Amberwood Estates Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Amberwood Estates Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 24, 2023

  See the deficiency cited at Event ID F7TJ13. Based on interview and record review, the facility failed to ensure each resident received adequate oversight to prevent an elopement or unaccompanied exit from the facility when one of 15 sampled residents left the building unaccompanied during a winter evening. The facility failed to provide necessary protective oversight when no member of the facility staff verified if the resident had been signed out for a leave of absence. The resident was missing for over 21 hours and was found outside approximately six miles away from the facility. The resident was evaluated at the hospital and diagnosed with hypothermia (Resident #15). The facility census was 92. The administrator was notified on 3/23/23 at 11:37 A.M. […]

• Immediate jeopardy, isolatedF689Nov 2, 2022

  Based on interview and record review, the facility failed to ensure each resident received adequate oversight to prevent an elopement or unaccompanied exit from the facility when one of 15 sampled residents left the building unaccompanied during a winter evening. The facility failed to provide necessary protective oversight when no member of the facility staff verified if the resident had been signed out for a leave of absence. The resident was missing for over 21 hours and was found outside approximately six miles away from the facility. The resident was evaluated at the hospital and diagnosed with hypothermia (Resident #15). The facility census was 92. The administrator was notified on 3/23/23 at 11:37 A.M. of an Immediate Jeopardy (IJ) past-noncompliance which began on 2/16/23. […]

• Immediate jeopardy, isolatedF689Nov 2, 2022

  Based on interview and record review, the facility failed to ensure each resident received adequate oversight to prevent an elopement or unaccompanied exit from the facility when one of 15 sampled residents left the building unaccompanied during a winter evening. The facility failed to provide necessary protective oversight when no member of the facility staff verified if the resident had been signed out for a leave of absence. The resident was missing for over 21 hours and was found outside approximately six miles away from the facility. The resident was evaluated at the hospital and diagnosed with hypothermia (Resident #15). The facility census was 92. The administrator was notified on 3/23/23 at 11:37 A.M. of an Immediate Jeopardy (IJ) past-noncompliance which began on 2/16/23. […]

• Actual harm, isolatedF600Aug 4, 2021

  Based on observation, interview and record review, the facility failed to ensure a resident was free from neglect by failing to ensure a staff member provided the services necessary to avoid physical harm. Certified Nursing Assistant (CNA) A failed to follow the resident's plan of care, the facility abuse and neglect policy and acceptable standards of practice for one resident (Resident #2) when he/she transferred the resident without the required mechanical lift. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The census was 71. The Administrator was notified on 11/4/21 at 4:00 P.M., of the past non-compliance which occurred on 10/21/21. On 10/25/21 the administrator became aware of the violation of the resident's right to be free from neglect. […]

• No harm, potential for more than minimal, widespreadF835Nov 2, 2022

  Based on interview and record review, the facility management company failed to ensure payments were issued or issued in a timely manner, to the facility's medical director, dietician, and other necessary vendors utilized to provide services for the needs of residents. The census was 78. 1. During an interview on 10/17/22 at 11:26 A.M., the housekeeping/laundry director said a third party vendor took over housekeeping and laundry in August 2022. Prior to August, supplies, including linens, were ordered from Vendor I. Vendor I reported issues with not getting paid. During an interview on 11/3/22 at 8:17 A.M., an accounts receivable representative from Vendor I said the vendor is a medical supply company that provides anything needed in a hospital setting, from linens to wheelchairs. […]