Alden Debes Rehab: Heart Medication Gaps Found - IL
The resident, identified in inspection records only as R1, was prescribed two medications used to manage heart conditions: Diltiazem HCL ER, a calcium channel blocker used to control heart rate and blood pressure, and Amlodipine, another calcium channel blocker prescribed for similar purposes. Both went missing from the medication cart on multiple occasions, and nurses noted the gaps in progress notes rather than resolving them.
Progress notes from October 20, October 21, and October 22 each documented that R1's Diltiazem was either "on order from pharmacy," "on order," or "unavailable." A note from October 29 repeated the same. On October 26 and again on October 31, nurses recorded that R1's Amlodipine was not available.
Six entries. Eleven days. The medications were never noted as administered on those dates.
The facility's own medication administration policy, last updated in September 2020, states that drugs must be given in accordance with the written orders of the attending physician. R1 had a physician's order for both medications. The order didn't change. The medications simply weren't there.
What the progress notes don't show is what happened next, whether anyone called the prescribing physician to report the gaps, whether a pharmacist was contacted urgently, or whether R1 was monitored more closely on the days the doses were missed. The inspection report documents the absences. It does not document any corrective action taken in the moment.
Diltiazem HCL ER and Amlodipine are both prescribed to manage cardiovascular conditions, and neither is a medication a patient takes once and forgets. They work by keeping levels consistent in the bloodstream over time. A missed dose is not simply a gap on a chart. For a resident whose physician determined these medications were necessary, the days without them were days the treatment plan wasn't being followed.
Federal inspectors cited the facility under F0760, the deficiency tag covering free from medication errors, and classified the level of harm as minimal harm or potential for actual harm. The citation notes that few residents were affected.
That classification reflects the federal framework inspectors use to categorize findings, not a determination that nothing went wrong for R1. The resident received a physician's order for two heart medications and, on at least six recorded days across October, did not receive them. The notes nurses left behind suggest they were aware of the shortages each time. The notes do not suggest the problem was fixed quickly.
Alden Debes Rehab & Health Care Center is a long-term care and rehabilitation facility in Rockford. The November inspection was complaint-driven, meaning someone, whether a resident, family member, or staff, filed a complaint that prompted regulators to investigate.
The inspection report runs six pages. The medication deficiency appears on the final page.
What it describes is a month in which a nursing home resident needed heart medication, the pharmacy either didn't send it or ran out, and the facility's response, as documented in its own records, was to write it down and move on. October 20. October 21. October 22. October 26. October 29. October 31. Each time, a nurse charted that the medication wasn't there. Each time, the note ended.
R1's physician had written the orders. The pharmacy was apparently on notice. The policy said doses must follow physician orders. None of that, on those six days, produced the medication.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alden Debes Rehab & Hcc from 2025-11-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 22, 2026 · Our methodology
ALDEN DEBES REHAB & HCC in ROCKFORD, IL was cited for violations during a health inspection on November 25, 2025.
Both went missing from the medication cart on multiple occasions, and nurses noted the gaps in progress notes rather than resolving them.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.