Inspection·January 10, 2025

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 interview and record review the facility failed to ensure pain and anxiety medications were documented on the Medication Administration Record for 1 of 3 residents (R1) reviewed for medications. The findings include: R1's face sheet showed he was admitted to the facility 2/14/23 with diagnoses to include Type 2 Diabetes Mellitus without complications, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Depression, hyperlipidemia, chronic kidney disease, anxiety disorder, dysphagia, anemia, atherosclerotic heart disease, abdominal aortic aneurysm, and peripheral vascular disease. R1's facility assessment dated [DATE] showed he has severe cognitive impairment. R1's January 2025 Physician Order Sheet showed, Ativan 0.5 mg give 0.25 tablet by mouth every 12 hours as needed for anxiety .Norco 5-325 mg Give 1 tablet by mouth every 8 hours as needed for pain . Tylenol Extra Strength Oral Tablet 500 mg . Give 2 tablets by mouth every 6 hours as needed for pain . R1's January 2025 eMAR (electronic Medication Administration Record) showed no documentation of administration of Ativan, Tylenol, or Norco. R1's Narcotic Count Sheet for Lorazepam (Ativan) 0.25 mg tablets showed doses signed out 1/3/25 at 8:00 PM and 1/5/25 at 4:30 PM. R1's Narcotic Count Sheet for Norco 5-325 mg showed doses signed out 1/2/25 and 1/3/25. On 1/10/25 at 9:35 AM, V3 (Licensed Practical Nurse-LPN) said she gave R1 a dose of Ativan on 1/3/25 due to his behaviors of yelling out, being restless, and anxious. V3 said controlled medications should be documented when administered on the eMAR and on the narcotic sign out sheet. On 1/10/25 at 11:24 AM, V6 (LPN) said she gave a dose of Ativan to R1 on 1/5/25 when he was anxious while not feeling well. On 1/10/25 at 10:20 AM, V2 (Director of Nursing-DON) said the nurses are expected to be signing controlled medications out on the eMAR (electronic Medication Administration Record) and on the narcotic sign out sheet. V2 said it is important for the nurses to sign the medication out on the eMAR so other nurses can easily see when the resident last received each medication. (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 01/10/2025 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)