Inspection visit
Inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
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 a resident received assistance with
showers. This applies to 1 of 3 (R2) residents reviewed for activities of daily living in the sample of 4. The
findings include: On 2/4/26 at 12:05 PM, R2 was in her room sitting in a chair. There was no contact
isolation sign posted outside of her room. R2's hair covering was in place, and she did not have a shower
stall in her bathroom. R2 said when she was admitted on [DATE], she was on isolation for a blood infection.
She was asking staff if she could shower, staff told her she could not leave the room because she was in
isolation. R2 said yesterday 2/3/26, she got off isolation and finally got a shower (11 days later). R2 said
she smelled bad and that was the worst not being able to shower that long.On 2/5/26 at 9:08 AM, V11
(Certified Nursing Assistant-CNA) said residents should receive showers twice a week. If a resident is in
contact isolation, they can leave their room to shower. On 2/5/26 at 11:24 AM, V9 (CNA) said R2 was in
isolation for a while she did not assist R2 with showering and certain residents could leave their room to
shower. On 2/5/26 at 11:48 AM, V7 (RN) confirmed R2's contact isolation was discontinued on 2/3/26 and
she received a shower. R2 mentioned she had not received a shower prior. R2's current care plan shows
she has a deficit (ADL) performance deficit with interventions including assisting with setting up supplies for
bathing, assist with personal hygiene, assist with ADL tasks. R2's care plan shows she was on contact
isolation precautions. R2's Bath/Shower Report provided on 2/5/26 shows she did not receive showers
twice a week. The facilities Bath/Tub or Shower policy dated 7/25 states, To provide cleanliness and comfort
to the resident, to assist in bathing . to prevent body odors.
Residents Affected - Few
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:
145142
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
145142
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/05/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alden Debes Rehab & Hcc
550 South Mulford Avenue
Rockford, IL 61108
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
FORM CMS-2567 (02/99)
Previous Versions Obsolete
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 safety interventions were in place for a
resident at risk for falls. This applies to 1 of 3 (R2) reviewed for safety in the sample of 4. The findings
include: R1's face sheet shows she has diagnoses including osteomyelitis, palliative care, type 2 diabetes,
heart disease, chronic kidney disease stage 3, hypertension, mild cognitive impairment, and lymphedema.
R1's Fall Incident Report dated 2/1/26 documents (R1) observed on the floor on the right side of her bed
lying on he left side. CNA at bedside stated she got weak and let go. Right side of forehead lump with
swelling, right eye bruising, chin abrasion, right elbow small cut, right ring finger bruise and small cut and
left knee bruising. R1's current care plan shows she is at risk for falls, self care deficit performance, requires
assistance from staff with bed mobility, interventions include use side rail support, cue resident to grasp
side rail for positioning.On 2/4/26 at 12:58 PM, R1 was lying in large bariatric bed, her eyes closed and did
not respond to her name after several attempts. A large dark purple/greenish bruise was to the right side of
her eye/forehead area and a small laceration to her chin. R1's bedside table was located to the right side of
her bed and thick bilateral floor mats on the floor. On 2/4/26 at 1:02 PM, V14 (Certified Nursing
Assistant-CNA) said R1 fell from her bed during care. R1 was a one person assist with bed mobility now
she is a two person assist. She did not have side rails in place prior to the fall, she can hold on to the side
rails for bed mobility and should have both floor mats on the floor. On 2/4/26 at 1:12 PM, V5 (Licensed
Practical Nurse-LPN) said she was R1's nurse when she fell on 2/1/26. V10 (CNA) reported R1 fell when
she was changing her in the bed. R1 fell towards the right side of her bed where the bedside table was
located. I'm guessing she hit her head on the bedside table. The floor mats were not on the floor when she
entered the room. R1 sustained a right black eye, scrap to her chin, and bruising to her left knee. V5 said
she notified, the physician, hospice and left a message for R1's guardian. R1 did not have side rails in place
prior to the fall, they just put them up after the fall. R1 can hold on to the side rails with bed mobility. On
2/5/26 at 8:53 AM, V10 (CNA) said on 2/1/26, she was providing incontinence care to R1. She rolled R1 to
her side and she was holding on the bedside table because she did not have side rails in place. V5 said one
hand was on R1's body and with the other hand she leaned back trying to get the towel and she left go of
the bedside table and rolled off the bed. R1 usually is able to hold on the bedside table but she said she got
weak and let go. V10 said she put the floor mats up during cares and R1 needs something to hold for bed
mobility.R1's Restorative Nursing assessment dated [DATE] shows R1 is on a bed mobility program. R1 will
role side to side during care and repositioning, using side rails as needed . the use of side rails is indicated
and serves as an enabler to promote independence. On 2/5/26 at 9:58 AM, V6 (Restorative Nurse) said
confirmed R1 is on a bed mobility program and should have side rails for bed mobility. V6 said if side rails
are indicated for bed mobility he would in the request order for the side rails. I don't know why side R1 did
not have the side rails on. He is not sure who is responsible for making sure side rails are in place. R1's
strength levels vary day to day, if she is weak she should have something to hold onto. V6 said it's okay for
residents to hold on to the equipment including bed side table, windowsill for extra piece of mind. The
facility's Management of Falls Policy states, The facility will assess hazards and risks, develop a plan of
care to address hazards and risks, implement appropriate interventions and revise the resident's plan in
order to minimize the risks for fall incidents and/or injuries to the resident.
Event ID:
Facility ID:
145142
If continuation sheet
Page 2 of 2
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
FAQ · About this visit
Common questions about this visit
What happened during the February 5, 2026 survey of ALDEN DEBES REHAB & HCC?
This was a inspection survey of ALDEN DEBES REHAB & HCC on February 5, 2026. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ALDEN DEBES REHAB & HCC on February 5, 2026?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide care and assistance to perform activities of daily living for any resident who is unable."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.