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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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