Inspection·June 23, 2025

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to follow their abuse policy by not immediately reporting, investigating and protect residents while and investigation is underway for 1 of 3 residents (R1) reviewed for abuse in the sample of 9. Residents Affected - Few The findings include: The facility's Abuse Prevention Program Facility Policy and Procedure dated 10/2023 shows, Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about or suspect to the administrator immediately or to an immediate supervisor who must then immediately report it to the administrator .Upon learning of the report, the administrator or a designee shall initiate an incident investigation .The facility will take steps to prevent potential abuse while the investigation is underway Employees of the facility who have been accused of abuse will be removed from resident contact immediately until the results of the investigation have been reviewed by the administrator .The investigator will attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable When an allegation of abuse .has occurred, the resident's representative and the Department of Public Health's regional office shall be informed by telephone or fax .This report shall be made immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse On 6/23/25 at 11:35 AM, V1 (Administrator/Abuse Coordinator) said that the facility follows their Abuse Prevention Policy. V1 said that all allegations should be reported to him immediately and he then sends an initial report to IDPH within two hours. V1 said that if a staff member is an alleged perpetrator, they are immediately sent home until the investigation is completed. V1 said that an investigation is started and the resident, any involved witnesses, other staff and other residents are interviewed to try and determine if abuse occurred. V1 said that he did not hear about R1's allegations of assault until he came in on the morning of 6/16/25. V1 said that the nurse did text him but she should have called him to report the allegation. V1 said that he did start an investigation that day by talking with V15 (Licensed Practical nurse) about the incident and asking who, where, when but V15 was unable to provide any additional information. V1 said that he did not speak to R1 about the incident. V1 said that the day got busy and he knew he was already late for reporting to IDPH so he did not send in a report on 6/16/25. V1 said that he heard later in the day that V11 (Certified Nursing Assistant) was the alleged perpetrator and was sent home. R1's Care Plan shows, [R1] is at risk for abuse and/or neglect due to her mental illness and hx (history) of abuse .Follow facility policy for all suspected or reported instances of abuse and/or neglect. Take all reports seriously . (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 5 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 06/23/2025 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)