Health inspection·July 17, 2025

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few chart. Showers are documented on shower sheets. Staff should document what they are doing, should notify the family, tell them we are moving, and why we are moving to be transparent. Staff should and let them know how we are handling/eradicate it, and the timeframe when they can go back to their room etc. On 7/15/25 at 10:58 AM, V1 stated she talked to V10 RN because she was the nurse that documented in residents record that families were called about the room change. V10 stated she didn't tell the families because maintenance didn't have confirmation that it was a bed bug. V1 stated the facility should have called the POA/family of the residents on 7/9/25 when they had confirmation of the bed bugs. V1 stated the residents were showered on 7/4/25 and moved to a new room on 7/5/25. The Skin Check Note dated 7/5/25 at 9:22 PM for R2 showed, skin issues note small red marks noted to left lower extremity, hip, and thigh.The Communication Note dated 7/5/25 at 9:56 AM for R2 showed the power of attorney was called and notified that R2 would be moving to room [ROOM NUMBER] for maintenance. No additional Progress and/or Communication Notes were documented from 7/5/25 to the date of the survey on 7/15/25 that showed the POA was notified of the bed bugs in R2's room. R3's Progress Notes from 7/6/25 through the survey investigation date of 7/15/25 did not show the power of attorney was notified that bed bugs were found in R3's room.The Census List for R2 dated 7/15/25 showed on 7/5/25 he was moved from 395-1 to 350-1.The Face Sheet for R2 dated 7/15/25 showed diagnoses including Alzheimer's disease, hyperlipidemia, dementia, hearing loss, hypertensive heart disease, gout, osteoarthritis, and benign prostatic hyperplasia. The facility's Bed Bug Prevention and Management policy (7/8/25) showed, facility staff will implement measures to prevent, eradicate, and contain bed bugs as part of the facility's overall pest control program. 1. The facility shall take a systematic approach to bed bug prevention and management, including monitoring and detection, treatment of affected resident(s), eradication of pests, and prevention of recurrence. 3.e. Document in the medical record for each resident affected: Physician and family notification. Intervention and treatments. Notifications regarding any room changes. Response to treatment, and any monitoring efforts. 4. Eradication of pests: a. If a bug is found that meets the description of a bed bug, maintenance will notify pest control company for verification and eradication. B. [NAME] personal protective equipment, including gown, gloves, mask, hair, and shoe coverings. C. Check resident rooms adjacent to the room in which the bug was found. Check at night with a flashlight when bed bugs are most active. d. Tightly bag belongings, do not remove items or furniture from room. i. remove resident from room, shower, and get clothing from storage. ii. Place resident in a new room until treatment is completed. 5. Prevention of Recurrence: b. Monitor for bed bugs. Consider increase in housekeeping/cleaning efforts during this timeframe. c. Consider sealing cracks and crevices to remove hiding places. d. Follow up on treatment in the recommended timeframe. e. Maintain documentation of actions taken for treatment, eradication, and prevention.2. The Progress Noes dated 7/4/25 for R3 did not show any documentation regarding bed bugs being found in his room, and care and/or procedures done related to the bed bugs. The Skin Check Note dated 7/5/25 at 6:19 AM showed, resident had a shower today; scattered red marks noted on the top of his head, left hip, and right lower extremity.The Progress Notes/Communication Note dated 7/5/25 for R3 showed the power of attorney was called and notified that R3 would be moving to room [ROOM NUMBER] temporarily for maintenance. She advised the pacemaker (transmitter for pacemaker) was in the windowsill. This writer notified staff to move pacemaker (transmitter) to room [ROOM NUMBER]. On 7/15/25 at 11:35 AM, V7 POA stated she was not told R3 was moved because of bed bugs. V7 stated she was told they were doing some thins to his room and he would be moved back eventually. R3's Progress Notes from 7/6/25 through the survey investigation date of 7/15/25 did not show the power of attorney was notified that bed bugs were found in R3's room.The Census List for R3 dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145771 If continuation sheet Page 2 of 3 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 07/17/2025 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 7/15/25 showed on 7/5/25 he was moved from 395-2 to 350-2.The Face Sheet for R3 dated 7/15/25 showed diagnoses including Alzheimer's disease, abdominal aortic aneurysm, hypercholesterolemia, cataract, anemia, macular degeneration, hypertensive and chronic kidney disease, atherosclerotic heart disease, atrial fibrillation, sarcopenia, ataxia, cardiac pacemaker, and dementia. The Care Plan dated 6/6/25 for R3 showed he requires moderate to extensive assistance for bathing, showering, bed mobility, dressing, personal hygiene, and toilet use.The facility's Bed Bug Prevention and Management policy (7/8/25) showed, facility staff will implement measures to prevent, eradicate, and contain bed bugs as part of the facility's overall pest control program. 1. The facility shall take a systematic approach to bed bug prevention and management, including monitoring and detection, treatment of affected resident(s), eradication of pests, and prevention of recurrence. 3.e. Document in the medical record for each resident affected: Physician and family notification. Intervention and treatments. Notifications regarding any room changes. Response to treatment, and any monitoring efforts. 4. Eradication of pests: a. If a bug is found that meets the description of a bed bug, maintenance will notify pest control company for verification and eradication. B. [NAME] personal protective equipment, including gown, gloves, mask, hair, and shoe coverings. C. Check resident rooms adjacent to the room in which the bug was found. Check at night with a flashlight when bed bugs are most active. d. Tightly bag belongings, do not remove items or furniture from room. i. remove resident from room, shower, and get clothing from storage. ii. Place resident in a new room until treatment is completed. 5. Prevention of Recurrence: b. Monitor for bed bugs. Consider increase in housekeeping/cleaning efforts during this timeframe. c. Consider sealing cracks and crevices to remove hiding places. d. Follow up on treatment in the recommended timeframe. e. Maintain documentation of actions taken for treatment, eradication, and prevention. Event ID: Facility ID: 145771 If continuation sheet Page 3 of 3