Health inspection·November 4, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to ensure an allegation of abuse was reported to the Illinois Department of Public Health (IDPH), within two hours of notification of the allegation and withing five days of the abuse allegation for one of three residents (R2) reviewed for abuse in the sample of three. Findings include: 11/3/2024, at 11:20 AM, R1 said, on Tuesday 10/15/2024, at 5:04 AM, he heard someone (female) say, don't push me, don't push me, followed by a thump. R1 said the conversation was coming from the room directly above him. R1 said he then heard the same female voice say, why did you do that, you pushed her down, she's hurt, you threw her on the floor, and don't push me. R1 identified the voice as R3, R2's former roommate at the time of the incident but could not identify the staff member's voice. R1 said he recorded the incident on his phone. R1 said he reported the incident to V3 (ADON-Assistant Director of Nursing) on 10/15/2024, at approximately 10:30 AM. I made her aware of what happened; she listened to the recording. R1 said V4 (Minimum Data Set Coordinator) took a statement from me on Friday 10/18/2024. R1 said V4 listened to the recording and asked me to text it (recording to him) which I did. 11/3/2024, at 1:52 PM, V4 (Minimum Data Set Coordinator) said via telephone, that is correct, I spoke with R1 on 10/18/2024. R1 said he heard yelling and screaming and reported it. R1 played the tape to for a staff member who reported it to V1 (Administrator). I went to speak with him because V1 asked me to interview R1. V4 said, I listened to recording, I heard noises or yelling, I could not discern words. R1 texted me the recording, I forwarded it to V1, V2 (Director of Nursing), and V5 (Consulting Administrator). V4 said, then I left it, it was beyond the boundaries of my job description. I cannot investigate, I cannot point fingers. 11/3/2024, at 2:56 PM, V3 (Assistant Director of Nursing) said, V7 (Registered Nurse/Wound Care Coordinator) informed me R1 wanted to speak with me; he has an audio from R2's fall. I went to R1's room; said there was a fall around 5:00 AM for R2. I listened to the recording, I could hear voices, but they weren't clear. I reported it immediately to V2 (Director of Nursing). I asked V2 to follow up with R1. 11/3/2024, at 3:10 PM, V1 (Administrator) said, he found out about the allegation of staff to resident abuse he believes from the V2 (Director of Nursing) on 10/18/2024, I was leaving the country. 11/3/2024, at 3:18 PM, V2 (Director of Nursing) said, I didn't hear about the allegation until 10/21/2024. R2's daughter reported to me there was an audio recording that R1 showed her, that you could (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 11/04/2024 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)