Ambassador Healthcare: Fall Safety Failures - IN
His TV remote had no batteries.
The bed rail meant to keep him safe was broken, stuck in the down position, a small black knob on it that wouldn't turn. A licensed practical nurse who knew about the rail said she didn't have the tools to fix it. Nobody had fixed it before he fell.
Inspectors from the Centers for Medicare and Medicaid Services visited the facility on August 12, 2025, responding to a complaint. What they found in the records of the resident identified as Resident B traced a series of failures that began the moment he arrived.
He was admitted on July 26, 2025. An intake screening completed that day noted he had a recent fall history and was at high risk for falls. It flagged bilateral bed rails as a safety measure. The next morning, at 8:45 a.m., he fell in his room.
His family member, interviewed by inspectors on August 11, told them Resident B had been asking about his television since he arrived. The remote had no batteries. That morning, they said, he thought he was getting up to turn on the TV himself. The remote kept going missing throughout his stay, the family member said, and watching television was something he genuinely cared about.
The fall investigation checklist, handed over by the facility's executive director on the morning of the inspection, confirmed the left bedside rail was stuck in the down position at the time of the fall. LPN 4, interviewed that afternoon, said she was aware the enabler bar wasn't working. The knob wouldn't engage. She said it was the responsibility of the admissions coordinator, the certified nursing aides, and maintenance to make sure newly admitted residents had working equipment in their rooms.
None of them had.
The facility's own falls protocol required nurses to assess a resident after a fall, documenting vital signs, pain levels, neurological status, any signs of fracture or head injury, and the circumstances of how the fall happened. It also required post-fall monitoring every shift for 72 hours.
Inspectors reviewed the electronic health record. There were no post-fall assessments documented for July 27, the day Resident B fell. Not one.
The Director of Nursing, interviewed on August 12 at 2:06 p.m., said she did not know why.
The care plan confirmed that fall interventions, the safeguards the facility had already identified as necessary for a high-risk patient, were not implemented until July 28. That was a full day after he had already fallen.
Resident B had Parkinson's disease, a condition that affects balance, muscle control, and coordination. He also had a fracture at the T11 and T12 vertebrae of his spine. The facility's own protocol noted that post-fall monitoring was especially important for ruling out delayed complications, including late fractures and subdural hematoma, a type of bleeding in the brain that can develop hours or days after a fall and can be fatal if missed.
The protocol was specific. The record was empty.
Inspectors cited the deficiency as causing minimal harm or potential for actual harm, affecting a small number of residents. The citation was tied to a complaint filed against the facility.
What the record doesn't resolve is what those 24 unmonitored hours after the fall meant for a man with a broken spine and a degenerative neurological disease, lying in a room where the equipment assigned to protect him had arrived broken, and where the one thing that might have kept him in bed, a working remote control, never had batteries in it to begin with.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 4, 2026 · Our methodology
AMBASSADOR HEALTHCARE in CENTERVILLE, IN was cited for violations during a health inspection on August 12, 2025.
His TV remote had no batteries.
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.