Forest City Rehab & Nrsg Ctr
321 Arnold Avenue · Rockford, IL · 61108 · 8153975531
213 certified beds For profit - Limited Liability company Chain: Saba Healthcare
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $141,775 in fines in the last 24 months.
- 7 citations involved actual harm to residents.
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
3 immediate-jeopardy citations in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
2 abuse-related citations at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
$141,775 in federal fines in the last 24 months
2 fines — CMS fines are reserved for verified, serious non-compliance.
Total nurse staffing below 3.0 hours per resident-day
2.49 reported hours vs the 3.48 minimum CMS's own staffing study recommends.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 2 of 5 Quality measures: 1 of 5
| Total nurse hours / resident-day | 2.49 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.47 | 0.55–0.75 |
| Weekend hours / resident-day | 2.00 | ≈ weekday level |
| Nursing turnover / year | 44% | median 45% |
| Fines (3-yr window) | 4 · $192,920 |
Inspection citations (65 in the current record)
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Potential for harm · D March 9, 2026 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected March 10, 2026 · Quality of Life and Care
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Potential for harm · D February 23, 2026 · found via complaint
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected February 25, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Actual harm · G February 6, 2026 · found via complaint
Provide enough food/fluids to maintain a resident's health.
Corrected February 7, 2026 · Quality of Life and Care
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Potential for harm · D February 6, 2026 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected February 7, 2026 · Quality of Life and Care
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Potential for harm · D November 19, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected November 20, 2025 · Resident Rights
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Potential for harm · D November 19, 2025
Reasonably accommodate the needs and preferences of each resident.
Corrected November 20, 2025 · Resident Rights
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Potential for harm · D November 19, 2025
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected November 20, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D November 19, 2025
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected November 20, 2025 · Quality of Life and Care
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Potential for harm · D November 19, 2025
Ensure medication error rates are not 5 percent or greater.
Corrected November 20, 2025 · Pharmacy Service
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Potential for harm · D November 19, 2025
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected November 20, 2025 · Nutrition and Dietary
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Potential for harm · F November 19, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected November 20, 2025 · Nutrition and Dietary
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Potential for harm · D November 19, 2025 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected November 20, 2025 · Quality of Life and Care
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Potential for harm · E November 19, 2025 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected November 20, 2025 · Quality of Life and Care
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Potential for harm · D November 19, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected November 20, 2025 · Quality of Life and Care
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Potential for harm · D November 19, 2025 · found via complaint
Provide enough food/fluids to maintain a resident's health.
Corrected November 20, 2025 · Quality of Life and Care
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Potential for harm · F November 19, 2025 · found via complaint
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected November 20, 2025 · Nutrition and Dietary
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Potential for harm · D November 19, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected November 20, 2025 · Infection Control
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Potential for harm · D October 22, 2025 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected October 23, 2025 · Quality of Life and Care
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Potential for harm · D June 23, 2025 · found via complaint
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected June 24, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D June 23, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected June 24, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D June 23, 2025 · found via complaint
Respond appropriately to all alleged violations.
Corrected June 24, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D June 5, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected June 6, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E February 18, 2025 · found via complaint
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected February 19, 2025 · Nutrition and Dietary
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Potential for harm · E February 18, 2025 · found via complaint
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected February 19, 2025 · Nutrition and Dietary
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Actual harm · G January 28, 2025 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected January 31, 2025 · Quality of Life and Care
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| January 28, 2025 | Fine | $5,044 |
| October 24, 2024 | Fine | $136,731 |
| April 11, 2024 | Fine | $39,965 |
| April 11, 2024 | Payment Denial | 5 days |
| December 7, 2023 | Fine | $11,180 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 145937 · certified since July 1, 1997. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.