Alpine Fireside Health Center
ALPINE FIRESIDE HEALTH CENTER in ROCKFORD, IL — inspection on March 31, 2026.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
administered for pain control.
This applies to 1 of 5 residents (R1) reviewed for pain in the sample of
following right femur fracture repair. R1's diagnosis includes peripheral vascular disease, Alzheimer's disease late onset, dementia unspecified, falls, diabetes, and osteoarthritis. R1's Physician Orders dated December 2025 shows orders including oxycodone (opioid) 5mg (milligrams) every 4 hours as needed for moderate or severe pain. R1's nurses notes dated 12/27/25 at 1:38 PM documents behaviors yelling/screaming.
Pain severe pain interventions include scheduled pain medication administrated and as needed medication administration. R1's Medication Administration Record (M.A.R.) dated December 2025 shows there was no pain medication administered at 1:38 PM for R1's pain. R1's M.A.R. shows acetaminophen 325 mg was given at 3:34 PM. On 3/31/26 at 12:27 PM, V4 (Registered Nurse) said R1 was confused, she could not communicate if she was having pain it was more through her facial grimacing and behaviors. R1 was getting scheduled acetaminophen for pain and had orders for oxycodone as needed. If we are waiting for pain medication to be delivered from the pharmacy we can pull it from the emergency supply if needed. On 3/31/26 at 12:09 PM, V2 (Director of Nursing-DON) said R1 was re-admitted to the facility following a right femur fracture with surgical repair. We received discharge instructions from the hospital with the narcotic scripts.
Sometimes the e-scripts are faxed to our pharmacy.
She was not aware of R1 having pain concerns after her re-admission. If the narcotic is not available, nursing can pull the medication from the emergency supply box.
Oxycodone was available in the emergency supply box. At 1:53 PM, V2 (DON) said R1 arrived to the facility on [DATE] at 10:27 AM.
The nurse's note at 1:38 PM shows she was having severe pain. V2 confirmed R1 did not receive pain medication at that time. V2 said R1 could not communicate if she was having pain. R1 was more non-verbal showing pain with behaviors.
Tylenol is not going to cut it for pain control for a resident following hip surgery. V2 said nursing should have pulled the narcotic pain medication from the emergency supply and confirmed the order was to give oxycodone 5mg for moderate to severe pain and she is not sure why nursing did not administer the narcotic. R1's Controlled Substance Record for Oxycodone 5 mg shows it was delivered to the facility on [DATE] at 10:00 PM.
The sheet shows R1 received the first dose on 12/28/25 at 1:00 AM.
The facility's Pain Management Policy reviewed 2025 states, the facility will ensure pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person centered- care plan and the residents goals and preferences. ? 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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE