Inspection·September 25, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on medical record review, review of facility investigation report, resident and staff interviews, and policy review, the facility failed to ensure medications were consumed at the time of administration. This affected one (#08) out of three residents reviewed for medication administration. The facility census was 25. Findings include: Review of the medical record for Resident #08 revealed an admission date of 07/24/24 with medical diagnoses of acquired left below the knee amputation (BKA), chronic obstructive pulmonary disease, congestive heart failure, obsessive-compulsive disorder (OCD), major depression, and peripheral vascular disease. Review of the medical record for Resident #08 revealed an admission Minimum Data Set (MDS) assessment, dated 07/29/24, which indicated Resident #08 was cognitively intact and required substantial/maximum staff assistance with toilet hygiene and bathing, supervision with transfers and set-up assistance with eating and bed mobility. The MDS indicated Resident #08 received antidepressant, anticoagulant, antibiotic, and opioid medications. Review of the medical record for Resident #08 revealed physician orders dated 07/24/24 for acetaminophen 650 milligram (mg) one tablet by mouth every four hours as needed, 07/25/24 for cholecalciferol (vitamin D3) 1000 units one tablet by mouth daily and oxycodone-acetaminophen (Percocet) 5-325 mg one tablet by mouth every four hours as needed, 07/26/24 for Colace (stool softener)100 mg one tablet by mouth two times per day, and 08/15/24 for gabapentin 100 mg one tablet by mouth every evening. Review of Resident #08's medical record revealed there was no physician order, assessment or care plan allowing the resident to self administer medications. Review of the medical record for Resident #08 revealed a nurse progress note dated 08/24/24 at 4:41 A.M. written by Licensed Practical Nurse (LPN) #75 which stated the nurse gave Resident #08 his morning medications, watched the resident take medications and left the room. The note stated a State Tested Nursing Assistant (STNA) went into Resident #08's room to empty his catheter and saw Resident #08 putting medications into his pillowcase. The note stated LPN #75 and Director of Nursing (DON) went to into Resident #08's room and asked where he placed his medications. Resident #08 denied having the medications. The note stated LPN #75 checked in Resident #75's pillowcase and found a medication cup in a glove with two gabapentin tablets, one acetaminophen tablet, two stool softener tablets, four Vitamin D3 tablets, and ten Percocet tablets. The note continued to state the LPN educated Resident #08 on severe misuse of medications and how important it was to have his medications on him and to take them with compliance. (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 09/25/2024 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)