Inspection·June 5, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review the facility failed to report an allegation of alleged sexual abuse within the required timeframe to the Illinois Department of Public Health (IDPH). This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 10. The findings include: R1's progress notes dated June 1, 2025 shows, R1 was discharged home on May 31, 2025 after being out on pass with her daughter (V11). V11 R1's Daughter decided to keep her home and not bring her back to the facility. On June 5, 2025 at 9:55 AM, V11 R1's daughter stated, after she removed her mom from the facility R1 told her that someone raped her while she was the facility. She reported that to V3 Admissions. On June 5, 2025 at 10:45 AM, V3 Admissions stated, V11 R1's daughter called her on Monday or Tuesday (June 2nd/June 3rd) to report a missing cell phone. During the phone call V11 stated, R1 told her that someone sexually abused her while she was the facility. She reported that information to V1 Administrator. On June 5, 2025 at 1:00 PM, V1 Administrator stated, V3 Admissions did report to him that R1's daughter (V11) was saying that she was sexually abused at the facility. He did not report the allegation of abuse to Illinois Department of Public Health. He thought since R1 was no longer a resident at the facility it did not need to be reported like normal abuse allegations. The facility's report to IDPH regional office dated June 5, 2025 shows, Date of occurrence: June 3, 2025. Resident Name: R1. Description of occurrence: On June 3, 2025, V11 R1's daughter contacted our facility between 11:00 AM - 12:00 PM regarding her mother's missing cell phone. During the call, she casually mentioned- without providing specific details or names- that her mother alleged being sexually assaulted during her stay Date sent to IDPH regional office: 6/5/2025 (2 days after initial allegation). The facility's abuse prevention program facility policy and procedure dated October 2023 shows, VIII: External Reporting: 1. Initial reporting of allegations- When an allegation of abuse, exploitation, neglect, mistreatment or misappropriation of resident property has occurred, the resident's representative and the Department of Public Heath's (IDPH) regional office shall be informed by telephone or fax. Public Health shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property has been reported and is being investigated This report shall be made immediately, but not later than two hours after the allegation is made, (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 06/05/2025 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)