Health inspection·July 1, 2025

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to ensure foods were dated, expired foods were discarded, and kitchen temperature logs were complete. This applies to all residents residing in the facility. The findings include: The facility census report dated 6/30/25 showed 123 residents resided in the facility. On 7/1/25 at 9:29 AM, the reach-in refrigerator had multiple food items missing dates. The items included five plated lettuce salads, half a brick of open butter, open cheese slices, a plastic container of fruit cocktail, an open bag of shredded cheese, an opened and browning bag of shredded lettuce. The same refrigerator had a plastic container of puree bread dated 6/23 and a cut up watermelon dated 6/25. A stainless-steel pan held an undated turkey breast in the same refrigerator. At 9:39 AM, V5 (Dietary Aide) stated any undated food needs to be tossed out. No date means it must go in the garbage. The dates tell us when it is too old to serve and when the food has gone bad. On 7/1/25 at 9:45 AM, the walk-in refrigerator had approximately 28 individual size cups of pudding which were all undated. The same refrigerator had a tub of cottage cheese that showed best by 6/28/25. The refrigerator had a tub of sour cream with an expiration date of 4/21/25. On 7/1/25 the five temperature logs for all the refrigerators and freezers were reviewed by this surveyor. Each log was posted on the unit doors and reflected the month of June 2025. Multiple days were missing on every log. Dietary staff were questioned for the location of the current day's temperatures and were unable to locate any of them. On 7/1/25 the food temperature logs were reviewed with V4 (Dietary Manager) present. Multiple food temperatures were missing from the logs, including multiple days at a time for the evening meals. On 7/1/25 at 9:50 AM, V4 (Dietary Manager) stated the July 2025 refrigerator and freezer logs have not been put out yet. They have not even been started. They should be done every day and somebody didn't do it right. The storage units (refrigerators and freezers) need temperature checks at least two times each day. It ensures the units are working correctly and keeps resident food safe. Bad storage temperatures can spoil food and make residents sick. V4 was questioned about the multiple missing temperatures on the June logs and said there is no way to know if the units were working right if the temperatures aren't on the logs. V4 said every food needs a date to show when it comes in and when it was opened. Old food is dangerous to eat. Any food that is expired or not dated should be thrown out. All the kitchen staff are responsible for dating food and checking the dates. V4 said the (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 07/01/2025 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)