Inspection·July 3, 2019

F 0582 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #76 to discharge home with orders for outpatient therapy. Continued review of a nurse progress note dated 02/19/19 at 11:39 A.M. revealed the resident discharge home. Review of a skilled nursing facility protection notification review revealed the facility initiated a discharge from Medicare part A services when benefit days were not exhausted. Resident # 76's last covered day of part A service was 02/19/19. Documentation revealed the resident was not given a NOMNC. Interview on 07/03/19 at 11:36 A.M. with the DON revealed Resident #76 was discharge home when skilled benefit days remained. The DON reported the residents physician gave discharge orders for the resident to discharge from the facility and continue therapy at home. The DON verified a NOMNC was not given to Resident #76 or the residents representative. The DON revealed the NOMNC was not provided to Resident #76 because the discharge order was given by the orthopedic doctor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366234 If continuation sheet Page 2 of 11 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 366234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Nursing Center of Rockford 201 Buckeye Street Rockford, OH 45882 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review and staff interview; the facility failed to provide the resident/resident representative a written summary of the baseline care plan. This affected two (#12, #73, and #13) of three residents reviewed for baseline care plans. The census was 24. Findings include: 1. Review of the medical record for Resident #12 revealed the resident was admitted to the facility on [DATE]. Diagnoses include congestive heart failure, chronic obstructive pulmonary disease, major depressive disorder, anxiety disorder, post traumatic stress disorder, and diabetes mellitus type one. Review of the admission minimum data set (MDS) assessment dated [DATE], revealed Resident #12 had intact cognition. Review of the medical record for Resident #12 revealed no evidence of a written summary of the baseline care plan being given to the resident. Interview on 07/02/19 at 1:30 P.M. with the Director of Nursing (DON) verified there was no written summary of the baseline care plan given to Resident #12. The DON revealed he/she was not aware of the requirement. 2. Review of the medical record for Resident #73 revealed the resident was admitted to the facility on [DATE]. Diagnoses include insomnia, chronic pain, anxiety, major depressive disorder, muscle spasms, chronic fatigue, multiple spasms, and multiple sclerosis. Review of the admission MDS assessment dated [DATE], revealed Resident #73 had intact cognition. Review of the medical record for Resident # 73 revealed no evidence of a written summary of the baseline care plan being given to the resident. Interview on 07/02/19 at 1:31 P.M. with the DON verified there was no written summary of the baseline care plan given to Resident #73. 3. Review of the the medical record for Resident #13 revealed the resident was admitted to the facility on [DATE]. Diagnoses include cerebral palsy, anxiety, major depressive disorder, diabetes mellitus type two, spastic hemiplegia, bipolar disorder, and hydronephrosis. Review of the quarterly MDS assessment dated [DATE], revealed the resident had intact cognition. Review of the medical record for Resident # 13 revealed no evidence of a written summary of the baseline care plan being given to the resident. Interview on 07/02/19 at 1:32 P.M. with the DON verified there was no written summary of the baseline care plan given to Resident #13. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366234 If continuation sheet Page 3 of 11 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 366234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Nursing Center of Rockford 201 Buckeye Street Rockford, OH 45882 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review and staff interview; the facility failed to develop and implement a person-centered comprehensive care plan for the use of psychoactive, anticoagulant, and diuretic medications. This affected one (#12) of five residents reviewed for unnecessary medication. The census was 24. Findings include: Review of the medical record for Resident #12 revealed the resident was admitted to the facility on [DATE]. Diagnoses include congestive heart failure, chronic obstructive pulmonary disease, major depressive disorder, anxiety disorder, post traumatic stress disorder, and diabetes mellitus type one. Review of the admission minimum data set (MDS) assessment dated [DATE], revealed Resident #12 was administered antianxiety, anticoagulant, and diuretic medication on seven days during the seven day reference period. Review of the medication administration record dated 06/19 and 07/19 revealed Resident #12 was administered xanax (antianxiety medication) one milligram (mg), one tablet by mouth twice a day, buspirone (antianxiety medication) 10 mg, one tablet by mouth three times a day, eliquis (anticoagulant medication) five mg, one tablet by mouth twice a day, and lasix (diuretic medication) 80 mg, one tablet by mouth daily. Review of Resident #12's comprehensive care plan revision date 06/19/19, revealed there was no care plan to address the use of and potential for drug related complications associated with the use of psychoactive, anticoagulant, and diuretic medication. Interview on 07/03/19 at 9:05 A.M. with the Director of Nursing (DON) verified there was no comprehensive care plan to address psychoactive, anticoagulant, and diuretic medications ordered and administered to Resident #12. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366234 If continuation sheet Page 4 of 11 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 366234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Nursing Center of Rockford 201 Buckeye Street Rockford, OH 45882 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review and resident and staff interviews, the facility failed to ensure a resident was adequately secured on the facilities transportation bus. This affected one (#73) of one resident reviewed for accident/hazards. The census was 24. Findings include: Review of the medical record for Resident #73 revealed the resident was admitted to the facility on [DATE]. Diagnoses include insomnia, chronic pain, anxiety, major depressive disorder, muscle spasms, chronic fatigue, multiple spasms, and multiple sclerosis. Review of the admission minimum data set (MDS) assessment dated [DATE], revealed Resident #73 had intact cognition. The resident required limited assistance of one staff for transfers. Documentation revealed the resident's mobility devices was a wheel chair (manual or electric). Review of the nurse progress notes dated 06/20/19 at 3:15 A.M. revealed Resident #73 complained of nausea and headache. Vital signs were systolic blood pressure 130 millimeters of mercury (mmHg) and diastolic blood pressure 75 mmHg, pulse 94, temperature 98 degrees Fahrenheit, and oxygen saturation 95 percent on room air. Documentation revealed the resident request to be sent to hospital for evaluation and treatment. Resident #73 returned to the facility on [DATE] at 9:02 A.M. Review of hospital documentation dated 06/20/19, revealed the Resident #73 presented to the hospital with complaints of headache and nausea. Resident #73 reported his/her wheel chair tipped over causing the resident to hit her/his head in the process. Documentation revealed the physical exam of the head was normocephalic and atraumatic, the residents pupils were equal round and reactive to light, and the assessment of the neck revealed range of motion (ROM) within normal limits (WNL). Continued review of the documentation revealed Resident #73 was oriented to person, place, and time. There were no cranial nerve deficits. A computerized tomography (CT) scan of Resident #73's head was completed Findings were no acute intracranial hemorrhage, mass effect or midline shift. No abnormal extra axial fluid collection and the graywhite matter differentiation is maintained without evidence of acute infarct. There was no evidence of hydrocephalus. Visual portion of the orbits demonstrate no acute abnormalities. Visualization of paranasal sinuses and mastoid air cells demonstrate no acute abnormalities. Visualization of the soft tissue/skull documented no acute abnormalities. Interview on 07/01/19 at 1:58 P.M. with Resident #73 revealed the resident's electric wheel chair tipped over in facilities bus when returning from an appointment on 06/19/19. Resident #73 reported striking his/her head when the chair tipped. Resident #73 revealed the chair did not completely tip over, but slightly tipped because the electric wheel chairs four point anchor system was not used correctly. The resident revealed the wheel chair had four areas located at the base of the chair used to anchor the chair in place while being transported. Resident #73 revealed three of the anchors were secured using the buses tether strap system. The resident revealed the fourth anchor and tether strap were not secured, allowing the chair to tip over far enough that the resident struck his/her head. Interview on 07/01/19 at 5:55 P.M. with Director of Maintenance (DOM) #418 revealed the DOM #418 transported Resident #73 to an appointment approximately two weeks ago. DOM #418 revealed on the way (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366234 If continuation sheet Page 5 of 11 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 366234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Nursing Center of Rockford 201 Buckeye Street Rockford, OH 45882 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few back to the facility, while taking a turn, the DOM heard a noise in the back of the bus. The DOM #418 then looked in the rearview mirror and observed the resident chair slightly tipped over. The DOM revealed the bus seat next to the resident prevented the chair from tipping over completely. DOM #418 reported he/she immediately stopped the bus and went to assess the situation. The DOM #418 reported Resident #73 denied hitting his/her head and reported no injury or other complaints. DOM #418 revealed this employee then put the electronic wheel chair back into place and continued the drive back to the facility. DOM #418 confirmed Resident #73's wheel chair contained four anchors located at the base of the chair. DOM #418 further verified three of the four anchors were secured to the bus using the buses tether strap system. The DOM #418 confirmed the fourth anchor was not secured because DOM #418 was not aware of the four tether strap located on the bus to secure the wheel chair. Observation on 07/01/19 at 6:15 P.M. with DOM #418, of the facilities transportation bus, verified the cargo area of the bus contained four tether straps that were to be used to secure wheel chairs for residents who were transported to appointments in wheel chairs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366234 If continuation sheet Page 6 of 11 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 366234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Nursing Center of Rockford 201 Buckeye Street Rockford, OH 45882 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview; the facility failed to treat an urinary tract infection to maintain bladder function for a resident who utilizes an indwelling urinary catheter. This affected one (#13) of one resident reviewed for urinary catheter. The census was 24. Findings include: Review of the the medical record for Resident #13 revealed the resident was admitted to the facility on [DATE]. Diagnoses include cerebral palsy, anxiety, major depressive disorder, diabetes mellitus type two, spastic hemiplegia, bipolar disorder, and hydronephrosis. Review of the quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #13 had intact cognition. The resident was totally dependent upon staff for bed mobility, transfers, toilet use, and personal hygiene. The resident utilized an indwelling urinary catheter. Review of a physician order dated 06/21/19, revealed Resident #13 was ordered the antibiotic medication ciprofloxacin 500 milligram (mg), take one tablet by mouth two times a day for 10 days. Review of a microbiology report collection date 06/21/19 revealed Resident #13 had abnormal urinalysis results. A culture and sensitivity was to follow. Continued review of the microbiology report revealed on 06/25/19 the final urine culture was completed. The urine culture identified the organisms staphylococcus aureus, colony count greater than 100,000 and pseudomonas aeruginosa, colony count greater than 100,000. Continued review of the microbiology report revealed the identified organisms were resistant to the antibiotic ciprofloxacin. Review of the medication administration record dated 06/19 and 07/19, revealed Resident #13 was administered ciprofloxacin 500 mg tablet per the physicians order for a urinary tract infection on 06/27/19, 06/28/19, 06/29/19, 06/30/19, 07/01/19, 07/02/19, and 07/03/19. Interview on 07/02/19 at 3:30 P.M. with the Director of Nursing (DON) revealed the ciprofloxacin medication was ordered for Resident #13 while at the hospital for evaluation and treatment, to treat a urinary tract infection. Continued interview with the DON verified the microbiology report collection date 06/25/19, identified the organisms were resistant to ciprofloxacin. The DON further verified the resident began receiving the inappropriate antibiotic on 06/27/19, six days after the order. The DON also verified the physician was not notified of Resident #13's current orders for ciprofloxacin or the laboratory results. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366234 If continuation sheet Page 7 of 11 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 366234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Nursing Center of Rockford 201 Buckeye Street Rockford, OH 45882 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Potential for minimal harm Based on personnel record review and staff interview, the facility failed to complete annual performance evaluations for two State Tested Nurse Aides (STNA) #402 and #426 reviewed. This had the potential to affect 24 of 24 residents residing in the facility. The facility census was 24. Residents Affected - Many Findings include: Review of the personnel records for two State Tested Nurse Aides (STNA #402 and #426) were silent for annual performance evaluations. During an interview with the Director of Nursing (DON) on 07/03/19 at 3:05 P.M., she verified annual performance evaluations were not completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366234 If continuation sheet Page 8 of 11 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 366234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Nursing Center of Rockford 201 Buckeye Street Rockford, OH 45882 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident record review, staff interviews, and policy review; the facility failed to implement standard precautions when a resident's used/dirty urinary catheter bag was placed in another resident's storage basin which contained personal hygiene products. This affected one (#13) of 16 resident reviewed during the initial pool process for infection control. Additionally, the facility failed to implement a water management program for the prevention and spread of Legionella. This had the potential to affect 24 of 24 residents who reside at the facility. The census was 24. Residents Affected - Many Findings include: 1. Observation on 07/01/19 at 10:12 A.M. of Resident #13's shared bathroom revealed a storage basin was sitting on the counter next to the sink. The storage basin was noted to contain multiple denture cleaner tablets, a tube of tooth paste, body wash, and other bottles of hygiene products. Laying directly on top of the denture cleaner tablets, tube of tooth paste, body wash, and other hygiene products was a used/dirty catheter bag. Review of the the medical record for Resident #13 revealed the resident was admitted to the facility on [DATE]. Diagnoses include cerebral palsy, anxiety, major depressive disorder, diabetes mellitus type two, spastic hemiplegia, bipolar disorder, and hydronephrosis. Review of the quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #13 had intact cognition. The resident was totally dependent upon staff for bed mobility, transfers, toilet use, and personal hygiene. The resident utilized an indwelling urinary catheter. Review of Resident #13's plan of care revealed the resident had an alteration in elimination related to supra pubic catheter. Review of a microbiology report collection date 06/21/19 revealed Resident #13 had abnormal urinalysis results. A culture and sensitivity was to follow. Continued review of the microbiology report revealed on 06/25/19 the final urine culture was completed. The urine culture identified the organisms staphylococcus aureus, colony count greater than 100,000 and pseudomonas aeruginosa, colony count greater than 100,000. Review of the medication administration record dated 06/19 and 07/19, revealed Resident #13 was administered ciprofloxacin 500 mg tablet per the physicians order for a urinary tract infection. Interview on 07/01/19 at 10:14 P.M. with Resident #13 revealed the resident had his/her own teeth and did not use a partial or dentures. Resident #13 verified the storage basin containing hygiene products located in the residents shared bathroom belonged to Resident #13's roommate, Resident #12. Resident #13 revealed this resident did not use the shared bathroom except when staff would go into the bathroom to empty the residents urinary catheter bag into the toilet. The resident further revealed this residents hygiene products where kept in the night stand and chest of drawers. Resident #13 did not know how the used catheter bag got into Resident #12's basin of hygiene products and reported staff should have placed the used bag into the trash. Interview on 07/01/19 at 10:17 A.M. with state tested nurse aid (STNA) #425 verified the storage basin, located in shared bathroom of Resident #13 and Resident #12, contained multiple denture cleaner (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366234 If continuation sheet Page 9 of 11 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 366234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Nursing Center of Rockford 201 Buckeye Street Rockford, OH 45882 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many tablets, a tube of tooth paste, body wash, other bottles of hygiene products and a used/dirty catheter bag. STNA #425 verified the basin of hygiene products belonged Resident #12 and the dirty catheter bag belonged to Resident #13. The STNA verified Resident #12 did not have a urinary catheter. 2. Review of the Legionella Policy dated 07/01/18 revealed the facility was to complete weekly flushes of little used outlets, monthly hot and cold water temperature monitoring and quarterly shower head descaling and disinfection. Review of the submitted documentation was silent for flushing or checking of water temperatures . Review of the Legionella Risk Assessment revealed the facility should have a water management program in place to reduce the growth and spread of Legionella. Interview with the Corporate Maintenance Director on 07/03/19 at 3:50 P.M., verified the facility had not completed flushes nor checking or monitoring of water temperatures. This deficiency is a recite to the complaint survey completed 05/21/19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366234 If continuation sheet Page 10 of 11 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 366234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Nursing Center of Rockford 201 Buckeye Street Rockford, OH 45882 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review and staff interview; the facility failed to implement antibiotic stewardship protocol to ensure appropriate antibiotic use. This affected one (#13) of one resident review of a urinary tract infection. The census was 24. Residents Affected - Few Findings include: Review of the the medical record for Resident #13 revealed the resident was admitted to the facility on [DATE]. Diagnoses include cerebral palsy, anxiety, major depressive disorder, diabetes mellitus type two, spastic hemiplegia, bipolar disorder, and hydronephrosis. Review of the quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #13 had intact cognition. The resident was totally dependent upon staff for bed mobility, transfers, toilet use, and personal hygiene. The resident utilized an indwelling urinary catheter. Review of a physician order dated 06/21/19, revealed Resident #13 was ordered the antibiotic medication ciprofloxacin 500 milligram (mg), take one tablet by mouth two times a day for 10 days. Review of a microbiology report collection date 06/21/19 revealed Resident #13 had abnormal urinalysis results. A culture and sensitivity was to follow. Continued review of the microbiology report revealed on 06/25/19 the final urine culture was completed. The urine culture identified the organisms staphylococcus aureus, colony count greater than 100,000 and pseudomonas aeruginosa, colony count greater than 100,000. Continued review of the microbiology report revealed the identified organisms were resistant to the antibiotic ciprofloxacin. Review of the medication administration record dated 06/19 and 07/19, revealed Resident #13 was administered ciprofloxacin 500 mg tablet per the physicians order for a urinary tract infection on 06/27/19, 06/28/19, 06/29/19, 06/30/19, 07/01/19, 07/02/19, and 07/03/19. Interview on 07/02/19 at 3:30 P.M., with the Director of Nursing (DON) revealed the ciprofloxacin medication was ordered for Resident #13 while at the hospital for evaluation and treatment. The DON reported the ciprofloxacin was ordered to treat a urinary tract infection. Continued interview with the DON verified the microbiology report collection date 06/21/19, identified the organisms were resistant to ciprofloxacin. The DON further verified the facility failed to identify Resident #13's urinary tract infection organism was resistant to the prescribed antibiotic. The DON further verified the physician was not notified of Resident #13's current orders for Ciprofloxacin and it was started on 06/27/19, six days after the order. Review of the policy titled Stewardship Policy dated 10/17, revealed widespread use of antibiotics has resulted in an alarming increase in antibiotic resistant infections and a subsequent need to rely on board spectrum antibiotics that might be more toxic and expensive. Antibiotic stewardship consists of coordinated interventions aimed at treating infections while promoting appropriate use. The policy revealed the facility will provide regular feed back on antibiotic use to clinicians about appropriate antibiotic use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366234 If continuation sheet Page 11 of 11