Inspection visit
Inspection
7 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 7 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
3. On 9/10/24 at 10:15 AM, during the Resident Council Meeting, R19 and R84 stated they had problems
with water dripping out of their air/heating units. R19 stated the thermostat in her room cover has been off
for a long time. R19 stated the wires and innards are just sticking out. R19 stated the heat/air unit took a
long time to change the temperature in the room. R19 and R84 stated the air conditioner/heater units would
have water pool under them when they were running. R19 and R84 stated this has happened multiple
times. R19 stated a pink basin was placed under the unit to catch the water and needed to be dumped
once in a while. R84 stated housekeeping has had to place towels under the unit to collect the water. R84
stated she first time she knew about it was when she stepped in water walking around the end of the bed
on the way to the bathroom.
On 9/10/24 at 10:35 AM, R19's thermostat did not have a cover on it which had the internal wiring and
controls exposed. The cover was not seen in R19's room. R19's air unit was running. The bottom edge of
the unit felt damp with a few droples of water on it.
On 9/10/24 at 10:45 AM, V5 Maintenance Director translated the interview with V13 Housekeeper. V13
stated R19 and R84's air/heating units have had problems with dripping water when they are running. V13
stated sometimes when they are running we have needed to leave towels and mop up the water when it
happens. When it gets hotter out it is worse.
On 9/11/24 at 10:30 AM, V5 stated the units in R19 and R84's rooms have had issues with lots of
condensation when the air units are running. We need to make sure the drain tubes on the units are clear
to drain the water outside which should stop the water dripping on the floor. The water should not be on the
floor. We have used towels in R84's room. In R19's room we were using a basin to collect the water dripping
from the unit. When it is hotter outside the units work longer which causes more condensation to occur.
With the cooler weather it has not been an issue.
Based on observation, interview and record review the facility failed to provide a clean, comfortable,
homelike environment to 4 of 25 residents (R92, R28, R19, R84) reviewed for clean, comfortable, homelike
environment in the sample of 25.
The findings include:
1. On 9/9/24 at 8:31 AM, R92 was seated in a wheelchair in his room. Multiple areas of chipped paint were
noted on the walls of R92's room. Large, grease-like stains were noted across the walls of R92's room.
Large black scuff marks were noted on the wall behind R92's bed. A urinal, half-filled with urine, sat on the
floor, by R92's bed. A strong odor of urine was noted in R92's bathroom. R92 stated, My bathroom stinks.
My room is dirty looking. I don't live like this. I am a clean person. I
(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 12
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
09/11/2024
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)
F 0584
have to empty that (urinal). They don't.
Level of Harm - Minimal harm
or potential for actual harm
2. On 9/9/24 at 10:00 AM, V7 (Power of Attorney (POA) for R28) was in the facility, visiting R28. V7 stated,
This place is filthy. The walls are chipped and dirty. V7 pointed to the wall by R28's bathroom. The wall had
multiple scuff marks with missing, chipped paint.
Residents Affected - Some
On 9/9/28 at 11:38 AM, V7 was seated in the first-floor dining room of the facility with R28. V7 pointed to
ceiling tiles in the dining room. Two ceiling tiles, located on the northwest part of the dining room ceiling,
were covered with a black-like substance. V7 stated, That's mold.
On 9/10/24 at 11:30 AM, V5 Maintenance Director stated the facility recently hired a painter due to
complaints about the chipped, scuffed walls located throughout the facility. V5 stated he was unsure when
the last time the interior of the facility was painted. V5 stated, I took down two moldy ceiling tiles in the
first-floor dining room this morning. I need to get better about monitor the ceiling tiles for mold.
The facility's Quality of Life-Homelike Environment policy dated 5/2017 showed, The facility staff and
management shall maximize, to the extent possible, the characteristics of the facility that reflect a
personalized, homelike setting. These characteristics include: Clean, sanitary and orderly environment .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145908
If continuation sheet
Page 2 of 12
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
09/11/2024
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)
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review the facility failed to provide the necessary care and services for a
resident that required a sleep study for 1 of 25 residents (R28) reviewed for necessary care and services in
the sample of 25.
Residents Affected - Few
The findings include:
R28's admission Record dated 9/29/23 showed R28 was admitted to the facility with diagnoses of
insomnia, dysarthia (difficulty speaking), dysphagia, and CVA (cerebrovascular accident) with right arm/leg
hemiplegia (weakness).
R28's current care plan showed R28 was dependent on staff for toileting, repositioning, mobility, and
transfers.
On 9/9/24 at 10:00 AM, V7 (Power of Attorney (POA) for R28) was in the facility, visiting R28. V7 stated, He
(R28) was supposed to have a sleep test done months ago but it was never done. They said it was because
they didn't have a way to transport him (to the test) after 5 PM. I can't take him myself. He's dead weight. I
can't lift him in and out of the car. I also live an hour away.
R28's Nurse Practitioner (NP) note dated 12/4/23 showed, Sleep medicine study if ok with PCP (primary
care physician) .
A physician order for R28, dated 12/5/23, showed, Sleep study, r/o OSA (rule out obstructive sleep apnea).
R28's nurses notes and appointment notes dated 12/6/23-3/16/24 were reviewed and showed a sleep
study was never completed on R28.
R28's nurses note dated 3/16/24 showed, Resident states he is not sleeping well at night. Resident states
that current sleep regimen is not working. He was found with his head down on the table sleeping in the
dining room.
R28's nurses notes and appointment notes dated 3/17/24-5/2/24 were reviewed and showed a sleep study
was never completed on R28.
R28's nurses note dated 5/2/24 showed, Resident had an appointment today and needs to call to schedule
for a sleep study .
R28's appointment note dated 6/17/24 showed R28's outpatient sleep study, that had been scheduled for
6/17/24, was canceled by the facility due to the POA (V7) not being able to provide care to R28 during his
sleep study testing.
R28's notes dated 6/18/24-8/2/24 were reviewed and showed R28 a sleep study was never completed on
R28.
A physician order for R28, dated 8/2/24, showed V3 Assistant Director of Nursing (ADON), canceled R28's
order for a sleep study.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145908
If continuation sheet
Page 3 of 12
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
09/11/2024
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)
F 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 9/10/24 at 9:20 AM, V3 ADON stated R28's sleep study, ordered in December 2023, was ordered
because R28 was having trouble sleeping. When V3 was asked why she canceled R28's sleep study order
in August 2024, V3 stated, I am not sure. I might have been going through resident's charts and cleaning up
old orders. V3 stated she canceled R28's order for a sleep study without contacting R28's physician. V3
stated, I know we attempted to schedule his study but there was some issue he couldn't go. No family to go
with. He still needs the study. We could check to see if it could be done in-house or maybe a staff member
could go with him.
On 9/10/24 at 9:35 AM, V2 Director of Nursing (DON) stated any outpatient testing or studies ordered on
residents should be scheduled as soon as possible. V2 stated, We have had residents go out (out of the
facility) for a sleep study before. We have also had residents that have had sleep studies done in-house (in
the facility). V2 stated, If family can't go to the test with the resident, I would see if the test could be done
here (in the facility) or see if a staff member could go with the resident.
The facility's Lab and Diagnostic Test Results-Clinical Protocol policy dated 9/2012 showed, The physician
will identify and order diagnostic and lab testing based on diagnostic and monitoring needs. The staff will
process test requisitions and arrange for test .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145908
If continuation sheet
Page 4 of 12
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
09/11/2024
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)
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
2. On 9/9/24 the facility provided the Pressure Report List. The document show, R120 with an admit date of
6/4/24, has pressure injuries present on admission: stage 4 pressure injury to right hip and stage 3
pressure injury to sacral area.
Residents Affected - Few
R120's Braden Scale dated 9/9/24 show R120 was a high risk for pressure injuries.
R120's careplan date initiated 6/12/24 show Apply pressure reduction or low air loss therapy pressure
relieving cushion when up in wheelchair.
On 9/9/24 at 9:10 AM, R120 was in bed, a regular mattress was noted in her bed. R120 had a regular foam
cushion to her wheelchair.
On 9/10/24 at 8AM, (V9) Wound Nurse assessed and provided wound treatment to R120's pressure
injuries to right hip stage 4 measuring 1.0 centimeters x1.0 cm x 0.30 cm and sacral area.sacral area stage
3- 2.5cm x.0.5cm x0.10cm V9 said R120's pressure injuries were in advanced stages of stage 3 and stage
4. V9 confirmed that R120 just have a regular mattress. This regular mattress is not indicated for stage 3 or
4. V9 said the facility will order a lo air loss mattress today. V9 said R120 prefers to stay in bed most of the
time but will also get a better relieving cushion to R120's wheelchair
On 9/10/24 at 1:25 PM, V2 (Director of Nursing) said the facility regular mattress is a pressure relieving
mattress indicated only for up to stage 2, not appropriate for R120 who has stage 3 and stage 4 pressure
injuries.
The facility policy on Prevention of Pressure Ulcers/Injuries dated 2017 show, Support Surfaces and
pressure redistribution, Select appropriate support surfaces based on residents mobility, continence, skin
moisture and perfusion body size, weight and overall risk factors.
Based on observation, interview and record review the facility failed to identify a resident's pressure injury
prior to the injury becoming a Stage 2. The facility also failed to implement pressure injury prevention
interventions and pressure relieving interventions. These failures apply to 2 of 6 residents (R28, R120)
reviewed for pressure injuries in the sample of 25.
The findings include:
1. R28's admission Record dated 9/29/23 showed R28 was admitted to the facility with diagnoses of
dysarthia (difficulty speaking), dysphagia, diabetes mellitus, and CVA (cerebrovascular accident) with right
arm/leg hemiplegia (weakness).
R28's care plan dated 9/21/24 showed R28 was dependent on staff for toileting, repositioning, mobility, and
transfers. The plan showed, Check all of body for breaks in skin and treat promptly as ordered by doctor.
R28's Monthly Summary report dated 8/10/24 showed R28 had no pressure injuries or impairments to his
skin.
R28's nurse notes dated 8/11/24-9/8/24 showed no documentation of R28 having any pressure injuries or
wounds.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145908
If continuation sheet
Page 5 of 12
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
09/11/2024
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)
F 0686
Level of Harm - Minimal harm
or potential for actual harm
On 9/9/24 at 10:00 AM, V7 (Power of Attorney (POA) for R28) was in the facility, visiting R28. R28 was
seated in a wheelchair. R28 appeared sleepy. When R28 was asked if he had any pain, R28 stated, My
butt. R28 was unable to state when the pain to his buttocks started. V7 stated, I don't think he has any
wounds to his butt. No one has reported that to me, but they get him up in the morning and don't lay him
down again until after lunch. Some days, he is up in his wheelchair for hours.
Residents Affected - Few
On 9/9/24 at 10:50 AM, R28 remained seated in a wheelchair.
On 9/9/24 at 11:30 AM, R28 remained seated in a wheelchair.
On 9/9/24 at 1:11 PM, V6 and V8 Certified Nursing Assistants (CNA) wheeled R28 into his room to provide
cares to R28. V6 CNA was asked when she last toileted or provided incontinence care to R28, V6 stated,
When I got him up this morning, around 8 AM. V6 and V8 transferred R28 via mechanical lift from his
wheelchair to bed. V6 and V8 repositioned R28 in bed and removed R28's incontinence brief. R28's
incontinence brief was saturated with urine. Multiple, large, creases were noted to the skin of R28's
buttocks. A large, reddened area was noted to R28's sacral area with a quarter-sized, fluid-filled blister
noted to R28's right inner sacral area. V6 CNA stated, His bottom is a little red, but he's had that.
R28's Wound Assessment Report dated 9/10/24 showed R28 had a new, facility-acquired Stage 2 pressure
injury to his sacrum, measuring 4.0 centimeters (cm) x 8.0 cm x unknown.
On 9/10/24 at 10:15 AM, V9 Wound Nurse stated R28 is wheelchair bound and dependent on staff for most
cares due to his CVA. V9 stated R28 is unable to reposition himself and is incontinent of bowel and bladder.
V9 stated she initially assessed R28's sacral wound, on 9/9/24, as a MASD (moisture associated skin
damage) that was caused by R28 most likely being wet with urine for periods of time. He is someone who
need to be kept clean and dry. He needs to be repositioned every two hours. V9 stated that when she
reassessed R28's sacral area on 9/10/24, she staged R28's sacral injury as a Stage 2 pressure injury due
to her finding an opened blister to R28's sacrum.
The facility's Prevention of Pressure Ulcers/Injuries policy dated 7/2017 showed, The purpose of this
procedure is to provide information regarding identification of pressure ulcer/injury risk factors and
interventions for specific risk factors . Inspect the skin on a daily basis when performing or assisting with
personal care or ADLs (activities of daily living) . Keep the skin clean and free of exposure to urine and
fecal manner . At least every two hours, reposition residents who are reclining and dependent on staff for
repositioning .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145908
If continuation sheet
Page 6 of 12
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
09/11/2024
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)
F 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM
and/or mobility, unless a decline is for a medical reason.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review the facility failed to provide treatment and services to residents
with limited range of motion to to 2 of 10 residents (R120, R34) reviewed for limited range of motion in the
sample of 25.
The findings include:
1.R120's diagnoses include stroke and transient ischemic attack (TIA) with right sided limitations. R120's
admit date [DATE].
On 9/9/24 on 9:10 AM, R120 was in bed. R120 was alert and smiling but aphasic (inability to express
herself/communicate) R120's right hand was contracted closed fist and whole right hand curled inward.
R120's latest Restorative assessment dated [DATE] show R120 has limitations to extremities including
R120's upper extremities.
On 9/10/24 at 8:25 AM- (V4) previous Restorative Nurse said R120 was admitted from home due to stroke
(admit date [DATE]), with right hand contractures. R120 was assessed at that time due to limited range of
motion to her right hand but R120 was not on any Restorative Program (range of motion-ROM). R120 also
has no device to her contracted right hand. ROM should have been implemented to prevent further decline.
V4 said she will have therapy assessed R120 today.
On 9/10/24 at 11 AM, V4 said R120 was just now placed on passive ROM to right hand and AROM to left
hand.
On 9/10/24 V4 and V12 (present Restorative Nurse) presented this surveyor an Occupational Therapy note
dated 9/10/24 (today) documenting, R120 will now have right hand splint.
The facility policy entitled Restorative Nursing Services dated 7/2017 show, Residents will receive
restorative nursing care as needed to help promote optimal safety and independence.
2. R34's Restorative: ROM (range of motion): AROM (active range of motion) to all extremities/all joints x10
reps twice daily do PROM (passive range of motion) if unable to preform AROM. Look Back 30 days. On
8/18/2024, 8/22/2024, 9/1/2024, 9/8/2024 R34 only received AROM one time on those days.
On 9/10/2024 at 9:46AM, V4 Registered Nurse Previous Restorative Nurse stated [R34] is part of
restorative services. V4 said [R34] should be seen twice a day for restorative AROM or PROM. V4 said the
restorative services provided should be documented in the computer twice a day. V4 said if a resident is
unavailable staff should follow up with the resident another time to make sure the resident receive services
twice a day.
The facility's Restorative Nursing Services policy revised July 2017 states residents will receive restorative
nursing care as needed to help promote optimal safety and independence.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145908
If continuation sheet
Page 7 of 12
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
09/11/2024
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)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 09/9/24
at 9:25 AM, V11 (Ccertifide Nursing Assistant-CNA) was in R104's room to transfer R104 from the bed to
the wheelchair. R104 scooted himself at the edge of the bed and tried to boost himself up by putting both of
his hands in the wheelchair arms in front of him. R104 tried to stand up but then sits back down unable to
pull himself up. R104 tried again but still unable to pull himself to standing position, then said to V11, I think
I need help V11 (CNA) applied a gait belt around R104 waist, then pulled R104 up by pulling the back of
R104's pants then placed R104 in his wheelchair. V11 did not use the gaitbelt that was already in R104's
waist to transfer R104 to his wheelchair.
R104's careplan dated 6/8/24 show, (R104) has terminal diagnosis of Multiple Sclerosis-hospice services .
R104 has intention tremor, nystagmus, other tremors, poor coordination, ataxia, (poor muscle control that
causes clumsy movements) history of falls.
On 9/10/24 at 1:25 PM, V2 (Director of Nursing) said staff should use gait belt for safe transfers for both
staff and the resident.
The facility policy entitled Safe Lifting and Movement of Residents dated 7/17 show, In order to protect the
safety and well being of staff and residents and to promote quality care, this facility uses appropriate
techniques and devices to lift and move residents. 4. Staff responsible for direct resident care will be trained
in the use of .(gait/transfer belts.)
Based on observation, interview, and record review the facility failed to ensure a resident did not attempt to
exit the facility out a fire exit door, and failed to transfer a resident with a gait belt which applies to 2 of 25
residents (R39, R104) reviewed for safety in a sample of 25.
The findings include:
1. R39's Facility assessment dated [DATE] showed R39 to be a [AGE] year old male male with moderate
cognitive deficits. This Assessment showed R39 was admitted to the facility with diagnoses which include:
cognitive communication deficit, hemiplegia an hemiparesis following a cerebral infarction, and history of
traumatic brain injury.
On 9/9/24 at 12:10 PM, R39 was attempting to go out the South East fire exit door in his wheelchair at the
end of the hallway. The exit door is adjacent to R39's room. R39 pushed the release bar to open the door.
The door alarm was not going off when the door was opened. There was no staff in the hallway at the time
R39 opened the door. R39 was in his wheelchair having difficulty exiting the door. V14 Human Resources
Manager was alerted by this writer to check on R39 as he attempted to exit the doorway. V14 was able to
stop R39 from exiting the door. V14 redirected R39 into his room. V14 stated the alarm should have gone
off for the door being opened. At the top of the metal doorway the door sensor was hanging down and a
wire was sticking out approximately 6 inches.
On 9/9/24 at 12:20 PM, V5 Maintenance director arrived at the doorway. V5 opened the door, and the alarm
did not go off. V5 pointed to a yellow light on the ceiling. V5 stated that light should flash, and it should have
an alarm go off. V5 stated he did not know what happened to the alarm sensor. V5 stated the alarm had
been working during morning rounds this morning. V5 stated the sensor may have been damaged and wire
looked like it had been hit or pulled by something. V5 stated they had
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145908
If continuation sheet
Page 8 of 12
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
09/11/2024
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)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
brought in some of the personal protective equipment (PPE) boxes this morning from the storage container
(pointed to container in the parking area), and it could have been hit by one of the bigger boxes. V5 stated
the alarms should be working all the time.
On 9/9/24 at 12:45 PM, V15 (R39 Family) was interviewed with R39 present. V15 stated R39 used to
garden a lot, and they have tomato plants we check on. V15 asked R39 if he was trying to go see the
tomato plants. R39 nodded yes to the question.
On 9/10/23 at 11:35 AM, V2 Director of Nursing stated R39 has had no previous exit seeking behaviors. V2
stated the door alarm should have activated when R39 attempted to go out the door.
The facility Door Alarm Policy dated 12/2023 showed .the door alarm system needs to be maintained in
proper repair and equipment is functioning appropriately
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145908
If continuation sheet
Page 9 of 12
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
09/11/2024
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)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
2. On 9/9/24 at 11:00 AM, R90 was sitting in his reclined wheelchair in his room. R90's urinary catheter
drainage bag was tucked to R90's right side hip level above the level of the bladder.
Residents Affected - Few
At 12: 15 pm- R90 was still in his room watching TV, catheter bag remained in the same position, tucked on
his right side hip level above the level of the bladder, urine was noted backflowing in the tube.
V10 (Registered Nurse) who was with this surveyor said the catheter bag needs to be lowered, below the
level of the bladder to prevent from urine backing flow to prevent infection.
R90's latest careplan show, The resident has a Foley Catheter 16fr 10cc Balloon: Neurogenic bladder, has
history of Urinary Tract Infections (UTI's.)
3. R39's admission Record dated 5/31/24 showed R39 was admitted with diagnoses of a urinary tract
infection and benign prostatic hyperplasia with lower urinary tract symptoms.
R39's care plan dated 6/5/24 showed R39 had a urinary catheter placed to drain his urine.
On 9/9/24 at 9:03 AM, as this surveyor entered R39's room, V6 Certified Nursing Assistant (CNA) was
repositioning R39 in his wheelchair. V6 then placed R39's (uncovered) urinary catheter drainage bag
directly on the floor, underneath the seat of R39's wheelchair.
On 9/10/24 at 9:35 AM, V2 Director of Nursing stated urinary catheter bags are to be kept off the floor for to
prevent infection.
The facility's Catheter Care Urinary policy revised September 2014 states, the urinary drainage bag must
be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag
from flowing back into the urinary bladder.
The facility policy entitled Catheter Care Urinary revised 9/2013 show, The purpose of this procedure is to
prevent catheter- associated urinary tract infections. 3. The urinary drainage bag must be held or positioned
lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into
the urinary bladder.
Based on observation, interview, and record review the facility failed to maintain resident catheters below
the level of the bladder and keep the drainage bag off the floor. This applies to 3 of 8 (R66, R90, R39)
residents reviewed for catheters in the sample of 25.
The findings include:
1. On 9/9/2024 at 11:09AM, R66's urinary catheter drainage bag was observed hanging on the resident's
walker level with the resident's bladder. Urine was observed sitting in the catheter tubing with sediment
present in the tubing.
On 9/10/2024 at 11:53AM, V2 Director of Nursing (DON) said catheter bags should be kept below the level
of the resident's bladder to prevent infections.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145908
If continuation sheet
Page 10 of 12
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
09/11/2024
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)
F 0690
R66's Order Summary Report dated 9/9/2024 shows an order for Foley Catheter, change monthly and PRN
(as needed).
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145908
If continuation sheet
Page 11 of 12
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
09/11/2024
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)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review the facility failed to wash hands and change gloves and
failed to implement Enhance Barrier Precaution (EBP) for 2 of 25 residents ( R104, R39) reviewed for
infection control in the sample of 25.
Residents Affected - Few
The findings include:
1. On 9/9/24 at 9:10 AM, V11 (Certified Nursing Assistant-CNA) was providing incontinence care to R104.
R104 had a bowel movement. After providing incontinence care and without changing her soiled gloves,
V11 turned R104 side to side and applied new incontinent brief, applied R104's blanket, pulled the privacy
curtain, opened R104's closet looking for clothings then said she needs to go out and get something. V11
then removed her soiled gloves and left R104's room without washing her hands.
On 9/11/24 at 8:10 AM, V3 (Assistant Director of Nursing -ADON) said staff should change their gloves and
wash their hands when completing dirty task to clean task, when the gloves is visibly soiled and when a
tasks was completed wash hands to prevent the spread of infection.
The Facility Policy entitled Personal Protective Equipment dated 9/2010 -Using gloves, Purpose the use of
gloves, 1. To prevent the spread of infection.
Handwashing/Hand Hygiene dated 8/2015 show, This facility considers hand hygiene the primary means to
prevent the spread of infections.
2. The facility's Residents on Enhanced Barrier Precautions list dated 9/9/24 showed R39 was on
Enhanced Barrier Precautions (EBP) due to having a urinary catheter in place.
On 9/9/24 at 9:03 AM, an EBP sign hung on the door to R39's room. As this surveyor entered R39's room,
V6 Certified Nursing Assistant (CNA) was repositioning R39 in his wheelchair. V6 then placed R39's urinary
catheter drainage bag on the floor, underneath the seat of R39's wheelchair. V6 CNA wore gloves but no
gown. V6 stated, I just did catheter care and peri-care (incontinence care) on (R39). When V6 was asked if
R39 was on Enhanced Barrier Precautions, V6 stated, No, (R39) is not. His roommate is because he (the
roommate) has a (urinary) catheter.
On 9/10/24 at 9:35 AM, V2 Director of Nursing stated, Anyone with wounds, IV lines (intravenous), or
someone that has a (urinary) catheter should be on Enhanced Barrier Precautions. Staff are to wear gowns
and gloves when providing cares to residents.
The facility's Enhanced Barrier Precautions (EBP) policy dated 3/2023 showed, EBP may be indicated
(when Contact Precautions do not otherwise apply) for residents with any of the following: Indwelling
medical devices, regardless of MDRO (multidrug-resistant organisms) colonization status (central lines,
urinary catheters, feeding tubes, hemodialysis catheters, tracheostomies and ventilators) . The policy
showed staff are to don a gown and gloves prior to providing high-contact activities, such as urinary
catheter care or incontinence care, to residents.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145908
If continuation sheet
Page 12 of 12
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Back to topCitations
7 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the September 11, 2024 survey of AMBERWOOD CARE CENTRE?
This was a inspection survey of AMBERWOOD CARE CENTRE on September 11, 2024. The surveyor cited 7 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at AMBERWOOD CARE CENTRE on September 11, 2024?
Yes, 7 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receivin..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.