Forest City Rehab: Resident Left in Soiled Brief - IL
The resident, identified as R27 in inspection records, remained in his wheelchair from around 5 AM until after noon on November 17 without staff checking or changing his incontinence brief. When certified nursing assistants finally transferred him to bed at 12:15 PM, they discovered dried, hardened stool stuck to the crease between his buttocks and dark yellow urine filling his brief.
R27's roommate told inspectors the resident had been sitting in his wheelchair since around 5 AM that morning. "They don't lay him down much during the day," the roommate said.
The inspection revealed R27 had developed redness on his buttocks, groin and scrotum from prolonged exposure to the wet brief. Skin creases from the soiled incontinence product were visible on his buttocks when staff removed it.
One of the nursing assistants who transferred R27 to bed stated his brief had last been changed sometime between 5 AM and 6 AM when staff got him up for the day. That meant R27 had been sitting in waste for more than seven hours.
R27's care plan documented his complete dependence on staff for toileting, incontinence care, transfers and repositioning due to his intellectual disability and paralytic syndrome. The plan specifically required staff to keep his skin clean and dry and reposition him according to facility protocol.
But the facility's own repositioning policy, dated June 2014, requires staff to turn and reposition residents unable to move themselves every two hours. A licensed practical nurse confirmed to inspectors the next day that residents should be repositioned every two hours to prevent skin breakdown and checked for incontinence every two hours.
The violation occurred despite clear documentation in R27's records that he was incontinent of both bowel and bladder and required complete assistance with all personal care.
R27's roommate observed the neglect firsthand. When inspectors arrived in the room at 10:21 AM, the roommate looked at them and explained that R27 "doesn't talk" and had been sitting in the wheelchair since early morning.
The resident remained in his wheelchair in the dining room until nursing assistants finally used a mechanical lift to transfer him to bed more than an hour later.
The inspection found the facility failed to follow its own policies for a resident who could not advocate for himself or communicate his needs. R27's nonverbal status and cognitive impairment made him completely dependent on staff to recognize when he needed care.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm to the resident. The deficiency affected few residents, according to the inspection report.
The facility's failure to provide basic incontinence care violated federal regulations requiring nursing homes to provide assistance with activities of daily living for residents unable to perform these tasks themselves.
Forest City Rehab & Nursing Center is located on Arnold Avenue in Rockford. The complaint inspection was completed November 19, 2025.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Forest City Rehab & Nrsg Ctr from 2025-11-19 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 15, 2026 · Our methodology
FOREST CITY REHAB & NRSG CTR in ROCKFORD, IL was cited for violations during a health inspection on November 19, 2025.
R27's roommate told inspectors the resident had been sitting in his wheelchair since around 5 AM that morning.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at FOREST CITY REHAB & NRSG CTR?
- R27's roommate told inspectors the resident had been sitting in his wheelchair since around 5 AM that morning.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in ROCKFORD, IL, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from FOREST CITY REHAB & NRSG CTR or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 145937.
- Has this facility had violations before?
- To check FOREST CITY REHAB & NRSG CTR's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.