Forest View Rehab & Nursing Center

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

completing self-harm/suicide risk screening assessments accurately, including properly recording the assessment score, completing timely and accurately with appropriate, individualized interventions in place.

Suicide risk assessments need to be completed upon admission, quarterly, upon significant changes, and as needed.The facility created a process to address the results of the self-harm/suicide risk screening assessment to ensure recommendations from the screening, and measurable care plan interventions are put in place to instruct staff on how to keep residents safe. The facility created a policy and guidelines to the self-harm/suicide risk assessment and implemented on [DATE REDACTED].Nursing staff were in-serviced by DON/ADON (Director of Nursing/Assistant Director of Nursing) starting on [DATE REDACTED], and will complete on [DATE REDACTED], to ensure that residents with suicidal ideation will be monitored every shift under behavior monitoring and will be documented in the EMR (Electronic Medical Record). Residents with a history of obtaining sharp objects will have room searches conducted during angel rounds as permitted by residents or POA (Power of Attorney).Beginning [DATE REDACTED], an audit tool will be completed by Administrator, DON and or ADON on every resident upon admission, re-admission, quarterly and with significant changes to ensure that suicide risk screening assessments are completed accurately with appropriate individualized care plans as follows: Three times a week for the first two weeks, two times a week for two weeks, one time week for two weeks, and one time a month for two months.QAPI (Quality Assurance Performance Improvement) Committee, which meets monthly, will review for compliance, and determine that compliance has been met. An emergency QAPI meeting was held on [DATE REDACTED], and attended by the Medical Director and interdisciplinary team.

Event ID:

Facility ID:

If continuation sheet

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

11/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Forest View Rehab & Nursing Center

535 South Elm Itasca, IL 60143

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 0835

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Level of Harm - Minimal harm or potential for actual harm

Based on interview and record review, the administration failed to provide oversight and leadership to ensure staff is qualified to work as a Social Service Director. The administration also failed to ensure self-harm/suicide risk screening assessments were completed accurately, timely, and individualized and measurable care plan interventions were put in place for residents identified at risk for suicide. This applies to all 130 residents living in the facility.The findings include: The Facility Data sheet dated October 24, 2025, shows the facility census as 130 residents. Concerns were identified regarding the accuracy, timeliness, and individualized care plan interventions for multiple residents screened by V12 (SSD-Social Service Director) for self- harm/suicide risk, including Resident R1, Resident R5, Resident R6, Resident R7, Resident R8, Resident R9, Resident R10, Resident R11, Resident R12, Resident R13, and Resident R17. On October 30, 2025, at 3:00 PM, V12's employment record showed on July 19, 2021, V12 was hired as the facility's full-time Social Service Director. V12's employment record shows V12 has completed four years of high school education. V12 did not have any college education listed in her employment record. The facility's Job Description for the position title of Director of Social Services shows the education requirements for the position of Director of Social Services as either a bachelor's degree in psychology or sociology, a B.A. (Bachelor of Arts) or M.A. (Master of Arts) in social work, or a Licensed Clinical Social Worker's Certificate. The facility does not have documentation to show V12 had any of the required education or certificates as shown in her job description. On January 10, 2022, V12 signed the form entitled Job Description for the position title of Director of Social Services. The form V12 signed shows, I have read

this job description and fully understand the requirements set forth therein. On October 30, 2025, at 3:30 PM, V1 (Administrator) said he is not sure if V12 (SSD- Social Service Director) has all the required qualifications to work as the Social Service Director.

Residents Affected - Many

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

Event ID:

Facility ID:

If continuation sheet

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

11/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Forest View Rehab & Nursing Center

535 South Elm Itasca, IL 60143

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 0850

Hire a qualified full-time social worker in a facility with more than 120 beds.

Level of Harm - Minimal harm or potential for actual harm

Based on interview and record review, the facility failed to employ a qualified social worker on a full-time basis. This applies to all 130 residents residing in the facility. The findings include: The Facility Data sheet dated October 24, 2025, shows the facility census as 130 residents. On October 30, 2025, at 3:30 PM, V1 (Administrator) said he is not sure if V12 (SSD- Social Service Director) has all the required qualifications to work as the facility's Social Service Director. On October 30, 2025, at 3:00 PM, V12's employment record shows on July 19, 2021, V12 was hired as the facility's full-time Social Service Director. V12's employment

record shows V12 has completed four years of high school education. V12 did not have any college education listed in her employment record. The facility's Job Description for the position title of Director of Social Services shows the education requirements for the position of Director of Social Services as either a bachelor's degree in psychology or sociology, a B.A. (Bachelor of Arts) or M.A. (Master of Arts) in social work, or a Licensed Clinical Social Worker's Certificate. The facility does not have documentation to show V12 had any of the required education or certificates as shown in her job description. On January 10, 2022, V12 signed the form entitled Job Description for the position title of Director of Social Services. The form V12 signed shows, I have read this job description and fully understand the requirements set forth therein.

On November 3, 2025, at 2:37 PM, V18 (Medical Director) said, I was not aware [V12] (SSD) does not have

the qualifications necessary to be the Social Service Director. You cannot hire someone without the right qualifications. The facility should have followed the regulations and the job description. I did not know this.

Residents Affected - Many

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

Event ID:

Facility ID:

If continuation sheet