F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to notify a resident's representative of a
significant change of condition. This applies to 1 of 3 (R1) residents reviewed for notification in the sample
of 3.
The findings include:
R1's face sheet shows she is a [AGE] year old female with diagnoses including chronic respiratory failure
with hypercapnia, candidiasis, congestive heart failure, type 2 diabetes, pulmonary hypertension, chronic
kidney disease stage 3, lymphedema and tracheostomy status. R1's face sheet shows V11 is listed as
responsible party/emergency contact #1 V12 (R1's daughter) is listed as emergency contact #2.
On 12/17/24 at 9:29 AM, R1 was observed lying in bed with a tracheostomy in place. R1 said she came
back from the hospital recently and does not recall being on a ventilator while at the facility before going to
the hospital. R1 said her family was upset the staff did not notify them of her condition change.
On 12/17/24 at 12:30 PM, V4 (Registered Nurse-RN) said on 12/4/24, V8 (Respiratory Therapist-RT)
notified him her oxygen levels were low. He notified the nurse practitioner and orders were received for a
breathing treatment and if not resolved place R1 on a mechanical ventilator to help her breathe. R1 was
placed on a mechanical ventilator to help her breathe and maintain her oxygen levels. The family was upset
and worried the next day when they saw R1 on the mechanical ventilator and were not notified. V4 said he
did not notify the emergency contact because, R1 is alert and oriented and there was no change in her
cognition.
On 12/17/24 at 1:00 PM, V11 (R1's spouse) said he was not notified R1 was placed on a mechanical
ventilator until the next day when he came to visit and saw her on the ventilator. V12 (R1's daughter) said
she too was not notified of R1 being placed on the ventilator to help her breathe.
On 12/17/24 at 2:18 PM, V8 (RT) said on 12/4/24, R1 was very lethargic she checked her oxygen levels,
and they were in the 70's. She provided respiratory treatment and interventions to relieve her respiratory
distress but could not maintain R1's oxygen saturation above 90%. R1 was then placed on a mechanical
ventilator. When a resident is placed on a mechanical ventilator it is an emergent situation, nursing should
notify the family and the physician of the residents change in condition.
On 12/17/24 at 12:08 PM, V2 (DON) said V12 (R1's daughter) was asking why R1 was placed on the
(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:
145665
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
12/17/2024
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 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
ventilator and why no one was notified about her being placed on the ventilator. At the time R1 was
agreeable to be placed on the ventilator. It's up to R1 if she wanted her emergency contact notified of her
condition change.
R1's nurse note dated 12/5/24 documents Change of Condition, (R1's) oxygen saturation was dropping to
77%, as per RT. Breathing treatment and ambu bag with 40% concentration initiated. RT suctioned copious
amounts of thick secretions .NP (Nurse Practitioner) was notified and orders received to connect (R1) onto
a mechanical ventilator.
The facility's Notification for Change of Condition Policy revised 2024 states, The facility will provide care to
residents and provide notification of resident change in status. The facility must immediately inform the
resident; consult with the resident's physical; and if known, notify the resident's legal representative or an
interested family member when there is .a significant change in the resident's physical, mental or
psychosocial status (i.e. deterioration in health .), a need to alter treatment significantly .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145665
If continuation sheet
Page 2 of 2
