Amberwood Care Centre

Inspectors wroteBased on interview and record review the facility failed to ensure a blind resident that wanted to participate in smoking times at the facility was assisted to the activity for 1 of 3 residents (R1) reviewed for resident rights in the sample of 10.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide assistance with activities of daily for two residents (R1 & R2) reviewed for activities of daily living in the sample of 10.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was supervised while being toileted to prevent an injury. This applies to 1 of 3 residents (R1) reviewed for safety/supervision in the sample of 7.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was seen by a podiatrist. This applies to 1 of 3 residents (R1) reviewed for foot care in the sample of 4.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the facility was at a comfortable temperature and failed to accurately assess and monitor ambient room temperatures during an outage of the air conditioning system. This applies to all residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure foods were dated, expired foods were discarded, and kitchen temperature logs were complete. This applies to all residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to report an injury of unknown origin for 1 of 3 residents (R1) reviewed for accidents in the sample of 3.

Inspectors wroteBased on interview and record review the facility failed to ensure pain and anxiety medications were documented on the Medication Administration Record for 1 of 3 residents (R1) reviewed for medications.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a clean, comfortable, homelike environment to 4 of 25 residents (R92, R28, R19, R84) reviewed for clean, comfortable, homelike environment in the sample of 25.

Inspectors wroteBased on interview and record review the facility failed to provide the necessary care and services for a resident that required a sleep study for 1 of 25 residents (R28) reviewed for necessary care and services in the sample of 25.

Inspectors wroteBased on observation, interview and record review the facility failed to identify a resident's pressure injury prior to the injury becoming a Stage 2. The facility also failed to implement pressure injury prevention interventions and pressure relieving interventions. These failures apply to 2 of 6 residents (R28, R120) reviewed for pressure injuries in the sample of 25.

Inspectors wroteBased on observation, interview and record review the facility failed to provide treatment and services to residents with limited range of motion to to 2 of 10 residents (R120, R34) reviewed for limited range of motion in the sample of 25.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident did not attempt to exit the facility out a fire exit door, and failed to transfer a resident with a gait belt which applies to 2 of 25 residents (R39, R104) reviewed for safety in a sample of 25.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain resident catheters below the level of the bladder and keep the drainage bag off the floor. This applies to 3 of 8 (R66, R90, R39) residents reviewed for catheters in the sample of 25.

Inspectors wroteBased on observation, interview and record review the facility failed to wash hands and change gloves and failed to implement Enhance Barrier Precaution (EBP) for 2 of 25 residents ( R104, R39) reviewed for infection control in the sample of 25.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the residents received the correct portion size of fried potatoes, mixed vegetable, and pureed Italian sausage during the lunch meal for all residents receiving meals in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to have a narcotic pain patch available for a resident as ordered. This failure applies to one of three residents (R1) reviewed for pain medications in the sample of ten.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide privacy to a resident while providing personal care. This applies to one of three residents (R1) reviewed for privacy in the sample of 16.

Inspectors wroteBased on interview and record review the facility failed to continue an ordered antibiotic when a resident returned from the hospital. This applies to one of three residents (R1) reviewed for medications on the sample list of 16. Findings inlcude: The facility face sheet for R1 shows diagnosis to include spinal stenosis, benign prostatic hyperplasia with lower urinary tract symptoms and schizoaffective disorder. The facility assessment dated [DATE] for R1 shows him to have severe cognitive impairment and requires maximum assistance with all cares. The hospital records for R1 show he was in the hospital from [DATE] to 10/27/23 with a diagnosis of pyelonephritis (Kidney infection). The final discharge medication list from R1's 10/27/23 hospital discharge shows an order for cefdiner (antibiotic) to be given twice a day for the next 5 days starting on 10/27/23. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the safety of a resident while sitting unsupervised outside on a patio for 1 of 3 residents (R1) reviewed for safety on the sample list of 6.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the designated smoking area was kept clean and safe for smoking. The facility failed to ensure residents were supervised when smoking, fall interventions were implemented, and extension cords were not being used for 4 of residents (R82, R21, R77, & R12) reviewed for safety and supervision in the sample of 25 and 1 resident (R3) outside of the sample.

Inspectors wroteBased on observation, interview, and record review the facility failed to protect a resident's dignity by knocking prior to entering a resident's room and failed to change soiled linens. This applies to 1 of 2 residents (R14) reviewed for dignity in the sample of 25.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide incontinent care prior to the resident developing inflamed skin; failed to provide oral care; and failed to provide handwashing. This applies to 4 of 4 (R2, R14, R72, & R16) residents reviewed for activities of daily living in the sample of 25.

Inspectors wroteBased on observation, interview, and record review the facility failed to monitor resident weights per physician request and failed to ensure a knee immobilizer was applied per physician order for 3 of 5 residents (R13, R38, and R27) reviewed for quality of care in the sample of 25.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a catheter bag was maintained in a way to prevent cross contamination and failed to ensure catheter orders and maintenance interventions were in place for 2 of 4 residents (R46) reviewed for catheters in the sample of 25.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with a continuous tube feeding was in the proper position for 1 of 3 residents (R72) reviewed for tube feeding in the sample of 25.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the filter on a resident's oxygen concentrator was clean, a nasal canula was not left laying on the floor, and oxygen was administered as needed for a resident (R21) reviewed for oxygen in the sample of 25.

Inspectors wroteBased on interview and record review the facility failed to ensure medications were available for 1 of 1 resident (R13) reviewed for medications in the sample of 25.

Inspectors wroteBased on observation, interview, and record review the facility failed to handle soiled linens and change gloves after providing incontinence care to prevent cross-contamination. This applies to 2 of 2 residents (R2 &R32) reviewed for infection control in the sample of 25.

Inspectors wroteBased on observation, interview, and record review the facility failed to treat residents in a dignified manner. This applies to 2 of 25 residents (R26 and R18) reviewed for dignity in the sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide privacy for a resident during personal cares for one of 25 residents (R2) reviewed for privacy in the sample of 25.

Inspectors wroteBased on interview and record review the facility failed to implement a policy for the recording of grievances for 1 of 25 residents (R6) reviewed for grievances in the sample of 25.

Inspectors wroteBased on observation, intervention, and record review the facility failed to change gloves and perform hand hygiene to prevent cross contamination for three of 25 residents (R79, R2, R4) reviewed for infection control in the sample of 25.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pressure injury prevention interventions were in place and failed to identify a deep tissue injury (DTI) for two of four residents (R79, R2) reviewed for pressure injuries in the sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 8 residents (R104) reviewed for foot care received toenail care in the sample in 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fall prevention interventions were in place for three of 25 residents (R2, R72, R39) reviewed for safety in the sample of 25.

Inspectors wroteBased on observation, interview, and record review the facility failed to keep a urinary drainage bag below the level of the bladder for one of three residents (R79) reviewed for catheters in the sample of 25.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a residenta midline intravenous access (IV) site based upon professional standard of practice by not changing the dressing for one of one resident (R79) reviewed for IV access in the sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a CPAP (continuous positive airway pressure) machine was obtained for one resident (R104) with obstructive sleep apnea out of 5 reviewed for respiratory care in the sample of 25.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement pain management interventions for one of 25 residents (R79) reviewed for pain in the sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications as ordered. There were 27 opportunities with 9 errors resulting in a 33.33% error rate. This applies to 2 of 3 residents (R79, R104) observed in the medication pass. 1. R79's Order Summary Report dated 4/5/22 shows an order for Arginaid packet two times daily for wound healing, Ascorbic Acid 500 mg (milligram) two times daily, cholecalciferol 1000 units two times per day, enulose solution (lactulose) give 15 ml (milliliters) one time a day for constipation, keppra tablet 1000 mg two times a day for seizures, morphine sulfate ER (extended release) 15 mg every 12 hours for pain, senna S 8.6 mg-50 mg two tablets two times a day for bowel management, and sodium chloride table 1 gram two tablets by mouth three times per day for low sodium. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure food processing equipment was properly sanitized before using for 3 of 3 residents (R18, R21 and R26) reviewed for sanitization in the sample of 25.