Alpine Care of Zion

In the surveyor’s words

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

• Immediate jeopardy, isolatedF684Aug 5, 2024

  Based on interview and record review the facility failed to follow the physician's order to send R1, who was hypoxic, and having difficulty breathing to the hospital. This failure resulted in R1's deterioration towards the end of the evening shift, on [DATE] to needing cardiopulmonary resuscitation (CPR) on [DATE] at 2:25AM, to R1's death at the facility in her room at 3:10AM, for 1 of 5 residents reviewed for quality of nursing care in the sample of 5. The Immediate Jeopardy began on [DATE], towards the end of the 3:00PM to 11:00PM shift, when V6 (RN-Registered Nurse) provided R1 with a 100% non-rebreather due to R1 having difficulty breathing and becoming hypoxic with blood oxygen levels dropping below 90%. […]

• Actual harm, isolatedF684Aug 8, 2025

  Based on interview and record review the facility failed to assess a surgical wound and change the dressing as ordered for13 days. This failure resulted in R2 developing an infection in the left knee surgical wound requiring hospitalization and surgery on 6/3/25. This applies to 1 of 3 residents (R2) reviewed for surgical wounds in the sample of 5.The findings include: R2's Physician's Order Sheet dated August 8, 2025 shows that she was admitted to the facility on [DATE] with diagnoses including Anxiety Disorder, Dementia and History of Falling. This document also shows orders for: Left Leg non-removeable dressing every day shift for wound care and an appointment scheduled with V6 (Orthopedic Physician) on 6/18/25. […]

• Actual harm, isolatedF686Sep 27, 2023

  Based on observation, interview and record review the facility failed to identify or assess an unstageable deep tissue sacral pressure injury. This failure resulted in R108's sacral pressure injury being infected upon identification/evaluation, requiring intravenous antibiotic therapy. The facility also failed to identify a left heel pressure injury and failed to ensure treatments were in place per physician orders. This applies to 2 of 5 residents (R108 & R131) reviewed for pressure injuries in the sample of 29. The findings include: 1. […]

• Actual harm, isolatedF600Oct 19, 2022

  Based on interview and record review, the facility failed to protect a female resident from being sexually abused by a male resident. This failure resulted in R187 sexually assaulting R116 on 10/12/22. This applies to 1 of 27 residents (R116) reviewed for abuse in a sample of 27. The findings include: The facility Abuse Report Final Form dated 10/18/22 states, On October 12, 2022 at 9:30 AM, V16 (Certified Nursing Assistant/CNA) went into R116's room and observed R187 standing at (R116's) bedside. […]

• Actual harm, isolatedF689Mar 22, 2022

  Based on observation, interview, and record review the facility failed to transfer a resident from recliner chair to bed using a mechanical lift in a safe manner. This failure resulted in R1 falling out of the mechanical lift sling onto the floor where she sustained a fractured ankle, a laceration to her head and elbow, an [CONDITION(S)], and pulled out her [CONDITION(S)] catheter on 3/14/22. This applies to 1 of 3 residents (R1) reviewed for safety in a sample of 3. The findings include: The Facility Incident Report dated 3/18/22 states, On 3/14/22 at around 9:00 PM, assigned V4 (CNA) was transferring resident to the bed and resident fell on to the floor on her right side. Immediately V4 notified V3 (RN) nurse on duty that resident fell during transfer and was on the floor. […]