Amberwood Health And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure staff followed basic competencies and nursing skills when administering medication for 3 (Residents #14, #244, #245) residences observed during medication administration. The findings include: 1. A review of the quarterly Minimum Date Set (MDS) with Assessment Reference Date of [DATE] revealed Resident #14 had a Brief Interview of Mental Status score of 15 indicating the resident was cognitively intact and received scheduled pain medication regimen. a. A plan of care for Resident #14 (revision on [DATE]) revealed Resident #14 had chronic pain related knee pain, back pain, age related decline, muscle wasting and shrinkage of muscle mass, and muscle spasms. b. According to the Medication Administration Record (MAR) Resident #14 had a physician's order for lidocaine External Cream 4% apply to both knees and shoulders. c. On [DATE] at 12:05 PM, the Surveyor observed Licensed Practical Nurse (LPN) #2 apply…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record reviews, and facility policy review, the facility failed to ensure the medication error rate was not greater than 5%. The medication errors occurred with 3 (Resident #14, #244, #245) sampled residents observed during medication administration. The finding include: 1. A review of the quarterly Minimum Date Set (MDS) with Assessment Reference Date (ARD) of [DATE] revealed Resident #14 had a Brief Interview of Mental Status score of 15 indicating cognitively intact, and received a scheduled pain medication regimen. a. A plan of care for Resident #14 (revision on [DATE]) revealed Resident #14 had chronic pain related to r knee pain, back pain, age related decline, muscle wasting or thinning of the muscle mass, and muscle spasms. b. According to Medication Administration Record (MAR) Resident #14 had a physician's order for lidocaine External Cream 4 % apply to both knees and shoulders. c. On [DATE] at 12:05 PM, the Surveyor observed Licensed Practical Nurse (LPN) #2 apply…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and facility policy review the facility failed to ensure the facility was free from significant medication error for 2 (Resident #244, #245) sampled residents who were administered the wrong medication during observed medication administration. The findings include: 1. Resident #244 was admitted on [DATE] and did not have a completed admission Minimum Data Set (MDS). a. A plan of care for Resident #244 (date initiated [DATE]) revealed Resident #244 had a nutritional problem or potential nutritional problem related to throat and difficulty swallowing. b. According to Medication Administration Record (MAR) Resident #244 had a physician's order for Sucralfate Suspension 1 gram (GM)/10 milliliter (ML) give 1 gram by mouth before meals and at bedtime for gastric protection. c. On [DATE] at 4:06 PM, the Surveyor observed LPN #3 add 5 ml of diphenhydramine viscous lidocaine added to water and administered to Resident #244. d. On [DATE] at 9:30 AM, the Surveyor reviewed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure food items expired food items were promptly removed/discard by the expiration or use by dates as when it was delivered, staff washed their hands, and dietary staff washed their hands and between clean tasks when contaminated. The findings are: 1. On 11/12/24 at 10:13 AM, the following observations were made in the refrigerator in the activity lounge. a. There was an opened bottle of tomatoes juice on a shelf with no received date on it. b. One turkey sandwich was inside a container on a shelf with an expiration date of 11/08/2024. 2. On 11/12/24 at 10:49 AM, Dietary Aide (DA) #1 picked up the water hose with her bare hand, used it to spray off leftover food items from the dishes, contaminating her hands. She placed dishes in the dirty racks and pushed them into the dish washing machine to wash. After the dishes stopped washing, the Dietary Aide #1 turned on the hand washing sink faucet and washed her hands. She turned off the faucet with her bare hands. Her hands contaminated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure leftover food items were discarded to maintain food quality; foods stored in the freezer, refrigerator, and dry storage area were covered, sealed, and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; expired dairy products and food items were promptly removed/discarded on or before the expiration or use by date to prevent the growth of bacteria; dietary staff washed their hands between dirty and clean tasks and before handling clean equipment or food items to prevent potential for cross contamination; and failed to ensure 1 of 2 ice machines and 1 of 2 ice machine holders were maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 79 residents who receive meals from the kitchen (total census: 83) as documented on a list…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility failed to ensure nailcare was regularly provided or offered, to maintain good personal hygiene, prevent infection and possible skin tears for 2 (Residents #10 and #26) of 12 (Residents #1, 10, 23, 26, 30, 49, 51, 57, 61, 71, 79, and #236) sampled residents who required staff assistance with nail care on Hall 100. This failed practice had the potential to affect 27 residents who required staff assistance for nail care as documented on a list provided by the Administrator on 11/15/23 at 09:14AM. The findings are: 1.On 11/12/23 at 10:15 AM Resident #10 was in bed. His fingernails were long and had a dark black dry substance underneath his nails. a. On 11/13/23 at 08:35 AM, Resident #10 was sitting in bed eating breakfast. His fingernails were long with a dark black substance under them. b. On 11/14/23 at 08:45AM, Resident #10 was lying in the bed with breakfast in front of him. He had some white substance in his right hand eating it. Certified Nursing Assistant (CNA) #6 was asked to observe Resident #10's nails and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure controlled medications stored in the medication room were kept secured by a lock and that expired medications were removed from the 200 Hall medication cart to prevent use. These failed practices had the potential to affect all 84 residents who reside in the facility. The findings are: On 11/13/23 at 09:24 AM, the Surveyor was inspecting the medication cart on Hall 200 and discovered the following over the counter (OTC) medications which had expired: Docusate Sodium 100 milligrams (mg) stool softener with an expiration date of 9/23 and Ocular Vitamin with an expiration date of 10/23. On 11/13/23 at 08:40 AM, the centrally located medication room was observed with the Assistant Director of Nursing (ADON) in attendance. Upon inspection of the nonlocked refrigerator, the Hall 100 lock box contained a 30 milliliter bottle of Lorazepam (a schedule IV controlled substance) with 18 milliliters inside the bottle. The Surveyor reached in and opened the lock box without a key. The ADON was asked if the lock box…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility failed to ensure meals were served in a method that maintained the appearance of cold and hot foods at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. This failed practice had the potential to affect 20 residents who received meal trays in their rooms on the 100 Hall, 24 residents who received meal trays on the 200 Hall, 7 residents who received meal trays in their room on the 300 Hall, 21 residents who received meal trays in their room on the 400 Hall, as documented on a list provided on 11/13/2023 at 4:07 PM. The findings are: 1. On 11/12/23 at 10:35 AM, the Surveyor asked Resident #79 if his hot food stays hot and cold food stays cold. Resident #79 stated, They serve us cold food. 2. On 11/12/23 at 12:58 PM, an unheated food cart that contained 24 trays for lunch was delivered to the 200 Hall by Certified Nursing Assistant (CNA) #1. At 01:25 PM, immediately after the last resident was served on the 200 Hall, the temperature…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure that pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 1 of 1 meal observed. The failed practice had the potential to affect 3 residents who received pureed diets, as documented on the list provided Dietary Supervisor #1 on 11/13/2023 at 04:07 PM. The findings are: 1. On 11/12/23 at 11:49 AM, Dietary Employee (DE) #3 placed 4 servings of pepper steaks into a blender, added 2 more pepper steaks, broth and pureed. At 11:57 AM, DE #3 poured the pureed meat into a pan on the steam table. The consistency of the pureed pepper steaks was thick and not smooth. There were pieces of meat still visible in the mixture. 2. On 11/12/23 at 12:20 PM, DE #1 placed 3 servings of bread into a blender, added whole milk and pureed. At 12:23 PM, (DE) #1 poured the pureed bread into 3 bowls. The consistency of the pureed bread was runny. There were intact pieces of breadcrumbs in the mixture. 3. On 11/12/23 at 12:21 PM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.