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
(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
08/30/2024
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)
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146167
If continuation sheet
Page 2 of 2
