Inspection·February 25, 2026

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident was supervised while being toileted to prevent an injury. This applies to 1 of 3 residents (R1) reviewed for safety/supervision in the sample of 7. The findings include:R1's face sheet lists her diagnoses to include: Alzheimer's Disease and dementia. R1's unwitnessed incident report dated 2/18/26 shows, CNA (certified nursing assistant) informed writer that resident was on the floor in her bathroom. Nurse arrived observed resident sitting on buttocks with shirt on, brief down to the ankles, and with gripper socks on. The same report also shows, R1 is oriented to person only and other info shows, Resident stated to CNA I will like some privacy while using the restroom. On 2/25/26 at 1:11 PM, V6 Licensed Practical Nurse (LPN) stated, he admitted R1 when she came to the facility a day before. She was agitated about being at the facility but eventually calmed down. She would try to stand up by herself sometimes. She was a high fall risk. The night R1 fell he was doing medication pass when the CNA (V7) informed him R1 fell. He observed her on the floor in the bathroom across from the toilet on her buttocks with her back against the wall. R1 said, she didn't know how she fell and was tired. The CNA (V7) told V6 LPN she assisted R1 to the toilet and R1 asked for some privacy. R1's daughter was in the room at the time and told her it was ok she left because she was in the room with her. V7 CNA left the room. R1's daughter came out of the room and told V7 CNA she was leaving. When V7 CNA went back to the room she found her on the floor in the bathroom. V6 LPN stated, residents who are high risk for falls should not be left alone in the bathroom. On 2/25/26 at 1:39 PM, V7 CNA stated she was the CNA that cared for R1 the night she fell. It was the first time she had taken care of R1 since she was admitted . The last time she took R1 to the bathroom she asked for some privacy. The daughter was in the room and said it was ok she left. It was dinner time and the drinks came up from the kitchen. She was passing out drinks to residents when R1's daughter came to her and told her it was best she left now while her mom was in the bathroom otherwise she would want to leave with her. V7 CNA asked if she was still on the toilet and the R1's daughter told her she was. V7 CNA continued to pass drinks to a few more residents and then went to check on R1. When she got back to R1's room, R1 was already on the floor. The facility's IDPH (Illinois Department of Public Health) incident report form shows, R1 had a fall on 2/18/26 at 6:00 PM. On 2/18/26 the resident (R1) had a fall while attempting to self transfer in her bathroom. The resident pain, no injuries observed on assessment, Provider & POA (power of attorney) notified of fall & provider ordered resident to be sent to the ER (emergency room) for eval (evaluation). EMS (emergency medical system) arrived & resident sent to the ER without incident. Imaging in the ER revealed a left 4th finger fracture. Final Report: Upon staff interview & record review it was determined that the resident was in the bathroom sitting on the toilet with her daughter present in her room, resident daughter stated she would stay with resident while she was in the bathroom, resident daughter approached staff CNA down the hallway & she stated she was leaving 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 02/25/2026 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)