145818
03/05/2025
Rock River Health Care
707 West Riverside Boulevard Rockford, IL 61103
F 0755
Level of Harm - Minimal harm or potential for actual harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Based on interview and record review the facility failed to ensure the accuracy of medication administration records (MAR) for 3 of 3 residents (R1, R2, and R3) reviewed for pharmacy services in the sample of 3.
Residents Affected - Few The findings include: 1. R1's MAR printed on 3/5/25 had blank spots for 2/8/25 and 2/9/25 for the following medications: aspirin, budesonide-formoterol fumarate inhaler, cholestyramine, colchicine, flecainide acetate, folic acid, glipizide, furosemide, pregabalin, metoprolol, pantoprazole sodium, apixaban, and hyoscyamine sulfate. On 3/5/25 at 1:10 PM, R1 said to the best of her recollection she did receive her medications on 2/8/25 and 2/9/25. A facility assessment done on 3/4/25 showed R1's mental status was intact. 2. R2's MAR printed on 3/5/25 had blank spots for 2/8/25 and 2/9/25 for the following medications: aripiprazole, atorvastatin, cholecalciferol, clonazepam, donepezil hydrochloride, fenofibrate, fluoxetine, furosemide, Humalog insulin, Lantus insulin, miconazole, polyethylene glycol, montelukast sodium, multivitamin, mirabegron, nystatin powder, olanzapine, oxybutynin chloride, clopidogrel bisulfate, cholestyramine, Humalog insulin, apixaban, hydroxyzine pamoate, metoprolol tartrate, potassium chloride, vitamin c, carbidopa-levodopa, and gabapentin. R2's Controlled Drug Receipt document showed R2 received clonazepam on 2/8/25 and 2/9/25. On 3/5/25 at 1:20 PM, R2 said she received her medications on 2/8/25 and 2/9/25. A facility assessment done on 1/5/25 showed R2's mental status was moderately impaired. 3. R3's MAR printed on 3/5/25 had blank spots for 2/9/25 for the following medications: cholecalciferol, escitalopram oxalate, lispro insulin, lantus insulin, multivitamin, clopidogrel bisulfate, pantoprazole sodium, sevelamer HCL, vitamin C, and loratadine. On 3/5/25 at 1:15 PM, R3 said he did receive his medications on 2/9/25. A facility assessment done on 1/30/25 showed R3's mental status was intact.
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145818
03/05/2025
Rock River Health Care
707 West Riverside Boulevard Rockford, IL 61103
F 0755
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
On 3/5/25 at 1:53 PM, V10 (Licensed Practical Nurse) said she took care of R1, R2, and R3 on 2/8/25 and 2/9/25 during the time frame that corresponded with the blank spots on the MARs. V10 said she gave R1, R2, and R3 all their scheduled medications but forgot to document on the MAR that the medications were given. On 3/5/25 at 1:41 PM, V4 (Registered Nurse) said once a nurse gives a medication it should be documented as given on the MAR. V4 added that the MAR is documented proof medications were given to the residents. V4 said, if there were blank spots on the MAR it could lead to confusion if a medication was given. On 3/5/25 at 12:13 PM, V1 (Administrator) said there should be no blank spots on the MAR. V1 said blank spots on a MAR indicates the medication was not given.
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145818
03/05/2025
Rock River Health Care
707 West Riverside Boulevard Rockford, IL 61103
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm or potential for actual harm
Based on observation, interview, and record review the facility failed to ensure staff followed enhanced barrier precautions by not wearing the required personal protective equipment (PPE) when emptying an indwelling urinary catheter drainage bag for 1 of 2 residents (R1) reviewed for infection control in the sample of 3.
Residents Affected - Few
The findings include: R1's Order Summary Report printed on 3/5/25 showed R1 was on enhanced barrier precautions because of an indwelling urinary catheter. R1's Care Plan with an initiated date of 6/27/24 showed R1 was at high risk for infection because of a catheter. Listed under interventions was, PPE to be worn during high contact activities: gown, and gloves and shield when risk of splash is present (i.e. emptying a catheter, working with feeding tube, etc.). R1's name appeared on the December 2024 infection control log. The log indicated R1 received an antibiotic for a urinary tract infection. On 3/5/25 at 8:12 AM, on the door of R1's room was a sign indicating R1 was on enhanced barrier precautions. R1 had an indwelling urinary catheter drainage bag hanging on the bedframe that contained urine. V3 (Certified Nursing Assistant) was emptying R1's indwelling urinary catheter drainage bag. V3 had on gloves. V3 did not have on a gown or a splash guard. On 3/5/25 at 11:50 AM, V7 (Infection Control Nurse) said enhanced barrier precautions are an infection control intervention. V7 added that when staff empty an indwelling urinary catheter drainage bag, they should wear the following PPE: gloves, gown, and a splash guard. The facility's Enhanced Barrier Precautions policy with a revision date of 8/15/24 showed the purpose is to reduce the transmission of novel or targeted multi-drug-resistant organisms .Enhanced Barrier Precautions require the use of gown and glove during high contact resident care activities. High contact resident care activities include Device care and use of an indwelling medical device such as urinary catheter . the same policy showed gowns and gloves are the minimum level of PPE. Additional PPE may be required depending on the situation/resident (e.g., face shield may be used when splashes and sprays are likely to occur).
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