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Complaint Investigation

Alpine Care Of Zion

November 14, 2025 · Zion, IL · 2534 Elim Avenue
Citations 1
CMS Rating 2/5
Beds 244
Provider ID 145665
Healthcare Facility
Alpine Care Of Zion
Zion, IL  ·  View full profile →
Inspection Summary

Alpine Care of Zion in ZION, IL — inspection on November 14, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0880
Infection Control Deficiencies
Potential for More Than Minimal Harm

Provide and implement an infection prevention and control program.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure resident's bathrooms had an antiseptic handwash for 4 of 8 residents (R5, R6, R7 and R8) reviewed for infection control in the sample of 8.The findings include:1.On 11/14/25 at 9:40 AM, R5's bathroom had no hand soap. R5 said there has been no hand soap in the bathroom for a while, I have asked for hand soap repeatedly from staff, but I am ignored. I feed myself, I do things for myself, I have nothing to wash my hands, only plain water, no soap. R5's facility assessment dated [DATE] show a BIMS of 13- no cognitive impairment.2. On 11/14/25 at 9:55 AM, R6's bathroom had no hand soap. R6 said there has been no soap for a long time now, staff should know we have no soap to use to wash our hands.R6's facility assessment dated [DATE] show a BIMS of 13- no cognitive impairment.3. On 11/14/25 at 12:45 PM, R7 was eating his lunch in his room.

His bathroom had no hand soap. R7 stated It's been months that there has been no hand soap, they took everything out because they said there was a recall of the hand soap and gave us hand sanitizer but never filled the hand soap.

There was nothing to use to remove germs after using the bathroom, we were all taught that we are supposed to wash our hands, right? R7's facility assessment dated [DATE] show a BIMS of 15- no cognitive impairment.4. On 11/14/25 at 1pm. R8 said staff removed the hand soap because they were talking about a recall. R8 said after using the bathroom, after meals, or after going out to smoke, there is no soap to wash his hands. R8 said staff just replaced the hand soap just now, actually just a moment ago.R8's facility assessment dated [DATE] show a BIMS of 15- no cognitive impairment.Both V5 (Certified Nursing Assistant) and V6 Social Services confirmed with this Surveyor that there was no hand soap in R4-R8's bathrooms. On 11/14/25 at 1:00 PM, V2 (Director of Nursing) said there was a hand soap recall but that was way back in August 2025.

All residents should have access to hand soap in their bathrooms for handwashing to prevent infection.On 11/14/25 at 1:30 PM, V7 (Maintenance Director) said he had informed his housekeeping staff to make sure all bathrooms have soap to prevent infection.The facility policy entitled hand hygiene dated 6/30/25 show, hand hygiene is important in controlling infections. the facility will comply with the CDC guidelines in regard to hand hygiene.

Hand washing with soap and water for at least 20 seconds is recommended: d- before eating and after personally using the toilet.

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

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Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in ZION, IL, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Alpine Care of Zion or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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