Alpine Care of Evanston

In the surveyor’s words

From the most serious findings on record at Alpine Care of Evanston, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Feb 2, 2024

  Based 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). […]

• Actual harm, isolatedF689Jul 13, 2026

  Based 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.The findings include:R2 is a [AGE] year-old male admitted on [DATE] with mild cognitive impairment as per the Minimum Data Set (MDS) dated [DATE] and with an admitting diagnosis including hemiplegia secondary to cerebral infarction/CVA, seizure, and history of falling.On 7/11/26 at 9:50 AM, R2 was observed on his bed and stated, I can't walk. The lady (V3) tried to put me in the wheelchair, and I fell. I was heavy for her, and she was holding my hand to transfer. […]

• Actual harm, isolatedF600Sep 9, 2024

  Based 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. Findings include: R1's current face sheet documents R1 is an [AGE] year-old individual initially admitted to the facility on [DATE], with medical diagnosis that include but not limited to: displaced fracture of greater trochanter of left femur, subsequent encounter for closed fracture with routine healing, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. […]

• Actual harm, isolatedF656Feb 2, 2024

  Based 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. Findings include: R3 is a [AGE] year-old female with history of COPD, substance use disorder, hypertension, failure to thrive, and aphasia. […]

• Actual harm, isolatedF689Feb 10, 2023

  Based on observation, interview and record review the facility failed to implement adequate supervision and specific interventions for 2 (R76, R147) of 4 of residents who were identified as a high fall risk in a sample of 24. R76 had an unwitnessed fall that resulted in a right femoral fracture. Findings include: On 2/7/2023 at 10:30am R147 was observed in bed with the call light hanging off the side of the bed. On 2/7/2023 at 10:35am V21(Licensed Practical Nurse-LPN) said that R147 is a high fall risk and had a fall on 2/6/2023 without an injury. On 2/8/2023 at 12:00pm V2 (Director of Nursing-DON) said that R147 is a fall risk and should have the call light within reach. An Order Review Report documents a Fall Precaution order for 1/17/2023. […]