Inspection Reports for
Ambassador Healthcare

Complaint 2578556 involved issues including failure to include family in virtual appointments, lack of TV remotes, failure to follow grievance procedures, inadequate fall prevention and assessment, and missing inventory sheets for resident belongings.

The facility failed to include a resident's family in a virtual physician follow-up, did not provide TV remotes to newly admitted residents, failed to follow grievance policies, did not ensure proper fall prevention and post-fall assessments, and failed to complete inventory sheets for resident belongings.

This inspection relates to Complaint IN00462662 regarding abuse reporting and Complaints IN00462276 and IN00462795 regarding discharge planning and home health nursing referrals. The abuse allegation was not reported as required. The discharge referral for nursing services was delayed, impacting resident care.

The facility failed to report an allegation of verbal abuse to the state within the required two-hour timeframe for one resident. Additionally, the facility failed to ensure a resident was referred for home health nursing services upon discharge, resulting in delayed care for a PICC line and antibiotic treatment.

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.

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.

The facility was found deficient in multiple areas including failure to provide privacy during care, inadequate call light accessibility, failure to maintain comfortable sound levels, insufficient nail and oral care, delayed vision services, improper pressure ulcer care, lack of range of motion interventions, unsafe resident transfers without gait belts, and ineffective monitoring of bed and chair alarms.

This citation relates to Complaint IN00451390.

The facility failed to ensure that one of three residents reviewed for pressure ulcers received appropriate care and routine documentation of the wound status. The wound care treatment was delayed and nursing progress notes lacked consistent assessment documentation.

Complaint IN00451390 was substantiated with federal/state deficiencies cited at F686 related to pressure ulcer treatment and documentation.

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.

This citation relates to Complaint IN00449305.

The facility failed to complete a thorough investigation of the root cause of a fall and failed to implement fall interventions for Resident B. Additionally, the facility failed to maintain complete and accurate documentation of Resident B's falls.

Complaint IN00449305 was substantiated with federal/state deficiencies cited at F689 and F842 related to fall investigation and documentation.

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.

The investigation was triggered by complaints IN00443195 and IN00447316. The complaints were substantiated with deficiencies cited at F755 related to medication administration safety.

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.

This citation relates to Complaints IN00443195 and IN00447316. The resident was not sent to the hospital, but the physician was notified of the incident.

The facility failed to ensure safe medication administration by leaving medications unattended at a resident's bedside, resulting in the resident consuming medication without proper supervision. The Director of Nursing addressed the issue with staff and reviewed facility policies on medication administration.

The investigation was triggered by complaints IN00442082, IN00442125, and IN00442039 regarding abuse, neglect, and failure to report incidents. The complaints involved allegations of physical and sexual abuse between residents, inadequate incident reporting to authorities, and insufficient follow-up assessments after falls and behavioral incidents.

The facility failed to ensure residents remained free from physical and sexual abuse, failed to report incidents timely to appropriate authorities, and failed to complete required assessments and follow-up after falls and behavioral incidents for multiple residents.

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.

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.

This investigation was complaint-related, triggered by allegations of sexual abuse by CNA 3 against three male residents during his first orientation shift on 3-19-24 to 3-20-24. The complaint was substantiated with immediate jeopardy initially cited and later downgraded after corrective actions.

The facility failed to protect residents from sexual abuse by a newly hired CNA during his first orientation shift, resulting in immediate jeopardy that was later removed. The facility also failed to fully implement abuse prevention policies, timely report the abuse allegation within two hours, and include all pertinent persons in the investigation.

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.

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.

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.

This Federal Tag relates to Complaint IN00422934. The complaint involved failure to properly document wound treatment administration and conduct weekly wound assessments for pressure ulcers.

The facility failed to ensure wound treatments were properly signed off as administered, weekly wound assessments were not consistently conducted, and duplicate treatments were provided for the same pressure ulcer in one resident reviewed.

Complaint IN00422934 was substantiated with federal/state deficiencies cited at F686 related to pressure ulcer care and other issues.

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.

The facility was found deficient in timely completion and accuracy of Minimum Data Set (MDS) assessments, updating care plans, providing appropriate resident care including nail and facial hair care, ensuring availability of resident activities, proper treatment and documentation of gastrostomy tube care, provision of passive range of motion exercises, fall prevention interventions, safe resident transfers, respiratory therapy management, and food safety practices related to beard restraints in the kitchen.

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.

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.

The facility failed to accurately code Minimum Data Set assessments for hearing aid use and restraint use for several residents. Additionally, the facility failed to ensure catheter bags were kept off the floor and provided privacy bags for catheter bags for residents with Foley catheters.