Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Amberwood Care Centre during CMS and state inspections, most recent first.
A cognitively impaired, high fall-risk resident with Alzheimer's and dementia, who required substantial/maximal assistance with toileting, was left alone in the bathroom after requesting privacy while her daughter was in the room. The CNA relied on the daughter’s assurance that she would stay, then left to pass drinks to other residents. The daughter later informed the CNA in the hallway that she was leaving and that the resident remained on the toilet, but the CNA continued passing drinks before returning to the room. When the CNA and an LPN returned, the resident was found on the bathroom floor after an unwitnessed fall while attempting to self-transfer, and was later found to have sustained a finger fracture.
A resident with multiple medical conditions, including diabetes and peripheral vascular disease, was not seen by a podiatrist for about six months despite repeated requests and visible signs of severe toenail overgrowth. Staff acknowledged the resident's need for podiatry care, but the resident was not added to the podiatry list or seen during scheduled visits, contrary to facility policy.
During an extended air conditioning outage, the facility failed to maintain safe and comfortable room temperatures, with logs showing multiple areas exceeding 80°F for several days. Several residents with complex medical conditions reported discomfort and worsening symptoms due to the heat, and staff confirmed the environment was excessively hot. Temperature monitoring was inconsistently performed and relied on inadequate equipment, and not all residents were offered fans or room changes as required by facility policy.
Surveyors identified that the facility did not consistently date or discard expired foods, and failed to maintain complete temperature logs for food storage and meal preparation. Multiple undated and expired food items were found in kitchen refrigerators, and temperature records were missing for several days. Dietary staff confirmed these lapses, and several residents and CNAs reported frequent issues with cold or overcooked meals, with many residents leaving food uneaten.
A resident with severe cognitive impairment was found to have acute rib fractures, with no clear cause identified. Staff confirmed the resident had no pain or injury following a previous fall, and pain only developed days later. Despite facility policy requiring reporting of injuries of unknown origin, no such report was filed, and the incident was not properly documented to authorities.
A resident with severe cognitive impairment developed acute rib fractures of unknown origin, and the facility failed to conduct a formal investigation as required. Despite staff noting no pain or incidents between an earlier fall and the onset of pain, and the physician questioning the link between the fall and the fractures, the DON confirmed that only informal notes were made and no formal investigation was completed.
A resident with severe cognitive impairment and multiple medical conditions did not have their pain and anxiety medications documented on the eMAR, despite being administered by LPNs. The facility's policy requires immediate documentation, which was not followed, leading to a deficiency.
The facility failed to maintain a clean and homelike environment for several residents. One resident's room had chipped paint, stains, and a strong urine odor, while another's power of attorney noted moldy ceiling tiles and dirty walls. Two residents experienced water pooling from air/heating units, with one unit missing a thermostat cover. The Maintenance Director acknowledged these issues, which contradicted the facility's policy for a clean and orderly environment.
A resident with insomnia and other medical conditions did not receive a scheduled sleep study due to logistical issues and a canceled order by the ADON without physician consultation. Despite options for in-house testing or staff assistance, the study was not completed, contrary to facility policy.
Two residents in an LTC facility suffered from inadequate pressure injury care. One resident developed a Stage 2 pressure injury due to insufficient repositioning and incontinence care, while another with pre-existing Stage 3 and 4 injuries was not provided with appropriate pressure-relieving surfaces. These deficiencies highlight the facility's failure to adhere to care plans and policies.
The facility failed to provide adequate range of motion (ROM) services to two residents. One resident with a history of stroke was not placed on a restorative program or given a device for contractures until prompted by a surveyor. Another resident, part of the restorative services program, did not receive the prescribed twice-daily ROM exercises consistently. These actions were contrary to the facility's policy on restorative nursing services.
The facility failed to prevent a resident with cognitive deficits from attempting to exit through a fire exit door due to a malfunctioning alarm and inadequate supervision. Additionally, a CNA improperly transferred a resident with Multiple Sclerosis by not using a gait belt, contrary to the resident's care plan and facility policy.
The facility failed to maintain proper catheter care for three residents, with drainage bags positioned incorrectly, leading to potential infection risks. One resident's bag was at bladder level, another's was above the bladder causing backflow, and a third's was placed on the floor. Staff acknowledged the need for bags to be below bladder level, as per facility policy.
The facility failed to follow infection control protocols for two residents. A CNA did not change gloves or wash hands after providing incontinence care to a resident, and another CNA did not wear a gown while caring for a resident on Enhanced Barrier Precautions due to a urinary catheter. These actions were against the facility's policies on glove use, hand hygiene, and EBP.
The facility failed to provide correct meal portion sizes to residents, as observed during a lunch meal. The dietary aide used incorrect serving utensils, resulting in portions that did not meet the facility's dietary guidelines. The Certified Dietary Manager and Registered Dietician confirmed the discrepancies, noting that the facility's policies on portion control and nutritional adequacy were not followed.
Failure to Supervise High Fall-Risk Resident During Toileting
Penalty
Summary
Failure to ensure adequate supervision during toileting occurred when a cognitively impaired, high fall-risk resident with Alzheimer's disease and dementia was left alone in the bathroom and subsequently sustained a fall with injury. The resident’s records, including a Morse Fall Scale dated 2/16/26, identified her as high risk for falls due to a history of falling, impaired gait, and a tendency to overestimate or forget her limits. Her MDS indicated she was not cognitively intact and required substantial/maximal assistance with toileting, and her care plan documented impaired cognitive function, confusion, impaired balance, and high fall risk related to gait/balance problems. Staff interviews confirmed that she was “pleasantly confused,” frequently tried to get up on her own, and was considered a high fall risk who should not be left alone in the bathroom. On the evening of the incident, a CNA assisted the resident to the toilet while the resident’s daughter was present in the room. The resident requested privacy, and the daughter told the CNA it was acceptable to leave because she would remain in the room. The CNA left the room and began passing drinks to other residents. The daughter then informed the CNA in the hallway that she was leaving and that the resident was still on the toilet, explaining she did not want her mother to see her leave. The CNA continued passing drinks to a few more residents before returning to check on the resident, at which time the resident was found on the bathroom floor sitting on her buttocks. The nurse’s assessment and the facility’s incident report documented that the fall was unwitnessed, occurred in the bathroom while the resident was attempting to self-transfer, and resulted in a left 4th finger fracture identified on ER imaging.
Failure to Provide Timely Podiatry Care for Resident with Foot Complications
Penalty
Summary
A resident with a history of hemiplegia, hemiparesis following cerebral infarction, COPD, type 2 diabetes with diabetic peripheral angiopathy with gangrene, anxiety, and peripheral vascular disease was admitted to the facility and had not been seen by a podiatrist for approximately six months. The resident reported to several staff members the need to see a podiatrist, and staff responses indicated he would be added to the list for a podiatry visit. Upon observation, the resident's left big toenail was found to be extremely overgrown, curved, thickened, jagged, and discolored, with additional overgrown toenails and a prior amputation of the left third toe digit. A Licensed Practical Nurse confirmed the resident's request for podiatry care and acknowledged the toenails were overgrown. The Director of Nursing stated that the facility sends a census to the podiatrist before their bimonthly visits and notifies them of new admissions, but confirmed the resident had not yet been seen. The facility's policy requires residents with foot disorders or medical conditions associated with foot complications to be referred to qualified professionals, but this was not followed in this case.
Failure to Maintain Safe Ambient Temperatures During Air Conditioning Outage
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment by not ensuring that ambient room temperatures remained within acceptable ranges during an extended air conditioning outage. Multiple temperature logs documented that temperatures in resident rooms and common areas consistently exceeded 80 degrees Fahrenheit, with some readings as high as 91 degrees. The facility's own policy required action when temperatures rose above 80 degrees, but logs showed that this threshold was repeatedly surpassed over several days. Despite the ongoing issue, temperature monitoring was not consistently performed, and the last available log was not current for the final days of the outage. Residents with significant medical conditions, including multiple sclerosis, congestive heart failure, chronic obstructive pulmonary disease, and cognitive impairments, reported discomfort and adverse effects due to the heat. One resident with multiple sclerosis stated that the heat exacerbated his symptoms, causing him to remain in bed for several days to avoid worsening his condition. Other residents described the environment as "really hot," with some noting increased fatigue, sweating, and respiratory discomfort. Staff interviews confirmed that the facility was "drastically hot" and that many residents stayed in their rooms with fans, though not all residents were offered fans or room changes to cooler areas. The facility's maintenance and administrative staff acknowledged the air conditioning failure and described efforts to contact repair services and monitor temperatures. However, it was revealed that temperature checks were being conducted using surface thermometers rather than devices capable of accurately measuring ambient air temperature. The administrator was unaware that this method was insufficient for monitoring room conditions. The facility's policies required routine monitoring and specific actions when temperatures exceeded safe levels, but these procedures were not fully implemented, and documentation of temperature monitoring was incomplete for the final days of the incident.
Failure to Properly Store, Date, and Monitor Food Temperatures
Penalty
Summary
Surveyors found that the facility failed to ensure proper food storage, dating, and temperature monitoring in the kitchen, affecting all residents. During observation, multiple food items in both the reach-in and walk-in refrigerators were found without dates, including salads, butter, cheese, fruit cocktail, shredded lettuce, turkey breast, pudding cups, and cut watermelon. Some items were past their expiration dates, such as cottage cheese and sour cream. Dietary staff confirmed that undated or expired food should be discarded, and that all foods must be labeled and dated according to facility policy. Additionally, review of refrigerator and freezer temperature logs revealed multiple missing entries for both June and July, with dietary staff unable to locate current temperature records. Food temperature logs for prepared meals also had multiple missing entries, particularly for evening meals. Interviews with residents revealed frequent complaints about the quality and temperature of the food, with several stating that meals were often served cold, overcooked, or inedible. Certified Nurse Aides corroborated these complaints, noting that residents regularly left food uneaten and that staff had to address kitchen errors. Review of facility policies confirmed the requirement for food to be covered, labeled, and dated, and for temperatures to be recorded and monitored. The lack of adherence to these procedures led to the deficiency cited by surveyors.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for one resident who was reviewed for accidents. The resident, who had severe cognitive impairment and multiple diagnoses including dementia and metabolic encephalopathy, was found to have acute, minimally displaced fractures of the right 10th and 11th ribs. Staff interviews and record reviews revealed that the resident had a documented fall on one date, with no injury or pain noted at that time or in the days following. Several staff members, including LPNs and CNAs, confirmed that the resident did not complain of pain or show signs of injury until a week later, when he began to guard his right side and express pain during movement. Upon discovery of the rib fractures, the Director of Nursing attributed the injuries to the earlier fall, despite the absence of pain or symptoms in the intervening period. The nurse practitioner and physician both expressed doubt that the fractures could have resulted from the earlier fall, given the delayed onset of pain and the typical presentation of rib fractures. The facility did not file a separate report for the injury of unknown origin, and the incident log did not list any other accidents or injuries for the resident between the fall and the discovery of the fractures. The facility's Abuse and Prevention Program requires that injuries of unknown source be reported to the Department of Public Health, especially when the source is not observed or cannot be explained and the injury is suspicious due to its extent. Despite this policy, the facility was unable to provide a report regarding the injury of unknown origin, and the only report submitted referenced the earlier fall, which staff and medical review could not conclusively link to the rib fractures.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident who was found to have acute, minimally displaced right lateral fractures of the 10th and 11th ribs. The resident, who had severe cognitive impairment and multiple diagnoses including dementia and metabolic encephalopathy, was noted to have fallen on one occasion, but did not exhibit pain, bruising, or complaints immediately following the fall. Staff interviews confirmed that the resident had no pain or abnormal findings in the days following the fall, and no further incidents or injuries were reported until the resident began complaining of pain several days later. On the day the pain was first reported, staff observed the resident guarding his right side and expressing discomfort during movement. A body check was performed, and an X-ray was ordered, which revealed the rib fractures. Multiple staff members, including LPNs and CNAs, stated that the resident had not experienced any new falls, injuries, or incidents between the initial fall and the onset of pain. The physician also noted the unusual delay in the onset of pain and questioned the attribution of the fractures to the earlier fall, given the absence of symptoms immediately after the incident. Despite the discovery of the fractures and the lack of a clear cause, the facility did not conduct a thorough investigation into the injury of unknown origin. The Director of Nursing acknowledged that there was no formal investigation, only informal notes about staff conversations. The facility was unable to provide an investigation report as required by its own Abuse and Prevention Program, which mandates a formal process for injuries of unknown source, including interviews, documentation review, and a final report.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to ensure proper documentation of pain and anxiety medications for a resident with severe cognitive impairment and multiple medical conditions, including Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, and anxiety disorder. The resident's January 2025 Physician Order Sheet prescribed Ativan for anxiety and Norco and Tylenol for pain, but the electronic Medication Administration Record (eMAR) showed no documentation of these medications being administered. However, the Narcotic Count Sheets indicated that doses of Ativan and Norco were signed out on specific dates. Interviews with facility staff revealed that the medications were administered but not documented on the eMAR as required by the facility's policy. An LPN confirmed administering Ativan to the resident on two occasions due to anxiety and restlessness, while the Director of Nursing acknowledged the importance of documenting medication administration on the eMAR for continuity of care. The facility's policy, revised in April 2007, mandates immediate documentation of medication administration, which was not adhered to in this case.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for several residents, as evidenced by multiple observations and interviews. One resident, seated in a wheelchair, was found in a room with chipped paint, grease-like stains, and black scuff marks on the walls. A urinal half-filled with urine was on the floor, and a strong odor of urine was present in the bathroom. The resident expressed dissatisfaction with the cleanliness of the room, stating that they had to empty the urinal themselves. Another resident's power of attorney noted the facility's uncleanliness, pointing out chipped and dirty walls and moldy ceiling tiles in the dining room. The Maintenance Director acknowledged the issues, stating that a painter had been hired due to complaints about the walls and that moldy ceiling tiles had been removed. Additionally, two residents reported problems with their air/heating units, which caused water to drip and pool on the floor. One resident's thermostat cover was missing, exposing internal wiring, and the air unit was damp with water droplets. The Maintenance Director confirmed that the units had issues with condensation, especially in hotter weather, and that towels and basins were used to manage the water. The facility's policy emphasized maintaining a clean, sanitary, and orderly environment, which was not upheld in these instances.
Failure to Conduct Sleep Study for Resident
Penalty
Summary
The facility failed to provide necessary care and services for a resident who required a sleep study. The resident, who was admitted with diagnoses including insomnia, dysarthria, dysphagia, and cerebrovascular accident with right arm/leg hemiplegia, was dependent on staff for various activities. Despite a physician order for a sleep study to rule out obstructive sleep apnea being placed in December 2023, the study was never completed. The resident's Power of Attorney (POA) expressed concerns about the inability to transport the resident for the study due to logistical challenges, including the POA's inability to physically assist the resident and the distance from the facility. The Assistant Director of Nursing (ADON) canceled the sleep study order in August 2024 without consulting the resident's physician, citing a possible attempt to clean up old orders. The Director of Nursing (DON) acknowledged that outpatient testing should be scheduled promptly and mentioned that sleep studies could be conducted in-house or with staff assistance if family members were unavailable. Despite these options, the sleep study was not completed, and the facility's policy required staff to arrange for necessary diagnostic tests as ordered by physicians.
Failure to Prevent and Address Pressure Injuries
Penalty
Summary
The facility failed to identify and address pressure injuries in two residents, leading to deficiencies in care. Resident R28, who was admitted with conditions such as dysarthria, dysphagia, diabetes mellitus, and hemiplegia due to a cerebrovascular accident, was dependent on staff for mobility and personal care. Despite a care plan that required regular skin checks and repositioning every two hours, R28 was left in a wheelchair for extended periods without being repositioned or provided incontinence care. This neglect resulted in a facility-acquired Stage 2 pressure injury on R28's sacrum, which was initially misidentified as moisture-associated skin damage by the wound nurse. Resident R120, admitted with pre-existing Stage 3 and Stage 4 pressure injuries, was not provided with appropriate pressure-relieving support surfaces as outlined in the facility's policy. Despite being at high risk for pressure injuries, R120 was found using a regular mattress and foam cushion, which were inadequate for the severity of her wounds. The facility's failure to provide a low air loss mattress and appropriate wheelchair cushion contributed to the lack of proper care for R120's advanced pressure injuries.
Failure to Provide Adequate ROM Services
Penalty
Summary
The facility failed to provide appropriate treatment and services to residents with limited range of motion, specifically affecting two residents. One resident, who was admitted with a history of stroke and transient ischemic attack, exhibited right-sided limitations and contractures in the right hand. Despite being assessed for limited range of motion upon admission, the resident was not placed on any restorative program or provided with a device to address the contractures until the surveyor's intervention. This lack of timely intervention contributed to the resident's continued limitations. Another resident, who was part of the restorative services program, was supposed to receive active range of motion exercises twice daily. However, records indicated that the resident only received these exercises once on several occasions. The previous restorative nurse acknowledged that the resident should have been seen twice daily and that the services provided should have been documented accordingly. The facility's policy on restorative nursing services, which aims to promote optimal safety and independence, was not adhered to in these cases.
Failure to Prevent Exit and Improper Transfer Technique
Penalty
Summary
The facility failed to ensure a resident did not attempt to exit the facility through a fire exit door and failed to transfer a resident using a gait belt, which are deficiencies identified during the survey. In the first incident, a male resident with moderate cognitive deficits and a history of traumatic brain injury attempted to exit the facility through a fire exit door in his wheelchair. The door alarm did not activate when the resident pushed the release bar, and there was no staff present in the hallway at the time. The Human Resources Manager was alerted and managed to stop the resident from exiting. Upon inspection, it was found that the door sensor was damaged, with a wire sticking out, possibly due to being hit by large boxes of personal protective equipment earlier that day. The Director of Nursing confirmed that the resident had no previous exit-seeking behaviors and that the door alarm should have been functional. In the second incident, a Certified Nursing Assistant (CNA) was observed transferring a resident with a terminal diagnosis of Multiple Sclerosis from the bed to a wheelchair without using a gait belt, despite the resident's care plan indicating the need for such assistance due to poor coordination and a history of falls. The CNA applied a gait belt around the resident's waist but did not use it during the transfer, instead pulling the resident up by the back of their pants. The Director of Nursing stated that staff should use gait belts for safe transfers, as outlined in the facility's policy on safe lifting and movement of residents.
Improper Catheter Care and Positioning
Penalty
Summary
The facility failed to maintain proper catheter care for three residents, leading to potential risks of urinary tract infections. For one resident, the urinary catheter drainage bag was observed hanging on the resident's walker at the same level as the bladder, with urine and sediment present in the tubing. Another resident was found with the catheter drainage bag positioned at hip level, above the bladder, causing urine to backflow into the tube. Both the Director of Nursing and a Registered Nurse acknowledged that catheter bags should be kept below the bladder level to prevent infections. Additionally, a third resident's urinary catheter drainage bag was placed directly on the floor under the wheelchair seat by a Certified Nursing Assistant. The facility's policy, revised in 2014, clearly states that urinary drainage bags must be positioned lower than the bladder to prevent backflow and potential infections. Despite this policy, the facility did not adhere to the guidelines, resulting in improper catheter care for the residents involved.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during incontinence care for two residents. In the first instance, a Certified Nursing Assistant (CNA) provided incontinence care to a resident who had a bowel movement. The CNA did not change her soiled gloves after completing the care and proceeded to handle the resident's belongings and leave the room without washing her hands. This action was contrary to the facility's policy on glove use and hand hygiene, which emphasizes changing gloves and washing hands to prevent the spread of infection. In the second instance, a resident on Enhanced Barrier Precautions (EBP) due to having a urinary catheter was not properly managed. A CNA was observed repositioning the resident in a wheelchair and placing the urinary catheter drainage bag on the floor without wearing a gown, despite having performed catheter and peri-care. The CNA was unaware that the resident was on EBP, which requires staff to wear gowns and gloves during high-contact activities. The facility's policy mandates EBP for residents with indwelling medical devices, and the failure to follow this protocol was noted.
Incorrect Meal Portioning for Residents
Penalty
Summary
The facility failed to ensure that residents received the correct portion sizes of their meals, specifically fried potatoes, mixed vegetables, and pureed Italian sausage during a lunch meal. Observations revealed that the dietary aide, V5, used incorrect serving utensils and methods, such as using a 3-ounce spoodle instead of the recommended 4-ounce for mixed vegetables and measuring shredded potatoes with his hand instead of using a scoop. This resulted in residents receiving incorrect portion sizes, which did not align with the facility's dietary guidelines. The Certified Dietary Manager, V3, confirmed that the serving sizes used were incorrect and did not match the recommended sizes listed in the facility's dietary book. For instance, the pureed mixed vegetables were served in 2-ounce portions instead of the required 4 ounces, and the pureed Italian sausage and bun were served in a 2 and 3/4-ounce scoop instead of the correct 5 and 2/3 ounces. V3 acknowledged that the dietary staff should follow the serving sizes outlined in the menu and recipes provided. The Registered Dietician, V4, emphasized that the menus are designed to meet the nutritional needs of residents, and the facility is expected to adhere to the specified serving sizes using appropriate utensils. The Director of Nursing, V2, also agreed that the recommended serving sizes should be followed. The facility's policies on menu and nutritional adequacy, pureed food preparation, and portion control were not adhered to, leading to the deficiency in meal portioning.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 248 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Rockford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mercyhealth Javon Bea Hospital -snf | 0 mi | ★★★★★ | 0 | 0 |
| Willows Health Center | 1.5 mi | ★★★★★ | 13 | 0 |
| Rock River Health Care | 1.8 mi | ★★★★★ | 14 | 1 |
| East Bank Center, Llc | 2 mi | ★★★★★ | 1 | 0 |
| River Bluff Nursing Home | 2.1 mi | ★★★★★ | 6 | 0 |
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