Alpine Care Of Zion
Alpine Care of Zion in ZION, IL — inspection on March 27, 2026.
Found 2 citations. 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.
Inspection Findings
living (ADLs) in the sample of 5.The findings include:On 3/26/26 at 9:25 AM, R1 was lying in bed on a
last changed; maybe around 7:00 AM, but staff have not been back around to check on him.On 3/26/26 at 9:39 AM, V4, Certified Nursing Assistant (CNA), brought her supplies and began to change R1. V4 took the front of R1's incontinence brief and it was completely saturated with urine and had a foul smell. V4 said she does not know the last time R1 was changed. R1 then said V7, CNA, changed him last. V4 said it V7 last changed him, then it was probably around 6:00 AM because V7 is the night shift CNA. As V4 continued to change and provide incontinence care to V4, deep grooves/indentations from his brief were noted in his thighs/groin area, especially to his left thigh which was red and inflamed.
After V4 cleaned up R1's backside, she said she needed to do a full linen change and pointed out a dried ring of urine on R1's fitted sheet. V4 said residents should be changed every two hours. V4 said day shift is from 7:00 AM to 3:00 PM.On 3/26/26 at 10:15 AM, R2 was lying in bed on a low air loss mattress. V5, CNA, came in to change R2. V5 said she does not know the last time R2 was changed; she has not changed him yet today. V5 said when she starts her shift, she has to get the residents ready for breakfast and she had to feed R2. V5 began to change R2 and pulled down the front of his incontinence brief which was saturated with foul smelling urine. As R2 was turned with no assistance from R2 to remove the soiled brief the back of the brief was saturated with urine too. V5 said residents are supposed to be changed every two hours.On 3/26/26 at 11:28 AM, V2, Director of Nursing (DON), said residents should be changed every two hours, and as needed.R1's Restorative Section GG effective 1/28/26 shows R1 is dependent on staff for personal hygiene and requires substantial/maximal assistance to roll left and right, move from sitting to lying or from lying to sitting, and is dependent on staff to move from sitting to standing or to move from bed to a chair or from a chair to bed, and the ability to get on/off a commode. R1's current care plan provided by the facility (undated) shows R1 requires assistance with ADLs (bed mobility, personal hygiene, toileting) and will be assisted with ADLs as needed.R2's current care plan provided by the facility (undated) shows R2 has bowel and bladder incontinence and an ADL self-care performance and impaired mobility deficit related to limited range of motion (ROM). R2 has frequent bladder incontinence and staff are to check and change him including washing, rinsing, and drying his perineum every two hours and as needed. R2 requires total staff assistance for toilet use.The facility's Incontinent and Perineal Care Policy (reviewed/revised 6/6/24) shows it is the policy of the facility to provide perineal care to ensure cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the resident's skin condition.
Rounds will be done at least every two hours to check for incontinence during each shift.
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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
145665 03/27/2026
Alpine Care of Zion 2534 Elim Avenue Zion, IL 60099
incontinence care in the sample of 5.The findings include:On 3/26/26 at 10:15 AM, V5, Certified
pulled R2's urine saturated brief down and used peri wash and disposable wipes to cleanse his front peri area. V5 retracted R2's foreskin and cleaned his glans, wiped his groin, then turned R2 and removed the soiled brief and linens.
Using the same gloves and without hand hygiene, V5 arranged and rolled a clean fitted sheet, pad and brief under R2. V5 positioned R2 on his back and fastened his brief. V5 went to the door and obtained assistance. V5 and V6, CNA, boosted R2 up in bed. V5 put a clean gown on R2 and then covered him with a clean top sheet and his own personal blanket. RV5 proceeded to adjust R2's pillows, tidy up the items on R2's overbed table, and remove the garbage. V5 left the room with a bag of soiled linens wearing the same gloves she had on throughout the entire task.On 3/26/26 at 11:28 AM, V2, Director of Nursing (DON), said during incontinence care, gloves need to be changed after removing dirty briefs and dirty linens and anytime they are visibly soiled.
After wiping the dirty, soiled areas, the gloves should be changed and hands sanitized.The facility's Incontinent and Perineal Care Policy (reviewed/revised 6/6/24) shows it is the policy of the facility to provide perineal care to ensure cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the resident's skin condition.
Put on gloves, wash and dry the perineal area and discard disposable items, remove gloves and put on a new set of clean gloves to put on clean briefs/incontinent pads.
Complete hand washing after the procedure.