Amberwood Health and Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Feb 23, 2023

  Based on observation, interview, and record review the facility failed to provide adequate supervision to prevent elopement for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. This failed practice resulted in Past Immediate Jeopardy which caused or could have caused serious harm, injury, or death to 1 (Resident #1) discharged resident and 4 current residents who were identified at risk for elopement, as documented on a list provided by the Administrator on 2/23/23 at 9:00 a.m. The Administrator was informed of the Past Non-Compliance on 2/23/23 at 12:00 p.m. The findings are: 1. Resident #1 had a diagnosis of Dementia with Agitation and Cerebrovascular Accident. […]

• No harm, potential for more than minimal, widespreadF812Nov 16, 2023

  Based on observation, record review and interview, the facility failed to ensure leftover food items were discarded to maintain food quality; foods stored in the freezer, refrigerator, and dry storage area were covered, sealed, and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; expired dairy products and food items were promptly removed/discarded on or before the expiration or use by date to prevent the growth of bacteria; dietary staff washed their hands between dirty and clean tasks and before handling clean equipment or food items to prevent potential for cross contamination; and failed to ensure 1 of 2 ice machines and 1 of 2 ice machine holders were maintained in a clean and sanitary condition to prevent potential… […]

• No harm, potential for more than minimal, widespreadF812Sep 1, 2022

  Based on observation, record review, and interview, the facility failed to ensure foods stored in the freezer and dry storage area were covered, sealed, and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen, failed to ensure 1 of 2 ice machines was maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages for residents who received meals from 1 of 1 kitchen, and dietary staff failed to wash their hands before handling clean equipment. These failed practices had the potential affect 84 residents who received meals from the kitchen (total census: 92) as documented on a list provided by Dietary Supervisor. on 8/30/2022. The findings are: 1. […]

• No harm, potential for more than minimal, patternF726Nov 14, 2024

  Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure staff followed basic competencies and nursing skills when administering medication for 3 (Residents #14, #244, #245) residences observed during medication administration. The findings include: 1. A review of the quarterly Minimum Date Set (MDS) with Assessment Reference Date of [DATE] revealed Resident #14 had a Brief Interview of Mental Status score of 15 indicating the resident was cognitively intact and received scheduled pain medication regimen. a. A plan of care for Resident #14 (revision on [DATE]) revealed Resident #14 had chronic pain related knee pain, back pain, age related decline, muscle wasting and shrinkage of muscle mass, and muscle spasms. b. […]

• No harm, potential for more than minimal, patternF759Nov 14, 2024

  Based on observation, interviews, record reviews, and facility policy review, the facility failed to ensure the medication error rate was not greater than 5%. The medication errors occurred with 3 (Resident #14, #244, #245) sampled residents observed during medication administration. The finding include: 1. A review of the quarterly Minimum Date Set (MDS) with Assessment Reference Date (ARD) of [DATE] revealed Resident #14 had a Brief Interview of Mental Status score of 15 indicating cognitively intact, and received a scheduled pain medication regimen. a. A plan of care for Resident #14 (revision on [DATE]) revealed Resident #14 had chronic pain related to r knee pain, back pain, age related decline, muscle wasting or thinning of the muscle mass, and muscle spasms. b. […]