F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review the facility failed to ensure fall interventions were in place for
residents with a history of falls for 2 of 3 residents (R2, R3) reviewed for safety and supervision in the
sample of 3.
The findings include:
1. R2's Fall Risk assessment dated [DATE] showed R2 had eight (8) falls in the facility from 2/2/24-3/27/24.
The assessment showed the facility utilized chair and bed alarms as fall interventions for R2.
R2's current care plan showed R2 remained at high risk for falls related to her unsteady gait, history of
previous falls, and diagnosis of dementia with behaviors. The care plan listed alarms on chair and bed to
alert staff of unplanned movement as one of R2's fall interventions since 3/1/23.
On 3/28/24 at 9:50 AM, R2 was in bed. R2's upper body (head, torso, buttocks) were on the bed. R2's legs
were off the bed, propped up on the seat of a wheelchair, that was positioned next to R2's bed. No mats
were noted on the floor next to R2's bed. Folded floor mats were noted against the wall, by the foot of R2's
bed. A pad alarm was placed partly under R2's buttocks and partly hanging off R2's bed. The cord attached
to the pad was not connected to the alarm box. The cord laid on the floor, under R2's bed. The alarm box
was turned off, hanging off the siderail of R2's bed.
On 3/28/24 at 11:30 AM, R2 was in bed, with her entire body positioned in the bed. The pad alarm was in
place, under R2 and turned on. V4 (Family of R2) was seated in a chair, next to R2's bed. V4 stated that
when he arrived that morning, he too found R2 with her upper body in bed and her feet in a wheelchair next
to the bed. He also found R2's pad alarm had been disconnected and turned off. V4 stated, That happens a
lot. When I come in and the alarm isn't on. She needs the alarm. She has a weak back and is constantly
moving around, trying to get comfortable. When she moves around, she falls out of bed. She just fell out of
bed again last night.
On 4/1/24 at 9:07 AM, V8 Licensed Practical Nurse stated R2 should have a pad alarm or clip alarm in
place due to her risk of falls. V8 also stated R2 is to have mats lying on the floor next to her bed anytime R2
is in bed.
2. A Facility Census Form dated 4/1/24 showed R3 resided in a room, on the skilled care/intermediate care
wing, from 12/20/23-3/29/24.
(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 2
Event ID:
146066
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
04/01/2024
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
R3's progress notes dated 1/1/24-3/29/24 showed R3 had three (3) falls in the facility on 1/21/24 (2 falls)
and 1/25/24. A note dated 1/21/24 at 7:41 PM showed R3 fell as he was trying to get out of his recliner. A
note dated 1/25/24 showed clip and bed alarms had been placed on R3 as fall interventions.
R3's current care plan showed R3 remained at risk for falls due to his history of previous falls, unsteady
gait, and the amputation of toes to his right foot. The plan showed, Clip and bed alarm in place to alert staff
of any unplanned movement.
On 3/28/24 at 9:56 AM, R3 was seated in a recliner in his room. No pad alarm was noted under R3. No clip
alarm was attached to R3. A clip alarm was noted hanging off the handle of a wheelchair in R3's room. The
clip alarm was turned off.
On 4/1/24 at 9:39 AM, V2 Director of Nursing stated floor mats and position alarms are used as fall
interventions for residents in the facility. V2 stated, If a resident is at high risk for falls, we do use bed/chair
alarms and floor mats next to their beds as fall interventions. We also try to keep them in view of our staff.
CNAs (certified nursing assistants) should be checking many times during their shift to make sure alarms
are in place and working. If a resident needs an alarm, it's documented on their care plan.
The facility's Fall Policy (undated) showed, On admission and re-admission, a Fall Risk Assessment will be
completed. Interventions will then be implemented for those residents assessed at risk for falls. These
measures will be documented in the Plan of Care .
The facility's Fall Prevention Program policy (undated) listed assisted devices/alarms and low bed/mat on
the floor as fall interventions used in the facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146066
If continuation sheet
Page 2 of 2
