also wear gloves and a gown for the following high contact activities .changing briefs or assisting with toileting. V11 and V12 (Certified Nursing Assistants) were in R457's room providing incontinence care to R457. V11 and V12 rolled R457's over on her left side and a large amount of loose and watery stool was noted. V11 and V12 had gloves on but no gown. V11 cleansed R457's buttocks and perineal area, took clean linens off of R457's bedside table and placed them on the bed without changing her soiled gloves. V11 then removed her soiled gloves and applied clean gloves without performing hand hygiene in between glove changes. V12 stated R457 is not on any isolation precautions so they only need to wear gloves for all cares. I just had to get stool sample due to R457 having increased loose stools so they think she might have some sort of infection. We should be putting hand sanitizer on in between glove changes, I guess we were just nervous. On 7/17/24 at 10:48AM, V4 (Wound Care Nurse) stated, (R457) is on enhanced barrier precautions. She has been since she came here because she has wounds, a tracheostomy, and a tube feeding. Staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145665 If continuation sheet Page 17 of 18 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 145665 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Care of Zion 2534 Elim Avenue Zion, IL 60099 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)

F 0880 should be wearing a gown and gloves for all cares with her. Level of Harm - Minimal harm or potential for actual harm On 7/18/24 at 1:36PM, V2 (Director of Nursing) stated, (R457) is on enhanced barrier precautions. All resident's that have increased risk of infections (wounds, trach/vent, g-tube, catheter, dialysis) are on enhanced barrier precautions. If staff are providing incontinence care to a resident on enhanced barrier precautions they should be wearing a gown and gloves at all times. Residents Affected - Some The facility's policy titled, Infection Prevention and Control revised on 6/6/24 showed, The facility has established a policy to Identify, Record, Investigate, Control, Test, and Prevent infections in the facility .5. Enhanced barrier precautions-an infection control intervention designed to reduce transmission of MDRO's (Multi-Drug Resistant Organisms) .a. involves the use of gloves and gowns during high contact resident activities for residents infected or colonized with MDRO's as well as residents with wounds and/or indwelling medical devices. 2) R98's electronic face sheet printed on 7/19/24 showed R98 has diagnoses including schizophrenia, carrier of carbapenem-resistant enterobacterales, dementia with agitation, pneumonia, tracheostomy status, and altered mental status. R98's physician's orders dated 6/5/24 showed, Contact isolation precautions: history of carbapenem resistant acinetobacter baumanni in sputum . On 7/17/24 at 9:56AM, R98's door had a sign showing, Contact Precautions. V14 (Housekeeper) walked out of R98's room with gloves, gown, and surgical mask on. V14 then walked around the corner in front of another resident's room to obtain a wet floor sign to put in front of R98's door. V14 then removed his personal protective equipment (PPE) and threw it in the garbage on his housekeeping cart. V14 stated staff are supposed to take PPE off before we leave the room so we don't spread any illnesses. I wasn't even thinking when I walked down the hall with it on. I don't feel well today so I am a little disoriented. On 7/18/24 at 1:36PM, V2 (Director of Nursing) stated, Personal protective equipment should not be worn out of an isolation room because staff could spread the infection to other areas of the building and that defeats the purpose of isolation. The facility's policy titled, Infection Prevention and Control revised on 6/6/24 showed, The facility has established a policy to Identify, Record, Investigate, Control, Test, and Prevent infections in the facility .2. Contact Precaution-intended to prevent transmission of infectious agents spread by direct or indirect contact with patient or the environment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145665 If continuation sheet Page 18 of 18