Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment,
and neglect by anybody.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to protect one (R1) resident's right to be free from physical
abuse out of three sampled residents. This failure resulted in R2 becomming physically aggressive to R1.
Findings Include:
R1's clinical records show R1 was admitted in the facility on 5/16/23 with diagnoses including but not
limited to Unspecified Dementia Without Behavioral Disturbance and Chronic Obstructive Pulmonary
Disease. R1's Minimum Data Set (MDS) dated [DATE] shows R1 has moderate cognitive impairment.
R1's progress notes dated 7/22/24 written by V5 (Registered Nurse/RN) documents in part: On 7/22/24 at
about 1:00 PM R1 was allegedly hit on the head and milk was thrown in the face by [R2]. The incident
occurred in the dining room and was witnessed by staff. Staff intervened, both residents were separated
and initiated one-on-one monitoring. A head-to-toe assessment was completed, and no visible injuries were
noted. Medical Doctor and family member made aware.
R2's clinical records show R2 was admitted in the facility on 5/25/24 with diagnoses included but not limited
to Restlessness and Agitation and Other Schizophrenia. R2's MDS dated [DATE] shows R2 has moderate
cognitive impairment.
R2's progress notes dated 7/22/24 written by V5 documents in part: At around 1:00 PM, V5 was notified by
witnessed staff that R2 hit [R1] on the head and threw milk at [R1's] face. The incident occurred in the
dining room and was witnessed by staff.
On 9/25/24 at 10:44 AM, interviewed R1 regarding the incident that happened with R2 in the dining room
on 7/22/24. R1 stated R1 was sitting in the dining room eating lunch. R2 walked towards R1's table and
then grabbed R1's milk. R1 told R2 to give R1's milk back. R2 threw the milk carton on R1's forehead and
laughed about it. R1 stated it was full of milk and it hurt but did not injure R1. R1 further stated, The staff
wanted to send me to the hospital but no Ma'am I won't go. I told [R2] I'm old enough to be your
grandmother. I don't know what I did to [R2]. I still see [R2] but we are not in the same room. [R2] would
pass by me and look at me with a smile on her face. I feel safe. I don't mind seeing [R2] as long as [R2]
doesn't bother me.
On 9/25/24 at 11:24 AM, interviewed R2 and noted R2 with unclear speech and mumbles. R2 stated R2
remembers what happened with R1 when R2 threw the carton of milk at R1's head in the dining room. R2
stated R2 was angry at R1 that was why R2 threw the carton of milk on R1. R2 did not answer further
questions from the Surveyor and started to get agitated.
(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 3
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
09/27/2024
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 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 9/25/24 at 11:36 AM, interviewed R3 and stated R3 witnessed the incident between R1 and R2 on
7/22/24 in the dining room. R3 stated it was during lunch time and R3 was joking that R3 didn't like the
chicken. R2 got up and took R3's plate and R1 said something to R2 stating, Don't be taking her plate. R3
stated all of a sudden, R2 took a carton of milk and hit R1 on R1's head. R3 stated R1 was angry, and staff
came. R3 stated the staff intervened and separated R1 and R2. R3 stated the problem with R2 is that R2
would walk around and mess with other people's foods. R3 stated R2 has very bad behaviors and gets
aggressive at times. R3 stated R2 has been very aggressive even with the staff in the facility.
On 9/25/24 at 10:18 AM, interviewed V6 (Certified Nursing Assistant) regarding R1 and R2's incident on
7/22/24 and stated it happened while the residents were having lunch in the dining room. V6 stated, They
were just having lunch. [R2] finished at first. [R2] got up from her chair like [R2] was going out of the dining
room and then the next thing [R2] grabbed someone's milk and [R1] was sitting beside that person and was
trying to tell [R2] that it was rude you don't have to do that and then immediately [R2] just threw the milk on
[R1's] forehead. I was in the dining room monitoring the residents and by the time I got to both of them, [R2]
already threw the milk on [R1's] forehead. [R1] got up and wanted to fight [R2] but I immediately intervened
and separated them.
On 9/25/24 at 11:13 AM, interviewed V7 (Activity Director) regarding R1 and R2's incident on 7/22/24 and
stated that during lunch time R2 wanted more chicken. R2 was leaving when R2 went to R3's tray and took
food from R3' tray. R1 said something first to put it back and R2 picked up the milk and threw the milk on
R1's head. It was an abrupt moment. Staff immediately intervened and redirected R1 and R2. V5 assessed
R1. V7 stated R2 has behaviors when it triggers, R2 may take things from people. V7 stated R2 goes on
one on one monitoring and staff re-directs R2.
On 9/25/24 at 12:19 PM, a phone interview conducted with V9 (Certified Nursing Assistant) regarding R1
and R2's incident on 7/22/24 and stated, They were just finishing lunch [R2] was walking past [R1] and then
[R2] grabbed the lunch from [R3's] tray. [R1] said something to [R2] and then [R2] got upset and grabbed
the milk and threw it at [R1]. It hit [R1] on her head. [R1] was complaining of a headache. [V5] checked on
[R1] and [V5] gave [R1] something for pain. I was picking up trays in the dining room before it happened. I
just had picked up the tray from across the table where [R1's] table was at and then I saw the incident. I
intervened right away. The staff quickly grabbed [R2] and escorted [R2] back to her room. [R1] stayed in the
dining room.
On 9/25/24 at 11:58 AM interviewed V1 (Administrator) and stated V1 is the abuse coordinator. V1 stated If
there's a resident-to-resident altercation, V1 expects staff to separate them. Do one on one supervision with
the perpetrator. The nurse has to do the whole assessment. They call the doctor and carry out orders.
Facility calls the psychiatry doctor and notify family and or the guardian. V1 stated the types of abuse are
verbal, mental, physical, misappropriation, seclusion, sexual, and neglect. V1 stated, abuse is a willful act
that your trying to injure or hurt a person, you're deliberately hurting the person. V1 stated the residents
have the right to reside in the facility free from abuse.
The facility's policy titled, ABUSE PREVENTION PROGRAM dated 2/7/17 reads in part:
Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by
accidental means. This assumes that all instances of abuse or residents, even those in coma, cause
physical harm or pain or mental anguish. Physical abuse includes hitting, slapping, pinching, kicking, and
controlling behavior through corporal punishment.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146167
If continuation sheet
Page 2 of 3
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
09/27/2024
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 0600
Level of Harm - Minimal harm
or potential for actual harm
The facility's policy on RESIDENTS' RIGHTS with no date reads in part: Residents have the rights to safety.
Residents must not be abused, neglected, or exploited by anyone - financially, physically, verbally, mentally
or sexually. The facility must be safe, clean, comfortable and homelike.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146167
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
FAQ · About this visit
Common questions about this visit
What happened during the September 27, 2024 survey of FOSTER HEALTH & REHAB CENTER?
This was a inspection survey of FOSTER HEALTH & REHAB CENTER on September 27, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at FOSTER HEALTH & REHAB CENTER on September 27, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect b..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.