Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Colonial Nursing Center Of Rockford during CMS and state inspections, most recent first.
Surveyors found that the facility's dishwasher was not reaching the required temperature or sanitizer concentration to properly sanitize dishes. A dietary aide did not check or know how to check these parameters during the shift, and the administrator was aware of the issue prior to the survey. Facility policy required regular testing and recording of both temperature and sanitizer levels, which was not followed.
Infection control failures were identified when an LPN and CNA did not wear gowns during care for a resident with a PEG tube who was on EBP, and there was no signage at the room entrance indicating EBP. The facility also had no documentation showing Legionella water management control measures were completed, and a resident’s urinary catheter bag was found uncovered on the floor instead of secured below the bladder.
The facility failed to designate a qualified infection preventionist to oversee the infection prevention and control program. Review of records showed no current staff member was certified in infection control and prevention. The DON said she had been responsible for the program but had no specialized infection prevention training or certification, and the Administrator confirmed this. Although the Administrator identified a contracted RN as certified, the DON stated that RN was not actively overseeing the program or reviewing infection control logs or audit findings.
Residents were unable to access their personal funds outside of regular business office hours, as confirmed by staff and resident interviews. Personal funds were not available after 4:00 P.M. on weekdays, nor on weekends or holidays, and there was no alternative method for residents to obtain money when the business office was closed.
Failure to Monitor Resident After Positive COVID-19 Test: A resident with multiple chronic conditions tested positive for COVID-19 and was placed in isolation, but the record showed no documented monitoring of VS, including temp or O2 sat, and no documented respiratory assessments after the positive test. The resident stated staff performed a few additional COVID tests that were negative, while the Administrator confirmed the chart lacked documentation of ongoing clinical monitoring or further test results.
Failure to Provide Access to Optometry Services: A resident with multiple psychiatric and medical diagnoses was cognitively intact and wore glasses, but the record showed no eye doctor visit since admission. The facility optometrist log showed no recent optometrist visits, and the resident stated she had not been given the opportunity to see an eye doctor and that her vision had worsened slightly. SS confirmed the resident had not been seen by an optometrist since before admission and that the facility had been unable to arrange an optometrist to come to the facility.
Failure to Prevent and Investigate Falls: A resident with Parkinsonism, dementia, schizophrenia, COPD, and depression had repeated episodes of weakness, tremors, and an unsteady gait while ambulating with a walker. Nursing notes and direct observation showed the resident dropping to his knees multiple times, including while the DON observed the activity, yet the episodes were not treated as falls, were not investigated, and no fall-related interventions were initiated. The resident’s care plan included walker assistance and guidance to lower self to the floor on knees, but the Administrator confirmed these incidents should have been considered falls.
Medication Given Outside Ordered Blood Pressure Parameters: A resident with multiple psychiatric and medical diagnoses had an order for losartan to be held if SBP was below 100, but the MAR showed the medication was given when BP readings were below the ordered parameter. The DON confirmed the doses were administered even though they should have been held per the physician order and facility policy.
Failure to complete ordered lab testing for a resident with COPD, anxiety, Ogilvie syndrome, DM, depression, hyperlipidemia, and A-fib. The resident was cognitively intact and dependent on staff for several ADLs. A physician order required multiple labs to be completed every June, but the medical record contained no documentation that the ordered labs were completed in 2025, and the DON confirmed the missing documentation.
Missing Annual CNA Performance Reviews: The facility failed to complete annual performance reviews for two CNAs. Personnel records showed no documentation of annual evaluations for either CNA, and the BOM confirmed the missing reviews. The issue affected two of three CNAs reviewed and had the potential to affect all 33 residents.
Surveyors identified extensive sanitation and food storage deficiencies in the kitchen, including uncovered trash near clean utensils, food debris on surfaces, dirty equipment, expired and unlabeled food items, and improper storage practices. Dietary staff confirmed ongoing issues with labeling and cleanliness, and a prior health inspection had cited similar non-compliance with food contact surface sanitation.
A resident with multiple medical conditions was found hoarding medications in his pillowcase after a nurse administered them and observed him taking them. The facility's policy required observation of medication consumption, which was not effectively followed, leading to a deficiency.
Dishwasher Fails to Sanitize Dishes Due to Improper Temperature and Sanitizer Checks
Penalty
Summary
The facility failed to ensure that the dishwasher was adequately sanitizing dishes, as observed during a survey. The dishwasher was labeled to require a minimum temperature of 120 degrees Fahrenheit and a sanitizer concentration of 50 parts per million (ppm). However, during three separate observations, the wash temperature reached only 110 degrees Fahrenheit and the rinse 115 degrees Fahrenheit. Additionally, testing of the sanitizer did not result in a color change on the test strip, indicating improper sanitizer levels. A dietary aide operating the dishwasher did not check the water temperature or sanitizer concentration during the shift and was unsure how to perform these checks. The aide demonstrated how to turn on the dishwasher but confirmed not having tested the required parameters. The facility's policy required that the chemical solution be tested once per shift and water temperatures checked after each meal and recorded. The administrator acknowledged awareness of the dishwasher's temperature issue prior to the survey and stated that a repair part had been ordered.
Infection Control Failures With EBP, Water Management Documentation, and Catheter Bag Storage
Penalty
Summary
Enhance barrier precautions were not implemented for a resident with a PEG tube. Resident #1 was admitted with diagnoses including hemiplegia, diabetes mellitus, irritable bowel syndrome, pathological fracture, depressive disorder, hypertension, and schizophrenia, and an annual MDS indicated moderately impaired cognition and nutrition through a feeding tube. A physician order dated 06/06/25 required EBP related to the PEG tube. During observation of medication administration on 12/30/25, an LPN administered medications through the resident’s PEG tube and rectally, and incontinence care was provided after the rectal medication, but neither the LPN nor the CNA assisting her wore gowns. The LPN confirmed that gowns were not worn, stated the resident should have been on EBP because of the PEG tube, and confirmed there was no signage at the room entrance indicating EBP. The DON also confirmed the resident was on EBP due to the PEG tube and that there was no signage at the entrance to the room. Legionella prevention control measures were not documented in the facility’s water management program binder. The binder listed control measures such as monthly flushing and cleaning of hot water heaters, monthly cleaning of faucets and replacement of aerators as needed, monthly cleaning of shower heads and replacement as needed, monthly cleaning of drinking fountains to remove scale, and quarterly cleaning and sanitizing of ice machines, but there was no documentation that any of these measures had been completed. The Maintenance Director confirmed he had not been documenting any control measure checks. In addition, Resident #35’s urinary catheter bag was observed uncovered and laying on the floor toward the foot of the bed. The resident stated staff had removed the bag from his walker and placed it on the floor while cleaning the walker, and the DON verified that the catheter bag was uncovered and on the floor and stated it should be secured below the bladder and not laid on the floor.
Qualified Infection Preventionist Not Designated
Penalty
Summary
The facility failed to designate a qualified infection preventionist responsible for oversight of the infection prevention and control program. Review of infection control program documentation showed no evidence that any current staff member was certified in infection control and prevention. The DON stated she had been responsible for the infection control program since 10/20/25, but she had not received specialized training in infection prevention and had not obtained infection control and prevention certification. The Administrator confirmed the DON had not received specialized training or certification, and stated that Contracted RN #36 had been certified in infection prevention. However, the DON later stated that CRN #36 was not actively overseeing the infection control program and had not been in the facility to review infection control logs or audit findings. The facility policy stated that the designated Infection Preventionist is responsible for oversight of the program and serves as a consultant on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations.
Failure to Provide Resident Access to Personal Funds After Business Hours
Penalty
Summary
The facility failed to make residents' personal funds available outside of regular business office hours, affecting three residents reviewed for access to their funds. Residents reported being unable to obtain money from their personal accounts after 4:00 P.M. on weekdays, as well as on weekends and holidays, due to the business office being closed. Staff interviews confirmed that personal funds are not kept in the medication cart or otherwise accessible when the business office is closed. One resident was unaware of how much money was available or how to access it, only knowing that someone would assist with purchases when needed. Observations confirmed that posted banking hours were limited to Monday through Friday, 8:00 A.M. to 4:00 P.M., and that the business office was inconsistently open during the survey period.
Failure to Monitor Resident After Positive COVID-19 Test
Penalty
Summary
The facility failed to ensure a resident who tested positive for COVID-19 was monitored for changes in health status according to CDC guidance. Resident #34 was admitted with diagnoses including gastroparesis, diabetes mellitus, hypertension, and depression, and a quarterly MDS indicated the resident was cognitively intact and needed partial/moderate staff assistance with several activities of daily living. A nurses' note documented that the resident returned from the hospital, tested positive for COVID-19, and was placed in isolation. A physician order was written for airborne isolation for three days, and later discontinued, with another order to recheck the resident for COVID-19 one time only. The medical record contained no documentation that staff obtained the resident's temperature or oxygen saturation levels since 06/01/25, and no documentation that staff monitored the resident's clinical status after the positive COVID-19 test or documented further COVID-19 test results. During interview, the resident stated staff had completed a few more tests that were negative, but confirmed no respiratory evaluations or vital signs had been obtained since the positive test. The Administrator also confirmed the record did not contain documentation of respiratory monitoring, vital signs, or further COVID-19 test results, and that the resident did not have a current isolation order in place. The facility policy stated staff would be alert to signs of COVID-19 and notify the physician of symptoms such as fever, cough, shortness of breath, fatigue, headache, sore throat, congestion, nausea, vomiting, or diarrhea.
Failure to Provide Access to Optometry Services
Penalty
Summary
The facility failed to ensure a resident was provided the opportunity to see an optometrist for vision services. Resident #05 was admitted with diagnoses including schizoaffective disorder, suicidal ideations, hypertension, diabetes mellitus, depression, post traumatic stress disorder, and anxiety. The quarterly MDS dated 10/01/25 indicated the resident was cognitively intact, required supervision with bathing, was independent with bed mobility and transfers, and required set-up with eating and toileting. The MDS also indicated no vision issues with the use of glasses. Review of the medical record showed no documentation that the resident had been seen by an eye doctor since admission. The facility's optometrist log showed the last optometrist visit to the facility was on 03/14/24. During interview, the resident stated she had not been provided the opportunity to see an eye doctor since admission and reported her vision had worsened a little since then, though it had not affected her ability to perform ADLs. Social Service confirmed the resident had not been seen by an optometrist since prior to admission and stated the facility had been trying to arrange another optometrist for the facility but had not been successful.
Failure to Prevent and Investigate Falls
Penalty
Summary
The facility failed to provide care and services to prevent falls for one resident with Parkinsonism, COPD, schizophrenia, dementia, and depression. The resident’s record showed a fall-risk care plan with interventions for staff to walk with the resident when feeling weak, provide one-person assistance with transfers when weak, and encourage the resident to lower self to the floor on knees to prevent falls. Another care plan noted lack of coordination and an unsteady gait, with staff to assist the resident with a wheeled walker for mobility. Nursing notes documented that the resident was very weak, repeatedly dropped to his knees, was given a wheelchair, and continued to try to use the walker and go to his knees; the physician and neurology group were notified about increased tremors, shakes, weakness, and the resident going down on his knees several times. On observation, the resident was seen ambulating independently with a walker, had an uncoordinated and unsteady gait, and dropped to his knees multiple times while holding onto the walker before standing back up and continuing down the hall. The DON observed the resident during this activity. The Administrator confirmed the resident’s episodes of dropping to his knees due to weakness were not investigated as falls and that interventions to prevent further falls were not initiated. The Administrator also confirmed the care plan did not identify the resident lowering himself to his knees as a behavior, and stated these incidents should have been considered falls. The facility policy defined an intercepted fall as a fall and required assessment, post-fall assessment, incident reporting, physician and family notification, care plan review, documentation, and witness statements when applicable.
Medication Given Outside Ordered Blood Pressure Parameters
Penalty
Summary
The facility failed to ensure a medication was administered as ordered for one resident out of five reviewed for medication administration. Resident #05 was admitted with diagnoses including schizoaffective disorder, suicidal ideations, hypertension, diabetes mellitus, depression, post-traumatic stress disorder, and anxiety. The resident’s physician ordered losartan potassium 50 mg by mouth daily, with instructions to hold the medication if systolic blood pressure was less than 100. Review of the December 2025 MAR showed the resident received losartan potassium on 12/07/25 when blood pressure was 98/62, on 12/20/25 when blood pressure was 94/54, and on 12/21/25 when blood pressure was 99/66. During interview, the Administrator confirmed the medication was administered on those dates even though the resident’s blood pressure was outside the ordered parameters and the medication should have been held. The facility policy stated medications are to be administered as ordered and vital signs are to be obtained and recorded when applicable, with medications held when vital signs are outside physician-prescribed parameters.
Failure to Complete Ordered Laboratory Testing
Penalty
Summary
The facility failed to ensure laboratory work was completed according to physician orders for one resident out of five reviewed for unnecessary medications. Resident #04 was admitted on 06/29/22 with diagnoses including COPD, anxiety, Ogilvie syndrome, diabetes mellitus, depression, hyperlipidemia, and atrial fibrillation. The resident’s quarterly MDS indicated the resident was cognitively intact and required varying levels of assistance with toileting, showering, transfers, bed mobility, and other care needs. A physician order dated 08/24/22 directed that multiple laboratory values be completed every June, including TSH, T4, T3, FT4, lipid panel, CBC, CMP, A1C, magnesium, B12, and Vitamin D. Review of the medical record found no documentation that these laboratory values were completed in 2025, and the DON confirmed during interview that the record did not contain documentation supporting completion of the ordered labs.
Missing Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete annual performance reviews for Certified Nurse Aides (CNAs) as required. Review of personnel records showed that CNA #13, hired on 04/25/23, had no documentation of an annual performance review completed in 2025. Review of CNA #18, also hired on 04/25/23, likewise showed no documentation of an annual performance review completed in 2025. An interview with the Business Office Manager on 12/31/25 at 12:11 P.M. confirmed that there were no annual evaluations for CNA #13 and CNA #18. This deficiency affected two of three CNAs reviewed and had the potential to affect all 33 residents in the facility.
Widespread Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
Surveyors observed multiple sanitation and food safety deficiencies in the facility's kitchen, including an uncovered trash can near clean utensils, food splatter and debris around clean utensil holders, and open containers of food left uncovered. Additional issues included a hooded sweatshirt stored on a food cart, food particles on surfaces where clean plates were held, and dirty equipment such as a microwave and mixer with dried food residue. The kitchen floor was dirty with scattered food debris and a black coating, and the stove had burnt food on the burners. The refrigerator contained uncovered, undated cake, food caked on racks and the bottom, and undated, unlabeled breaded meat. There were also expired and improperly stored food items, such as outdated hamburger and apple slices, undated lunch meats, and an open box of unpasteurized eggs. The freezer had open bags of hamburger patties stored in cardboard boxes. Interviews with dietary staff confirmed the presence of pancake mix residue on the sink, grease on storage shelves, and ongoing issues with nursing staff not labeling opened lunch meats. The dietary manager acknowledged the outdated and improperly sealed food items, as well as the overall lack of cleanliness in the kitchen. A review of the local health department's inspection report indicated previous non-compliance with cleaning and sanitizing food contact surfaces. Facility policy required proper storage, preparation, and labeling of food, but these standards were not met, affecting the safety and sanitation of food service for all residents.
Failure to Ensure Medication Consumption at Time of Administration
Penalty
Summary
The facility failed to ensure that medications were consumed at the time of administration for a resident, leading to a deficiency. The resident, who was cognitively intact, had a history of acquired left below the knee amputation, chronic obstructive pulmonary disease, congestive heart failure, obsessive-compulsive disorder, major depression, and peripheral vascular disease. The resident was prescribed several medications, including antidepressants, anticoagulants, antibiotics, and opioids, but there was no physician order or care plan allowing self-administration of these medications. An incident occurred where a nurse administered medications to the resident and observed him taking them. However, shortly after, a nursing assistant discovered the resident hiding medications in his pillowcase. The medications found included gabapentin, acetaminophen, stool softeners, Vitamin D3, and Percocet. The resident admitted to pocketing the medications in his cheek before hiding them. The facility's policy required nurses to observe the consumption of medications, which was not effectively followed in this case, leading to the deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 88 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Rockford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Divine Rehabilitation And Nursing At Shane Hill | 1 mi | ★★★★★ | 0 | 0 |
| Celina Manor | 9.8 mi | ★★★★★ | 13 | 0 |
| Gardens At Celina | 9.9 mi | ★★★★★ | 3 | 0 |
| Van Wert Manor | 12 mi | ★★★★★ | 0 | 0 |
| Vancrest Health Care Center | 12.1 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Colonial Nursing Center Of Rockford.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.