Inspection·June 6, 2024

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to store medication in a manner to prevent diversion for 2 residents (R8, R9) in 5 med rooms reviewed for medication storage in the sample of 13. The findings include: On 6/5/24 at 10:15 AM, all five medication rooms were checked for medication storage compliance. V5, Registered Nurse (RN), unlocked the A wing medication room door. This surveyor opened the unlocked refrigerator. The refrigerator contained an unopened bottle of morphine sulfate liquid on the top shelf. The bottle label showed it was issued for R8. The C wing medication room was unlocked by V6, RN. This surveyor opened the unlocked refrigerator. The refrigerator contained two ABHR suppositories in a clear plastic baggie on a shelf. The label on the baggie showed it was issued for R9. At 10:20 AM, V6 was asked what ABHR stood for. V6 looked the information up on his phone and said it stood for Ativan, Benadryl, Haldol and Reglan. On 6/6/24 at 8:55 AM, V2, Director of Nursing (DON), said morphine and lorazepam should be stored under two locks. It's a controlled drug and could be misused or abused. R8's 5/30/24 hospice record showed a physician signed order for morphine concentrate 100 milligram (mg)/5 milliliter (ml) (20mg/ml) oral solution. Administer 0.25ml (5 mg) orally or sublingually every 1-2 hours as needed. For pain or dyspnea. R8's record showed she was a current facility resident. The facility's 9/2022 Medication Pass Guidelines showed Schedule II controlled substances must be kept double locked. It is a good practice to keep all controls under double lock. The Drug Enforcement Administration (DEA) website showed morphine was a Schedule II narcotic under the Controlled Substances Act. R9's 11/30/23 hospice orders showed a physician signed order for ABHR suppository (Ativan 0.5 mg; Benadryl 25 mg; Haldol 0.5 mg; Reglan 10 mg;), 1 suppository rectally, every four hours as needed for nausea or vomiting. R9's record showed he passed away in the facility on 4/5/24. (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: 145259 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 145259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Park Strathmoor 5668 Strathmoor Drive Rockford, IL 61107 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)