Health inspection·May 14, 2024

F 0689 Level of Harm - Actual harm Residents Affected - Few On 5/14/24 at 11:05 AM, V6 stated he was doing rounds early morning on 5/8/24. V6 stated R1 was awake and sitting at the edge of the bed so he toileted her and got her ready for the day. V6 said, .once she's up she likes to stay up . V6 said he transferred R1 to her wheelchair and brought her out the nurses' station. V6 said he left R1 at the nurses' station and went down the hall to speak with V4. V6 said two to three minutes later he heard a resident yelling out at the nurses' station, so he investigated. V6 said R1 was sitting on the floor with her back resting on another resident's wheelchair. V6 said, There was no alarm in her wheelchair at that time. I didn't realize she was supposed to have one .Supposedly she had a chair alarm, and it was left in the recliner . V6 clarified the recliner was at the nurses' station and the night prior and the staff member who transferred R1 out of that recliner did not place the chair alarm in the wheelchair. V6 said, after the fall, R1 was transferred to the wheelchair and approximately 30 minutes later she began to complain of pain to the left hip. V6 said, The purpose of the chair alarm is to alert the staff that someone is trying to get up. It is true, a chair alarm might not prevent a fall. It might prevent a fall if we can get there quick enough. V6 stated the supervisor who responded to the fall was V11 RN. On 5/14/24 at 12:58 PM, V4 stated she was R1's third shift nurse beginning on 5/7/24. V4 stated, the morning of 5/8/24, she heard another resident yelling at the nurses' station and R1 was found sitting on the floor with her back resting against another resident's wheelchair. V4 stated R1 did not have a chair alarm in her wheelchair; it was in the recliner. V4 said, It was supposed to be in the wheelchair. When the CNA got her up, I don't think he realized it wasn't there. The purpose of the chair alarm is to alert us the resident is getting off the pad or let us know they are getting up. The chair alarm gives us a heads up that someone is trying to move just so we know if they are moving. On 5/14/24 at 11:30 AM, V11 Part-time House Supervisor stated she responded to R1's fall. V11 said, while she was filling out the fall report, .I got to the alarm part, and I asked CNA was the chair alarm sounding? Because I didn't understand what took so long for them to respond if they were responding to a resident screaming instead of the alarm and the CNA said the alarm was in the recliner. I asked was it was supposed to be in the wheelchair, and they said yes. By the time I looked at the wheelchair, they had put the alarm in the wheelchair. The purpose of the chair alarm is to let us know when someone is starting to get out of the chair. It should alarm as soon as their butt gets off that pad so we can start moving toward the resident right away. Chair alarms don't always prevent a fall, but they can give us a couple of extra seconds to respond to a resident to get them to sit back down before they fall. We generally have fewer staff on third shift, so I would say those alarms are even more important on third shift than other shifts because, if they only have two CNAs for four halls, they can't be everywhere, so it helps them to respond when a resident is getting up. On 5/14/24 at 2:06 PM, V2 Director of Nursing stated the purpose of chair alarms is to reduce the risk of falls to the resident. They help by giving the staff a heads up that the person is trying to get up and they can attempt to intervene. [R1] should have had a chair alarm that morning when she fell . On 5/14/24 at 1:14 PM, V12 Nurse Practitioner stated she was on-call when R1's Xray results became available. V12 said she does not know R1's history; however, the fractures she sustained are fractures I see after someone has a fall. On 5/14/24 at 1:20 PM, V13 Medical Director/R1's provider stated the fractures R1 sustained are .typical and most common after a fall . V13 stated R1's fractures were a result of the fall and most likely and undiagnosed condition of osteoporosis (weakening of the bones). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145771 If continuation sheet Page 2 of 5 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 05/14/2024 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 - Actual harm Residents Affected - Few R1's Care Plan showed, [R1] is at risk for fall r/t (related to): confusion, weakness, incontinence, Poor communication & comprehension, Impaired physical mobility, unaware of safety needs & her own risk factor, hx of fall, behavior of self-transferring without assist, aggressive behaviors towards the staff when redirected, impulsive behavior . The care plan showed the following intervention, Chair alarm when up in chair/wheelchair. Date initiated 12/15/23. R1's April and May 2024 Medication Administration Record showed pain assessments were completed every shift (every 8 hours). Except for one pain assessment in April 2024, R1 did not have documented pain during these shift assessments until after her fall on 5/8/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145771 If continuation sheet Page 3 of 5 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 05/14/2024 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 0776 Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to provide timely radiology services for a resident who fell and was experiencing pain to her hip. This applies to 1 of 3 residents reviewed for falls/radiology services in the sample of 3. Residents Affected - Few The findings include: R1's Face Sheet (admission Record) showed an admission date of 12/13/23 with diagnoses to include dementia, depression, and left femur fracture (admitting diagnosis). R1's 5/8/24 Event Note from 5:30 AM showed, Resident observed sitting on floor with her back against another resident w/c (wheelchair) while other resident sitting in w/c. Resident stated that she didn't hit her head. No pain noted. Resident stated that she was just getting up. House supervisor notified, resident assessed, ROM wnl (Range of Motion within normal limits) The note showed vital signs and a neurological assessment was completed. The not continued, Resident c/o (complains of) discomfort to left hip post fall . The note showed the provider was notified and an Xray was ordered. R1's 5/8/24 Communication note from 6:23 AM, showed Resident c/o (complains of) pain to left hip, received orders to do Xray to left hip . R1's 5/9/24 Follow-up note from 2:17 PM, showed Resident continues of f/u (follow-up) post-fall, no apparent injuries noted, continues with pain to LT buttock . R1's Xray report showed her left hip Xray was done on 5/9/24 at 4:30 PM (nearly 36 hours after the order.) The report showed an Acute (sudden onset) acetabular and left inferior pubic ramus fractures (fractures of the pubic bone where the hip connects to the pubic bone.) . On 5/14/24 at 9:56 AM, V8 Licensed Practical Nurse (LPN, day nurse on R1's unit) stated the Xray company can take more than 24 hours to do an Xray. V8 said she will give the family the option to have the resident sent out if they would like it done sooner. On 5/14/24 at 10:00 AM, V9 LPN (R1's day nurse) stated the Xray company can take 24 to 48 hours to arrive. V8 said she will give the family the option to have the resident sent out if they would like the Xray done sooner. On 5/14/24 at 10:22 AM, V10 R1's Power of Attorney/Spouse stated, They did call me after the fall. They said they were going to do some Xrays to see if she had broken anything. They did not say there would be a delay in the Xray, and they didn't ask me, if I would want it done sooner, I could have her sent out. I didn't realize it was going to take that long to have the Xray done. They said it was going to be done in house, so I thought it would be done sooner. I thought they had something there [at the facility] to do the Xray. If they told me it was going to take 24-48 hours for the Xray, and I was given the option to send her out, I would have told them to send her out. On 5/14/24 at 2:06 PM, V2 Director of Nursing stated, ideally Xrays would be done within 24 hours, however, the facility has no control over their contracted imaging company. V2 said, If we had known the Xray was going to take that long, we probably would have sent her out. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145771 If continuation sheet Page 4 of 5 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 05/14/2024 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 0776 On 5/14/24 an imaging policy was requested; the facility provided a change in condition policy. Level of Harm - Minimal harm or potential for actual harm The Change in Condition policy (revision 12/22) showed, The nurse will clarify if the attending wants the resident to be treated in the facility (x-rays and labs may take up to 24 hours for completion) or sent out to the hospital for evaluation and treatment (immediate). Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145771 If continuation sheet Page 5 of 5