Inspection Reports for
Amberwood Estates Nursing and Rehabilitation

The facility failed to maintain adequate pest control in resident rooms, with multiple ants observed in Resident #4's room and brown droppings (rat feces) behind Resident #5's bed. Additionally, an air conditioning unit leak caused wall discoloration and damage in Resident #4's room. Maintenance logs were incomplete, and pest control measures were insufficiently documented or effective.

The complaint investigation was substantiated with findings that CNA A was not removed immediately after the resident alleged abuse on 7/31/25 and staff failed to notify the Administrator and Director of Nursing promptly. The resident provided a written statement and multiple staff statements were collected. The resident was diagnosed with multiple conditions but had no cognitive impairment. The facility initiated interventions including staff in-service and social services follow-up.

The facility failed to ensure residents were free from potential abuse when CNA A was not immediately removed after the allegation and continued to provide care until the end of the shift. Staff also failed to promptly notify the Administrator and Director of Nursing. The investigation included multiple staff and resident interviews and review of statements, revealing inconsistent accounts but no physical evidence of injury.

The facility failed to ensure timely processing and administration of Tramadol 50 mg for Resident #1, resulting in 6 missed doses due to delays in pharmacy processing and lack of signed prescriptions. Staff documented medication administration when the medication was not delivered, and the facility lacked a protocol to ensure timely prescription signing and medication availability.

The report identified deficiencies related to maintaining residents' personal and medical records confidentiality, ensuring a safe, clean, and homelike environment, and providing adequate supervision to prevent accidents. All deficiencies were noted as causing minimal harm or potential for actual harm affecting a few or some residents.

The facility was found deficient in maintaining resident privacy and confidentiality, ensuring appropriate water temperatures, timely reporting and investigating abuse allegations, providing adequate wound care and assessments, and conducting thorough fall investigations. Specific issues included exposure of resident medical information, use of personal devices for sending prescriptions, water temperatures exceeding safe limits, incomplete abuse and drug diversion investigations, presence of maggots in a resident's wound, and incomplete fall documentation.

The facility had multiple deficiencies including failure to maintain resident dignity and privacy, inadequate promotion of resident self-determination, unsafe and non-functional bathroom equipment, failure to prevent resident-to-resident abuse, inadequate assistance with activities of daily living including showers, failure to prevent skin impairments, lack of restorative nursing services, unsafe resident handling and transfers, incomplete smoking assessments, malfunctioning exit door alarms with inadequate staff response, missing dialysis orders and communication, insufficient staffing, failure to notify physicians of pharmacy recommendations, lack of gradual dose reductions for psychotropic medications, improper medication storage and labeling, inaccurate medication administration documentation, failure to follow infection control practices, and non-functional call light system for a resident.

The facility was found deficient in maintaining functional bathroom equipment and call lights, preventing resident abuse, providing adequate assistance with activities of daily living including showers, and maintaining sufficient nursing staff to meet resident needs. Several residents experienced issues such as clogged toilets, non-functional call lights, inadequate showering, and insufficient staff support for care and safety.

The complaint investigation focused on the facility's failure to supervise a resident who left on leave of absence on 2/1/24 and did not return by midnight as expected. The facility staff did not know the resident's whereabouts, failed to report the missing resident to the physician, local authorities, or the Department of Health and Senior Services as required. The resident had a history of cocaine use and was homeless. The facility did not assess or plan care for the resident's substance use disorder risk. The resident's belongings were left behind, and the facility did not follow proper missing resident protocols, including timely notification and investigation.

The facility failed to accurately complete the Minimum Data Set assessment for one resident and did not provide adequate supervision or timely reporting when the resident left on leave of absence and did not return. Staff did not know the resident's whereabouts, failed to notify authorities, and did not assess or care plan for the resident's substance use disorder risk. The resident was homeless with a history of drug abuse and left the facility without belongings, and the facility did not follow proper missing resident protocols.

The complaint investigation revealed that on 11/30/23, Resident #3 stabbed Resident #2 in the face with a fork. The facility intervened by separating the residents, providing medical care, updating care plans, notifying authorities, and providing staff training. Resident #3 was given an emergency discharge. The facility also failed to notify the responsible party about a pressure ulcer development for Resident #1 and failed to provide required RN coverage on weekends.

The facility failed to notify a resident's responsible party after a pressure ulcer developed, failed to prevent physical abuse when one resident stabbed another with a fork, and failed to provide a registered nurse on duty for eight consecutive hours on weekends. The facility took corrective actions including separating residents, providing medical care, updating care plans, and staff training.

The facility failed to ensure residents had reasonable access to a telephone in a private area and failed to ensure phone calls from outside the facility were received after 8:00 P.M. The cordless phone for residents was not working, and the corded phone was located in a non-private nurse's station area. Additionally, phone calls to the facility after 8:00 P.M. were not answered due to lack of receptionist coverage and unplugged phone lines.

The facility was found deficient in ensuring residents' privacy and access to communication, maintaining a clean and homelike environment, following medication administration orders, and maintaining an effective pest control program. Issues included lack of private phone access, unclean floors and walls, insufficient linens and towels, piled-up trash with maggots in dining areas, missed medication administrations, and evidence of mice infestation throughout the facility.

The facility failed to ensure an effective discharge planning process addressing resident goals and needs, including caregiver support and referrals. Residents who were unable to carry out activities of daily living did not consistently receive showers as scheduled or desired. The facility also failed to provide adequate supervision to prevent an elopement, resulting in a resident being missing for over 21 hours and found with hypothermia. Documentation and communication deficiencies were noted in discharge planning and shower scheduling.

The facility was found deficient in multiple areas including failure to ensure resident privacy during personal care, inaccurate resident assessments, incomplete care plans, inadequate pressure ulcer care, insufficient fall prevention interventions, improper gastrostomy tube feeding practices, medication administration errors, unsanitary food storage and kitchen equipment conditions, and failure to follow infection prevention and control protocols during incontinence care.

The facility had multiple deficiencies including failure to assess resident ability to self-administer medications, failure to ensure call lights were functional and within reach, improper management of resident funds, inadequate monitoring of personal refrigerators, failure to maintain personal inventory lists, failure to clean tube feeding spillage, water temperature issues, failure to provide scheduled showers, failure to identify and notify physician of resident eye inflammation, failure to reposition residents, incomplete post-fall assessments, improper tube feeding care, medication errors, lack of quality control for blood glucose testing, improper food preparation and storage, infection control lapses, failure to maintain side rails and bed safety, and malfunctioning call light system on the 500 hall.