Deficiency Records for Amberwood Estates Nursing and Rehabilitation
Updated as of November 01, 2021
This is not the most recent data for Amberwood Estates Nursing and Rehabilitation. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Ensure that residents are free from significant medication errors. | Health | 2021-08-04 | 2021-10-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-08-04 | 2021-09-23 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-08-04 | 2021-09-10 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2021-08-04 | 2021-09-10 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2021-08-04 | 2021-09-10 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2021-08-04 | 2021-09-10 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-08-04 | 2021-09-10 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-08-04 | 2021-09-10 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-08-04 | 2021-09-10 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-08-04 | 2021-09-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-08-04 | 2021-09-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-04 | 2021-09-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-08-04 | 2021-09-10 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-08-04 | 2021-09-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-04 | 2021-09-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-04 | 2021-09-10 | 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 | 2021-08-04 | 2021-09-10 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-08-04 | 2021-09-10 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-08-04 | 2021-09-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-08-04 | 2021-09-10 | 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 | 2021-08-04 | 2021-09-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-08-04 | 2021-09-10 | 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 | 2021-08-04 | 2021-09-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-04 | 2021-09-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-08-04 | 2021-09-10 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-08-04 | 2021-09-10 | N |
| Use approved construction type or materials. | Fire Safety | 2021-08-04 | 2021-09-10 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-08-04 | 2021-09-10 | 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 | 2021-08-04 | 2021-09-10 | 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 | 2021-08-04 | 2021-09-10 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-08-04 | 2021-09-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-04 | 2021-09-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-08-04 | 2021-09-10 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-08-04 | 2021-09-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-08-04 | 2021-09-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-08-04 | 2021-09-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-08-04 | 2021-09-10 | N |
| Ensure electrical receptacles or cover plates have distinctive color or marking. | Fire Safety | 2021-08-04 | 2021-09-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-08-04 | 2021-09-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-01-04 | 2021-01-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-10-09 | 2020-11-13 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2020-10-09 | 2020-11-13 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-10-09 | 2020-11-13 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-10-09 | 2020-11-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-07-22 | 2020-08-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-06-22 | 2020-08-06 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-03-05 | 2020-04-19 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2020-03-05 | 2020-04-19 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2020-03-05 | 2020-04-19 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2020-03-05 | 2020-04-19 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2020-03-05 | 2020-04-19 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-03-05 | 2020-04-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-03-05 | 2020-04-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-03-05 | 2020-04-19 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2020-03-05 | 2020-04-19 | 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 | 2020-03-05 | 2020-04-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-03-05 | 2020-04-19 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-03-05 | 2020-04-19 | 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 | 2020-03-05 | 2020-04-19 | 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 | 2020-03-05 | 2020-04-19 | 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 | 2020-03-05 | 2020-04-19 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2020-03-05 | 2020-04-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-03-05 | 2020-04-19 | 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 | 2020-03-05 | 2020-04-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-03-05 | 2020-04-19 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-03-05 | 2020-04-19 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2020-03-05 | 2020-04-19 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2020-03-05 | 2020-04-19 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2020-03-05 | 2020-04-19 | N |
| Meet other general requirements. | Fire Safety | 2020-03-05 | 2020-04-19 | 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 | 2020-03-05 | 2020-04-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-03-05 | 2020-04-19 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2020-03-05 | 2020-04-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-03-05 | 2020-04-19 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-03-05 | 2020-04-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-03-05 | 2020-04-19 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-03-05 | 2020-04-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-03-05 | 2020-04-19 | 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 | 2019-11-22 | 2020-01-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-22 | 2020-01-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-07 | 2019-09-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-08-07 | 2019-09-16 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-08-07 | 2019-09-16 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-03-27 | 2019-05-22 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-03-27 | 2019-05-22 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2019-03-27 | 2019-05-22 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2019-03-27 | 2019-05-22 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2019-03-27 | 2019-05-22 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2019-03-27 | 2019-05-22 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-03-27 | 2019-05-22 | 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 | 2019-03-27 | 2019-05-22 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-03-27 | 2019-05-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-03-27 | 2019-05-22 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-03-27 | 2019-05-22 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-03-27 | 2019-05-22 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-03-27 | 2019-05-22 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-03-27 | 2019-05-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-03-27 | 2019-05-22 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-03-27 | 2019-05-22 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-03-27 | 2019-05-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-27 | 2019-05-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-03-27 | 2019-05-22 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-03-27 | 2019-05-22 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-03-27 | 2019-05-22 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-03-27 | 2019-05-22 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-03-27 | 2019-05-22 | N |
| Post nurse staffing information every day. | Health | 2019-03-27 | 2019-05-22 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-03-27 | 2019-05-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-03-27 | 2019-05-22 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-03-27 | 2019-05-22 | 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 | 2019-03-27 | 2019-05-22 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-03-27 | 2019-05-22 | 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 | 2019-03-27 | 2019-05-22 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-03-27 | 2019-05-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-27 | 2019-05-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-03-27 | 2019-05-22 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-03-27 | 2019-05-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-27 | 2019-05-22 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-03-27 | 2019-05-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-03-27 | 2019-05-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-27 | 2019-05-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-03-27 | 2019-05-22 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-03-27 | 2019-05-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-03-27 | 2019-05-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-03-27 | 2019-05-14 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-11-29 | 2018-12-31 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-11-29 | 2018-12-31 | Y |
| Respond appropriately to all alleged violations. | Health | 2018-11-29 | 2018-12-31 | Y |
