Health inspection·November 13, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to ensure allegations of resident-to-resident abuse were immediately reported for 2 of 5 residents (R2, R3) reviewed for abuse in the sample of 5. Residents Affected - Few The findings include: On 11/13/24 at 10:32 AM, V3 (Licensed Practical Nurse/LPN), said she was the nurse when (V5) the Unit Attendant (UA) reported R2 hit R3 a couple of months ago in September. V3 said everyone wrote statements and V19 (the former Director of Nursing/DON) and V18 (the former Assistant DON), came around and took statements. On 11/13/24 at 10:54 AM, V5 (UA) said R2 has hit other residents and she saw R2 hit R3 a couple months ago. V5 said V18 spoke to her about the incident. On 11/13/24 at 3:47 PM, V6 (Unit Manager/RN) said R2 was walking through the dining room on 9/24/24 with his one-to-one assigned caregiver and R2 struck out at R3. V6 said V18 came around and took resident and staff interviews. V6 said he assumed the nurse on duty reported the incident. On 11/13/24 at 11:27 AM, V7 (CNA) said R2 tried to hit V5, then he went around and punched R3 by her belly. V7 said R3 was just sitting in her wheelchair at the time. V7 said V18 might have done an investigation because she was asked to write a statement about what happened. On 11/13/24 at 11:47 AM, V11 (CNA) said she was on the unit and heard R2 hit R3, but she did not see it happen. V11 said no one ever came and spoke to her about the incident. On 11/13/24 at 9:53 AM, V1 (Administrator) said there have been no abuse allegations or investigations in the past two months. On 11/13/24 at 2: 26 PM, V1 said she is not aware of any incidents between R2 and another resident in the last couple of months. V1 said V18 was in the facility for about a month, and she never received any abuse allegations from V18. V1 said if her ADON is doing interviews with staff about potential abuse, she should be informing her about it; she needs to do an investigation and reporting of any allegations. On 11/13/24 at 3:21 PM, V2 (DON) said she is not aware of R2 hitting a resident in the last couple of months. V2 said if she had been told about R2 hitting another resident, she would report it to the Abuse Coordinator (V1), then the abuse coordinator is responsible to do an investigation. The facility's Abuse Policy dated 4/12/21 showed, This facility prohibits mistreatment .or abuse of (continued on next page) 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 REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145771 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 11/13/2024 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)