Center For Extended Care at Amherst

In the surveyor’s words

From the most serious findings on record at Center For Extended Care at Amherst, in the surveyor’s own words.

• Immediate jeopardy, isolatedF656Jun 10, 2025

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had right sided weakness from a stroke and whose care plan interventions included that he/she required the assistance of two staff members for bed mobility, including turning and repositioning in bed, the Facility failed to ensure that staff consistently implemented and followed interventions from his/her plan of care. When on [DATE] at 1:15 P.M., while attempting to change his/her bed sheets, Certified Nurse Aide (CNA) #1 turned and repositioned Resident #1 on his/her left side in bed, without having another staff member present to assist her, Resident #1 rolled out of the bed and landed on his/her knees on the floor. […]

• Immediate jeopardy, isolatedF689Jun 10, 2025

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had right sided weakness from a stroke and required the assistance of two staff members for turning and repositioning in bed, the Facility failed to ensure he/she was provided with the necessary level of staff assistance to maintain his/her safety and prevent an incident/accident resulting serious injury and death. On [DATE] at 1:15 P.M., while attempting to change his/her bed sheets, Certified Nurse Aide (CNA) #1, without another staff member to assist her, positioned Resident #1 on his/her left side away from her, and Resident #1 rolled out of the bed, landing on his/her knees on the floor. […]

• Actual harm, isolatedF656Apr 7, 2026

  Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who was non-ambulatory and per his/her care plan required the assistance of two staff members with a mechanical lift for all transfers, the Facility failed to ensure staff consistently implemented and followed his/her care plan interventions for transfers, when on 03/14/26, Certified Nurse Aide #1 transferred Resident #1 by herself using a stand pivot transfer technique, Resident #1 was later diagnosed with a left ankle fracture. Findings include:Review of the Facility Policy titled Care Plans, Comprehensive Person-Centered, dated as revised March 2022, indicated that care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. […]

• Actual harm, isolatedF689Apr 7, 2026

  Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who was non-weight bearing and required two staff members and a mechanical lift for all transfers, the Facility failed to ensure he/she was provided with the necessary level of staff assistance and assistive devices, to maintain his/her safety to prevent an incident/accident resulting in an injury, when on 03/14/26, Certified Nurse Aide #1 transferred Resident #1 alone, without a mechanical lift, using a stand pivot type transfer. Resident #1 was later found with bruising and swelling to his/her left ankle and was diagnosed with a left ankle fracture, (which was consistent with the type of injury that could occur with the twisting motion of a stand-pivot a pivot transfer). […]

• Actual harm, isolatedF686Jun 4, 2025

  Based on observations, interviews, and records reviewed, the facility failed to provide care consistent with professional standards of practice to prevent deterioration of a pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) for one Resident (#41), of five applicable residents reviewed for pressure ulcer care and services, out of a total sample of 26 residents. Specifically, for Resident #41, the facility failed to implement the Physician's order for the use of prophylaxis booties for a Deep Tissue Injury (DTI- pressure induced damage to underlying tissues, including muscles, bones, and subcutaneous layers, while the skin surface may remain intact.) pressure ulcer resulting in the Resident ' s… […]