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.