Foster Health & Rehab: Verbal Abuse Unreported - Chicago, IL
The resident at the center of the allegation, identified in inspection records only as R2, was later hospitalized with altered mental status.
The sequence of events, reconstructed from inspector interviews conducted in late December 2025, shows a facility where a verbal abuse allegation moved from witness to charge nurse to administrator and then stopped. Nobody called the Illinois Department of Public Health. Nobody suspended the employee. Nobody sat down to investigate.
The staff member accused of cursing at R2 is identified in the report as V6. The witness who reported hearing it is V9. The charge nurse who received the report and buried it is V5. The administrator, who also serves as the facility's human resources director, is V1.
V9 told V5 that V6 had cursed at R2 during the medical appointment, using the phrase "shut the f**k up." V5's response, as she later described it to inspectors, was to decide she didn't believe it. She told inspectors she had never heard V6 curse before. V6, she said, was a good person.
That was where V5 left it.
When inspectors pressed V5 on whether she had actually told the administrator that V6 cursed at R2, her answer shifted. "Oh yeah," she said, according to the inspection report. "I just told on myself, okay." V9 had, in fact, reported the specific language. V5 had passed it along to V1, the administrator. But neither of them, V5 explained, believed V9, so neither of them acted on it.
V1's account, given to inspectors on December 23, confirmed the basics. V5 had kept her informed about other issues involving R2, including a broken wheelchair and transportation problems related to the medical appointment. But V5, V1 said, had not reported the verbal abuse allegation. "I take full responsibility," V1 told inspectors. "Leave V5 and V3 out of this."
The statement was notable for two reasons. First, V5 had already told inspectors she did report it to V1. Second, V1's declaration of sole responsibility came in the same breath as her explanation that she simply could not locate any documentation showing V6 had completed abuse training during orientation. "I must have misplaced the abuse training," V1 said.
By December 24, the story had shifted again. V1 told inspectors she had called the hospital and spoken directly with R2. She said R2 told her he did not know who V6 was. She also reported that V5 had contacted her to walk back part of her earlier statement, saying she had been confused during the inspector interview and had mistakenly said she told V1 about the cursing allegation.
R2 was in the hospital being treated for altered mental status.
The inspection report does not characterize V1's decision to call the hospitalized resident and ask him to confirm or deny an abuse allegation. It records the call and its result. R2 said he did not know who V6 was. V1 appeared to treat this as resolution.
It was not resolution. The question of whether V6 cursed at R2 was never formally investigated. No written report was submitted to the Illinois Department of Public Health. V6 was not suspended pending any review. The facility's own abuse policy, dated January 3, 2025, states that initial reporting of allegations shall be completed immediately upon notification, that a written report shall be sent to the Department of Public Health, and that the administrator or designee will investigate and obtain documentation related to the incident.
None of that happened.
On December 26, the final day of the inspection, V1 addressed the training records one more time. The abuse training V6 received during orientation, she explained, had been verbal. There was no paperwork. No signed acknowledgment form. The facility's own policy states that all employees will sign an Abuse Policy Employee Acknowledgement form. V1 acknowledged there was nothing to show. "I take full responsibility," she said again.
The inspection report assigns the deficiency a harm level of minimal harm or potential for actual harm, affecting few residents. That classification reflects the regulatory scoring framework, not a judgment about what it means to tell a nursing home resident to shut up during a medical appointment, or about what it means to learn that happened and decide, because you think someone is a good person, that it probably didn't.
What the record shows is a charge nurse who filtered an abuse report through her own opinion of the accused and passed along a version that omitted the key detail. An administrator who received enough information to understand something had happened and took no formal action. A facility that could not document that its employee knew the rules about abuse when she was hired. And a hospitalized resident, confused enough to be admitted for altered mental status, whom the administrator called to ask whether he remembered being cursed at.
V5's slip during the inspector interview, "I just told on myself, okay," is the clearest moment in the report. She knew what she had heard. She knew what she had told the administrator. She had spent the interview trying to describe her own inaction as disbelief, and then the truth came out in a single unguarded sentence.
V1's repeated offers to take full responsibility, offered twice across two days of interviews, did not include any account of what she would have done differently if V5 had told her the full allegation from the start. She said only that V6 would have been suspended immediately, reported to IDPH, and investigated. That is what she said she would have done. It is not what she did when the allegation eventually reached her, through inspectors, in full.
R2 was in the hospital. V6 remained uninvestigated. The training records did not exist.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Foster Health & Rehab Center from 2025-12-26 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
FOSTER HEALTH & REHAB CENTER in CHICAGO, IL was cited for abuse-related violations during a health inspection on December 26, 2025.
The resident at the center of the allegation, identified in inspection records only as R2, was later hospitalized with altered mental status.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.