Inspection·February 9, 2026

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident with an order for a Urology consult received an evaluation by a urologist for 1 of 3 residents (R1) reviewed for care and services in the sample of 8.The findings include:R1's Physician Order Sheet documents that R1 has diagnoses that include multiple sclerosis (MS) and neuromuscular dysfunction of the bladder needing indwelling urinary catheter due to urinary retention.On 2/9/26 at 8:25 AM, V14 (R1's Power of Attorney/POA) said she had a concern with R1 being hospitalized due to multiple urinary tract infections (UTIs) while R1 was at the facility. R1 had indwelling urinary catheter. R1 also has MS. R1 was supposed to see a specialist due to urinary tract infections. V14 said she did not hear any update from the facility.R1's hospital records dated 12/14/25, documents R1 was admitted to the hospital from [DATE] to 12/19/25 due to sepsis- UTI. R1 was discharged back to the facility on [DATE] with an order for R1 to be referred to a Urologist. R1 was again admitted to the hospital from [DATE]-[DATE] due to UTI-sepsis.On 2/5/26 at 11 AM, V6 (Registered Nurse-RN) said the Urology office in town did not take R1's insurance. V6 said she did not notify R1's physician or family that R1 did not see the Urologist as ordered on 12/19/25. On 2/9/26 at 12PM, V2 (Director of Nursing) said R1 has MS and needs the indwelling urinary catheter due to urinary retention. R1 had recurrent UTI's needing hospitalizations. R1 should have been referred to a Urologist for bladder management and ongoing care due to the recurrent UTI's. 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 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 02/09/2026 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)