Ambassador Healthcare at College Park

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Feb 13, 2026

  Based on observation, clinical record review, review of facility's policies and procedures, resident representative and staff interviews, the facility failed to adequately supervise 1 (Resident #900) of 3 sampled residents with cognitive impairment, confusion and poor safety awareness to prevent unsafe wandering and elopement.On 11/28/25 at approximately 9:45 a.m., Resident #900 who was cognitively impaired, ambulatory, confused and had poor safety awareness walked past the unattended front desk of the facility and exited the building through the unlocked front door.Resident #900 crossed a two lane road and walked 0.5 mile to the dorm of a State College through uneven terrain and near water ponds. The college staff found Resident #900 wandering in the dorm, confused, unsteady and shaking. […]

• Immediate jeopardy, isolatedF835Feb 13, 2026

  Based on observation, review of facility's policies and procedures, clinical record review, resident representative and staff interviews, the facility administration failed to provide effective oversight and implement processes to ensure the safety of residents, including unsafe wandering and elopement of 1 (Resident #900) of 3 cognitively impaired and confused residents reviewed.On 11/28/25 at approximately 9:45 a.m., Resident #900 who was cognitively impaired, ambulatory, confused and had poor safety awareness walked past the unattended front desk of the facility and exited the building through the unlocked front door.Resident #900 crossed a two lane road and walked 0.5 mile to the dorm of a State College through uneven terrain and near water ponds. […]

• Immediate jeopardy, isolatedF578Feb 13, 2021

  Based on record review and interview, the facility failed to honor advanced directives and administered cardiopulmonary resuscitation to 1 (#2) of 3 residents sampled against the resident's expressed wishes. The facility Cardiopulmonary Resuscitation (CPR) policy does not provide for withdrawal of CPR when a valid Do Not Resuscitate Order (DNRO) is located after CPR is initiated. These actions resulted in Immediate Jeopardy that started on [DATE] when one (Resident #2) of 3 residents receiving cardiopulmonary resuscitation against the resident's expressed wishes. The facility's actions deprived Resident #2 of a natural death. RN Staff E involved in the incident had 10 assigned residents with a DNR status. There were a 40 residents total in the facility with DNROs. […]

• Immediate jeopardy, isolatedF835Feb 13, 2021

  Based on record review and staff interview the facility failed to utilize its resources effectively to ensure each resident's resuscitation wishes were honored. The facility administration failed to develop and implement written policies and procedures to ensure residents' wishes for advanced directives were honored. The facility failed to self-identify the deficient practice with a likelihood of negative outcome. The facility's failure to honor residents' wishes not to be resuscitated would likely result in the resident experiencing major physical trauma including broken ribs, lung bruising, internal bleeding, damage to the airway and internal organs, and deprivation of a natural death. There were a 40 residents total in the facility with wishes not to be resuscitated. […]

• Actual harm, isolatedF600Apr 30, 2025

  Based on record review, review of facility's policies and procedures and staff interviews, the facility failed to protect the resident's rights to be free from neglect by failing to follow safety precautions specified in the care plan to prevent avoidable accident with injury for 1 (Resident #1) of 3 dependent residents reviewed. The findings included: Review of facility Policy titled Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, Injury of unknown source and Investigations, effective date 4/01/22 revealed neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. […]