The Ambassador Sidney Inc

In the surveyor’s words

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

• Actual harm, isolatedF689Jul 7, 2021

  Based on observations, record review, facility investigation review, staff interviews and facility policy review the facility failed to ensure the safety of 2 of 3 Residents (R) (R6 and R7) reviewed with known fall risks by not ensuring care planned interventions in place at all times. The facility also failed to prevent environmental hazards in the bathhouse that resulted in resident sustaining a right femoral fracture from fall for 1 of 3 (R2) residents reviewed. The facility reported a census of 33 residents. Findings include: 1. According to the Quarterly Minimum Data Set (MDS) dated [DATE], R2 had the following diagnoses: non-traumatic [CONDITION(S)], severe intellectual disabilities, [CONDITION(S)], dementia, and depression. […]

• No harm, potential for more than minimal, patternF812Mar 20, 2025

  Based on observation, interview and policy review the facility failed to ensure that staff used adequate infection control practices during meal service. The facility reported a census of 40 residents. Findings include: In an observation of the lunch meal on 3/17/25 at 11:45 AM, Staff G, Dietary Aide (DA) prepared a peanut butter and jelly sandwich for a resident. Staff G first donned gloves, then touched the bread bag, grabbed two slices of bread, grabbed a utensil and held the bread with one gloved hand and spread with other. At 12:02 PM, Staff G prepare a cheese sandwich. The staff member first donned gloves, opened the lid on the container, bread bag, touched the pan, then with the same gloved hands, grabbed out a couple slices of cheese. […]

• No harm, potential for more than minimal, patternF803Feb 24, 2023

  Based on observation, interview, record review, and policy review, the facility failed to ensure menus were followed related to consistency. This failure had the potential to affect up to 9 residents who received a mechanical soft diet or a pureed diet and could result in unintentional weight loss for those residents who were nutritionally at risk and who may have difficulty with swallowing. Findings include: Review of a document provided by the facility titled Menus-Regular and Modified, dated 01/2020 indicated . Menus are planned and followed to meet the nutritional needs of residents in accordance with physician's orders . […]

• No harm, potential for more than minimal, patternF813Feb 24, 2023

  Based on observation, interview, and record review, the facility failed to ensure the food a resident brought in from the outside was dated and labeled. The facility further failed to ensure residents' personal refrigerators were routinely cleaned. This had the potential to affect 5 of 13 (Resident (R) 18, R24, R5, R23, and R19) residents reviewed with personal refrigerators in their rooms. Findings include: Review of a document provided by the facility titled Room Refrigerators dated ,d+[DATE] indicated . It is the policy of this facility to promote cleanliness while providing residents/patients access to food brought into the facility by family . All resident/patient room refrigerators will be provided and stocked by family . […]

• No harm, potential for more than minimal, patternF812Dec 2, 2021

  Based on observations, policy review and interview the facility failed to maintain 4 of 4 larger sheet pans, 2 of 6 smaller sheet pans, and 1 utility cart used in food prep area in a manner that was free of food residue. The facility reported a census of 37 residents. Findings included; Observation on 12/01/21 at 10:58 AM revealed 2 smaller sheet pans and 4 larger sheet pans contained baked on food residue. A utility cart with an enclosed bottom had dried food residue on the front of the doors and on the bottom of the cart. The Equipment Sanitation and Safety policy dated 04/2017 directed all food service equipment is to be safely operated and maintained in a sanitary manner following procedures specific to the individual piece of equipment. […]