Health inspection·July 1, 2025

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to identify a new skin alteration for a resident who is at risk for developing pressure wounds which applies to 1 of 3 residents (R1) reviewed for pressure wounds in a sample of 3. Residents Affected - Few The findings include: R1 facility assessment dated [DATE] showed R1 is a [AGE] year-old cognitive male resident admitted to the facility on [DATE] with diagnoses which include a history of traumatic brain injury, bilateral lower leg amputation, lack of coordination, and unspecified dementia. This assessment showed R1 is dependent or needs maximum assistance with activities of daily living which include transferring, bed mobility, showering/bathing, and getting dressed. On 7/1/25 at 10:30 AM, V2 Director of Nursing performed a skin check on R1. During the skin check, two open areas were identified. One on the right and left lower buttocks. The right open area was measured at 1.2 x 0.5 x 0.1 centimeters (cm). The left buttock open area was measured at 0.75 x 2.0 x 0.1 cm. Both open areas were light red with slight, thin, clear exudate. Both open areas were over previously healed pressure wounds. The facility's undated list of residents with pressure wounds provided on 7/1/25 did not have R1 listed as a resident with current pressure wounds. The facility's scheduling calendar and sign out log show R1 had an appointment with a new primary care provider (PCP) on 6/26/25. These documents showed R1 left the faciity on 6/26/25 at 9:30 AM and returned to the facility at 12:12 PM. R1's shower sheet dated 6/26/25 showed R1 received a complete bed bath with discoloration on buttocks. This document showed no new identified open areas. On 7/1/25 at 10:15 AM, V12 PCP office nurse stated during R1's office visit (6/26/25) two open areas were identified on R1 lower buttocks. R1's medical record showed no new orders, skin assessments, or progress notes related to new open skin areas. R1's current care plan showed R1 is at risk for skin breakdown with interventions which include routine skin checks being done daily with cares and weekly with bath or shower schedules. Any new skin issues or concerns should be relayed to the charge nurse for further assessments and or treatments. (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: 145818 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 145818 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rock River Health Care 707 West Riverside Boulevard Rockford, IL 61103 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)