Amber Manor Care Center

In the surveyor’s words

From the most serious findings on record at Amber Manor Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF609Jul 7, 2026

  Based on interview and record review, the facility failed to ensure an allegation of abuse was reported to the state agency timely for 1 of 1 allegations of abuse reviewed. Following an allegation of abuse, the facility failed to report the allegation to the state agency within the required timeframe. (Resident D)Finding includes:A review of grievances on 7/6/26 at 11:30 A.M. included a concern from Resident D's family member regarding the resident's care on 6/14/26. A review of facility reported incidents on 7/6/26 at 11:40 A.M. included an incident reported on 6/15/26 at 9:58 A.M. The facility reported incident included that Resident D stated she had been fondled during the night by a woman with short blonde hair. Record review on 7/6/26 at 2:00 P.M. […]

• No harm, potential for more than minimal, isolatedF842Jul 7, 2026

  Based on interview and record review, the facility failed to ensure resident records were complete and accurate for 1 of 3 residents reviewed for death. Resident records contained documentation that the drug Morphine Sulfate was administered on multiple occasions while the resident did not receive the medication. (Resident D)Finding includes:A record review on 7/6/26 at 2:00 P.M., Resident D's diagnoses included, but were not limited to dementia and respiratory failure. Resident D's most recent Significant Change Minimum Data Set (MDS) assessment, dated 3/20/26, indicated the resident had severe cognitive impairment and received hospice services. A list of allergens for Resident D included, but were not limited to, Morphine Sulfate. […]

• No harm, potential for more than minimal, isolatedF690Aug 11, 2025

  Based on observation, interview, and record review, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections (UTIs) for 1 of 2 residents reviewed for urinary tract infections (UTIs). A resident with a history of UTIs and an indwelling suprapubic urinary catheter was observed with his urinary catheter bag hanging on a trash can containing used gloves and paper towels. (Resident 2) Finding includes:On 8/5/25 at 9:30 A.M., Resident 2 was observed sitting in the recliner in his room with his indwelling urinary catheter bag hanging on a trash can to his left next to the regular trash can. The trash can labeled for catheter use only contained used gloves and paper towels that were touching the urinary catheter bag. […]

• No harm, potential for more than minimal, isolatedF881Aug 11, 2025

  Based on interview and record review, the facility failed to follow an antibiotic stewardship program that monitored unnecessary antibiotic use for 2 of 2 residents reviewed for antibiotic use. Residents did not receive antibiotics as ordered by the physician. (Resident 2, Resident 1)Findings include:1. On 8/6/25 at 1:00 P.M., Resident 2's clinical record was reviewed. Diagnoses included, but were not limited to, obstructive uropathy. The most recent annual Minimum Data Set (MDS) Assessment, dated 6/18/25, indicated Resident 2 was cognitively intact, independent for transfers and toileting, and had an indwelling urinary catheter. […]

• No harm, potential for more than minimal, isolatedF757Jan 15, 2025

  Based on observation, interview, and record review, the facility failed to adequately monitor signs and symptoms of adverse reactions to newly prescribed pain medications for 1 of 3 residents reviewed for pain. No routine monitoring of adverse reactions were documented in the resident's record while the resident displayed signs of decreased alertness and increased difficulty with mobilization and eating following an increase in the resident's pain medication regimen. (Resident D) Finding includes: During an observation on 1/14/25 at 11:15 A.M., Resident D was sitting up in a recliner in her room. Resident D did not respond when spoken to and appeared to be asleep. […]