Inspection Report
Complaint Investigation
Deficiencies: 26
Mar 7, 2025
Visit Reason
State-compiled facility profile showing 17 inspections from August 1, 2021 through July 31, 2025 with deficiency history and enforcement actions.
Findings
Across 17 inspections, The Amberleigh had a total of 40 violations with multiple complaint surveys showing various deficiencies related to resident services, admission and retention standards, medication management, and records and reports. Several inspections resulted in no violations, and enforcement actions include a stipulation and order issued in September 2024.
Complaint Details
Multiple complaint surveys are included, with violations noted in several complaint investigations from 2023 to 2025.
Deficiencies (26)
| Description |
|---|
| 488.7 (b) (1) (iv) — Resident services: Investigation of incidents involving resident health, safety, injury or death. |
| 485.11 (b) — Records and reports: Operators must supply and provide access to information and records as determined by the department. |
| 488.4 (c) (5) — Admission and retention standards: Must not accept or retain persons who repeatedly behave in a manner impairing resident well-being or facility operation. |
| 488.7 (b) (12-13) — Resident services: Incident report requirements including resident's version of events. |
| 1001.10 (i) (5-8) — Resident services: Case management services including information referral and coordination. |
| 1001.10 (l)(1) — Medication management: Medication acquisition, storage, disposal, and assistance with self-administration. |
| 485.5 (f) — Operating certificates: No changes or modifications without prior written approval. |
| 486.2 (j) (1-2) — Inspection: Correct violations or submit plan for correction within 30 days. |
| 488.4 (a) — Admission and retention standards: Admit and retain only individuals requiring certified services. |
| 488.4 (c) (11) (vi) — Admission and retention standards: Medical evaluation attesting ability to use and maintain medical equipment. |
| 1001.7 (h) (1) — Admission and retention standards: Medical evaluation including date, history, medication regimen, and assistance needed. |
| 1001.7 (k) (2) — Admission and retention standards: Development of Individualized Service Plan with resident and representatives. |
| 1001.7 (k) (5) — Admission and retention standards: Review and revision of Individualized Service Plan every six months or as needed. |
| 488.7 (b) (11) — Resident services: Incident report preparation for various resident incidents. |
| 488.8 (b) (4) — Food service: Availability and use of resident dietary regimen and allergy information in food service area. |
| 488.12 (l) — Disaster and emergency procedures: Notification of regional office for emergencies or service interruptions. |
| 1001.8 (f) (1)-(2) (i-ii) — Consumer and resident protections: Written residency agreements with required disclosures. |
| 1001.10 (l) (2) — Medication management: Development of policies and procedures for medication management compliance. |
| 1001.10 (l) (4-7) — Medication management: Requirements for PRN medication orders and administration. |
| 1001.11 (c) (2) (i-iv) — Personnel: Sufficient qualified staff and training requirements for resident aides. |
| 488.7 (d) (8) (i-iii) — Resident services: Storage requirements for medications including locked cabinets and separation from food. |
| 488.10 (e) (1) — Records and reports: Filing of annual financial statement with department. |
| 488.10 (e) (4) — Records and reports: Submission of quarterly statistical information report including census and deaths. |
| 402.4(b)(2)(iv) — General requirements: Policies and procedures for criminal history record checks and supervision of temporary employees. |
| 402.6(b) — Criminal history record check process: Submission of forms and fingerprints for prospective employees. |
| 488.3 (d) — General provisions: Access for authorized employees or agents to residents, grounds, buildings, and records. |
Report Facts
Inspections on page: 17
Total violations: 40
No-violation inspections: 5
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