Amberwood Care Centre

In the surveyor’s words

From the most serious findings on record at Amberwood Care Centre, in the surveyor’s own words.

• Actual harm, isolatedF600Oct 12, 2022

  Based on observation, interview, and record review the facility failed to ensure a resident was free from abuse for 1 of 3 residents (R2) reviewed for abuse in the sample of 7. This failure resulted in R2 showing visible distress when recalling the incident. The findings include: On 10/12/22 at 9:50 AM, V4 Certified Nursing Assistant stated I was on shift when R3 came up to me and said there is a black guy in there (motioning toward the dining room) touching a white lady where he shouldn't. V4 said she went to the dining room and R1 was sitting next to R2 side by side. V4 said she did not see any touching at that time, but pulled R2 to the side and asked her if R1 touched her. V4 said R2 said he brushed my chest with his hand. V4 said she reported this to the nurse. […]

• No harm, potential for more than minimal, widespreadF584Jul 3, 2025

  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. […]

• No harm, potential for more than minimal, widespreadF812Jul 1, 2025

  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. […]

• No harm, potential for more than minimal, widespreadF803Jun 15, 2024

  Based on observation, interview, and record review the facility failed to ensure the residents received the correct portion size of fried potatoes, mixed vegetable, and pureed Italian sausage during the lunch meal for all residents receiving meals in the facility. The findings include: The facility data sheet dated 6/15/24 shows 126 residents reside in the facility. On 6/15/24 at 12:06PM, V5 (Dietary Aide) was plating the lunch meal. There were three large pans on the steam table: one with Italian sausage, one with mixed vegetable, one with shredded potatoes. There were four smaller pans, one with chopped/ground Italian sausage, pureed Italian sausage and bun, mashed potatoes, and pureed vegetables. The large pan of mixed vegetables had a spoodle with a white handle resting in it. […]

• No harm, potential for more than minimal, widespreadF908Jan 4, 2023

  Based on observation, interview and record review the facility failed to ensure the dryer vents and ductwork were clean and did not have lint built up on or inside of the equipment. This has the potential to affect all 120 residents in the facility. The findings include: The Resident Roster dated 1/3/23 showed there were 120 residents residing in the facility. On 1/3/23 at 11:45 AM V1 (Administrator) and V2 (Vice President of Operations) stated, This morning a laundry girl said she saw smoke where the washers and dryers are located. The fire alarm went off and we went running downstairs. In the laundry room there was a lot of smoke. V2 stated she grabbed the fire extinguisher and sprayed everywhere in the laundry room including overhead in the duct work for dryer 2 that was on fire. […]