CMS Inspection Results for AMBERWOOD CONV. HOSPITAL

The Center for Medicare & Medcaid Services (CMS) contracts with each state to conduct inspections once every 9-15 months to assure that certified facilities meet the minimum Medicare and Medicaid quality and performance standards.

• 09/03/2008 Health Survey for AMBERWOOD CONV. HOSPITAL

Administration
Deficiency	Scope	Level of Harm
Keep accurate and appropriate medical records.	Pattern	Minimal harm or potential for actual harm
Environmental
Deficiency	Scope	Level of Harm
Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Actual harm
Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
Make sure there is a program to prevent/deal with mice, insects, or other pests.	Pattern	Potential for minimal harm
Pharmacy Service
Deficiency	Scope	Level of Harm
Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Make sure that each resident's nutritional needs were met.	Isolated	Actual harm
Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Isolated	Minimal harm or potential for actual harm
Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.	Isolated	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Isolated	Minimal harm or potential for actual harm
Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
Resident Rights
Deficiency	Scope	Level of Harm
Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged.	Isolated	Minimal harm or potential for actual harm

 

• 08/25/2008 Fire Safety Survey for AMBERWOOD CONV. HOSPITAL

Automatic Sprinkler Systems
Deficiency	Scope	Level of Harm
automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
Corridor Walls and Doors
Deficiency	Scope	Level of Harm
corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
Miscellaneous
Deficiency	Scope	Level of Harm
fire safety features required by current fire safety codes.	Pattern	Minimal harm or potential for actual harm

 

• 05/24/2007 Health Survey for AMBERWOOD CONV. HOSPITAL

Administration
Deficiency	Scope	Level of Harm
Keep accurate and appropriate medical records.	Pattern	Minimal harm or potential for actual harm
Mistreatment
Deficiency	Scope	Level of Harm
Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Pattern	Minimal harm or potential for actual harm
Nutrition and Dietary
Deficiency	Scope	Level of Harm
Make sure that the attending doctor orders special diets.	Isolated	Minimal harm or potential for actual harm
Provide a tasty and well-balanced diet that meets the nutritional needs of each resident.	Widespread	Potential for minimal harm
Pharmacy Service
Deficiency	Scope	Level of Harm
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Isolated	Minimal harm or potential for actual harm
Make sure that each resident gets help to keep vision and hearing.	Isolated	Minimal harm or potential for actual harm
Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	Isolated	Minimal harm or potential for actual harm
Resident Rights
Deficiency	Scope	Level of Harm
Provide services to meet the needs and preferences of each resident.	Pattern	Minimal harm or potential for actual harm
Let residents give themselves their drugs if they are able.	Pattern	Minimal harm or potential for actual harm

 

• 05/22/2007 Fire Safety Survey for AMBERWOOD CONV. HOSPITAL

Building Service Equipment
Deficiency	Scope	Level of Harm
heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Widespread	Potential for minimal harm

 

• 03/06/2006 Fire Safety Survey for AMBERWOOD CONV. HOSPITAL

Interior Finish
Deficiency	Scope	Level of Harm
fire-resistant room wall surfaces.	Pattern	Potential for minimal harm

 

• 02/28/2006 Health Survey for AMBERWOOD CONV. HOSPITAL

Environmental
Deficiency	Scope	Level of Harm
Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
Have a program to keep infection from spreading.	Pattern	Potential for minimal harm
Mistreatment
Deficiency	Scope	Level of Harm
Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Widespread	Potential for minimal harm
Nutrition and Dietary
Deficiency	Scope	Level of Harm
Make sure that the attending doctor orders special diets.	Isolated	Minimal harm or potential for actual harm
Pharmacy Service
Deficiency	Scope	Level of Harm
Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Isolated	Minimal harm or potential for actual harm
Properly mark drugs and other similar products.	Pattern	Potential for minimal harm
Quality Care
Deficiency	Scope	Level of Harm
Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	Isolated	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan.	Widespread	Potential for minimal harm
Resident Rights
Deficiency	Scope	Level of Harm
Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
Let residents give themselves their drugs if they are able.	Isolated	Minimal harm or potential for actual harm
Let the resident refuse treatment or refuse to take part in an experiment.	Isolated	Minimal harm or potential for actual harm