Inspection·August 13, 2025

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 ensure residents who require staff assist were provided incontinence care and facial grooming in a timely manner. This applies to 3 of 33 residents (R9, R90 & R85) reviewed for activities of daily living (ADLs) in the sample of 33. The findings include: Residents Affected - Few 1. On 8/11/25 at 9:48 AM, R9 was lying in bed. She was partially covered with a sheet. Her bed pad was under her feet instead of her buttocks. The bed pad had a wet, yellow circle where her feet were resting. The bottom sheet also had a wet, yellow circle under her buttocks. At 11:26 AM, R9 was still resting in the same position in her bed. She was still laying in a wet, yellow circle. There was a strong urine odor. At 12:14 PM, V9 4th floor nursing supervisor was feeding R9 in bed. She remained in the same position in bed. V9 4th floor nursing supervisor covered R9 with a blanket and fed her lunch. R9 was still lying in a urine saturated bed. At 12:32 PM, V10 and V11 Certified Nursing Assistants (CNA) changed R9. R9 had wet through her disposable brief, the bed pad and onto the bottom sheet. V10 CNA stated, she was taking care of R9 as her CNA. When asked, if R9 was changed this AM, she stated, it's hard, she be fighting. R9 did not fight the CNAs when they changed her at 12:32 PM. On 8/13/25 at 11:26 AM, V2 Director of Nursing stated, R9 can not verbalize her needs so she is a check and change. She should be checked and changed every 2 hours and as needed. R9's urinary continence task did not show she was changed at all on 8/11/25. The task list shows, she was last changed on 8/10/25 at 8:03 PM. R9's restorative section GG dated 2/19/25 shows, she requires partial/moderate assistance with toileting hygiene. The assessment has not been updated since. R9's electronic medical record shows, she was re-admitted to hospice on 6/9/25. 2. R85's facility assessment dated [DATE] documents R85 has no cognitive impairment (BIMS of 15.) The same assessment show R85 is dependent on staff for toileting, R85 is always incontinent of bladder and bowel functions and R85 has no behaviors of rejection of care. On 8/11/25 at 10:45 AM, R85 said she has MS (multiple sclerosis) and she need two (2) staff to toilet her. R85 said she wears two incontinent pads because no one changes her after she gets up in the morning. Once I'm up at around 10: 30 AM, I am up until 7:30pm, trying to find someone to change me is hard, they say they are busy or they have no one to help them to change me, so I just decided to have 2 pads, a pad beneath me on chair in case my urine leaks due to not being changed. R85 said she would like to be changed at least once after she gets up. On 8/12/25 at 1PM V18 (Certified Nursing Assistant-CNA) said R85 wears 2 pads or double briefs. R85 also seats with a pad under her because she does not want to be wet in her chair. V18 (CNA) said she toilets R85 when she was working but she cannot speak for other staff or on PM shift. On 8/13/25 at 10am, V12 (3rd floor Nurse Supervisor) and V2 (Director of Nursing) said they spoke to R85 yesterday and R85 said the same thing, that R85 was not toileted when she ask staff to toilet her. V12 and V2 both said that starting today, they made a schedule with the agreement of R85. After R85 gets up, staff has to toilet R85 at around 1:30 PM and between 8-9:30 PM. R85's careplan dated 7/1/25 show, R85 has ADL Self Care Performance Deficit and Impaired Mobility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145665 If continuation sheet Page 2 of 6 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 08/13/2025 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)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few r/t MS,. morbid severe obesity, slurred speech, diplopia, contracture- left knee, pain in left knee,. peripheral autonomic neuropathy, neuromuscular dysfunction of bladder, vitamin D deficiency, DVT with intervention of assist resident as needed : I am Dependent with staff with Toilet Hygiene. The facility Policy on incontinence care dated 6/30/25 show it is the policy to provide perineal care to ensure cleanliness and comfort for the resident to prevent infection and skin irritations and to observe the resident skin condition 3. R90's Face Sheet printed on 8/11/25 showed she admitted to the facility on [DATE]. The same document showed she was a [AGE] year-old female and diagnosed with severe intellectual disabilities, tracheostomy, and dependent on a ventilator. On 08/11/2025 at 10:08 AM, R90 was in bed. R90 had facial hair. The facial hair was located on R90's top lip area and continued around to her chin. The facial hair was about 1/8 to 1/4 inch long and could be visible half way across the room. On 08/11/2025 at 1:42 PM, V7 (R90's Family Member/Guardian) said R90 was nonverbal and dependent on staff for activities of daily living (ADL). V7 said R90 had long facial hair and needed to be shaved. On 08/11/2025 at 12:54 PM, V8 (Certified Nursing Assistant) said she was familiar with R90. V8 said R90 was nonverbal, dependent on staff for ADL, and did not refuse care. A facility assessment done on 07/31/2025 showed R90 was dependent on staff for shaving and did not reject care. R90's Behavior Task documentation from admission [DATE]) to present (8/12/25) did not indicate R90 refused care. R90's Care Plan with an initiated date of 7/28/25 showed she required assistance with ADLs. The facility's General Care policy with a revised date of 6/30/25 showed it is the facility's policy to care for every resident to meet their needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145665 If continuation sheet Page 3 of 6 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 08/13/2025 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review the facility failed to ensure a medication refrigerator was maintained in the acceptable temperature range for 4 of 4 residents (R18, R73, R34 and R143) reviewed for medication storage in the sample of 33.The findings include:On 8/12/25 at 9:10 AM, the surveyor and V16 (Licensed Practical Nurse) checked the 3rd floor medication refrigerator. The medication refrigerator felt warm. The thermometer inside the medication refrigerator showed a temperature of 54 degrees Fahrenheit (F). V16 closed the refrigerator and waited for approximately 25 minutes. The medication refrigerator was again checked, the thermometer inside now showed a temperature of 60 degrees F. V16 said the medication refrigerator should be in the 40's degrees (F) to maintain effectiveness of the medications. Inside the medication refrigerator was R18's unopened Humalog Lispro quick pen, (insulin pen), R73's unopened Humalog quick pen (insulin pen), R34's eye drops of Latanoprost Ophthalmic Solution 0.005 %, and R143's Dulaglutide Subcutaneous Solution Auto-injector 1.5 MG/0.5ML (Trulicity.)On 8/12/25 at 9:35 AM V12 (3rd floor Supervisor) said unopened insulin pen should be stored at a temperature of 36 to 46 degrees (F). V12 also said the eye drops and the Trulicity should also be within that range 36-46 degree F. V12 said we will replace the refrigerator as soon as possible. V12 said she will also check the medications inside the medication refrigerator affected. On 8/12/25 at 10:15 am, V17 (Maintenance) said he had to replace the medication refrigerator; the refrigerator was not functioning (not cooling) due to too much ice buildup. V17 said he had provided a new refrigerator now for the medication room.A document entitled Temperature log provided by V2 (DON), showed the Refrigerator Medication temperature must be kept on 36-46 digress F.The Facility Policy on Medication Storage dated 7/2/25 show It is the facility's policy to comply with Federal Regulations in storage labeling and disposal of medications. Event ID: Facility ID: 145665 If continuation sheet Page 4 of 6 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 08/13/2025 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)

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, interview, and record review the facility failed to serve a resident their preferred meal portion/size for 1 of 33 residents (R10) reviewed for food preferences in the sample of 33.The findings include:On 08/11/2025 at 10:26 AM, R10 said he was always hungry after meals. R10 said he was to receive double portions of food, however he was not getting double portions of food. R10's Order Summary Report dated 08/11/25 showed R10 was to get double portions of food.On 08/11/2025 at 12:02 PM, R10 was in his room eating. The serving size of his meal appeared to be the same size as a regular meal. The meal ticket on R10's tray did not indicate R10 was to get double portions. On 08/11/2015 at 12:30 PM, V3 (Food Service Manager) said if a resident was to get double portions it would be listed on the meal ticket and that is how the kitchen would know to serve double portions of food. On 08/12/2025 at 10:33 AM, V4 (Dietitian) said R10 was to receive double portions as it was R10's preference. V4 stated R10 reported he was hungry after meals so double portions were ordered. V4 said the double portions were not added as a weight management intervention. Event ID: Facility ID: 145665 If continuation sheet Page 5 of 6 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 08/13/2025 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure staff wore the required personal protective equipment (PPE) when entering a COVID-19 isolation room for 1 of 1 residents (R21) reviewed for infection control in the sample of 33. The findings include:On 08/11/2025 at 10:30 AM, there was a sign on R21's door. The sign indicated R21 was on isolation. The sign indicated everyone that entered the room was to wear the following PPE: a N-95 mask, gloves, isolation gown, and eye protection. On 08/11/2025 at 10:35 AM, R21 was in her room and V5 (Certified Nursing Assistant) entered R21's room with linens. V5 had on PPE however she did not have on any eye protection.On 08/11/2025 at 10:45 AM, V5 exited R21's room with a clear bag of what appeared to be dirty linens. On 08/12/2025 at 10:58 AM, V6 (Infection Control Nurse) said R21 was on isolation for COVID-19. V6 said staff should wear a N-95 mask, gloves, isolation gown, and eye protection when entering R21's room. R21's Order Summary Report dated 8/12/25 showed an order to maintain at all times strict contact and droplet isolation due to active COVID-19 infection.R21's Care Plan with an initiated date of 08/05/25 showed R21 required isolation for COVID-19. Listed under interventions was to use appropriate PPE. The facility's Preventing and Controlling Acute Respiratory Illness Outbreaks in Skilled Nursing Facilities and Other Facilities Providing Skilled Care policy with a revised date of 07/16/25 showed required PPE for COVID-19 isolation included eye protection. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145665 If continuation sheet Page 6 of 6