Ambassador Healthcare

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Apr 19, 2024

  Based on interview and record review, the facility failed to protect the residents ' right to be free from sexual abuse for 3 of 3 male residents by a staff member while providing incontinence care. The staff member was on his first night of orientation without the presence of the regular staff member which he was paired with for his orientation for the shift. This action resulted in mental anguish for all 3 residents. (Residents B, C, D and CNA 3) This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on, 3-20-24 at approximately 2:00 a.m., when CNA 3 masturbated 1 of 3 residents. The Administrator and Director of Nursing were notified of the Immediate Jeopardy on 4-17-24 at 11:55 a.m. […]

• No harm, potential for more than minimal, patternF689Apr 30, 2025

  Based on observation, interview, and record review, the facility failed to implement fall interventions, as care planned; transfer a resident utilizing a gait belt, as required; ensure position change alarm use was monitored for efficacy on an on-going basis; and ensure position change alarm use was aimed at assisting staff to assess for patterns and routines of residents for 4 of 5 residents reviewed for accidents. (Residents 23, 31, 41, and 71) Findings include: 1. The clinical record for Resident 71 was reviewed on 4/24/25 at 11:55 a.m. Her diagnoses included, but were not limited to, rheumatoid arthritis, diabetes mellitus, and stage four pressure ulcer of sacral region. […]

• No harm, potential for more than minimal, patternF812Feb 20, 2024

  Based on observation, interview, and record review, the facility failed to ensure beard restraints were utilized while working with food. This had the potential to affect 89 out of 94 residents who receive food from the kitchen. Findings include: A kitchen tour was conducted on 2/13/24 at 9:45 a.m., with the Dietary Manager (DM). Cook 22 was observed in the food preparation area with the DM and they both were observed with having facial hair and no beard restraint was utilized. Another kitchen tour was conducted on 2/13/24 at 10:47 a.m., with the DM and Cook 22. The food temperatures were obtained and both DM and Cook 22 were standing over the food without wearing a beard restraint. […]

• No harm, potential for more than minimal, isolatedF550May 13, 2026

  Based on interview, observation and record review, the facility failed to ensure residents maintained dignity by assisting residents with toileting needs in a timely manner, resulting in incontinence for 1 of 4 residents reviewed for resident rights. (Resident 14) Findings Include: The clinical record for Resident 14 was reviewed on 5/7/26 at 12:05 p.m. The resident's diagnoses included, but were not limited to: morbid obesity (body mass index of 40 or higher), essential tremors (progressive neurological disorder that caused involuntary rhythmic shaking), mononeuropathy of bilateral upper limbs (damage to or compression of individual peripheral nerves in both arms or hands), and chronic pain syndrome. […]

• No harm, potential for more than minimal, isolatedF561May 13, 2026

  Based on observation, interview, and record review, the facility failed to honor a resident's bathing time preference for 1 of 1 resident reviewed for choices. (Resident 14)Findings include:The clinical record for Resident 14 was reviewed on 5/7/26 at 12:05 p.m. The resident's diagnoses included, but were not limited to: morbid obesity (body mass index of 40 or higher), essential tremors (progressive neurological disorder that caused involuntary rhythmic shaking), mononeuropathy of bilateral upper limbs (damage to or compression of individual peripheral nerves in both arms or hands), and chronic pain syndrome. The activities of daily living (ADL) care plan, revised on 12/19/25, indicated the resident required moderate assistance with self-care and mobility tasks related to weakness. […]