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Complaint Investigation

St Anthony's Nsg & Rehab Ctr

Inspection Date: September 24, 2025
Total Violations 1
Facility ID 145387
Location ROCK ISLAND, IL
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Inspection Findings

F-Tag F0760

Pharmacy Service Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0760

Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or potential for actual harm

Based on interview and record review the facility failed to administer medication as ordered by the physician for one resident (Resident R3), reviewed for respiratory treatments, in a sample of three residents. The facility's Medication Administration Policy dated 10/14/24 documents, The facility will provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all medications, to meet the needs of each resident.Resident R3's medical record documents Resident R3 was admitted to the facility 9/15/25 with the following diagnoses: Acute respiratory failure with hypoxia, pneumonia, chronic obstructive pulmonary disease (with acute exacerbation), chronic systolic (congestive) heart failure, atrial fibrillation, and hypertension. Resident R3's hospital discharge order documents the following: Albuterol (2.5milligrams/ 3 milliliters) 0.083% nebulizer solution, take 2.5 milligrams by nebulization every six hours.A review of Resident R3's Order Summary Report and Medication Administration Records dated September 2025 document, Albuterol Sulfate Nebulization Solution (2.5 milligrams/ 3 milliliters) 0.083%, 2.5 milligrams inhale orally via nebulizer every six hours as needed for SOB (shortness of breath), does not show staff documentation of medication being administered as ordered.Resident R3 stated that Resident R3 admitted to the facility 9/15/25 from the hospital and he did not receive any nebulizer treatments while residing at facility (1 day). Resident R3 stated that he has been prescribed continuous oxygen therapy and nebulizer treatments for many years. Resident R3 stated that he asked to be discharged on 9/16/25 because he was not getting the medication he needed. V15 (Facility Nurse Practitioner) verified Resident R3's nebulizer treatment orders were not transcribed or administered as ordered.

Residents Affected - Few

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

Event ID:

📋 Inspection Summary

ST ANTHONY'S NSG & REHAB CTR in ROCK ISLAND, IL inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in ROCK ISLAND, IL, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from ST ANTHONY'S NSG & REHAB CTR or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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