Inspection·January 11, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to have a narcotic pain patch available for a resident as ordered. This failure applies to one of three residents (R1) reviewed for pain medications in the sample of ten. The findings include: The facility face sheet for R1 shows he was admitted to the facility on [DATE] with diagnoses to include spinal stenosis, bipolar disorder, emphysema, and encephalopathy. The facility assessment dated [DATE] shows R1 to be cognitively intact and is dependent on staff for his care. The December 2023 Physician orders shows an order for a narcotic pain patch to be applied and replaced every 72 hours. The medication administration record for December 2023 shows no pain patch was applied on 12/24/23 or 12/25/23. On 1/10/24 at 1:00PM, R1 said he went without his pain patches for two days and was told the pharmacy had run out of them. On 1/10/24 at 9:30 AM, V9 Licensed Practical Nurse (LPN) said she had placed a pain patch on R1 on 12/26/23, the day the patches were delivered by the pharmacy. V9 said the patches had been reordered but not delivered. V9 said when one pain patch is left in his supply, they should be reordered from the pharmacy. On 1/10/24 at 12:25 PM, V11 LPN said when the pain patches need to be reordered when the supply is down to two to ensure they are delivered in time from the pharmacy. On 1/10/24 at 10:15 AM, V2 Director of Nursing (DON) said the patches were delayed at being delivered due to an insurance issue. V2 said she was unable to see when the pain patches were reordered. V2 said the facility will pay for the patches for R1 until the insurance authorizes them. V2 said the patches should be available for the residents use. On 1/10/24 at 11:09 AM, V10 facility pharmacist said they needed to get prior authorization from R1's insurance company and Physician when they were alerted R1 needed more pain patches. V10 said more patches can not be issued until they get the prior authorization from the insurance or the facility agrees to pay for them. The facility controlled drug receipt form shows the facility used the last pain patch for R1 on 12/21/23 and a new refill was not received until 12/26/23. (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: 145908 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 145908 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Amberwood Care Centre 2313 North Rockton Avenue Rockford, IL 61103 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)