Ambassador, A Villa Center

In the surveyor’s words

From the most serious findings on record at Ambassador, A Villa Center, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 17, 2023

  Based on observation, interview, and record review, the facility failed to provide adequate safety measures to ensure resident safety for one resident (R40) of four residents reviewed for accidents and hazards, resulting in R40 falling with fractures during staff assisted shower and increased likelihood for accidents and/or injuries. Findings include: Review of the Face Sheet and Annual Minimum Data Set (MDS) dated [DATE], reflected R40 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), dementia without behavior disturbances, and depression. […]

• No harm, potential for more than minimal, widespreadF804Aug 17, 2023

  Based on observation and interview, the facility failed to ensure palatable food temperatures and food texture, resulting in poor satisfactory of meals by residents, affecting all resident who consume food from the kitchen. Findings include: On 8/16/23 at 12:16 PM, a food cart was observed to be delivered to the second level. At 12:21 PM, staff were observed to begin passing trays. At 12:27 PM, a test tray was pulled from the cart, before staff were done passing all of the trays. […]

• No harm, potential for more than minimal, widespreadF812Aug 17, 2023

  Based on observation, interview, and record review, the facility failed to maintain the physical facility, maintain plumbing in good repair, and maintain equipment, resulting in the potential for contamination of the physical facility and food product, affecting all residents who consume food from the kitchen. Finding include: On 8/16/23 at 11:04 AM, the floor underneath the dish machine drain board was observed to have dissolved floor tile grout. Two tiles were observed to be loose at this time. Additionally, the waste disposal flex cuff, in the dish washing area, was observed to be leaking slightly. According to the 2017 FDA Food Code Section 6-201.11 Floors, Walls, and Ceilings. […]

• No harm, potential for more than minimal, widespreadF921Aug 17, 2023

  Based on observation, interview, and record review, the facility failed to maintain resident rooms in good repair, maintain clean ventilation, and maintain backflow protection, resulting in a non-homelike facility and potential for contamination of the domestic water supply, affecting all residents in the facility. Findings include: During an environmental inspection on 8/16/23 between 12:16 PM and 2:03 PM, the following observations were made: -Two ceiling tiles, in the hall near room [ROOM NUMBER], were observed to be stained with water damage. -The shower room, near room [ROOM NUMBER], was observed to have gum or [NAME] adhesive on the floor; the ceiling in the shower enclosure was observed to have bubbling paint. […]

• No harm, potential for more than minimal, widespreadF804Jun 28, 2022

  This citation pertains to intakes MI 557, MI 091, MI 335. Based on observation interview and record review the facility failed to ensure that food was served at palatable temperatures and correct portions in a timely manner, affecting 152 residents out of 152 residents that consumed foods from kitchen, resulting in potential weight loss and decrease pleasure with meals. Findings include: R22 Record review revealed resident was admitted into the facility on [DATE] with a pertinent diagnosis of nutritional deficiency. During interview on 6/28/22 at 10:05 AM with R22, when asked if food was served hot, R22 stated, Its lukewarm at best. […]