Inspection·February 22, 2024

F 0569 Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility policy the facility failed to ensure resident funds were conveyed in a timely manner. This affected two residents (#20 and #23) of three reviewed for personal funds. The facility census was 19. Residents Affected - Few Findings include: 1. Review of the medical record of Resident #20 revealed an admission date of [DATE] and a date of death on [DATE]. Diagnoses included acute and chronic respiratory failure with hypercapnia and hypoxia, hypotension, chronic obstructive pulmonary disease, anxiety disorder, emphysema, and quadriplegia C5-C7 incomplete. Review of the facility form titled, Transaction Report, dated [DATE] to [DATE] revealed Resident #20's account had a payment applied on [DATE] in the amount of $25,000.00. A second payment was applied on [DATE] in the amount of $7,000.00, and a third on [DATE] in the amount of $7,000.00. A refund of $7,500.00 was issued on [DATE]. There was a balance of $7,500. Interview on [DATE] at 10:30 A.M. with Business Office Manager (BOM) #150 and Director of Accounts Receivable (DAR) #151 revealed Resident #20 admitted under Medicare Part A with Michigan Blue Cross/Blue Shield as secondary payment. His insurance changed to Medicaid pending on [DATE], at which time he owed $1500.00 per day. Resident #20 expired on [DATE] for a total of $31,500.00 owed for the 21 days. The facility received a payment of $25,000.00 on [DATE], a payment of $7000.00 on [DATE], and $7000.00 on [DATE] totaling $39,000.00. At the time of his death Resident #20 had an outstanding balance of $6,000.00 as the facility was waiting on the co-insurance check to cover the $6,000.00 from [DATE] to [DATE]. This would leave a balance in the account of $1,500. A follow-up interview on [DATE] at 11:20 A.M. with BOM #150 and DAR #151 revealed Resident #20's estate should have received the $1,500.00 within the 30 days following his death. 2. Review of the medical record of Resident #23 revealed an admission date of [DATE] and a discharge date of [DATE]. Diagnoses include wedge compression fracture of T11-T12 vertebra and unspecified intellectual disabilities. Review of the payor sources revealed Resident #23 was private pay beginning [DATE] until discharged . Review of the, Transaction Report, dated [DATE] to [DATE] revealed Resident #23 had a positive (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: 366234 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 02/22/2024 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)