Above 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 Amber Manor Care Center during CMS and state inspections, most recent first.
Improper Catheter Bag Placement and Inadequate UTI Prevention: A resident with a suprapubic catheter and history of UTIs was observed with the catheter bag hanging on a trash can that contained used gloves and paper towels touching the bag. The resident stated staff sometimes used the can for trash, and the record showed repeated UTIs, current catheter care orders, and a care plan that did not document this setup or the trash can being kept free of trash.
Failure to Monitor and Administer Antibiotics as Ordered: Two residents with recurrent UTIs received antibiotics in amounts that did not match MD orders, including extra doses of Macrobid, Omnicef, Amoxicillin, and Bactrim DS. One resident had an indwelling urinary catheter and suprapubic catheter site issues; the other had diabetes, Parkinson's disease, and a history of UTIs. The DON and Regional Consultant were unaware of concerns, despite an Antibiotic Stewardship Policy calling for facility-wide monitoring of antibiotic use.
A facility failed to monitor a resident for adverse reactions to newly prescribed pain medications, leading to decreased alertness and increased difficulty with mobilization and eating. Despite the resident's history of chronic pain and opioid dependence, no routine monitoring was documented. Staff and family noted a decline in the resident's alertness and communication abilities, but the facility did not create required pain event forms or update the care plan.
CNAs failed to adhere to the facility's hand hygiene policy during care for a resident, performing handwashing with insufficient scrub times. The DON confirmed the expectation for a minimum 20-second handwashing duration, as outlined in the facility's guidelines.
A resident with epilepsy and arthritis received an excessive dose of acetaminophen, exceeding the 3000 mg limit in a 24-hour period. Staff interviews revealed that the facility failed to notify the physician as required by policy, and there was no documentation of communication in the resident's health record.
A resident with COPD and pulmonary fibrosis did not receive respiratory care consistent with their orders. The oxygen concentrator was set to 1LPM instead of the ordered 2LPM, and the resident was left without supplemental oxygen during care, leading to respiratory distress. Facility policy requires licensed nurses to adjust oxygen settings, which was not followed.
The facility failed to follow infection control practices during perineal care for two residents. CNAs did not change gloves or perform hand hygiene between tasks, and a staff member emptied a urinal without gloves. The Infection Preventionist confirmed the need for glove changes and hand hygiene between tasks, as per facility policy.
Improper Catheter Bag Placement and Inadequate UTI Prevention
Penalty
Summary
The facility failed to ensure appropriate treatment and services to prevent UTIs for a resident with a history of UTIs and an indwelling suprapubic urinary catheter. On 8/5/25, the resident was observed sitting in a recliner with the urinary catheter bag hanging on a trash can next to him. The trash can labeled for catheter use only contained used gloves and paper towels that were touching the catheter bag. The resident stated he had a suprapubic catheter, a history of UTIs, and slept and sat in his recliner. He also stated the trash can designated for his catheter was sometimes used by staff to discard trash before leaving his room instead of using the regular trash can. Record review showed diagnoses including obstructive uropathy, a current order for suprapubic catheter care each shift, and a care plan that included assistance with catheter care and observing the tubing and urinary catheter bag. The care plan did not document that the resident used a trash can to hang his catheter bag or that the trash can labeled for catheter use only was sometimes not kept free of trash. The resident’s record also showed multiple UTIs during the year, including treatment for symptoms and positive urine findings in March, April, and July, with cultures showing possible contamination and E. coli growth. On 8/7/25, the DON and IP observed the catheter bag hanging on the trash can labeled for catheter use only, with trash in the can, and the DON stated the trash can should not have any trash in it and should only be used to place the catheter bag on.
Failure to Monitor and Administer Antibiotics as Ordered
Penalty
Summary
The facility failed to follow its antibiotic stewardship program that was intended to monitor unnecessary antibiotic use for 2 of 2 residents reviewed for antibiotic use. For Resident 2, who had diagnoses including obstructive uropathy and an indwelling urinary catheter, the record showed multiple UTIs in 2025. For one episode, the resident complained of drainage from his penis and was ordered Bactrim DS for 7 days after a urine culture was reported as possible contamination; for another, he complained of burning at a urology appointment and was ordered Macrobid for 5 days, but received 6 doses instead of 5; and for a later UTI with bladder spasms and urine leaking from the suprapubic catheter site, he was ordered Omnicef for 5 days but received 11 doses instead of 10. For Resident 1, who had diabetes mellitus type II, a history of UTIs, and Parkinson's disease, the record showed multiple UTIs during the review period. After increased incontinence and a urine culture showing Aerococcus urinae, the resident was ordered Amoxicillin for 7 days but received 25 doses instead of 21. During another episode with increased urinary frequency, confusion, and needing assistance of 2 staff for transfers, the resident was ordered Rocephin IM once, then 2 additional daily doses after culture results showed E. coli. During a later UTI with increased urinary frequency and urgency, the resident was ordered Bactrim DS for 7 days but received 16 doses instead of 14. During interview, the DON and Regional Consultant were unaware of any concerns with antibiotics not being administered as ordered and stated staff would be expected to follow physician orders. The facility's Antibiotic Stewardship Policy stated it was intended to optimize treatment of infections, reduce adverse events from unnecessary or inappropriate antibiotic use, and encompass a facility-wide system to monitor antibiotic use.
Failure to Monitor Adverse Reactions to Pain Medication
Penalty
Summary
The facility failed to adequately monitor signs and symptoms of adverse reactions to newly prescribed pain medications for a resident. The resident, who had a history of migraines, chronic pain, opioid dependence, and Parkinson's disease, was observed to have decreased alertness and increased difficulty with mobilization and eating following an increase in her pain medication regimen. Despite these changes, there was no routine monitoring of adverse reactions documented in the resident's record. Observations and interviews revealed that the resident was often unresponsive and appeared lethargic, with saliva hanging from her chin, and was difficult to arouse. The resident's family and staff noted a decline in her alertness and communication abilities since the increase in pain medications and her admission to hospice. The facility's policy required that any change in pain indicators or verbalizations from the resident should trigger a pain event form and care plan update, which was not done in this case. Interviews with nursing staff indicated that they were aware of the resident's increased lethargy but did not document it as required. The Director of Nursing acknowledged that no events were created for the resident regarding her new pain medications because her chronic pain was an ongoing issue. Hospice notes also documented the resident's lethargy and difficulty in responding, but the facility relied on hospice for monitoring adverse reactions, which was not sufficient as hospice visits were infrequent.
Inadequate Hand Hygiene Practices Observed
Penalty
Summary
The facility failed to maintain proper infection control practices during an observation of care involving a resident. Certified Nurse Aides (CNAs) 3, 6, and 11 assisted a resident with toileting and did not adhere to the facility's hand hygiene policy. Specifically, CNA 11 performed handwashing with a scrub time of only 10 seconds, while CNA 3 and CNA 6 washed their hands for 5 and 9 seconds, respectively, after removing gloves. Additionally, CNA 6 handed the resident a tissue before performing hand hygiene, further deviating from the expected protocol. The Director of Nursing (DON) confirmed that all staff, including contracted personnel, are expected to follow the facility's hand hygiene policy, which mandates a minimum of 20 seconds of handwashing using a rotary motion and friction. The facility's policy, titled 'Guidelines for Handwashing/Hand Hygiene,' was provided by the DON and clearly outlines the requirement for hand hygiene before and after direct physical contact with residents and after glove removal. This deficiency was related to a specific complaint, IN00449891.
Failure to Notify Physician of Excessive Acetaminophen Dose
Penalty
Summary
The facility failed to ensure proper physician notification before or after administering an excessive dose of acetaminophen to a resident with epilepsy and arthritis, who was also noted to have moderate cognitive impairment. The resident had physician orders for acetaminophen, with a maximum limit of 3000 mg in a 24-hour period. However, the Medication Administration Record (MAR) indicated that the resident received a total of 3900 mg of acetaminophen within a 24-hour period, exceeding the prescribed limit. Interviews with staff, including an LPN and the Director of Nursing (DON), revealed that staff were expected to monitor the total acetaminophen intake to ensure it did not exceed the 3000 mg limit. The LPN indicated that if a dose over the limit was required, staff should either ask the resident to wait or contact the physician for an alternative medication. The facility's Physician Notification policy required documentation of any communication with the physician in the resident's electronic health record, but there was no evidence of such communication in this case.
Failure to Provide Consistent Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care consistent with the resident's orders and care plans for a resident diagnosed with pulmonary fibrosis and COPD. The resident was observed resting in bed with an oxygen concentrator set to 1LPM, despite physician orders for continuous administration of oxygen at 2LPM. During incontinence care, the resident's head of bed was lowered, and the nasal cannula was removed, leaving the resident without supplemental oxygen for 20 minutes. The resident was observed to be audibly wheezing during this time, indicating respiratory distress. The Director of Nursing indicated that staff should stop care if signs of respiratory distress are observed and allow the resident to recover. However, the resident reported that it was common for the oxygen to be off and the head of the bed flattened during care. A Registered Nurse confirmed the resident's order for 2L continuous oxygen and adjusted the concentrator to the correct setting. The facility's policy requires oxygen settings to be adjusted by a licensed nurse, but this was not followed, leading to the deficiency.
Infection Control Lapses During Perineal Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during the provision of perineal care for two residents. During an observation, Certified Nurse Aide (CNA) 9 did not change gloves or perform hand hygiene after cleaning a resident's vaginal and rectal areas before obtaining a clean brief. In another instance, CNA 7 used gloved hands to touch room items, such as a curtain and a remote, before assisting with perineal care without changing gloves or performing hand hygiene. Additionally, a staff member was observed emptying a urinal without wearing gloves, which is against the facility's Standard Precautions Guidelines policy. The Infection Preventionist confirmed that gloves should be changed, and hand hygiene should be performed between dirty and clean tasks, and new gloves should be used when touching items in the room before providing direct care. The facility's policies emphasize the importance of hand hygiene and the use of protective equipment to prevent infection transmission.
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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 Petersburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brickyard Healthcare - Petersburg Care Center | 1 mi | ★★★★★ | 13 | 0 |
| Good Samaritan Home & Rehabilitative Center | 10.8 mi | ★★★★★ | 1 | 0 |
| Villages At Oak Ridge, The | 11.6 mi | ★★★★★ | 1 | 0 |
| Hillside Manor Nursing Home | 13 mi | ★★★★★ | 31 | 1 |
| Prairie Village Nursing And Rehabilitation | 13.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.