Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Amberwoods Of Farmington during CMS and state inspections, most recent first.
A non‑ambulatory resident with multiple comorbidities, including MS, morbid obesity, bilateral femur fractures, and CKD, who was fully dependent for transfers, fell during a mechanical lift transfer from bed to an electric wheelchair. Two CNAs were using the lift when it tipped, causing the resident to fall to the floor, graze an arm on the wheelchair, and sustain a back contusion confirmed in the ED. The supervising RN found the resident supine on the floor and could not later determine whether the correct sling was used or whether the lift legs had been opened for stability, and the DON likewise could not verify sling selection or lift positioning. Facility policies and education required proper sling selection, inspection, use of at least two trained staff, and opening the lift base to the widest position during transfers, but documentation and interviews did not confirm these requirements were followed at the time of the incident.
A resident with multiple complex conditions, including MS, morbid obesity, chronic kidney disease, and bilateral femur fractures, was care planned to be transferred from bed to an electric wheelchair using a mechanical lift with two staff assistance. During one such transfer, two CNAs used a mechanical lift that tipped over, causing the resident to fall to the floor, complain of left arm pain, and later be found in the ED to have a back contusion. The supervising RN documented the fall from the lift and noted the resident’s anxiety and shortness of breath at the scene. Subsequent review and interviews with the DON and RN responsible for education revealed that the facility could not produce documentation that the involved CNAs, including an agency aide, had received required training or demonstrated competency in mechanical lift use, despite facility policies mandating orientation, annual competency validation, and safe transfer training (including mechanical lifts) for both employed and contracted staff.
Food Labeling and Temp Log Deficiencies: Surveyors observed an opened salad dressing container in the refrigerator with an outdated date and a frozen apple pie with no open or expiration date. Review of the food temp log showed multiple missed meal temperature entries, and staff interviews identified that one cook repeatedly failed to complete the log while the FSD noted there had been no recent in-service on the process.
Contracted staff training and facility assessment deficiencies: The facility failed to ensure all contracted individuals providing direct or indirect resident care received the mandatory education listed in the facility assessment or that records were maintained for those trainings. The Administrator, ADNS, and Medical Director stated that only agency nurses and nurse aides received facility-required training, while other contracted providers such as podiatry, ophthalmology, audiology, wound care, psychiatry, hospice, lab, pharmacy, radiology, and provider services received only general orientation. The facility assessment listed mandatory training topics for contracted individuals and volunteers, but it did not outline the length, frequency, or mechanism for that training.
A contracted Podiatrist was observed moving between residents while wearing the same gloves, without hand hygiene, and with podiatry tools and a cart containing visibly soiled items and a container of liquid used for instruments. The Podiatrist provided nail care to multiple residents with diabetes, vascular disease, dementia, immunodeficiency, MRSA history, ESBL resistance, and fungal nail infections, including a resident on EBP, while stating he did not need to clean equipment between residents unless there was visible blood or pus. Facility staff and policies required hand hygiene, glove changes, gown use for EBP, and cleaning/disinfection of reusable instruments.
Failure to assess a newly identified pressure ulcer occurred when staff found a coccyx wound on a resident with DM, CKD, dementia, and limited mobility. The wound nurse did not complete initial measurements after the resident was cleaned up, and the ADON was not asked to assess the area when it was first identified. The wound was later documented by the wound MD as a facility-acquired Stage 3 pressure ulcer, while facility records and interviews showed the required immediate assessment and documentation were not completed.
Failure to Supervise Resident at Risk for Elopement: A resident with dementia and moderate cognitive impairment was identified as at risk for wandering and elopement, with care plan interventions including supervision with wheelchair mobility. Camera footage showed the resident self-propelling from the lobby through the front doors and outside the facility without staff present, and a visitor later brought the resident back inside. RN and DNS interviews confirmed the resident did not have a wander guard in place at the time and that staff did not consider the event an elopement.
Failure to Offer and Document Pneumococcal #20 Vaccination: A resident with a history of MRSA, CKD, and bipolar disorder had prior pneumococcal #23 documentation and later physician orders for pneumococcal #20, but the record did not show the vaccine was offered or provided. The MDS also contained conflicting entries, with one assessment stating the vaccine was offered and declined and another stating the resident was up to date, while the ADNS and IP reported no documentation of an offer or decline in the EMR.
The facility failed to maintain an effective training program for contracted providers beyond agency nursing and nurse aide staff. Documentation was not available for contracted services such as MDs, APRNs, podiatry, ophthalmology, audiology, wound care, psychiatry, hospice, lab, pharmacy, and radiology for required topics including communication, resident rights, abuse/neglect/exploitation, QAPI, infection control, compliance and ethics, and behavioral health. The Administrator and DNS stated they only tracked credentials for contracted providers and provided general orientation, while the facility assessment listed mandatory training for contracted individuals and volunteers but did not define the length, frequency, or mechanism for that training.
A resident with diagnoses including paranoid schizophrenia, bipolar disorder, depression, and OCD did not have a PASARR Level II screen completed after new qualifying psychiatric diagnoses were identified. The SW stated staff are responsible for submitting Level II PASARR requests when a qualifying diagnosis is found after admission, but could not explain why the screen had not been completed and was in the process of submitting one. A facility PASARR policy was not provided.
Mechanical Lift Transfer Failure Resulting in Resident Fall and Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a non‑ambulatory, fully dependent resident remained free from injury during a mechanical lift transfer. The resident had multiple significant diagnoses, including multiple sclerosis, morbid obesity, chronic kidney disease, fractures of both femurs, arthritis, and low back pain, and was care planned to be transferred daily from bed to an electric wheelchair using a mechanical lift with assistance from two staff. A quarterly MDS documented that the resident had intact cognition but was dependent on staff for transfers. On the date of the incident, during a transfer from bed to wheelchair using a mechanical lift, the lift tipped and the resident fell to the floor. According to written statements from two CNAs, they were transferring or repositioning the resident with a mechanical lift when the lift tipped, causing the resident to fall and the resident’s left arm to graze the wheelchair armrest and wheel. When the supervising RN arrived, she found the resident lying supine on the floor with the head near the foot/side of the bed and feet toward the doorway, with the wheelchair nearby. The resident complained of left arm pain, appeared very anxious, and was short of breath. The resident was transported to the emergency room, where imaging was negative, and a contusion on the left side of the back was documented. Interviews and record review showed that the facility could not determine whether the correct sling size was used or whether the legs of the mechanical lift were opened to the widest position for stability at the time of the incident, despite facility policies and education materials requiring proper sling selection and full opening of the lift base during transfers. The DNS and RN supervisor both stated that CNAs are responsible for selecting the appropriate sling based on resident weight and ensuring the lift legs are opened, but neither could confirm these steps were followed during the event. The Director of Maintenance had no maintenance or repair records for the lift from the time of the incident, and there was no documentation clarifying whether equipment malfunction or staff technique contributed to the lift tipping. The facility’s policies required at least two trained staff for mechanical lift transfers and annual competency validation, but the incident occurred during such a transfer and resulted in the resident’s fall and injury.
Lack of Documented Mechanical Lift Training Leads to Resident Fall During Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff and nurse aides had documented training and competency in the use of a mechanical lift for a resident who required this device for transfers. The resident had multiple significant diagnoses, including multiple sclerosis, morbid obesity, chronic kidney disease, bilateral femur fractures, and other conditions, and was care planned to be transferred daily from bed to an electric wheelchair using a mechanical lift with the assistance of two staff. A quarterly MDS identified the resident had intact cognition and was dependent on staff for transfers. On the date of the incident, a reportable event form documented that during a transfer in the resident’s room, the mechanical lift tipped, resulting in the resident falling to the floor and complaining of left arm pain. Written statements from two nurse aides indicated they were transferring the resident from bed to wheelchair with a mechanical lift when the lift tipped over, causing the resident to fall and his/her left arm to graze the wheelchair armrest and wheel. The supervising RN’s progress note documented that upon entering the room, she observed the resident lying supine on the floor with the wheelchair nearby, complaining of left arm pain, appearing very anxious, and short of breath. The resident remained on the floor until EMS arrived and was then transferred to the hospital. An emergency room discharge summary identified that the resident had fallen from a mechanical lift, with imaging negative for fractures and a contusion on the left side of the back noted. Interviews and record review showed that the facility could not provide evidence that the two nurse aides involved had been trained or had demonstrated competency in mechanical lift use, despite facility policies requiring such training and annual competency validation. The DNS confirmed that staff are responsible for proper sling selection and positioning of the lift, including opening the base for stability, but she and the Administrator were unable to locate documentation of mechanical lift training or competency for the involved aides. RN #1, who is responsible for staff education and competency validation, stated that CNAs must receive education and demonstrate competency in mechanical lift use upon hire and annually, but confirmed that agency staff receive only a brief general orientation without mechanical lift training or competency validation, and that no documentation of mechanical lift competency for one involved aide at hire or annually could be found. Facility policies on CNA education, contracted services, and mechanical lift transfers all required safe handling, orientation, and annual competency validation, including for mechanical lifts, which were not supported by available documentation for the staff involved in this incident.
Food Labeling and Temperature Log Deficiencies
Penalty
Summary
Food was not labeled appropriately and food temperatures were not completed prior to serving. During a kitchen tour, surveyors observed a bottle of thousand island dressing in the reach-in refrigerator that was half filled and dated 12/31/24. The Food Service Director stated that opened condiments such as salad dressing should be used within 3 months of opening and then discarded. Surveyors also observed a frozen apple pie in the walk-in freezer wrapped in saran seal with no open date or expiration date, and the Food Service Director could not locate an open date or expiration date but believed it was from a recent event. Review of the food temperature log showed multiple missed entries for breakfast, lunch, and dinner meals on several dates in June and July. Interviews with Dietary Aide #1 and the Food Service Director identified that one specific cook appeared to be the staff member who did not log temperatures, and Dietary Aide #1 stated she had to remind that staff member to complete the food temperatures and log the results. The Food Service Director stated she had spoken about taking and logging food temperatures, but there had not been any recent in-service training on completing this task. The facility policy directed that food marking systems be in place to reduce foodborne illness, that salad dressing be used within 4 months of opening, and that foods placed in the tray line be brought to the appropriate temperature and recorded on the Cooks Temp Log.
Contracted Staff Training and Facility Assessment Deficiencies
Penalty
Summary
The facility administration failed to ensure that all contracted staff who provided direct or indirect care to residents met the training requirements or received the mandatory training identified in the facility assessment and regulatory requirements before and during service in the facility. The facility assessment dated [DATE] listed a training plan for mandatory education for new and existing employees, contracted individuals, and volunteers in effective communication, resident rights, abuse, neglect, and exploitation, QAPI, infection control, compliance and ethics, nurse aide competency, behavioral health, non-pharmacological interventions, and dementia care. On 8/25/25, the facility was asked to provide education and training documentation for contracted staff listed in the facility assessment training plan. The facility provided training documentation for two contracted agencies that supplied nursing and nurse aide staffing, but did not provide documentation for other contracted agencies that provided direct and indirect care to residents. During interview, the Administrator and ADNS identified that the facility used contracted services for podiatry, ophthalmology, audiology, wound care, psychiatry, nursing services, provider services, hospice, laboratory, pharmacy, and radiology services. The Administrator stated that only agency nurses and nurse aides received the listed training and that the agency maintained those records, with staff prevented from working if required training was not completed. The Medical Director stated he had been working at the facility for a little over a year, was not aware that contracted staff had to receive education on topics such as communication, resident rights, abuse, neglect, exploitation, QAPI, infection control, behavioral health, or compliance and ethics from the facility, and had only received a general orientation to the building. The Administrator and DNS later stated they were not aware that contracted providers were to receive the mandatory education or that the facility should maintain those records, and acknowledged that the facility assessment did not address the length, frequency, or mechanism of training for contracted individuals and volunteers even though it did for employees.
Failure to Maintain Standard Precautions During Podiatry Care
Penalty
Summary
The facility failed to ensure a contracted Podiatrist maintained standard precautions and failed to ensure podiatry equipment was cleaned and disinfected between residents. During observation, the Podiatrist exited a resident room wearing latex gloves and pushed a cart down the corridor containing soiled gloves, unused gloves, a clear plastic container with bluish liquid, and multiple metal clipping tools, including tools with visible white debris and a rotary tool with an off-white used sanding tip. The cart did not contain hand sanitizer, and the container also had a paper towel with three drops of a red substance. The Podiatrist entered and exited resident rooms while continuing care, including a room with enhanced barrier precautions posted on the door, and was observed moving from one resident to another without changing gloves or performing hand hygiene. The Podiatrist provided podiatric care to 22 residents, many of whom had diagnoses placing them at high risk for foot complications, including diabetes, peripheral vascular disease, dementia, immunodeficiency, chronic kidney disease, MRSA history, ESBL resistance, and fungal nail infections. The podiatry notes documented thick, brittle, discolored toenails with fungal odor, pain on palpation, and subungual debris for multiple residents, and treatment often included trimming and debridement using both manual and mechanical means. One resident was on enhanced barrier precautions, and another had chronic venous hypertension with ulcer and inflammation of both lower extremities and pressure-induced deep tissue damage of the heel. Interviews showed the Podiatrist acknowledged he had not changed gloves or washed his hands after providing care and stated he did not believe cleaning nail equipment was required between non-infectious residents unless there was visible blood or pus. He also stated the rotary tool did not need cleaning unless visibly contaminated and could be wiped with dry gauze. Facility staff stated contracted staff were expected to follow infection prevention standards, including hand hygiene, glove changes, gown use for enhanced barrier precautions, and cleaning of equipment, and the facility’s policies required hand hygiene before and after resident care and cleaning or disinfection of reusable instruments before use on another patient.
Failure to Assess Newly Identified Pressure Ulcer
Penalty
Summary
Failure to complete an assessment upon identification of a new pressure ulcer occurred for a resident admitted with lack of coordination, type 2 diabetes mellitus with chronic kidney disease, and dementia. The resident’s care plan identified risk for skin breakdown, and the admission assessment noted a new denuded skin issue on the buttocks, with a Braden score of 18 indicating mild risk for skin impairment. Physician orders were entered for barrier cream and later for wound cleansing, barrier cream, an air mattress, and calcium alginate treatment as the coccyx wound progressed. On 7/16/25, therapy and the wound nurse identified a skin injury to the coccyx. The wound nurse stated the resident was soiled at the time and no measurements were taken, and she did not return after the resident was cleaned up to complete the initial wound measurements. She notified the APRN and placed the resident on the wound MD list for the following week. The facility’s pressure ulcer list identified the wound as a facility-acquired Stage 3 pressure ulcer starting on 7/16/25, and the first wound provider assessment occurred on 7/22/25, when the wound was staged as a Stage 3 coccyx pressure wound measuring 1.1 cm x 0.6 cm x 0.2 cm. Interviews confirmed that an assessment should be completed immediately when a new wound is identified, but the ADON was not requested to assess the resident when the area was found. Review of the 24-hour reports for 7/16/25 and 7/17/25 did not identify an alteration in skin, and a skin observation note documented refusal. The resident stated he/she had not refused bottom care since admission. Facility policy required nursing staff and practitioners to assess and document significant risk for pressure ulcers, and required newly identified skin areas to be investigated and documented with measurements and wound details.
Failure to Supervise Resident at Risk for Elopement
Penalty
Summary
The facility failed to supervise a resident with dementia, anxiety, depression, adjustment disorder, restlessness, and agitation who was identified as at risk for wandering and elopement. The resident’s elopement evaluation identified the resident as at risk for elopement, and the care plan included interventions such as clearly identifying the room and bathroom, engaging the resident in activities, redirecting when self-propelling outside the unit, and supervising wheelchair mobility. The quarterly MDS assessment identified moderate cognitive impairment and the need for supervision with wheelchair mobility. On 7/26/25, recorded camera footage showed the resident seated in a wheelchair in the front lobby, pushing the bar to open the front door, then opening the first and second sets of doors and exiting the facility. The resident self-propelled the wheelchair toward the side of the building and was outside the camera’s view for several minutes before a female visitor brought the resident back to the front lobby. RN #1 stated she received a call from a visitor who had assisted the resident from outside the front door back inside the facility and that the resident was calm when she arrived. RN #1 also stated the resident did not have a wander guard in place at that time. Facility staff and documentation reflected conflicting information about the resident’s elopement protection. The revised care plan later identified a wander guard on the wheelchair and 15-minute checks, while the ADNS stated the resident had previously been identified as at risk for elopement and that a wander guard was used, but could not explain why it was not on the wheelchair at the time of the incident. The DNS stated the resident was at risk for elopement but did not consider the event an elopement and did not report it to the state agency. The facility elopement policy stated residents are assessed for elopement risk and those at risk are to have an individualized comprehensive care plan developed.
Failure to Offer and Document Pneumococcal #20 Vaccination
Penalty
Summary
The facility failed to offer or provide the pneumococcal #20 vaccination for Resident #25. Review of the infection preventionist’s vaccine line list showed the resident received pneumococcal #23 on 10/31/20, with no other pneumococcal vaccines documented as administered. A physician order dated 12/24/24 directed administration of the pneumococcal vaccine, and the resident’s Pneumonia Vaccine Education Documentation Form dated 12/29/24 indicated the resident elected and agreed to receive pneumococcal PVC #20. Another physician order dated 1/21/25 directed administration of Prevnar #20 intramuscular suspension. Resident #25 was readmitted in March 2025 and had diagnoses including a history of MRSA, chronic kidney disease, and bipolar disorder. A physician order dated 3/19/25 again directed administration of the pneumococcal vaccine. The quarterly MDS identified the resident as moderately cognitively impaired, with no behaviors, and indicated the pneumococcal vaccine was offered and declined; the significant change MDS identified the resident as moderately cognitively impaired, with no behaviors, and indicated the pneumococcal vaccination was up to date. Interviews with the ADNS and IP indicated the facility was catching up on immunizations, used admission consent forms indefinitely, did not keep all vaccines in house, and the new EMR search did not find any offering or documentation that Resident #25 was offered pneumococcal #20 or declined it.
Failure to Train Contracted Providers on Required Facility Topics
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for all individuals providing services under contractual arrangements. During review of facility documentation, policies, and interviews, the facility was unable to provide education and training records for contracted agencies other than the two agencies that supplied nursing and nurse aide staffing. The requested topics included communication, resident rights, abuse, neglect, and exploitation, QAPI, infection control, compliance and ethics, nurse aide training, and behavioral health training for contracted individuals providing direct and indirect services to residents. Interviews with the Administrator and ADNS confirmed that the facility used contracted services for podiatry, ophthalmology, audiology, wound care, psychiatry, nursing services, provider services, hospice, laboratory, pharmacy, and radiology. The Administrator stated that only contractual nurses and nurse aides received the required training and that those trainings were maintained by the staffing agencies. The Administrator also stated that if the required training was not completed, agency nurses and nurse aides could not pick up shifts, and that other contracted providers were instructed to follow facility staff direction in an emergency. The Medical Director stated he had worked at the facility for a little over a year, was not aware that contracted staff had to receive facility education on communication, resident rights, abuse, neglect, exploitation, QAPI, infection control, behavioral health, or compliance and ethics, and had only received a general orientation to the building. APRN #2 stated she had not received any facility-specific education or training and was not directed to provide proof of training to the facility. The Administrator and DNS later stated they were not aware that contracted providers were required to receive and have documentation of mandatory education, and acknowledged that the facility assessment listed training requirements for contracted individuals and volunteers, but the assessment did not outline the length, frequency, or mechanism of training for those groups.
Failure to Complete PASARR Level II Screening After New Psychiatric Diagnosis
Penalty
Summary
The facility failed to obtain and complete a PASARR Level II screen for one resident after the resident received qualifying psychiatric diagnoses. Resident #6 had diagnoses of paranoid schizophrenia, bipolar disorder, depression, and obsessive-compulsive disorder, and the quarterly MDS identified intact cognition with extensive assistance needed for bed mobility, transfers, toileting, and hygiene. During interview, the social worker stated that staff are responsible for submitting Level II PASARR requests when a qualifying diagnosis is identified after admission, and identified that Resident #6 developed new diagnoses of paranoid schizophrenia and bipolar disorder on 1/25/22, which required a PASARR Level II screening. The social worker could not explain why no Level II screen had been completed for the resident and stated she was in the process of submitting one. A facility PASARR Level II screen policy was requested but not provided.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Farmington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Lake Healthcare At New Britain | 1.1 mi | ★★★★★ | 0 | 0 |
| Autumn Lake Healthcare At West Hartford | 1.6 mi | ★★★★★ | 21 | 0 |
| Monsignor Bojnowski Manor | 3.3 mi | ★★★★★ | 3 | 0 |
| West Hartford Health & Rehabilitation Center | 4 mi | ★★★★★ | 22 | 0 |
| Apple Rehab Farmington Valley | 4.2 mi | ★★★★★ | 1 | 0 |
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