Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. 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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to ensure the facility was at a comfortable
temperature and failed to accurately assess and monitor ambient room temperatures during an outage of
the air conditioning system. This applies to all residents residing in the facility.
The findings include:
The facility provided a resident roster dated 6/23/25 showing 121 residents were residing in the facility.
R2's face sheet showed he was admitted to the facility 11/2/23 with diagnoses to include dysarthria,
hemiplegia and hemiparesis, muscle weakness, depression, congestive heart failure, and atherosclerotic
heart disease.
R7's face sheet showed he was admitted to the facility 9/5/23 with diagnoses to include Multiple sclerosis,
venous insufficiency, muscle spasm, hyperlipidemia, muscle weakness, hypertension, and activated protein
c resistance.
R8's face sheet showed he was admitted to the facility 9/7/23 with diagnoses to include Chronic Obstructive
Pulmonary Disease, cognitive communication deficit, anxiety disorder, depression, radiculopathy,
polyneuropathy, Type 2 Diabetes, spinal stenosis, and low back pain. R8's facility assessment dated [DATE]
showed he has no cognitive impairment.
R9's face sheet showed he was admitted to the facility 6/24/22 with diagnoses to include spinal stenosis,
atrial fibrillation, emphysema, chronic kidney disease, anxiety disorder, and hyperlipidemia. R9's facility
assessment dated [DATE] showed she has no cognitive impairment.
R10's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include anxiety
disorder, paroxysmal atrial fibrillation, congestive heart failure, muscle weakness, acute kidney failure,
presence of prosthetic heart valve, hypertension, anemia in chronic kidney disease, and seizures. R10's
facility assessment dated [DATE] showed he has moderate cognitive impairment.
On 6/24/25 at 12:46 PM, R7 was lying in bed. R7 said he was doing good except the heat issue which has
been going on since Friday (6/20/25). R7 said the facility is working on the issue but it is taking forever. R7
said,They have a maintenance guy working on it. It affects my MS (multiple sclerosis). I spent Friday,
Saturday, Sunday, and Monday in bed to not take any chances. I get really weak with heat due to my MS
(Multiple Sclerosis). At first they were checking temperatures, it was 86
(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 4
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
07/03/2025
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)
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
degrees in here and that is way too hot for me. They had the air conditioning working at one point but then it
broke down completely.
On 6/24/25 at 12:32 PM, R8 said, They have to fix this air conditioning. Its been really hot .
On 6/24/24 at 3:01 PM, V5 CNA (Certified Nursing Assistant) said, . I didn't work this past weekend but I
worked yesterday (6/23/25). It was drastically hot. I was sweating . A lot of them stayed in their rooms with
the fans on .
On 6/25/25 at 1043, R10 said, The staff have been encouraging water but they haven't offered a room
change. I would have moved rooms if there was one cooler available. This heat made me sleep more
because I have been trying to ignore it. I guess it is not too bad right now but it sure could be cooler. I
wasn't offered a fan. A fan would probably help.
On 6/25/25 at 10:50 AM, R2 said, . I'm just trying to stay cool. Our room was hot last night. Today (6/25/25)
and yesterday (6/24/25) for sure were hot in here. Its hotter in here today than it was yesterday. My eyes are
watering and my nose is stopped up .
The facility's temperature log dated 6/21/25 at 2:50 PM showed 24 of 26 temperatures recorded throughout
areas of the facility were out of range. The out of range temperatures were between 80.1 degrees through
83.5 degrees Fahrenheit.
The facility's temperature log dated 6/21/25 at 3:29 PM showed 17 of 23 temperatures recorded were out of
range. The out of range temperatures were between 80.2 degrees and 86.9 degrees.
The facility's temperature log dated 6/21/25 at 4:21 PM showed 11 of 28 temperatures recorded throughout
areas of the facility including resident rooms and common areas were out of range. The out of range
temperatures were between 80.1 degrees and 85.5 degrees.
The facility's temperature log dated 6/21/25 at 5:19 PM showed 14 of 29 temperatures recorded throughout
areas of the facility including hallways and resident rooms were out of range. The out of range temperatures
were between 80.4 degrees and 86.2 degrees.
The facility's temperature log dated 6/21/25 at 10:30 PM showed 20 of 21 temperatures recorded
throughout areas of the facility were out of range. The out of range temperatures were between 80.1
degrees and 84.5 degrees.
The facility's temperature log dated 6/22/25 and titled 3rd shift showed 28 of 44 temperatures recorded
throughout areas of the facility were out of range. The out of range temperatures were between 80.4
degrees to 86.2 degrees.
The facility's temperature log dated 6/22/25 at 7:00 AM showed 20 of 26 temperatures recorded throughout
areas of the facility including hallways and resident rooms were out of range. The out of range temperatures
were between 80.1 degrees and 88.6 degrees.
The facility's temperature log dated 6/22/25 at 9:00 AM showed 30 of 62 temperatures recorded throughout
areas of the facility remained out of range. The out of range temperatures were between 80.1 degrees and
86.4 degrees.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145908
If continuation sheet
Page 2 of 4
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
07/03/2025
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)
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
The facility's undated and untimed temperature log showed 13 of 28 temperatures recorded throughout the
facility were out of range. The out of range temperatures were between 80.6 degrees and 85.3 degrees.
The facility's temperature log dated 6/22/25 at 12:02 PM showed 19 of 46 temperatures recorded
throughout areas of the facility including resident rooms were out of range. The out of range temperatures
were between 80.3 degrees and 84.8 degrees.
The facility's temperature log dated 6/22/25 at 12:44 PM showed 3 of 22 temperatures recorded throughout
the facility were out of range. This log sheet showed a notation that R7's room had no air at all. The out of
range temperatures were between 80.0 degrees through 91.0 degrees.
The facility's temperature log dated 6/22/25 between 3:30 and 4:00 PM showed 26 of 41 temperatures
recorded throughout areas of the facility were out of range. The out of range temperatures were between
80.3 degrees and 85.4 degrees.
The facility's temperature log dated 6/22/25 at 5:00 PM showed 17 of 37 temperatures recorded throughout
areas of the facility including resident rooms remained out of range. The out of range temperatures were
between 81.0 degrees and 85.8 degrees.
The facility's temperature log dated 6/22/25 and titled 2nd shift showed 23 of 35 temperatures recorded
throughout areas of the facility were out of range. The out of range temperatures were between 80.2
degrees and 86.5 degrees.
The facility's temperature log dated 6/22/25 at 10:00 PM showed 31 of 37 temperatures recorded were out
of range. The out of range temperatures were between 80.2 degrees and 88.0 degrees.
The facility's temperature log dated 6/22/25 at 11:30 PM showed 28 of 43 temperatures recorded
throughout areas of the facility were out of range. The out of range temperatures were between 80.1
degrees and 86.5 degrees.
The facility's temperature log dated 6/23/25 at 3:30 AM showed 17 of 46 temperatures recorded were out of
range. The out of range temperatures were between 80.2 degrees and 85.8 degrees.
The last temperature log kept by the facility was dated 6/23/25 at 9:30 AM and showed 23 temperatures
were recorded and all within range. No logs were presented for 6/24/25 and 6/25/25.
On 6/25/25 at 2:28 PM, V1 Administrator and this surveyor entered R7's room and used a thermometer that
is capable to checking ambient room air temperatures. R7's room was 81 degrees.
On 6/25/25 at 10:54 AM, V10 (Maintenance Director) said, Right now we have a technician from [a local
heating and air repair company] working on cleaning the compressors. The outage was reported to me on
Saturday (6/21/25) around 1:40 PM by the nurse who was on call . I called and verified the problem. They
confirmed it was hotter in some areas of the building than others. I told them to check the rest of the units
on 2nd floor. At that moment I called [a local heating and air conditioning repair company] and opened a
ticket telling them we had no air conditioning and that it was an emergency because we are a healthcare
place. I notified the Administrator and Director of Nursing that the air conditioning was not working. Around
3:30 PM, I called [the heating and air conditioning repair company] again since I hadn't heard anything from
them and reiterated this was a very emergency and we
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145908
If continuation sheet
Page 3 of 4
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
07/03/2025
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)
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
had 127 residents in the building with no air conditioning. Give or take 10-20 minutes later I received a call
from the technician saying he was already on his way over here. We got the air conditioning up and running
on Saturday (6/21/25). Our air conditioning system has 2 chillers, a stage 1 and a stage 2. He was able to
put stage 1 back up and running. The technician here now came back Sunday (6/22/25) in the early
morning to work on stage 2 . Monitoring was put in place of temperatures. We were doing all surface
temperatures. V10 showed the thermometer to the surveyor. V10 said, This is the only thermometer we use.
I did the first monitoring of temperatures and we were doing the temps almost every hour of different areas
of the facility. We were also taking temperatures in the hallways and in the rooms to make sure what
temperature both hallways and rooms were. I turned all those log sheets into the administrator as well. We
are still monitoring temperatures at this time. I haven't done any since yesterday (6/24/25).We can not be
any higher than 80 degrees so the temperatures that we are normally at are around 74-76 degrees. This is
for hallway temperature and room temperature as well. The technician yesterday put the replacement parts
in. Today he arrived around 7:00 AM and he is cleaning the condenser on the roof. He did have to shut the
system down to clean the compressor. On 6/25/25 at 11:00 AM, V10 used the thermometer and checked
the temperature in the hallway. The temperature of the hallway was 81.5 degrees.
On 6/24/25 at :44 PM V1 (Administrator) said, The air conditioning issues started on Saturday (6/21/25). We
got the people out and they got it back up and going but it had a hard time keeping up. We ordered portable
units in to supplement, they were here Saturday (6/21/25) and Sunday (6/22/25). Sunday there were
temporary parts put in. We got more portable units yesterday. Today they were back in and put the
permanent parts in. Everything is up and running at this time . We were rounding with extra water passes.
monitoring residents, and monitoring temperatures. There were some rooms that were in the low to mid 80
degrees. We offered room moves .
On 6/25/25 at 12:30 PM, V1 said she has obtained thermometers that read ambient air temperatures and
would be checking temperatures throughout the facility. V1 said she was not aware that surface
temperatures were not sufficient for monitoring room temperatures.
The facility's policy and procedure effective 4/1/24 showed, Summer Temperature Monitoring Guidelines,
Purpose: to provide a safe and comfortable environment for residents. To determine if the Extreme Hot
weather Guidelines need to be implemented. Person Responsible: Facility Administrator. Guidelines:
Routine temperature and humidity monitoring of the facility will occur at minimum of two times per day
during daylight hours. For example, 10:00 AM and 4:00 PM. These temperatures/humidity's are to be taken
in the warmest areas of facility identified through base-line monitoring. Should the combined value fall in the
shaded area of the chart the Hot Weather Policy must be implemented . Should it be determined that the
high temperatures procedures do not sufficiently maintain resident safety for an extended period of time
determined by facility Administrator in concert with the [NAME] President of Clinical Operations. The facility
will consult with Public Health regarding next steps to ensure resident well being .
The facility's policy and procedure with revision date of 4/15/24 showed, Extreme Hot Weather Guidance .
Purpose: Provide guidance to facility in times of unseasonably hot weather and/or cooling system
malfunction. Responsible Party: Facility staff . Should the temperature index for relative humidity and
temperature in this facility rise above 80 degrees, the facility shall implement the appropriate high
temperature procedures. Should a specific area of the facility rise above 80 degrees, it may be necessary to
relocate residents to a cooler section of the facility .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145908
If continuation sheet
Page 4 of 4
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
1 citation 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.
FAQ · About this visit
Common questions about this visit
What happened during the July 3, 2025 survey of AMBERWOOD CARE CENTRE?
This was a inspection survey of AMBERWOOD CARE CENTRE on July 3, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at AMBERWOOD CARE CENTRE on July 3, 2025?
Yes, 1 deficiency was 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.