Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alpine Care Of Zion during CMS and state inspections, most recent first.
Two cognitively intact residents with known personality conflicts and behavioral issues, including one with significant psychiatric diagnoses and another with substance use and anxiety disorders, were allowed to continue unsupervised interactions that escalated into a physical altercation on an elevator. One resident in a wheelchair rolled onto another resident’s foot and walker, cornering him and refusing to move, requiring an activity aide to intervene so he could exit. The wheelchair user later alleged she had been struck with a walker and injured, while the other resident reported foot pain from being run over; hospital records documented contusions for the alleging resident, and an x-ray for the other resident was negative. Facility leadership and social services acknowledged prior incidents and ongoing conflict between the two residents, yet effective measures to prevent further abusive interactions were not implemented.
Two residents who were incontinent and dependent on staff for ADLs and toileting were not changed in a timely manner, resulting in briefs that were completely saturated with foul-smelling urine and, in one case, skin indentations, redness, and a dried ring of urine on the bed linens. CNAs reported they did not know when the residents were last changed and acknowledged that residents are supposed to be checked and changed at least every two hours, while the DON and the facility’s incontinence policy also required two-hourly rounds and perineal care as needed, which were not carried out as planned.
A CNA provided incontinence care to a resident and, after removing a urine-saturated brief and cleansing the perineal area, failed to change gloves or perform hand hygiene before handling clean linens, applying a clean brief and gown, repositioning the resident, adjusting pillows, tidying the overbed table, and removing garbage and soiled linens. The DON later confirmed that facility policy requires changing gloves after contact with soiled briefs and linens and performing hand hygiene, which was not followed in this observed episode of care.
A resident with multiple risk factors for skin breakdown reported pain and a sore on the right buttock, but staff failed to assess, document, and implement ordered treatments for a facility-acquired pressure ulcer. Despite an order for barrier cream, no treatment was provided, and the wound nurse was unaware of the open area until the survey. Required documentation and interventions were not completed according to facility policy.
Multiple residents reported that their bathrooms lacked hand soap for an extended period, despite repeated requests to staff. Staff confirmed that soap had been removed due to a recall and was not replaced in a timely manner, leaving residents without the means to perform proper hand hygiene as required by facility policy.
A resident who was cognitively intact and seeking discharge or transfer closer to family repeatedly requested assistance from social services but did not receive follow-up or referrals. Despite being able to pay for 24-hour care at home and having a suitable home environment, the resident's discharge planning was not initiated as required by facility policy.
Surveyors found that a medication refrigerator on one unit was warm and reading 54–60°F, despite facility requirements that refrigerated medications be stored between 36–46°F. At the time of the observation, the refrigerator contained unopened Humalog insulin pens for two residents, Latanoprost ophthalmic solution for another resident, and a Trulicity auto-injector for a fourth resident. An LPN and the unit supervisor confirmed that these medications should be kept within the 36–46°F range, and maintenance later reported the refrigerator was not cooling properly due to ice buildup, resulting in medications being stored outside the acceptable temperature range.
A resident with dementia, poor trunk control, impulsive behavior, and non-compliance with transfer status was observed in a wheelchair with a lap restraint in place, and records showed the restraint had been in continuous use with routine checks documented. The only documented restraint assessment was from the prior year, despite facility policy requiring at least quarterly assessment and potential reduction. Nursing staff reported that the restraint was used for trunk support and fall risk but acknowledged there were no current restraint or restraint-reduction assessments, and the resident’s MDS inaccurately documented that no physical restraints were used.
A deficiency was cited for failure to provide timely incontinence care and grooming to dependent residents. One nonverbal hospice resident was observed lying for several hours in urine-soaked linens, with strong urine odor present, and records showed no incontinence care documented that day despite a check-and-change schedule. Another resident with MS, morbid obesity, and neuromuscular bladder dysfunction, fully dependent for toileting, reported wearing double pads and sitting on an extra pad because staff did not change her after she got up and often told her they were too busy or lacked help when she requested toileting. A ventilator-dependent resident with severe intellectual disabilities, fully dependent for ADLs and not refusing care, was observed with clearly visible, overgrown facial hair despite being assessed as dependent on staff for shaving.
A resident who reported feeling hungry after meals had an order for double food portions based on his preference, but was observed receiving a regular-sized meal. His meal ticket did not indicate the double-portion order, and the Food Service Manager stated that kitchen staff rely on the meal ticket to know when to serve double portions. The dietitian confirmed that double portions had been ordered as a preference, not as a weight management intervention, yet this preference was not reflected on the meal ticket or in the portion actually served.
A resident on isolation for active COVID-19 had physician orders, a care plan, a door sign, and a facility policy all requiring use of an N-95 mask, gloves, isolation gown, and eye protection for anyone entering the room. A CNA was observed entering the resident’s room with linens and later exiting with soiled linens while not wearing the required eye protection, despite the infection control nurse confirming that eye protection was part of the mandated PPE for COVID-19 isolation.
A resident with chronic respiratory issues was placed on a mechanical ventilator due to low oxygen levels, but the facility failed to notify her family. Despite the resident being alert, the family only learned of the situation upon visiting the next day. The facility's policy requires immediate notification of significant changes, which was not adhered to in this case.
A resident with a history of pleural effusion and shortness of breath experienced hypoxia and difficulty breathing. Despite a physician's order to send the resident to the hospital, staff failed to do so, leading to the resident's deterioration and death. The use of a non-rebreather mask without proper order and inadequate communication of critical test results contributed to the incident.
The facility failed to address and follow up on concerns raised by residents during council meetings, including issues with medications, call light wait times, and television service. Despite residents regularly voicing complaints, there was little or no documented follow-up, and the Activities Director and Administrator acknowledged the importance of the grievance process but did not ensure systematic resolution of these concerns.
The facility failed to follow proper infection control protocols, including the use of PPE for residents on isolation precautions. Staff did not wear gowns or perform hand hygiene during high-contact care activities, and PPE was not removed before leaving isolation rooms. These lapses occurred despite clear policies and care plans indicating the need for enhanced barrier precautions for residents with medical devices and infections.
A facility failed to maintain resident dignity and hygiene in two incidents. A CNA spoke disrespectfully to a resident with multiple diagnoses, pressuring them to eat without regard for their dignity. In another case, staff neglected to change a soiled sheet for a resident with severe cognitive impairment, despite being informed of the issue, compromising the resident's dignity and comfort.
A resident with multiple diabetic wounds on toes, feet, and heels was not provided with necessary off-loading devices to prevent pressure on wounds. Despite staff acknowledging the need for off-loading, the resident's heels were observed resting on the bed without any protective devices. Facility guidelines required off-loading, but documentation showed no record of heel protectors being used.
A resident with severe cognitive impairment and swallowing issues was found unsupervised, drinking non-thickened liquids, contrary to her dietary requirements. Facility staff confirmed the need for nectar thick liquids and supervision to prevent aspiration, but the facility lacked a policy on aspiration precautions.
A resident with moderate cognitive impairment and multiple health conditions was found without a catheter securement device, lying on the catheter tubing, and with the drainage bag positioned above the bladder. The facility's staff failed to clean the catheter tubing after the resident was incontinent of stool, contrary to the care plan and best practices to prevent infection.
The facility failed to ensure accurate weight measurements for two residents, resulting in significant discrepancies. One resident experienced a notable weight loss despite good intake, while another showed a rapid weight gain without verification. The process for obtaining and documenting weights was inconsistent, and required follow-ups were not conducted.
A facility failed to obtain orders and assess a resident's dialysis site, leading to a deficiency in care. The resident, with multiple diagnoses including end-stage renal disease, had no physician's orders for permacath site assessment in July 2024. Despite policy requirements for daily assessment, documentation lacked guidance for staff, resulting in inconsistent site assessments. The DON acknowledged the need for specific orders to ensure proper care.
The facility failed to administer medications timely and correctly for two residents. One resident missed a dose of Hydralazine due to late administration, while another was not instructed to rinse their mouth after using an inhaler, risking thrush. These incidents reflect lapses in following medication pass procedures and manufacturer instructions.
A resident with severe protein-calorie malnutrition and undergoing chemotherapy was not offered dietary substitutions for a pureed diet, despite expressing dissatisfaction with the meal provided. The CNA confirmed no substitutions were available, and the DON acknowledged the resident's dislike for the food and the potential impact on their nutritional intake. This was contrary to the facility's policy requiring equivalent nutritional substitutes.
The facility failed to maintain the third-floor shower room and a resident's air conditioning unit in a safe and sanitary condition. Water was leaking from the ceiling in the shower room, with evidence of mold and water damage, affecting 53 residents. A resident with lung problems had a missing air conditioning cover, exposing insulation and other materials. The maintenance department did not regularly inspect these areas, relying on staff reports, and failed to address the issues promptly.
A facility failed to provide proper tracheostomy care, leading to potential cross-contamination. A resident with a tracheostomy did not receive care as ordered, and a respiratory therapist used soiled gloves to handle clean supplies and placed soiled items on the resident's bed. The facility's guidelines for maintaining cleanliness and documenting care were not followed.
Failure to Prevent Resident-to-Resident Physical Abuse and Manage Known Conflict
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse and to adequately manage known resident-to-resident conflicts. Two cognitively intact residents with significant psychiatric and substance use histories, one with schizoaffective disorder, bipolar type, major depressive disorder, anxiety disorder, and PTSD, and the other with alcohol abuse, cocaine abuse, and generalized anxiety disorder, had a history of interpersonal conflict. The facility was aware of prior incidents between them, including a previous verbal disagreement that escalated and a prior allegation by one resident that was disproven by camera footage. Despite this known pattern of conflict, both residents continued to encounter each other without effective preventive measures in place, including on the elevator where the incident occurred. On the date of the incident, one resident was on the elevator when the other attempted to enter with a wheelchair. According to multiple statements, the wheelchair rolled onto the first resident’s foot and walker, cornering him in the elevator. The elevator doors closed and traveled to another floor while the resident being blocked called out for help. An activity aide heard the calls for help, found the resident unable to exit the elevator because the other resident refused to move, and physically assisted in repositioning the wheelchair so the blocked resident could exit. Staff and resident accounts describe the wheelchair-using resident as upset and “a little difficult,” and behavior notes document that she sought out conflict and fabricated information about another resident as an identified behavior on her care plan. Following the elevator encounter, the wheelchair-using resident alleged that the other resident hit her with his walker and ran over her foot, and she called the police and demanded to go to the hospital. Hospital records documented contusions of her right shoulder and left foot. The other resident reported that his foot had been run over by the wheelchair, resulting in soreness; an x-ray of his foot was negative for acute fracture or dislocation. The facility’s final incident investigation documented conflicting accounts: one resident alleging being struck and run over, and the other reporting being run over and confined in the elevator. The Director of Nursing and Social Services acknowledged ongoing personality conflicts between the two residents and that the resident making repeated allegations had “it out for” the other, yet the residents continued to have direct, unsupervised interactions that culminated in this physical altercation and associated injuries.
Failure to Provide Timely Incontinence and ADL Care
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and assistance with activities of daily living (ADLs) for residents who were unable to care for themselves. One resident, lying in bed on a low air loss mattress, reported being incontinent and currently wet and was unsure of the last time he had been changed, estimating it may have been around 7:00 AM. When a CNA began changing him at 9:39 AM, his incontinence brief was completely saturated with foul-smelling urine, and the CNA did not know when he was last changed, stating that if the night shift CNA had last changed him, it was probably around 6:00 AM. Deep grooves and indentations from the brief were observed in his thighs and groin area, with redness and inflammation noted on the left thigh, and a dried ring of urine was seen on the fitted sheet, prompting a full linen change. This resident’s assessment and care plan documented that he was dependent on staff for personal hygiene, bed mobility, toileting, and transfers, and required assistance with ADLs as needed. Another resident, also on a low air loss mattress, was observed at 10:15 AM when a CNA came in to change him and stated she did not know the last time he had been changed and had not changed him yet that day, explaining she had to get residents ready for breakfast and feed this resident. When the CNA removed the incontinence brief, the front and back were saturated with foul-smelling urine, and the resident did not assist with turning. The care plan for this resident showed bowel and bladder incontinence, frequent bladder incontinence, impaired mobility related to limited ROM, and required total staff assistance for toilet use, with instructions for staff to check and change him, including full perineal care, every two hours and as needed. Both CNAs and the DON stated that residents are supposed to be checked and changed at least every two hours and as needed, and the facility’s Incontinent and Perineal Care Policy required rounds at least every two hours to check for incontinence during each shift, which was not followed in these instances.
Failure to Change Gloves and Perform Hand Hygiene During Incontinence Care
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to incontinence care for one resident. During an observation, a CNA provided incontinence care to a resident wearing a urine-saturated brief. While wearing a single pair of gloves, the CNA pulled down the saturated brief, used peri wash and disposable wipes to cleanse the resident’s front perineal area, retracted the foreskin and cleaned the glans, and wiped the groin. The CNA then turned the resident, removed the soiled brief and linens, and, without changing gloves or performing hand hygiene, arranged and rolled a clean fitted sheet, pad, and brief under the resident. The CNA positioned the resident on his back and fastened the clean brief, still using the same gloves. The CNA then continued additional resident care and environmental tasks without changing gloves or performing hand hygiene. With the same gloves, the CNA obtained assistance to boost the resident up in bed, put a clean gown on the resident, covered him with a clean top sheet and personal blanket, adjusted the resident’s pillows, tidied items on the overbed table, and removed the garbage. The CNA left the room carrying a bag of soiled linens while still wearing the same gloves used throughout the entire procedure. The DON later stated that during incontinence care, gloves should be changed after removing dirty briefs and linens and after wiping soiled areas, and that hands should be sanitized, which was also reflected in the facility’s Incontinent and Perineal Care Policy requiring glove changes and handwashing at specified points in the procedure.
Failure to Identify and Treat Facility-Acquired Pressure Ulcer
Penalty
Summary
A deficiency occurred when the facility failed to identify, assess, and implement treatment orders for a resident who developed a facility-acquired pressure ulcer. The resident, who had risk factors such as impaired mobility, bowel incontinence, and peripheral vascular disease, reported pain and a sore on his right buttock to staff approximately two weeks prior to the survey. Despite the resident's report and a previous order for barrier cream, no dressing or cream was being applied, and the resident stated that nothing had been done after he informed staff. During observation, an open area was found on the resident's right buttock with no treatment in place, and the wound nurse was unaware of the open area until the day of the survey. Further review revealed that the barrier cream ordered for the resident was not present in his room, and there was no documentation in the electronic health record regarding the skin alteration. The wound nurse was unable to locate wound notes for the previously identified skin issue, and the care plan, while noting the potential for pressure ulcer development and interventions, was not being followed as treatments were not administered as ordered. The facility's policy requires prompt identification, documentation, and treatment of skin breakdown, but these steps were not carried out for this resident.
Failure to Provide Hand Soap in Resident Bathrooms for Infection Control
Penalty
Summary
The facility failed to ensure that residents' bathrooms were stocked with antiseptic hand soap for four out of eight residents reviewed for infection control. Observations revealed that multiple residents' bathrooms lacked hand soap, and residents reported that this had been an ongoing issue. Residents stated that they had repeatedly requested hand soap from staff but were ignored, and some mentioned that the soap had been removed due to a recall and was not replaced for an extended period. Residents affected were assessed as having no cognitive impairment and were able to articulate their concerns clearly. Staff interviews confirmed the absence of hand soap in the bathrooms, and it was acknowledged by both the Director of Nursing and the Maintenance Director that a soap recall had occurred months prior, but soap had not been replenished in a timely manner. The facility's own hand hygiene policy, which aligns with CDC guidelines, requires handwashing with soap and water, especially before eating and after using the toilet. The lack of hand soap in resident bathrooms directly contravened this policy and compromised infection control practices.
Failure to Initiate Discharge Planning Upon Resident Request
Penalty
Summary
The facility failed to initiate and follow through with discharge planning upon a resident's request, resulting in a deficiency. The resident, who was cognitively intact with a BIMS score of 15 and was at the facility for therapy, expressed a desire to either return home or transfer to another facility closer to family. Despite multiple requests made to different social workers, the resident did not receive any updates or assistance regarding his discharge or transfer options. The resident was capable of private pay for 24-hour nursing care at home and had a home environment suitable for his needs, but no progress was made toward facilitating his discharge or transfer. Documentation shows that a social worker met with the resident and acknowledged his request, but only provided supportive listening and did not take further action or make referrals to other facilities. The social worker documented the conversation but did not follow up or initiate the discharge process. The Social Service Director confirmed that no referrals had been made for the resident, and discharge planning had not started as required by facility policy, which mandates that discharge planning begin at admission and be reevaluated regularly. This lack of action resulted in the resident's needs and preferences for discharge not being addressed.
Improper Refrigeration of Medications Outside Required Temperature Range
Penalty
Summary
Surveyors identified a failure to maintain a medication refrigerator within the facility’s required temperature range for medications stored for four residents. During an observation of the 3rd floor medication refrigerator, the unit felt warm and the internal thermometer read 54°F. After the refrigerator door was closed and approximately 25 minutes passed, a recheck showed the internal temperature had increased to 60°F. The facility’s temperature log, provided by the DON, specified that the medication refrigerator temperature must be maintained between 36°F and 46°F, and staff interviewed acknowledged that medications such as unopened insulin pens, eye drops, and Trulicity should be stored within that 36–46°F range. At the time of the observation, the refrigerator contained an unopened Humalog Lispro insulin pen for one resident, an unopened Humalog insulin pen for another resident, Latanoprost 0.005% ophthalmic solution eye drops for a third resident, and a Dulaglutide (Trulicity) 1.5 mg/0.5 mL auto-injector for a fourth resident. The LPN present and the 3rd floor supervisor both confirmed that the refrigerator temperature was outside the acceptable range needed to maintain the effectiveness of these medications. Maintenance staff later stated that the refrigerator was not cooling due to excessive ice buildup, which resulted in the unit not functioning properly, but at the time of the surveyor’s observation, these medications remained stored in a refrigerator that was operating above the facility’s specified temperature parameters.
Failure to Perform Ongoing Assessment for Physical Restraint Use
Penalty
Summary
Surveyors identified a deficiency related to the use and assessment of a physical restraint for one resident. The resident was observed seated in a wheelchair in the hallway by the nurse’s station wearing a waist (lap) restraint attached to the wheelchair. Documentation showed a Physical Restraints Informed Consent dated 08/22/2024 indicating the lap restraint was used due to dementia, non-compliance with transfer status, impulsive behavior, and poor trunk control. A restraint assessment from the same date documented that the device prevented the resident from standing, transferring, or walking, met the definition of a restraint, and that the resident was unable to remove it independently, with staff responsible for removing it during ADLs. The Medication Administration Record for 08/2025 showed ongoing use of the waist restraint with instructions to check every two hours for skin integrity and circulation, marked as completed on all shifts from August 1 through August 11, 2025. Despite the ongoing use of the restraint, staff interviews and records revealed a lack of ongoing restraint assessments. The Restorative Nurse stated that restraint assessments should be completed annually and quarterly and that if the restraint is used for trunk support, the restorative nurse performs the assessment; however, the only restraint assessment available for this resident was dated 08/22/2024. The Falls/Psychotropic Nurse reported that the resident was a fall risk and that the restraint was used due to poor trunk support, but acknowledged having no restraint assessment or restraint reduction assessment for the resident. Additionally, the resident’s MDS dated 07/2025 indicated that physical restraints were not used, which conflicted with the observed and documented use of the lap restraint. The facility’s restraint policy, revised 07/03/25, stated that the use of the restraining device may be assessed and reduced at least quarterly, but there was no evidence of such ongoing assessments for this resident.
Failure to Provide Timely Incontinence Care and Grooming for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and grooming assistance to dependent residents. One resident who was nonverbal, on hospice, and required check-and-change incontinence care every two hours was observed lying in bed in urine-soaked linens for an extended period. Surveyors first observed a wet, yellow circle under the resident’s buttocks and feet at 9:48 AM, with a strong urine odor noted later, and the resident remained in the same wet position through at least 12:14 PM while being fed lunch in bed. The resident was not changed until 12:32 PM, at which time staff found the disposable brief, bed pad, and bottom sheet saturated with urine. The CNA assigned to the resident stated the resident was difficult to care for because she “be fighting,” although the resident did not resist care during the observed change. Documentation showed no urinary continence task entries for that day and indicated the last recorded change occurred the previous evening, despite the resident’s care needs and hospice status. Another resident with multiple sclerosis, morbid obesity, impaired mobility, neuromuscular bladder dysfunction, and no cognitive impairment reported being dependent on staff for toileting and always incontinent of bowel and bladder. This resident stated she wore two incontinence pads and sat on an additional pad in her chair because staff did not change her after she got up in the morning and that staff often told her they were busy or lacked help when she requested toileting. She reported remaining up for many hours without being changed and expressed a desire to be changed at least once after getting up. A third resident, a ventilator-dependent individual with severe intellectual disabilities and dependent on staff for ADLs, was observed with visible facial hair on the upper lip and chin, approximately 1/8 to 1/4 inch long, noticeable from halfway across the room. The resident’s guardian confirmed the resident was nonverbal, dependent on staff, and needed shaving, and facility records showed she was dependent on staff for shaving and did not reject care, with no documentation of care refusal in behavior tasks.
Failure to Provide Ordered Double Meal Portions Based on Resident Preference
Penalty
Summary
The facility failed to provide a resident with meals in accordance with his documented food portion preference for double portions. On 08/11/2025 at 10:26 AM, the resident reported he was always hungry after meals and stated he was supposed to receive double portions of food but was not getting them. The resident’s Order Summary Report dated 08/11/2025 showed an order for double portions of food. At 12:02 PM the same day, observation of the resident eating in his room showed his meal appeared to be the same size as a regular meal, and the meal ticket on his tray did not indicate that he was to receive double portions. At 12:30 PM, the Food Service Manager stated that if a resident was to receive double portions, this would be listed on the meal ticket, which is how the kitchen staff would know to serve double portions. On 08/12/2025 at 10:33 AM, the Dietitian confirmed the resident was to receive double portions based on his preference after he reported being hungry after meals, and clarified that the double portions were ordered as a preference and not as a weight management intervention.
Failure to Ensure Complete PPE Use for Resident on COVID-19 Isolation
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) protocols for a resident on COVID-19 isolation. On 08/11/2025 at 10:30 AM, a sign on the resident’s door indicated the resident was on isolation and required anyone entering the room to wear an N-95 mask, gloves, isolation gown, and eye protection. At 10:35 AM, a certified nursing assistant entered the resident’s room with linens wearing PPE but without any eye protection, and later exited the room with a clear bag of what appeared to be dirty linens. On 08/12/2025 at 10:58 AM, the infection control nurse confirmed the resident was on isolation for COVID-19 and stated that staff should wear an N-95 mask, gloves, isolation gown, and eye protection when entering the room. The resident’s Order Summary Report dated 08/12/2025 showed an order to maintain strict contact and droplet isolation at all times due to active COVID-19 infection, and the resident’s care plan initiated on 08/05/2025 included an intervention to use appropriate PPE. The facility’s policy on preventing and controlling acute respiratory illness outbreaks, revised 07/16/2025, also specified that required PPE for COVID-19 isolation included eye protection. This deficiency was based on observation, interview, and record review showing that staff did not fully comply with the posted isolation requirements, the resident’s physician orders and care plan, and the facility’s written infection control policy regarding PPE use for COVID-19 isolation.
Failure to Notify Family of Resident's Ventilator Use
Penalty
Summary
The facility failed to notify a resident's representative of a significant change in condition, specifically when the resident was placed on a mechanical ventilator. The resident, a female with multiple diagnoses including chronic respiratory failure and congestive heart failure, was observed to have low oxygen levels. Despite being alert and oriented, the resident's family was not informed of the change in her condition until they visited the next day and saw her on the ventilator. The Registered Nurse (RN) involved did not notify the emergency contact, believing it was unnecessary due to the resident's cognitive status. The Respiratory Therapist (RT) noted that the resident was lethargic with oxygen levels in the 70s, requiring respiratory treatment and eventually placement on a mechanical ventilator. The facility's policy mandates immediate notification of the resident's legal representative or family member in such significant changes, but this was not followed. The Director of Nursing (DON) acknowledged the family's concerns about the lack of notification, indicating that the decision to inform the emergency contact was left to the resident, who was agreeable to the ventilator placement.
Failure to Follow Physician's Orders Leads to Resident's Death
Penalty
Summary
The facility failed to follow a physician's order to send a resident, who was experiencing hypoxia and difficulty breathing, to the hospital. This oversight led to the resident's condition deteriorating towards the end of the evening shift, eventually requiring cardiopulmonary resuscitation (CPR) and resulting in the resident's death in their room. The incident involved a registered nurse who provided the resident with a 100% non-rebreather mask due to low blood oxygen levels but did not follow the physician's order to send the resident to the hospital. The resident had a history of pleural effusion and episodes of shortness of breath with activity and changes in position. Despite the physician's order to send the resident to the hospital if they experienced difficulty breathing, the staff did not act on this directive. The resident's condition was further complicated by the use of a non-rebreather mask without a proper order, and the oxygen flow rate was not maintained at the necessary level to ensure adequate oxygenation. The physician was not informed of the results of a stat chest x-ray, which showed significant findings that could have warranted further action. The lack of communication and failure to follow the physician's orders contributed to the resident's decline and eventual death. The facility's policies on physician orders and oxygen therapy were not adhered to, resulting in a critical lapse in care for the resident.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to address and follow up on resident concerns brought forward in resident council meetings. During a resident council meeting held as part of the facility's Annual Certification Survey, several residents, including the resident council president and vice president, reported that they regularly voiced complaints at these meetings. However, they noted that there was little or no follow-up on their concerns, such as issues with late and missing medications, long wait times for call lights, and downgraded television service. The minutes from previous meetings did not document these concerns, and residents expressed frustration over the lack of communication regarding the resolution of their issues. The Activities Director, who attended the meetings and took minutes, acknowledged the importance of the grievance process but admitted not keeping track of follow-ups on grievances from the meetings. The Administrator also recognized the importance of the grievance process for both understanding resident issues and ensuring residents feel heard. Despite this acknowledgment, there was no evidence of a systematic approach to addressing and resolving the concerns raised during resident council meetings, as reflected in the absence of documented follow-up in the meeting minutes.
Infection Control Deficiencies in PPE Use and Isolation Precautions
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, particularly in the use of personal protective equipment (PPE) for residents under isolation precautions. In the case of a resident with severe cognitive impairment and multiple medical conditions, including a tracheostomy and g-tube, staff did not wear gowns while providing incontinence care, despite the resident being on enhanced barrier precautions. Additionally, staff failed to perform hand hygiene between glove changes, which is crucial to prevent cross-contamination. The resident's care plan and facility policy clearly indicated the need for gowns and gloves during high-contact activities, yet these protocols were not followed. Another incident involved a housekeeper who exited a resident's room wearing PPE, including gloves, gown, and mask, and walked down the hallway before removing the PPE. This action contradicts the facility's policy, which requires PPE to be removed before leaving an isolation room to prevent the spread of infections. The housekeeper acknowledged the mistake, attributing it to feeling unwell and disoriented at the time. Further deficiencies were observed with other residents who required enhanced barrier precautions due to medical devices like catheters and wounds. In one instance, a resident's room lacked appropriate signage and PPE containers, leading to staff providing care without gowns. Another resident, on contact isolation, was attended to by a nurse who failed to don a gown before entering the room. These lapses in protocol highlight a systemic issue in the facility's infection control practices, as staff did not consistently follow established guidelines for PPE use and hand hygiene.
Failure to Maintain Resident Dignity and Hygiene
Penalty
Summary
The facility failed to treat residents in a dignified manner, as evidenced by two separate incidents involving residents R147 and R457. For resident R147, who was admitted with multiple diagnoses including malignant neoplasms and severe protein calorie malnutrition, the deficiency was observed when a CNA, V19, was overheard speaking to R147 in a disrespectful manner. The CNA expressed impatience and a lack of empathy by stating that they had other residents to feed and pressured R147 to eat without considering the resident's dignity and need for privacy during meals. In the case of resident R457, who has severe cognitive impairment and is dependent on staff for all ADLs, the deficiency was noted when CNAs V11 and V12 failed to change the resident's soiled fitted sheet after an episode of vomiting. Despite being informed of the soiled linens, the staff left the room without addressing the issue, compromising the resident's dignity and comfort. This inaction was further compounded when a wound care nurse and CNA also neglected to change the soiled sheet, despite being notified by the surveyor. The Director of Nursing later acknowledged that sheets should be changed immediately when soiled, highlighting the facility's failure to uphold resident dignity and proper infection control practices.
Failure to Off-load Heels for Resident with Diabetic Wounds
Penalty
Summary
The facility failed to ensure that a resident's heels were off-loaded, as required for wound care management. On multiple occasions, a resident identified as R204 was observed lying in bed with his heels resting directly on the bed surface, without any off-loading devices such as boots or pillows in place. Despite the presence of gauze dressings on his feet and heels, the necessary off-loading to prevent pressure on his wounds was not implemented. Certified Nursing Assistants (CNAs) and a Registered Nurse (RN) acknowledged the need for off-loading but did not take action to elevate the resident's heels during care. The resident, R204, had multiple full-thickness diabetic wounds on his toes, feet, and heels, as documented by a Wound Care Physician's Note. The facility's Wound Care Guidelines required the use of supportive devices to off-load pressure from bony prominences, including the heels. However, the Point of Care Task documentation showed no record of heel protectors being applied or removed, indicating a lack of adherence to the prescribed wound care protocol. This oversight in care was observed over consecutive days, highlighting a deficiency in following the established wound care guidelines.
Failure to Provide Nectar Thick Liquids and Supervision
Penalty
Summary
The facility failed to ensure that a resident, identified as R4, received nectar thick liquids as required for her safety. R4, who has severe cognitive impairment and requires staff supervision for eating, was observed alone in her room drinking a liquid nutritional supplement from a straw and had a half-empty cup of water on her bedside table. Both drinks were not nectar thickened, contrary to her dietary requirements. Certified Nurse Aides (V5 and V10) confirmed that R4 needs thickened liquids to prevent aspiration due to her swallowing issues and should not be drinking regular consistency liquids without supervision. Further interviews with facility staff, including a Registered Nurse (V9) and the Director of Nurses (V2), revealed that R4 is confused, has behaviors, and is resistive to care. She requires mechanical soft foods and nectar thickened liquids to prevent swallowing problems. V2 emphasized that residents with aspiration precautions should be supervised with foods and liquids to prevent choking and aspiration. However, it was noted that the facility lacked a policy related to aspiration precautions or swallowing problems, contributing to the oversight in R4's care.
Deficiency in Catheter Care for a Resident
Penalty
Summary
The facility failed to ensure proper catheter care for a resident, leading to a deficiency. The resident was observed lying in bed on top of the indwelling urinary catheter tubing without a securement device in place. The catheter drainage bag was positioned above the level of the bladder, contrary to best practices that prevent backflow and potential infection. The resident's incontinence brief was open, and the catheter tubing was not cleaned during care, despite the resident being incontinent of a large bowel movement. Staff confirmed the absence of a securement device and acknowledged that the catheter tubing should be free of kinks to prevent backflow and infection. The resident, who has moderate cognitive impairment and is dependent on toileting hygiene, has a care plan indicating the need for catheter care every shift and positioning of the catheter bag below the bladder. The facility's policy requires the catheter bag to be positioned below the bladder to prevent backflow, but it does not explicitly mention keeping the tubing free of kinks. The resident's medical history includes conditions such as peripheral vascular disease, diabetes, and chronic kidney disease, which may increase the risk of complications from improper catheter care.
Failure to Ensure Accurate Weight Measurements
Penalty
Summary
The facility failed to ensure accurate weight measurements for two residents, leading to significant discrepancies in their recorded weights. One resident, who had multiple diagnoses including Parkinson's disease and major depressive disorder, experienced a significant weight loss over a few months. Despite receiving a regular diet with supplements and having good oral intake, the resident's weight dropped from 196 lbs to 169 lbs over three months. The dietitian noted the weight loss and intended to follow up, but a re-weigh was not conducted, and the process for obtaining and entering weights was inconsistent. Another resident, diagnosed with conditions such as schizophrenia and dementia, showed a significant weight gain of 20 lbs within five days. The resident had lymphedema, which could affect weight, but no re-weigh was conducted to verify the accuracy of the recorded weight. The facility's policy required monthly weights and assessment of significant weight changes by the interdisciplinary team, but this was not adhered to in these cases. Interviews with the dietitian and the Director of Nursing revealed issues with the process of obtaining and documenting weights. The dietitian typically communicated recommendations via email, but there was a lack of follow-up and oversight. The Director of Nursing indicated that weights should be rechecked if there is a significant change, but this protocol was not followed, leading to the deficiencies noted in the report.
Failure to Assess Dialysis Site for Resident
Penalty
Summary
The facility failed to obtain orders and assess a resident's dialysis site for a resident who requires dialysis services. The resident, identified as R56, has multiple diagnoses including end-stage renal disease and dependence on renal dialysis. Despite having a permacath on the right chest for hemodialysis, there were no physician's orders for the assessment of the permacath site in July 2024. This lack of orders resulted in the absence of consistent site assessments, as confirmed by the registered nurse and licensed practical nurse involved in the resident's care. The facility's policy requires that the condition of the hemodialysis site be assessed and recorded daily. However, the monitoring documentation for R56 showed no area for staff to document or be aware of the need to assess the permacath site. The Director of Nursing acknowledged that nurses should ensure the dressing is in place and the site is covered when the resident returns from dialysis, but there was no specific order in the resident's chart to guide this practice. This oversight led to a deficiency in providing safe and appropriate dialysis care for the resident.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to administer medications in a timely manner for two residents, leading to a missed dose and improper medication administration. For one resident, who had diagnoses including nontraumatic intracerebral hemorrhage and hypertension, the facility did not administer the first dose of Hydralazine at the scheduled time. The nurse manager was informed late, and the nurse practitioner was contacted to decide on the course of action, resulting in the decision to skip the second dose. The facility's policy requires adherence to medication pass procedures, which was not followed in this instance. In another case, a resident was administered an inhaler medication without being instructed to rinse their mouth afterward, as per the manufacturer's instructions. This step is crucial to prevent thrush, a fungal infection, especially when using inhaled steroids. The failure to follow these instructions was observed during medication administration, highlighting a lapse in the facility's adherence to proper medication administration protocols.
Failure to Provide Dietary Substitutions for Resident on Pureed Diet
Penalty
Summary
The facility failed to offer a dietary substitution to a resident, identified as R147, who was on a pureed diet due to multiple medical conditions including malignant neoplasm of the esophagus, dysphagia, and severe protein-calorie malnutrition. During an observation, R147 expressed dissatisfaction with the meal provided, stating it was cold and unappetizing, and mentioned a preference for previous meals like gravy and potatoes. The CNA, V19, confirmed that no substitutions were available for R147's pureed diet, indicating that the resident was limited to the menu items provided. The Director of Nursing, V2, acknowledged the resident's dislike for the pureed food and the potential impact of not offering substitutes, especially given R147's ongoing chemotherapy and associated nausea. The facility's policy, revised on 6/6/24, mandates offering food substitutes equivalent in nutritional value to the main meal, but this was not adhered to in R147's case. The failure to provide dietary alternatives as per the facility's policy and federal regulations resulted in a deficiency in meeting the nutritional needs and preferences of the resident.
Deficiencies in Shower Room and Resident Room Maintenance
Penalty
Summary
The facility failed to maintain the third-floor shower room in a safe, comfortable, and sanitary condition, affecting 53 residents who use this area. During an inspection, it was observed that water was steadily dripping from the ceiling grates in the shower room, and there was evidence of water damage and mold. The Maintenance Director, V4, was unaware of the source of the water and had not taken steps to address the issue, despite it being reported in the maintenance log eight days prior. The shower room was still in use, and no drying fans were present to mitigate the water damage. Additionally, there was a lack of documentation on the steps taken to address the leaks, and the maintenance department did not regularly inspect the shower rooms. A resident, R1, was found to have a missing air conditioning cover in their room, exposing pink insulation and other materials. R1, who has lung problems and uses humidified oxygen for a tracheostomy, expressed concern about the potential health risks of breathing in materials from the exposed wall. The Maintenance Director acknowledged the issue but stated that the maintenance department relies on staff to report such concerns and does not conduct regular inspections of the air conditioning units. The facility's maintenance policy requires that all equipment and the building environment be maintained by the maintenance department, with issues reported by staff to be addressed as soon as possible. However, the facility failed to adhere to this policy, as evidenced by the ongoing water leaks and the unresolved issue with R1's air conditioning unit. A request for the facility's Mold and/or Water Mitigation Policy was made but not received, indicating a potential gap in the facility's procedures for handling such issues.
Failure in Tracheostomy Care and Cross-Contamination Prevention
Penalty
Summary
The facility failed to provide tracheostomy care in a manner that prevents cross-contamination and did not complete the care as ordered for a resident. During an observation, a respiratory therapist (RT) donned protective gear to enter a resident's room, who had a tracheostomy attached to humidified oxygen. The RT removed the resident's inner cannula and placed it on the bed, then used the same soiled gloves to handle a new inner cannula and continued the procedure without changing gloves. The RT placed soiled supplies directly on the resident's bed and did not use a drape from the trach care kit, increasing the risk of cross-contamination. The RT acknowledged that gloves should be changed when dirty and that trach treatments should be documented in the Respiratory Record. The resident had multiple diagnoses, including chronic respiratory failure and chronic obstructive respiratory disease, and was cognitively intact. The facility's guidelines required tracheostomy care every shift and as needed, with specific procedures for maintaining cleanliness and documenting care. However, the care was not completed as ordered on several days, and the RT did not follow the facility's guidelines for disposing of soiled supplies and maintaining a clean environment during the procedure. Another RT confirmed that the observed procedure was not conducted properly and emphasized the importance of moving from clean to dirty tasks to reduce infection risk.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 418 citations issued within 25 miles in the last 12 months — including the 19 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Zion
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Allure Of Zion | 2.3 mi | ★★★★★ | 18 | 0 |
| Aspyre Of Waukegan | 4.2 mi | ★★★★★ | 16 | 2 |
| Elevate Care Waukegan | 6.4 mi | ★★★★★ | 25 | 0 |
| Waukegan Health And Rehab | 6.5 mi | ★★★★★ | 3 | 0 |
| Avina On 32nd | 7 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.