Foster Health & Rehab Center

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

day his wheelchair broke. I was at the desk with Resident R2 and two other ladies. I was trying to get Resident R2 seen by the physician while we were there, because it took a long time waiting to receive an appointment. I did not curse at Resident R2. While I was speaking, Resident R2 did cut me off, but I did not curse at Resident R2.On 12/23/25 at 2:00 PM V5 [Office Manger], stated, I received a phone call from V9 [Medical Clinic Manager] and asked when Resident R2's transportation will be there for pick up. Also, V9 said that V6 was rude to Resident R2. That's all V9 said to me, she did not say how or what V6 did to Resident R2. I did not believe V9, because I never heard V6 curse.Surveyor asked V5, why did she say she never heard V6 curse, did V5 say V6 cursed at Resident R2?V5 stated, Oh yeah, I just told

on myself, okay. V9 did say she heard V6 curse at Resident R2 saying ‘shut the f_ _k up'. I did not tell V3 [Director of Nursing], but I told V1 [Administrator] immediately. But V1 and I knew V6 did not curse at Resident R2, because she is a good person, and we never heard V6 curse before, V1 and I did not believe V9.On 12/23/25 at 3:00 PM, V1 [Administrator] stated, V5 kept me informed about Resident R2's broken wheelchair and transportation issues. V5 did not report Resident R2 was verbally abused by V6 at his medical appointment, but I take full responsibility leave V5 and V3 out of this. I am the human resource director. I cannot locate V6's abuse training during orientation. I must have misplaced the abuse training. If I was made aware of the allegation, V6 would have been suspended immediately, reported to IDPH, and investigation would have occurred.On 12/24/25 at 10:10 AM, V1 stated [during telephone conversation], I called the hospital and spoke with Resident R2. I asked Resident R2 if V6 cursed at him, Resident R2 said he did not know who V6 was. Resident R2 was admitted to the hospital for altered mental status. Also, V5 told me she was confused during the interview, and she mistakenly said she told me V6 cursed at Resident R2.On 12/26/25 at 11:30 AM, V1 stated, The abuse training orientation was verbal, I do not have any documentation that V6 received abuse training. I take full responsibility.Policy in part:Abuse and Prevention dated 1/3/25This affirms the right of our residents to be free from abuse. The facility is committed to protecting our residents from abuse by anyone including, but not limited to facility staff, and other residents. Abuse means any physical, mental, sexual, verbal inflicted upon a resident. Verbal abuse is

the use of oral, written, gestured language that willfully includes disparaging and derogatory terms to the resident within in their hearing distance regardless of their age, ability to comprehend or disability.

Employees: Orientation and training employees: Resident rights, resident needs, to prevent and report abuse. All employees will sign an Abuse Policy Employee Acknowledgement form. Employees are required to immediately report any occurrences of potential mistreatment they observed, hear about, or suspect to supervisor and or administrator. Reporting: Initial reporting of allegations shall be completed immediately upon notification of the allegation. The written report shall be sent to the Department of Public Health.

Investigating: The administrator or designee will investigate the allegations and obtain a copy of any documentation related to the incident.

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Foster Health & Rehab Center

2840 West Foster Avenue 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

wheelchair. How V6 reported the incident was so vague, I did not speak to anyone. We rescheduled the appointment. On 12/24/25 at 09:15 AM V3 (Director of Nursing) stated the wheelchair that broke, Resident R2 had it for a long and it was a regular wheelchair in weight. Policy:Titled Accident Incident/Fall Reporting Policy revised 01/01/25 document in part: Any accident/incident will be reported immediately to the nurse or appropriate person designated to be in charge. A written report will be completed for anu individual (resident) involved in an accident or an incident while residing in the facility. Purpose: To ensure that accidents and incidents that occur with residents is identified, reported, investigated, and resolved. To provide a database to study the cause of accidents/incidents and to provide assistant in implementing corrective actions to prevent reoccurrence when possible. Procedure: 1. If a resident is involved in and accident/incident an immediate assessment of the resident will be completed. 2. The nurse responsible for

the oversite and care of the resident will complete an incident/accident report. When possible, a descriptive statement will be obtained from the resident and any witnesses. (Utilize the witness statement form). 3. The nurse will notify the resident's attending physician/nurse practitioner. Any actions/communications are to be documented in the resident's medical record. 4. The surrogate or authorized representative is to be notified of the accident/incident. 5. Any accident/incident report, which has occurred, shall be reported to the nurse's manager on duty or designee. 6. An accident/incident report will be completed as soon as information is obtained. The report is to be completed as fully as possible before the nurse ends the shift.

An exact description of the circumstances surrounding the incident/accident will be provided. Only facts will be documented. 7 The occurrence will be documented in the resident's medical record. Documentation in

the medical record should include the following: Description of the occurrence, Physical and mental status of the resident, Time of physician notification and physician response/orders, Time of notification of the resident's family, guardian, or responsible party. 8. A complete incident/accident report will be submitted to

the Director of Nurses or designee. 10. Documentation of the resident's physical and mental status will be completed each shift following the incident for a minimum of 72 hours or until the condition symptoms improve. Neuro-checks will be completed according to policy. 11. The occurrence is to be communicated shift to shift as part of the unit report until the resident is stabilized. 13. A thorough investigation will be completed within 5 business days. 14. Based on the results of the investigation, the resident care plan is revised as necessary to prevent or minimize further accidents/incidents when possible. 15. A complete investigation tool and other written information will be maintained with the incident report.

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