Alden Park Strathmoor
Inspection Findings
F-Tag F0755
F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
the cart when passing medications and locked the cart when stepping into resident rooms.2. Resident R3 admission
record shows an admit date of 6/3/25, with multiple diagnoses including aphasia (difficulty speaking) following a cerebral infarct (stoke), vascular dementia, and major depressive disorder. The 9/8/25 quarterly resident assessment and care screening documents her to have moderate cognitive impairment. The undated care plan showed she is resistive to care. She will also refuse/resist medications at times; including spitting medications out after administration despite education/encouragement and incentivized programming from staff.R3s nursing progress notes of 10/8/25 at 10:13 PM, show the counselor found in her room several pills that had been hidden by resident. DON aware and demanded 15-minute checks, and for the nurse to be aware of that behavior and assure the resident is taking her pills properly.On 11/22/25 at 12:00 PM, V3, V1 Administrator, and V7, Assistant Director of Nursing, said they were unaware of the incident. V3 said nurses should be staying with residents while administering medications and make sure
they are not cheeking the pills.On 11/22/25 at 12:30 PM, V10, Behavioral Health Director, said, We found
the pills in her room where she had spat the pills back into a cup following one of her medication administrations. I do not recall the number of pills, but it appeared to have been from 1 med pass. She was
on daily room checks because she tends to hoard things. I gave the pills to the nurse to verify if they were hers. That is one of her behaviors, refusing her medications. On 11/22/25 at 1:00 PM, V8 said the [NAME] did find the medications and it looked like they were wet and had been spit out. He did not know how long
she had those and was not able to identify the pills. He said when giving medications, the nurses are supposed to make sure the resident takes the pills and have them open their mouth to make sure they are taken. Resident R3 is pretty compliant with doing the mouth check if you just ask her. V8 said Resident R3 has a history of cheeking and pocketing her medication.On 11/22/25, Resident R3 said she was not going to take her medications. Resident R3 was alert but confused and had difficulty expressing her thoughts. Her room was located on the behavioral unit. On 11/22/25 at 10:20 AM, V4 said the nurse should stay with a resident to make sure they take their medications. On 11/22/2025 at 10:18 AM, Resident R2 said he receives his medications daily when scheduled but did indicate two weeks ago, an African American agency nurse had come into his room on
the evening shift and set a med cup that contained pills and a cup of water on my bedside table. Resident R2 then indicated that this nurse said here's your meds then went back to her med cart that was outside of his doorway. Resident R2 added that the nurse was standing in the doorway with her back turned away from him. Resident R2 said he picked up the med cup and self-administered the medications with the water left by the nurse.On 11/22/2025 at 10:42 AM, Resident R4 said a few weeks ago, a nurse on the evening shift left pills in a med cup on her bedside table then left the room and did not return. Resident R4 said she does not recall taking the medications
on that day.The facility's 2/2019 policy for Medication pass guidelines documents 11. Administering medications; Watch the resident swallow all medications. Do NOT leave any meds with the resident to take later. Do mouth checks, if necessary, to ensure meds were swallowed.The facility's 4/2019 policy for medication pass guidelines documents 3. Locking carts/keys: Carry your keys with you at all times. Never leave keys unattended in carts or out of the nurse's control, Do not leave cart(s) unlocked when unattended, lock cart when not in direct view. Schedule II controlled substances MUST be kept double locked.
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ALDEN PARK STRATHMOOR in ROCKFORD, IL inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in ROCKFORD, IL, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from ALDEN PARK STRATHMOOR or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.