Deficiencies per Year
24
18
12
6
0
Severe
High
Moderate
Low
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 106
Capacity: 106
Deficiencies: 0
Jun 20, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00461809.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00461809 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Payor Type - Medicare: 20
Census Payor Type - Medicaid: 69
Census Payor Type - Other: 17
Inspection Report
Life Safety
Census: 107
Capacity: 137
Deficiencies: 5
Jun 11, 2025
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101 standards.
Findings
The facility was found not in compliance with several Life Safety Code requirements including hazardous area door self-closing devices, fire alarm system date/time accuracy, sprinkler system installation deficiencies, and corridor door latching issues. Corrective actions were planned and/or completed for each deficiency.
Severity Breakdown
SS=E: 4
SS=C: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure the corridor door to a hazardous area (Activities room) was provided with a self-closing device. | SS=E |
| Failed to maintain the fire alarm system with accurate time and date information. | SS=C |
| Failed to maintain sprinkler system ceiling construction; loose escutcheon with annular space around sprinkler head in Building 01 corridor. | SS=E |
| Failed to maintain sprinkler system ceiling construction; loose escutcheon with annular space around sprinkler head in Building 02 resident room RH13. | SS=E |
| Failed to ensure 1 of 82 resident room corridor doors (room #217) latched properly to resist passage of smoke. | SS=E |
Report Facts
Certified beds: 137
Census: 107
Residents potentially affected: 14
Residents potentially affected: 40
Residents potentially affected: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jared Glaub | Executive Director | Signed report |
| Maintenance Director | Interviewed and involved in corrective actions for multiple deficiencies | |
| Facility Administrator | Interviewed and involved in exit conference |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 104
Deficiencies: 0
May 12, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00459163.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00459163 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 19
Medicaid census: 69
Other payor census: 16
Inspection Report
Annual Inspection
Census: 102
Capacity: 102
Deficiencies: 8
Apr 30, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from April 23 to April 30, 2025.
Findings
The facility was found deficient in multiple areas including failure to provide privacy during care, call light accessibility, maintaining comfortable sound levels, nail and oral care, timely optometry services, pressure ulcer prevention, contracture management, and fall prevention interventions including proper use of alarms and gait belts.
Severity Breakdown
SS=D: 7
SS=E: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to provide privacy during care for 2 residents during observations. | SS=D |
| Failed to ensure call lights were within reach and fluids available at bedside for 3 residents. | SS=D |
| Failed to maintain comfortable sound levels for 1 resident due to bed alarm volume. | SS=D |
| Failed to provide nail and oral care for 3 residents. | SS=D |
| Failed to timely provide optometry services and address missing glasses for 2 residents. | SS=D |
| Failed to provide pressure wound interventions for 1 resident at high risk for pressure injuries. | SS=D |
| Failed to implement interventions for bilateral hand contractures for 1 resident. | SS=D |
| Failed to implement fall interventions as care planned, including gait belt use and monitoring of bed/chair alarms for 4 residents. | SS=E |
Report Facts
Survey dates: 6
Census: 102
Total capacity: 102
Residents affected by privacy deficiency: 2
Residents affected by call light deficiency: 3
Residents affected by nail/oral care deficiency: 3
Residents affected by optometry deficiency: 2
Residents affected by pressure ulcer deficiency: 1
Residents affected by contracture deficiency: 1
Residents affected by fall prevention deficiency: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jared Glaub | Laboratory Director or Provider/Supplier Representative | Signed the inspection report. |
| RN 11 | Registered Nurse | Involved in privacy deficiency observations for Residents 50 and 36. |
| CNA 10 | Certified Nurse Aide | Involved in privacy deficiency observations for Residents 50 and 36. |
| RN 8 | Registered Nurse | Observed privacy curtain absence for Resident 36. |
| LPN 2 | Licensed Practical Nurse | Verified call light accessibility for Resident 67 and pressure wound dressing for Resident 67. |
| LPN 13 | Licensed Practical Nurse | Assisted Resident 71 with call light cord adjustment. |
| CNA 3 | Certified Nurse Aide | Interviewed regarding Resident 22's fluid accessibility. |
| DON | Director of Nursing | Provided multiple policy interviews and oversight of corrective actions. |
| CNA 12 | Certified Nurse Aide | Verified Resident 9's fingernail condition. |
| LPN 4 | Licensed Practical Nurse | Interviewed about Resident 66's toenail condition. |
| RN 9 | Registered Nurse | Cared for Resident 98 and interviewed about contracture interventions. |
| CNA 15 | Certified Nurse Aide | Assisted in transferring Resident 41 without gait belt. |
| LPN 17 | Licensed Practical Nurse | Interviewed about Resident 31's chair alarm. |
Inspection Report
Renewal
Deficiencies: 0
Apr 30, 2025
Visit Reason
The visit was conducted for Paper Compliance to the Recertification and State Licensure Survey.
Findings
Ambassador Healthcare was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the Paper Compliance to the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 104
Capacity: 104
Deficiencies: 0
Mar 28, 2025
Visit Reason
This visit was conducted to investigate Complaint IN00456135 at Ambassador Healthcare.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00456135 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 15
Medicaid census: 73
Other payor census: 16
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 14, 2025
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00451390 completed on February 10, 2025.
Findings
Ambassador Healthcare was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the complaint investigation. The complaint was corrected.
Complaint Details
Complaint IN00451390 was investigated and found to be corrected as of the review date March 14, 2025.
Inspection Report
Complaint Investigation
Census: 105
Capacity: 105
Deficiencies: 0
Feb 25, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00453554.
Findings
No deficiencies related to the allegations are cited. Ambassador Healthcare was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regards to the Investigation of Complaint IN00453554.
Complaint Details
Complaint IN00453554 -- No deficiencies related to the allegations are cited.
Report Facts
Medicare census: 12
Medicaid census: 71
Other payor census: 22
Inspection Report
Complaint Investigation
Census: 104
Capacity: 104
Deficiencies: 1
Feb 10, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00451390 regarding allegations related to pressure ulcer care.
Findings
The facility failed to ensure that one of three residents reviewed for pressure ulcers received the required care and services to treat the identified wound and document its status routinely. Documentation gaps and lack of consistent wound care assessments were noted.
Complaint Details
Complaint IN00451390 was substantiated with federal/state deficiencies cited at F686 related to pressure ulcer treatment and documentation.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure one resident received proper care and services for a pressure ulcer and failed to routinely document the wound status. | SS=D |
Report Facts
Census: 104
Total Capacity: 104
Medicare Census: 22
Medicaid Census: 71
Other Payor Census: 11
Pressure ulcer size: 8
Pressure ulcer size: 7
Pressure ulcer size: 6.5
Pressure ulcer size: 6.5
Pressure ulcer depth: 0.1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jared Glaub | Laboratory Director or Provider/Supplier Representative | Signed the report |
| Director of Nursing | Director of Nursing | Interviewed regarding wound care documentation and policies |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 7, 2025
Visit Reason
The inspection was conducted as a paper compliance review of the complaint investigation IN00449305 completed on January 8, 2025.
Findings
Ambassador Healthcare was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the complaint investigation. The complaint was corrected.
Complaint Details
Complaint IN00449305 was investigated and found to be corrected.
Inspection Report
Re-Inspection
Census: 101
Capacity: 101
Deficiencies: 0
Jan 8, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00443195 and IN00447316 completed on 12/9/24, conducted in conjunction with the Investigation of Complaint IN00449305.
Findings
Ambassador Healthcare was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the PSR to the Investigations of Complaints IN00443195 and IN00447316. Both complaints IN00443195 and IN00447316 were corrected.
Complaint Details
This visit was related to complaints IN00443195, IN00447316, and IN00449305. Complaints IN00443195 and IN00447316 were corrected as of this visit.
Report Facts
Census: 101
Total Capacity: 101
Medicare Census: 16
Medicaid Census: 72
Other Payor Census: 13
Inspection Report
Complaint Investigation
Census: 101
Capacity: 101
Deficiencies: 2
Jan 7, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00449305, conducted in conjunction with Post Survey Revisit to Investigations IN00443195 and IN00447316 completed on 12/9/24.
Findings
The facility failed to complete a thorough investigation of the root cause of a fall and failed to implement a fall intervention for one resident (Resident B). Additionally, the facility failed to have complete and accurate documentation of the resident's fall. The resident fell twice on 12/2/24 with no injuries, but documentation was struck out as duplicate and the Director of Nursing was unaware of the second fall.
Complaint Details
Complaint IN00449305 was substantiated with federal/state deficiencies cited at F689 and F842 related to fall investigation and documentation.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to complete a thorough investigation of the root cause of a fall and failed to implement a fall intervention for 1 of 3 residents reviewed for accidents (Resident B). | SS=D |
| Failed to have complete and accurate documentation of a resident's fall for 1 of 3 residents reviewed for accidents (Resident B). | SS=D |
Report Facts
Census: 101
Total Capacity: 101
Medicare Census: 16
Medicaid Census: 72
Other Payor Census: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jared Glaub | Executive Director | Signed the report |
| LPN 2 | Licensed Practical Nurse | Nurse caring for Resident B during falls on 12/2/24, notified physician of falls |
| CNA 1 | Certified Nurse Aide | Cared for Resident B during falls on 12/2/24, reported no management communication about falls |
| Director of Nursing | Director of Nursing | Unaware of second fall, struck out duplicate documentation, responsible for fall investigation protocol |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 104
Deficiencies: 1
Dec 9, 2024
Visit Reason
The visit was conducted for the investigation of complaints IN00443195 and IN00447316 related to medication administration practices at the facility.
Findings
The facility failed to ensure medication administration was conducted safely, specifically leaving medication unattended at a resident's bedside. Resident G was observed with unattended medications and had taken medication without proper assessment. The facility acknowledged the issue and implemented corrective actions including policy revision, staff training, and routine audits.
Complaint Details
The investigation was triggered by complaints IN00443195 and IN00447316. The complaints were substantiated with deficiencies cited at F755 related to medication administration safety.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure medication administration was conducted in a safe manner and did not include leaving medication unattended at a resident's bedside. | SS=D |
Report Facts
Residents rooms observed for unattended medications: 25
Resident census: 104
Licensed capacity: 104
Medicare residents: 19
Medicaid residents: 70
Other payor residents: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jared Glaub | Executive Director | Signed the report |
| Resident G | Resident involved in medication administration deficiency | |
| Licensed Practical Nurse 3 | LPN | Provided 6:00 a.m. dose of medication on 12/4/24 |
| Registered Nurse 4 | RN | Provided 11:00 a.m. dose of medication on 12/4/24 |
Inspection Report
Life Safety
Census: 93
Capacity: 137
Deficiencies: 0
Oct 3, 2024
Visit Reason
A Pre-Occupancy Life Safety Code Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) to assess compliance with life safety requirements prior to occupancy.
Findings
Ambassador Healthcare was found in compliance with Medicare/Medicaid participation requirements, the Life Safety Code from Fire, and the 2012 edition of NFPA 101, Chapter 19, Existing Health Care Occupancies. The facility consists of four attached buildings, all fully sprinklered, with a fire alarm system and battery-operated smoke detectors in resident sleeping rooms.
Report Facts
Facility capacity: 137
Census: 93
Inspection Report
Complaint Investigation
Census: 104
Capacity: 104
Deficiencies: 4
Sep 5, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00442039, IN00442082, and IN00442125 involving allegations of abuse and neglect at Ambassador Healthcare.
Findings
The facility was found deficient in ensuring residents were free from abuse and neglect, failed to report alleged violations properly, did not complete required assessments after falls, and failed to monitor and supervise residents with dementia leading to inappropriate resident-to-resident interactions. Multiple residents were involved in incidents of physical and sexual abuse, and follow-up actions and notifications were inadequate.
Complaint Details
The investigation was triggered by complaints IN00442039, IN00442082, and IN00442125 involving allegations of abuse including physical abuse, sexual abuse, failure to report incidents properly, inadequate assessments after falls, and failure to supervise residents with dementia leading to inappropriate interactions.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure residents remained free from physical abuse for 2 of 13 residents reviewed for abuse (Resident K and Resident M). | SS=D |
| Failed to thoroughly report allegations of sexual abuse and resident-to-resident physical altercations to the Indiana Department of Health for 4 of 13 residents reviewed for abuse (Resident N, Resident P, Resident K, and Resident M). | SS=D |
| Failed to complete initial assessments after a fall and follow-up assessments after residents had a fall with injury for 2 of 3 residents reviewed for accidents (Resident D and Resident C). | SS=D |
| Failed to monitor and supervise a resident with dementia resulting in potential for resident-to-resident interaction and failed to monitor and supervise residents on the memory care unit, assess residents, conduct follow-up, and notify family and physician of inappropriate sexual contact between two residents for 4 of 13 residents reviewed for abuse (Resident N, Resident P, Resident K, and Resident L). | SS=D |
Report Facts
Census: 104
Total Capacity: 104
Residents reviewed for abuse: 13
Residents reviewed for accidents: 3
Residents involved in abuse reporting failure: 4
Audit frequency: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jared Glaub | Administrator | Facility Administrator named in report signature and involved in abuse reporting and investigation |
| LPN 2 | Licensed Practical Nurse | Reported resident-to-resident abuse incident and attempted to notify Director of Nursing |
| LPN 3 | Licensed Practical Nurse | Provided behavior notes and observations related to Resident K |
| QMA 4 | Qualified Medication Aide | Witnessed and intervened in resident-to-resident abuse incident |
| Director of Nursing | Director of Nursing | Responsible for assessments and follow-up; interviewed regarding deficiencies |
| Social Services 1 | Social Services | Responsible for care plans and interventions; interviewed regarding incident follow-up |
| RN 11 | Registered Nurse | Reported sexual abuse incident to Administrator and police |
| LPN 7 | Licensed Practical Nurse | Reported incident of Resident K kissing Resident L |
| CNA 8 | Certified Nursing Assistant | Observed Resident K kissing Resident L |
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 5, 2024
Visit Reason
Paper compliance review of the Investigation of Complaints IN00442039, IN00442082, and IN00442125 completed on September 5, 2024.
Findings
Ambassador Healthcare was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review of the complaint investigation.
Complaint Details
The visit was related to complaint investigations IN00442039, IN00442082, and IN00442125. Compliance was found based on paper review.
Inspection Report
Complaint Investigation
Census: 108
Capacity: 108
Deficiencies: 0
Jul 23, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00438611.
Findings
No deficiencies related to the allegations in Complaint IN00438611 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00438611 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 24
Medicaid census: 69
Other payor census: 15
Inspection Report
Complaint Investigation
Census: 105
Capacity: 105
Deficiencies: 0
Jun 27, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00436978.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00436978 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 105
Census Payor Type Medicare: 23
Census Payor Type Medicaid: 66
Census Payor Type Other: 16
Inspection Report
Re-Inspection
Census: 101
Capacity: 101
Deficiencies: 0
May 16, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00430919 completed on April 19, 2024, conducted in conjunction with the Investigations of Complaints IN00433240 and IN00433654.
Findings
Ambassador Healthcare was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Investigation of Complaint IN00430919. Complaints IN00433240 and IN00433654 had no deficiencies related to the allegations cited.
Complaint Details
Complaint IN00430919 was corrected. Complaints IN00433240 and IN00433654 had no deficiencies related to the allegations.
Report Facts
Census: 101
Total Capacity: 101
Medicare Census: 17
Medicaid Census: 68
Other Payor Census: 16
Inspection Report
Complaint Investigation
Census: 101
Capacity: 101
Deficiencies: 0
May 16, 2024
Visit Reason
This visit was for the investigation of complaints IN00433240 and IN00433654, conducted in conjunction with the Post Survey Revisit to the investigation of complaint IN00430919 completed on April 19, 2024.
Findings
No deficiencies related to complaints IN00433240 and IN00433654 were cited. Complaint IN00430919 was corrected. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00433240 - No deficiencies related to the allegations are cited. Complaint IN00433654 - No deficiencies related to the allegations are cited. Complaint IN00430919 - Corrected.
Report Facts
Census Bed Type: 101
Census Payor Type - Medicare: 17
Census Payor Type - Medicaid: 68
Census Payor Type - Other: 16
Inspection Report
Follow-Up
Census: 93
Capacity: 137
Deficiencies: 0
Apr 24, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 03/05/24.
Findings
At this PSR Emergency Preparedness and Life Safety Code survey, Ambassador Healthcare was found in compliance with all applicable Medicare and Medicaid participation requirements, Emergency Preparedness Requirements, and Life Safety Code standards.
Report Facts
Certified beds: 137
Census: 93
Inspection Report
Complaint Investigation
Census: 101
Capacity: 101
Deficiencies: 3
Apr 19, 2024
Visit Reason
This visit was for the investigation of complaints related to allegations of sexual abuse by a staff member during incontinence care on the night shift of 3-19-24 into 3-20-24.
Findings
The facility failed to protect residents' rights to be free from sexual abuse by a staff member during incontinence care, resulting in Immediate Jeopardy that was removed after one week. The investigation confirmed inappropriate touching of three male residents by a newly hired CNA during his orientation shift. The facility failed to report the abuse allegation within two hours and did not fully include all pertinent witnesses in the investigation.
Complaint Details
Complaint IN00430919 involved allegations of sexual abuse by CNA 3 against three male residents (Residents B, C, and D) during incontinence care on 3-19-24 to 3-20-24. The facility suspended and terminated CNA 3, conducted interviews, and reported the incident to the Indiana Department of Health on 3-20-24 at 4:28 p.m., which was beyond the required two-hour reporting timeframe. The Immediate Jeopardy was removed on 3-27-24 after staff inservice, but noncompliance remained at a lower severity level.
Severity Breakdown
Immediate Jeopardy: 1
Level D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to protect residents from sexual abuse by a staff member during incontinence care. | Immediate Jeopardy |
| Failed to implement abuse prohibition policies and procedures including timely reporting and thorough investigation. | Level D |
| Failed to report allegation of staff to resident sexual abuse within two hours of facility awareness. | Level D |
Report Facts
Census: 101
Total Capacity: 101
Report submission time: 16
Audit frequency: 5
Audit frequency: 3
Audit frequency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 3 | Certified Nursing Assistant | Staff member who committed sexual abuse against residents during orientation shift |
| Executive Director | Provided interviews and timeline of events related to abuse allegation and reporting | |
| Director of Nursing | Received abuse allegation report and participated in investigation | |
| CNA 4 | Certified Nursing Assistant | Orientation partner of CNA 3 during the shift of abuse; interviewed about CNA 3's behavior |
| CNA 5 | Certified Nursing Assistant | Reported abuse allegation from Resident C to DON |
| Human Resources staff | Provided information on CNA 3's hiring and orientation process |
Inspection Report
Life Safety
Census: 93
Capacity: 137
Deficiencies: 12
Mar 5, 2024
Visit Reason
Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health.
Findings
The facility was found not in compliance with several Life Safety Code requirements including emergency preparedness plan updates, means of egress obstructions, fire alarm system maintenance, sprinkler system deficiencies, fire door inspections, and improper use of extension cords.
Severity Breakdown
SS=C: 1
SS=E: 8
SS=F: 2
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to review and update the Emergency Preparedness Plan (EPP) annually as required. | SS=C |
| Exit to the outside in the dialysis unit was obstructed with carts and equipment. | SS=E |
| Pull station for the hood Ansul system in the kitchen was obstructed by a trash receptacle. | SS=E |
| Fire alarm system visual semi-annual inspection documentation was not provided. | SS=F |
| Soiled Utility and Kitchenette in the West building lacked sprinkler coverage due to removed dry pendent sprinklers. | SS=E |
| Ceiling tiles missing in Dialysis storage room, affecting sprinkler operation. | SS=E |
| Portable K-Class fire extinguisher in kitchen was obstructed by a trash receptacle. | SS=E |
| Annual inspection and testing of fire door assembly at Oxygen Transfilling room was not documented. | SS=E |
| Oxygen storage/transfer room lacked signage indicating full and empty tanks and no smoking. | SS=E |
| Flexible cords used improperly as substitutes for fixed wiring at nurses station and sprinkler riser air compressor. | SS=F |
| Corridor door to classroom storage room did not close and latch properly and had a hole where door knob should be. | SS=E |
| Sprinkler head in room RH11 missing escutcheon plate. | SS=E |
Report Facts
Certified beds: 137
Census: 93
Deficiencies cited: 11
Residents potentially affected: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jared Glaub | Executive Director | Named as facility representative signing the report |
| Maintenance Director | Interviewed regarding multiple deficiencies and corrective actions | |
| Administrator | Interviewed regarding multiple deficiencies and corrective actions |
Inspection Report
Annual Inspection
Census: 94
Capacity: 94
Deficiencies: 11
Feb 20, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00422934.
Findings
The facility was found to have multiple deficiencies including untimely Minimum Data Set (MDS) assessments, inaccurate coding of assessments, failure to update care plans, inadequate activities, improper wound care documentation, lack of passive range of motion exercises, fall intervention failures, improper respiratory care, and food safety violations related to beard restraints in the kitchen.
Complaint Details
Complaint IN00422934 was substantiated with federal/state deficiencies cited at F686 related to pressure ulcer care and other issues.
Severity Breakdown
SS=D: 10
SS=E: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to ensure Minimum Data Set (MDS) Assessments were completed timely for 3 of 4 residents reviewed. | SS=D |
| Failed to accurately code dental status, urinary status, and falls for 3 of 34 residents reviewed. | SS=D |
| Failed to update care plans after changes in resident condition or refusals for 3 of 34 residents reviewed. | SS=D |
| Failed to provide adequate nail care and facial hair grooming for 2 of 7 residents reviewed. | SS=D |
| Failed to provide in-room activities for 1 of 4 residents reviewed for activities. | SS=D |
| Failed to date gastrostomy tube dressing and piston irrigation syringe for 1 resident reviewed. | SS=D |
| Failed to ensure wound treatments were signed off as administered, conduct weekly wound assessments, and prevent duplicate treatments for 1 of 3 residents reviewed for pressure ulcers. | SS=D |
| Failed to provide Passive Range Of Motion (PROM) exercises for 1 of 4 residents reviewed for range of motion. | SS=D |
| Failed to ensure fall interventions were implemented and failed to transfer residents safely for 2 of 5 residents reviewed for accidents. | SS=D |
| Failed to date oxygen tubing and storage bag, store oxygen tubing in a sanitary manner, and have physician orders for oxygen therapy for 2 of 4 residents reviewed for respiratory therapy. | SS=D |
| Failed to ensure beard restraints were utilized while working with food in the kitchen, potentially affecting all residents receiving food. | SS=E |
Report Facts
Census: 94
Total Capacity: 94
Deficiencies cited: 11
Fall risk assessment date: Sep 9, 2023
Fall risk assessment date: Nov 25, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jared Glaub | Executive Director | Signed the report and mentioned in plan of correction |
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 20, 2024
Visit Reason
The document relates to paper compliance for the Recertification, State Licensure, and Complaint Investigation completed on February 20, 2024.
Findings
Ambassador Healthcare was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance to the Recertification, State Licensure, and Complaint Investigation.
Inspection Report
Complaint Investigation
Census: 94
Capacity: 94
Deficiencies: 0
Nov 9, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00417556.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00417556 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 9
Medicaid census: 67
Other payor census: 18
Inspection Report
Complaint Investigation
Census: 95
Capacity: 95
Deficiencies: 0
Sep 14, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00413438 and IN00416714.
Findings
No deficiencies related to the allegations in complaints IN00413438 and IN00416714 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaints IN00413438 and IN00416714 found no deficiencies related to the allegations.
Report Facts
Census Bed Type: 95
Census Payor Type - Medicare: 6
Census Payor Type - Medicaid: 74
Census Payor Type - Other: 15
Inspection Report
Complaint Investigation
Census: 96
Capacity: 96
Deficiencies: 0
Jun 8, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00409455.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00409455 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare residents: 24
Medicaid residents: 65
Other payor residents: 7
Inspection Report
Complaint Investigation
Census: 97
Capacity: 97
Deficiencies: 0
Apr 14, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00405298 and IN00406326.
Findings
No deficiencies related to the allegations in complaints IN00405298 and IN00406326 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00405298 and Complaint IN00406326 were investigated with no deficiencies cited related to the allegations.
Report Facts
Census SNF/NF beds: 97
Census total residents: 97
Census Medicare residents: 21
Census Medicaid residents: 66
Census other payor residents: 10
Inspection Report
Complaint Investigation
Census: 95
Capacity: 95
Deficiencies: 0
Mar 15, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00403497 and IN00403707.
Findings
No deficiencies related to the allegations in complaints IN00403497 and IN00403707 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaints IN00403497 and IN00403707 found no deficiencies related to the allegations.
Report Facts
Census SNF/NF beds: 95
Census Payor Type Medicare: 24
Census Payor Type Medicaid: 61
Census Payor Type Other: 10
Inspection Report
Complaint Investigation
Census: 94
Capacity: 94
Deficiencies: 0
Mar 1, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00396557.
Findings
The complaint was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00396557 was substantiated, but no deficiencies related to the allegations were cited.
Report Facts
Census SNF/NF: 94
Total Capacity: 94
Medicare Census: 18
Medicaid Census: 64
Other Payor Census: 12
Inspection Report
Re-Inspection
Census: 90
Capacity: 137
Deficiencies: 0
Jan 17, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 12/13/22.
Findings
At this PSR Emergency Preparedness survey, Ambassador Healthcare was found in compliance with Emergency Preparedness Requirements. At the PSR Life Safety Code survey, the facility was found in compliance with Medicare/Medicaid participation requirements and Life Safety Code standards.
Report Facts
Certified beds: 137
Census: 90
Inspection Report
Renewal
Deficiencies: 0
Dec 20, 2022
Visit Reason
Paper Compliance to the Recertification and State Licensure completed on November 21, 2022.
Findings
Ambassador Healthcare was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the Paper Compliance to the Recertification and State Licensure.
Inspection Report
Routine
Census: 88
Capacity: 137
Deficiencies: 22
Dec 13, 2022
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted to assess compliance with federal and state regulations including emergency preparedness, fire safety, and facility maintenance.
Findings
The facility was found not in compliance with several emergency preparedness requirements including failure to annually review and update the Emergency Preparedness Plan, policies and procedures, communication plan, and training/testing programs. Life safety deficiencies included corridor obstructions, exit discharge issues, missing exit signage, sprinkler system maintenance issues, fire door malfunctions, electrical safety concerns, and ventilation problems in the oxygen storage room.
Severity Breakdown
Level 1: 1
Level 2: 3
Level 3: 18
Deficiencies (22)
| Description | Severity |
|---|---|
| Failed to review and update the Emergency Preparedness Plan annually. | Level 3 |
| Failed to develop and implement emergency preparedness policies and procedures including subsistence needs for staff and residents. | Level 3 |
| Failed to develop and implement a system to track location of on-duty staff and sheltered residents during emergencies. | Level 3 |
| Failed to develop and maintain an emergency preparedness communication plan including contact information for the State Long Term Care Ombudsman. | Level 3 |
| Failed to develop and maintain a communication plan to provide information about facility occupancy, needs, and ability to provide assistance. | Level 3 |
| Failed to develop and maintain an emergency preparedness training and testing program reviewed and updated annually. | Level 3 |
| Failed to conduct at least two emergency preparedness exercises annually including unannounced staff drills. | Level 3 |
| Failed to implement emergency power system inspection, testing, and maintenance requirements including missing documentation of a required 4-hour load test. | Level 1 |
| Corridor obstruction: a three-drawer cart without wheels stored in corridor outside resident room RH12. | Level 3 |
| Exit discharge issues including obstructed sidewalk, gap in ramp, and unstable railings at multiple exits. | Level 3 |
| Missing exit signage outside east exit to direct egress path. | Level 3 |
| Sprinkler system deficiencies including missing escutcheons on sprinkler heads and obstructed sprinkler spray pattern due to storage. | Level 3 |
| Portable fire extinguishers in maintenance area were stored on floor unsupported. | Level 2 |
| Corridor doors with holes penetrating completely through the door and one door failing to close and latch properly to resist passage of smoke. | Level 3 |
| Storage of combustible materials in stairwell under staircase. | Level 3 |
| Ground fault circuit interrupter (GFCI) receptacle in dining room failed to trip and indicated open ground wiring. | Level 2 |
| Multiple electrical junction boxes missing covers exposing wiring. | Level 2 |
| Use of homemade extension cord concealed under baseboard in soiled utility room. | Level 3 |
| Power strip in therapy area lacked required UL rating. | Level 3 |
| Dishwasher powered by extension cord made of Romex concealed under baseboard. | Level 3 |
| Presence of unauthorized crock pot in resident room without established policies for appliances not supplied by facility. | Level 3 |
| Oxygen storage room ventilation fan not working and vent missing cover. | Level 3 |
Report Facts
Deficiencies cited: 22
Facility capacity: 137
Current census: 88
4-hour load test interval: 36
Number of residents potentially affected by corridor obstruction: 4
Number of residents potentially affected by exit discharge issues: 25
Number of residents potentially affected by missing exit signage: 25
Number of residents potentially affected by sprinkler system deficiencies: 10
Number of residents potentially affected by fire extinguisher storage: 8
Number of residents potentially affected by corridor door smoke passage: 15
Number of residents potentially affected by oxygen room ventilation: 20
Number of residents potentially affected by GFCI receptacle failure: 20
Number of residents potentially affected by power strip UL rating: 5
Number of residents potentially affected by extension cord misuse: 2
Number of residents potentially affected by unauthorized appliance: 2
Inspection Report
Complaint Investigation
Census: 85
Capacity: 85
Deficiencies: 0
Dec 6, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00395934.
Findings
The complaint was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00395934 was substantiated, but no deficiencies related to the allegations were cited.
Report Facts
Medicare census: 19
Medicaid census: 56
Other payor census: 10
Inspection Report
Annual Inspection
Deficiencies: 2
Nov 21, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with regulatory requirements, including accuracy of Minimum Data Set (MDS) assessments, catheter care, and infection prevention.
Findings
The facility failed to accurately code MDS assessments related to hearing aid use and restraint status for three residents, and failed to ensure catheter bags were kept off the floor and provided with privacy bags for two residents, posing infection risks.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to accurately code Minimum Data Set assessments for use of hearing aids and restraints for three residents. | SS=D |
| Failed to ensure catheter bags were not touching the floor and failed to provide privacy bags for catheter bags for two residents. | SS=D |
Report Facts
Residents reviewed for assessments: 30
Residents affected: 3
Residents reviewed for Foley catheter/UTI: 2
Audit percentage: 10
Audit frequency: 1
Audit frequency: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Mantooth | Executive Director | Signed the report |
| MDS Coordinator | Responsible for ensuring accuracy of MDS assessments and conducting audits | |
| Director Of Nursing | Director Of Nursing | Interviewed regarding catheter bag care and staff responsibilities |
| MDS Nurse 1 | Interviewed regarding error in coding trunk restraint for Resident 55 |
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