Health inspection·March 7, 2024

F 0686 Level of Harm - Actual harm At 1:08 PM, V2 assisted to observe R117's right heel wound. R117 was in bed with heel boots on, and both feet resting on the mattress. The offloading pillow was on the floor. V2 asked staff why the heels were not offloaded; they responded because he was eating. R117's right lateral heel had a non-blanchable red purple irregularly shaped area approximately the size of a quarter. Residents Affected - Few On 3/7/24 at 10:00 AM, V17 Unit Coordinator and V18 Registered Nurse-RN assisted to observe R117's left lateral ankle wound. R117 was in a wheelchair in his room. R117 had bilateral foam heel boots on with both feet resting on the foot pedals of the chair. There were inflatable boots with the heels open on the top shelf of the closet. V17 said those were from the hospital. R117's left foot was positioned outward allowing the left lateral ankle to rest on the heel boot. The left lateral ankle had non-blanchable red-purple area approximately the size of a dime. R117's (late entry) skin concern notes effective 3/4/24 at 1:16 PM showed discoloration to bilateral heels. This note showed to float heels when in bed, ace wraps to bilateral legs, apply in the morning and remove at night, medical doctor will be in the facility tomorrow to assess wounds and power of attorney gave consent for wound care to follow. R117's 3/4/24 wound weekly observation tool showed a right heel suspected deep tissue injury measuring 3 centimeters (cm) X 4 cm. Float heels in bed/chair, wound care to see 3/6/24. R117's wound doctor notes showed no mention of the heel wound being assessed. The note showed a Stage 1 pressure injury to the left lateral ankle measuring 2.5 X 0.6 cm and a Stage 2 pressure wound to the right upper medial buttock measuring 0.9 X 1.1 X 0.1 cm. This note showed to offload the wounds. A 3/5/24 nursing note showed the medical doctor ordered heel lift boots while in wheelchair and a wedge when in bed. R117's physician order sheet printed 3/6/24 at 1:10 AM showed orders dated 3/5/24 to float heels while in bed at all times and heel lift boots while up in wheelchair for pressure relief. An order for a gel dressing to the right upper medial buttock was ordered on 3/6/24 and to start on 3/8/24. An order for skin prep to the left lateral ankle was dated 3/6/24 and to start 3/8/24 (wound found 3/4/24). There were no treatment orders for the heel wound found 3/6/24 until 3/7/24. The facility's 4/12/2021 Pressure Ulcer Prevention Policy showed interventions necessary to maintain skin integrity or promote healing will be incorporated into the plan of care based on each resident's individual needs and risks. This policy was less than a page and a half in length. Additional pressure injury policies and/or procedures was requested twice, and none was received. The facility's 10/12/2023 Wound Treatment Management Policy showed wound treatments will be provided in accordance with physician's orders. In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders. Treatments will be documented on the Treatment Administration Record or in the electronic health record. R117's 2/9/24 pressure injury risk assessment showed he was bedfast and completely immobile (does not make even slight changes in body or extremity position without assistance). R117's care plan showed impaired mobility related to cognitive loss, incontinence, pain, visual deficit, inconsistent motivation to participate in his care, and required hands on assist with repeated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145771 If continuation sheet Page 2 of 17 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 145771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bluff Nursing Home 4401 North Main Street Rockford, IL 61103 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)

F 0686 Level of Harm - Actual harm Residents Affected - Few verbal directions to participate in and to complete bed mobility and repositioning. R117's care plan showed he required assistance from 2 staff members using a total mechanical lift for all transfers, was non-weight bearing and non-ambulatory. R117's 2/9/24 care plan showed a closed right hip fracture related to a fall. The 2/16/24 potential for pressure development related to decreased mobility care plan was updated 3/4/24 to show 2 new bilateral heel deep tissue injuries. Interventions dated 3/5/24 showed to apply heel lift boots and off load heels while in bed. R117's 2/15/24 facility assessment showed severe cognitive impairment and bilateral lower extremity range of motion impairment. This assessment showed dependence for toileting, bathing, lower body dressing, putting on and taking off footwear, roll left and right, sit to lying, and lying to sitting on side of bed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145771 If continuation sheet Page 3 of 17 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 145771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bluff Nursing Home 4401 North Main Street Rockford, IL 61103 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to supervise a resident with behaviors (R131) and failed to supervise a resident during meals (R24) for 2 of 9 residents reviewed for safety in the sample of 31. The findings include: 1. R131's face sheet printed on 3/5/24 showed diagnoses including but not limited to alzheimer's Disease, dementia with agitation, anxiety disorder, and insomnia. R131's facility assessment dated [DATE] showed severe cognitive impairment and the ability to walk independently. The same assessment showed rejection of care and wandering behaviors. On 3/5/24 at 11:19 AM, R131 was in the group lounge area. R131 was able to speak but was confused and used short yes/no answers. R84's face sheet printed on 3/7/24 showed diagnoses including but not limited to dementia and cognitive communication deficit. R84's mental assessment dated [DATE] showed severe cognitive impairment. On 3/6/24 at 9:42 AM, R84 was seated in a wheelchair and had a chair alarm attached to the back of her shirt. R84 was confused and unable to answer questions. On 3/5/24 at 10:35 AM, V11 (Unit Clerk) said R131 has good and bad days. He gets moody and needs redirection. V11 said R131 likes to push other residents in the wheelchair and does wander around the unit. On 3/5/24 at 12:00 PM, V8 (Licensed Practical Nurse) said R131 has behaviors which vary day to day. R131 continually takes off his shoes and socks, wanders the unit, and touches things. R131 needs to be led away from areas he does not belong in. On 3/6/24 at 9:45 AM, V5 (Registered Nurse) said R131 is very confused and needs constant redirection. He enters other resident rooms and tries to push residents around in their wheelchairs. He requires supervision when he is out of bed. It is not safe for him to be wandering around the unit alone. On 3/6/24 at 9:54 AM, V12 (CNA-Certified Nurse Aide) stated R131 walks continually around the unit. He wanders aimlessly and needs supervision when he is awake. He doesn't always know what he is doing, and we never know when his behaviors are going to kick in. On 3/5/24 at 2:10 PM, V10 (CNA) stated he was in the unit dining room after dinner on the evening of 2/22/24. V10 said R84 was seated in her wheelchair at the table and finishing her meal. There were no other residents present other than R131. V10 said R131 was aimlessly wandering which was a typical behavior for him. V10 said R131 was also known to frequently try to assist other residents with pushing their wheelchairs around for them. V10 said he saw R131 behind R84's wheelchair and was trying to help push her wheelchair. V10 said he turned his back for a short time and when he looked again, he saw R131 pulling on the alarm cord that was attached to R84's shirt. V10 said R131 was yanking the cord and the front of R84's shirt was pulling tight against her throat. R84 did not yell out or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145771 If continuation sheet Page 4 of 17 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 145771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bluff Nursing Home 4401 North Main Street Rockford, IL 61103 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some react physically. R84 did start coughing and spilled her juice down the front of her. V10 said he immediately went to R131 and had to pull the cord out of R131's hand to stop the interaction. V10 said V6 (RN-Registered Nurse) was down the hallway and responded when she heard V10 yelling at R131 to stop. On 3/6/24 at 10:10 AM, V6 (RN) said she did not witness the incident between R131 and R84 but did hear it. V6 said she was down the hall prior and saw V10 going in and out of the dining room to clear away dinner dishes. V6 said she heard V10 telling R131 to stop, stop. V6 said she immediately went to the dining room and saw V10 directing R131 away from R84's wheelchair. V6 said V10 told her R131 had been trying to pull on the alarm cord attached to the wheelchair. V6 said R131 is confused and does normally wander around the facility. R131 needs close monitoring and a constant eye on him. He tries to assist residents with pushing them in their wheelchairs. Staff know all about his behaviors and should immediately interject when he tries. He needs redirection when he is displaying his confused behaviors. On 3/7/24 at 9:00 AM, V9 (CNA) said R131 has low cognition, and it has been declining progressively. R131 begins sundowning (behaviors that start when sunset begins setting) every day after lunch. We are all aware of it and know he is escalating. We keep away from directly touching him but know to watch him. Everybody should be watching him and be ready to redirect right away. On 3/7/25 at 9:25 AM, V2 (Director of Nurses) said R131 and R84 should have been separated immediately when staff noticed them. R131 needs constant monitoring and redirection. Staff should have intervened right away. It is unsafe for demented residents to be assisting others and it is a safety issue. The facility's Resident with Dementia policy dated 4/22 states: 9. Analyze behaviors which are symptomatic of dementia and how the behavior reflects the individual resident's dementia losses and anticipate potential triggers which may precipitate behavior reactions. 2. The facility face sheet for R24 shows diagnoses to include dementia, anxiety and heart failure. The facility assessment dated [DATE] shows moderate cognitive impairment and requires set-up assistance with eating. On 3/6/24 at 9:05 AM, R24 was observed lying flat in her bed trying to drink her thickened juice. R24's breakfast tray was in front of her and contained the crusts from her toast. R24 had egg's all over her chest. R24 was observed raising and lowering the head of her bed. On 3/6/24 at 12:56 PM, R24 was observed lowering the head of her bed to the flat position and attempted to feed herself. No staff were observed on the hallway. On 3/06/24 at 2:30,V30 Unit manager, said R24 has days where she is more alert and oriented than other days. R24 requests the thickened liquids and mechanical soft foods. R24 will focus and obsess on different things and right now that is she says she has hot urine and needs to lay flat in her bed. V30 said she has spoken to R24 about this and educated on not laying flat while eating. On 3/07/24 at 9:20 AM, V31 Licensed Practical Nurse (LPN) said R24 is oriented to person and her room but can't remember anything extensive. V31 said R24 can feed herself and prefers to eat in bed. V31 said R24 will use the bed control to lower her head of bed and has also raised her legs higher than her head. V31 said if she saw R24 lying flat in bed eating she would quickly raise her head of the bed for safety reasons. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145771 If continuation sheet Page 5 of 17 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 145771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bluff Nursing Home 4401 North Main Street Rockford, IL 61103 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 3/7/24 at 9:30 AM, V32 Certified Nursing Assistant (CNA) said R24 is mostly alert and oriented. V32 said when a resident is eating in bed, the head of their bed must be in the upright position since it is not safe to eat in bed while lying flat. On 3/7/24 at 9:35 AM, V2 Director of Nursing (DON) said he expects the staff to have residents in the upright position for eating in bed to protect them from choking. V2 said R24 needs supervision when she is lowering her head of the bed. The nursing progress notes dated 11/10/23, 11/26/23, 11/28/23 and 12/6/23 showed R24 was adjusting her bed into unsafe positions and the staff were educating her on safety and removing the bed controls from her. The facility care plan for R24 shows it was updated on 3/6/24, after concerns were reported to facility management. The care plan showed R24 will at times place herself flat and eat/drink. An intervention of encouraging her to have the head of her bed elevated while eating was added. The care plan for activities of daily living was also updated on 3/6/24 to show a new intervention of providing education to R24 regarding the risk of choking while eating lying flat in bed. No interventions for supervision were added to R24's care plan. The facility policy for meal supervision and assistance dated 10/12/23 shows the resident will be prepared for a well balanced meal in a calm environment, location of her choice and will adequate supervision and assistance to prevent accidents . The undated policy for in-room dining shows residents will be monitored when dining in their rooms by nursing staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145771 If continuation sheet Page 6 of 17 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 145771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bluff Nursing Home 4401 North Main Street Rockford, IL 61103 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)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm Based on observation, interview, and record review the facility failed to identify decreased food intake for residents and implement interventions to prevent a significant weight loss for 2 of 6 residents (R50 & R87) reviewed for nutrition in the sample of 31. Residents Affected - Few These failures resulted in a 5% weight loss in one month for R50 and R87. The findings include: 1. On 3/5/24 at 10:03 AM, R50 was in bed with the head of her bed raised. R50 had her tray table in front of her with her breakfast tray sitting on it. R50 had a sausage patty, hardboiled egg, roll, french toast, water, and chocolate milk. The french toast was cut in half and did not have any syrup on it. R50 picked up the hardboiled egg, looked at it and sat it back down on the tray table. R50 did not eat any of her breakfast. R50 was talking gibberish to herself and when asked questions. No staff were observed assisting R50 with breakfast. On 3/5/24 at 1:06 PM, R50 was sitting in her bed with the head of her bed elevated. R50 had her tray table in front of her with her lunch sitting on it. R50 had au gratin potatoes, broccoli, cake, beef a Roni, water, and juice. R50 did not eat any of her food; lunch was served at around 12:15 PM. R25 CNA (Certified Nursing Assistant) came into the room to assist R50's roommate and stated R50 hasn't been eating but will drink her fluids and then left the room. The Care Plan dated 2/7/24 for R50 showed, R50 has an ADL (activity of daily living) self-care performance deficit related to cognitive loss, episodes of impaired balance, resistive with staff during care, bi-lateral lower extremity edema, incontinence, alteration in endurance, new to facility, and requires repeated verbal directions, coaxing, encouragement and hands on assist to participate in and to complete daily care and tasks. Eating: R50 is able to feed herself after staff assist with set up of meal. Provide finger foods when R50 has difficulty using utensils. Provide milkshakes or liquid food supplements when R50 refuses or has difficulty with solid food or provide nutritious foods that can be taken from a cup or a mug where appropriate. R50 has potential nutritional problem. Provide, serve diet as ordered. Monitor intake and record every meal. Registered dietician to evaluate and make diet change recommendations as needed. The Nutrition/Dietary Note dated 2/15/24 for R50 showed, Diet: Regular with regular texture and thin liquids. Per Nursing notes, resident requires cues and intermittent 1:1 assist to stay on task with meals. The weights for R50 documented in the electronic medical record as of 3/6/24 showed on 2/1/24 her weight was 163. 4 pounds and on 3/1/24 her weight was 152.4 pounds. R50 had an 11-pound weight loss in one month = 6.7% weight loss. On 3/6/24 at 3:30 PM, V40 RN (Registered Nurse/Unit Coordinator) stated, significant weight changes come up in the weights section of the computer charting. V40 stated they meet every Thursday for a meeting to discuss weight changes. V40 stated she did want to get a re-weigh for R50 to see if the weight was accurate. V40 stated if there was a weight loss the doctor and power of attorney would be notified. V40 stated she would discuss the weight change with the registered dietician, and she will see the resident and make recommendations. V40 stated she believes R50's weight is accurate because she looks like she has lost some weight. Staff should be encouraging her to eat. V40 stated she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145771 If continuation sheet Page 7 of 17 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 145771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bluff Nursing Home 4401 North Main Street Rockford, IL 61103 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)

F 0692 Level of Harm - Actual harm thinks R50 might be needing more help and that it hasn't been brought to her attention yet by staff. V40 stated if a resident refuses to eat staff can offer a supplement, come back later, and try to get the resident to eat, and try to find out why the resident is not eating. V40 stated that no one has said anything to her about R50 not eating. Residents Affected - Few On 3/7/24 at 8:37 AM, V23 CNA (Certified Nursing Assistant) stated, if the resident is not eating, we will let the nurse know. We assist if they need help eating. If not eating with assistance, then let nurse know. V23 stated she would offer the resident something else like fruit or if they can tell her what they want she will get that. V23 stated they can offer supplement shakes. V23 stated if there were a big weight change for a resident, she would let the nurse know. On 3/7/24 at 9:18 AM, V20 RD (Registered Dietician) stated she is at the facility 8 times per month so usually twice per week on Mondays and Thursdays. V20 stated she was on vacation and had V21 RD filling in for her remotely this last Monday. V20 stated she typically is the one that goes through the weights to look for weight changes. V20 stated the facility has weekly weight meetings and will bring stuff to her attention as well. V20 stated she printed off a list of residents and weight concerns from home and circled the residents that she needs reweighs on and have questions about. V20 stated she would talk to the unit coordinator to see if they thought the weights in question were legitimate or not. V20 stated V21 listed R50 as needing to be re-weighed on Monday (3/4/24) to make sure the weight was accurate. As of last night (3/6/24) she did not see that R50 had been reweighed. V20 stated typically when she asks for a reweigh, she would have to wait for the new weight to know if it is accurate before she makes recommendations. V20 stated if the reweigh is not in there then apparently nothing was done. V20 stated she would have looked through R50's notes to see if she was refusing to eat and/or not feeding herself. If R50 was not feeding herself then staff could assist her. Staff could do verbal cueing. V20 stated she would expect a note in R50's chart saying she prefers liquids over food. V20 stated if the staff know R50 is declining in eating then they should be there to assist the resident with eating and verbal cues. V20 stated R50 eating in her room alone would not be good; it would be better to be out at a table. The Nutrition/Dietary Note dated 3/7/24 at 9:49 AM for R50 showed, RD Weight Review; Principal diagnosis: unspecified dementia, severe, with other behavioral disturbances. Comfort care in place & do not hospitalize per family preference. Notified of reweigh per unit coordinator of 154.2#. Weight reflecting a significant weight loss of 5.6% (9.2 pounds) x/times 30 days. Meal intake remains variable, however, appears to have declined. Per records, resident requires cues and intermittent 1:1 assist to stay on task with meals. Noted Resident was fed per staff times 1 meal on 2/10, 2/17, 2/18, 2/29 & 3/2 per records. No labs to review. Discussed weight loss with unit coordinator and she will notify the power of attorney and primary care physician. Unit coordinator reports resident likes milk and has been taking fluids well. Will recommend supplement shakes twice a day to assist with calorie & protein needs. Monitor acceptance of supplement. Continue to cue & assist resident at meals as needed. Recommend weekly weight monitoring. Monitor intake & weight. The Face Sheet dated 3/8/24 for R50 showed medical diagnoses including unspecified dementia, severe, with other behavioral disturbance, macular degeneration, history of anxiety disorder, hypertension, unspecified psychosis, polyneuropathy, hypothyroidism, hypercholesterolemia, vitamin D deficiency, and gastroesophageal reflux disease. 2. The Weights and Vitals Summary Sheet dated 3/7/24 for R87 showed on 2/1/24 his weight was 202.6 pounds and on 3/1/24 his weight was 186 pounds. R87 had a significant weight loss of 16.6 pounds in one month that equals and 8.2% weight loss. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145771 If continuation sheet Page 8 of 17 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 145771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bluff Nursing Home 4401 North Main Street Rockford, IL 61103 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)

F 0692 Level of Harm - Actual harm The Face Sheet dated 3/7/24 for R87 showed diagnoses including alzheimer's disease, muscle weakness, protein-calorie malnutrition, generalized arthritis, hypertension, vitamin D deficiency, mixed hyperlipidemia, bilateral hearing loss, atherosclerotic heart disease, paroxysmal atrial fibrillation, cerebrovascular disease, gastro-esophageal reflux disease, benign prostatic hyperplasia, and type 2 diabetes mellitus. Residents Affected - Few The Progress Notes from 2/1/24 through 3/7/24 at 8:57 AM did not show any documentation related to R87's weight loss. The Nutrition Intake Documentation for R87 from 2/7/24 through 3/6/24 showed staff documented the resident ate 76-100% of his meals except for 3 meals where he ate 51-75%. On 3/7/24 at 8:41 AM, R22 LPN (Licensed Practical Nurse) reviewed R87's weights in the electronic medical record and stated usually when the weight loss is like R87's the dietician will come in and see the resident, have the resident re-weighed and go from there. R22 stated R87 eats really well and usually has a weight gain. R22 stated she was not aware of R87's weight loss and would have him re-weighed. On 3/7/24 at 8:59 AM, V3 RN (Registered Nurse/Unit Coordinator) stated they have meetings every week about weights. V3 stated that the dietician was on vacation. V3 reviewed R87's weight in the computer and stated he is going to have R87 re-weighed because doesn't think the weight is accurate. V3 stated R87 usually eats great and has no eating problems that he is aware of. V3 stated the dietician goes through the building. There is a meeting that the unit coordinators go to, to talk about weight losses and gains. They re-weigh residents if needed. V3 stated if the documented weight is something ridiculous then it is brought to his attention. V3 stated R87's weight loss was kind of ridiculous. The Weights and Vitals Summary Sheet dated 3/7/24 for R87 showed at 10:56 AM he was re-weighed, and his weight was 186.4 which was a 16.2-pound weight loss. This was an 8% significant weight loss in one month from his 2/1/24 weight of 202.6 pounds. The Care Plan dated 1/25/24 for R87 showed R87 is able to feed himself independently, staff assist with set up as and if needed. R87 has a potential nutritional problem related to his weight being higher than recommended for his height. Monitor intake and weight. Monitor/record/report as needed any signs/symptoms of malnutrition: emaciation (cachexia), muscle wasting, significant weight loss: 3 pounds in 1 week, >5% in 1 month, >7.5% in 3 months, and >10% in 6 months. The Nutritional Management policy (10/12/23) showed, the facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. A systematic approach is used to optimize each resident's nutritional status: a. Identifying and assessing each resident's nutritional status and risk factors; b. Evaluating/analyzing the assessment information; c. Developing and consistently implementing pertinent approaches; d. Monitoring the effectiveness of interventions and revising them as necessary. A comprehensive nutritional assessment will be completed by a dietician within 72 hours of admission, annually, and upon significant change in condition. Care Plan implementation: Interventions will be individualized to address specific needs of resident. Examples include but are not limited to iii. Weight related interventions; iv. Environmental interventions; vi. Physical assistance or provision of assistive devices. The physician will be notified of i. significant changes in weight, intake, or nutritional status Nutritional recommendations may be made by dietician based on resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145771 If continuation sheet Page 9 of 17 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 145771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bluff Nursing Home 4401 North Main Street Rockford, IL 61103 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)

F 0692 preferences, goals, clinical condition, or other factors and followed up with the physician/practitioner for orders as per facility policy, if indicated. Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145771 If continuation sheet Page 10 of 17 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 145771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bluff Nursing Home 4401 North Main Street Rockford, IL 61103 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)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident's oxygen tank was not empty and failed to ensure a resident's nebulizer mask was changed as ordered for 1 of 1 resident (R7) reviewed for respiratory care in the sample of 31. Residents Affected - Few The findings include: R7's face sheet showed a [AGE] year-old male with diagnoses of dementia, chronic obstructive pulmonary disease, interstitial lung disease, dependence on supplemental oxygen, Type 2 Diabetes, hypertensive heart disease, and osteoarthritis. On 03/05/24 at 11:35 AM, R7 was in a recliner in his room. The oxygen cannula in his nose was connected to a portable oxygen tank attached to the back of a wheelchair positioned in front of him. The gauge on the oxygen tank showed the tank was empty. The flow meter was set at 4 liters per minute. R7 asked if anything was coming out of the tubing and said he did not adjust the oxygen. There was a nebulizer mask lying on a table next to the recliner. The mask was not covered and was in direct contact with the table. The mask was dated 2/25/24. There was an oxygen concentrator in the room with long tubing attached and lying on the bed. At 11:41 AM, R7 self-transferred from the recliner to the wheelchair and an alarm sounded. At 11:45 AM, V15 Certified Nursing Assistant-CNA responding to the chair alarm. V15 assisted R7 to the toilet. R7 asked V15 to check his oxygen tank to see if there was any in there. V15 left and came back with returned with V16 Licensed Practical Nurse-LPN. V16 checked and asked R7 to not turn the oxygen up as it should be set at 2 liters per minute. V16 replaced the tank with a full one. V16 said R7 had three different lung diseases and gets short of breath very easily. V16 said R7 receives breathing treatments using the nebulizer once per shift. V16 said he had one at 5:00 AM and the next one is scheduled for 1:00 PM. R7 said he did receive his morning breathing treatment. V15 assisted R7 back to the recliner and R7 was moderately short of breath. On 03/06/24 at 12:25 PM, V2 Director of Nursing-DON said nebulizer treatment masks should be changed weekly to avoid contamination. They get dirty and should be stored in a bag when not in use. We don't want residents getting sick from inhaling any contaminants. It's important that a resident's oxygen supply is not empty so they don't suffer from hypoxia (low oxygen level) which could cause organ failure, death or harm. R7's physician order sheet-POS showed a 3/5/24 order for oxygen to be administered continuously at 2-4 liters via nasal cannula. R7's care plan showed he was on oxygen therapy related to respiratory illness and showed to administer oxygen. R7's March 2024 Medication Administration Record-MAR showed he received the medicated nebulizer treatments three times a day daily. The facility's 10/7/23 Oxygen Administration Policy showed oxygen is administered under orders of a physician. Staff shall change oxygen tubing and mask/cannula weekly and as needed if it becomes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145771 If continuation sheet Page 11 of 17 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 145771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bluff Nursing Home 4401 North Main Street Rockford, IL 61103 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)

F 0695 soiled or contamination. Keep delivery services covered in plastic bag when not in use. Oxygen warning signs must be placed on the door of the resident's room where oxygen is in use. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145771 If continuation sheet Page 12 of 17 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 145771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bluff Nursing Home 4401 North Main Street Rockford, IL 61103 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to properly label an opened vial of Tuberculin solution (31 residents residing on Cardinal Unit) and an insulin pen (R93) reviewed during the medication storage and labeling task. The findings include: 1. The facility Resident Census report dated 3/5/24 showed 31 residents reside on Cardinal unit. On 3/7/24 at 8:47 AM, V3 (Unit Coordinator) opened the medication room and unlocked the small padlock on the refrigerator. Inside the door of the refrigerator was an unopened vial of tuberculin solution and an opened 5 ml vial of Tuberculin 5 TN/ml, containing 5 ml (vial showed for 50 doses). The opened vial did not have an opened date written on the vial or the box. V3 said the opened vial should have been labeled with the open date, so the staff know when it expires. V3 said he wasn't sure how long the vial was good for, then immediately said, Maybe 30 days? I'm going to need to throw that out. V3 said each unit has their own house stock vial of Tuberculin and this vial was used for new admissions and any residents needing TB testing on the unit. On 3/7/24 at 11:32 AM, V2 (DON - Director of Nursing) said whenever a vial of Tuberculin is opened, it should be labeled with an open date. V2 said once the vial is open it is only good for 30 days. V2 said it's important to label the medication vial with an open date to ensure residents are not receiving meds that are expired or beyond their shelf life. The FDA (Food and Drug Administration) Package Insert for the Tuberculin vial showed that an opened vial that is in use should be discarded after 30 days. The facility's Storage/Labeling/Packing of Medications Policy dated 12/2023 showed, To store medications and biologicals under proper conditions of temperature, light, and security . 5. Individual resident's medications are stored and labeled according to legal requirements of acceptable manufacturing practices. 6. Each resident's medications are kept separately from others. 7. Each resident's medications are stored in original containers and must be properly labeled . 2. On 3/7/24 at 10:50 AM, V19 (RN - Registered Nurse) opened her medication cart. In the top drawer was a glargine insulin pen. This pen was not labeled with the resident's name, nor did it have an open date or expiration date written on it. The surveyor asked who the glargine insulin pen belonged to and V19 replied, Oh, that's for [R93]. I know it's his because he's the only resident on that medication. The medications that are sent by our pharmacy are labeled with the resident's name, but I think this pen was filled by his insurance. It's from an outside pharmacy, so it didn't come with a label. It should have been labeled when it arrived. R93's Face sheet printed 3/7/24 showed diagnoses to include idiopathic peripheral autonomic neuropathy, non-pressure chronic leg ulcers, diabetes, obesity, heart failure, peripheral vascular disease, and long term use of insulin. R93's Physician Order Sheet showed an order for glargine insulin pen. Inject 86 Units two times a day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145771 If continuation sheet Page 13 of 17 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 145771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bluff Nursing Home 4401 North Main Street Rockford, IL 61103 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm On 3/7/24 at 11:32 AM, V2 (DON) said the insulin pen should be labeled with the resident name and open date. V2 said insulin is usually good for 28 days, once it is used. V2 said the open is date is important, so we know when to discard the medicine. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145771 If continuation sheet Page 14 of 17 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 145771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bluff Nursing Home 4401 North Main Street Rockford, IL 61103 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 3/6/24 at 9:08 AM, R111 was lying in bed on her left side for a dressing change to the pressure ulcer on her sacrum. V39 LPN (Licensed Practical Nurse) and V37 CNA (Certified Nursing Assistant) was at bedside for care, and both had gloves on. V37 removed R111's incontinence brief, discarded the brief an changed her gloves. V37 took a wet washcloth and washed R11's rectum, buttocks, and lower back. V37 draped the soiled washcloth over the bed rail. V37 grabbed the towel and patted R111's buttocks dry and draped the towel over the bed rail. R111 did not change her gloves and had her hands on R111's back to keep her on her right side while V39 changed the dressing. V37 removed the soiled linen from R111's side rail and laid it on top of her night stand next to the resident's drink. V37 then repositioned the resident in bed and pulled her sheet up. V39 stated gloves are to be changed after you clean an area that was dirty and before going to a clean area. V39 stated gloves should be removed then, hand sanitizer used, and new gloves put on for infection control. V37 stated she normally has a bag and basin with her. V37 stated the dirty linen should not be on nightstand because it is unsanitary. Residents Affected - Few The Face Sheet for R111 showed diagnoses including alzheimer's disease, major depressive disorder, muscle weakness, parkinson's disease, anorexia, dementia, type 2 diabetes, hyperlipidemia, hypertension, and anxiety. The Care Plan dated 12/20/23 for R111 showed she has an activity of daily living self-care performance deficit related to dementia, confusion, weakness, depression, hypertension, language barrier and type 2 diabetes mellitus. She requires extensive assistance by 1-2 staff for toileting. R111 is totally dependent on 1 staff for personal hygiene and oral care. Toilet use: staff will assist to complete peri/incontinence care to maintain good skin integrity. Wears incontinence briefs. The facility's Incontinence Care policy (4/12/22) showed, place soiled linens and clothing in the appropriate linen containers. The facility's Personal Protective Equipment policy (10/12/23) showed, change gloves and perform hand hygiene between clean and dirty tasks, when moving from one body part to another, when heavily contaminated, or when torn. Based on observation, interview, and record review, the facility failed to provide incontinence care in a manner to prevent cross contamination, failed to ensure a CNA removed contaminated gloves and appropriately performed hand hygiene after providing incontinent care for two of four (R103, R111) residents reviewed for infection control in a sample of 31. Findings include: 1. R103's face sheet printed on 3/7/24 showed R103 was admitted to the facility on [DATE]. R103 has diagnoses including but not limited to dementia, hypertensive heart and chronic kidney disease, peripheral vascular disease, and palliative care. R103's physicians order sheet printed on 3/7/24 showed side rail use per assessment and resident/agent's choice. R103's Minimum Data Set (MDS) printed on 3/7/24 showed R103 is dependent with 2 or more assist required. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145771 If continuation sheet Page 15 of 17 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 145771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bluff Nursing Home 4401 North Main Street Rockford, IL 61103 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R103's care plan printed on 3/7/24 showed R103 has cognitive loss, staff will check, change and provide peri/incontinent care upon awakening, before and after meals as needed, before bed, during nighttime bed checks as indicated. On 03/07/24 at 10:24AM, R103 was sitting in her reclining chair in the unit dining room. She was resting her head on a pile of folded bandanas that were on the table. V38 (Certified Nursing Assistant) CNA encouraged R103 to lay down and was then transported to her room and put in bed via mechanical lift. V38 said She (R103) is totally dependent care. On 3/7/24 at 10:38AM, V38 and V37 (Certified Nursing Assistant) CNA provided incontinent care after putting R103 to bed. R38 was wiping the fecal matter from R103's buttock area then turned off the bed alarm with her gloved hand while doing incontinent care when the alarm began to sound off. She did not remove her gloves or wash her hands. The alarm sounded again, and she turned off the alarm again without removing her gloves or washing her hands. V38 then touched R103's hand when R103 reached up and grabbed V38's hand while V38 was still cleaning the fecal matter from the R103's buttock area. When V38 was finish she pulled up the side rail, grabbed a walker that was in front of the floor mat leaning against the wall, and then gave R103 a call light cord. V38 moved the garbage can and placed the floor mat in front of the bed. V38 did not remove the soiled gloves that was being used to clean up R103. V38 then set the white rectangular shaped alarm on the floor mat that was in front of the bed. She adjusted, the wheelchair and turned off the light, walked out of room, and put the dirty brief that was in a plastic bag into the trash barrel that was outside the room and removed her gloves, threw them in the trash and then sanitized hands. On 3/7/24 at 10:48AM, V38 said no I did not change my gloves and wash my hands, but I usually do. Yes, I touched her, her chair, and the floor mat, I also touched the curtain bed alarm and the walker. I know it is not sanitary, I could spread germs. (R103) can get sick yes, she has a roommate and she could get sick from the germs. The staff could be affected also by the germs. On 03/07/24 at 10:53 AM, V39 (License Practical Nurse) LPN said they should change gloves and wash their hand after doing peri care and touching the dirty or soiled brief. They should not be touching the clean environment when in the room. They could spread the fecal matter and germs. It affects (R103) by her touching the things the CNA has already touch and she can get sick. On 03/07/24 at 10:59 AM, V40 (Registered Nurse/Unit Director) RNUD said they should be changing gloves and washing hand and wiping front to back making sure not to put dirty gloves on the (R103) or any other items in the room. If there is fecal matter it is a big infection control issue. It could get the (R103) sick especially on this unit. It is basically spreading germs. V40 said if they (residents) touch the dresser, or any item tin the room then put their hands in the mouth they could get sick. On 03/07/24 at 11:08 AM, V2 (Director of Nursing) and V1 (Administrator) ADM said they should practice hand hygiene. They should be washing their hands and gloving. It could cause contamination to and the (R103) and the environment. V2 said we don't want them (CNA's) to get the sheets and bed rails dirty. They (CNA's) should not be touching bed alarm or anything in the room. There could be contamination from the fecal matter. (R103) could get sick. V1 (Administrator) ADM said we could have GI issues or pink eye if they touch their eyes. The facility's infection control policy dated 4/12/21 showed the facility's written program is for the implementation of systems that provide a safe, sanitary, and comfortable environment and helps (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145771 If continuation sheet Page 16 of 17 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 145771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bluff Nursing Home 4401 North Main Street Rockford, IL 61103 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm prevent the development and transmission of communicable disease and infections . 6) Hand hygiene is utilized to reduce the spread of germs to residents and the risk of the health care provider's colonization of infection by germs acquired from a resident. The facility utilizes hand hygiene via hand washing and alcohol-based hand sanitizers . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145771 If continuation sheet Page 17 of 17