Inspection·December 20, 2023

F 0686 bed when they are floating. V3 said they do not use heel boots for R89. Level of Harm - Minimal harm or potential for actual harm V13's NP (Nurse Practitioner) note dated December 20, 2023 shows, Stage II pressure injury to coccyx. Wound is 2.5 cm (centimeter) X 1.0 cm X 1.0 cm. Defined edges with surrounding skin 4 cm X 5 cm non-blanching area. Cleanse area with wound cleanser, apply A & D ointment to wound and surrounding area, cover with foam dressing daily. Deep tissue injury left heel: Continue to paint area with betadine, cover with foam dressing daily. Float heels while in bed. Left great toe deep tissue injury: Cleanse area, apply betadine to toe, cover with foam dressing until resolved. Staff informed to call family to bring in soft shoes. Residents Affected - Few The facility's undated Wound Care Policy shows, To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146066 If continuation sheet Page 2 of 7 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 146066 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Fireside Health Center 3650 North Alpine Road Rockford, IL 61114 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review the facility failed to ensure food was stored, prepared and distributed in a manner to prevent cross-contamination, failed to ensure food items in the refrigerator and freezer were labeled and dated with an open date and failed to ensure that kitchen was kept in sanitary condition. This applies to all 36 residents residing in the the facility. The findings include: The Resident Roster printed on 12/18/23 shows there are 36 residents residing at the facility. On 12/18/23 at 8:37 AM, there was an open bag of cranberry sauce and an unlabelled bag of a half angel food cake in the freezer. In the refrigerator there was a dried pink substance splattered on a bag of mozzarella cheese and on the lid of a mayonnaise container. There was a dried pink substance on the shelf of the refrigerator. There was a white liquid under the jar of mayonnaise and food debris scattered throughout the bottom of the refrigerator. In the walk in refrigerator there was an unlabeled plastic bag of roast beef, an unlabeled, uncovered tray of apple crisp, an unlabeled, uncovered tray of chocolate cake and a tray of unlabeled, uncovered small cups of salad dressing. In the dry storage are there were boxes of food on the floor. V17 (Dietary Manager) said that they were delivered on Friday (3 days prior). There was multiple fruit flies observed in the dishwasher area and near the juice machine. The juice machine drip pan was half filled with juice. There was dried sticky juice on the floor beneath the juice machine. There was multiple areas of food debris seen on the floor throughout the kitchen. There was a canister vacuum with white powdered substance on the top of it sitting next to the food preparation table. On 12/18/23 at 10:30 AM, V17 prepared the pureed lunch. After pureeing the noodles, V17 placed the noodles from the food processor bowl into a container. While he was transferring the noodles, liquid from the underside of the food processor was dripping into the container. V17 then pureed the carrots and when he was transferring them from the food processor bowl to the container, liquid was dripping into the container. V17 said, That's just sanitizer agent from the dish machine dripping out. On 12/18/23 at 12:00 PM, V17 started serving the noon meal from the steam table in the kitchen Above the steam table were three fans. The grille of the fans had a thick layer of brown/gray debris on them with strings of the debris blowing out of them. Four ceiling tiles in front of the fans had multiple pieces of brown/gray debris or them. V17 plated and served the noon meal using multiple (more than 10) chipped plates. The chips were observed on the top serving surface of the plates. On 12/18/23 at 2:00 PM, V17 said that food in the refrigerator or freezer should be covered or in a closed container or bag and the food should be labeled with the date it was prepared and the item name. V17 said that chipped plates should not be used especially if the chip is on the serving surface. V17 said that they do have a cleaning schedule and a different area of the kitchen is cleaned weekly but he does not have a log of when it was cleaned. The facility's undated Food Safety Requirements Policy shows, Dry food storage-keep foods/beverages in a clean, dry area off the floor .Safe refrigerated storage include: .Labeling, dating, and monitoring refrigerated food Keeping foods covered or in tight containers All equipment used in the handling of food shall be cleaned and sanitized, and handled in a manner to prevent contamination (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146066 If continuation sheet Page 3 of 7 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 146066 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Fireside Health Center 3650 North Alpine Road Rockford, IL 61114 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)

F 0812 The facility's undated Kitchen Sanitation Policy shows, All food service areas shall be kept clean, sanitary and free from liter and rubbish . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146066 If continuation sheet Page 4 of 7 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 146066 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Fireside Health Center 3650 North Alpine Road Rockford, IL 61114 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure staff used required personal protective equipment (PPE) when entering an isolation room, failed to perform hand hygiene to prevent cross contamination and failed to ensure residents and staff were tested for COVID-19 to prevent the spread of infection. This applies to all 36 residents residing in the facility. Residents Affected - Many The findings include: 1. A Resident Roster dated 12/18/23 shows that there are 36 residents residing in the facility. An undated facility provided list of residents who were COVID positive shows that a resident on the 200 Hall tested positive for COVID-19 on 11/13/23. The list shows that 20 residents on the 100 Hall and 200 Hall tested positive between 11/13/23 and 11/24/23. The list shows that by 11/16/23 there were residents on all hallways testing positive. On 12/19/23 at 10:30 AM, V1 (Administrator) said that the COVID-19 outbreak started on 11/13/23 and all staff and residents were tested on the 11/14/23 and 11/15/23. V1 said that there were multiple staff and residents throughout the facility that tested positive on those days. V1 said that they originally started contact tracing for testing but then resident and staff were coming up positive facility wide so they started testing facility wide. V1 said that they test all agency staff prior to their work day but the facility's staff do not get routinely tested because they wear N95 masks while working. On 12/19/23 at 1:08 PM, V2 (Director of Nursing) said that after a resident tested positive on 11/13/23, they tested all of the residents twice in that week and then after that, they have been testing them if they develop any COVID symptoms but have not done any routine testing on them besides the first week. V2 said that she is not sure if the staff were being tested on a routine basis. On 12/19/23 at 1:45 PM, V14 (Licensed Practical Nurse) said that she tested for COVID-19 the other day due to cold like symptoms and it was negative but besides that she has not done any routine testing during the current COVID-19 outbreak. V14 said that in the past (many months ago) they had to test on a routine basis but she has not with this current outbreak. On 12/19/23 at 3:54 PM, V15 and V16 (Activity Aides) both said that they work with residents throughout the facility. V15 and V16 both said that they have not tested positive for COVID-19 within the last three months. V15 and V16 both said that their boss told them last week that they had to test for COVID-19 and did a test but that is they only test that they have done recently. V15 and V16 both said that they have not had any additional COVID-19 testing done in months. On 12/19/23 at 12:23 PM, V18 (Local Health Department Infection Control Coordinator) said that once a facility identifies a positive resident or staff member, they should be testing all residents and staff every 3-5 days until they have had no new cases for 14 days if the outbreak is facility wide. The facility was unable to provide evidence that all residents and staff that were not COVID positive after the initial testing were tested every 3-7 days after a facility wide outbreak was identified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146066 If continuation sheet Page 5 of 7 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 146066 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Fireside Health Center 3650 North Alpine Road Rockford, IL 61114 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many The facility's undated Coronavirus (COVID-19) Testing Plan and Response Strategy shows, Outbreak Scenario: Facility wide testing of employees and residents will take place if deemed appropriate by facility administration or facility medical director or as directed by [Local Health Department] or the [State Health Department] If one or more resident or employee tests positive for COVID-19, contact tracing will be conducted. Baseline testing for possibly exposed persons will be conducted. Monitoring and testing of residents and employees will continue until no new resident or employee cases are identified for a period of atleast 14 days since the most recent positive result, then weekly testing, or as mandated by local health department or [State Health Department] per positivity rate or facilities discretion after contact tracing is done. 3. R89's Physician Orders Sheet dated December 1, 2023-December 31, 2023 shows she was admitted to the facility on [DATE] with diagnoses including weakness, urinary tract infection, polyosteoarthritis, congestive heart failure. On December 19, 2023 at 10:06 AM, V5 CNA (Certified Nursing Assistant) provided incontinence care to R89. R89 had a large amount of soft stool in her incontinence brief. V5 wiped R89's front peri area of the stool, then touched the resident's body to help her turn, touched the resident's dresser drawer, and R89's clean incontinence brief. V5 then wiped R89's buttocks area of the large stool and place the clean incontinence brief under R89. V5 did not change her gloves or perform hand hygiene prior to touching clean surfaces. On December 20, 2023 at 9:03 AM, V12 CNA said gloves should be changed when going from dirty to clean items so that germs do not get transferred. 4. R32's Physician Orders Sheet dated December 1, 2023-December 31, 2023 shows R32 was admitted to the facility on [DATE] with diagnoses including urinary tract infection, metabolic encephalopathy, and acute kidney failure. An order was entered on October 12, 2023 for maintain contact isolation precautions for ESBL (Extended spectrum beta-lactamases-Escherichia Coli) in urine every shift. An order was entered on December 6, 2023 for Macrodantin 50 mg once daily. (antibiotic used to treat urinary tract infections). R32's Care Plan Effective September 7, 2023 shows resident is on contact isolation precautions related to ESBL in urine. Protective personal equipment to be worn only if splash of bodily fluids are anticipated. On December 18, 2023 at 9:28 AM, there was a sign on R32's door that showed contact isolation: gloves and gown required. On December 19, 2023 at 9:41 AM, V4 CNA walked out of R32's room. V4 did not know why R32 was on isolation but had to find out from the nurse. V4 said that R32 was on contact isolation for ESBL in her urine. V4 said she had just helped R32 to use the restroom and R32 urinated in the toilet. V4 said R32 can be incontinent at times. R32 said staff do not wear gowns when they toilet her. V4 said that staff only wear gloves to take care of R32. V4 said, We just wear gloves, she's only on contact isolation. On December 20,2023 at 9:03 AM, V12 CNA said masks, shoe covers, goggles, gloves, down, and head cover should be worn when a resident is on contact isolation so that the bacteria does not stick to her and give the bacteria to another resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146066 If continuation sheet Page 6 of 7 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 146066 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Fireside Health Center 3650 North Alpine Road Rockford, IL 61114 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On December 20, 2023 at 9:32 AM, V3 CNA Supervisor said when residents are on contact isolation, Staff do not have to gown up unless we anticipate spitting projectiles, normally they just wear gloves. We never worn gowns unless we anticipate splashing of urine and we don't wear gowns when taking residents to the bathroom. The facility's Contact Isolation Policy dated August 6, 2023 does not include information on wearing gowns during resident care. 5. The facility's Infection Log for December 2023 shows R90 is on droplet isolation precautions due to respiratory illness symptoms. On December 28, 2023 at 11:30 AM, there was a sign on R90's door that reflected Droplet Isolation. Upon donning PPE, V4 CNA said, I'm not going to put a N95 mask on because I already have one on. V4 did not place an extra barrier over her current N95 mask. V4 CNA went into R90's room to attempt to toilet her. V4 stood next to R90's bed while R90 was lying in it and asked R90 if she needed to be toileted. V4 was less than three feet away from R90. R90 was actively coughing while V4 was interacting with R90. V4 did not change her N95 masks upon exiting R90's room and prior to interacting with other residents. On December 20, 2023 at 9:03 AM, V12 CNA said N95 masks should be changed when exiting a resident's room when they are on droplet isolation. 2. The facility's December 2023 Infection Log showed R21 was on droplet isolation precautions. On 12/18/23 at 8:40 AM, there was a droplet isolation sign on the door of R21's room. The sign indicated staff were to wear the following personal protective equipment (PPE): mask, gown, and gloves. On 12/18/23 at 8:48 AM, V10 (Certified Nursing Assistant- CNA) entered R21's room to deliver a meal tray and set R21 up to eat. The only PPE V10 had on when entering R21's room was a surgical mask. V10 came within 3 feet of R21 when setting up R21 to eat. R21 did not have a mask on. On 12/18/23 at 2:21 PM, V11 (CNA) entered R21's room to get vital signs. The only PPE V11 had on was a N95 mask. R21 did not have a mask on. On 12/18/23 at 2:36 PM, V8 (Infection Control Nurse) said staff should wear the following PPE when entering R21's room: N95 mask with a surgical mask covering the N95 mask, isolation gown, and gloves. The facility's Droplet Precaution policy showed gowns should be used whenever giving direct care to the resident or being within three feet unless the resident is masked. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146066 If continuation sheet Page 7 of 7