Forest City Rehab & Nrsg Ctr
FOREST CITY REHAB & NRSG CTR in ROCKFORD, IL — inspection on November 19, 2025.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Based on observation, interview and record review the facility failed to provide incontinence care to and reposition a resident dependent on staff for these cares for 1 of 33 residents (R27) reviewed for activities of daily living (ADLs) in the sample of 33.The findings include:R27's current care plan showed R27 was nonverbal and cognitively impaired due to his diagnoses of intellectual disability and paralytic syndrome.
The plan showed R27 is dependent on staff for toileting/incontinence care, transfers and repositioning. R27 was incontinent of bowel and bladder.
The plan showed staff will reposition R27 as per facility protocol and keep R27's skin clean and dry. On 11/17/25 at 10:21 AM, R27 was seated in a high-back wheelchair in his room. R97 (R27's roommate) was also in the room. R97 looked at this surveyor and stated, He (R27) doesn't talk.
When R97 was asked how long R27 had been up in his wheelchair that morning, R97 stated, He's been up in the wheelchair since around 5 AM.
They (staff) don't lay him down much during the day. On 11/17/25 at 11:36 AM, R27 remained seated in his high-back wheelchair in the dining room of the facility.On 11/17/25 at 12:15 PM, V5 and V6 Certified Nursing Assistants (CNA) transferred R27, from his wheelchair to bed, via a mechanical lift. V5 and V6 CNAs removed R27's incontinence brief. A large amount of dried out, hard stool was stuck to the crease between R27's buttocks. R27's brief contained a large amount of dark yellow urine.
Redness was noted to the skin of R27's buttocks, groin and scrotum.
Skin creases, caused by exposure to R27's wet incontinence brief, were noted to R27's buttocks. V6 CNA stated R27's incontinence brief was last changed sometime between 5 AM-6 AM when staff had gotten him up and out of bed for the day. On 11/18/25 at 9:26 AM, when V7 Licensed Practical Nurse (LPN) stated residents are to be repositioned every 2 hours to help prevent skin breakdown. V7 stated residents should be checked every 2 hours for incontinence and changed if soiled.The facility's Repositioning and Turning policy dated June 2014 showed, It is the policy of the Nursing Department that residents, unable to reposition themselves, will be turned and repositioned every two hours, in accordance with their needs.
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
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/19/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Forest City Rehab & Nrsg Ctr
321 Arnold Avenue Rockford, IL 61108
SUMMARY STATEMENT OF DEFICIENCIES
- R51's Care Plan with a completed date of 10/15/25 showed R51 was at risk for breakdown in skin
integrity as evidenced by pressure over boney prominences.
Listed under interventions was for a low air loss mattress.
On 11/17/2025 at 8:41 AM, R51 was in bed.
Hanging on the foot of the bed was an air mattress pump.
There was a black tube coming from the pump that was disconnected from the mattress resting on the floor.
The green power switch was in the off position.
On 11/17/2025 at 11:22 AM and on 11/18/25 at 8:01 AM, R51 was in bed and there was no change in R51's air mattress pump.
- R73's Care Plan with a completed date of 10/1/25 showed R73 was at risk for breakdown in skin integrity
as evidenced by pressure over bony prominences.
On 11/17/2025 at 10:23 AM, R73 was in bed.
Hanging on the foot of the bed was an air mattress pump.
The green power switch was in the off position and not lit up.
On 11/18/2025 at 8:00 AM, R73 was in bed and the air mattress pump remained off.
On 11/18/2025 at 11:36 AM, V7 (Licensed Practical Nurse) said an air mattress is a preventative intervention for residents at risk for pressure injuries and if a resident has an air mattress it should be working/on.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/19/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Forest City Rehab & Nrsg Ctr
321 Arnold Avenue Rockford, IL 61108
SUMMARY STATEMENT OF DEFICIENCIES
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure electrical wiring was appropriately insulated and stowed out of reach in one resident's room (R149) and failed to ensure a resident was transferred in a safe manner for 2 of 6 residents (R149, R147) reviewed for safety in the sample of 33.
The findings include: 1. On 11/18/25 at 12:53PM, R149 showed the surveyor two wires sticking out of the wall in the resident's room. R149's room has a black and a white electrical wire hanging out of a conduit tube under the window.
The electrical wires were wrapped with black electrical tape.
On 11/18/25 at 1:25PM, V12 Maintenance used a voltage tester to check the electrical wires.
The voltage tester started flashing and emitted a tone signifying electrical current was present in the wires. V12 Maintenance said, there is 120 volts of electrical power coming through the wires.
The wires should be enclosed with wire caps (rather than electrical tape).
The facility's Preventative Maintenance Program dated 02/19 shows all electrical equipment is checked for safety.
- R147's Restorative assessment dated [DATE] showed he required partial to moderate assistance of staff
for transfers and toileting due to his diagnoses of frequent falls, cerebrovascular accident (CVA) and bilateral carotid stenosis.
On 11/17/25 at 9:01 AM, V8 and V9 Certified Nursing Assistants (CNA) entered R147's room to provide cares. V9 CNA wheeled R147 into the bathroom via his wheelchair. V9 then transferred R147, from his wheelchair to the toilet, by placing her arm under R147's left arm and guiding R147's buttocks onto the toilet. V9 did not use a gait belt when transferring R147. V8 CNA stood in the doorway of the bathroom and watched as V9 CNA transferred R147.
On 11/18/25 at 1:03 PM, V10 Restorative Nurse stated R147 required partial to moderate assistance of one staff for all transfers which included the use of a gait belt to ensure R147's safety. V10 stated R147 was at risk for falls due to his previous falls in the facility.
The facility's Gait Belt policy dated January 2025 showed, Purpose: To provide support and safety during ambulation, lifting, or transferring residents.
Place the gait belt around the resident's waist.
Make certain that the belt fits snugly.
Grasp belt webbing securely at resident's back and resident's right or left side to support resident balance during transfers.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/19/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Forest City Rehab & Nrsg Ctr
321 Arnold Avenue Rockford, IL 61108
SUMMARY STATEMENT OF DEFICIENCIES
On 11/18/2025 at 1:39 PM, V15 (Dietician) said all the residents who have orders to receive magic cup are either at risk for weight loss or have had weight loss and the magic cup is an intervention to prevent weight loss. V15 said she was not aware the facility had run out of the magic cup and ice cream, but they should have given a substitute.
The facility provided Supplementation policy dated 8/5/2023 shows supplements are given to meet resident nutritional needs and to maintain weight.
- R153's Order Summary Report printed on 11/17/2025 showed an order for weekly weights to be done
every Tuesday.
The order had a start date of 4/1/2025.
On 11/17/2025 at 10:10 AM, R153 said she was not being weighed every week and she was not sure why.
R153's October Medication Administration Record (MAR) and Weight and Vital Summary document for October showed a weekly weight recorded for two out of four weeks in October.
The October MAR had not applicable documented for 10/7/2025, 10/21/2025, and 10/28/2025.
R153's November MAR printed on 11/19/2025 and Weight and Vital Summary document for November showed weekly weights were done for one of two weeks.
The November MAR had not applicable documented for 11/4/2025, 11/11/2025, and 11/18/2025.
On 11/18/2025 1:37 PM, V15 (Dietitian) stated weekly weights are done to closely monitor a resident's weight to see of interventions are working or if interventions need to be added.
The facility's Weight Assessment and Interventions policy with reviewed date of 1/24 showed ensure that residents are monitored for undesirable weight loss or gain so appropriate interventions can be put in place in a timely manner.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/19/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Forest City Rehab & Nrsg Ctr
321 Arnold Avenue Rockford, IL 61108
SUMMARY STATEMENT OF DEFICIENCIES
Based on observation, interview and record review the facility failed to follow the menus for residents on regular, mechanical and pureed diets.
This failure has the potential to affect all 166 residents residing in the facility.
The findings include: The CMS-671, Long- Term Care Facility Application for Medicare and Medicaid form that was completed by the facility on 11/17/25 shows there were 166 residents residing in the facility. A list of resident diet orders shows all 166 residents receive food prepared by the facility.
Facility provided menus show on 11/17/25 during the noon meal a biscuit should be served to residents receiving a regular diet, a soft biscuit served to residents receiving mechanical soft diets and pureed bread should be given to residents on pureed diets. On 11/17/25 the noon meal food service line on the first floor was continuously observed from 11:35 AM until 12:15 PM.
Resident meals trays were prepared by V22 (Cook/Dietary Aide) which included BBQ chicken, mashed potatoes, vegetable, oven roasted potatoes, and dessert.
There were no biscuits, or bread on the serving line and residents were not served any during the meal service. On 11/17/25 at 12:09 AM, V22 said that she did not make biscuits for the residents because it is too much for their oven space. V22 also said she did not make or give bread to any residents on a pureed diet. On 11/18/25 at 9:55 AM, V14 (Dietary Manager) said the facility menus should be followed and she was not aware that biscuits/bread was not served to the residents on 11/17/25. On 11/18/25 at 1:37 PM, V15 (Dietician) said the menus should be followed and if they do not give what is on the menus or give a replacement item the caloric intake would be less then planned.
The facility provided Cycle Menu policy dated 9/26/23 shows that the menus are planned out ahead using national guidelines and will meet the nutritional needs of the residents.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/19/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Forest City Rehab & Nrsg Ctr
321 Arnold Avenue Rockford, IL 61108
SUMMARY STATEMENT OF DEFICIENCIES
Provide and implement an infection prevention and control program.
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure staff wear personal protective equipment (PPE) and have signs posted for residents on enhanced barrier precautions (EBP) isolation which applies to 2 of 33 residents (R117, R82) reviewed for infection control in a sample of 33.The findings include: 1) R117's Medical Record showed R117's is a [AGE] year-old female resident readmitted to the facility on [DATE] with diagnoses which includes Stage 4 pressure ulcer of the sacral (tailbone) region.
On 11/17/25 at 12:30 PM V5 and V6 Certified Nursing Assistants (CNAs) entered R117's room, performed a mechanical lift transfer, and peri-care without placing a blue gown on prior to entering the room. R117 has a sign on the door for EBP isolation precautions to be used.
R1's Physician Orders printed on 11/17/25 showed R117 has dressing change orders which include using a crushed antibiotic and antibacterial solution to be applied to R117's wound.
On 11/18/25 at 2:45 PM V4 Infection Control Preventionist (ICP) stated R117 is on EBP for a chronic wound which is currently being treated for an infection.
Gowns and gloves should be worn during high contact care.
On 11/19/25 at 9:35 AM, V5 stated if someone is on EBP then a gown and gloves need to be used during cares. V5 stated they should have worn a gown during R117's care.
The facility's EBP policy dated 11/28/22 showed EBP require the use of gown and gloves during high contact care activities which includes changing briefs or assisting with toileting. EBP applies to resident with a chronic wound.
- R82's current care plan showed R82 had a urinary catheter in place due to his diagnoses of prostate
cancer and obstructive and reflux uropathy.
R82's Order Summary Report dated 7/16/25 showed a physician order for R82 to have Enhanced Barrier Precautions (EBP) in place due to having a urinary catheter.
On 11/17/25 at 8:53 AM and 1:27 PM, R82 was in bed with a urinary catheter in place. No Enhanced Barrier Precautions (EBP) signage was noted on or by the door to R82's room.
On 11/18/25 at 9:26 AM, R82 was in bed with a urinary catheter in place. No Enhanced Barrier Precautions (EBP) signage was noted on or by the door to R82's room.
On 11/18/25 at 9:26 AM, when V7 Licensed Practical Nurse (LPN) was asked how staff identify if a resident is on EBP or any type of isolation precautions, V7 stated, There is a sign posted on the resident's door which identifies what type of isolation the resident is on and what PPE (personal protective equipment) staff are required to wear when providing cares.
The facility's Enhanced Barrier Precautions policy dated 4/28/25 showed, Enhanced Barrier Precautions apply to residents with a wound (chronic wounds, not shorter-lasting wounds, such as skin breaks or tears covered with an adhesive dressing) or similar dressing and indwelling medical device (e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator) .
Facility ID: