Inspection·July 3, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few phone, I did not do anything. I did not call R1's emergency contact [V11], I did not call R1's physician. V4 told me she was going to notify V1 [Administrator]. I received a third phone call from the hospital security campus police around 3:00 PM. The police reported that R1 was missing from the hospital campus and was seen leaving on camera. He notified R1's family member [V11] and made a police report.I received a fourth phone call around 4:00 PM or 5:00 PM. I am not sure of the time, but it was during my evening medication pass. The call was from R1's family member [V11]. V11 reported to me she received a phone call from the hospital and told her that R1 was missing. I told V11, I was sorry to hear that. I did not notify R1's family member [V11] that R1 was missing from the emergency department. I was first made aware of R1 missing around 2:00 PM. I was busy passing out medications. I thought the male I spoke to told me he already had notified V11 and the police. I documented in R1's progress notes today as a late entry for 6/26/2025 12:14 PM, that I received a phone call from the police stating that R1 was seen leaving the hospital on camera. I documented my note wrong. I received a phone call from the hospital security campus police, not the city police department. I also documented I spoke with R1's family member [V11] and made her aware that R1 was missing. I documented that because the hospital security campus police told me they notified V11. I should have documented more clearly. I do not know if the report was made within the hospital or if the report was made with city police department. I documented the note for 12:15 PM, but I am not sure what time I received the phone call.On 6/27/25, at 9:50 AM, V12 [Director of Emergency Department] stated, R1 was seen at the hospital's cancer clinic. R1 was brought over to the emergency department with the nursing home facility escort and transport due to R1 complaining of chest pains during her cancer center appointment. R1 was signed in to the emergency room on 6/27/25, at 12:00 PM with her escort. At 12:10 PM, R1 had an EKG completed. V14 [Hospital Emergency Department Triage Register Nurse] at 12:20 PM, 12:33 PM, and 12:53 PM called R1's name with no answer. R1's EKG results were unchanged, and no acute distress was noted. R1 was not seen by a physician in the emergency department. Nothing in R1's EKG or labs results would have granted R1 to be admitted to the hospital. R1 would have been returned to the nursing facility. The hospital security searched the hospital campus area. R1 nor her nursing facility escort was located. At 2:30 PM, I phoned the nursing facility and spoke to V8 [Licensed Practical Nurse] and verified R1 was in fact a resident with the nursing facility. V8 said R1 was a resident there. V8 told me the escort V5[Restorative Aide/Certified Nurse Assistant Escort] was back at the facility. V8 then transferred me to the Assistant Director of Nursing [V4]. I told V8 and V4. R1 reported to the emergency department intake desk at 12:00 PM, completed an EKG, and was called by triage nurse three times with no answer. V4 and V8 both confirmed V5 left an elopement risk resident and returned back to the facility. Before any person is admitted to the hospital, they are assessed by a physician that makes the decision if a person is going to be admitted . R1 was never admitted to the hospital. Once the resident is admitted to the hospital, the hospital staff is responsible for the resident. R1's escort was to remain with R1 knowing she was an elopement risk that the cancer center nursing staff told V5, not to leave R1. I phoned R1's family member listed and city police department [#2-00954- Officer V15/City Police Officer]. On 6/27/25, at 11:00 AM, V5 [Restorative Aide/Certified Nurse Assistant/Escort] stated, I been a certified nurse assistant for ten years. I have been escorting residents to their medical appointments for nine months. I was asked to go with R1 to her medical appointment at the cancer center. R1 is alert and oriented, but R1 has some psych issues. R1 is ambulatory and uses a walker. R1 and I arrived at the cancer center at 9:22 AM. We walked in and I signed R1 in for her appointment. We waited an hour and half, and then R1 was called back around 10:30 AM to see V17 [ Advanced Practice Registered Nurse/Nurse Practitioner]. I went back (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145429 If continuation sheet Page 2 of 10 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 145429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wentworth Rehab & Hcc 201 West 69th Street Chicago, IL 60621 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 into the room with R1. R1 told V17 that she was having chest pain and dizziness. They took R1's vital signs a few times. V17 said I am sending you to the emergency room to be admitted to the hospital. During R1's assessment, I asked V17 if it was alright for me to step out of the room, to blow my nose. V17 stated no, I need to stay with R1 at all times because she is an elopement risk. So, I stated never mind and blew my nose in the room. V17 gave R1 a wheelchair to sit in and told R1 and I to have a seat in the waiting area lobby for the hospital escort. About twenty minutes later a female transport person arrived and pushed R1 in her wheelchair to the emergency department and went with R1. We made it to the emergency department around 12:00 PM. We went to the intake desk and signed R1 into the emergency department. The transport staff lady then walked away. The intake lady walked around the desk and removed the cancer center wrist band and placed the emergency department wrist band. I do not know the name of the intake lady nor her job title. The intake lady might have been like a receptionist. I don't think she was a nurse or physician. I told the intake lady that R1 was a high elopement risk and was there anything else for me to do. The intake lady said no. I asked if I could leave and the intake lady said yes. The intake lady started pushing R1 to the back then I left the emergency department and called V6 for a transportation ride. I walked back over to the cancer center. I returned back to the nursing facility at 12:52 PM. The intake lady did not tell me R1 was admitted to the hospital. I did not receive any paperwork from the emergency department that indicated R1 was admitted to the hospital. V6 [ Unit Manager/Certified Nurse Assistant] and V8 [Licensed Practical Nurse] were made aware R1 was in the emergency room. I did not tell V6 or V8 that R1 was an elopement risk, I forgot to tell them.On 6/28/25, at 9:15 AM, V1 [Administrator] stated, R1 was located yesterday [6/27/25] evening by staff.On 7/1/25, at 12:19 PM, V10 [Restorative Nurse] stated, On 6/27/25 around 6:45 PM, I saw R1 coming out of a corner store and brought R1 back to the facility. I immediately phoned V1 [Administrator] and told him R1 was back in the facility. I took R1 vital signs, and they within normal limits. I completed a body assessment and phoned R1's primary physician with no answer. R1's nurse was told to follow up with R1's physician and family.On 6/28/25, at 9:30 AM, R1 stated, I had an appointment on Thursday [6/26/25], when I started having chest pain. The nurse practitioner sent me and V5 to the emergency room so I could get checked out. V5 asked some lady if she could leave, and the lady said yes. I went to the back for an EKG. When I returned to the waiting area, V5 was gone. I went to the bathroom when I heard someone call my name, but I was on the toilet. When I came out the bathroom, I asked a lady the desk who called my name. The lady said, they will call you again. Then I wanted some fresh air and walked outside. When I was outside a nice lady gave me ten dollars. I went back in the hospital and sat in the lobby, not the emergency department, because I could not find the emergency department. No one came for me to see the doctor. I never saw a doctor. I slept there in a chair all night long, and my chest stopped hurting. The next day [6/27/25] around 12:00 PM, I left the hospital and caught the bus heading south to my favorite store. I went into the store and bought some lunch meat, bread, and cheese. When I was coming out of the store, I saw V10 [Restorative Licensed Practical Nurse] when she called my name. V10 brought me back to the nursing facility.On 7/2/25, at 1:00 PM, V1 [Administrator] stated, on 6/26/25 I received a phone call from V4 [Assistant Director of Nursing] reported she received a phone call from the hospital that during R1's appointment she complained of chest pain and was sent to the emergency room to be admitted accompanied with her escort [V5]. I spoke with V5, and she reported R1 was checked in to the emergency department and hospital staff was taking R1 to the back. V5 received permission to leave. There was a custody of change from the facility's escort to the hospital staff. R1 eloped from the emergency department under the hospital staff supervision, not under the facility's supervision. V5 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145429 If continuation sheet Page 3 of 10 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 145429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wentworth Rehab & Hcc 201 West 69th Street Chicago, IL 60621 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 FORM CMS-2567 (02/99) Previous Versions Obsolete reported she told the hospital staff that R1 was an elopement risk and asked was there anything else to do, the emergency room staff said no and gave V5 permission to leave. Once I learned R1 was missing, V2 [Assistant Administrator] and I went out driving around the hospital looking for R1. V8 received a phone call from the hospital police reported R1 was on camera boarding a bus heading north bound. I called off the search, because I knew at that point R1 was not in the hospital local area. On 6/27/25 around 7:00 PM, V18 observed R1 coming out of a corner store, and R1 came back to nursing facility. V5 R1 told me in summary that she was taken to the emergency room with V5. Prior to going to the back, the intake lady told V5 she could leave. R1 said she went outside for fresh air, and someone gave her ten dollars. R1 said she went back in the hospital, but no one called her name, and she slept there all night. The day R1 said she left the hospital lobby the next day [6/27/25] and got on the bus heading south bound to her favorite store to buy some lunch meat because R1 said she was hungry. R1 said coming out the store, facility staff recognized her and gave her a ride back to the nursing facility. R1's census report is not correct, due to poor communication. R1's census report indicated R1 was not discharge from the nursing facility until 7/1/25 and re-admitted back on 7/2/25. I was made aware that R1 was missing on 6/26/25 around 2:00 PM, and R1 was located on 6/27/25 around 6:30 PM. R1 was missing for 28 hours. [R1's clinical record indicate R1 was a resident with the facility on the day R1 was reported missing, R1 was not discharged .]Policy Documented in part: Elopement and Management of Missing Resident dated 3/28/23.It is the policy of this facility to report and investigate all reports of missing resident and to minimize risk of elopement. Suspected Missing Resident:If unable to locate the resident, call 911 to report resident missing. Notify resident's legal representative/responsible party of the occurrence and determine if friends or family know where the resident may attempt to go.Notify attending physician or Nurse practitioner.Complete Incident reportIf the resident has not been located for 24 hours contact morgue and notify the Illinois Department of Public Health with a summary of the incident report after the dependent resident is missing for 24 Escort for Appointment: dated 2/25.The facility will provide staff escorts to resident appointment as needed. Facility escorts attend the appointment with the resident, then return to the facility with the resident and any pertinent documentation from the appointment. If a resident is transferred to the hospital and or emergency room during an appointment, the escort should return to the facility once the resident has been taken by emergency transport or has been received by the hospital and or emergency room.These guidelines are not meant to be exclusive or exhaustive. Guidelines are meant to leave room for the exercise of professional judgement based on individual circumstances. Event ID: Facility ID: 145429 If continuation sheet Page 4 of 10 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 145429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wentworth Rehab & Hcc 201 West 69th Street Chicago, IL 60621 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to provide adequate supervision for 1 [R1] of three residents who is an elopement risk. This failure resulted in R1 eloping from the emergency department and not being located by facility staff until 06/27/2025. Findings Include,R1's clinical record indicates in part: R1 was admitted on [DATE], with the following medical diagnoses but not limited to non-Hodgkin lymphoma, schizoaffective disorder, syncope and collapse, tremors, convulsions, major depression, essential hypertension, and anxiety disorder. R1's minimum data set [MDS] Brief Interview Mental Status Score Indicates R1 is cognitively intact, alert, and oriented x/times3.Facility's appointment book:R1 was scheduled for follow up appointment at a cancer clinic with V5 [Restorative Certified Nurse Aide/Escort]. The appointment time was 9:30 AM.R1's Emergency Department Notes, documented in part:R1 was signed in to the emergency room on 6/27/25, at 12:00 PM. At 12:10 PM, R1 had an EKG (electrocardiogram) completed. V14 [Hospital Emergency Department Triage Register Nurse] at 12:20 PM, 12:33 PM, and 12:53 PM called R1's name with no answer. R1's EKG results were unchanged, and no acute distress was noted. R1 was not seen by a physician in the emergency department.R1's Progress Notes Documented in Part:On 6/26/2025, at 12:14 PM, Nurses Note V8 [Licensed Practical Nurse]Note Text: The resident [R1] is out at an appointment for an infusion. The resident [R1] was sent to the ER [emergency department] due to C/O [complaints of] chest pains. Nurses Note V8 [Licensed Practical Nurse] Effective Date: On 6/26/2025, at 14:15:00 [2:15 PM]Created Date: On 6/27/2025, 09:29:31 [9:29 AM]On 6/26/2025, at 2:15 PM, [Documented on 6/27/25 at 9:29 AM]Note Text: Writer received a phone from the police stating that the R1 was seen leaving the hospital on camera. The writer spoke with the resident's mother who is aware of resident leaving the hospital. A police report was made. The physician was made aware as well. [Progress note entered late}. On 6/27/25, at 12:07 PM, V8 said she received phone call from the hospital security not the city police department. A report was made with the hospital security, not with the city police department. On 6/27/2025, at 9:44 AM, Nurses Note V9 {Licensed Practical Nurse] Note Text: Writer received call from ER director [V12-Director Emergency Department] inquiring if resident [R1] returned to the facility. V12 was made aware that resident [R1] has not returned. V12 also asked if resident's mother was made aware and if she heard from the resident. Writer made V12 aware that facility did speak with resident's family member [V11] and she was aware. On 6/27/2025, at 10:13 AM, Interdisciplinary Team Note [Administrator V1] Note Text: Writer received a call from the hospital police [V7 Hospital Campus Security]. V7 provided report #25-00954. V7 called to ensure that this facility had been properly notified that while receiving care from hospital emergency department the resident [R1] had left the hospital, and the hospital police were making efforts to locate the resident [R1]. V7 inquired if the resident [R1] may have returned to facility and requested any phone numbers, addresses, and contact persons that the facility had on file. Writer provided V7 with all requested information and any background information the facility had on the resident [R1]. V7 made the writer aware that the hospital police would provide any updates. Writer made V7 aware that the facility would do the same. V7 provided the writer with a phone for any updates. On 6/27/2025, at 7:29 PM, Nurses Note Restorative [V10- Licensed Practical Nurse] Note Text: While out searching the community for the resident [R1], R1 was observed standing in front of the store at the bus stop. Staff prompted resident [R1] to come back to the facility. R1 was cooperative and agreed to allow staff transport her back to the facility. Administration was made aware.Interviews:On 6/27/25, at 9:40 AM, V8 [Licensed Practical Nurse] stated, I was R1's nurse yesterday [6/26/25]. I worked from 7:00 AM to 7:00 PM. R1 is not here in the facility. R1 had an appointment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145429 If continuation sheet Page 5 of 10 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 145429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wentworth Rehab & Hcc 201 West 69th Street Chicago, IL 60621 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few yesterday [6/26/25] at 9:30 AM. R1 left the facility at 8:30 AM. Approximately a couple hours later, the doctor's office called and said R1 was being sent to the emergency department, due to R1 complaining of chest pain. R1 was admitted to the hospital.On 6/27/25, at 12:05 PM, surveyor asked V8, why didn't she report R1 was admitted to the hospital to the surveyor. During record review of V8's progress note dated 6/26/25, but entered on 6/27/25, at 9:29 AM, surveyor was indicated that V8 documented R1 was missing from the emergency department.On 6/27/25, at 12:07 PM, V8 stated, I was confused, I am sorry. I was not made aware by hospital staff that R1 was admitted to the hospital. I received a phone call on 6/26/25 around 10:00 AM, from the cancer clinic. The clinic reported R1 was complaining of chest pain and was being sent over to the emergency department for an evaluation. I documented the phone encounter late at 12:14 PM, because I was busy. I received a second phone call from someone at emergency department, I don't know who I spoke to, but it was a male, at approximately 2:00 PM. This male reported to me that R1 was missing from the emergency department. The person from the emergency department also said R1 arrived at the emergency department with an escort but could not locate R1 nor the escort. I immediately transferred the phone call to V4 [Assistant Director of Nursing]. When I got off the phone, I did not do anything. I did not call R1's emergency contact [V11]. I did not call R1's physician. V4 told me she was going to notify V1 [Administrator]. I received a third phone call from the hospital security campus police around 3:00 PM. The campus police reported that R1 was missing from the hospital campus and was seen leaving on camera. He notified R1's family member [V11] and made a police report. I received a fourth phone call around 4:00 PM or 5:00 PM. I am not sure of the time, but it was during my evening medication pass, from R1's family member [V11]. V11 reported to me she received a phone call from the hospital. The hospital told her R1 was missing. I told V11, I was sorry to hear that. I did not notify R1's family member [V11] that R1 was missing from the emergency department. I was first made aware of R1 missing around 2:00 PM. I was busy passing out medications. I thought the male I spoke to told me he already had notified V11 and the police. I documented in R1's progress notes today as a late entry for 6/26/2025, at 12:14 PM, that I received a phone call from the police stating that R1 was seen leaving the hospital on camera. I documented my note wrong. I received a phone call from the hospital security campus police, not the city police department. I also documented I spoke with R1's family member [V11] and made her aware that R1 was missing. I documented that because the hospital security campus police told me they notified V11. I should have documented more clearly. I do not know if the report was made within the hospital or if the report was made with the city police department. I documented the note at 12:15 PM, but I am not sure what time I received the phone call.On 6/27/25, at 9:50 AM, V12 [Director of Emergency Department] stated, R1 was seen at the hospital's cancer clinic. R1 was brought over to the emergency department with the nursing home facility escort and transported due to R1 complaining of chest pains during her cancer center appointment. R1 was signed in to the emergency room on 6/27/25, at 12:00 PM, with her escort. At 12:10 PM, R1 had an EKG completed. V14 [Hospital Emergency Department Triage Register Nurse] at 12:20 PM, 12:33 PM, and 12:53 PM, called R1's name with no answer. R1's EKG results were unchanged, and no acute distress was noted. R1 was not seen by a physician in the emergency department. Nothing in R1's EKG or labs results would have granted R1 to be admitted to the hospital. R1 would have returned to the nursing facility. The hospital security searched the hospital campus area. R1 nor her nursing facility escort was located. At 2:30 PM, I phoned the nursing facility and spoke to V8 [Licensed Practical Nurse]. V8 verified R1 was in fact a resident with the nursing facility. V8 stated R1 was a resident there. V8 told me the escort V5 [Restorative Aide/Certified Nurse Assistant Escort] was back at the facility. V8 then transferred me to the Assistant Director (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145429 If continuation sheet Page 6 of 10 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 145429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wentworth Rehab & Hcc 201 West 69th Street Chicago, IL 60621 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of Nursing [V4]. I told V8 and V4, R1 reported to the emergency department intake desk at 12:00 PM, completed an EKG, and was called by the triage nurse three times with no answer. V4 and V8 both confirmed V5 left an elopement risk resident and returned back to the facility. Before any person is admitted to the hospital, they are assessed by a physician that makes the decision if a person is going to be admitted . R1 was never admitted to the hospital. Once the resident is admitted to the hospital, the hospital staff is responsible for the resident. R1's escort was to remain with R1 knowing she was an elopement risk. The cancer center nursing staff told V5, not to leave R1. I phoned R1's family member listed and the city police department [#2-00954- Officer V15/City Police Officer]. On 6/27/25, at 10:09 AM, V13 [Director of Cancer Center] stated, R1 was seen on 6/27/25, at 9:30 AM, for a follow up appointment. During the appointment R1 complained of chest pains and dizziness. R1 vital signs indicated R1's heart rate was elevated, and blood pressure was low. V17 [Advanced Practice Registered Nurse/Nurse Practitioner] assessed R1 and told R1 and V5, R1 needs to be evaluated in the emergency department. During the assessment in a private room, V5 asked V17 if she could go outside. V17 told V5 no, because R1 is an elopement risk and has to stay with R1 at all times. We got R1 a wheelchair waited for internal transport to arrive. Transport arrived and pushed R1 in the wheelchair along with V5. They walked over to the emergency department. At 2:16 PM, the emergency department notified V16 [Cancer Center Registered Nurse] that R1 was not seen by a physician. She was called three times, and the resident was not present. The emergency department was made aware that R1 was a high-risk elopement resident.On 6/27/25, at 10:22 AM, V16 [Cancer Center Registered Nurse/Nurse Navigator] stated, I received a phone call from the emergency department. The emergency department stated R1 was called by the triage nurse three times. R1 nor V5 was present. I confirmed with V17 that R1 was a flight risk and V5 was told to stay with R1 at all times. I called R1's nursing facility spoke with V8. V4 verified R1's name and date of birth . V8 and V4 both confirmed V5 left R1 at the emergency department and V5 returned back to the nursing facility after V5 was told R1 was an elopement risk. V8 and V4 were both made aware that V5 left R1 in the emergency department and R1 was missing. V4 said she will tell her administrator immediately. I called R1's family member [V11] and made her aware that R1's escort left R1 in the emergency department and returned back to the nursing facility. R1 was missing. On 6/24/25, I called the nurse and confirmed R1 will be accompanied with an escort due to R1 being a flight risk. R1 has made attempts in the past to leave the cancer center and staff located R1 trying to leave the clinic. R1 has a known history of elopement. V5 was completely aware R1 was an elopement risk and she [V5] should not have left R1 alone. R1 was not seen by a physician, nor was R1 ever admitted to the hospital. On 7/2/25, at 12:30 PM, V6 [Unit ManagerCertified Nurse Assistant] stated, R1 was admitted with a follow up appointment at the cancer center on 6/26/25, at 9:30 AM. R1 and V5 left the facility with an 8:30 AM pick up. All escorts go out with the resident, they are to stay with the resident. If anything, abnormal occurs the staff will call me. I did not know R1 was an elopement risk. According to my cell phone text messages on 6/26/25. At 11:26 AM, V5 [Restorative Certified Nurse Assistant/Escort] texted me [They are about to admit her, they are waiting for transport to get them [V5 and R1]. I responded: [okay let me know when you are ready]. At 12:15 PM, V5 texted [ I am ready for pickup.] I responded [Okay].At 12:38 PM, I [V6] texted V5: [Did they tell you why they are keeping R1]V5 texted [R1 told the cancer center that she had a heart attack two days ago, and she [R1] passed out that morning. The cancer center is worried about R1's heart rate is high, and blood pressures is low]. I responded [Oh wow, Okay]. Then I immediately reported this information to R1's nurse.On 6/27/25, at 11:00 AM, V5 [Restorative Aide/Certified Nurse Assistant/Escort] stated, I been a certified nurse assistant for ten years. I have been escorting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145429 If continuation sheet Page 7 of 10 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 145429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wentworth Rehab & Hcc 201 West 69th Street Chicago, IL 60621 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few residents to their medical appointments for nine months. I was asked to go with R1 to her medical appointment at the cancer center. R1 is alert and oriented, but R1 has some psych issues. R1 is ambulatory and uses a walker. R1 and I arrived at the cancer center at 9:22 AM. We walked in and I signed R1 in for her appointment. We waited an hour and half, and then was called back around 10:30 AM to see V17 [ Advanced Practice Registered Nurse/Nurse Practitioner]. I went back into the room with R1. R1 told V17 that she was having chest pain and dizziness. They took R1's vital signs a few times. V17 said I am sending you to the emergency room to be admitted to the hospital. During R1's assessment, I asked V17 if it was alright for me to step out of the room to blow my nose. V17 said no, I needed to stay with R1 at all times because she is an elopement risk. So, I said never mind and blew my nose in the room. V17 gave R1 a wheelchair to sit in and told R1 and I to have a seat in the waiting area lobby for the hospital escort. About twenty minutes later a female transport person arrived and pushed R1 in her wheelchair to the emergency department and I went with R1. We made it to the emergency department around 12:00 PM. We went to the intake desk and signed R1 into the emergency department. The transport staff lady then walked away. The intake lady walked around the desk and removed the cancer center wrist band and placed on the emergency department wrist band. I do not know the name of the intake lady nor her job title. The intake lady might have been a receptionist, I don't think she was a nurse or physician. I told the intake lady that R1 was a high elopement risk and asked if there anything else for me to do. The intake lady said no. I asked if I could leave, and the intake lady said yes. The intake lady started pushing R1 to the back then I left the emergency department and called V6 for a transportation ride. I walked back over to the cancer center. I returned back to the nursing facility at 12:52 PM. The intake lady did not tell me R1 was admitted to the hospital. I did not receive any paperwork from the emergency department that indicated R1 was admitted to the hospital. V6 [ Unit Manager/Certified Nurse Assistant] and V8 [Licensed Practical Nurse] was made aware R1 was in the emergency room. I did not tell V6 or V8 that R1 was an elopement risk, I forgot to tell them. On 6/28/25, at 9:15 AM, V1 [Administrator] stated, R1 was located yesterday [6/27/25] evening by staff.On 7/1/25, at 12:19 PM, V10 [Restorative Nurse] stated, On 6/27/25 around 6:45 PM, I saw R1 coming out of a corner store and brought R1 back to the facility. I immediately phoned V1 [Administrator] and told him R1 was back in the facility. I took R1 vital signs, and they were within normal limits. I completed body assessment and phoned R1's primary physician with no answer. R1's nurse was told to follow up with R1's physician and family.On 6/28/25, at 9:30 AM, R1 stated, I had an appointment on Thursday [6/26/25], when I started having chest pain. The nurse practitioner sent me and V5 to the emergency room so I could get checked out. V5 asked some lady if she could leave, and the lady said yes. I went to the back for an EKG. When I returned to the waiting area, V5 was gone. I went to the bathroom when I heard someone call my name, but I was on the toilet. When I came out the bathroom, I asked a lady the desk who called my name. The lady said, they will call you again. Then I wanted some fresh air and walked outside. When I was outside a nice lady gave me ten dollars. I went back in the hospital and sat in the lobby, not the emergency department, because I could not find the emergency department. No one came for me to see the doctor. I never saw a doctor. I slept there in a chair all night long, and my chest stopped hurting. The next day [6/27/25] around 12:00 PM, I left the hospital and caught the bus heading south to my favorite store. I went into the store and bought some lunch meat, bread, and cheese. When I was coming out of the store, I saw V10 [Restorative Licensed Practical Nurse] when she called my name. V10 brought me back to the nursing facility.On 6/28/25, at 11:30 AM, V4 [Assistant Director of Nursing] stated, I received a phone call from V16, and she told R1 was seen at the cancer clinic for a follow visit. During the visit R1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145429 If continuation sheet Page 8 of 10 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 145429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wentworth Rehab & Hcc 201 West 69th Street Chicago, IL 60621 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few complained of chest pain, syncope, dizziness and lightheadedness. V17 [Advanced Practice Registered Nurse/Nurse Practitioner] assessed R1 and noted R1 with an elevated heart rate. R1 was sent to the emergency department with V5 her escort. V17 told V5 to stay with R1 because she was an elopement risk. R1 was called by the emergency triage nurse three times. R1 nor her escort were present, and R1 was missing. I told V16 that V5 made it back to the facility around 1:00 PM. I reported the incident to the administrator [V1] and V3 [Director of Nursing]. I was not made aware prior to R1's appointment that R1 was an elopement risk. R1 is new to the facility, she was admitted on [DATE]. R1's elopement risk assessment completed on admission; she was not an elopement risk. I did not have a conversation with V5. The administrator took over the situation.On 7/1/25, V18 [Restorative Aide/Certified Nurse Assistant] stated, I been an escort for thirteen years. The escort protocol is to stay with the resident the whole time. If a resident is being admitted , staff stay until they are fully admitted . Meaning, until the resident is in their assigned room. If I had to leave the resident due to timing or end of my shift, I would call the director of nursing so she would send another escort to take my place.On 7/2/25, at 2:45 PM, V11 [R1's Family Member] stated, The hospital notified me on 6/26/25, that my family member was missing from the emergency department. I did not know R1 was at the emergency department, nevertheless missing. The nursing facility did not notify me of anything. The facility knew R1 was an elopement risk because I told them. R1 lived in the locked unit because they knew her history. After I knew R1 was missing, I waited a couple of hours to see if the facility was going to notify me, but they did not. I called the facility and spoke to V8, she acted as if she did not know R1 was missing. I was so upset. I was happy to learn R1 was located the next evening and was not hurt or harmed. A few months ago, R1 was attacked and raped on the city train. R1 is not to be left alone in the community. The facility knows her history and recent trauma. On 7/2/25, at 1:30 PM, V3 [Director of Nursing] stated, The escorts are supposed to stay with the resident while out at an appointment. Once the hospital emergency department staff took R1 to the back, there was an exchange in custody and the nursing facility staff could leave. V5 asked if she could leave and was told she could. V5 notified nursing staff here that R1 was going to be admitted and was taken to the back with hospital staff. V5 called for a pickup ride. V5 reported back to nursing facility. R1 was discharged from the nursing facility on 6/26/25 at 6:43 PM. The facility was made aware R1 was missing around 2:00 PM. R1 was located on 6/27/25 and brought back to nursing facility. Once a resident is discharged from the facility, upon return the resident is re-admitted . R1's clinical record does not indicate any re-admission assessments nor documentation. The nursing staff was not aware that R1 was an elopement risk.On 7/2/25, at 1:00 PM, V1 [Administrator] stated, on 6/26/25, I received a phone call from V4 [Assistant Director of Nursing] reported she received a phone call from the hospital that during R1's appointment she complained of chest pain and sent to the emergency room to be admitted accompanied with her escort [V5]. I spoke with V5, and she reported R1 was checked in to the emergency department and hospital staff was taking R1 to the back. V5 received permission to leave. There was a custody of change from the facility's escort to the hospital staff. R1 eloped from the emergency department under the hospital staff supervision, not under the facility's supervision. V5 reported she told the hospital staff that R1 was an elopement risk and asked was there anything else to do. The emergency room staff said no and gave V5 permission to leave. Once I learned R1 was missing, V2 [Assistant Administrator] and I went out driving around the hospital looking for R1. V8 received a phone call from the hospital police reported R1 was on camera boarding a bus heading north bound. I called off the search, because I knew at that point R1 was not in the hospital local area. On 6/27/25 around 7:00 PM, V18 observed R1 coming out of a corner store, and R1 came back to nursing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145429 If continuation sheet Page 9 of 10 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 145429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wentworth Rehab & Hcc 201 West 69th Street Chicago, IL 60621 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete facility. V5 R1 told me in summary that she was taken to the emergency room with V5. Prior to going to the back, the intake lady told V5 she could leave. R1 said she went outside for fresh air, and someone gave her ten dollars. R1 said she went back in the hospital, but no one called her name, and she slept there all night. The day R1 said she left the hospital lobby the next day [6/27/25] and got on the bus heading south bound to her favorite store to but some lunch meat because R1 said she was hungry. R1 said coming out the store, facility staff recognized her and gave her a ride back to the nursing facility. R1's census report is not correct, due to poor communication. R1's census report indicated R1 was not discharged from the nursing facility until 7/1/25 and re-admitted back on 7/2/25. I was made aware that R1 was missing on 6/26/25 around 2:00 PM. R1 was located on 6/27/25 around 6:30 PM. R1 was missing for 28 hours. [R1's clinical record indicate R1 was a resident with the facility on the day R1 was reported missing, R1 was not discharged .]Policy Documented in part: Escort for Appointment: dated 2/25.The facility will provide staff escorts to resident appointment as needed. Facility escorts attend the appointment with the resident, then return to the facility with the resident and any pertinent documentation from the appointment. If a resident is transferred to the hospital and or emergency room during an appointment, the escort should return to the facility once the resident has been taken by emergency transport or has been received by the hospital and or emergency room.These guidelines are not meant to be exclusive or exhaustive. Guidelines are meant to leave room for the exercise of professional judgement based on individual circumstances. Elopement and Management of Missing Resident dated 3/28/23.It is the policy of this facility to report and investigate all reports of missing resident and to minimize risk of elopement. Suspected Missing Resident:If unable to locate the resident, call 911 to report resident missing. Notify resident's legal representative/responsible party of the occurrence and determine if friends or family know where the resident may attempt to go.Notify attending physician or Nurse practitioner.Complete Incident reportIf the resident has not been located for 24 hours contact morgue and notify the Illinois Department of Public Health with a summary of the incident report after the dependent resident is missing for 24 hours. Event ID: Facility ID: 145429 If continuation sheet Page 10 of 10