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Deficiency Records for Amberwood Estates Nursing and Rehabilitation

A list of the most recent deficiencies for Amberwood Estates Nursing and Rehabilitation. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

A list of the most recent deficiencies for Amberwood Estates Nursing and Rehabilitation. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2024-04-18 2024-05-30 N
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Health 2024-04-18 2024-05-30 N
Provide and implement an infection prevention and control program. Health 2024-04-18 2024-05-30 N
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Health 2024-04-18 2024-05-30 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2024-04-18 2024-05-30 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2024-04-18 2024-05-28 N
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Health 2024-04-18 2024-05-28 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2024-04-18 2024-05-28 N
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Health 2024-04-18 2024-05-28 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-04-18 2024-05-28 N
Post nurse staffing information every day. Health 2024-04-18 2024-05-28 N
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2024-04-18 2024-05-28 N
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Health 2024-04-18 2024-05-28 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2024-04-18 2024-05-28 N
Make sure that a working call system is available in each resident's bathroom and bathing area. Health 2024-04-18 2024-05-28 N
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2024-04-18 2024-05-28 Y
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Health 2024-04-18 2024-05-28 Y
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2024-04-18 2024-05-28 N
Use approved construction type or materials. Fire Safety 2024-04-18 2024-05-28 N
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. Fire Safety 2024-04-18 2024-05-28 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2024-04-18 2024-05-28 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2024-04-18 2024-05-28 N
Properly install and monitor supervisory attachments on automatic sprinkler systems. Fire Safety 2024-04-18 2024-05-28 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2024-04-18 2024-05-28 N
Install corridor and hallway doors that block smoke. Fire Safety 2024-04-18 2024-05-28 N
Have simulated fire drills held at unexpected times. Fire Safety 2024-04-18 2024-05-28 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2024-04-18 2024-05-28 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2024-04-18 2024-05-28 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2024-04-18 2024-05-28 N
Ensure proper usage of power strips and extension cords. Fire Safety 2024-04-18 2024-05-28 N
Ensure each resident receives an accurate assessment. Health 2024-02-09 2024-03-21 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-02-09 2024-03-21 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2024-01-03 2024-01-29 Y
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Health 2024-01-03 2024-01-29 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2024-01-03 2024-01-03 Y
Ensure residents have reasonable access to and privacy in their use of communication methods. Health 2023-07-31 2023-08-14 Y
Ensure residents have reasonable access to and privacy in their use of communication methods. Health 2023-06-09 2023-08-14 Y
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Health 2023-06-09 2023-07-19 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2023-06-09 2023-07-19 Y
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Health 2023-06-09 2023-07-19 Y
Plan the resident's discharge to meet the resident's goals and needs. Health 2023-03-24 2023-04-13 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-03-24 2023-04-13 Y
Plan the resident's discharge to meet the resident's goals and needs. Health 2022-11-02 2023-04-13 Y
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Health 2022-11-02 2023-04-13 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-11-02 2023-04-13 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2023-02-09 2023-03-03 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-02-09 2023-03-03 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2022-11-02 2023-03-03 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2022-11-02 2023-03-03 Y
Respond appropriately to all alleged violations. Health 2022-11-02 2023-03-03 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-11-02 2023-03-03 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-03-24 2023-02-17 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-11-02 2023-02-17 Y
Administer the facility in a manner that enables it to use its resources effectively and efficiently. Health 2022-11-02 2023-02-09 Y
Follow proper procedures when the fire alarm was out of service for more than 4 hours. Fire Safety 2022-12-08 2023-01-10 Y
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-12-08 2023-01-10 Y
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Fire Safety 2022-12-08 2023-01-10 Y
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2022-12-08 2022-11-18 Y
Keep residents' personal and medical records private and confidential. Health 2022-09-09 2022-10-07 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2022-09-09 2022-10-07 N
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Health 2022-09-09 2022-10-07 N
Ensure medication error rates are not 5 percent or greater. Health 2022-09-09 2022-10-07 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-09-09 2022-10-07 N
Provide and implement an infection prevention and control program. Health 2022-09-09 2022-10-07 N
Ensure each resident receives an accurate assessment. Health 2022-09-09 2022-10-07 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2022-09-09 2022-10-07 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-09-09 2022-10-07 Y
Meet other general requirements. Fire Safety 2022-09-09 2022-10-07 N
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Fire Safety 2022-09-09 2022-10-07 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-09-09 2022-10-07 N
Install corridor and hallway doors that block smoke. Fire Safety 2022-09-09 2022-10-07 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2022-09-09 2022-10-07 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2022-09-09 2022-10-07 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2022-09-09 2022-10-07 N
Meet requirements for the use and maintenance of medical gas equipment. Fire Safety 2022-09-09 2022-10-07 N
Honor the resident's right to manage his or her financial affairs. Health 2022-02-15 2022-03-25 N
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Health 2022-02-15 2022-03-25 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-02-15 2022-03-25 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-02-15 2022-03-25 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-02-15 2022-03-25 N
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Health 2022-02-15 2022-03-25 N
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2022-02-15 2022-03-25 N
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Health 2022-02-15 2022-03-25 N
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2022-02-15 2022-03-25 N
Ensure medication error rates are not 5 percent or greater. Health 2022-02-15 2022-03-25 N
Provide timely, quality laboratory services/tests to meet the needs of residents. Health 2022-02-15 2022-03-25 N
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2022-02-15 2022-03-25 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-02-15 2022-03-25 N
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. Health 2022-02-15 2022-03-25 N
Make sure that a working call system is available in each resident's bathroom and bathing area. Health 2022-02-15 2022-03-25 N
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Health 2022-02-15 2022-03-25 N
Allow residents to self-administer drugs if determined clinically appropriate. Health 2022-02-15 2022-03-25 Y
Reasonably accommodate the needs and preferences of each resident. Health 2022-02-15 2022-03-25 Y
Implement emergency and standby power systems. Fire Safety 2022-02-15 2022-03-25 N
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. Fire Safety 2022-02-15 2022-03-25 N
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Fire Safety 2022-02-15 2022-03-25 N
Have exits that are accessible at all times. Fire Safety 2022-02-15 2022-03-25 N
Install proper backup exit lighting. Fire Safety 2022-02-15 2022-03-25 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2022-02-15 2022-03-25 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-02-15 2022-03-25 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2022-02-15 2022-03-25 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2022-02-15 2022-03-25 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2022-02-15 2022-03-25 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2022-02-15 2022-03-25 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2022-02-15 2022-03-25 N
Provide and implement an infection prevention and control program. Health 2022-02-15 2022-03-11 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2021-11-04 2021-11-03 Y
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2024-04-18 Not Fixed N

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