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 Page 1 of 2 145937 145937 10/22/2025 Forest City Rehab & Nrsg Ctr 321 Arnold Avenue Rockford, IL 61108

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 R3 and confirmed that some of the weekend treatments were not signed off as being completed and should have been.R3's Care Plan dated 9/10/25 showed, pressure ulcer to right lateral ankle related to pressure over bony prominences, mechanical factors, and alteration in sensation manifested by hemiplegia affecting right dominant side. Followed by a sound care provider. 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. 145937 Page 2 of 2