Inspection·November 9, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident's call light was accessible within reach to call for staff assistance, which affected two (R1 and R10) residents in the sample of 24 reviewed for accommodation of needs. Residents Affected - Few Findings include: 1) On 11/6/23 at 10:51 AM, R1 was observed in bed, turned to right side, with the red call light string not within R1's reach, being wedged in the bed frame under the side rail where it connects with the bed frame. On 11/7/23 at 11:00 AM, R1's red call light string remained in the same position as observed on 11/6/23, with it wedged in between the bed frame and the right bed side rail, and was not within R1's reach. R1's admission Record documents diagnoses of chronic obstructive pulmonary disease, hypertension, epilepsy, Alzheimer's disease, schizophrenia, arthritis, ventral hernia, and osteoarthritis. R1's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview of Mental Status (BIMS) score of 5, which indicates that R1 has severe cognitive impairment. R1's Function Status for bed mobility and transfer is coded as extensive assistance with staff support of two + (plus) persons physical assist. R1's Care Plan, date initiated 2/16/22, documents R1 has a focus of an ADL (Activities of Daily Living) self-care performance deficit, with an intervention of encourage (R1) to use bell to call for assistance. R1's Care Plan, date initiated 9/13/23, documents R1 has a focus of at risk for falls due to gait and balance problems and unaware of safety needs with an intervention of be sure (R1's) call light is within reach and encourage the resident to use it for assistance as needed. (R1) needs prompt response to all requests for assistance. 2) On 11/6/23 at 11:15 AM, R10 was observed ambulating with a walker from the bathroom with V5 (Certified Nursing Assistant, CNA) performing stand by assist. R10 was then then laying in bed, and V5 exiting the room. R10's red call light string was pinned to the privacy curtain, which was bunched up together against the wall behind R10's bed and chair. R10's call light was not within R10's reach. On 11/6/23 at 11:17 AM, R10 was asked if R10 was able to reach R10's red call light string from R10's bed, R10 stated, No. R10's admission Record documents, in part, diagnoses of rheumatoid arthritis, muscle weakness, hypertension, morbid obesity, malignant neoplasm of breast, peripheral vascular diseases, osteoporosis, embolism and thrombosis of unspecified deep veins of lower extremity, major depressive disorder, anxiety disorder, COVID-19, and chronic kidney disease. R10's MDS, dated [DATE], documents a BIMS score of 15, which indicates R10 is cognitively intact. R10's Function Status for bed mobility and transfer is coded as extensive assistance with staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146167 If continuation sheet Page 2 of 21 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 11/09/2023 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 0558 support of one-person physical assist. Level of Harm - Minimal harm or potential for actual harm R10's Care Plan, date initiated 1/11/17, documents R10 has a focus of an ADL self-care performance deficit with an intervention of encourage (R10) to use bell to call for assistance. Residents Affected - Few R10's Care Plan, date initiated 3/18/21, documents R10 has a focus of at risk for falls due to generalized weakness, balance problems with ambulating and during transitions and psychoactive drug use with an intervention of be sure (R10's) call light is within reach and encourage the resident to use it for assistance as needed. (R10) needs prompt response to all requests for assistance. On 11/8/23 at 9:25 AM, V2 (Director of Nursing, DON) stated residents call light must be placed within the residents reach. When asked the purpose of having the call light within reach, V2 stated, Because the call light is a life line for any resident. V2 stated it must be placed conveniently within the residents reach, either attached to the pillow or the mattress. V2 stated residents use the call light to call for staff assistance, and We don't know if the resident needs something. It could be respiratory distress, and they shouldn't have to be struggling to find the call light. Facility policy titled Call Light, dated April 2014, documents, Purpose: To respond to residents' requests and needs in a timely and courteous manner . Standards: 1. All residents shall have the nurse call light system available at all times and within easy accessibility to the residents at the bedside or other reasonable accessible location. Facility job description undated and titled Certified Nursing Assistant, documents, Certified Nursing Assistant. Summary: The Certified Nursing Assistant (CNA) is responsible for providing resident care and support in all activities of daily living and ensures the health, welfare and safety of all residents. Essential Duties and Responsibilities: . answering call lights and requests. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146167 If continuation sheet Page 3 of 21 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 11/09/2023 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain a doctor's order and document the code status in one resident's (R17) electronic medical record. This failure affected one resident (R17) reviewed for Advanced Directives in a sample of 24 residents. Findings include: R17's admission record includes a diagnoses of but not limited to cerebral palsy, acute respiratory failure, dysphagia, and encephalopathy. R17's ([DATE]) Resident Assessment Instrument documented Section C. is blank. BIMS (Brief Interview for Mental Status) section C is blank. R17's Physician Order Sheet (POS) active orders, dated [DATE], indicate no order obtained for an Advanced Directive. R17's face sheet printed on [DATE] at 12:26 PM indicates no code status in the Advance Directives section. On [DATE] at 11:30 AM, V2, DON (Director of Nursing), stated, There should be an order from the doctor for an Advanced Directive. The nurses get the orders for an Advanced Directive. V2 stated the code status should be in the electronic medical record, and the purpose for an Advanced Directive is to know the code status of the residents. On [DATE] at 1:50 PM, V8, RN (Registered Nurse), stated, A resident's code status should be in the computer. Surveyor asked V8 it there was a code status and a physician order in the computer for R17. V8 looked into the computer and stated, I do not see a code status or physician's order for (R17) in the computer. There should be a physician's order and a code status should be in (R17's) records in the computer. Facility Advance Directives Policy (revised [DATE]), documents, The purpose of this policy is to reflect residents wish about receiving Cardiopulmonary Resuscitation (CPR) and Life- Sustaining treatments such as medical interventions and artificial administered nutrition. At the time of admission residents will be interviewed regarding their code status and/or preference and will be documented in their electronic health record. Facility Job description titled, Registered Nurse, documents, Essential Duties and Responsibilities: Complete and file required record keeping forms/charts upon the resident's admission, transfer and/or discharge. Receive and transcribe orders for physician and record on the care provided to the resident as well as the residents response to the care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146167 If continuation sheet Page 4 of 21 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 11/09/2023 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident's low air loss (LAL) mattress was not layered with multiple linen layers, which affected one resident (R9) in the sample of 24 residents reviewed for pressure ulcers. Residents Affected - Few Findings include: On 11/6/23 at 12:11 PM, R9 was in bed on a LAL (low air loss) mattress, after being provided care and repositioning in bed by V5 (Certified Nursing Assistant, CNA), V6 (CNA) and V8 (Registered Nurse, RN). R9's sacral wound dressing observed intact, with date marked 11/6/23. This surveyor observed the following layers of linens under R9's body on the LAL mattress: bath blanket, incontinence pad and then a quadruple folded bath blanket (6 linen layers). R9 observed positioned in a supine position on the 6 linen layers on R9's LAL mattress. Surveyor asked R9 if surveyor could observe wound care on 11/7/2023, and R9 refused surveyors request. R9's admission Record documents, diagnoses of severe sepsis with paraplegia, pressure ulcer of other site (stage 3), hypertension, localized edema, atrial fibrillation, COVID-19, arthritis, septic shock, neuromuscular dysfunction of bladder, reduced mobility, and unspecified hearing and visual loss. R9's Minimum Data Set (MDS), dated [DATE], documents the Staff Assessment for Mental Status indicates R9 has no problems with short and long term memory, and R9's Cognitive Skills for Daily Decision Making is modified independence. R9's Skin Conditions (section M) documents R9's Skin and Ulcer/Injury Treatments include a pressure reducing device for bed. R9's Weekly Observation Tool, dated 10/6/23, documents an air mattress is used for special equipment/preventative measures. On 11/8/23 at 9:25 AM, V2 (Director of Nursing, DON) stated, A low air loss mattress is used as a prevention and treatment for residents with pressure ulcers. The air circulation helps by reducing pressure of a resident's body from the air that comes from the low air loss mattress, like the resident is floating. The low air loss mattress is different from the ordinary mattress, which can be hard on the body. When asked what linens the nursing staff are to place on top of the LAL mattress (linens in between the top of the LAL mattress and the resident), V2 stated, If linens are to be used at all, then it should be a light linen than can be in between the torso to the knee for repositioning purposes. V2 stated, It should be one layer which allows the purpose of the functioning of the air circulating to really work on the resident. When asked if there are multiple layers of linen used, like a bath blanket, incontinence pad, and then a quadruple folded bath blanket on a LAL mattress, what would be the effect on the resident, V2 stated, It's ineffective with 6 layers. R9's Wound Evaluation and Management Summary, dated 10/24/23, V17 (Wound Physician) documents R9's bed support surface is Group 2 for R9's Stage 3 sacral pressure wound, full thickness. In Center for Medicare and Medicaid Services article, dated 4/7/22 and titled Pressure Reducing Support Surfaces - Group 2 - Policy Article, documents styles of Group 2 powered pressure reducing mattress (alternating pressure, low air loss, or powered flotation without low air loss) which is characterized by all of the following: an air pump or blower which provides either sequential inflation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146167 If continuation sheet Page 5 of 21 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 11/09/2023 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 0686 Level of Harm - Minimal harm or potential for actual harm and deflation of the air cells or a low interface pressure throughout the mattress, and inflated cell height of the air cells through which air is being circulated is 5 inches or greater, and height of the air chambers, proximity of the air chambers to one another, frequency of air cycling (for alternating pressure mattresses), and air pressure provide adequate beneficiary lift, reduce pressure and prevent bottoming out, and a surface designed to reduce friction and shear, and can be placed directly on a hospital bed frame. Residents Affected - Few Facility policy, dated 5/19/17, and titled Wound Management Program: Pressure Injury Prevention, documents, Policy: It is the policy of this facility to implement measures to protect the resident's skin integrity and prevent skin breakdown whenever possible. Purpose: The purpose of this policy is to establish and provide consistent measure for the prevention of pressure injuries based upon the assessment of pressure injury risk. Procedure: . A. Sensory deficits, mobility impairment, and activity limitations: . support surfaces including pressure reduction and pressure relief devices will be used as appropriate; devices may include gel, static air, foam, or alternating air. Facility policy undated and titled Residents' Rights for People in Long Term Care Facilities, documents the facility must provide services to keep your physical and mental health, at their highest practical levels. Facility job description undated and titled Registered Nurse (RN), documents, Registered Nurse. Summary: The RN is responsible for providing direct nursing care to residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision (must) be in accordance with current federal, state and local standards, guidelines, and regulations that govern our facility and as may be required by the Director of Nursing to endure that the highest degree of quality of care is maintained at all times. Essential Duties and Responsibilities: Direct the day-to-day functions of the nursing assistance . Provide leadership to nursing personnel assigned to your unit/shift. Facility job description undated and titled Certified Nursing Assistant, documents, Certified Nursing Assistant. Summary: The Certified Nursing Assistant (CNA) is responsible for providing resident care and support in all activities of daily living and ensures the health, welfare and safety of all residents. Essential Duties and Responsibilities: . provide assistance in ambulating, turning, and positioning residents . performs other duties assigned. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146167 If continuation sheet Page 6 of 21 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 11/09/2023 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an extra tracheostomy (trach) tube was stored at a resident's bedside, which affected one (R15) resident in the sample of 24 residents reviewed for tracheostomy status. Residents Affected - Few Findings include: On 11/6/23 at 1:19 PM, R15 was in R15's room, with R15's trach tube secured in placed with trach ties (foam ties with self fasteners) around R15's neck. R15 showed this surveyor R15's type of trach tube, which is a cuffless trach tube. No extra trach tube is observed stored in R15's room, on the bedside table, drawers, or in R15's bags. This surveyor asked R15 is there was an extra trach tube in R15's room, and R15 pointed to the trach tube cleaning kit, which is not an extra trach tube. On 11/8/23 at 9:25 AM, V2 (Director of Nursing, DON) stated an extra trach should be available and close to R15's room for safety to secure R15's airway if R15's trach tube comes out of the trachea stoma and is not able to be reinserted. This surveyor informed V2 there was no back up (extra) trach tube at R15's bedside, and V2 stated it was at the nurse's station. On 11/8/23 at 10:51 AM, V2 walked to the only nurse's station in the facility to retrieve R15's extra trach tube. Per V2's request, V8 (Registered Nurse, RN) checked the two treatment/supply carts in the nurse's station, and R15's extra trach tube was not observed. R15's admission Record, documents, in part, diagnoses of encounter for attention to tracheostomy, malignant neoplasm of larynx, chronic obstructive pulmonary disease, type 2 diabetes mellitus, atherosclerotic heart disease of native coronary artery, peripheral vascular disease, hypertension, and solitary pulmonary nodule. R15's Minimum Data Set (MDS), dated [DATE], documents the Staff Assessment for Mental Status indicates R15 has no problems with short and long term memory, and R15's Cognitive Skills for Daily Decision Making is modified independence. R15's Care Plan, with revision date of 5/13/23, documents for R15's tracheostomy maintenance, an intervention is Tube Out Procedures: Keep extra trach tube and obturator at bedside. If tube is coughed out, open stoma with hemostat. If tube cannot be reinserted, monitor/document for signs of respiratory distress. If able to breathe spontaneously, elevate HOB (head of bed) 45 degrees and stay with resident. Obtain medical help immediately. Facility policy, dated October 2018, and titled Tracheostomy: Care and Suctioning, documents, Policy: Care and suctioning of a tracheostomy will be done upon physician's order and as needed, by nurse, respiratory therapist or speech therapist, to maintain a patent airway to facility the removal of accumulated tracheal secretions. Facility policy undated and titled Residents' Rights for People in Long Term Care Facilities, documents the facility must provide services to keep your physical and mental health, at their highest practical levels. Your facility must be safe, clean, comfortable and homelike. Facility job description undated and titled Registered Nurse (RN), documents the RN reports to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146167 If continuation sheet Page 7 of 21 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 11/09/2023 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Director of Nursing (DON), and Registered Nurse. Summary: The RN is responsible for providing direct nursing care to residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision (must) be in accordance with current federal, state and local standards, guidelines, and regulations that govern our facility and as may be required by the Director of Nursing to endure that the highest degree of quality of care is maintained at all times. Essential Duties and Responsibilities: Direct the day-to-day functions of the nursing assistance . Administer professional services . as required . performs other duties as assigned. Facility job description undated and titled Director of Nursing Service, documents, Purpose of Your Job Position: The primary purpose of your job position is to plan, organize, develop and direct the overall operation of the Nursing Service Department in accordance with current Federal, State and local standards, guidelines and regulations governing our facility, and as may be directed by the Administrator, to assure that the highest degree of quality care can be maintained at all times. Major Duties and Responsibilities: . 18. Assure that the Residents' Rights are followed by nursing service personnel at all times . 23. Assure that nursing service personnel follow established safety regulations in the use of equipment and supplies, providing care/services, etc. (and the rest), at all times. 24. Assure that the department is maintained in a clean and safe manner for resident comfort and convenience by assuring that necessary equipment and supplies are maintained and operable to perform such duties and services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146167 If continuation sheet Page 8 of 21 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 11/09/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to store biologicals in a safe manner, and failed to label opened multi dose vials. These failures have the potential to affect all 35 residents using this medication refrigerator. Findings include: On 11/07/2023 at 11:19 AM, during observation of medication storage room and refrigerator with V10 (Registered Nurse/RN) the following were observed: The medication refrigerator temperature was -18 degrees Fahrenheit (F) and was confirmed by V10. Located in this refrigerator were: R11's unopened Lantus 100/ml with icicles formed on the vial. R287's Novolog 100/ml (back Label states store at 36-46 degrees F, Avoid Freezing). 2 House stock vials of Tuberculin PPD (purified protein derivative). One Tuberculin vial was unopened, and the second Tuberculin vial was opened with no label of when it was opened. The tuberculin label states store at 36-46 degrees Fahrenheit and do not freeze. V10 stated she will discard all these medications and order new ones. V10 also stated the temperature of the refrigerator should be between 31-40 degrees Fahrenheit. Also located in this refrigerator was an employees' COVID-19 nasopharyngeal sample Specimen. V10 confirmed the COVID-19 nasopharyngeal sample Specimen was for an overnight shift nurse, and stated there is a different fridge for these specimens, and this should not be in here. On 11/07/2023 at 11:40 AM, V2 (Director of Nursing/DON) stated, 'COVID-19 specimens should be in a different fridge and the temperature should be between 31-41 degrees Fahrenheit. V2 stated she will waste the medications that are in the medication fridge that is reading -18 degrees, and will reorder. V2 stated the medication is not effective if frozen. On 11/07/23 at 11:36 AM with V10 during observation of the medication cart the following was observed: R33's opened Insulin Lispro 100/ml, without a date showing when it was opened. On 11/07/23 at 1:40 PM V2 stated, Insulin should be refrigerated, and other medications that are recommended by pharmacy. The refrigerator should be between 30-40 degrees Fahrenheit, and when opening a multi dose vial it should be dated when opened. The opened medication expires 28 days after or what pharmacy recommends. The COVID-19 specimen samples have their own refrigerator, and should not be stored in the medication refrigerator, because it can cause infection. V2 stated medications in the refrigerator that was -18 degrees Fahrenheit were disposed of, and new medications were ordered ASAP (as soon as possible). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146167 If continuation sheet Page 9 of 21 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 11/09/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Facility presented policy titled, Storage of Medications, with revised date of 9/19, stated, The nursing staff shall be responsible for maintain medication storage and preparation areas in a clean, safe, and sanitary manner. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurse's station or other secured location. Medications must be stored separately from food and must be labeled accordingly. Ensure insulin is properly labeled with resident's name and date of opening, dispose of 28 days after opening. Re-order if necessary. Facility presented another policy titled, LTC (Long Term Care) Facility Pharmacy Services and Procedures Manual: Storage of Medications, with revised date of 11/20. This policy states: Refrigerated 36 degrees Fahrenheit to 46 degrees Fahrenheit (2 degrees Celsius to 8 degrees Celsius) with a thermometer to allow temperature monitoring. Medications requiring refrigeration are kept in a refrigerator at temperatures between 2 degrees Celsius (36 degrees Fahrenheit) and 8 degrees Celsius (46 degrees Fahrenheit) with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146167 If continuation sheet Page 10 of 21 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 11/09/2023 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R10's admission Record documents, in part, diagnoses of rheumatoid arthritis, muscle weakness, hypertension, morbid obesity, malignant neoplasm of breast, peripheral vascular diseases, osteoporosis, embolism and thrombosis of unspecified deep veins of lower extremity, major depressive disorder, anxiety disorder, COVID-19 and chronic kidney disease. Residents Affected - Some R10's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status (BIMS) score of 15 which indicates that R10 is cognitively intact. On 11/6/23 at 11:01 AM, R10's resident refrigerator in R10's room was observed with an empty thermometer log taped to the side of the refrigerator. Inside R10's refrigerator, the following was observed: no thermometer; an opened 2% milk container (236 milliliters), approximately half full, with an expiration date of 10/17/23; and a bag of snack size candy bars and cookies. On 11/6/23 at 11:17 AM, when asked how often staff are checking the temperature readings and contents of R10's refrigerator, R10 stated, They don't come in often to check my refrigerator. 3. R37's admission Record documents diagnoses of heart failure, cardiomyopathy, hypertension, atrial fibrillation, and cellulitis of right and lower limbs. R37's MDS, dated [DATE], documents a BIMS score of 15 which indicates that R37 is cognitively intact. On 11/6/23 at 11:57 AM, R37's resident refrigerator in R37's room was observed with an empty thermometer log taped to the side of the refrigerator. R37 stated R37 hasn't seen any staff check inside the refrigerator. 4. R30's admission Record documents diagnoses of hypertension, cardiac arrest, acute respiratory failure, cerebral infarction, and anoxic brain injury. R30's MDS, dated [DATE], documents a BIMS score of 15 which indicates that R30 is cognitively intact. On 11/6/23 at 12:04 PM, R30's resident refrigerator in R30's room was observed with an empty thermometer log taped to the front of the refrigerator. When asked if staff are checking the temperature and items inside R30's refrigerator, R30 stated, No. Honestly, no. When asked if they are cleaning inside the refrigerator, R30 stated, No. Not unless I tell them. Inside R30's refrigerator, the following were observed: no thermometer, an opened apple juice container (64 fluid ounces); one opened chocolate candy bar (full size 1.55 ounces); and two chocolate and raspberry chocolate bars (unopened, 3.5 ounces). Facility temperature logs (empty) posted in R10, R30 and R37's rooms on 11/6/23, document Temp Log Cooler with the date, time, temperature and initials for the temperature readings, with no documentation. On 11/6/23 at 12:33 PM, V5 (Certified Nursing Assistant/CNA) was requested to come to R10's room and asked for the copy of the posted refrigerator log on the side of R10's refrigerator. V5 confirmed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146167 If continuation sheet Page 11 of 21 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 11/09/2023 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 0813 Level of Harm - Minimal harm or potential for actual harm R10's refrigerator log is blank with no staff initials, dates or temperatures. V5 retrieved R10's empty refrigerator log and made a copy. On 11/6/23 at 12:35 PM, V5 viewed inside R37's room that the posted refrigerator log on R37's refrigerator is blank with no staff initials, dates or temperatures. Residents Affected - Some On 11/6/23 at 12:36 PM, V5 viewed inside R30's room that the posted refrigerator log on R30's refrigerator is blank with no staff initials, dates or temperatures. When asked who is responsible for completing the temperature checks and log for resident refrigerators, V5 stated, I don't do this. When asked again who is responsible, V5 stated, The kitchen. On 11/7/23 at 11:34 AM, V12 (Dietary Manager) visited R30's room to examine the refrigerator with no thermometer present inside the refrigerator. V12 stated there is no thermometer designated in R30's refrigerator, and V12 ordered more refrigerator thermometers that will be arriving this Thursday. V12 stated V12 checks the resident refrigerators daily for the inside refrigerator thermometer readings. V12 stated, This is brand new to me to make these checks and V12 is over heading it. V12 stated, I try to fit it (refrigerator temperature checks) in, and they put it on me. When asked what is V12 responsible for during these refrigerator checks, V12 stated, I am supposed to check the dates (of food and drinks) and if they are expired. I would be responsible to take it out if the food or drink item is expired. When asked if the expired food or drink item remains in the refrigerator, what could be the possible effect to the resident, V12 stated, It's major. Resident can get sick or can cause death. When asked if V12 checked R10's refrigerator's temperature and completed log, V12 said, Yes. V12 opened the door to view R10's refrigerator log. V12 stated, No. I haven't done it yet today. V12 stated V12 did not go into R10's room to perform a refrigerator viewing and temperature check. This surveyor informed V12 there was no thermometer in R10's refrigerator on 11/6/23 with an opened, expired milk carton from 10/17/23 present. When asked about R37's refrigerator temps, and V12 stated, I have not assessed (R37's) refrigerator yet. On 11/7/23 at 12:05 PM, V12 (Dietary Manager) stated the appropriate temperature within the residents' personal refrigerators should be 34 to 40 degrees Fahrenheit (F). Facility policy undated and titled Residents' Rights for People in Long Term Care Facilities, documents the facility must provide services to keep your physical and mental health, at their highest practical levels. Your facility must be safe, clean, comfortable and homelike. Based on observation, interview, and record review, the facility failed to provide a thermometer for four resident (R10, R30, R33, and R37) refrigerators; failed to properly log refrigerator temperatures for four residents (R10, R30, R33, and R37); failed to discard expired food from a resident (R10) refrigerator; and failed to clean a resident (R33) refrigerator. These failures affected R10, R30, R33 and R37 in the sample of 24 residents. Findings include: 1. R33 has diagnoses which includes, but is not limited to: unspecified severe protein-calorie malnutrition, cachexia, anemia, specified diabetes mellitus with diabetic neuropathy, type 2 diabetes mellitus with diabetic neuropathy, orthostatic hypotension, weakness, adult failure to thrive, abnormal weight loss, enterocolitis due to clostridium difficile, fatty liver, and retention of urine. R33's Brief Interview for Mental Status (BIMS), dated 09/30/23, documents R33 has a BIMS score of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146167 If continuation sheet Page 12 of 21 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 11/09/2023 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 0813 15, which indicates R33 is cognitively intact. Level of Harm - Minimal harm or potential for actual harm On 11/06/23 at 11:31 AM, R33's personal room refrigerator was unclean, with visible black dirt throughout the inside of the refrigerator surface, a thick layer of a dried red liquid adhered to the bottom shelf of the refrigerator and the door of the refrigerator, missing refrigerator temperature logs for 11/04/23 and 11/05/23, and without a temperature thermometer. Residents Affected - Some On 11/07/23 at 11:57 AM, R33's personal room refrigerator remained unclean, with visible black dirt throughout the inside of the refrigerator surface, a thick layer of a dried red liquid adhered to the bottom shelf of the refrigerator; missing refrigerator temperature logs for 11/04/23 and 11/05/23, without a temperature thermometer, and a temperature log recorded for 11/06/23 for 35 degrees Fahrenheit (F). On 11/07/23 at 12:00 PM, V1 (Administrator) stated the Dietary and Housekeeping department at the facility oversee the residents personal refrigerators. V1 stated V12 (Dietary Manager) is responsible for cleaning and logging the residents personal refrigerator temperatures. V1 was asked how often the temperatures are logged for the residents personal refrigerators. V1 stated, I don't know. You would have to ask (V12). On 11/07/23 at 12:10 pm, V12 (Dietary Manager) stated V12 was delegated the responsibility a few weeks ago to oversee the residents personal refrigerators in the facility. V12 stated the housekeepers are responsible for cleaning the residents refrigerators weekly and V12 is responsible for logging the residents personal refrigerators temperatures daily. V12 was asked regarding the residents personal refrigerator thermometers. V12 stated all the residents personal refrigerators should have a thermometer, and V12 is aware the residents personal refrigerators were missing thermometers. V12 explained V12 ordered new refrigerator thermometers for the residents personal refrigerators that should be arrive to the facility by the end of the week. V12 was asked regarding how often the residents personal refrigerator temperatures are logged V12 stated, Every day. When V12 was asked regarding the importance of keeping the residents personal refrigerators clean, ensuring that the resident personal refrigerators have a thermometer and residents personal refrigerator temperatures are logged every day, V12 stated, For safety and so the residents don't get sick with Salmonella or diseases. The facility's document titled Temp (Temperature) Log Cooler shows no temperature was recorded/logged for 11/04/23 and 11/05/23 for R33's personal refrigerator. The facility's document, dated 11/15, and titled Refrigerators (Resident) Policy for Maintaining and Cleaning, documents, Purpose: To ensure that all resident refrigerators are in proper working order and are kept clean. Procedure: 1. Dietary/Housekeeping staff is responsible for ensuring that a resident's refrigerator is in proper working order and clean upon the resident/family bringing in the refrigerator. 2. Dietary is responsible for overseeing care for a resident with a refrigerator and will check all contents for proper date of food items and check for cleanliness of the refrigerators on a daily basis. 3. If the Dietary Team finds that the refrigerator has outdated food, Dietary will dispose of all outdated food and will notify the resident . 5. The Dietary/Housekeeping staff will clean resident refrigerators on a weekly and as needed basis. 6. The Dietary/Housekeeping supervisor will ensure all resident refrigerators are in working order and kept clean. 7. A thermometer will be kept in the resident's refrigerator and the temperature will be taken and recorded daily. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146167 If continuation sheet Page 13 of 21 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 11/09/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to perform proper hand hygiene; failed to appropriately don and doff personal protective equipment (PPE) for a contact and droplet isolation room; failed to post a contact and droplet precautions isolation sign outside a positive COVID-19 resident's isolation room; failed to provide a resident with a tracheostomy covering to prevent transmission of COVID-19 droplets when a COVID-19 positive resident exits out of the isolation room; failed to ensure a contaminated item removed from a contact and droplet isolation room does not contaminate surfaces outside of the isolation room; failed to ensure a nasopharyngeal COVID-19 test sample was not stored in the facility's medication refrigerator; and failed to follow the facility's COVID-19 policy and procedures. These failures affected R1, R9, R10, R15 and R29 and has the potential to affect all 35 residents in the facility. Residents Affected - Many Findings include: 1. On 11/6/23, V3 (Assistant Administrator) provided this surveyor with a document titled Residents with Isolation Status documenting R1, R9, R10, R15 and R29's names. Floor plan document, updated on 11/6/23, documents R1, R9, R10, R15 and R29's are on COVID-19 isolation. R1's admission Record documents diagnoses of COVID-19, chronic obstructive pulmonary disease, hypertension, epilepsy, Alzheimer's disease, schizophrenia, arthritis, ventral hernia, and osteoarthritis. R1's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview of Mental Status (BIMS) score of 5, which indicates R1 has severe cognitive impairment. R1's Care Plan, date initiated 11/7/23, documents R1 has a focus of an infection of the COVID-19 with strict isolation - Droplet and Contact for COVID-19 positive. All services to be provided in the room. R1's COVID-19 laboratory test document, with a test date of 11/2/23, documents a positive (+) result for COVID-19. R10's admission Record documents, in part, diagnoses of COVID-19, rheumatoid arthritis, muscle weakness, hypertension, morbid obesity, malignant neoplasm of breast, peripheral vascular diseases, osteoporosis, embolism and thrombosis of unspecified deep veins of lower extremity, major depressive disorder, anxiety disorder, and chronic kidney disease. R10's MDS, dated [DATE], documents a BIMS score of 15, which indicates R10 is cognitively intact. R10's Care Plan, date initiated 11/7/23, documents R10 has a focus of an infection of the COVID-19 with strict isolation - Droplet and Contact for COVID-19 positive. All services to be provided in the room which includes an intervention of staff will maintain proper use of PPE donning and disposal of equipment used. R10's COVID-19 laboratory test document, with a test date of 11/2/23, documents a positive (+) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146167 If continuation sheet Page 14 of 21 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 11/09/2023 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 0880 result for COVID-19. Level of Harm - Minimal harm or potential for actual harm On 11/6/23 at 10:46 AM, a contact precautions isolation sign observed posted on R1's and R10's room door, with no droplet precautions isolation sign noted. Residents Affected - Many Facility isolation sign (undated), titled Contact Precautions, documents, Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. On 11/6/23 at 10:55 AM, V5 (Certified Nursing Assistant, CNA) was observed entering R1's and R10's room wearing an isolation gown, gloves, and surgical face mask, with no face shield or goggles. V5 stated V5 was entering the room to attend to R10 who was in the bathroom, but R10 said (through the door) R10 needed more time. V5 doffed gown and gloves and exited R1's and R10's room (used alcohol based hand rub {ABHR} when exiting the room). On 11/6/23 at 11:07 AM, V5 entered R1's and R10's room bringing in linens, towels, and an incontinence brief to perform care for R1. V5 was observed wearing a gown, gloves, and surgical face mask, with no face shield or goggles. V5 assisted R1 in turning in bed to the left side to open R1's soiled incontinence brief, and V5 was observed leaning V5's body and making contact with R1's left side of bed. V5's bottom of isolation gown at knee level was observed lifted up on top of R1's bed linens, and the inside of R1's isolation gown was in contact with R1's bed linens. V5 completed R1's incontinence care and then doffed V5's gloves while in R1's and R10's room. V5 did not perform hand hygiene. V5 retrieved another pair of gloves from V5's uniform under R1's isolation gown, and donned the gloves. V5 went into the bathroom wearing the same isolation gown V5 cared for R1 with, and the new donned gloves to perform care for R10. On 11/6/23 at 11:15 AM, R10 was observed walking out of the bathroom with a walker with V5's stand by assistance to get R10 to bed. V5 assisted with elevating R10's feet up onto the bed. On 11/6/23 at 11:16 AM, V5 was observed walking towards R1's side of the room near the door. V5 doffed V5's gloves and discarded the gloves in the red garbage bin inside the room near the door. V5 moved R1's bedside table with V5's bare hands to reach R1's bed controls on the left side of the bed. V5 touched R1's bed controls and elevated R1's head of the bed. V5 then doffed V5's gown by pulling the front of the gown away from V5's body (with bare hands) to remove the gown, discarded the gown, and exited the room. 2. R9's admission Record documents diagnoses of severe sepsis with COVID-19, paraplegia, pressure ulcer of other site (stage 3), hypertension, localized edema, atrial fibrillation, arthritis, septic shock, neuromuscular dysfunction of bladder, reduced mobility, and unspecified hearing and visual loss. R9's Minimum Data Set (MDS), dated [DATE], documents the Staff Assessment for Mental Status indicates R9 has no problems with short and long term memory and R9's Cognitive Skills for Daily Decision Making is modified independence. R9's Care Plan, date initiated 11/7/23, documents R9 has a focus of an infection of the COVID-19 with strict isolation - Droplet and Contact for COVID-19 positive. All services to be provided in the room which includes an intervention of done (don) proper PPE. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146167 If continuation sheet Page 15 of 21 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 11/09/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many R9's COVID-19 laboratory test document, with a test date of 11/2/23, documents a positive (+) result for COVID-19. On 11/6/23 at 12:11 PM, R9's contact and droplet precautions isolation sign observed posted on R9's door. V5 (Certified Nursing Assistant/CNA), V6 (CNA), and V8 (Registered Nurse/RN) were in R9's room wearing a gown, gloves, and surgical face masks, and assisting R9 with repositioning and activities of daily living (ADL) care. No face shields or goggles observed on V5, V6 and V8. Facility isolation signs (undated) with the left side of sign titled Contact Precautions and the right side of the sign titled Droplet Precautions observed with bold lettering of N95/Face shield on the far right side of the dual isolation posting. The Contact Precautions sign documents, in part, Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Picture images of a gown and gloves are indicated on the contact precautions sign. The Droplet Precautions, documents, in part, Everyone Must: Clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry. Picture images of a person wearing a face mask and a face shield and a person wearing a face mask and goggles are indicated on the droplet precautions sign. 3. R15's admission Record, documents diagnoses of encounter for attention to tracheostomy, malignant neoplasm of larynx, chronic obstructive pulmonary disease, type 2 diabetes mellitus, atherosclerotic heart disease of native coronary artery, peripheral vascular disease, hypertension, and solitary pulmonary nodule. R15's Minimum Data Set (MDS), dated [DATE], documents the Staff Assessment for Mental Status indicates that R15 has no problems with short and long term memory and R15's Cognitive Skills for Daily Decision Making is modified independence. R15's Care Plan, date initiated 11/6/23, documents R15 has a focus of (R15) has infection of the COVID-19 with strict droplet/contact isolation. R15's Care Plan, date initiated 11/6/23, documents, Droplet/Airborne isolation precautions related to: COVID-19 infection with interventions of all services are rendered in resident room and maintain droplet, airborne precaution. R15's COVID-19 laboratory test document, with a test date of 11/2/23, documents a positive (+) result for COVID-19. On 11/6/26 at 12:45 PM, R15 was observed sitting at a chair in the nurse's station of the facility while staff are passing lunch trays to residents in rooms. R15 then walked to R15's room for the lunch tray. R15's contact and droplet precautions isolation sign were observed posted on R15's door. On 11/6/23 at 12:49 PM, R15 walked out of R15's contact and droplet isolation room with a face mask over R15's nose and mouth; however, audible respiratory congestion can be heard with R15's breathing through R15's tracheostomy, which is not covered with a mask. R15 is attempting to mouth to this surveyor, and then R15 walks back to the nurse's station to obtain R15's white board that R15 left on the ledge of the nurse's station desk. R15 stood in hallway writing and communicating with surveyors with audible respiratory congestion noted from R15's uncovered tracheostomy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146167 If continuation sheet Page 16 of 21 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 11/09/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm 4. On 11/6/23 at 1:08 PM, V5 (CNA) donned gown and gloves while wearing surgical face mask and entered R9's contact and droplet isolation with R9's lunch meal tray. V5 did not apply a face shield or goggles. V5 set up the bedside table and R9's tray for R9 to eat in bed. V5 removed gloves and doffed V5's gown by pulling the front of the gown away from V5's body (with bare hands) to remove the gown, discarded the gown, and exited the room. Residents Affected - Many On 11/6/23 at 1:11 PM, V5 donned gown and gloves while wearing surgical face masks and entered R1's and R10's contact and droplet isolation while holding R1's and R10's lunch meal trays and entered their room. On 11/6/23 at 1:15 PM, V5 doffed V5's gloves and gown inside R1's and R10's room and exited the room without performing hand hygiene. V5 touched the Dietary meal tray cart door in the hallway, and moved the meal tray cart. V5 then used ABHR. 5. On 11/7/23 at 11:00 AM, R1's and R10's room door was closed, with only the contact precautions isolation sign posted. R10 was sitting in the chair telling V9 (CNA) which clothes of R10's were dirty. V9 picked up R10's dirty clothes and put them in plastic bags per R10's directions. V9 was wearing a surgical face mask, gown, and gloves, with no face shield or goggles. V9 then doffed V9's gown and gloves and exited R1's and R10's room. On 11/7/23 at 11:08 AM, V9 (CNA) donned gloves and a gown while wearing a surgical face mask, and then entered R1's and R10's room carrying an empty plastic bag. On 11/7/23 at 11:10 AM, V9 exited R1's and R10's isolation room, as V9 was throwing away the doffed gown, gloves, and V9's surgical face mask in red garbage bin inside the room by door. V9 pulled out the tied plastic bag with R10's dirty clothing item from inside the room and set on the floor outside of the room. V9 reached inside the box of clean surgical face masks on top of the PPE bin right outside R1's and R10's door, and placed another face mask on V9's face. V9 performed hand hygiene. On 11/8/23 at 9:25 AM, V2 (Director of Nursing, DON/Infection Preventionist) stated hand hygiene is the number one way to prevent the spread of infection. V2 stated staff are to wear gloves when providing ADL care to residents, but wearing gloves does not substitute for staff to perform hand hygiene. V2 stated staff are to perform hand hygiene before resident care, after resident care, and in between different resident's care. V2 stated when a staff member removes his or her gloves during resident care, the staff member must perform hand hygiene before donning a new pair of gloves. Gloves don't replace hand hygiene. Microorganisms and bacteria are invisible bacteria and can be there if they have gloves on. Staff must do hand hygiene before putting gloves on. When asked the purpose of hand hygiene, V2 stated, To break the chain of the spread of infection. V2 stated staff are to teach residents to mask properly to prevent the spread of COVID-19 and to keep residents healthy. We (staff) don't want to spread COVID-19. V2 stated residents should stay inside their isolation rooms, and if residents do come out of their isolation rooms, then staff are to redirect them back into their room. V2 stated, We want to contain the spread (of infection). Break the chain. V2 stated if a staff member touches items with bare hands or comes in contact with surfaces inside a resident's contact and droplet isolation room, then everything is soiled that the staff member came in contact within the isolation room. V2 stated staff must do hand hygiene before the staff member comes out of the isolation room. V2 stated residents who test positive for COVID-19 are placed on droplet and contact precautions. Droplet precautions isolation is used for positive COVID-19 residents because droplets are expelled and go into the air, and we can inhale it. We use masks to prevent it from spreading. V2 stated the COVID-19 droplets are expelled from COVID-19 positive residents via the nose and mouth. Eye (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146167 If continuation sheet Page 17 of 21 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 11/09/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many protection like goggles or faces shields are to donned by staff when entering a positive COVID-19 contact and droplet precautions isolation room because COVID-19 microorganisms can go through the eyes, mucous membranes. Droplets are absorbed through mucous membranes. When asked about R15's tracheostomy, V2 stated COVID-19 microorganisms can be expelled out R15's tracheostomy stoma. When asked how are staff providing coverage over R15's tracheostomy to prevent transmission of COVID-19 droplets, V2 stated, I don't have an answer for that. When this surveyor informed V2 about R15 having R15's white board on the nurse's station desk on 11/6/23, V2 was asked what could happen to anyone else who comes in contact with the area where R15's white board was located, and V2 stated, It's cross contamination. V2 stated contact precautions isolation dictates that staff wear gloves and gown. Resident has infection, and it can be in the room. V2 stated the purpose of wearing gloves and a gown is to prevent the infection from coming onto staff. They (staff member) have it on your clothes or you embrace something. Staff can spread to someone else if (staff member) touches that person. When asked how are staff or visitors to know what PPE is to be worn going into an isolation room, V2 stated, We have a sign and put it on there outside the room. Sign should tell them what PPE to don. V2 stated the contact and droplet signs posted on the resident room doors have pictures on them of what staff are supposed to wear. V2 stated steps to donning PPE for a contact and droplet isolation room are for staff to don the gown first, then put on face mask (if not already wearing one), next to put on goggles or face shield, and lastly to don gloves. When asked what type of mask that staff are to wear when entering a positive COVID-19 resident's room (contact and droplet isolation), V2 stated, N95 (mask). V2 stated N95 masks are more secure that ordinary (surgical) masks which are more permeable than N95 masks. V2 stated the isolation gown when donned covers a staff member from neck down to a staff member's knees (depending on height). When asked if the inside of a staff member's isolation gown comes in contact with the environment in a positive COVID-19 resident's room, V2 stated, Staff have to change to put on another gown. It's contaminated. When asked if a staff member doffs gloves while still in a positive COVID-19 resident's room and touches surfaces with bare hands, V2 stated, Staff have to wash hands first before putting on gloves or before touch anything else in room. V2 stated the process to doff PPE before exiting a contact and droplet isolation room for the staff member is to remove gloves first due to gloves have been touching a lot of things (in room) and are contaminated. V2 stated the next step in doffing PPE is to remove the gown by uniting the ties behind the neck and then to pull the gown off from the inside of the gown and roll it inside out. V2 stated gloves and gowns are to be removed and discarded inside the resident's room, then the staff member steps outside the room, performs hand hygiene, then can remove the face shield or goggles to disinfect. V2 stated face masks are not doffed inside the room, and can be replaced after hand hygiene outside the room. When 2 residents who are positive for COVID-19 the same room together, PPE must be changed in between resident care along with hand hygiene. V2 stated this practice is safer for infection control. V2 stated staff exiting a room with bagged soiled linen from a positive COVID-19 isolation room should make sure not to drag it on floor in the hallway due to cross contamination concerns. On 11/6/23, V1 (Administrator) verified there are 35 residents residing in the facility. Facility policy, dated September 2023, and titled Infection Control Policy/Procedures: General Infection Control. Purpose: To establish methods and criteria, necessary within the facility and its operation, to prevent and control infections and communicable diseases. Responsibility: All employees and Quality Assurance Committee. Policy: It is the policy of this facility to maintain an infection control program designed to provide a safe, sanitary and comfortable environment, and to prevent or eliminate when possible the development and transmission of disease an infection . 7. All facility personnel (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146167 If continuation sheet Page 18 of 21 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 11/09/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many are required to routinely wash hands and use appropriate barrier precautions to prevent transmission of infections . Components: . 2. Transmission Based Precautions: additional precautions are applied when the transmission characteristics of, or impact of, infection with a specific microorganism are not fully prevented by routine practices. Additional precautions include: Contact precautions, for epidemiologically significant microorganisms or microorganisms with very low infective dose or situations when heavy contamination of the resident's environment is anticipated. Droplet precautions, for microorganisms primarily transmitted by the large droplet route . 3. Respiratory Etiquette: A combination of measures to be taken by the infected person designed to minimize the transmission of respiratory microorganisms . Includes covering cough, hand hygiene, wearing a mask if unable to contain cough. Facility policy dated September 2023 and titled Infection Control Policy/Procedures: Hand Hygiene, documents, in part, Purpose: Hand hygiene is the most effective way of preventing the transmission of healthcare-associated infection to resident, staff, and visitors. 1. Hand hygiene shall be performed: Before contact with a resident or resident's environment. Before a clean or aseptic procedure. After exposure or risk of exposure to blood and/or body fluids. After contact with a resident or resident's environment. 2. Alcohol-based hand rubs (ABHR) containing 60-90% (percent) alcohol may be used for performing hand hygiene . 10. Handwashing is essential. Alcohol based hand rubs/gels and handwashing are the Gold Standard of Prevention. Facility policy dated September 2023 and titled Infection Control Policy/Procedures: Selection/Use of Personal Protective Equipment (PPE), documents, in part, Purpose: Personal Protective Equipment (PPE) is an essential element in preventing the transmission of disease causing microorganisms. If used incorrectly, PPE will fail to prevent transmission and may facilitate the spread of disease. Appropriate PPE will also protect staff from exposure. The following shall apply when selecting in using PPE: . 2. Staff shall be trained in correct use and donning/doffing procedures for PPE. 3. Gloves and other single-use PPE (e.g. {for example} gowns, masks) shall be worn once for a single resident/procedure and shall be discarded following use . 5. Gloves: . shall be worn when handling contaminated equipment or devices and when cleaning and disinfecting contaminated surfaces or equipment. Hand hygiene must be performed before putting on and after removing gloves. 6. Masks, Eye Protection and Face Shields: Masks, eye protection, and face shields work together to protect the mucous membranes (i.e. eyes, nose, and mouth) from droplets, splashes or sprays of blood or body fluids (e.g. cough or sneeze, release of drainage from skin lesions, etc.). Proper eye protection must protect eyes in all directions and should be worn when splashes, sprays, or droplets of fluid are expected . 7. Gowns: Long-sleeved gowns protect uncovered skin and clothing during procedures and resident care activities likely to produce soiling or generate splashed or sprays of blood, body fluids, secretions, or excretions. Gowns should cover the front and back of the staff from the neck to mid-thigh . 8. PPE must be donned (applied) and doffed (removed) using the following specific sequence to prevent contamination of staff and the environment. Donning (Applying PPE): 1. Perform hand hygiene. 2. Put on gown with opening to the back. Fasten closures. 3. Put on mask. Secure ties to head or elastic loops behind ears. Mold the flexible band to the bridge of nose. Ensure snug fit to face and below chin with no gaping or venting. 4. Put on protective eyewear or face shield. 5. Put on gloves by pulling the gloves over the cuffs of the gown. Doffing (Removing) PPE: 1. Remove gloves by grasping the outside cuff of one glove near the wrist and peel away from the hand, turning the glove inside out. Hold the glove in the opposite gloved hand. Slide finger or thumb under the wrist of the remaining glove and peel the glove off and over the first glove. Discard gloves in the garbage. 2. Remove gown by unfastening closures and grasping the outside of the gown at the back of the shoulders, pulling the gown down over the arms. Turn the gown inside (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146167 If continuation sheet Page 19 of 21 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 11/09/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many out during removal. 3. Remove protective eyewear or face shield by grasping the headband or earpieces and carefully pulling away from face. Do not touch front of eyewear or shield. 4. Carefully remove mask by bending forward slightly, touching only the ties or elastic loops. Discard the mask in the garbage. 5. Perform hand hygiene. Facility policy dated 5/15/23 and titled Coronavirus (COVID-19) Policy/Surveillance, documents, in part, Policy: This policy is to educate, prevent the spread, identify and treat the Coronavirus. Responsibility: All Staff and Visitors . High-Risk Exposure: Exposure of a staff member to a person with COVID in any of the following circumstances: Staff member not wearing either face mask or respirator. Staff member not wearing eye protection . Respiratory germs prevention spread within your facility: . Restrict residents to their rooms as much as possible during outbreak. If they must leave room for any reason, have them wear a facemask . support and encourage hand and respiratory hygiene etiquette by residents, staff and visitors. Encourage staff hand hygiene according to CDC (Centers for Disease Control and Prevention) Guidelines including before and after resident contact, after contaminated surface and equipment contact and after removing personal protective equipment (PPE) . Any resident warranting isolation precautions or restrictions, post sign on door or wall clearly identifying this . Encourage hand hygiene before entering and exiting residents' rooms . Staff to wear appropriate PPE (gown, gloves, N95 respirator, eye protector) daily during care of COVID + (positive) . Core Principles of COVID-19 Infection Prevention: Hand Hygiene: Alcohol based hand rub preferred . PPE worn appropriately . Facemasks/KN95/N95 Usage: . N95 required to enter COVID + room. Facility policy dated 4/3/13 and titled Infection Control, documents, in part, Policy: It is the policy of this facility to provide guidelines for appropriate precautions regarding individuals known or suspected to have infection or colonization of drug resistant organism confirming to the Center for Disease Control, State/Federal Regulations. Procedure: . 5. Staff nurse shall be responsible in carrying out all the functions of the isolation procedures . 6. Staff nurse is responsible for the following: . c. Post the appropriate sign by the door so that all personnel and visitors will be alerted of the isolation precautions. Facility policy undated and titled Residents' Rights for People in Long Term Care Facilities, documents, in part, that the facility must provide services to keep your physical and mental health, at their highest practical levels. Your facility must be safe, clean, comfortable and homelike. Facility job description undated and titled Certified Nursing Assistant, documents, in part, Certified Nursing Assistant. Summary: The Certified Nursing Assistant (CNA) is responsible for providing resident care and support in all activities of daily living and ensures the health, welfare and safety of all residents. Facility job description undated and titled Registered Nurse (RN), documents, in part, that the RN reports to the Director of Nursing (DON), and Registered Nurse. Summary: The RN is responsible for providing direct nursing care to residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision (must) be in accordance with current federal, state and local standards, guidelines, and regulations that govern our facility and as may be required by the Director of Nursing to endure that the highest degree of quality of care is maintained at all times. Essential Duties and Responsibilities: Direct the day-to-day functions of the nursing assistance . Administer professional services . as required . performs other duties as assigned. Facility job description undated and titled Director of Nursing Service, documents, in part, Purpose of Your Job Position: The primary purpose of your job position is to plan, organize, develop and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146167 If continuation sheet Page 20 of 21 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 11/09/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many direct the overall operation of the Nursing Service Department in accordance with current Federal, State and local standards, guidelines and regulations governing our facility, and as may be directed by the Administrator, to assure that the highest degree of quality care can be maintained at all times. Major Duties and Responsibilities: . 18. Assure that the Residents' Rights are followed by nursing service personnel at all times . 23. Assure that nursing service personnel follow established safety regulations in the use of equipment and supplies, providing care/services, etc. (and the rest), at all times. 24. Assure that the department is maintained in a clean and safe manner for resident comfort and convenience by assuring that necessary equipment and supplies are maintained and operable to perform such duties and services . 39. Develop, maintain, and implement infection control policies and procedures to assure that a sanitary environment is maintained at all times and that aseptic and isolation techniques are followed by all personnel. 6. On 11/07/2023 at 11:19 AM, during observation of medication storage room and refrigerator, an employee's COVID-19 nasopharyngeal Specimen was found. V10 (Registered Nurse/RN) stated, This is a night shift employee's COVID-19 nasopharyngeal specimen sample that needed to be tested for COVID-19. There is a different fridge for these specimens; this specimen sample should not be in here. On 11/07/2023 at 11:40 AM, V2 stated, COVID specimens should be in different fridge and the temperature should be between 31-41 degrees Fahrenheit. 7. R29 has diagnoses which includes iron deficiency anemia, repeated falls, lymphedema, difficulty in walking, essential hypertension, trauma subdural hemorrhage without loss of consciousness, reduced mobility, COVID 19, and low back pain. R29's Brief Interview for Mental Status (BIMS), dated 07/26/23, documents R29 has a BIMS score of 15, which indicates R29 is cognitively intact. R29's Care Plan documents: Problem: (R29) have an infection of the COVID 19 strict isolation: Droplet & Contact for COVID 19 positive all services to be provided in room . Interventions: Follow facility policy and procedure for line listing, summarizing and reporting infections. R29's Order Summary Report (POS/Physician Order) shows R29 has an order for COVID 19 test, dated 11/02/23. R29's test result: COVID 19, dated 11/02/23, shows that R29 positive for COVID 19. R29's progress note, dated 11/02/23, documents R29 tested positive for COVID 19 and was placed on strict contact and droplet isolation. On 11/06/23 at 11:13 AM, R29's room door had an isolation sign stating, Contact Precautions with an isolation bin set up out of R29's room. No Droplet Precaution isolation signage, no N95 mask or face protection (face shield, goggles) observed in isolation bin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146167 If continuation sheet Page 21 of 21