Alpine Care of Evanston

Inspectors wroteBased on interviews and record reviews, the facility failed to follow its mechanical lift policy by not using a mechanical lift for residents who are too heavy to lift or cannot assist with a transfer. This failure resulted in a metatarsal fracture in 1 of 3 residents (R2) reviewed for transfer and injury in a sample of 4.

Inspectors wroteBased on interview and record review the facility failed to implement facility abuse policy post resident to resident physical altercation. This failure affected one (R2) of three residents reviewed for abuse.

Inspectors wroteBased on interviews and record review, the facility failed to ensure appropriate monitoring and supervision to a resident with known fall risk and impaired safety awareness to prevent accident hazards for 1 (R1) of 3 residents reviewed for supervision needs in the sample of 3.

Inspectors wroteBased on interview and record review, the facility failed to ensure that 1 of 3 residents (R1) was treated with dignity and respect during care interactions and administrative care plan meetings reviewed for dignity from the sample of 3. R1 is a [AGE] year-old with diagnoses including but not limited to Meniere's Disease, PTSD, and Acute Metabolic Acidosis. R1's MDS dated [DATE] section C for cognition shows R1 with a BIMS (Brief Interview for Mental Status) of 15 demonstrating cognitively intact. On 01/09/2026, R1 reported that V14 LPN slammed medications onto her table and said a profanity while giving her her medications. The resident subsequently overheard the nurse refer to her as a f***ing problem. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain order for usage of oxygen, ensure oxygen tubing are label on date when it was changed, and oxygen humidifier water bottle are not emptied. This deficiency affects all four residents (R3, R9, R85 and R96) in the sample of 20 reviewed for Oxygen management.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident medications were appropriately stored. This deficiency has to potential to affect all 5 residents (R7, R32, R49, R60, R74) reviewed for medication storage in a sample of 20. Findings Include:On 12/2/25 at 11:30AM, Observed V7 Wound Care Nurse (WCN), V21 Wound Tech, and V22 CNA (Certified Nurse Assistant) performed wound care to R7. Observed the following medications at bedside: Ketoconazole 2% cream, Zinc Oxide 4%, Triamcinolone 0.1% ointment and Mupirocin ointment 2%. V7 WCN that treatment medications should not be allowed at bedside unless ordered by physician but R7 requested his medications at bedside. She said that R7's son also brought medications from home. R7 said that he has the CNA apply those medications after incontinence to his buttocks. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that call light is placed within reach of resident who can use it all times. This deficiency affects one (R7) of three residents in the sample of 20 reviewed for Resident's accommodation of needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident was out of bed when requested for 1 of 4 residents (R18) in a sample of 20 reviewed for self-determination.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure an indwelling urinary catheter was placed below the waist for 1 resident's (R77) and failed to follow physician order for indwelling catheter size usage and failed to empty the urinary drainage bag every shift and as needed for 1 resident (R7) of 4 reviewed for urinary catheter in a sample of 20.

Inspectors wroteNumber of residents sampled:1Number of residents cited:1Based on observation, interview, and record review the facility failed to ensure enteral (tube) feeding management was implemented with medication administration affecting 1 of 1 (R85) resident reviewed for enteral feeding management in a sample of 20. Findings Include:On 12/3/2025 at 8:15 AM, V19 (Registered Nurse) administered one medication via enteral tube for R19 without checking tube feeding (TF) placement prior to administration. V19 stated she did not check for placement, but TF should be checked for placement prior to medication administration using pH strip or by aspiration. TF site was covered with clean dry dressing; there was no other placement confirmation identified. TF bottle was hanging and infusing at 50ml/hr, container did not have a visible start time. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to use appropriate infection control practices during medication administration. The facility also failed to obtain an order for EBP (Enhanced barrier precaution), place signage and set up for resident with surgical drainage tube on left inner thigh. This deficiency affects two (R89 and R96) in the sample of 20 reviewed for Infection Control Program.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure to update facility's daily nurse staffing information form posted at the front desk. This failure has the potential to affect 92 residents receiving care in the facility.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy in alerting a resident's responsible party of a change in condition for weight loss and new identified wound. This affected one resident (R1) of three residents reviewed for notification of change in condition.

Inspectors wroteBased on interview and record review the facility failed to assess newly identified wound. The facility also failed to notify physician and obtain wound care treatment. This deficiency affects one (R1) of two residents reviewed for Wound/Pressure Ulcer Prevention and management.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident care areas were maintained in a clean, safe, and homelike condition by failing to ensure resident's rooms were clean, failing to adequately clean resident's care equipment after use and stored in a clean condition, and failing to keep resident's room furniture free of damage. These failures apply to six of six residents (R5, R10, R60, R62, R81, and R88) reviewed for environment.

Inspectors wroteBased on interview and record review, the facility failed to provide effective fall interventions and adequate supervision for a resident while smoking. This failure applied to one (R21) of one resident reviewed for falls.

Inspectors wroteBased on interviews and records review, the facility failed to follow their policy to ensure a resident was free from abuse by one staff member being physically abusive toward one resident (R1), out of seven residents reviewed. This failure resulted in R1 experiencing emotional trauma.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their identified offender policy by not complying with state regulations in performing criminal background checks within 24 hours of the admission of a new resident and failed to schedule a fingerprint-based criminal history record inquiry with 72 hours of receiving the initial criminal background results for 4 (R8, R12, R35, R67) of 5 residents reviewed for identified offenders. This failure has the potential to affect the safety and well-being of all 89 residents that currently reside in the facility.

Inspectors wroteBased on interview and record review, the facility staff failed to recognize a resident was experiencing an opioid overdose and failed to administer Narcan (opioid reversal agent) for a resident with a known history of substance abuse who was currently on opioid pain medication as well as Methadone; the facility failed to have protocols in place were in accordance with recommendations from SAMHSA (Substance Abuse and Mental Health Services Administration). This failure applied to one (R3) of one resident reviewed for overdose and resulted in R3 being emergently transferred to local hospital due to being found unresponsive and requiring administration of opioid reversal agent (Narcan). The Immediate Jeopardy began on 6/13/23 when R3 overdosed while in the facility and V7 (RN) failed to identify R3 was experiencing an overdose and failed to administer opioid overdose reversal agent. [...]

Inspectors wroteBased on interview and record review, the facility failed to have a comprehensive care plan upon admission that included effective interventions to address history and risk of substance abuse for a resident with a history of substance use disorder. This failure applied to one (R3) of four residents reviewed for comprehensive care plans and resulted in R3 having an overdose while in the facility with no related interventions in place; the facility subsequently failed to update R3's plan of care to include interventions for when substance use is suspected or identified upon R3's return to the facility after being hospitalized for overdose.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain resident medical records in accordance with accepted professional standards and practices by not having complete and readily accessible records available for healthcare oversight activities which included administration of resident medication administration. This failure applied to one of one (R3) resident reviewed for medical records.