Inspection·September 22, 2025

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to initiate discharge upon a resident's request for one (R1) of three residents reviewed for discharge planning in the sample of 3.The findings include:R1's facility assessment dated [DATE] show, R1 has no cognitive impairment with a BIMS of 15.On 9/22/25 at 9:45 AM R1 was in bed alert, R1 said he was here for therapy. R1 had been wanting to either go home or transfer to another facility in Kenosha Wisconsin near his family. R1 said he has spoken to different lady Social Workers. All I got as a response was we will look into it or will let you know or will get back to you. R1 said up to now, no one had gotten back to him or let him know of what was going on with his request to go home or to transfer to another facility. R1 said he can afford to pay a 24-hour nursing care at home (R1 was private pay). R1 said his home has a ramp and walk in shower. If he cannot go home yet and need to transfer to another facility, no one had updated him with what facilities he can go to in Wisconsin. A Social Service document dated 9/8/25 by V6 (Social Worker) show: On 9/6/25, this writer met with the resident (R1) after he requested to speak with Social Services.the resident requested information regarding transferring to a different facility in Wisconsin. This writer provided supportive listening and informed the resident that follow-up will be arranged to address his concerns and discuss available options.On 9/22/25 at 11:46 AM, V6 (Social Service) said she was at the facility last Saturday 9/6/25. V6 said she was informed that R1 requested to talk to a Social Worker, so she went to spoke to R1. R1 verbalized to her that R1 wanted to transfer to another facility, however R1 felt no one was assisting him to do this. V6 said she documented their conversation in R1's progress notes but did not do anything further. V6 said she did not do any follow up regarding R1's wish to discharge to another facility, also she did not do any referrals to other facilities in Wisconsin. V6 said one of the Social Workers at the facility but mainly assigned to 4th floor residents. V6 said she can also work with residents from another floor. R1 was on 2nd floor so she relayed R1's desire to discharge to V7. (Social Service Director)On 9/22/25 at 10 AM, V7 said she was the Social Service Director but took over as the Social Worker on 2nd floor beginning of August 2025 after the previous 2nd floor Social Worker left the facility. V7 said there has been no referrals for R1 made up to now to other facilities (approximately 2 weeks) after R1 had verbalized his desire to transfer to another facility or discharged . V7 said V6 (Social Worker on 4th floor) could have started referrals. All the Social Workers work together in this facility. V7 said as of today, (9/22/25) referrals will be sent and R1's family will be called to discuss R1's plan of discharge. Discharge planning should start on the day of admit.The facility policy on Discharge planning and instructions dated 6/30/25 show, facility to conduct proper discharge planning for all residents. Discharge planning shall be initiated by the facility and resident's admission and reevaluated quarterly. Social services shall evaluate its residents discharge planning potential in collaboration with facilities interdisciplinary team. Social services shall facilitate (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 09/22/2025 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)