Health inspection·October 18, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on interview and record review, the facility failed to follow their policy on abuse. This failure resulted in R1 and R3 bumping into one another while on the patio smoking , causing R1 to fall and sustain a right hip fracture. Findings Include: On 10/17/24 at 11:21 AM, R1 stated that R3 pulled R1on R1's left wrist at the smoking patio, and R1 fell on the concrete floor on R1's right hip. R1 stated that there was a staff monitoring at the smoking patio. R1 stated that the nurse told R1 to go to the hospital but R1 refused. R1 later agreed to go to the hospital and report to the police. On 10/17/24 at 12:15 PM, R3 stated R3 speaks Polish with little English. Via the phone V11 (Polish Interpreter) stated that R3 stated that R3 did not punch or pulled R1. R3 stated that R1 pulled R3's wheelchair. On 10/17/24 at 3:17 PM, V4 (Social Service Director) stated that staff reported to V4 that R1 and R3 had verbal altercation outside the smoking patio on 9/13/24 (Friday) R1 bumped R1's rollator into R3's wheelchair, and R1 and R3 exchanged profanity words. V4 stated on 9/16/24 R1 told V4 to call the police to report the incident between R1 and R3. V4 called the police and made the police report. On 10/17/24 at 3:39 PM, V27 (Smoking Monitor) stated that V1 is the abuse coordinator, and V27 will report any abuse to V1 immediately. V27 stated that V27 was monitoring sometimes in September after lunch time, and R1 was very anxious to get into the smoking area, R1 bumped R1' rollator into R3's wheelchair. V27 stated that R1 and R3 started exchanging profanity words, and V27 quickly separated R1 and R3. On 10/17/24 at 4:28 PM, V19 (Nurse Practitioner) stated that V19 was called on 9/13/24 that R1 was having verbal altercation with R3 and as R1 was walking away, R1 lost R1's balance and R1 fell on R1's right side. V19 stated that R1 was sent to Swedish hospital where the CT scan result shows fractures of the right superior and inferior pubic rami. V19 stated that CT scan is more detailed than Xray, the inferior pubic fracture could potentially be a new fracture related to the fall. On 10/17/24 at 5:02 PM, V2 (Director of Nursing/DON) stated that the nurse reported to V2 that R1 was rushing to the smoking patio and R1 bumped into R3's wheelchair, and R3 became angry and there was verbal altercation between R1 and R3. V9 stated that staff separated R1 and R3, R1 was very aggressive, R1 purposely put self on the floor, and R1 denied pain. V2 stated that R1 requested to be sent to the hospital for a second opinion on 9/16/24. (continued on next page) 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 Page 1 of 2 Event ID: 145343 Printed: 05/15/2026 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 145343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ambassador Nursing & Rehab Center 4900 North Bernard Chicago, IL 60625 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)