Ambassador Healthcare

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Based on interview and record review, the facility failed to include the resident's family in a physician follow-up visit with the neurosurgeon's office, at their request, after the resident's back surgery for 1 of 3 residents reviewed for physician appointments. (Resident B)The findings include:During an interview with Resident B's family member on 8/11/25 at 1:30 p.m., she indicated the family and Resident B had a virtual doctor's appointment with neurosurgery scheduled for 7/28/25 at 9:15 a.m. Resident B's family member indicated Licensed Practical Nurse (LPN) 3 had come into Resident B's room the morning of the appointment and mentioned something about a tablet to use for the appointment and Resident B's family member indicated she was not sure how to use the tablet. So, she wanted LPN 3 to have the doctor's office call her phone because the family, as well as the resident, wanted to speak to the surgeon about Resident B's fall the day before and not having the required back brace at the facility. The family member indicated

the resident was capable of participating in the virtual meeting and had questions and so did the family. The family member indicated LPN 3 took the phone call without including the family as requested. An Inpatient Discharge Instructions form was provided by the Executive Director on 8/12/25 at 10:30 a.m. It indicated Resident B was to receive a virtual home visit follow up appointment with neurosurgery on 7/28/25 at 9:15 a.m.During an interview with LPN 3 on 8/12/25 at 11:12 a.m., she indicated Resident B's wife was who set up the virtual appointment at the hospital and was unsure what phone number she gave them. LPN 3 indicated that any appointments for residents are recorded on their unit calendar. The unit calendar, for 7/28/25, indicated Resident B had a neurosurgeon virtual visit and the phone number of the neurosurgeon's office at 9:15 a.m. LPN 3 indicated she did not know how to use the tablet for virtual doctor's visits. When the neurosurgeon's office called the facility she took the call, provided information, and received new orders but did not think the family needed to be in on the phone call.During an interview with

the Director of Nursing (DON) on 8/12/25 at 2:06 p.m., she indicated physician's office usually will call the facility and set up a virtual office visit. The physician's office will provide us with an email/code for our tablet so everyone can be involved.During an interview with the Executive Director (ED) on 8/12/25 at 2:00 p.m.,

he indicated the facility did not have a policy regarding virtual doctor's appointments. This citation relates to Intake 2578556. 3.1-3(n)(3)

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Ambassador Healthcare

705 E Main St Centerville, IN 47330

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review, the facility failed to provide a homelike environment by not providing television (TV) remotes for newly admitted residents to watch TV per their preference for 2 of 3 residents reviewed for accommodation of needs. (Resident B and Resident D) Findings include: 1. During

an interview with Resident B's family member on 8/11/25 at 1:30 p.m., they indicated Resident B was admitted , on 7/26/25, and had a TV remote with no batteries. Resident B's family member indicated the morning Resident B fell, on 7/27/25, he had been asking about his TV and thought he was getting out of bed to turn on the TV when he fell. Resident B's family member indicated the TV remote kept coming up missing during his stay at the facility and he really enjoyed watching TV.

The clinical record for Resident B was reviewed on 8/11/25 at 11:00 a.m. The diagnoses included, but were not limited to, dementia and atrial fibrillation.

During an interview with Licensed Practical Nurse (LPN) 4 on 8/12/25 at 1:17 p.m., they indicated the Admissions Coordinator, Certified Nurse Aides (CNAs), and maintenance were responsible to ensure rooms were appropriately set up with working equipment and supplies.

1. 2. During an observation and interview with Resident D on 8/11/25 at 11:39 a.m., the resident was sitting in

her room and indicated she was admitted to the facility on [DATE REDACTED]. Resident D indicated she had been without a remote control to her TV since being admitted to the facility. At that time, the resident did not have

a TV remote visible in her room.

During an interview with Resident D on 8/12/25 at 11:10 a.m., she indicated she went three days without a remote since her admission to the facility. The resident indicated she was unable to walk or stand so she could not turn on her TV without a remote. Resident D indicated she stared at the walls all weekend. The resident indicated she reported to the nursing staff that she needed a remote control for her TV, but they told her that she would have to wait until Monday when maintenance was working. The resident indicated watching TV was about all she could physically do.

The clinical record for Resident D was reviewed on 8/12/25 at 1:55 p.m. The diagnoses included, but were not limited to, lung cancer, emphysema, heart failure, osteoporosis, anxiety and depression.

A progress note for Resident D, dated 8/8/25 at 9:50 a.m., indicated the resident was admitted to the facility. The resident was alert and oriented to person, place, time and situation. The resident was able to answer questions appropriately.

The plan of care for Resident D, dated 8/11/25, indicated the resident was alert and able to make leisure lifestyle choices and preferred self-directed activities in her room. The interventions included, but were not limited to, watching TV.

This citation relates to Complaint 2578556. 3.1-19(f)(5)

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Ambassador Healthcare

705 E Main St Centerville, IN 47330

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Based on interview and record review, the facility failed to ensure follow up was conducted on care concerns for a resident and the resident's family who had expressed multiple care concerns via email and follow the facility's policy pertaining to grievances for 1 of 3 residents reviewed for quality of care. (Resident B)Findings include: The clinical record for Resident B was reviewed on 8/11/25 at 11:00 a.m. The diagnoses included, but were not limited to, Parkinson's disease and rib fracture.During an interview with Resident B's family member on 8/11/25 at 1:30 p.m., they indicated they emailed the Admission's Director a list of concerns that Resident B's family had throughout their stay at the facility. During an interview with the Director of Nursing (DON) on 8/12/25 at 2:06 p.m., she indicated social services were responsible for filing

a grievance.During an interview with the Social Service Director (SSD) on 8/12/25 at 2:25 p.m., she indicated she was aware that Resident B's family had concerns and believed the Admission's Director was handling them. The SSD indicated whoever took the grievance was usually the person who fills them out and were then turned into her to file.During an interview with the Admission's Director on 8/12/25 at 2:34 p.m., she indicated she did not fill out a grievance after receiving Resident B's family member's email of concerns. The Admission's Director indicated she forwarded the email to the SSD, DON, Executive Director (ED), and physical therapy. The Admission's Director indicated she thought letting everyone know by email would update them on the concerns Resident B's family had. The Admissions Director provided an email with Resident B's family concerns.The email, dated 8/4/25, sent by Resident B's family, indicated the following care concerns: a missing back brace, thrown away items, delay in follow-up after a fall, cleanliness of resident's room, and care assistance.A Filing Grievances/Complaints Policy was provided by the ED on 8/12/25 at 3:00 p.m. It indicated, .7. Upon receipt of a grievance and/or complaint, the grievance officer will

review and investigate the allegations and submit a written report of such findings to the administrator within five (5) working days of receiving the grievance and/or complaint .This citation relates to Complaint 2578556.3.1-7(a)(2)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Ambassador Healthcare

705 E Main St Centerville, IN 47330

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited AMBASSADOR HEALTHCARE in CENTERVILLE, IN for a deficiency under regulatory tag F-F0684 during a complaint investigation conducted on 2025-08-12.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 6 deficiencies cited during this inspection of AMBASSADOR HEALTHCARE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-12.

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Based on interview and record review, 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 for 1 of 3 residents reviewed for falls. (Resident B)Findings include: The clinical record for Resident B was reviewed on 8/11/25 at 11:00 a.m. The diagnoses included, but were not limited to, Parkinson's disease and fracture of T11-T12 vertebra.An Admit/Readmit Screener, dated 7/26/25, indicated Resident B had recent falls and was at risk for falls.

Bilateral side rails for the bed were indicated for safety. A Resident Fall Investigation Checklist was provided by the Executive Director on 8/12/25 at 10:00 a.m. It indicated Resident B had a fall in his room on 7/27/25 at 8:45 a.m. The checklist indicated side rails need to be positioned and bedside rail on left side was stuck down. During an interview with Resident B's family member on 8/11/25 at 1:30 p.m., they indicated Resident B was admitted , on 7/26/25, and had a TV remote with no batteries. Resident B's family member indicated the morning Resident B fell, on 7/27/25, he had been asking about his TV and thought he was getting out of bed to turn on the TV when he fell. Resident B's family member indicated the TV remote kept coming up missing during his stay at the facility and he really enjoyed watching TV. During an interview with Licensed Practical Nurse (LPN) 4 on 8/12/25 at 1:17 p.m., she indicated Resident B's enabler bar on his bed was stuck down. The bar had a little black knob on it, but it wouldn't work. LPN 4 indicated she did not have the tools to fix the bed. LPN 4 indicated the Admissions Coordinator, Certified Nurse Aides (CNAs), and maintenance were responsible to ensure rooms were appropriately set up with working equipment and supplies for newly admitted residents. The Resident Fall Investigation Checklist indicated post fall assessments would be completed every shift for 72 hours post fall. No post fall assessments were documented in the electronic health record (EHR) for 7/27/25. The plan of care for Resident B indicated he was at risk for falls. The care plan indicated no fall interventions were implemented until 7/28/25.During an

interview with the Director of Nursing (DON) on 8/12/25 at 2:06 p.m., she indicated she did not know why any post fall assessments were not completed for 7/27/25.A policy entitled Falls - Clinical Protocol was provided by the Executive Director on 8/11/25 at 11:00 a.m. The policy indicated the following, .Assessment and Recognition . 2. In addition, the nurse shall assess and document/report the following . a. Vital signs . b.

Recent injury, especially fracture or head injury . c. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc . d. Change in cognition or level of consciousness . e.

Neurological status . f. Pain . h. Precipitating factors, details on how fall occurred . 3. The staff and practitioner will review each resident's risk factors for falling and document in the medical record . 5. The stall will evaluate and document falls that occur while the individual is in the facility . Monitoring and Follow-Up . 1. The staff, with the physician's guidance, will 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 . 2. The staff and physician will monitor and document the individual's response to interventions in-tended to reduce falling or the consequences of falling This citation relates to Complaint

1. 2578556. 3.1-45(a)(2)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Ambassador Healthcare

705 E Main St Centerville, IN 47330

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited AMBASSADOR HEALTHCARE in CENTERVILLE, IN for a deficiency under regulatory tag F-F0842 during a complaint investigation conducted on 2025-08-12.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 6 deficiencies cited during this inspection of AMBASSADOR HEALTHCARE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-12.