Inspection·January 10, 2025

F 0689 5.5 cm (centimeters). Level of Harm - Actual harm On 1/9/25 at 3:25 PM, V6 (WCN-Wound Care Nurse) stated she cared for R1 the day after the coffee burn on 12/30/24. V6 said she assessed and measured the burns, which had progressed from the assessment done the evening prior. V6 said there were open blisters to the back of her right thigh, knee, and calf. V6 said R1 was also seen by the nurse practitioner and her physician after her assessment. Residents Affected - Few R1's body skin check form dated 12/30/24 and signed by V6 (WCN) showed: burns from coffee-wound assessments. The form showed two areas on the back of right thigh measuring 14.0 x 5.5 cm and 4.0 x 2.0 cm (centimeters). One area on the back of the right knee measuring 2.5 cm x 2.0 cm. Two areas on the back of the right calf measuring 11.0 x 3.0 cm and 3.0 x 1.0 cm. On 1/9/25 at 3:08 PM, V5 (Nurse Practitioner) stated she saw R1's burns on 12/30/24 and agreed with the skin assessment done by the wound care nurse (V6). V5 said she recommended R1 be sent out to the local emergency room for evaluation and treatment. V5 said R1's daughter wanted R1 to be seen by the physician first, who was also in the building at that time. V5 said the physician did see R1 shortly after and diagnosed second degreed burns on the right leg. Orders were given for wound treatments and a referral to wound care. R1's chart note dated 12/30/24 by her physician states: Burn of second degree of unspecified thigh, initial encounter. Patient sustained a burn by spilling coffee on her right leg yesterday. Several blisters present, with the largest one ruptured on the posterior right thigh, exposing subcutaneous tissue with pink color. No other acute inflammatory changes. Recommend silver Silvadene to apply as directed: wound care consult; close monitoring for any early signs and symptoms of infection; notify MD/NP (medical director/nurse practitioner) with any concerns or changes; monitor. On 1/9/25 at 9:27 AM, V2 (Dietary Manager) stated R1 was burned on her thigh while drinking coffee in bed. V2 verified it occurred on 12/29/24 (Sunday) and he was notified of the incident the same day via the facility's interoffice email system. V2 stated the coffee temperatures are checked every day by himself. V2 said he is at the facility seven days a week, including weekends. V2 said he checks that the coffee is between 175-190*F (degrees Fahrenheit) when it comes out of the machine. V2 said he checks it by pouring the coffee into a cup and placing a stem thermometer into it. The temperature should be at the 175-190 degree range for the proper distribution temperature to serve it. V2 said he does not record any coffee temperatures unless there is an occurrence, like the burn R1 experienced. V2 said he records the temperatures for about one week then stops. V2 said he just assumes the coffee is at a safe level based on the machine temperature and that it drops to the proper serve temperature prior to leaving the kitchen. At 9:46 AM, this surveyor and V2 tested the hot water coming out of the coffee machine using a thermometer that had been observed calibrated to 32*F in an ice bath. The water registered 178.5*F. V2 said it was the same water source used to make resident coffee. On 1/9/25 at 10:05 AM, the last three months of coffee temperature monitoring logs were requested. The only log available was dated from 12/29/24 to 1/7/25 (week following R1's thigh burns). Temperatures ranged from 176*F to 189*F. On 1/9/25 at 1:33 PM, this surveyor entered the facility kitchen and V7 (outside service technician) was at the coffee machine with hand tools. V7 said he was just called that day to come in and lower the water temperature on the machine. V7 said it's running too hot and they want it turned down to serve it at a lower temperature. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146066 If continuation sheet Page 2 of 3 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 01/10/2025 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 - Actual harm Residents Affected - Few On 1/9/25 at 1:37 PM, V2 (Dietary Manager) said the technician was called in today even though the coffee was being served at the proper temperatures. At this interview, the dietary manager gave entirely different temperature levels and testing procedure. V2 said the coffee should be tested when it comes out of the machine, again after resting in the carafes, and third time after poured into the serving cups. The temperatures should be 175-190 at the machine, 170-160 in the carafes, and 145-150 in the serve cups. On 1/9/25 at 4:45 PM, temperatures of the coffee were taken by V2 prior to serving for the dinner meal. At 4:50 PM, the coffee coming out of the machine was 153*F. At 5:05 PM, coffee in the carafes was at 135*F. V2 stated the carafes will be left open and allowed to rest until the temperature drops. At 5:30 PM, coffee was poured into serving cups and was at 129*F. V2 said any coffee served will be tested and recorded like this going forward. The temperatures will be taken at every meal and documented on the log. Any coffee temperatures higher than allowed with be left in the kitchen until it cools down. V2 said every cook will be trained on the procedure. The day cook has been trained already, the evening cook and any cooks in training will be trained tomorrow. The facility's undated Coffee Machine Temperature Monitoring Policy states under the procedure section: Designated dietary staff member will monitor coffee machine to assure it is operating within normal temperature limits. The facility's undated Hot Liquid Policy states under the guideline section: 2. The temperatures of hot liquids will be checked that they are in range by the dietary department .3.e. Disallow hot liquids while lying in bed. The facility was unable to provide any policy related to normal coffee temperature limits. The facility was unable to provide any policy related to when and how to monitor hot liquid temperatures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146066 If continuation sheet Page 3 of 3