Inspection·December 17, 2024

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to serve coffee at a temperature to prevent burns. This failure resulted in R1 receiving a 12-inch, slough filled burn to her left thigh. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 3. This past compliance occurred from 12/1/2024-12/2/2024. Findings include: R1's admission Record (Face Sheet) showed she was admitted to the facility on [DATE] with diagnoses to include but not limited to Parkinson's Disease (degenerative brain disorder leading to tremors and a loss of motor function); tremors; depression; diabetes II; COPD (Chronic Obstructive Pulmonary Disorder, progressive lung disease caused by damage to the lungs); and rheumatoid arthritis. R1's 10/14/24 Quarterly Minimum Data Set (MDS) showed she was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. The MDS showed she used a wheelchair for mobility. The MDS showed R1 required setup or touching assistance for eating and partial/moderate assistance for oral hygiene. The MDS showed she required substantial/maximal assistance to roll left and right in bed; and she required substantial/maximal assistance to go from siting in bed to lying in bed. The MDS showed R1 does not walk. The facilities incident report from 12/1/24 showed, [R1] is an alert and oriented resident with a BIMS score of 14 on an all-female behavioral health unit. On 12/1/24 [R1] was wheeling down the hall independently per her baseline when she asked her friend to assist in moving her wheelchair. The friend complied and handed [R1] her coffee with a lid attached to hold while she helped her. Once completed [R1] attempted to hand the coffee back to her friend when she dropped the coffee onto her own left leg. The nursing staff on duty assessed the resident with noted redness to the left leg. NP (Nurse Practitioner) was notified with new treatment orders in place. POA notified of the incident and agrees with the current plan of care. [R1] was assessed by wound care MD on 12/2. The investigation started immediately . On 12/13/24 at 8:45 AM, R2 stated the councilors office on her locked behavioral unit had a single serving pod-type coffee maker (hereinafter referred to single-serving coffee maker, SSCM). R2 stated, at around 3:30 PM on 12/1/24, she dispensed a cup of coffee by herself then exited the councilors office. R2 said, as she exited the councilors office R1 was in her wheelchair and stuck against the wall. R2 said R1 requested assistance, so she handed her coffee to R1 then moved R1 away from the wall. R2 said when R1 handed the coffee back to her it spilled on R1. R2 said, .The coffee was fresh. I had just gotten it .The coffee is hot. The stuff I get from the counselors is hot, which is why I (continued on next page) 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 TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 145142 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Debes Rehab & Hcc 550 South Mulford Avenue Rockford, IL 61108 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)