Inspection·December 12, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review the facility failed to ensure a resident had his prescribed medication when leaving the facility on a pass home overnight for 1 of 3 residents reviewed for medications in the sample of 3. The findings include: The Nurse's Notes dated 11/28/24 for R1 did not show that he left the building on a pass with his power of attorney. A handwritten note given to R1's POA (Power of Attorney) on 11/28/24 showed, R1 does not have medication strip to provide his mother while out on pass. The note was signed by V4 LPN (Licensed Practical Nurse). The MAR (Medication Administration Record) dated November 2024 for R1 showed on 11/28/24 R1 received his morning medications. R1's evening medications for 11/28/24 were latanoprost opthalmic 0.005%, melatonin 3mg, benztropin mesylate 1mg, depakote 250 mg, depakote 500mg, lorazepam 0.5 mg, pepcid 20 mg, risperidone 0.25 mg. R1's morning medications for 11/29/24 were: aripirazole 5mg, atenolol 50 mg, furosemide 20 mg, spironolactone 50 mg, benztropine mesylat 1 mg, depakote 250 mg, depakote 500 mg, lorazepam 0.5 mg, pepcid 20 mg, risperidone 0.25 mg. R1's MAR dated 11/29/24 had a 1 documented for his morning medications which meant away from the facility with meds. On 12/12/24 at 9:10 AM, V2 DON (Director of Nursing) stated if a resident is going out for a morning appointment medications are given before the resident leaves. V2 stated if the resident is coming back after their appointment then medications would not be sent with the resident. V2 stated the nurse will ask when the resident is returning and if they are going to be out to dinner, shopping etc then the nurse sends the evening medications with the resident. If the resident is going home overnight or for a few days there are tiny envelopes with lines on them to put medications in. They write the name of the medication and when it is due on the envelope. They need to send medications with them. On 12/12/24 at 11:49 AM, V4 LPN stated, R1 was getting ready to leave and his strip of medications were not in the medication cart. V7 (R1's POA - Power of Attorney) was here and it was explained to her. V4 stated V7 was upset and asked why his medications were not there. V4 stated she did not know why. V4 stated she told V6 LPN and she showed her how to order medications. V4 stated they had some of his medications but not all of them. V4 stated she did not know which specific medications went with R1. V4 stated she knew the medication strip containing pills wasn't there. What was available was given is small envelopes that were labeled. V4 stated she did not know which medications were (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: 145937 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 145937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest City Rehab & Nrsg Ctr 321 Arnold Avenue Rockford, IL 61108 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)