Health inspection·November 25, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform a resident of of their plan of care. This failure affects one of three residents (R1) reviewed for resident's rights.Findings include:R1's admission Record dated 11/24/25 shows R1's diagnoses including End Stage Renal Disease, hypertensive heart and chronic kidney disease with heart failure, atherosclerotic heart disease, asthma, left kidney malignant neoplasm, paroxysmal atrial fibrillation, generalized anxiety disorder, anemia, insomnia, dependence on renal dialysis, hypertension, pain in right and left knees, osteoarthritis of knee, dorsalgia (pain in the back), chronic kidney disease, left shoulder osteoarthritis, obesity, hypothyroidism, presence of an artificial right knee joint, non-pressure chronic ulcer of the right lower leg, and goiter. R1's Minimum Data Set, dated [DATE] shows R1 is cognitively intact.On 11/24/25 at 10:16 AM, R1 said she doesn't know why her oxycodone (narcotic pain medication) was discontinued; no one discussed it with her. R1 said she asked repeatedly to speak to the nurse practitioner (NP), V8, but she never came. R1 said a nurse told her if someone stops taking a medication for a period of time, they could discontinue it. R1 said V8 just discontinued her oxycodone and all she is offered now is Tylenol.On 11/24/25 at 10:40 AM, V6, Licensed Practical Nurse (LPN), said R1 has oxycodone ordered as a scheduled dose, not as needed. V6 proceeded to look through orders on her computer and then said she didn't see it on R1's medication list. V6 said she wasn't aware of any changes in R1's oxycodone.On 11/24/25 at 2:13 PM, V9, LPN, said she always works on R1's wing. V9 said she doesn't know anything about R1's oxycodone being discontinued. V9 said it wasn't being discussed as a plan for R1. V9 said R1 still had oxycodone available the last time she worked. V9 said R1 also had scheduled Tylenol the last time she worked which was a new order for her. V9 said when she spoke to R1, about the scheduled Tylenol, R1 said she didn't know she was getting scheduled Tylenol. On 11/24/25 at 12:42 PM, V8 said prior to today, she probably last saw R1 in October. V8 said she doesn't think she discussed discontinuing R1's oxycodone at her last visit. V8 said she doesn't think anything specifically happened to trigger her to discontinue R1's oxycodone. V8 said she probably should have gone and discussed discontinuing R1's oxycodone with R1 prior to discontinuing it. V8 said she figured she would just discontinue it and see how it goes. R1‘s Order Summary shows V8 discontinued R1's oxycodone/acetaminophen 5-325 milligram tablet on 11/14/25 at 12:54 PM.V8's documentation of R1's last two visits dated 8/26/25 and 10/2/25 were reviewed and under the Plan section, both show R1 chart, vital signs, and medication list were reviewed and to continue orders and POC (Plan of Care). Neither visit documents plans to discontinue R1's oxycodone.R1's current care plan provided by the facility shows R1 has the potential to have pain due to weakness, dialysis, chronic pain, and arthritis. R1 has the potential for pain and receives opioid medications.The Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities booklet (Revised 11/18) shows residents have the right to participate in their own care, should receive the services and/or items Page 1 of 6 145142 145142 11/25/2025 Alden Debes Rehab & Hcc 550 South Mulford Avenue Rockford, IL 61108

F 0550 included in the plan of care and the facility must make arrangements to meet residents' needs and choices. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 145142 Page 2 of 6 145142 11/25/2025 Alden Debes Rehab & Hcc 550 South Mulford Avenue Rockford, IL 61108

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to ensure prescribed medications were acquired and provided for 1 of 3 residents (R1) in the sample of 3 reviewed for medication administration. Findings include:R1's admission Record dated 11/24/25 shows R1's diagnoses including End Stage Renal Disease, hypertensive heart and chronic kidney disease with heart failure, atherosclerotic heart disease, asthma, left kidney malignant neoplasm, paroxysmal atrial fibrillation, generalized anxiety disorder, anemia, insomnia, dependence on renal dialysis, hypertension, pain in right and left knees, osteoarthritis of knee, dorsalgia (pain in the back), chronic kidney disease, left shoulder osteoarthritis, obesity, hypothyroidism, presence of an artificial right knee joint, non-pressure chronic ulcer of the right lower leg, and goiter.R1's current care plan provided by the facility shows R1 requires long term use of prophylactic antifungal medication (fluconazole) for care and management of chronic healing surgical wounds. It is to be provided per physician's orders.R1's Medication Administration Record (MAR) for 10/1/25 to 10/31/25 shows R1 did not receive several medications in October of 2025 due to having no supply of medications to administer. R1 did not receive cetirizine (an allergy medication) on 10/15/25, 10/16/25, and 10/21/25, and 10/28/25, clonazepam (an anxiety medication) on 10/18/25, 10/19/25, 10/20/25, and 10/22/25 through 10/29/25, diltiazem HCL ER (a medication for R1's heart arrhythmia) on 10/20/25, 10/21/25, 10/22/25, 10/29/25 and 10/30/25, fluconazole (used to prevent surgical wound infection) on 10/20/25, 10/21/25, 10/22/25, 10/25/25, 10/26/25 and 10/28/25, Lyrica on 10/29/25, and amlodipine (a medication for high blood pressure) on 10/26/25 and 10/31/25.R1's Progress Notes dated 10/15/25 at 8:41 AM, 10/16/25 at 11:36 AM, 10/21/25 at 5:21 PM and 10/28/25 at 10:07 AM show cetirizine was not available or on order. R1's Progress Notes dated 10/18/25 at 8:02 PM, 10/19/25 at 10:01 PM, 10/20/25 at 9:03 PM, 10/22/25 at 8:44 PM, 10/23/25 at 8:34 PM, 10/24/25 at 9:14 PM, 10/25/25 at 7:48 PM, 10/28/25 at 7:54 PM, and 10/29/25 at 9:58 PM show R1's clonazepam was not available because it was either on order, waiting for delivery, awaiting delivery, not available, out, or no supply. R1's Progress Notes dated 10/20/25 at 11:24 AM, 10/21/25 at 5:21 PM, 10/22/25 at 9:35 AM, and 10/29/25 at 8:45 AM show R1's diltiazem HCL ER was either on order from pharmacy, on order, or unavailable. R1's Progress Notes dated 10/29/25 at 9:59 PM show R1's Lyrica was waiting for delivery. R1's Progress Notes dated 10/20/25 at 11:24 AM, 10/21/25 at 5:20 PM, 10/22/25 at 9:35 AM, 10/25/25 at 10:24 AM, 10/26/25 at 8:35 AM and 10/28/25 at 10:07 AM show R1's fluconazole was either on order from pharmacy, on order, or not available for administration. R1's Progress Notes dated 10/26/25 at 5:02 PM and 10/31/25 at 12:31 PM show R1's amlodipine was not available.On 11/24/25 at 10:40 AM, V6, Licensed Practical Nurse (LPN), said staff kept reordering R1's medications and they weren't being delivered. V6 said they eventually figured out the pharmacy wasn't sending R1's medications because of her bill.On 11/24/25 at 12:25 PM, V7, Social Services Director, said the nurses received a call from the pharmacy stating they wouldn't fill R1's medications again because she had a bill. V7 said the nurses informed her because she was the manager on duty.On 11/24/25 at 1:09 PM, V2, Assistant Administrator, said the pharmacy did say they were no longer able to provide R1's medications because her bill was so high.On 11/24/25 at 9:32 AM, V4, Assistant Director of Nursing (ADON), said if they don't have the medications, she wouldn't be able to give them.On 11/24/25 at 1:56 PM, V3, Director of Nursing (DON), said V7 informed her that R1 has a huge bill to the pharmacy which was not paid. R1's pharmacy bill was not paid, and they were not sending R1's medications for a period. V2 said she thinks there have been a couple times when R1 has gone without her medications while awaiting delivery from the pharmacy. V3 said R1 is a human being, and she needs her medications. On 11/24/25 at 3:55 PM, V3 said she does not know how long R1 was 145142 Page 3 of 6 145142 11/25/2025 Alden Debes Rehab & Hcc 550 South Mulford Avenue Rockford, IL 61108

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few out of her medications; maybe a few days. V3 could not provide the exact dates. V3 said when the nurses chart a code 9 on the MAR it means they are holding the medication due to a number of different reasons. V9 said she encourages her nurses to put a note in just to make sure they can document what happened. V3 said there isn't much difference between a code 9 and a code 5 when documenting on the MAR; the medication is being held (not given). V9 said the nurse doesn't always put in a progress note when they hold a medication, but she encourages it. V3 said they wouldn't document a 9 if they administered the medication. V3 said she doesn't know if there is a policy on what to do if a resident isn't receiving their medications from the pharmacy.On 11/24/25 at 12:42 PM, V8, Nurse Practitioner (NP), said the facility contacted her and said they were not getting R1's medications from the pharmacy. V8 said the facility should be providing the essentials to the residents, including medications. V8 said she told the facility they need to figure it out as R1 needs her medications.On 11/24/25 at 2:13 PM, V9, LPN, said during nurse-to-nurse report, she was told that the nurses kept reordering R1's medications and they were not being delivered. V9 said she was told the day shift nurse got a call from the pharmacy and the pharmacy said they weren't going to send R1's medications because she had an outstanding balance. V9 said she works the evening shift (2:00 PM to 10:00 PM) and the medications R1 was went without were Klonopin (also known as clonazepam) and Lyrica (used to treat nerve pain). V9 said she cannot give a medication they don't have.On 11/25/25 at 10:01 AM, V1, Administrator, the facility is ethically and legally responsible to provide the care and medications R1 needs regardless of whether R1 was paying her bill or not. The facility's Medication Administration: General Guidelines Policy (dated 01/2022) shows all medications shall be administered as prescribed. 145142 Page 4 of 6 145142 11/25/2025 Alden Debes Rehab & Hcc 550 South Mulford Avenue Rockford, IL 61108

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to administer cardiac medications as prescribed to 1 of 3 residents (R1) with a heart arrhythmia, heart disease, kidney disease, and hypertension in the sample of 3 reviewed for medications.Findings include:R1's admission Record dated 11/24/25 shows R1's diagnoses include, but are not limited to, End Stage Renal Disease, Hypertensive heart and chronic kidney disease with heart failure, atherosclerotic heart disease, asthma, left kidney malignant neoplasm, paroxysmal atrial fibrillation, generalized anxiety disorder, anemia, insomnia, dependence on renal dialysis, hypertension, pain in right and left knees, osteoarthritis of knee, dorsalgia (pain in the back), chronic kidney disease, left shoulder osteoarthritis, obesity, hypothyroidism, presence of an artificial right knee joint, non-pressure chronic ulcer of the right lower leg, and goiter.On 11/24/25 at 10:40 AM, V6, Licensed Practical Nurse (LPN), said staff kept reordering R1's medications and they weren't being delivered. V6 said they eventually figured out the pharmacy wasn't sending R1's medications because of her bill.On 11/24/25 at 2:13 PM, V9, LPN, said during nurse-to-nurse report, she was told that the nurses kept reordering R1's medications and they were not being delivered. V9 said she was told the day shift nurse got a call from the pharmacy and the pharmacy said they weren't going to send R1's medications because she had an outstanding balance. V9 said she cannot give a medication they don't have.On 11/24/25 at 9:32 AM, V4, Assistant Director of Nursing (ADON), said if they don't have the medications, she wouldn't be able to give them.On 11/24/25 at 1:56 PM, V3, Director of Nursing (DON), said V7 informed her that R1 has a huge bill to the pharmacy which was not paid. R1's pharmacy bill was not paid, and they were not sending R1's medications for a period. V2 said she thinks there have been a couple times when R1 has gone without her medications while awaiting delivery from the pharmacy. V3 said R1 is a human being, and she needs her medications. On 11/24/25 at 3:55 PM, V3 said she does not know how long R1 was out of her medications; maybe a few days. V3 could not provide the exact dates. V3 said when the nurses chart a code 9 on the MAR it means they are holding the medication due to a number of different reasons. V9 said she encourages her nurses to put a note in just to make sure they can document what happened. V3 said there isn't much difference between a code 9 and a code 5 when documenting on the MAR; the medication is being held (not given). V9 said the nurse doesn't always put in a progress note when they hold a medication, but she encourages it. V3 said they would NOT document a 5 or a 9 if they administered the medication. V3 looked up Diltiazem and Amlodipine and said Diltiazem is a blood pressure (BP) medication and Amlodipine can be used for BP, chest pain, and/or coronary artery disease. V3 said those can be significant medications to go without.On 11/24/25 at 12:42 PM, V8, Nurse Practitioner (NP), said the facility contacted her and said they were not getting R1's medications from the pharmacy. V8 said the facility should be providing the essentials to the residents, including medications. V8 said she told the facility they need to figure it out as R1 needs her medications.On 11/25/25 at 10:01 AM, V1, Administrator, the facility is ethically and legally responsible to provide the care and medications R1 needs regardless of whether R1 was paying her bill or not. R1's Medication Administration Record (MAR) for 10/1/25 to 10/31/25 shows R1 did not receive several medications in October of 2025 due to having no supply of medications to administer. R1 did not receive Diltiazem HCL ER (a medication for R1's heart arrhythmia (atrial fibrillation) on 10/20/25, 10/21/25, 10/22/25, 10/29/25 and 10/30/25 and Amlodipine (a medication for high blood pressure) on 10/26/25 and 10/31/25. R1's MAR for 10/1/25 to 10/31/25 shows R1 had an active order written on 10/24/25 for Amlodipine to be administered each evening. That order was discontinued on 10/29/25 and Amlodipine was ordered to be administered each morning on 10/29/25. Diltiazem HCL ER was ordered to be administered once daily on 5/6/25 for atrial fibrillation and Residents Affected - Few 145142 Page 5 of 6 145142 11/25/2025 Alden Debes Rehab & Hcc 550 South Mulford Avenue Rockford, IL 61108

F 0760 Level of Harm - Minimal harm or potential for actual harm scheduled at 8:00 AM.R1's Progress Notes dated 10/20/25 at 11:24 AM, 10/21/25 at 5:21 PM, 10/22/25 at 9:35 AM, and 10/29/25 at 8:45 AM show R1's Diltiazem HCL ER was either on order from pharmacy, on order, or unavailable. R1's Progress Notes dated 10/26/25 at 5:02 PM and 10/31/25 at 12:31 PM show R1's Amlodipine was not available.The facility's Medication Administration Policy (dated 09/2020) shows drugs must be administered in accordance with the written orders of the attending physician. Residents Affected - Few 145142 Page 6 of 6