Ambassador Manor Nursing Center

In the surveyor’s words

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

• Immediate jeopardy, patternF689Jul 11, 2025

  On 07/08/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to have a system in place to ensure residents were monitored for the safe use of electronic vaping devices.Resident #1, 6, and Resident #11 were observed to use supplemental oxygen. The latest cognition assessments showed all three residents were intact in their cognition. Their care plans showed the three residents smoked, vaped, or both. The care plan showed the residents were not to use smoking or vaping materials while in the possession of or near any type of oxygen.On 07/08/25 at 3:43 p.m., Resident #11 was observed sitting in their motorized wheelchair in their room, vaping. The two O2 concentrators present in their room were running for the resident and their roommate. […]

• No harm, potential for more than minimal, patternF684Mar 20, 2026

  Based on record review and interview, the facility failed to assess, monitor and intervene for 2 (#1 and #3) of 5 sampled residents reviewed for administration of medication and following physician orders. The administrator identified 124 residents who resided in the facility.Findings:Resident #1 had a physician order dated 03/09/26 for Insulin Aspart injection solution 100 units/mL (Insulin Aspart) (a medication for diabetes), which read in part, .FSBS 351- 400 =10 units Recheck in 2 hours. If still 400, Notify MD. FSBS 401 - 450 = 12 units Recheck in 2 hours, if till greater than 400 notify MD. Resident #1 had the following readings:On 03/09/26 at 9:00 p.m. FSBS 383, 03/10/26 at 4:00 p.m. FSBS 401, 03/10/26 at 9:00 p.m. FSBS 399, 03/11/26 at 07:30 a.m. FSBS 390, 03/11/26 at 11:00 a.m. […]

• No harm, potential for more than minimal, patternF760Mar 20, 2026

  Based on record review and interview, the facility failed to accurately transcribe admission orders and ensure medications were administered for one (#1) of three sampled residents reviewed for medication administration.The administrator identified 124 residents who resided in the facility. Findings:A medical diagnoses record showed Resident #1 had diagnoses which included encounter for orthopedic aftercare following surgical amputation, acquired absence of other right toes, diabetes mellitus due to underlying condition with diabetic amyotrophy, acute kidney failure, unspecified, chronic obstructive pulmonary disease, unspecified, and hyperkalemia. […]

• No harm, potential for more than minimal, patternF842Jul 11, 2025

  Based on record review and interview, the facility failed to maintain complete and accurate clinical records fortwo (#1 and #2) of three residents whose clinical records were reviewed for wound care documentation, andone (#6) of one resident whose clinical records were reviewed for medication administration. The alphabetical room roster showed there were 131 residents who resided in the facility.Findings: 1. The comprehensive assessment, dated 05/30/25, showed Resident #2 was severely impaired in daily decision making (BIMS = 5), had pressure ulcers and venous stasis ulcers, received pressure ulcer care, applications of ointments/medications, and the application of nonsurgical dressings. […]

• No harm, potential for more than minimal, patternF800Sep 22, 2023

  Based on observation, record review, and interview, the facility failed to cover food carts while being transported from the kitchen across the facility to prevent foreign contamination. The DON identified 112 residents received nutrition from the kitchen. Findings: On 09/21/23 at 8:40 a.m., breakfast trays were observed uncovered on a meal tray cart on the South Hall. The bottom half of the meal tray cart was uncovered with eight meal trays and fluids exposed as it was moved down the hall by staff. Residents and staff were observed to pass by the cart in near proximity of the uncovered meal cart. […]