Ambassador Nursing & Rehab Center

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision for two (R3, R4) of three residents with history of aggressive behaviors. The facility failed to ensure that R4, who required one-to-one supervision due to prior resident-to-resident altercation, was adequately supervised, resulting in another resident-to-resident altercation. Findings Include:The facility's final incident reportable for R3 and R4 dated 5/24/26 sent to State Agency on 5/29/26 at 3:38 PM reads in part: [R4] stated they engaged in an argument with [R3], and that [R3] got frustrated and pushed [R4]. [R3] denied the allegation adamantly stating he didn't make any type of physical contact with [R4]. [R3] further stated that [R4] pushed a chair that made contact with [R3's] walker and he got upset about it but never pushed [R4]. [...]

Inspectors wroteThe facility failed to prevent and protect residents from resident-to-resident physical abuse. This failure affects two (R1, R2) residents out of four residents reviewed for abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement interventions to prevent a resident from sustaining a serious fall related injury for one of three residents (R7) in the sample of thirteen. This failure resulted in R7 sustaining a subarachnoid bleed (brain bleed) after falling.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident remain free from abuse for one of four residents (R2) reviewed for abuse in the sample of 13.

Inspectors wroteBased on interviews and record review, the facility failed to report an allegation of resident abuse within two hours of notification. This failure affected one resident (R1) reviewed for Reporting of Alleged Violation.

Inspectors wroteBased on interview and record review, the facility failed to administer a resident's (R1) scheduled medication for neuropathic pain and failed to document physician notification of a resident (R1) missing scheduled doses of the neuropathic pain medication when reviewed for quality of care/treatment in the sample of 3 residents (R1, R2 and R3). This failure resulted in R1 experiencing increased neuropathic pain to bilateral lower extremities for 3 days and causing R1 to not consistently sleep for 2 nights due to increased nerve pain. Findings Include: On 8/20/2025 at 1:26 pm, V4 (LPN) stated that if a medication has not been received from the pharmacy, the nurse should call V2 (Director of Nursing), and the V2 will request that the nurse tell the pharmacy the medication is needed stat. [...]

Inspectors wroteF725Based on observation, interview and record review, the facility failed to ensure sufficient staff to administer medications as ordered by physician and attend to resident's needs or care in a timely manner. These failures could potentially affect all residents residing in the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to discard out-dated food items, store food items away from cleaning solution, and ensure food items were distributed and served to residents under sanitary conditions. This has the potential to affect 168 residents that receive nutrition from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure wheelchair armrest was not worn out or wabbly for 1 resident (R101) and failed to ensure call light were within reach and in good working order for four residents (R7, R17, R51, R98) reviewed for reasonable accommodation of needs out of a sample of 35.

Inspectors wroteF695Based on observations, interviews, and record reviews, the facility failed to: (A) Maintain proper storage of oxygen nasal cannula tubing for 3 (R39, R52, and R107). (C) Ensure nebulizer tubing and mask were changed for 1 (R62) resident. These failures affected four (R39, R52, R62, and R107) out of four residents reviewed for respiratory care in a sample of 35. Findings Include: R39's Minimum Data Set (MDS) dated [DATE], Brief Interview Score indicates he is cognitively impaired. R39 Physician Order Sheet (POS) dated 8/5/25 shows an active diagnosis which are not limited to: chronic obstructive pulmonary disease, dependence on supplemental oxygen, other fatigue, and acute respiratory failure with hypoxia. [...]

Inspectors wroteF755Based on observation, interview and record review, the facility failed to follow their policies and procedures to ensure resident received their medications according to the physician's order for 6 (R25, R34, R46, R77, R107 and R156) residents reviewed for medication administration in a sample of 35.

Inspectors wroteBased on observation, interview, and record review the facility failed to practice appropriate infection prevention and control measures by staff not wearing appropriate Personal Protective Equipment (PPE) while providing care to a resident (R167) on Enhanced Barrier Precautions (EBP) and failed to ensure that a resident (R177) with wounds was on Enhanced Barrier Precautions (EBP). These failures have the potential to affect R177 and all 62 residents residing on the 3rd floor.

Inspectors wroteF554Based on observations, interviews, and record reviews the facility failed to: 1. Obtain a physician order to keep medication at bed side for two (R107, and R126).2. Determine if self-administration of medication was appropriate for one (R107) out of two residents observed with medications at bed side table in a sample of 35. Findings Include:R107's Minimum Data Set/ MDS dated [DATE], Brief Interview Score (14) indicates she is cognitively intact. R107's Physician Order Sheet (POS) with active orders as of 8/5/25 shows Ventolin HFA inhalation aerosol solution 108 (90 base) MCG/ACT (Albuterol Sulfate) 2 puff inhale orally every 6 hours as needed for shortness of breath. R126's Minimum Data Set/ MDS dated [DATE], Brief Interview Score (15) indicates he is cognitively intact. [...]

Inspectors wroteNumber of residents sampled: 172Number of residents cited: 3 Based on observations, interviews, and record reviews, the facility failed to ensure a homelike environment for three residents (R42, R88, R172) out of a total sample of 172 residents in the facility.

Inspectors wroteNumber of residents sampled: 35Number of residents cited: 1 Based on interviews and record reviews the facility failed to submit an accurate Level I PASRR (Pre-admission Screening and Resident Review) assessment for R10 and failed to refer R10 to the appropriate state-designated authority for a Level II PASRR evaluation and determination after a significant change for one out of a total sample of 35 residents.

Inspectors wroteNumber of residents sampled: 35Number of residents cited: 1 Based on interviews and record reviews, the facility failed to follow-up and refer a resident with mental illness (R78) to the appropriate state-designated authority for a Level II PASRR (Pre-admission Screening and Resident Review) evaluation and determination for one out of a total sample of 35 residents.

Inspectors wroteNumber of residents sampled: 35Number of residents cited: 1 Based on interviews and record reviews, the facility failed to follow physician orders and perform daily wound care for R177 and failed to ensure accurate Treatment Administration Records (TAR) for R177 for one out of a total sample of 35 residents.

Inspectors wroteBased on observation, interview and record review the facility failed ensure hazardous items were stored securely for one R12 resident reviewed for safety in a sample of 35. Findings Include:R12 has diagnosis not limited to Dementia in Other Diseases Classified Elsewhere, Unspecified Severity, with Psychotic Disturbance, Dependence on Wheelchair, Disorder of Adult Personality and Behavior, Mood [Affective] Disorder, Cerebral Ischemia, Paranoid Personality Disorder and Altered Mental Status. R12's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 99 indicating resident is rarely/never understood. Section GG - Functional Abilities document in part: Personal hygiene: The ability to maintain personal hygiene, including combing hair, shaving (Dependent) Helper does all of the effort. R12's Care Plan Document in part: Dressing/Grooming: Focus: [...]

Inspectors wroteNumber of residents sampled: 35Number of residents cited: 1 Based on interviews and record reviews, the facility failed to follow provider orders and provide radiology services to one resident (R78) out of a total sample of 35 residents.

Inspectors wroteBased on interview, and record review the facility failed to protect one resident (R6) from physical abuse. This failure affected 1 of 3 residents reviewed for physical abuse and caused R6 to be sent to local hospital and R6 sustaining a comminuted left intertrochanteric fracture requiring R6 to have open reduction internal fixation of the left hip fracture.

Inspectors wroteBased on interview, and record review, the facility failed to provide adequate supervision for a resident (R6) at risk for falls and failed to ensure that a resident (R6) at risk for falls does not have repeated falls. These failures affected 1 of 3 residents, reviewed for falls and fall prevention interventions, caused R6 to be sent to local hospital and R6 sustaining a comminuted left intertrochanteric fracture requiring R6 to have open reduction internal fixation of the left hip fracture.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure the outgoing nurse signed the First Floor Team II Controlled Substances Check Form. This failure affected 4 (R2, R8, R9, and R10) residents reviewed for controlled medications in the total sample of 10 residents.

Inspectors wroteBased on interview and record review the facility failed to notify a physician of a residents (R7) condition/status. This failure affected 1 resident in the total sample of 10 residents.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure controlled substance is properly labeled. This failure affected 1 (R2) resident reviewed for labeling of controlled substance in the total sample of 10 residents.

Inspectors wroteBased on interview, and record review the facility failed to prevent resident to resident physical abuse for 1 (R2) of 4 (R1, R3, R4) residents reviewed for abuse. This failure resulted in R2 sustaining swelling to the left side of R2's face near the eyebrow. Findings Include R2 has diagnosis not limited to Long Term (Current) use of Anticoagulants, Insomnia, Fall, Adult Failure To Thrive, Low Back Pain, Cerebrovascular Disease, Aphasia Following Cerebral Infarction, Nontraumatic Subarachnoid Hemorrhage from Unspecified Intracranial Artery, Acute Embolism and Thrombosis of Unspecified Deep Veins of Unspecified Lower Extremity, Acute Kidney Failure, Seizures, Respiratory Failure, Unspecified with Hypoxia, Emphysema, Dysphagia, Hypertensive Heart Disease, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to make reasonable accommodations toward assisting one resident, R1 of three R5, R6 residents to maintain independent functioning and well being with R1's own needs and preferences. Findings inlude, R1's clinical record indicates in part, R1 is an eighty-five-year-old admitted with medical diagnosis of transient cerebral ischemic attack, vitamin D deficiency, atherosclerotic heart disease of native coronary artery, chronic obstructive pulmonary disease, weakness and retention of urine. R1's minimum data set indicates R1 is cognitively intact. On 8/27/24 at 1:45 PM, R1 stated I have back pain and need to use my cane for short distance. I use my walker for long distances. I have not hit anyone with my cane. I have not fallen since I been here in the facility. One day the social worker lady took my cane and did not tell me why. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to ensure residents were free from abuse by one staff member being physically abusive towards two residents ( R104, R119) out of five residents reviewed for abuse in a sample of 28. This failure resulted in the residents experiencing emotional trauma/fear and anxiety.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, label, and protect food items in accordance with professional standards for food service safety. This failure has the potential to affect 135 residents that eat food from the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly contain waste in dumpsters and failed to ensure dumpster lids were securely closed.

Inspectors wroteBased on interviews and review of records, the facility failed to ensure staff management is managed by the administration by allowing staff to work with multiple abuse allegations per policy. These failures have the potential to affect all the residents in the facility related to nursing staff to resident services.

Inspectors wroteBased on observations, interviews, and review of records the facility failures are as follows: Failed to follow laundry policy on maintaining clean environment/equipment used in air circulation and failed to sort and handle soiled linen to prevent overflowing in the laundry areas. Failed to follow Legionella policy on establishing preventive measures (worksheet, checklist, and other preventive means). Failed to follow its medication administration policy on handwashing while administering medications. These failures have the potential to affect all 139 residents in the facility who are receiving laundry and water services, and 20 residents receiving medications from the first-floor team two cart.

Inspectors wroteBased on observations, interviews and records review, the facility failed to follow its policy on disposing expired medication for one (R127) resident, and failed to properly store insulin for three (R4, R7, R90) of six residents reviewed in a sample of 28.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to follow their policy to ensure correct food temperatures were maintained when delivering food to residents for three (R50, R121, R104) residents reviewed for dietary services in a sample of 28.

Inspectors wroteBased on record review and interviews the facility failed to provide the right of every resident to formulate an advance directive and advance care planning for 1 of 1 resident (R29) reviewed in a sample of 28 residents. These failures have the potential to affect 1 resident (R29) to exercise the option for advance directives and choose treatment.

Inspectors wroteBased on observation, interviews and record review, the facility failed to protect the privacy and confidentiality of one (R40) resident's personal and medical records of six reviewed in a sample of 28.

Inspectors wroteBased on observations, interview and review of records, the facility failed to maintain a homelike environment for one (R80) out of 3 residents reviewed for homelike environment in a sample of 28.

Inspectors wroteBased on interview and record review the facility failed to assure that a resident who was incontinent of bowel and bladder received the appropriate services to restore continence to the extent possible for one (R111) resident reviewed for bowel and bladder in a sample of 28.

Inspectors wroteBased on observation, interviews, and review of records the facility failed to ensure that a resident's head was elevated during administration and flushing of enteral feeding for 1 out of 1 resident (R398) for a total sample of 28 residents. This failure has the potential to affect 1 resident (R398) in preventing aspiration related to enteral feeding.

Inspectors wroteBased on review of records and interview the facility failed to provide education for the benefits and risks of influenza and pneumococcal vaccinations for 2 out of 5 residents (R147 and R29) per policy. These failures have the potential to affect 2 residents (R147 and R29) in understanding the benefits and risks of vaccination and prevention of infections.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure that the resident's bathroom sink and toilet were maintained and working properly for 2 of 3 residents, R4 and R6 (R4, R6, R3) reviewed for physical environment in the sample of 3.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure waste management and odors were maintained regarding the facility's sewage pit. This failure has the potential to affect all 155 residents that reside in the facility. Findings Include: During the survey date of 2/24/24, upon entry of the facility, observed a light smell of sewage. V3[ MDS Coordinator] escorted surveyor to the basement conference room. Upon exiting the elevator, odor of feces and sewage was strong and offensive. V3 moved surveyor to another conference room on the first floor. On 2/24/24 at 12:04 PM, V3 [MDS Coordinator] stated, The smell in the basement is from the sewer. I am not sure why the odor is strong. Let's go to another conference room on the first floor, where the odor is not as strong. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior on 3 of 4 floors of the facility.

Inspectors wroteBased on record review and interview the facility failed to develop and implement a discharge care plan for three of three residents (R1, R11, R12) reviewed for discharge planning. On 11/16/23 V2 (Director of Nursing) provided R1's entire care plan as requested. Review of R1's care plan showed no care plan for potential discharge. R1's social service notes for the last full year was requested. On 11/20/23 V14 (Social Service Director) provided one page of notes dated 11/24/23. This note was reviewed and did not contain any information on R1's potential discharge. On 11/20/23 at 11:05am, V14 (Social Service Director) stated, there is only one page of notes for R1. V14 stated, I do not know why there is only one note. V14 stated, we do not develop a care plan for discharge unless they are discharging. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to document timely skin assessments upon readmission and failed to ensure that treatment orders were obtained and/or administered to R1 on readmission

Inspectors wroteBased upon observation, interview and record review the facility failed to ensure that staff are aware of how to transfer residents (from chair to bed) safely, failed to implement fall prevention interventions, and failed to provide supervision for one of three residents (R2) reviewed for falls.

Inspectors wroteBased on observations, interview and record review, the facility failed to follow its policy on infection control and prevention to prevent the spread of COVID -19 by not having biohazard garbage bins in a room of residents with confirmed COVID-19 infections and staff not wearing proper PPE (Personal Protective Equipment) when entering a room of a resident with confirmed COVID-19 infection. This deficiency has the potential of affecting all 123 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to document temperature reading on the reach-in cooler temperature log and ensure food is being discarded on or before the expiration date. This has the potential to affect all 124 residents in the facility who receive an oral diet.

Inspectors wroteBased on interview and record review the facility failed to follow Quality Assurance/ Performance Improvement Program (QAPI) policy and procedure by not analyzing, identifying, and implementing corrective actions. This failure has the potential to affect 128 residents in the facility receiving care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to clean the lint screen thoroughly in an effort to provide a safe environment to the residents. This failure has the potential to affect all 128 residents at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) care related to shaving for four residents (R6, R10, R65, and R71). This failure affected four residents from a sample of 64 residents.

Inspectors wroteBased on observation, interview, and record review that facility failed to ensure that CPAP/ BIPAP (Continuous Positive Airway Pressure/ Bilevel Positive Airway Pressure) machines were cleaned after each use for four residents (R55, R57, R121, and R433) that were reviewed in a sample of 66 residents. This failure has the potential to affect all eight residents that use CPAP machines.

Inspectors wrote5) R116 is [AGE] year old with diagnosis including but not limited to: Elevated of levels of Liver Transaminase levels, Alcoholic cirrhosis of liver, Anxiety disorder, Hypertensive heart disease and Localized edema. On 7/31/23 at 11:28 PM, Surveyor observed 2 half pint cartons of expired milk in R116's personal refrigerator. Both cartons of milk were dated 7/24/23. Old fruit observed on the side of the refrigerator, and temperature log with missing signatures on it. R116's refrigerator temperature log was missing temperature recordings for 7/22/23- 7/31/23. The dates of 7/22/23- 7/20/23 documents random dates. On 7/31/23 at 11:35 AM V17 LPN (Licensed Practical Nurse) said, Housekeeping is responsible for checking the temperature logs daily. Housekeeping are also responsible for cleaning the refrigerators and removing old and spoiled food. The milk in R116's refrigerator is expired. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the food cart was not left unattended without staff presence and failed to ensure staff perform appropriate hand hygiene prior to touching a resident's food tray. These failures affected R26 and have the potential to affect all 9 residents receiving an early tray on the 3rd floor.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide accommodation of call device system for one resident (R9) with physical limitations in a sample of 66 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident received mail timely in the facility and failed to ensure that a resident received personal mail unopened which affected R10 and R66 in the sample of 66 residents reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to inventory and document a resident's personal belongings and failed to ensure that a resident's personal belongings are labeled appropriately with the resident's name which affected one (R42) resident in the sample of 66 residents reviewed.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the low air loss mattress is set on an appropriate setting for 1 resident (R123) reviewed for pressure ulcer prevention in the total sample of 66 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff properly documented the medication administration record. This failure affected one resident (R37) in the sample of 66 residents. [...]