Health inspection·November 22, 2025

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure narcotic medication was safely stored and failed to ensure medications were administered for 2 of 4 (R1, R3) residents reviewed for medication storage and administration in the sample of 4.The findings include:1. The facility's undated and unsigned incident summary documents on 11/7/25, nursing staff on the behavioral care unit reported narcotic medications assigned to 2 residents were missing. A facility-wide search was immediately initiated. During the interview process, it was determined the medication cart had been left unlocked while the assigned nurse was within visible distance. This lapse in medication security allowed R1 to open the cart, remove several narcotic medications, and take them into his room with the intention of hiding them. On 11/22/25 at 1:00 PM, V8, Registered Nurse (RN), said he was working on the behavioral unit on 11/7/25, when he discovered missing narcotic medications in his medication cart. V8 said towards the end of his shift, he was verifying the count in his cart when he found 2 cards of Xanax (controlled medication) missing. He said the Director of Nursing was immediately notified. He said after searching the unit, the medication cards were found in R1s room. He does not know how R1 would have gotten the medications out of his cart. V8 said he had his keys throughout the shift, and the cart was within view. R1s face sheet documents he was admitted to the facility on [DATE], with multiple diagnoses including major depressive disorder, recurrent, severe with psychotic symptoms, and disorganized schizophrenia. The 10/29/25 quarterly resident assessment and care screening documents he is cognitively intact. R1s 8/31/23 care plan notes he displays socially inappropriate behaviors due to his poor impulse control and psychosis such as taking things that do not belong to him or disregarding rules that interfere with his immediate desires.On 11/22/25, R1 said he was compliant with taking his medications from the nurse. He denied taking any medication cards from the medication cart.On 11/22/25 at 10:20 AM, V4, Licensed Practical Nurse (LPN), said R1 wanders the unit and takes medications. The nurse must stay with him to ensure he takes them. She said the nurse is the only person with the keys to the medication cart. It must be locked when stepping away. She was not sure what had happened, but somehow R1 ended up with medication cards in his room. She said there was a meeting about not leaving keys on the medication cart.On 11/22/25 at 12:00 PM, V3, Corporate Nurse, said V8 was assigned to the behavioral unit for 2nd shift. Towards the end of the shift, 2 narcotic medication cards were missing, and it was reported to V9, Director of Nursing. After the cart was re-checked, a search was conducted. V3 said V8 reported to him the medication cart had been locked. V3 said he determined the medication cart was located at the nurse's station and V8 was there with another resident. R1 came around the cart and opened the drawer. V3 could not say is the drawer was locked for sure, but R1 had 2 cards of Xanax. V3 said the medication cards were intact and R1 had not removed any of the pills. On 11/22/25, the behavioral unit medication cart was observed to be locked when unattended, and V4 was the only nurse working on the unit. She unlocked (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 11/22/2025 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)