Health inspection·October 22, 2025

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to ensure residents pressure injury treatments were being completed for 2 of 3 residents (R2 & R3) reviewed for pressure injury in the sample of 4.The findings include:The findings include:1. Face Sheet dated 10/21/25 for R2 showed diagnoses including stage 4 pressure ulcer to the left lower back, type 2 diabetes mellitus, chronic obstructive pulmonary disease, adult failure to thrive, gastroesophageal reflux disease, anxiety, falls, and peripheral vascular disease.The Wound Care Physician Note dated 10/16/25 for R2 showed a stage 4 pressure wound to the left lower back with the objective of treatment to prevent deterioration. The October 2025 Treatment Administration Record (TAR) for R2 showed, collagen matrix silver external sheet - apply to wound topically one time a day every Saturday and Sunday for wound care and it was not signed off as being completed on 10/4/25 and 10/5/25. Wound care: left lower back - cleanse with wound cleanser, skin prep to peri wound, pack with collagen with silver and cover with gauze island dressing one time a day every Saturday and Sunday that was not signed off as being completed on 10/4/25 and 10/5/25. Wound Care: left lower back: cleanse with wound cleanser, skin prep peri wound, pack with antiseptic soaked kerlix and cover with gauze island dressing one time a day every Saturday and Sunday that was not signed off as being completed on 10/18/25. On 10/21/25 at 4:00 PM, V8 Wound Care Nurse stated the day the treatment order is put into the computer is the start date for the treatment. If the order was entered on 10/4/25 then the treatment would start on 10/5/25. V8 stated the treatments should be marked off on the Treatment Administration Record (TAR) after it is completed by the nurse. V8 stated she does wound treatments Monday - Friday and the floor nurses do the treatments on the weekends. V8 stated if it is not documented then it is not done. V8 stated it is important that residents receive their wound treatments as ordered so they don't get worse or become infected. V8 reviewed the October 2025 TAR for R2 and confirmed that some of the weekend treatments were not signed off as being completed and should have been.R2's Care Plan dated 9/22/25 showed wound management of left lower back. Provide wound care per treatment order. The facility's Pressure Ulcer and Skin Condition Assessment Policy (10/17/20) showed, physician ordered treatments shall be initialed by the staff on the Treatment Administration Record after each administration.2. The Face Sheet dated 10/21/25 for R3 showed diagnoses including right sided hemiplegia, obesity, asthma, traumatic brain injury, stage 3 pressure ulcer of right ankle, schizoaffective disorder, and edema. The October 2025 Treatment Administration Record (TAR) for R3 showed right lateral ankle - cleanse with wound cleanser, skin prep to peri-wound bed and cover with gauze island dressing one time a day every Saturday and Sunday for wound care that was not signed off as being completed on 10/4/25, 10/5/25, and 10/18/25.On 10/21/25 at 4:00 PM, V8 Wound Care Nurse stated the day the treatment order is put into the computer is the start date for the treatment. If the order was entered on 10/4/25 then the treatment would start on 10/5/25. V8 stated the treatments should be marked off on the Treatment Administration Record (TAR) after it is completed by the nurse. V8 stated she does wound treatments Monday - Friday and the floor Residents Affected - Few (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 10/22/2025 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)