Inspection·January 28, 2025

F 0686 Level of Harm - Actual harm Residents Affected - Few is no pressure injury listed. R1's Wound and Skin Alteration Review (Wound Nurse) dated 12/27/24 at 10:59 AM shows R1 has a nonstageable (NS) sacral (upper buttocks area) pressure injury measuring 7.2 by 8 by 0.1 centimeters with 90 percent slough. Under number 7. Healing Process, New Wound is marked. This same document shows a Stage 2 Pressure Injury is partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough and an Unstageable Pressure Injury is full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown, and/or eschar (tan, brown, or black) in the wound bed. On 1/27/25 at 11:50 AM, V3, Wound Care Nurse, said residents' wounds are supposed to be assessed within 24 hours of being admitted . V3 said R1's initial wound assessment was not done until 12/27/24; the admitting nurse did not identify R1's buttock wounds upon admission (on 12/20/24). V3 said R1's admitting diagnoses show R1 was admitted with Stage 2 pressure wounds of his right and left buttock, but when he assessed R1's wounds he saw overlapping wounds and classified the wound as an unstageable pressure wound of the sacrum. V3 said R1 was admitted with wound treatment orders on 12/20/24 to be done twice a day, every day of the week to the right and left buttocks. V3 said R1's wounds should have been assessed upon admission and treatments completed as ordered. V3 said the purpose of wound treatment is to try to help heal the wound, prevent infection, and to prevent it from deteriorating and getting worse. V3 said without wound treatment, wounds can deteriorate and get worse. On 1/27/25 at 12:46 PM, V2, Director of Nursing (DON), said R1 was admitted to the facility on [DATE] and she entered R1's wound treatment orders from his discharge orders from the hospital which should have been started that same day, as per physician orders. V2 said if the wound care nurse is in facility, when a resident is admitted , they do the admission skin/wound assessment, otherwise the admitting nurse does it. They should measure open wounds, but, some floor nurses are not comfortable staging them, a full wound assessment should be done optimally within 24 hours of admission. V2 said V4, Licensed Practical Nurse (LPN), was covering the wound care position on 12/18/24, 12/19/24, and 12/20/24 while V3 was on vacation. On 1/28/25 at 8:33 AM, V4 LPN said she was covering the wound care position on 12/18/24, 12/19/24, and 12/20/24 while V3 was on vacation. V4 said her responsibilities as wound care nurse included everything the wound nurse would do, such as wound treatments and (skin/wound) assessments of any new admissions. V4 said new admission assessments are done within the first hour or two after residents arrive. If the wound care nurse is not in the facility, he/she would do it the following day, but the admitting nurse would do a skin assessment, although they would probably not stage a pressure ulcer (pressure injury), they would document it and some nurses would measure and document the wound characteristics. V4 said the wound nurse would do the full assessment which includes identifying the type of wound, measurements, what the wound/peri wound looks like, any odor, any drainage, any characteristics, any pain, location, and she would stage a pressure ulcer. V4 said R1 was admitted on a Friday after she had already left, so she never saw him or his wound. V4 said the admitting nurse needs to look at the orders and put them in the computer as the floor nurses are responsible for wounds on the weekends. V4 said it would not be ok to do the initial wound assessment a week after a resident was admitted . V4 said a wound could deteriorate during that time. V4 said wound treatments are done per physician orders. The nurse looks at the TAR (treatment administration record), the MAR (medication administration record), and the Wound tabs to see what treatments need to be administered. If a day(s) was crossed out on those tabs, the nurse would not do the treatment. The responsible nurse signs off the day once the treatment is done. V4 said she does not know if R1's primary care provider (PCP) would have seen R1's wound but said if the PCP is giving the treatment orders for a wound, she would think they are evaluating or have evaluated the wound. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145937 If continuation sheet Page 2 of 3 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 01/28/2025 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)

F 0686 Level of Harm - Actual harm On 1/28/25 at 9:04 AM, V5, Nurse Practitioner (NP), said the facility needs to do wound treatments as ordered. If a resident refuses, they need to document that. V5 said R1 should have been seeing the wound care doctor and she did not look at his pressure wounds when she saw him in the facility. V5 said a wound can deteriorate in a week and lack of wound treatments could contribute to a wound deteriorating. Residents Affected - Few On 1/27/25 at 11:01 AM, V6, LPN, said the wound care nurse does the wound care treatments except for on the weekends. The floor nurse would look under the Wound tab to see if there are any wounds requiring treatment and carry out the orders. Once the treatment is completed, the treatment is signed off as being done; if the treatment is not signed off, it was not done. V6 said the purpose of wound care treatment is to keep wounds clean and healing. The facility's Wound Policy (reviewed 11/2022) shows the purpose is to promote a systematic approach and monitoring process for the care of residents with existing wounds and to promote healing of existing pressure ulcers. The goals of wound treatment include protecting the ulcer from contamination and promoting healing. The policy shows that current standards of Clinical Practice will be utilized. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145937 If continuation sheet Page 3 of 3