Health inspection·January 10, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to a.) provide appropriate supervision b.) reduce the risk of a fall for one (R5) resident out of five residents reviewed for falls, in a total sample of five residents. This failure resulted in R5 sustaining a fall without injury. Findings include: On 01/08/2025, at 11:45 AM, V6 (Certified Nursing Assistant) states that she is working the middle set assignment. Surveyor asked V6 which residents on her set are high fall risk. V6 states that R5 fell this morning. V6 continues that she was barely arriving to work when the night shift nurse found R5 on the floor, his bottom on the floor, in his room, next to his bed. 01/08/2025, 11:50 AM, R5 in bed lying down and in no apparent distress. R5 wearing white socks but not non-skid socks. R5's bed is not at the lowest position. Urinal noted approximately 5 feet away from R5's bed on the floor, sideways, no urine inside the urinal noted. Black shoes noted near R5's nightstand, next to R5's bed. Surveyor asked R5 what his full name is, R5 answered correctly. Surveyor asked R5 if he knows where he is at, R5 states the name of the facility. R5 was asked who the president is and R5 answered correctly. R5 was asked when Christmas is, and R5 answered 25th, but could not recall the month. R5 states that he did fall this morning. R5 states that he lost track of how many times he has fallen. R5 states that he cannot blame the staff entirely. R5 states that he needs some assistance with putting on his shoes. R5 states that sometimes he can get one shoe and not the other. 01/08/2025, 12:07 PM, R5's room door open, R5 sitting at edge of bed, attempting to stand, noted unbalanced, with no nonskid socks on. Surveyor informed V7 (Registered Nurse) and V7 went into R5's room to assist him. R5 sat down on his bed. V7 brought a spoon to R5. 01/08/2025, 12:09 PM, V7 states that R5 just wants to get up despite being weak and does not use the call light to call for assistance. V7 states that R5 forgets a lot. V7 states that R5's wheelchair is outside of R5's room because it is too tight for R5's roommate to get through. V7 states that R5's keeps forgetting to call for help. V7 reports that R5 has the urinal and bed commode, but he also forgets to use them. V7 continues to state we ask him (R5) why he didn't call, he says he forgot. He doesn't like to stay in the bed or wheelchair for too long. On 01/09/2025, at 2:48 PM, V17 (Licensed Practical Nurse) states that she was the night shift nurse for R5 on Tuesday night. V17 states that it was around 7:37 AM when R5's roommate approached V17 to inform her that R5 needed help. V17 states that she went to R5's room and R5 was at the edge of the (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 01/10/2025 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)