Health 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 Page 1 of 2 145908 145908 05/14/2025 Amberwood Care Centre 2313 North Rockton Avenue Rockford, IL 61103

F 0609 Level of Harm - Minimal harm or potential for actual harm returned from being off work for four or five days, R1 started complaining of pain and was grabbing his right side every time she moved him. V5 said R1 didn't know what was wrong and she notified V4 right away. V5 said no one had reported any injuries or falls or that R1 was having pain when she started her shift on 4/30/25; nothing was reported of which she knows. V5 said R1 was not having any pain the previous time she had cared for him. Residents Affected - Few On 5/14/25 at 2:41 PM, V7, LPN, said she came in to work (night shift) and got report from (evening shift) V3, on 4/30/25. V7 said she works almost every night on R1's floor. V7 said she was told V4 discovered R1 started having right sided pain that day. V7 said R1 did not have any pain the night before when she cared for him. V7 said it was completely new, nothing happened to R1 the night before (4/29/25) when she cared for him. V7 said he was himself; he had no injuries and no falls. V7 said R1's pain was, a total shock to her. On 5/14/25 at 1:15 PM, V6, Physician, said it seems odd that R1 fell on 4/23/25 and began having pain on 4/30/25. V6 said she would think R1 would have had pain immediately after falling on 4/23/25 if he sustained rib fractures as rib fractures can be very painful. V6 said it's difficult to attribute R1's rib fractures found on 4/30/25 with his fall on 4/23/25. V6 said it's hard to believe R1's fall on 4/23/25 could have caused his rib fractures identified on 4/30/25 since he had no pain immediately. V6 said she saw R1 on 5/1/25 and R1 was splinting his ribs, grimacing in pain with movement, and there was even a little tear coming from his eye. V6 said she prescribed him stronger medications to help with his pain. R1's Progress Notes show documentation on 4/23/25 at 9:43 PM that R1 was found on the floor in his room with no injury noted. The very next progress note documented was on 4/30/25 at 10:30 AM which shows R1 complained of pain to his right rib area and was noted to be holding his side and grimacing. R1's admission Record dated 5/14/25 shows R1's diagnoses include, but are not limited to cognitive communication deficit, dementia, and metabolic encephalopathy. R1's Minimum Data Set, dated [DATE] shows R1 has severe cognitive impairment. R1's Medication Administration Record for 4/1/25 to 4/30/25 shows R1 had a pain rating of 0 for the entire month until 4/30/25 when he had a pain rating of 5. R1's Radiology Results obtained 4/30/25 at 2:08 PM and resulted on 5/1/25 at 12:06 AM show R1 has acute minimally displaced right lateral fractures of his 10th and 11th ribs. The facility's Incidents by Incident Type log for the period of 3/1/25 to 5/14/25 show R1 fell on 4/23/25 and no other incidents were listed for R1 between his fall on 4/23/25 and 4/30/25. The facility was unable to provide a report regarding R1's injury of unknown origin discovered on 4/30/25. The facility's Abuse and Prevention Program shows the facility will file accurate and timely investigative reports. An injury should be classified as an injury of unknown source when the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident and the injury is suspicious because of the extent of the injury. The Department of Public Health will be notified of an injury of unknown source. 145908 Page 2 of 2