Inspection·June 15, 2024

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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. Based on observation, interview, and record review the facility failed to ensure the residents received the correct portion size of fried potatoes, mixed vegetable, and pureed Italian sausage during the lunch meal for all residents receiving meals in the facility. The findings include: The facility data sheet dated 6/15/24 shows 126 residents reside in the facility. On 6/15/24 at 12:06PM, V5 (Dietary Aide) was plating the lunch meal. There were three large pans on the steam table: one with Italian sausage, one with mixed vegetable, one with shredded potatoes. There were four smaller pans, one with chopped/ground Italian sausage, pureed Italian sausage and bun, mashed potatoes, and pureed vegetables. The large pan of mixed vegetables had a spoodle with a white handle resting in it. V5 verified this spoodle was a 3 ounce serving size (not the recommended 4 ounce). V5 used the spoodle to scoop up a level serving size of the mixed vegetables and put it on the plates. V5 used his gloved hand to measure a handful of shredded potatoes and put the handful of potatoes on the plate. V5 filled several plates with an Italian sausage and bun, spoodle of vegetables, and a handful of potatoes. V5 was asked how much the serving size of potatoes should be and said, I just give them a handful. I give them a little more than I'm supposed to. The pureed mixed vegetable, mashed potatoes, and chopped Italian sausage had a blue ice cream like scoop in it that V5 used to plate the servings. The pureed bread and Italian sausage had a green handled ice cream like scoop that V5 used to serve this item. V5 said all the residents received the shredded potatoes, except the pureed diets who got mashed potatoes. All the residents got the mixed vegetable except those on pureed diet, who received the pureed mixed vegetable. On 6/15/24 at 12:22PM, V3 (Certified Dietary Manager) looked at the food items on the steam table and the utensils being used to measure the items. V3 verified the pureed vegetables had a blue scoop, measuring 2 ounce (1/4 cup)of vegetable, the meat had a green scoop measuring 2 2/3 ounce of meat/bread, and the spoodle in the regular vegetables measured 3 ounces. V3 said they should be following the recommended serving size listed in the book provided, which also included the menu and recipes for the food items. V3 looked in the book and said the serving size should have been 4 ounces, or 1/2 cup, for the mixed vegetables (not 3 ounces). The pureed mixed vegetables should have been 4 ounces (not the 2 ounces served). V3 said the pureed Italian sausage serving size should be two ounces. V3 said the pureed italian sausage also had the bun pureed with it. V3 was asked if the 2 ounce portion included adding the bun to the meat and serving them together? V3 said no, I'm not sure what the serving size would be then. On 6/15/24 at 12:35PM, V3 said [V5] should not have been measuring the shredded potatoes with his (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 3 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 06/15/2024 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)