Health inspection·November 16, 2023

F 0583 Keep residents' personal and medical records private and confidential. 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 provide privacy to a resident while providing personal care. This applies to one of three residents (R1) reviewed for privacy in the sample of 16. Residents Affected - Few Findings include: The facility face sheet for R1 shows diagnosis to include spinal stenosis, benign prostatic hyperplasia with lower urinary tract symptoms and schizoaffective disorder. The facility assessment dated [DATE] for R1 shows him to have severe cognitive impairment and requires maximum assistance with all care. On 11/15/23 at 11:00 AM, R1 was being provided perineal care by V8 and V9 both Certified Nursing Assistants (CNA). R1 was completely naked and being turned side to side. The privacy curtain between the two beds was not pulled. R1's room mate and V3 Hospice Registered Nurse (RN) were both in the room and had a clear view of the care being provided to R1. On 11/15/23 at 11:10 AM, V3 Hospice RN said she wished the staff had closed the privacy curtain while providing care to R1. V3 said the situation made her uncomfortable. On 11/15/23 at 11:05 AM, V8 CNA said she should have pulled the privacy curtain while providing care to R1 for his privacy. On 11/15/23 at 11:30 AM, V9 CNA said the privacy curtain should have been pulled while providing care to R1. On 11/15/23 at 1:10 PM, V2 Assistant Director of Nursing said she would expect the staff to close the privacy curtain while providing care to a resident to protect the residents privacy. The facility policy with a revision date of 10/2017 for personal privacy shows the facility will strive to protect the resident's privacy regarding his or her personal care. Page 1 of 2 145908 145908 11/16/2023 Amberwood Care Centre 2313 North Rockton Avenue Rockford, IL 61103

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 interview and record review the facility failed to continue an ordered antibiotic when a resident returned from the hospital. This applies to one of three residents (R1) reviewed for medications on the sample list of 16. Residents Affected - Few Findings inlcude: The facility face sheet for R1 shows diagnosis to include spinal stenosis, benign prostatic hyperplasia with lower urinary tract symptoms and schizoaffective disorder. The facility assessment dated [DATE] for R1 shows him to have severe cognitive impairment and requires maximum assistance with all cares. The hospital records for R1 show he was in the hospital from [DATE] to 10/27/23 with a diagnosis of pyelonephritis (Kidney infection). The final discharge medication list from R1's 10/27/23 hospital discharge shows an order for cefdiner (antibiotic) to be given twice a day for the next 5 days starting on 10/27/23. The October Medication Administration Record (MAR) shows the medication was not started until 10/31/23. (4 days after the ordered start date) The Physician Order Sheet for R1 dated October 2023 shows the order for the antibiotic was not started until 10/31/23. On 11/15/23 at 10:35 AM, V2 Assistant Director of Nursing said when R1 came back from the hospital on [DATE] the order for the antibiotic was not transcribed onto the current orders and R1 did not receive his antibiotic right away. On 11/15/23 at 1:10 PM, V2 said she expects the staff to transcribe all ordered medications. On 11/16/23 at 1:30PM, V19 R1's Physician said the nurses should have started the antibiotic for R1 when he came back from the hospital as it was ordered. The facility policy with a revision date of July 2017 for reconciliation of medications on admission shows 2. Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interuption, in the correct dosages and routes, during the admission/tranfer process. 145908 Page 2 of 2