Inspection·February 5, 2024

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain dignity for three (R1, R2, R3) residents reviewed for dignity bag on indwelling catheter. Findings include: 1.R1 is a [AGE] year-old individual, with diagnoses as listed in the current face sheet to include but not limited to: : unspecified severe protein-calorie malnutrition, cachexia, adult failure to thrive, abnormal weight loss. R1's Minimum Data Set (MDS) section C (Cognitive Status), dated 12/31/2023, documents R1 has a BIMS (Brief Interview for Mental Status) score of 15/15, indicating R1 has intact cognation. R1's MDS(Minimum Data Set) section H (bladder and Bowel), dated 10/03/2023, documents have an Indwelling catheter. R1's POS (Physician Order Set) documents: 10/18/2023 -Foley catheters change 18th of every month on day shift. starting on the 18th and ending on the 18th every month for Prophylaxis. Change Foley bag on the 11th and 25th of every month. On 2/4/2024 at 9:47am, R1 was observed with the urinary bag hang on the side of his bed below the bladder. R1's bag was observed with no cover for dignity and was facing his roommate's side, visible to the roommate. The urinary bag had 300 cc of light-yellow urine. R1 said he did not like his urinary bag to show the urine draining to everyone. R1 said he is not able to reach the bag to cover it himself. 2. R2 is an [AGE] year-old individual admitted to the facility on [DATE]. R2's medical diagnoses as documented in current face sheet include but not limited to: spondylosis, unspecified, Parkinson's disease, urinary calculus, unspecified, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R2's MDS section C, dated 11/8/23, documents R2's BIMS was not assessed, and last scored BIMS is dated 1/24/2023, with R2's BIMS documented at 6/15, indicating R2 has severe cognitive impairment. R2's MDS section H (Bladder and Bowel) documents R2 has an Indwelling catheter. R2's POS (Physician Order Set) documents: (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 146167 Printed: 05/15/2026 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 146167 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2024 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)