Inspection·August 8, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to assess a surgical wound and change the dressing as ordered for13 days. This failure resulted in R2 developing an infection in the left knee surgical wound requiring hospitalization and surgery on 6/3/25. This applies to 1 of 3 residents (R2) reviewed for surgical wounds in the sample of 5.The findings include: R2's Physician's Order Sheet dated August 8, 2025 shows that she was admitted to the facility on [DATE] with diagnoses including Anxiety Disorder, Dementia and History of Falling. This document also shows orders for: Left Leg non-removeable dressing every day shift for wound care and an appointment scheduled with V6 (Orthopedic Physician) on 6/18/25. R2's admission assessment dated [DATE] states, left lower leg- cast.R2's Hospital Discharge Instructions dated 5/20/25 show an order for Dressing change every 3-5 days and as needed. Instructions: Place sheet of Xerofoam, 4x4s then Kerlix. Ace wrap from ankle to thigh. Then place splint to maintain leg extension. Then wrap from ankle to thigh again with another ace wrap to hold the splint.On 8/8/25 at 10:30AM V5 (LPN- Wound Care) stated, She came in with a few wounds on the legs and then the surgical on the (Left) knee.When she came here she had a hard cast on and as far as I know it was not removeable It was wrapped with an Ace wrap but it was a hard cast At least I thought it was a hard cast. I was not here the day they removed it. I may have overlooked the order for the wound care when she came in. We get a lot of (V6's- Orthopedic Physician) patients and their orders say 1-2 weeks but then we call to make an appointment and we can't get in for about a month. I have talked to him a few times since the wound infection but I don't think I talked to him before. He used to be very hard to get a hold of but now I have his direct number so I can reach him a lot easier. When (R2) came in I'm sure I talked to the primary care physician and told him she had a non removeable cast and he just said ok. On 8/8/25 at 12:06PM V4 (Registered Nurse) stated, I did the admission assessment for her. I checked the cast and I notified wound care. I don't remember seeing an order for wound care. I report to wound care and then they take over the orders from there. I don't recall her having any specific problems with the cast. She kept asking for Norco - very regularly. She did not complain of specific pain from the cast, just pain in general.On 8/8/25 at 3:00PM V10 (Wound Nurse Practitioner) stated, That info came from the patient. She was alert and oriented so I listened to what she said. (To not remove the dressing until she sees the ortho). At the time I saw her I did not have access to the orders and that is what the patient verbalized to me. I looked through the hospital record later before I finalized my note but I must have overlooked the order for treatment. In my experience I have seen physician's leave the dressing in place until the patient is seen in the office. Hers was a splint with batting, it was able to be removed but we had orders to leave it in place. 1 month would be a long time to leave the dressing in place but I go by what the surgeon says.R2's Progress Notes dated 6/3/25 state, During wound care around 10:50 AM, a putrid odor was noted coming from the residents non-removable cast. Wound care nurse opened the cast and noted bluish black tissue with Residents Affected - Few (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 08/08/2025 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)