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 Page 1 of 2 145771 145771 11/13/2024 River Bluff Nursing Home 4401 North Main Street Rockford, IL 61103

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few its residents Employees are required to report any incident, allegation or suspicion of potential abuse . they observe, hear about, or suspect to the administrator immediately, or to an immediate supervisor who must then immediately report it to the administrator .Supervisors shall immediately inform the administrator or designee of all reports of incidents, allegations or suspicion of potential abuse. The facility was unable to provide any reports or documentation of an investigation regarding the 9/24/24 incident between R2 and R3. 145771 Page 2 of 2