Health inspection·July 21, 2025

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident was free from significant medication error. This applies to 1 of 3 residents (R1) reviewed for medications in the sample of 3. The findings include: R1's face sheet shows he is a [AGE] year-old male with diagnoses including post traumatic seizures, COPD, major depressive disorder, anxiety, and personal history of traumatic brain injury.On 7/21/25 at 8:42 AM, R1 was in his room lying in bed, V5 (Licensed Practical Nurse-LPN) was in his room taking his vitals. At 8:43 AM, the emergency services arrived and entered R1's room. At 8:46 AM, R1 left the building with emergency services.On 7/21/25 at 8:46 AM, V6 (Certified Nursing Assistant-CNA) said R1 is alert and oriented x3, he was fine this morning when he got up and ate breakfast. After breakfast he wanted to lay down and usually, he refuses to lay down and stays up in his wheelchair till after dinner. He transferred R1 back in bed and R1's body started jerking in bed, repeatedly.On 7/21/25 at 8:50 AM, V5 (LPN) said R1 got up in his wheelchair this morning and after breakfast he wanted to get back in bed. That was unusual for him, R1 won't lay down for nothing. V6 notified me of R1's seizure activity this morning and she called 911. R1 takes several seizure medications and night shift staff administers his medications. R1 refuses his medications at times when he's aggravated, but we try to re-approach him when he calms down.On 7/21/25 at 10:24 AM, V3 (Registered Nurse-RN) showed this surveyor R1's medication cards. R1's Phenytoin 100 mg (milligrams) shows to give one tablet three times a day for seizures. This card shows 24 out of 30 tablets remained. Divalproex 500 mg three tablets three time a day for seizures. This card shows 13 out of 30 tables remained. Levetiracetam tablet 1000 mg one tablet twice a day for seizures. This card shows 14 out of 30 tablets remained.On 7/21/25 at 12:35 PM, V9 (Ombudsman) said she talked to R1 on 6/26/25 and he expressed concerns about not receiving his seizure medications. R1 said he was only getting one seizure medication, and the nursing staff were not bringing him his medication. She spoke with V1 regarding this concern, and he said R1 is refusing his medication. V9 said she is aware of V1 being on vacation this week.R1's Medication Administration Record (M.A.R.) dated July 2025 shows orders for Aptiom 800 mg give one tablet in the evening daily. The M.A.R. shows this medication was not administered three out of nineteen days. Dilantin 100 mg give three times a day. The M.A.R. shows this medication was not administered three doses out of 30 days.Divalproex Sodium tablet delayed release give three tablets by mouth. The M.A.R. shows six doses out of thirty days the medication was not administered.R1's M.A.R for June 2025 shows Aptiom 800 mg daily. The M.A.R. shows 2 refusals out of 30 days. Three doses of refusals out of thirty days the medication was not administered. Dilantin 100 mg three times a day. The M.A.R. shows five doses of refusals in thirty days. The M.A.R. shows this medication was not administered seven doses in thirty days. Levetiracetam tablet 1000 mg give one tablet twice a day. The M.A.R. shows two doses of refusals in thirty days. The M.A.R. shows this medication was not administered five doses in thirty days.On 7/21/25 at 1:11 PM, V2 said R1 is alert and oriented. He can be non-complaint with Residents Affected - Few (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: 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 07/21/2025 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)