Inspection·May 8, 2025

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on interview and record review, the facility failed to update a resident care plan as exacerbation of neurological symptoms began to occur. This failure affected 1 (R3) resident reviewed for care plan in the total sample of 5 residents. Findings include: On 05/05/2025 at 2:20pm, V2 (Director of Nursing) stated R3 was doing spastic movement of her upper extremities, flexion and extension. R3 never had this jerking movement before. It was as if she was trying to get out of her chair. It was just severe so we put her on 1:1 supervision. If you (staff) were with her, there is no spastic movement but as soon as you (staff) leave, R3 would have spastic movements of both her upper and lower extremities. I really think her cerebral palsy is exacerbating. There is a change on her baseline signs and symptoms. The exacerbation of R3's symptoms should be care planned. It is a problem that we need to focus on, we have to create a goal and add interventions. R3's careplan for cerebral palsy and spastic movement was not updated with new interventions. R3's careplan should be revised to include new interventions. I (V2) will update it today. R3's admission Record documented that R3's diagnoses (include but not limited to) cerebral palsy, metabolic encephalopathy, and reduced mobility. R3's (02/14/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: no entry. C0700. Short-Term memory Ok: 1 Memory problem. C0800. Long-Term Memory Ok: 1. Memory Problem. C1000. Cognitive Skills for daily decision making: 3 severely impaired. Section I0020. Indicate primary medical condition. 07. Other neurological conditions. I0020B. primary Medical Condition. Cerebral Palsy. R3's care plan (date initiated: 05/05/2023) documented, in part The resident has an alteration in musculoskeletal status r/t (related to) hx (history) of muscle wasting and atrophy, spasticity and involuntary/impaired movements of the limbs and trunk d/t (due to) Cerebral Palsy. Date Initiated: 05/05/2023. Revision on: 05/05/2025. Revision by: V2 (Director of Nursing). Give medication as prescribed. Date Initiated: 05/05/2025. Created on: 05/05/2025. Created by: V2 (Director of Nursing). Neurology/Psychiatrist referral PRN. Date Initiated: 05/05/2025. Created on: 05/05/2025. Created by: V2 (Director of Nursing). Of note, revision was made on day one of survey. The (10/20/2024) Care plans, comprehensive Person Centered documented, in part Policy Statement: A comprehensive, person-centered careplan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and implementation. 8. The comprehensive, person-centered care plan (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 05/08/2025 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)