Inspection·March 5, 2025

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. (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 3 Event ID: 145818 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 145818 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rock River Health Care 707 West Riverside Boulevard 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)