Amberwood Manor

Inspectors wroteBased on observation, record review and interview, the facility failed to maintain air temperatures at a comfortable level and failed to ensure floors and bathtubs were cleaned on the South unit. This affected all 22 residents (#2, #3, #5, #8, #9, #10, #11, #13, #15, #16, #17, #19, #20, #22, #24, #26, #28, #29, #31, #32, #238, and #240) who resided on the South unit. Findings Included: 1. Review of an email dated 07/31/24 at 2:35 P.M. revealed the Heating and Cooling company emailed the Administrator indicating the packaged terminal air conditioner (P-TAC ) units needed to be replaced in the facility due to the fact that they were [AGE] years old and could not be repaired anymore. Review of an email dated 09/11/24 at 4:18 P.M. [...]

Inspectors wroteBased on medical record review, review of personal funds records and interview, the facility failed to obtain appropriate witness signatures on the authorization for handling funds. This affected one (Resident #8) of five residents whose funds were reviewed.

Inspectors wroteBased on record review and interviews, the facility failed to administer medications as ordered to Resident #5 and Resident #238. This affected two (Resident #5 and #238) out of six residents reviewed for medications. Facility census was 37.

Inspectors wroteBased on review of the medical record and interview the facility failed to ensure weekly wound assessments were completed for Resident #5. This affected one resident (Resident #5) of three reviewed for pressure ulcers.

Inspectors wroteBased on record review and interview the facility failed to ensure fall interventions were in place and appropriate for Resident #14. The facility also failed to ensure Resident #26's wheelchair was not locked when Resident #26 was left unattended. This affected two (Resident #14 and #26) out of five residents reviewed for accidents. The facility census was 37.

Inspectors wroteBased on observation, medical record review, staff interview and facility policy the facility failed to ensure Resident #137 was provided fluids to maintain hydration. This affected one resident (Resident #137) of one residents reviewed for hydration.

Inspectors wroteBased on medical record review, interview and policy review, the facility failed to ensure monthly drug regimen reviews identified irregularities in a resident's drug regimen and failed to ensure pharmacy recommendations were responded to in a timely manner. This affected two (Residents #17 and #26) of five residents reviewed for medication use.

Inspectors wroteBased on record review, pharmacy recommendations, and interview, the facility failed to ensure as needed psychotropic drugs were limited to 14 days without a rationale for the order to be extended. This affected one (Resident #26) out of five residents reviewed for unnecessary medications. Facility census was 37.

Inspectors wroteBased of observations, review of the medical record and interview the facility failed to ensure medications were not left at bedside for Resident #15. This affected one resident ( Resident #15) of five residents reviewed for accidents.

Inspectors wroteBased on record review, observation, interview and policy review the facility failed to ensure staff performed hand hygiene to prevent possible cross contamination during Resident #7's medication administration. This affected one resident (Resident #7) of five observed for medication administration. The facility census was 37.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, facility investigation, self-reported incident (SRI) review, policy and procedure for Abuse, Neglect and Exploitation and, policy and procedure for Inventory Control of Controlled Substances review, the facility failed to ensure controlled medication was not misappropriated. This affected six (Residents #1, #2, #3, #4, #5, and #6) out of 41 residents that resided in the facility at the time of misappropriation.

Inspectors wroteBased on beneficiary protection notification review and staff interview, the facility failed to ensure residents discharged from skilled services were provided appropriate notification of services ending. This affected one Resident (#5) of three Residents reviewed for beneficiary protection notification. The facility census was 41.

Inspectors wroteBased on interview and record review the facility failed to hold quarterly plan of care meetings for Resident #24 for the developement of and updates to the plan of care for Resident #24. This affected one out of one resident reviewed for care conferences. The facility census was 41.

Inspectors wroteBased on record review, interview, and policy and procedure review, the facility failed to follow the bowel protocol when Resident #9 went five days without a bowel movement. This affected one Resident (#9) out of five Residents reviewed for bowel elimination. The facility also failed to notify the physician when Resident #26 gained three to five pounds in one day. This affected one Resident (#26) out of six Residents reviewed for weights. The facility census was 41.

Inspectors wroteBased on observation, family interview, medical record review and staff interview the facility failed to provide care and services to prevent worsening of identified joint contractures. This affected one Resident (#11) of one Resident reviewed for range of motion services. The facility census was 41.

Inspectors wroteBased on interview and record review the facility failed to provide a proper indication for Resident # 32's Depakote use. This affected one Resident (#32) out of five Residents reviewed for unnecessary medications. The facility census was 41.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure physician ordered laboratory testing was obtained and completed as ordered. This affected one Resident (#21) of five Residents reviewed for medication use. The facility census was 41.

Inspectors wroteBased on record review, interview and policy review the facility failed to ensure a physician ordered pressure ulcer treatment was implemented timely for Resident #6. This affected one resident (#6) of three residents reviewed for pressure ulcers.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the prescribing physician provided resident specific rationale for declining pharmacy review recommendations, acted upon pharmacy recommendations timely and/or identified missed laboratory studies. This affected three resident (#9, #14 and #24) of five residents reviewed for unnecessary medication use.

Inspectors wroteBased on record review and interview the facility failed to ensure Resident #9, who received routine diuretic medication had laboratory testing completed as ordered to monitor for the effectiveness and correct dosage of the medication and to monitor the resident's potassium level. This affected one resident (#9) of five residents reviewed for unnecessary medication use.

Inspectors wroteBased on record review and staff interview the facility failed to appropriately monitor Resident #14 who received psychotropic medications for resident specific behaviors. This affected one resident (#14) of five residents reviewed for unnecessary medication use.

Inspectors wroteBased on observation, record review, menu review, diet card review and interview the facility failed to ensure Resident #9 was provided a diet as ordered. This affected one resident (#9) of 12 residents who received meals on the south wing meal cart. The facility census was 31.