Health inspection·November 4, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide the necessary monitoring and supervision for a resident with a history of suicidal ideation and a history of obtaining knives. The facility also failed to have a system in place to accurately screen residents for suicide risk in a timely manner, and ensure residents with suicide risk were identified, and interventions were put in place. This failure resulted in R1 sustaining self-inflicted stab wounds and expiring at the facility from apparent suicide. This failure resulted in Immediate Jeopardy when the facility lacked interventions and processes to protect a resident with a history of suicidal ideation from keeping sharp knives in his room and sustaining self-inflicted stab wounds and expiring from apparent suicide. The Immediate Jeopardy began on [DATE], at approximately 6:00 AM when R1 was found expired in his bed by facility staff with stab wounds to his chest. The Administrator was notified of the IJ on [DATE], at 3:14 PM. This applies to 14 of 14 residents (R1, R5 - R17) reviewed for suicidal ideation in the sample of 17. The findings include:1. The EMR (Electronic Medical Record) shows R1 was a [AGE] year-old male resident admitted to the facility on [DATE]. The EMR continues to show R1 expired at the facility on [DATE]. R1 had multiple diagnoses including heart failure, non-traumatic subacute subdural hemorrhage, aortic stenosis, hypertensive heart disease, morbid obesity, Type 2 diabetes, atrial fibrillation, major depressive disorder, pyloric stenosis, right shoulder osteoarthritis, acute respiratory failure, history of venous thrombosis, and acute kidney failure.R1's MDS (Minimum Data Set) dated [DATE] shows R1 was cognitively intact, required supervision with eating, substantial/maximal assistance with oral and personal hygiene, and was dependent on facility staff for all other ADLs (Activities of Daily Living). R1 was always incontinent of bowel and bladder. R1's MDS continues to show R1 was feeling down, depressed, or hopeless, and had trouble sleeping nearly every day.The EMR shows R1's hospital paperwork dated [DATE], shows multiple active problems including suicidal ideation.The facility's final incident report submitted to the State Agency on [DATE] shows, On [DATE] at approximately 5:45 AM, staff discovered [R1] unresponsive and without vital signs. Blood was observed on his body and the floor beneath his bed. Emergency medical services (911) were immediately contacted, and [R1] was pronounced dead at 6:45 AM. A comprehensive investigation was completed, including staff interviews, medical record review, and collaboration with law enforcement and the coroner's office. Based on the findings: there is no evidence of foul play. The findings are consistent with self-harm, and the cause of death has been determined to be suicide. On [DATE] at 10;18 AM, V6 (RN-Registered Nurse) said, I had [R1] the night of the incident. I checked on [R1] two times. I didn't notice anything wrong with him. I went in there to check his blood sugar around 5:30 or 6:00 AM and when I went in there, I was shocked. I saw [R1's] mouth open, and the oxygen tubing wasn't in his nose, and I was thinking he passed away from removing the oxygen. I couldn't check his blood sugar because he was pale and cyanotic. There was a lot of blood, and when we opened the sheets, I was panicking Page 1 of 9 145752 145752 11/04/2025 Forest View Rehab & Nursing Center 535 South Elm Itasca, IL 60143

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few looking at the blood. I couldn't even see where it was coming from, and I was thinking it looked like a crime or something. I opened the blanket and there was blood by the incontinence brief. Blood was everywhere, and then when I moved to the other side by the window, I was about to collapse because I was so scared from the amount of blood on the floor. Then the other CNA (Certified Nursing Assistant) was searching and found two knives and there were blood stains on the knives. I called 911 and [V2] (DON-Director of Nursing). There was a lot of blood on his chest. I was scared to touch him, and I could see it coming from the left side of his chest. I asked the roommate if he noticed something. Last year, I had him and they said I had to send him out because he was going to kill himself with a plastic bag. We had him on one-to-one supervision, and then we searched, and we found knives. We removed the knives from his room, and he was mad at me for taking his things. I was surprised the hospital sent him back when that happened. I did not wake [R1] up on the night of [DATE] because he would get mad at me if I would wake him up. His roommate gets mad too. There's a person who visits, his friend. Maybe [R1] bought the knives or asked the lady to bring him knives. He likes to cut his fruits.On [DATE] at 1:57 PM, V3 (CNA) said, I was doing my last rounds on my unit on [DATE]. I saw [V7] (CNA) coming towards me, and he said [R1] passed away. I wasn't aware of how he had passed, and when I saw the blood on him, I saw two knives on the bedside table. They were wrapped in white paper towels. There were two knives. One with a black handle with a stainless-steel pointed tip, and then there was a smaller knife, and it was a light blue color and it was also pointed. [R1] was covered with blood on his chest and down his left-hand side of his body, and there was a puddle of blood on the floor. I wasn't able to see the puddle of blood on the floor when I entered the room because it was between the bed and wall by the window. The puddle was at least two feet in diameter. I work night shift and mostly everyone is in bed, and they don't come out of their room.On [DATE], at 1:37 PM, V4 (RN) said, I am usually assigned to [R1's] unit. In May of this year, [R1] had knives in his room.On [DATE], at 3:32 PM, V4 documented, Resident's friend came today to visit resident. Resident's knives (3 pieces) were given to the friend as per agreement with resident. SS (Social Services) aware.The facility does not have documentation to show R1 received education regarding keeping sharp knives in his room. The facility does not have documentation to show R1's room was searched for sharp objects at any time during the duration of his stay at the facility. On [DATE] at 12:27 PM, V15 (Psychiatric NP-Nurse Practitioner) said, I saw [R1] about two weeks before the incident of [DATE]. [R1] has always been dismissive. He always refuses evaluation and says he is not depressed and doesn't need me. I know from the staff he said he was depressed. He had not fired me yet, and never said he didn't want my services, but never entertained me to get enough information from him. He wasn't really completely open with me. I was just told [R1] committed suicide by using a knife. I can't imagine how he was able to do that. When I asked, they said he stabbed himself in the chest. I tried to start him on medications for depression, but he refused. He does not entertain my questions. I would never assume he was not suicidal. No staff told me that he kept sharp knives in his room. Because of his history of suicidal ideation, I would ask them to take them away because I would be afraid, he would harm himself. In my opinion, I would say you should not let someone keep a sharp knife in their room. People who attempted one or two times are likely to be successful on their other attempts.Local police department documentation dated [DATE], shows the date of R1's incident as [DATE]. V16 (Police Officer) documented, I went into [R1's] room and observed [R1] deceased with a large puddle of what appeared to be blood underneath his bed. [V6] RN stated in summary and not verbatim that: She is the night nurse and [R1] is her patient. She started her shift at 2315 (11:15 PM) on [DATE]. She checked on [R1] at approximately 0000 (midnight) and did not notice anything out of the usual. She did 145752 Page 2 of 9 145752 11/04/2025 Forest View Rehab & Nursing Center 535 South Elm Itasca, IL 60143

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few her rounds at approximately 0430 (4:30 AM), and [R1] appeared to be sleeping with his mouth closed. At approximately 0600 (6:00 AM) [V6] realized that [R1] had not paged nurses to his room to assist with anything as he typically does every day of the week. [V6] went to his room to check on him which is when she found him with his mouth open, not breathing, and cold to the touch. [V6] then realized there was blood on [R1's] body and blood on the ground and called 911 and asked her CNA to assist in trying to determine what had happened [V7] (CNA) and [V6] began to check [R1's] body and noticed what appeared to be cut marks on [R1's] legs. [V6] and [V7] then uncovered [R1's] body with his blanket and exited the room. [V6] stated that throughout her shift overnight she did not see anyone enter or exit [R1's] room or hear any unusual noises throughout the night. The nursing staff stated that in the past [R1] was caught with a knife in his room which is not allowed at the facility. The knife was confiscated. The facility then began to monitor packaged that [R1] received via mail. It was stated that on 2 separate occasions, [R1] had ordered a knife from [online retailer]. The knives were confiscated and never given to [R1]. The nurses confirmed that the knives that were wrapped in paper towel on the tray were there prior to their arrival and were left untouched. On [DATE] an autopsy was done on [R1]. The knives that were located on scene were used by the medical examiners to determine if the wounds may have been from the knives. The medical examiners stated that the wounds were consistent to that of the knives located. [R1's] bed is located in a tight corner in the room, with little room to maneuver for someone standing. It would not be feasible for anyone to enter that corner and leave wounds on [R1] that were consistent with the wounds found on the left side of his chest. There were no signs of blood spatter, or any indication of a struggle observed while on scene. Toxicology and coroner's report to follow.Pictures obtained by the local police of R1's room showed two large knives as described in the police report, as well as a third knife, on R1's bedside table. The third knife was orange in color and appeared to be a paring knife. The police evidence pictures also showed what appeared to be three cuts on R1's skin on his right upper thigh, and three cuts on R1's skin on his left upper thigh, as well as at least two stab wounds to R1's chest.On [DATE] at 10:01 AM, V5 (Deputy Coroner) said, R1's autopsy was completed, but official results have not been released due to pending toxicology results, which take approximately 8 to 12 weeks. V5 said, The preliminary cause of [R1's] death is apparent suicide. There were several places he had stab wounds. As of right now, it is being investigated as an apparent suicide. The death certificate will be available in approximately 8 to 12 weeks.The facility's Screening Assessment for Evaluating Self-Harm/Suicide Risk shows instructions for completing the screening tool. The assessment tool is used for evaluating self-harm/suicide risk quickly, in a standardized format for all residents to identify individuals who may be at risk. The screening tool category entitled Assessment shows 10 different questions, including resident age, history of previous suicide attempts and/or verbalization about ending his/her life, history of psychiatric/mental health problems, substance abuse, disturbed relationships, social isolation, chronic behaviors, and post-traumatic stress disorder. The assessment tool automatically generates a severity score based on the answers to the questions and categorizes them as: 0-5 Minimal or low risk, 6-15 Moderate risk, 16-20 Greater than moderate risk, and 21-30 High risk. The tool shows a blank box where the screener fills in the severity score and based on the severity score chooses the recommendations and outcome for the resident.The facility completed one screening assessment for evaluating R1's self-harm/suicide risk for the entirety of his stay at the facility. V12 (SSD-Social Service Director) completed the suicide risk screening on [DATE]. The screening assessment shows R1 had a moderate risk of self-harm/suicide with a numeric score of 6. V12 changed R1's risk assessment score to 4 and indicated R1 was minimal/low risk instead of the moderate risk score 145752 Page 3 of 9 145752 11/04/2025 Forest View Rehab & Nursing Center 535 South Elm Itasca, IL 60143

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few obtained by using the screening tool. The facility does not have any documentation to show R1's self-harm/suicide risk screening assessment was repeated quarterly or as needed with condition changes for the duration of his stay at the facility.The State of Illinois Petition for Involuntary/Judicial admission for R1, dated [DATE] shows R1 was in need of immediate hospitalization for the prevention of harm. I base the foregoing assertion on the following: [R1] is a [AGE] year-old male with a diagnosis of major depressive disorder. Resident expressed SI (Suicidal Ideation), stating that he is going to put a plastic bag over his head until he expires. Resident is in danger to self. V12 (SSD) is shown as the witness to the incident. R1 was sent to the local hospital and returned to the facility on [DATE] with no indication for inpatient psychiatric admission.The State of Illinois Petition for Involuntary/Judicial admission for R1, dated [DATE], and signed by V12 (SSD) shows R1 was in need of immediate hospitalization for the prevention of harm. I base the foregoing assertion on the following: [R1] is a [AGE] year-old male with a diagnosis of major depressive disorder. Our Human Resource Manager went to meet with [R1] to give him some paperwork and [R1] stated he is going to kill himself. [R1] has a noted history of SI. Resident is in danger to self.The facility does not have documentation to show R1 was rescreened for self-harm/suicide risk following R1's threats of suicide on [DATE] or [DATE]. On [DATE] at 3:44 PM, V12 (SSD) said self-harm/suicide risk screening assessments should be completed on every resident quarterly.On [DATE] at 3:10 PM, V12 admitted she changed R1's suicide risk assessment score from a moderate risk score of 6 to a low risk for suicide score of 4 when she completed R1's suicide risk screening on [DATE]. V12 said residents' care plan interventions are determined after completing the suicide risk screening. V12 continued to say she did not know why she did not screen R1 for suicide risk quarterly or following R1's threats of suicide. R1's care plans were reviewed. R1's care plan for history of self-harmful and self-mutilation ideations (thoughts) and/or behavior was initiated on [DATE]. Multiple interventions were initiated on [DATE] including: As warranted, conduct random room safety checks, personal wellness check. As warranted, conduct a room check/search, and remove any sharp objects or similar contraband (razor blades, razors, knives, scissors, hammer, nails, screwdriver, screws, needles, etc.). As warranted, conduct a room check/search and remove any other objects (in the opinion of the health care professionals) may pose a threat to safety.On [DATE], at 3:44 PM, V12 (SSD) said, the words as warranted in R1's care plan meant if he verbalized suicidal ideations, those actions would be implemented. On [DATE] at 11:21 AM, V1 (Administrator) and V2 (DON) were interviewed together. V2 said the facility's Self-harm/Suicide Risk Screening Assessment should be done for every resident upon admission to the facility, quarterly, and as needed. V2 continued to say as warranted in R1's care plan would mean as needed with his permission, and if R1 refused to have his room searched, facility staff should document the refusal. V1 said, there were no plans in place for scheduled searches of R1's room for contraband. The facility does not have any documentation to show safety checks were conducted of R1's room, including checking for sharp objects.2. R5's self-harm/suicide risk assessment screening was completed on [DATE]. V12 (SSD) completed the suicide risk screening. The screening assessment shows R5 had a moderate risk of self-harm/suicide with a numeric score of 7. V12 changed R5's risk assessment score to 4 and indicated R5 was at minimal/low risk instead of the moderate risk score obtained by using the screening tool. The EMR shows V12 also lowered R5's risk screening scores for the screenings dated [DATE], [DATE], [DATE], February 4, 2025, [DATE], [DATE], and [DATE]. The facility does not have care plans in place to address R5's moderate risk for self-harm/suicide risk.3. R6's self-harm/suicide risk assessment screening was completed on [DATE]. V12 (SSD) completed the suicide risk screening. The screening assessment shows R6 had a moderate risk of self-harm/suicide with a numeric score of 7. V12 145752 Page 4 of 9 145752 11/04/2025 Forest View Rehab & Nursing Center 535 South Elm Itasca, IL 60143

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few changed R6's risk assessment score to 3 and indicated R6 was at minimal/low risk instead of the moderate risk score obtained by using the screening tool. The EMR shows V12 also lowered R6's risk screening scores for the screenings dated [DATE], and [DATE]. The facility does not have care plans in place to address R6's moderate risk for self-harm/suicide risk.4. R7's self-harm/suicide risk assessment screening was completed on [DATE]. V12 (SSD) completed the suicide risk screening. The screening assessment shows R7 had a moderate risk of self-harm/suicide with a numeric score of 6. V12 changed R7's risk assessment score to 3 and indicated R7 was at minimal/low risk instead of the moderate risk score obtained by using the screening tool. The EMR shows V12 also lowered R7's risk screening scores for the screenings dated February 13, 2024, [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The facility does not have care plans in place to address R7's moderate risk for self-harm/suicide risk.5. R8's self-harm/suicide risk assessment screening was completed on [DATE]. V12 (SSD) completed the suicide risk screening. The screening assessment shows R8 had a moderate risk of self-harm/suicide with a numeric score of 6. V12 changed R8's risk assessment score to 5 and indicated R8 was at minimal/low risk instead of the moderate risk score obtained by using the screening tool. The facility does not have documentation to show R8 was screened for self-harm/suicide for the period of [DATE] to [DATE]. The EMR shows V12 also lowered R8's risk screening score for the screening dated [DATE] from 6 (moderate risk) to 5 (low risk). The facility does not have care plans in place to address R8's moderate risk for self-harm/suicide risk.6. R9's self-harm/suicide risk assessment screening was completed on [DATE]. V12 (SSD) completed the suicide risk screening. The screening assessment shows R9 had a moderate risk of self-harm/suicide with a numeric score of 8. The facility does not have documentation to show R9 was screened for self-harm/suicide for the period of February 9, 2024 to [DATE]. R9's suicide risk screening dated on February 9, 2024 shows R9 scored 8 (moderate risk of suicide). The facility does not have care plans in place to address R9's moderate risk for self-harm/suicide risk.7. R10's self-harm/suicide risk assessment screening was completed on [DATE]. V12 (SSD) completed the suicide risk screening. The screening assessment shows R10 had a moderate risk of self-harm/suicide with a numeric score of 7. The EMR shows the previous suicide risk screening completed for R10 was on [DATE], and R10 scored moderate risk for suicide. The facility does not have care plans in place to address R10's moderate risk for self-harm/suicide risk.8. R11's self-harm/suicide risk assessment screening was completed on [DATE]. V12 (SSD) completed the suicide risk screening. The screening assessment shows R11 had a moderate risk of self-harm/suicide with a numeric score of 7. The EMR shows the previous suicide risk screening completed for R11 was on [DATE], and R11 scored moderate risk for suicide. The facility does not have care plans in place to address R11's moderate risk for self-harm/suicide risk.9. R12's self-harm/suicide risk assessment screening was completed on [DATE]. V12 (SSD) completed the suicide risk screening. The screening assessment shows R12 had a moderate risk of self-harm/suicide with a numeric score of 6. V12 changed R12's risk assessment score to 5 and indicated R12 was at minimal/low risk instead of the moderate risk score obtained by using the screening tool. The EMR shows V12 also lowered R12's risk screening score for the screening dated [DATE] from 6 (moderate risk) to 5 (low risk). The facility does not have care plans in place to address R12's moderate risk for self-harm/suicide risk.10. R13's self-harm/suicide risk assessment screening was completed on [DATE]. V12 (SSD) completed the suicide risk screening. The screening assessment shows R13 had a moderate risk of self-harm/suicide with a numeric score of 8. V12 changed R13's risk assessment score to 3 and indicated R13 was at minimal/low risk instead of the moderate risk score obtained by using the screening tool. The EMR shows V12 also lowered R13's risk screening score for the screening dated [DATE] from 8 (moderate risk) to 3 (low risk). The facility does 145752 Page 5 of 9 145752 11/04/2025 Forest View Rehab & Nursing Center 535 South Elm Itasca, IL 60143

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few not have care plans in place to address R13's moderate risk for self-harm/suicide risk.11. R14's self-harm/suicide risk assessment screening was completed on [DATE] by V17 (SW-Social Worker). The screening assessment shows R14 had a moderate risk of self-harm/suicide with a numeric score of 6. V17 changed R14's risk assessment score to 4 and indicated R14 was at minimal/low risk instead of the moderate risk. The EMR shows the previous suicide risk screening completed for R14 was [DATE] and V12 changed R14's risk assessment score from 7 (moderate risk) to 5 (low risk). The facility does not have care plans in place to address R14's moderate risk for self-harm/suicide risk.12. R15's self-harm/suicide risk assessment screening was completed on [DATE]. V17 (SW) completed the suicide risk screening. The screening assessment shows R15 had a moderate risk of self-harm/suicide with a numeric score of 6. V17 changed R15's risk assessment score to 3 and indicated R15 was at minimal/low risk instead of the moderate risk score obtained by using the screening tool. The EMR shows V12 also lowered R15's risk screening score for the screening dated February 13, 2025 from 6 (moderate risk) to 3 (low risk). The facility does not have care plans in place to address R15's moderate risk for self-harm/suicide risk.13. R16's self-harm/suicide risk assessment screening was completed on [DATE]. V17 (SW) completed the screening. The screening assessment shows R16 had a moderate risk of self-harm/suicide with a numeric score of 7. The facility does not have documentation to show the self-harm/suicide risk assessment was completed from [DATE] to [DATE]. R16's self-harm/suicide risk assessment score on [DATE] was 7 (moderate risk). The facility does not have care plans in place to address R16's moderate risk for self-harm/suicide risk.14. R17's self-harm/suicide risk assessment screening was completed on [DATE]. V12 (SSD) completed the screening. The screening assessment shows R17 had a moderate risk of self-harm/suicide with a numeric score of 6. V12 changed R17's risk assessment score to 3 and indicated R17 was at minimal/low risk instead of the moderate risk score obtained by using the screening tool. The facility does not have documentation to show the self-harm/suicide risk assessment was completed from [DATE] to [DATE]. R17's self-harm/suicide risk assessment score on [DATE] was 6 (moderate risk). V12 changed the score from 6 (moderate risk) to 3 (low risk). The facility does not have care plans in place to address R17's moderate risk for self-harm/suicide risk.The facility presented an abatement plan to remove the Immediacy on [DATE], at 8:08 AM. The survey team was unable to accept the plan to remove the Immediacy. The abatement plan was returned to the facility for revisions.The facility presented an abatement plan to remove the Immediacy on [DATE], at 9:57 AM. The survey team was unable to accept the plan to remove the Immediacy. The abatement plan was returned to the facility for revisions.The facility presented an abatement plan to remove the Immediacy on [DATE], at 10:32 AM and the survey team accepted the abatement plan on [DATE], at 10:40 AM. The Immediate Jeopardy that began on [DATE], at approximately 6:00 AM was removed on [DATE], at 10:40 AM when the facility took the following actions to remove the immediacy:R5 - R17's suicide risk screening has been reviewed, reassessed and revised.R5 R17's Care plans were audited to ensure appropriate interventions are in place and were updated as necessary.All residents' self-harm care plans were reviewed and updated as necessary by Social Service Director (SSD), MDS coordinator and or designee.The facility identified no other residents who were at risk of self-harm and had a significant history of obtaining knives or other potential weapons identified via audit /record review. Furthermore, of those residents who did have a suicide ideation/verbalization there were no significant findings identified via room search, placing them at risk for self-harm.All residents' suicide risk screenings were audited and updated as necessaryAll residents self-harm care plans were reviewed and updated where necessary.SSD/designee is responsible for completing suicide risk screening assessments and have been in-serviced on [DATE], by V20 (Consultant Social Worker), V21 (RNC-Regional Nurse Consultant) 145752 Page 6 of 9 145752 11/04/2025 Forest View Rehab & Nursing Center 535 South Elm Itasca, IL 60143

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 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].Nursing staff were in-serviced by DON/ADON (Director of Nursing/Assistant Director of Nursing) starting on [DATE], and will complete on [DATE], 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], 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], and attended by the Medical Director and interdisciplinary team. 145752 Page 7 of 9 145752 11/04/2025 Forest View Rehab & Nursing Center 535 South Elm Itasca, IL 60143

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 R1, R5, R6, R7, R8, R9, R10, R11, R12, R13, and 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 145752 Page 8 of 9 145752 11/04/2025 Forest View Rehab & Nursing Center 535 South Elm Itasca, IL 60143

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 145752 Page 9 of 9