Ambassador Nursing & Rehab Center
Inspection Findings
F-Tag F0684
F 0684 Level of Harm - Actual harm Residents Affected - Few
call the doctor or nurse practitioner if the nurse does not receive a timely response from the initial call placed. V8 stated, It's not acceptable to leave a message with doctor on an answering service and not follow up. V7 stated that there has to be effective communication for continuity of care. V7 stated that there used to be an on-site nurse practitioner (V12) in the facility every Monday through Friday from 9:00 AM to 4:00 PM who would write the prescription refills for a resident's controlled substance medication that was due to be empty (zero remaining) over the weekend; therefore, there would be no lapse in medication coverage. V7 stated that V12 stopped working in the facility within the past 1 to 2 weeks while V7 was off of work. V7 stated that the if the nurse does not receive a return call back from a doctor or nurse practitioner,
the nurse should call the medical director of the facility, V13. V7 stated that with Resident R1 not receiving the scheduled Pregabalin three times a day for 2 and 1/2 days, Resident R1 would be in excruciating pain, discomfort and stress and this would affect Resident R1's mood, where Resident R1 would not be a happy client.
On 8/20/25 at 4:19 PM, V2 (DON) stated that Pregabalin is a controlled substance that requires a prescription from the doctor for pharmacy to refill this medication. V2 stated that nurses are expected to notify a resident's physician or nurse practitioner for renewal of Pregabalin prior to the medication being completely administered (zero capsules remaining). V2 stated that V12 (Former Nurse Practitioner) stopped working in the facility 2 weeks ago, and nurses are expected to follow up with the primary doctors/nurse practitioners for medication refills. V2 stated that V15 (Nurse Practitioner) is now managing some residents, including Resident R1, for pain management needs. When asked about V2 being notified or was V2 aware of Resident R1's Pregabalin not being administered as scheduled, V2 stated that V2 worked 4 hours in the facility on 8/15/2025 and was not answering or taking work phone calls over the weekend (8/16-8/17/2025) adding, I (V2) was [NAME] (missing in action). V2 stated that when a nurse goes to administer a medication to a resident and the medication is not available in the facility, the nurse will document a pharmacy code of 9 and will document the reason why the medication was not administered. V2 stated that the nurse is to notify
the doctor also of the resident missing a scheduled medication as ordered by the doctor. V2 stated, They (nurses) should be documenting the doctor when they notify them (doctors).
On 8/21/2025 at 12:50 PM, V15 (Nurse Practitioner) stated that V15 is the physical medicine nurse practitioner seeing several residents, including Resident R1, in the facility for pain management and evaluates frequency needs for narcotic medications. V15 stated that V15 visited Resident R1 on 8/18/25 and that Resident R1 has paraplegia. V15 stated that Resident R1 has used Hydrocodone-Acetaminophen sparingly (1 to 2 times) and that nurses verified this as well. V15 stated that Resident R1 is on scheduled medications for Resident R1's pain, such as Pregabalin, and Pregabalin has an indicated use for neuropathic or polyneuropathy pain. V15 stated that narcotics, like Hydrocodone-Acetaminophen, that are not needed long-term, should be weaned off, especially if the resident's pain is controlled by other medications. When asked the potential of Resident R1 not receiving scheduled Pregabalin as ordered, what are potential risks that Resident R1 can experience, and V15 stated that Resident R1's pain would increase and not be controlled. When asked how many days can a resident be without pain, or experiencing pain, when the resident is not receiving their scheduled doses of Pregabalin, V15 stated that V15 cannot give an exact time frame, but Pregabalin is a medication that needs to build up
in the system, and we don't want a lapse in giving this medication in my professional opinion.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
AMBASSADOR NURSING & REHAB CENTER in CHICAGO, IL inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in CHICAGO, IL, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from AMBASSADOR NURSING & REHAB CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.