Amberwood Post Acute

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Resident Rights Deficiencies

Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Quality of Life and Care Deficiencies

Provide or obtain dental services for each resident.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Rights Deficiencies

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Resident Rights Deficiencies

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies

Plan the resident's discharge to meet the resident's goals and needs.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Resident Rights Deficiencies

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Based on observation it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96. 1.Kitchen Hood system due hydrostatic testing | Facility scheduling testingNFPA 101: 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction.NFPA 96 11.2.1* Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction at leastevery 6 months.This deficiency has the potential to affect occupants, who might include residents, staff, and visitors throughout the facility. The administrator and maintenance director discussed d.. Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 1011. Antifreeze tested positive will need to be replaced | Facility scheduling replacement | Vendor will need to verify that new viscosity will not affect sprinkler system calculations 2. Annual sprinkler testing does not include annual forward flow testing NFPA 101: 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction.NFPA 25 13.6.2 Testing.13.6.2.1*All backflow preventers installed in fire protection system piping shall be tested annually by conducting a forward flow test of the system at the designed flow rate, including hose stream demand, where hydrants or inside hose stations are located downstream of the backflow preventer.This deficiency h.. The Colorado Division of Fire Prevention and Control conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70 (a).The facility is a one story, Type V(111) structure with a partial basement and is licensed for eighty eight (88) beds. The facility utilizes the partial basement for support services and it is not available for use by residents. The facility is equipped with a full National Fire Protection Association (NFPA) 13 automatic fire sprinkler system, which includes closets, bedrooms, bathrooms and common areas.This re-certification survey conducted on November 12, 2024 was for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19, "Existing Health Care Occupancies;" NFPA 99, Health Care Facilities Code (2012); and all referenced standards. The facility will meet these requirements when the following deficiency are corrected. The deficiencies cited were discussed with the Administrator and Maintenance Director during the exit conference conducted at the end on-site survey.

A recertification survey with complaint #CO37168 was completed on 10/9/24 to 10/15/24. Sixteen deficiencies were .. An Emergency Preparedness survey was conducted from 10/9/24 to 10/15/24. No deficiencies were cited. Based on interviews and record review, the facility failed to ensure one (#65) of two residents reviewed for accident.. Based on interviews and record review, the facility failed to ensure residents were permitted to remain in the facility and not transfer or discharge for one (#76) of two residents out of 39 sample residents.Specifically, the facility failed.. Based on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored in a.. Based on observations and interviews, the facility failed to ensure one (#3) of one resident out of 39 sample residents were free of significant medication errors.Specifically, the facility failed to ensure the insulin pen was primed prior t.. Based on observations, record review and interviews, the facility failed to ensure it was free of a medication error ra.. Based on observations, record review and interviews, the facility failed to ensure proper treatment and assistive devices to maintain vision abilities for one (#18) of one resident out of 39 sample residents.Specifically, the facility f.. Based on observations, record review and interviews, the facility failed to ensure residents were provided services th.. Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry.. Based on observations, record review and interviews, the facility failed to ensure services provided to residents met professional standards of quality for one (#15) of one resident out of 39 sample residents.Specifically, the facility fail.. Based on observations, record review and interviews, the facility failed to maintain an infection control program desi.. Based on record review and interviews the facility failed to permit a resident to return to the facility following a facility-initiated transfer to the hospital for one (#76) of two residents reviewed for discharge out of 39 sample resid.. Based on record review and interviews, the facility failed to assist residents in obtaining routine or emergency dental.. Based on record review and interviews, the facility failed to ensure money from personal funds accounts was managed accurately for four (#7, #17, #33 and #39) of four residents reviewed for personal funds accounts out of 39 sample re.. Based on record review and interviews, the facility failed to incorporate the recommendations from the PASRR (prea.. Based on record review and interviews, the facility failed to provide the resident representative with the proper discharge notifications for one (#182) of two residents out of 39 sample residents.Specifically, the facility failed to d.. VI. Resident #66A. Resident statusResident #66, under the age 65, was admitted on 11/3/23. According to the Octob..