Health inspection·August 30, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to investigate and report an allegation of abuse for one of three residents (R1) reviewed for abuse. Findings include: R1's face sheet documents R1 is a [AGE] year-old admitted to the facility on [DATE] with diagnoses including but not limited to: Arthritis, Multiple Sites; Type 2 Diabetes Mellitus, Acute Kidney Failure, Auditory Hallucinations, Visual Hallucinations, and Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. R1's MDS (Minimum Data Set of 5/30/2024) documents a BIMS (Brief Interview for Mental Status) of 6 or severe cognitive impairment. 8/29/2024 at 10:26 AM, V5 (Clinical Manager) said during a visit to see ophthalmologist on 8/16/2024, R1 alleged multiple staff (unknown) members punched and slapped resident. R1's escort (V4), who was present in the exam room, left exam room, went outside and called facility's DON (V2-Director of Nursing). V5 said upon V4's return, V4 said she spoke with V1 who said R1 has dementia; allegation was not true. V5 said per the ophthalmologist, R1 is always lucid when they see R1. V5 added, R1 said abuse has been going on for several months and hasn't been reported (by R1) because she is afraid to let anyone know. 8/29/2024 at 1:10 PM, R1 said she is experiencing ongoing physical abuse that started approximately 3 1/2 months ago; unable to offer any information about alleged abusers other than they are female and are not residents. R1 said the abuse occurs in her room, in the dining room. R1 said one of the alleged abusers hit R1 on her upper arm then later her hand (demonstrates by pushing Surveyor on their upper arm, then slapping Surveyor multiple times in rapid succession on the dorsum of Surveyor's hand) this morning. R1 added that alleged abuser works at the library. When asked by Surveyor if there are any witnesses to any of these incidents, R1 said yes, the lady who was buying bread in the cafeteria; I don't remember her name. R1 said all the other times it happened, I would cry and cry. My doctor said it's okay to report it. I never reported it, because I was afraid of retaliation. I don't feel safe (in the facility). 8/29/2024 at 1:55 PM V4 (Escort) via telephone said she escorted R1 to an appointment to the eye doctor on 8/16/2024. V4 said R1 was confused when V4 arrived at the facility that day, requiring a lot of cueing and re-direction that day. V4 said R1 told the doctor They beat me up. The doctor said who? He (the doctor) looked at me, I said I don't know anything about that. I left the room and called Page 1 of 2 146167 146167 08/30/2024 Foster Health & Rehab Center 2840 West Foster Avenue Chicago, IL 60625

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few V2 (DON-Director of Nursing); I told her what R1 said. V2 told me, R1 is a little unbalanced, R1 has dementia; if someone beat her, why doesn't she have a black eye? 8/29/2024 at 2:27 PM via telephone, V2 (DON-Director of Nursing) said, R1 went to an appointment on 8/16/2024; I think she told one of the doctors that someone hit her in the eye. V2 continued, if they saw her diagnosis (dementia), she just had discoloration to the sclera of her eye. No one abused her; we don't tolerate that at (the facility). I did speak with someone at the doctor's office. I informed them that no one hit R1. I told them that she was confused; that she has diagnoses including dementia, she (R1) makes things up. No one would ever mistreat her at (the facility). R1 talks to herself, residents with dementia say different things, that's their baseline. I looked at her (R1) when she returned to the facility. I would be making reportables (incident reports) all the time; would take R1 seriously if she were slumped over, not saying different things, doing something against her baseline. But nothing was wrong with her; there were no obvious signs of anything (skin discoloration, no altered level of consciousness). R1 never mentioned anything to anyone at the facility. This is what she (R1) does. 8/29/2024 at 3:00 PM V1 (Administrator) said abuse should be reported immediately. V1 said I wasn't told; I didn't find out until today about R1's abuse allegation. V1 added, I think an investigation was done; a reportable (alleged incident wasn't reported to IDPH-Illinois Department of Public Health) wasn't done. V1 said, R1 can't give you a description (of alleged abusers), a date or time. If she's not in bed, she's in the dining room, we have cameras in the facility. They (staff) were always putting eye drops in her eyes, was she confusing that with abuse. Facility incident reports for abuse (6/2024-8/2024) were reviewed; no report was found for R1's allegation of abuse (from 8/16/2024). Facility's Abuse Prevention Program Worksheet (2/2017, page 12) documents: This process is implemented where there is an allegation or reasonable cause to suspect that abuse, neglect, or exploitation of theft may have occurred. Name of the Resident who is the subject of the allegation, Date of Occurrence, and Primary Investigator. 146167 Page 2 of 2