Inspection·December 7, 2025

F 0686 Level of Harm - Actual harm Residents Affected - Few telehealth and when she saw the wound it was unstageable. V5 stated she couldn't see the wound bed because of the slough. V5 stated R1's wound was identified on 8/26/25 and she gave orders on 8/27/25. V5 stated they do a skin check on admission then skin checks are done twice per week with showers and when skin care is done. If there are any areas of concerns, then staff should alert the nurse. V5 stated she did not have an opinion on what happened for R1 until she talked to V1 Administrator. V5 came back and stated R1 didn't have anything (pressure injury) and then a few weeks later there was an unstageable area. V5 stated this is what she is supposed to say. V5 stated when there is an area of concern it should be identified when the area is red.On 12/7/25 at 4:00 PM, V2 Director of Nursing - DON stated, staff are to monitor skin when providing care. Staff are to monitor skin with changing, washing, etc. V2 stated anything unusual and/or not there previously should be reported to nursing. Areas of redness should be reported to nursing. Stage 1 and Stage 2 should be identified and reported right away. V2 stated R2 had a blister when it was identified. V2 stated in general they put preventative measures in place such as pressure relief mattress, supplements, floating heels, and wound care clinic referral.The Care Plan dated 8/26/25 for R1 showed, resident has unstageable pressure injury to coccyx (identified on 8/26/25). Air mattress to bed. Cushion to chair. Reposition at least every 2 hours as needed.The Minimum Data Set - MDS dated [DATE] for R1 showed severe cognitive impairment; dependent for toileting hygiene, shower/bath, and lower body dressing. Substantial/maximal assistance needed for personal hygiene, and upper body dressing. Transfers and rolling in bed were not attempted due to medical condition or safety concerns. The facility's Pressure Ulcer Prevention Policy Protocol (no date) showed, Plan: Reduce or eliminate pressure. Promote optimum mobility. Prevent skin breakdown. Intervention: Implement change of position on resident individual basis. Use preventive intervention support surfaces (as pressure-relieving heel devices, pillows, chair cushions, pressure relieving mattresses). Use of proper positioning, transferring, and turning techniques. Skin inspections. Manage urinary and/or fecal incontinence. Evaluation: Monitor skin as appropriate.The facility's Pressure Sore Policy (no date) stated residents with pressure sores, skin lesions/wounds will be monitored and documented. When the nurse is aware of pressure sores, skin lesions, wounds, venous ulcers or other skin abnormalities, the area is to be assessed, reported to clinician and documented.2. On 12/7/25 at 10:10 AM V3 Registered Nurse -RN and V4 Certified Nursing Assistant - CNA put on gown and gloves and went into R2's room for the dressing change to his right heel. V3 stated R2 has diabetes and edema; the edema led to a blister on his heel that opened. V3 stated she had seen R2 two days before the blister opened and he didn't have anything on his right heel. V3 stated R2 has a paste impregnated gauze bandage to his right leg/foot. V3 took her scissors and cut the elastic bandage from his right leg and foot. V3 then cut the paste impregnated gauze bandage from R2's right lower leg/foot and discarded it. V3 grabbed the wound cleanser from the table in his room, sprayed R2's right heel and the rest of the adhered dressing came off R2's heel. The dressing had black and yellow substance on it. V3 grabbed the collagenase ointment and applied it with her finger to the heel wound. V3 applied collagenase to two small open areas on R2's right lower leg. V3 applied abdominal pads to R2's right heel and over the two open areas on R2's leg. V3 took the paste impregnated gauze bandage with zinc and applied it to R2 's right heel/foot and lower leg. V3 took the paste impregnated gauze bandage with zinc and applied it to his left foot/heel and lower leg. V3 applied self-adherent elastic wrap over the top of the paste impregnated gauze bandage. V4 held R2's leg during the dressing change. V3 picked up trash in room and discarded it. V3 picked up the wound cleanser, zinc, and her scissors from the table, sat them down on R2's nightstand, removed her gloves, picked up the wound cleanser, scissors and zinc, and left the room. V3 stopped just outside the door of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146066 If continuation sheet Page 2 of 5 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 12/07/2025 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 0686 Level of Harm - Actual harm Residents Affected - Few R2's room, sat the wound cleanser, collagenase, and her scissors down on a PPE (personal protective equipment) container, used hand sanitizer and then picked the items up. V3 carried the items to the wound cart and sat them on top of the cart. V3 put the wound cleanser in the cart and the collagenase. V3 grabbed alcohol wipes and cleaned off her scissors. V3 was asked when gloves are to be changed, and she stated she could have changed her gloves between legs. V3 was asked if she could have changed her gloves after removing the soiled dressing and before putting on the clean one for infection control etc. V3 replied yes and said that made sense. V3 stated R2's feet are checked daily; the paste impregnated gauze bandage doesn't come off unless there is a reason to remove them. V3 stated the paste impregnated gauze bandage is done twice a week. The offloading boot was not put back on R2's heel before staff left the room and a soiled blue foot cover was left laying on a table in his room. The foot cover had some type of drainage on the inside of it where his heel would have been. R2 stated staff do not reposition him every two hours; he stated he is transferred from bed to recliner to wheelchair for meals and back to his recliner and/or bed. On 12/7/25 at 1:00 PM, V6 RN/Wound care Nurse stated, R2's pressure ulcer started as a blister on his right heel and was a blister when it was first identified. V6 stated the blister ruptured, the skin fell off, and there was a wound bed that was dry with necrotic tissue. It changed to an unstageable pressure injury, and he went to the wound clinic for that. V6 stated R2 is supposed to have both heels offloaded to prevent a pressure ulcer to the left side too. V6 stated gloves are to be changed during dressing changes/wound care after the old dressing is taken off gloves should be removed, hand sanitizer used, and new gloves applied. This is important to prevent contamination and infection.On 12/7/25 at 4:00 PM, V2 Director of Nursing DON stated, staff are to monitor skin when providing care. Staff are to monitor skin with changing, washing, etc. V2 stated anything unusual and/or not there previously should be reported to nursing. Areas of redness should be reported to nursing. Stage 1 and Stage 2 should be identified and reported right away. V2 stated R2 had a blister when it was identified. V2 stated in general they put preventative measures in place such as pressure relief mattress, supplements, floating heels, and wound care clinic referral.The Monthly Pressure Injury Report dated November 2025 showed R2 had a stage 2 facility acquired pressure injury to his right buttock that was identified at the facility on 10/2/25. R2 had an unstageable facility acquired pressure injury to his right great toe that was identified on 11/13/25 that was later put at a stage 2. R2 had a facility acquired right heel pressure injury that was identified at a stage 2 on 11/13/25 and changed to unstageable on 11/24/25. R2 had a facility acquired stage 2 right groin pressure injury that was identified at a stage 2 on 11/17/25.The Weekly Wound Assessment and Summary for R2 showed right heel pressure ulcer stage 2 with an onset date of 11/13/25. The measurements on 11/13/25 were 9.0 cm x 10.0 cm; wound bed with granulation tissue; moderate serosanguinous exudate; surrounding skin reddened. The Weekly Summary dated 11/13/25 for R2 showed the blister ruptured to his right heel. The upper half of the skin peeled back and put back over granulation tissue. R1's foot was swollen, and the skin appeared white/macerated from the drainage. Floating heels and a wound clinic referral were recommended.The Weekly Wound Assessment and Summary for R2 on 11/24/25 showed R2's right heel wound was changed to unstageable due to necrotic tissue. The Weekly Summary dated 11/24/25 for R2 showed there was 70 percent dry necrotic tissue in the center of the wound of his right heel that was surrounded by 30 percent granulation tissue. The edges of the wound were dry with some skin from the blister intact. The wound was changed to an unstageable pressure injury. Floating heels, monitoring of swelling to bilateral lower extremities was recommended and wound clinic appointment on 11/25/25.The Physician Order's for R2 showed, 11/23/25 - float heels every shift, Collagenase topical every evening shift weekly on Tuesday and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146066 If continuation sheet Page 3 of 5 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 12/07/2025 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 0686 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Friday. Apply nickel thick collagenase to right great toe wound. Apply abdominal pad and wrap leg in paste impregnated gauze bandage from toes to bend in knee.The Care Plan dated 11/25/25 for R2 showed, resident has an unstageable pressure injury to his right heel (stage 2 when identified on 11/13/25; became unstageable on 11/24/25). Resident has a stage 2 pressure injury to right buttock (identified on 10/2/25). Reposition resident at least every two hours and as needed. Recliner for repositioning during the day. Resident has a stage 2 pressure injury to the right great toe. No shoes. Reposition at least every two hours. Encourage resident to float heels while in bed.Resident has a stage 2 pressure injury to the right groin (identified on 11/17/25). Reposition resident at least every two hours and as needed. Monitor positioning of briefs. Every pressure injury stated to provide treatment as ordered; monitor and report if ineffective. R2's care plan did not show any behaviors to include refusal of care.The Progress Notes for November 2025 through 12/6/25 for R2 did not show any non-compliance with care.The Minimum Data Set (MDS) dated [DATE] for R2 showed no cognitive impairment; substantial/maximal assistance with rolling in bed; dependent for transfers, toileting hygiene, lower body dressing, and putting on/taking off footwear.The facility's Pressure Ulcer Prevention Policy Protocol (no date) showed, Plan: Reduce or eliminate pressure. Promote optimum mobility. Prevent skin breakdown. Intervention: Implement change of position on resident individual basis. Use preventive intervention support surfaces (as pressure-relieving heel devices, pillows, chair cushions, pressure relieving mattresses). Use of proper positioning, transferring, and turning techniques. Skin inspections. Manage urinary and/or fecal incontinence. Evaluation: Monitor skin as appropriate.The facility's Wound Dressing Change Policy (no date) showed, put on gloves. Remove soiled dressings and discard in appropriate container. Remove gloves, wash hands or use no rinse sanitizer and put on clean gloves. Cleanse wound with prescribed solution. Remove gloves and wash hands with soap and water. Apply prescribed dressings. Date and initial dressing. Remove gloves and assist resident to a comfortable position. Clean and return equipment to designated area. Event ID: Facility ID: 146066 If continuation sheet Page 4 of 5 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 12/07/2025 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 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 wore personal protective equipment when providing a dressing change for 1 of 3 residents (R3) reviewed for wounds in the sample of three.The findings include:On 12/7/25 at 2:25 PM, R3 was laying in bed and V3 Registered Nurse - RN was at bedside with gloves on and had just completed the wound vac dressing change to R3's right knee. V3 did not have a gown on. V6 RN/Wound Care Nurse entered R3's room wearing a gown and gloves to troubleshoot the wound vac dressing. After V3 and V6 left R3's room, R3 stated V3 did not have a gown on when she did her dressing change. On 12/7/25 at 4:00 PM, V2 Director of Nursing stated gown and gloves are to be worn when doing close contact care to prevent contamination and infection. The Care Plan dated 11/6/25 for R3 showed, resident on isolation related to methicillin resistant staphylococcus aureus - MRSA of nares, MRSA of right knee surgical wound revision. Protective personal equipment to be worn during cares.The Physician Orders dated 11/6/25 for R3 showed maintain contact isolation precautions for MRSA in right knee wound every shift.The Minimum Data Set - MDS dated [DATE] for R3 showed no cognitive impairment.The facility Health care Body Check Form dated 12/3/25 for R3 showed she has a surgical wound to her right knee. The wound measured 8.4 cm x 1.6 cm and had 13 cm of tunneling present at 12 o'clock. R3 had a wound vac in place that is changed on Monday, Wednesday, and Friday.The facility's Policy: Infection Control (no date) showed, all staff who have contact with residents and/or their environments must wear personal protective equipment - PPE as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infectious materials is likely. Wear PPE (e.g. gloves, gowns, etc.) when handling resident care equipment and instruments/devices that are visibly soiled or may have been in contact with blood or body fluids.The Facility's Contact Precautions policy (no date) showed gloves and gown are to be worn if there is contact with or potential contact with body fluids (except sweat), secretions, excretions, and mucous membranes are to be worn when administering direct patient care.The facility's Policy: Enhance Barrier Precautions showed enhance barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multi-drug resistant organisms that employs targeted gown and glove use during high contact resident care activities. High contact resident care activities include: h. Wound care: any skin opening requiring a dressing. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146066 If continuation sheet Page 5 of 5