Ambassador Healthcare: Fall Safety Failures - IN
Resident B had been at the facility for less than 24 hours when he fell in his room at 8:45 a.m. on July 27. His family member told inspectors he had been asking about his TV that morning and "thought he was getting out of bed to turn on the TV when he fell."
The remote control had no batteries.
Federal inspectors found the facility failed to ensure basic safety equipment was working and then failed to follow its own protocols after the fall occurred. Licensed Practical Nurse 4 confirmed to inspectors that the patient's "enabler bar" — the bed rail meant to help him safely get in and out of bed — was stuck down. "The bar had a little black knob on it, but it wouldn't work," she said. "I did not have the tools to fix the bed."
The patient's admission screening the day before had specifically noted he had "recent falls and was at risk for falls." The screening indicated bilateral side rails for the bed "were indicated for safety."
But nobody had ensured the safety equipment actually functioned.
LPN 4 told inspectors that the Admissions Coordinator, nursing assistants, and maintenance staff were all responsible for ensuring rooms were "appropriately set up with working equipment and supplies for newly admitted residents." The fall investigation checklist completed after the incident noted the "bedside rail on left side was stuck down."
The patient's family member described an ongoing problem with the TV remote during his stay. "The TV remote kept coming up missing during his stay at the facility and he really enjoyed watching TV," they told inspectors.
After Resident B fell, the facility's own policy required staff to complete post-fall assessments every shift for 72 hours. The policy mandated nurses assess and document vital signs, recent injury, musculoskeletal function, changes in cognition or consciousness, neurological status, and pain. Staff were required to evaluate precipitating factors and document details of how the fall occurred.
None of that happened.
Inspectors found no post-fall assessments documented anywhere in the electronic health record for July 27, the day of the fall. The Director of Nursing told inspectors on August 12 that "she did not know why any post fall assessments were not completed."
The facility's care plan showed Resident B was identified as being at risk for falls, but no fall prevention interventions were put in place until July 28 — the day after he fell.
Resident B's diagnoses included Parkinson's disease and a fracture of his T11-T12 vertebra. The facility's fall prevention policy emphasized that staff and physicians must "monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling." The policy also required staff to "follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved."
The inspection was triggered by a complaint filed with state regulators.
Federal inspectors cited Ambassador Healthcare for failing to ensure the nursing home area was free from accident hazards and for failing to provide adequate supervision to prevent accidents. The citation noted the facility "failed to ensure a resident's equipment of an enabler bar was functioning properly, failed to complete a thorough assessment after the resident's fall, and failed to implement fall interventions for a resident at high risk for falls."
The case illustrates how multiple system failures can converge around a single vulnerable resident. A patient with Parkinson's disease and a history of recent falls was placed in a room where basic safety equipment didn't work. When he tried to solve a simple problem — turning on a television he enjoyed watching — the broken safety rail that should have helped him get out of bed safely instead left him to fall.
The family member's account suggests Resident B may have been trying to reach the TV's power button because his remote control had been provided without batteries and kept disappearing during his stay.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ambassador Healthcare from 2025-08-12 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
AMBASSADOR HEALTHCARE in CENTERVILLE, IN was cited for violations during a health inspection on August 12, 2025.
Resident B had been at the facility for less than 24 hours when he fell in his room at 8:45 a.m.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.