Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Amberwood Manor during CMS and state inspections, most recent first.
The facility failed to maintain a comfortable and clean environment for residents on the South unit, affecting 22 residents. Outdated and malfunctioning P-TAC units led to cold room temperatures, with space heaters used as a temporary solution. Additionally, dirty floors and bathtubs were observed, with the Housekeeping Supervisor citing a lack of staff as the reason for unclean conditions. Dust accumulation and debris in heating units were also reported, contributing to unsanitary conditions.
A facility failed to obtain proper witness signatures for handling a resident's funds, affecting a resident with Alzheimer's and vascular dementia. The resident's family was unaware of the facility-managed funds account, and the authorization form lacked the resident's signature, instead having an infinity sign and two witness signatures. The facility was chosen as the representative payee by the Social Security Administration, but failed to inform the resident's responsible party, as statements were sent to the facility's address.
Two residents in an LTC facility did not receive medications as ordered, leading to deficiencies in care. One resident with diabetes did not receive prescribed insulin on two occasions due to unjustified nursing judgment, despite high blood glucose levels. Another resident did not receive evening medications because they were asleep, and the nurse did not attempt to administer them again. Both incidents were confirmed by facility staff.
A resident with a stage 4 pressure ulcer did not receive a weekly wound assessment as required by the facility's care plan. Despite being in and out of the hospital, there was no documentation of the resident refusing the assessment or any attempts to conduct it later. Interviews revealed the resident was particular about care timing, and the LPN did not document the refusal or attempt a later assessment.
Two residents experienced falls due to inadequate interventions and supervision. One resident, with Alzheimer's and moderate cognitive impairment, fell multiple times due to a non-functioning motion sensor and lack of a toileting program. Another resident, with traumatic brain injury and vascular dementia, fell when their locked wheelchair tipped forward. The facility failed to ensure proper safety measures and documentation.
A resident with multiple health conditions, including congestive heart failure and chronic kidney disease, was not provided with adequate fluids to meet her daily requirements. Observations revealed the absence of water in her room, and staff interviews confirmed delays in water delivery. The resident's fluid intake was significantly below her needs, and her lab results indicated potential dehydration.
The facility failed to address pharmacy recommendations for two residents, leading to unclarified medication orders and unaddressed irregularities. A resident had pain management orders that were not clarified, and another had antianxiety medications without specified parameters. The facility's policy requires physician response to pharmacy recommendations, which was not ensured in these cases.
A facility failed to limit the use of as-needed psychotropic medication to 14 days for a resident with multiple diagnoses, including anxiety and depression. The resident was prescribed Ativan without a documented rationale for extending the order beyond 14 days, as required by pharmacy recommendations. The physician did not sign or provide a rationale for the extended use, and the Director of Clinical Services confirmed the oversight.
A resident with multiple health conditions was found with a bottle of fluticasone propionate nasal spray on their over-the-bed table, despite not having an order to self-administer or keep medications at the bedside. A nurse confirmed that the resident should not have had any medication at the bedside.
A registered nurse failed to perform hand hygiene before administering medications to a resident with multiple health conditions, including traumatic brain injury and hypertension. The nurse touched various surfaces without cleaning her hands, contrary to the facility's infection control policy, which emphasizes hand hygiene as crucial for preventing infection spread.
An LTC facility failed to protect residents from the misappropriation of controlled medications by an agency RN. The issue was discovered when an LPN noticed discrepancies in narcotic records, revealing unrecognized signatures and missing documentation for medications like Oxycodone and Clonazepam. The affected residents had various medical conditions requiring pain management. The facility's policies on controlled substances and staff vetting were not adequately followed, leading to the misappropriation.
Facility Fails to Maintain Comfortable and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for residents on the South unit, affecting all 22 residents residing there. The primary issue was the failure to maintain air temperatures at a comfortable level due to outdated and malfunctioning packaged terminal air conditioner (P-TAC) units. Despite being informed by the Heating and Cooling company that the units needed replacement, the facility delayed action due to financial constraints and logistical challenges. As a result, residents were subjected to cold room temperatures, with some rooms as low as 62 degrees Fahrenheit, and space heaters were used as a temporary solution. Additionally, the facility failed to ensure cleanliness in the South unit, as observed in the dirty floors and bathtubs. The October 2024 Resident Council Minutes revealed complaints about housekeeping and dirty rooms. Observations confirmed the presence of dirt and ice melt salt buildup in hallways, dining rooms, and resident rooms. The Housekeeping and Laundry Supervisor acknowledged the issue, citing a lack of staff as the reason for the unclean conditions. Despite hiring new housekeepers, the floors in several rooms remained dirty. Further deficiencies were noted in the maintenance of resident rooms, with reports of dust accumulation and debris in heating units. Resident #9, who was allergic to dust, reported a thick layer of dust on her fan and debris in the heater unit. The bathtub in her room also had a brown, rusty appearance, with water backing up in the drain area. Housekeeper #372 confirmed the presence of standing water and discoloration in the tub, stating that attempts to clean it were unsuccessful. These issues were not addressed promptly, contributing to the overall unsanitary conditions in the facility.
Failure to Obtain Proper Authorization for Resident's Funds
Penalty
Summary
The facility failed to obtain appropriate witness signatures on the authorization for handling a resident's funds, affecting a resident who was a Medicaid recipient. The resident's granddaughter stated that the family had not been asked to sign any authorization for the facility to manage the resident's funds, and to their knowledge, the resident did not have a personal funds account with the facility. However, a review of the facility's records showed that the resident did have a personal funds account, with social security benefits being directly deposited and care costs automatically transferred to the facility. The authorization form had an infinity sign in place of the resident's signature, with two witness signatures, one of which was a Registered Nurse, and the Administrator signed as a representative payee. The resident's medical record indicated diagnoses of Alzheimer's disease and vascular dementia, with an assessment showing the resident was rarely or never able to understand others or make herself understood. The Administrator and a revenue cycle field specialist confirmed that the facility applied to be the resident's representative payee, and the Social Security Administration had chosen the facility for this role. However, the facility failed to ensure that the resident's responsible party was informed about the personal funds account, as quarterly statements were sent to the facility's address rather than to the responsible party.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to administer medications as ordered for two residents, leading to deficiencies in care. Resident #238, who has diagnoses including type 2 diabetes and major depressive disorder, did not receive their prescribed Lantus insulin on two occasions. Despite having high blood glucose levels, the insulin was withheld by an agency nurse due to the concurrent administration of metformin, which was not justified by the resident's medical condition or orders. The resident, who was cognitively intact, expressed distress and reported the issue, which was confirmed by the Director of Nursing. Resident #5, with a complex medical history including chronic kidney disease and diabetes, did not receive their evening medications as per their preference due to being asleep. The medications included critical drugs such as Buspar, Colace, and Eliquis. The resident reported that the nurse did not attempt to administer the medications again, contrary to expectations. This was corroborated by the Director of Clinical Services, who confirmed that the agency nurse did not make a second attempt to administer the medications.
Failure to Conduct Weekly Wound Assessments
Penalty
Summary
The facility failed to ensure weekly wound assessments were completed for a resident with a stage 4 pressure ulcer. The resident, who had multiple diagnoses including chronic kidney disease, diabetes, and a stage 4 pressure ulcer, was admitted to the facility with a care plan that required weekly assessments by the in-house skin/wound team. Despite this, there was no documented skin measurement or wound assessment for the week of December 10, 2024. The resident had been in and out of the hospital during this period, and the Director of Clinical Services suggested this was the reason for the missed assessment. However, there was no documentation of the resident refusing the assessment or any attempts to conduct it later. Interviews with facility staff revealed that the resident was particular about the timing of his care and had refused to see the wound nurse if she was not present at the expected time. The Licensed Practical Nurse confirmed that she did not document the resident's refusal or attempt to assess the wound on a later date. The facility's policy on skin and wound care emphasized evidence-based preventative care, yet the lack of documentation and follow-up on the resident's wound assessment indicated a failure to adhere to this policy.
Inadequate Fall Interventions and Supervision
Penalty
Summary
The facility failed to ensure appropriate fall interventions for Resident #14, who had multiple diagnoses including Alzheimer's disease and moderate cognitive impairment. Despite a care plan intervention to place a motion sensor in the bathroom, there was no evidence of the sensor being in place or functioning when Resident #14 fell on 11/29/24. Additionally, the resident was frequently incontinent of urine, but a toileting program was not implemented, and the restorative nursing services for transfers and toileting hygiene were not properly documented or executed. This lack of appropriate interventions and documentation led to multiple falls for Resident #14. Resident #26, who had moderately impaired cognition and multiple diagnoses including traumatic brain injury and vascular dementia, experienced an unwitnessed fall in the dining room. The resident was found on the floor next to a locked wheelchair, which they could not lock themselves. The post-fall huddle revealed that the resident attempted to turn the wheelchair, which was locked, causing them to tip forward and fall. The Director of Clinical Services confirmed that the wheelchair should not have been locked, indicating a failure in providing adequate supervision and ensuring the resident's safety.
Failure to Provide Adequate Hydration
Penalty
Summary
The facility failed to ensure adequate hydration for Resident #137, who was readmitted with multiple diagnoses including congestive heart failure, chronic kidney disease, and protein-calorie malnutrition. The resident's nutritional assessment indicated a daily fluid requirement of 1900 ml to 2100 ml, but documentation showed that her daily intake ranged from 480 ml to 960 ml, significantly below her needs. Laboratory results revealed elevated potassium and blood urea nitrogen levels, indicating potential dehydration. Observations and interviews on January 22 revealed that Resident #137 did not have a cup of water in her room, and she complained of a dry cough and a very dry tongue. A Certified Nursing Assistant (CNA) admitted that water delivery was delayed due to staffing issues, and the resident confirmed that she had not received sufficient water throughout the day. The Registered Dietitian (RD) confirmed that the resident's fluid intake was inadequate and that her lab results had worsened. The facility's Resident Hydration Policy requires that residents be offered sufficient fluids to maintain hydration, with nursing staff primarily responsible for fluid intake monitoring. However, the policy was not followed, as evidenced by the lack of water at the resident's bedside and the failure to meet her fluid requirements. The interdisciplinary team did not adequately address the resident's hydration needs, leading to the deficiency.
Failure to Address Pharmacy Recommendations in Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that monthly drug regimen reviews identified irregularities in the medication regimens of two residents and did not respond to pharmacy recommendations in a timely manner. For Resident #17, the pharmacy requested clarification on the use of acetaminophen and hydrocodone/acetaminophen for pain management, suggesting that hydrocodone/acetaminophen be reserved for more severe pain. However, there was no evidence that the physician responded to this recommendation, and the orders were not clarified until they were discontinued months later. Additionally, an order for Ativan was written without a time limit, and the pharmacy did not address this issue as per their recommendations. For Resident #26, the pharmacy recommended adding acetaminophen for mild pain and clarifying the use of Oxycodone for severe pain, but these recommendations were not signed or acted upon by the physician. Furthermore, the pharmacy suggested discontinuing one of the two antianxiety medications or specifying parameters for their use, but the facility physician declined this recommendation without addressing the psychiatric doctor's involvement. Another recommendation to adjust antidepressant and antianxiety medications was declined by the physician without providing a rationale. The facility's Medication Regimen Review policy requires that physicians either accept and act upon pharmacy recommendations or provide an explanation for rejecting them. However, in these cases, the facility did not ensure that the physicians responded appropriately to the pharmacy's recommendations, leading to a failure in addressing potential medication irregularities for the residents involved.
Failure to Limit As-Needed Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure that as-needed psychotropic medications were limited to 14 days without a documented rationale for extending the order. This deficiency affected one resident who was prescribed Ativan, an antianxiety medication, on an as-needed basis. The resident, who had a history of hepatic encephalopathy, traumatic brain injury, major depressive disorder, anxiety disorder, vascular dementia, visual hallucinations, and violent behavior, was admitted and readmitted with these diagnoses. The quarterly Minimum Data Set indicated that the resident had moderately impaired cognition and was receiving antianxiety and antidepressant medications. The pharmacy recommendation dated September 6, 2024, specified that as-needed psychotropic medications should be limited to 14 days unless the prescriber documented the specific condition being treated, the rationale for the extended period, and the duration for the as-needed order. However, the physician did not sign the pharmacy recommendation, accept or decline it, or provide a rationale for extending the Ativan order beyond 14 days. The resident continued to receive Ativan from September 6, 2024, until October 2, 2024, without the necessary documentation. The Director of Clinical Services confirmed that the pharmacy recommendation was not signed and no rationale was provided for the extended use of Ativan.
Medication Mismanagement at Bedside
Penalty
Summary
The facility failed to ensure that medications were not left at the bedside for a resident. Resident #15, who was admitted with multiple diagnoses including diabetes, hypertension, and dementia, was observed with a bottle of fluticasone propionate nasal spray on his over-the-bed table. The resident did not have an order to self-administer medications or to have them at the bedside. An interview with a registered nurse confirmed that the resident should not have had any medication at the bedside.
Failure in Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to ensure proper hand hygiene was performed by a registered nurse during the medication administration process for Resident #7. The resident, who was admitted with multiple diagnoses including traumatic brain injury, hypertension, and dysphagia, was observed receiving medications without the nurse performing hand hygiene. The nurse, identified as RN #364, did not clean her hands before obtaining and dispensing medications into a medication cup, which she handled by placing her finger inside. Furthermore, the nurse touched various surfaces, including the nurses' station and kitchen door handle, before administering the medications. The facility's hand hygiene policy, revised in February 2024, emphasizes the importance of hand hygiene in preventing infection spread and outlines specific instances when hand cleaning is required. Despite this policy, RN #364 admitted to not performing hand hygiene before administering medications to Resident #7, acknowledging the oversight. The facility's medication administration policy also mandates adherence to infection control practices, including hand hygiene before and after resident contact, which was not followed in this instance.
Misappropriation of Controlled Medications by Agency RN
Penalty
Summary
The facility failed to protect residents from the misappropriation of controlled medications, affecting six residents. The issue was discovered when an LPN noticed discrepancies in the narcotic accountability records during a routine medication count with an agency RN. The LPN observed unrecognized signatures and unusual times for medication administration, prompting an investigation by the DON. The investigation revealed that controlled medications, including Oxycodone, Clonazepam, Norco, Percocet, and Tramadol, were signed out with unrecognizable signatures and not documented as administered in the MAR. This affected residents with various medical conditions, including diabetes, Alzheimer's disease, chronic respiratory failure, and pain management needs. The discrepancies indicated that medications were potentially diverted by RN #103, who had a history of nursing board probationary actions related to theft and drug charges. The facility's policies on Inventory Control of Controlled Substances and Abuse, Neglect, and Exploitation were not adequately followed, as the agency RN was not properly vetted, and the narcotic counts were not accurately reconciled. The facility's failure to ensure proper documentation and accountability of controlled substances led to the misappropriation, impacting the residents' medication management and safety.
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Illustrative
What surveyors actually found near you
We read the 326 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near New Philadelphia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Park Village Hc Np Llc | 1.7 mi | ★★★★★ | 0 | 0 |
| Country Club Center I | 1.9 mi | ★★★★★ | 43 | 1 |
| New Dawn Rehabilitation And Healthcare Center | 1.9 mi | ★★★★★ | 7 | 0 |
| Schoenbrunn Healthcare | 3 mi | ★★★★★ | 8 | 0 |
| Park Village Health Care Center Inc | 4.1 mi | ★★★★★ | 9 | 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.