Inspection·May 14, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an injury of unknown origin for 1 of 3 residents (R1) reviewed for accidents in the sample of 3. The findings include: On 5/14/25 at 10:38 AM, V2, Director of Nursing (DON), said R1 did not fall on 4/30/25, the last time he fell prior to 4/30/25 was on 4/23/25. V2 agreed that her report to IDPH dated 5/1/25 could be misleading since it shows the date of incident is 4/30/25 at 6:00 PM, then describes R1 being found on the floor. V2 said they attributed R1's rib fractures (discovered on 4/30/25) to his fall from 4/23/25. V2 said she did not do an additional report on R1's rib fractures as an injury of unknown origin. On 5/14/25 at 11:09 AM, V3, Licensed Practical Nurse (LPN), said R1 fell on (Wednesday) 4/23/25. R1 was found at the end of his roommate's bed on the floor on his bottom, he was not in a weird position, and no objects were present that he would have fallen onto. V3 said R1's roommate said R1 was walking to the bathroom and fell to the floor onto his butt. V3 said she assessed R1, checked his range of motion and vital signs. V3 said R1 had no pain, bruising, or complaints. V3 said two CNAs (certified nursing assistants) used a gait belt and assisted R1 to a standing position and walked him to the bathroom. R1 did not have any complaints while walking and was not guarding. V3 said she took care of R1 again the following Monday (4/28/25) and noted nothing out of the ordinary. R1 did not complain of anything, he was quiet and did not complain of pain. V3 said V4, LPN, was R1's nurse on 4/30/25 from 7:00 AM until 7:00 PM and R1 complained of pain in his side. V3 said R1 did not have a new injury or accident between 4/23/25 and 4/30/25. On 5/14/25 at 11:46 AM, V4 said the CNA, V5, reported that R1 was guarding his right side and saying ow when she was toileting him on 4/30/25. V4 said she did a body check and R1 complained of pain with movement, especially bending to the side. R1 was grimacing and saying ouch. V4 said she informed V2, and the nurse practitioner (NP) and an X-ray was ordered. V4 said she is one of R1's primary nurses and R1 had no complaints of pain prior to 4/30/25, and his pain was noticeable that day with grimacing. V4 said nothing happened to him on 4/30/25; she looked at his record and saw his last fall was on 4/23/25. R1 had no other accidents, incidents, or injuries and there was no bruising or deformity noted on his skin check. V4 said it does not seem like R1's rib fractures happened when he fell on 4/23/25 because he did not have pain until 4/30/25, and that is what made her so concerned about his pain. V4 said she has no idea what could have triggered R1's rib pain on 4/30/25. On 5/14/25 at 12:48 PM, V5, said R1 is on her permanent assignment. V5 said on 4/30/25 when she (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 05/14/2025 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)