Health inspection·August 1, 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. Based on interview and record review, the facility failed to treat a resident in a dignified manner by not ensuring an incontinent resident was changed for 1 of 1 resident (R1) reviewed for dignity in the sample of 3. The findings include: R1's face sheet, printed on 8/1/25, showed diagnoses including but not limited to paraplegia, pressure ulcer of the sacral region stage 4 (lower area of the spine), third degree burns to the left and right lower legs, clostridium difficile (bacterial infection of the colon), neuropathic bladder, and chronic embolism/thrombosis of deep veins of right lower extremity. R1's facility assessment, dated 7/23/25, showed total staff dependence for toileting hygiene, dressing lower body, rolling, and transfers. The same assessment showed R1 is always incontinent of bowel. On 8/1/25 at 9:10 AM, R1 was seated in bed in her room. R1 was alert, oriented, and talkative. R1 stated she is a paraplegic and needs help from staff with brief changes. R1 said she had terrible diarrhea a few nights ago and needed her brief changed multiple times in one evening. R1 said around 9:45 PM, she put on her call light and was told by the CNA (Certified Nursing Assistant) her shift was ending and the next aide on duty would come in to change her. R1 said no staff checked on her or changed her until around 6:15 AM the next morning. R1 said V2 (Wound Care Nurse) was the person who finally came into her room that morning and got her cleaned up. On 8/1/25 at 9:35 AM, V3 (Certified Nurse Aide) stated, (R1's) mental cognition is good. She is totally with it. (R1) is paralyzed from the waist down and needs to be checked for incontinence several times each shift. (R1) cannot feel if she is wet or soiled. On 8/1/25 at 11:05 AM, V2 (Wound Care Nurse) stated R1 is alert and oriented times four. V2 said she did see R1 that morning, and she did have stool in her brief. V2 said R1 was complaining that it had been a long wait to be changed, but did not recall the exact length of time. V2 said R1 had diarrhea overnight and a smell was present in the room. V2 said the sheets had stool on them and looked like they needed to be changed. V2 said, It is important to keep residents clean. Stool can cause infection and is gross to lay in. Staff should be checking residents at least every two hours, especially those that are bed bound and need help turning. On 8/1/25 at 1:26 PM, V1 (Director of Nurses) stated staff do overnight bed checks for safety and incontinence every two hours. V1 said R1 does need bed checks during the night. Residents should be changed immediately to stop wound infections and to stop skin break down. It is a dignity thing too. No one wants to be laying in a dirty brief.The facility's Routine Resident Checks policy, dated 9/2020, states: 1. To ensure the safety and well being of our residents, a resident check will be made at least every two (2) hours throughout each 24-hour shift by nursing service personnel. 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 3 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 08/01/2025 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)