Ambassador Nursing & Rehab Center

In the surveyor’s words

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

• Actual harm, isolatedF689Dec 9, 2025

  Based on observation, interview and record review, the facility failed to develop and implement interventions to prevent a resident from sustaining a serious fall related injury for one of three residents (R7) in the sample of thirteen. This failure resulted in R7 sustaining a subarachnoid bleed (brain bleed) after falling.Findings include:Final Incident Report (11.6.2025) documents, in part: At approximately 5:00 AM, resident was noted sitting on the floor in the hallway. Resident noted with an open area to the back of his head.Resident was immediately assessed by NOD (Nurse on Duty). First aid was provided. Resident sent to emergency room for evaluation. Resident admitted with Subarachnoid hemorrhage and two staples to the back of head. Physician and family notified. […]

• Actual harm, isolatedF684Aug 21, 2025

  Based on interview and record review, the facility failed to administer a resident's (R1) scheduled medication for neuropathic pain and failed to document physician notification of a resident (R1) missing scheduled doses of the neuropathic pain medication when reviewed for quality of care/treatment in the sample of 3 residents (R1, R2 and R3). This failure resulted in R1 experiencing increased neuropathic pain to bilateral lower extremities for 3 days and causing R1 to not consistently sleep for 2 nights due to increased nerve pain.Findings Include: On 8/20/2025 at 1:26 pm, V4 (LPN) stated that if a medication has not been received from the pharmacy, the nurse should call V2 (Director of Nursing), and the V2 will request that the nurse tell the pharmacy the medication is needed stat. […]

• Actual harm, isolatedF600Jul 21, 2025

  Based on interview, and record review the facility failed to protect one resident (R6) from physical abuse. This failure affected 1 of 3 residents reviewed for physical abuse and caused R6 to be sent to local hospital and R6 sustaining a comminuted left intertrochanteric fracture requiring R6 to have open reduction internal fixation of the left hip fracture. Findings include: R6 has a diagnosis which include but are not limited to: Repeated falls, Alzheimer's disease, lack of coordination, abnormalities of gait and mobility, weakness, dementia, ataxic gait, unsteadiness on feet, and insomnia. […]

• Actual harm, isolatedF689Jul 21, 2025

  Based on interview, and record review, the facility failed to provide adequate supervision for a resident (R6) at risk for falls and failed to ensure that a resident (R6) at risk for falls does not have repeated falls. These failures affected 1 of 3 residents, reviewed for falls and fall prevention interventions, caused R6 to be sent to local hospital and R6 sustaining a comminuted left intertrochanteric fracture requiring R6 to have open reduction internal fixation of the left hip fracture.Findings include:R6 has a diagnosis which include but are not limited to: Repeated falls, Alzheimer's disease, lack of coordination, abnormalities of gait and mobility, weakness, dementia, ataxic gait, unsteadiness on feet, and insomnia. […]

• Actual harm, isolatedF600Jul 12, 2024

  Based on interview and record review, the facility failed to follow their policy to ensure residents were free from abuse by one staff member being physically abusive towards two residents ( R104, R119) out of five residents reviewed for abuse in a sample of 28. This failure resulted in the residents experiencing emotional trauma/fear and anxiety. Findings include: 1. According to R119's facesheet printed 7/11/24, R119 is [AGE] years old with diagnoses that include but are not limited to unilateral primary osteoarthritis, right and left knee; venous insufficiency; need for assistance with personal care. According to R119's MDS (Minimum Data Set), 6/3/24, R119 has a BIMS (Brief Interview for Mental Status) score of 15, indicating intact cognition. […]