Inspection·December 26, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete day his wheelchair broke. I was at the desk with R2 and two other ladies. I was trying to get R2 seen by the physician while we were there, because it took a long time waiting to receive an appointment. I did not curse at R2. While I was speaking, R2 did cut me off, but I did not curse at R2.On 12/23/25 at 2:00 PM V5 [Office Manger], stated, I received a phone call from V9 [Medical Clinic Manager] and asked when R2's transportation will be there for pick up. Also, V9 said that V6 was rude to R2. That's all V9 said to me, she did not say how or what V6 did to R2. I did not believe V9, because I never heard V6 curse.Surveyor asked V5, why did she say she never heard V6 curse, did V5 say V6 cursed at R2?V5 stated, Oh yeah, I just told on myself, okay. V9 did say she heard V6 curse at R2 saying ‘shut the f_ _k up'. I did not tell V3 [Director of Nursing], but I told V1 [Administrator] immediately. But V1 and I knew V6 did not curse at R2, because she is a good person, and we never heard V6 curse before, V1 and I did not believe V9.On 12/23/25 at 3:00 PM, V1 [Administrator] stated, V5 kept me informed about R2's broken wheelchair and transportation issues. V5 did not report R2 was verbally abused by V6 at his medical appointment, but I take full responsibility leave V5 and V3 out of this. I am the human resource director. I cannot locate V6's abuse training during orientation. I must have misplaced the abuse training. If I was made aware of the allegation, V6 would have been suspended immediately, reported to IDPH, and investigation would have occurred.On 12/24/25 at 10:10 AM, V1 stated [during telephone conversation], I called the hospital and spoke with R2. I asked R2 if V6 cursed at him, R2 said he did not know who V6 was. R2 was admitted to the hospital for altered mental status. Also, V5 told me she was confused during the interview, and she mistakenly said she told me V6 cursed at R2.On 12/26/25 at 11:30 AM, V1 stated, The abuse training orientation was verbal, I do not have any documentation that V6 received abuse training. I take full responsibility.Policy in part:Abuse and Prevention dated 1/3/25This affirms the right of our residents to be free from abuse. The facility is committed to protecting our residents from abuse by anyone including, but not limited to facility staff, and other residents. Abuse means any physical, mental, sexual, verbal inflicted upon a resident. Verbal abuse is the use of oral, written, gestured language that willfully includes disparaging and derogatory terms to the resident within in their hearing distance regardless of their age, ability to comprehend or disability. Employees: Orientation and training employees: Resident rights, resident needs, to prevent and report abuse. All employees will sign an Abuse Policy Employee Acknowledgement form. Employees are required to immediately report any occurrences of potential mistreatment they observed, hear about, or suspect to supervisor and or administrator. Reporting: Initial reporting of allegations shall be completed immediately upon notification of the allegation. The written report shall be sent to the Department of Public Health. Investigating: The administrator or designee will investigate the allegations and obtain a copy of any documentation related to the incident. Event ID: Facility ID: 146167 If continuation sheet Page 2 of 6 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 12/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Foster Health & Rehab Center 2840 West Foster Avenue Chicago, IL 60625 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to ensure a resident was properly assessed for the sizing of a wheelchair and failed to follow their Accident Incident/Fall Reporting Policy for one (R2) of three residents reviewed for wheelchair use.Findings Include:R2 has diagnosis not limited to Hyperlipidemia, Type 2 Diabetes Mellitus, Repeated Falls, Anxiety Disorder, Dysphagia, Major Depressive Disorder, Spinal Stenosis, Cervical Region, Pain, Low Back Pain, Fibromyalgia, Morbid (Severe) Obesity Due to Excess Calories, Generalized Anxiety Disorder. R2's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response.R2's Care Plan document in part: Problem: R2 is High risk for falls r/t (related/to) gait/balance problems. Interventions: Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT (interdisciplinary team) as to causes. Problem: Resident has Alteration in mobility/ Transfer R/T fibromyalgia, repeated falls, weakness and Pain.On 12/23/25 at 11:15 AM V9 called the surveyor and said when R2 came to the hospital the care giver (V6 Escort Provider) said R2 fell out of the van when the driver made a sharp turn. R2's wheelchair had a broken armrest, wheel and the wheelchair was unstable so we could not move R2 inside. It was as if the wheelchair was too small and R2 needed a larger wheelchair. V7 (Activity Director/Certified Nurse Assistant) arrived with a wheelchair that was the same size. I am concerned with R2's wellbeing and R2 waited 8 hours before they sent a van to pick R2 up. Both a coworker and I witnessed it. The facility came on 2 separate occasions, with 2 separate rides and with the wheelchair that was too small. V6 stated the resident fell in the van when they were trying to get him out of the van. When R2 arrived at the clinic a code blue was called. R2 told me he fell immediately after they left the facility, was not strapped in and was laying sideways for the entire ride on the van's floor. My concern was R2 had fallen, and they let R2 stay on the floor of the van. I made the facility aware of the situation around 9-10 am and they were dismissive and argumentative.On 12/23/25 at 11:37 AM V10 (Office Assistant) said R2 was here 5-6 hours later when the facility finally picked R2 up.On12/23/25 at 10:17 AM upon entering R2's room surveyor observed a large wheelchair located near the foot of R2's bed with damage to the left armrest cushion. R2 had been transferred to the hospital due to altered mental status.On 12/23/25 at 10:17 AM R3 stated R2 said he used to have a different wheelchair. The wheelchair that R2 had was like that one near R2's bed but it was just smaller.On 12/24/25 11:00 AM V16 (Certified Nurse Assistant) stated I was one of the people that cleaned R2 up, put on his clothes and helped put him in the wheelchair. I don't know if they had to change R2 out of the chair because it did not fit on the transportation van. R2 usually stays in bed because he cannot stand and does not have weight bearing for his ankles. On 12/23/25 at 12:49 PM When asked did she escort R2 to his appointment on 10/16/25 V6 (Escort Provider) responded, I pushed R2 to the transportation van. R2 changed wheelchairs into a smaller wheelchair because the big boy wheelchair would not fit on the van's transportation wheelchair ramp. R2 mentioned they gave him a reduced wheelchair, smaller wheelchair so it could fit on the ramp into the medical van. The driver came out and pushed R2 up the ramp. The floor in the van was a plain floor with straps on the side, inside the spokes of the wheels of the wheelchair. I am not sure if the driver strapped R2 in because I was outside of the van and I was not paying that close of attention. As far as I am concerned the driver did everything I could have sworn. There was a long bench seat in the van, and I can't tell you if R2 was strapped in because I was sitting next to the driver. R2 is a big guy. The driver said if you like you can sit in the front passenger seat. I did not sit in the back on the bench seat because it was not enough room. I am glad I was not back there because R2 would have Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146167 If continuation sheet Page 3 of 6 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 12/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Foster Health & Rehab Center 2840 West Foster Avenue Chicago, IL 60625 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few fell on me. The driver made a left turn and R2 fell. The wheelchair tilted sideways, and the wheels were in the air. R2 fell leaning towards the bench seat. I told the driver to pull over. The driver opened the door and R2 was facing the door behind the driver. The driver could not get R2 up and said he needed some help. R2 is alert and oriented x3. When we get to the clinic they came out and 911 was called. 911 used a sheet and blanket to get R2 up. R2 was uncomfortable because he was used to his own wheelchair. The wheelchair left wheel was bent in when R2 was tilted, that is why the driver could not get R2 back. The spinal people said you cannot push R2 to his appointment because they said it was unsafe to go to R2's appointment and they cancelled his appointment. The fire department, they were all over R2 and I was back where I could not see R2's position. I don't know how they got R2 out of the van. 911 put R2 back in the broken wheelchair, R2 was still sitting in his broken wheelchair, and we were sitting there forever waiting on another wheelchair. I called V1 (Administrator) to let her know the fire department handled that and let her know what happen. V7 (Activity Director/Certified Nurse Assistant) drove and brought a wheelchair from the facility, and they sent 2 men to take R2 out the broken wheelchair. One to 2 hours had gone by. It was about 5 hours before R2 went back to the facility. V5 (Office Manager) made an appointment for the medical van to come get R2 and I road back in the van with R2. R2 cannot stand.On 12/23/25 at 02:52 PM V11 (Registered Nurse) stated on 10/16/25 R2 went to the pain clinic for a usual appointment with transportation. R2 is a fall risk. In the middle of the day, I got call from administrator. R2 had a broken wheelchair, and they needed another wheelchair for him. The transportation driver made a sharp turn and R2 tilted. I got the information from the escort. We sent two certified nurse assistants with another wheelchair, to help R2 from the damaged wheelchair to another wheelchair.On 12/24/25 at 11:44 AM per telephone interview V17 (Registered Nurse) stated on 10/16/25 R2 came back from his appointment as usual at maybe 3 something. When a resident returns from an appointment we get the notes from the appointment. I was not aware of R2's incident and I am not aware of what kind of wheelchair R2 was in.On 12/23/25 at 03:09 PM V1 (Administrator) stated the escort (V6) was calling me about the incident. I had V5 (Office Manager) call the transportation company to report the incident and the driver. It was reported that V6 called and said the transportation driver made a sharp turn and the wheelchair tipped over. The driver got out the van to try to put the wheelchair back up straight. The nurse said V6 needed to call 911 to help assist R2 to another wheelchair. We had an uber to get R2 back to the facility. It was after 03:30 when they came back to the facility.On 12/23/25 at 01:33 PM V7 (Activity Director/Certified Nurse Assistant) stated R2's wheel on the wheelchair was broken. Management V1 (Administrator) wanted me to take another wheelchair to R2's appointment. It was said the clinic could not assist transferring R2, so me and 2 other Certified Nurse Assistants went with me. I drove my personal truck to take the wheelchair, and the two other certified nurse assistants rode in a different vehicle. I arrived first and once I got there; I tried to assist transferring R2 into the wheelchair, but R2 would not allow me to assist transferring him. R2 allowed the three of us to transfer him. R2 has a favorite wheelchair that is a standard size. It was a regular wheelchair that was broken. I was holding the chair as R2 was being transferred. We left after we transferred R2, and he had to be transported by transportation services back to the facility. They had to transport R2 because he cannot stand. R2 is very alert.On 12/23/25 at 01:48 PM V8 (Certified Nurse Assistant) stated The director of nursing and administrator called us and said we need to go assist R2. We met R2 in the wheelchair and they said R2's wheelchair was broken. V7 (Activity Director/Certified Nurse Assistant), V13 (Certified Nurse assistant) and I transferred R2 putting our arms under R2's armpit, lift, pivot and transfer R2 to the other wheelchair. It was a medium size wheelchair. R2 said thank God you all (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146167 If continuation sheet Page 4 of 6 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 12/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Foster Health & Rehab Center 2840 West Foster Avenue Chicago, IL 60625 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few came. R2 is not able to stand or walk. We left after R2 was transferred to the other wheelchair.On 12/24/25 at 09:53 AM V13 (Certified Nurse Assistant) stated the administrator called us and told us we need to go transfer R2 into another wheelchair. Me and V8 (Certified Nurse Assistant) rode together and met V7 (Activity Director/Certified Nurse Assistant) there. R2 was transferred into the wheelchair that we went with. I don't remember the size of the wheelchair. They gave R2 a bigger wheelchair after the incident. We came back to the facility after R2 was transferred to the wheelchair.On 12/23/25 at 02:03 PM V5 (Office Manager) stated the incident with R2 happened in October, this person picked R2 up, took a sharp turn in the vehicle and R2's wheelchair tilted. The vehicle was wheelchair accessible because R2 could not transfer. That is the account I got from R2 and from V6 (Escort Provider) because I was not present. The clearest report was from R2 saying the driver made a sharp turn and the wheelchair fell over, the parking guy came to help and said let's call 911. After they ascertained the wheelchair was broken, the doctor would not see R2 because R2 could not be pushed in the wheelchair. V7 (Activity Director/Certified Nurse Assistant) went to take the new wheelchair that R2 could fit in and be wheeled back in.On 12/24/25 10:35 AM V14 (Certified Nurse Assistant) stated I helped transfer R2 into the bed from the wheelchair. The wheelchair R2 was in was a regular wheelchair. I am not sure what size the chair was that we transferred R2 from into the bed.On 12/24/25 at 11:50 AM per telephone interview V18 (Restorative Nurse) stated When I started working there, I did a reassessment if R2's wheelchair was suitable but there is no assessment for the wheelchair itself. With the assessment we check if the resident is suitable for a wheelchair, then measure one side to the other side of the hips. That determines what size wheelchair is needed. I cannot recall what size R2's wheelchair was in and never had to document the size of his or anyone's wheelchair. I am aware of the incident that happened 10/16/25. The director of nursing told me that they needed to order another wheelchair. They did not tell me that I needed to reassess R2.On 12/23/25 at 09:27 AM V3 (Director of Nursing) stated I have no incident reports in the past 3 months.On 12/23/25 at 02:20 PM V3 (Director of Nursing) stated I was not here when they called about the incident with R2. When I came in the building around 2 pm (Registered Nurse) called and told me what happened. R2 went on an appointment and his wheelchair broke. I asked did R2 fall and V6 (Escort Provider) said R2 leaned over but he did not fall. The wheelchairs wheel broke, and they needed people to take him another wheelchair so two certified nurse assistants had to take R2 a wheelchair. V7 (Activity Director/Certified Nurse Assistant) went with the two certified nurse assistants. A Risk management was not done because no one said anyone fell on the floor. The wheel popped and leaned so they had to transfer R2 from one wheelchair to the other. A change of plain is considered a fall. R2 said he did not like that wheelchair, he liked the other wheelchair. R2's appointment as cancelled and after R2 came back from the appointment he did not fit properly in the wheelchair. I can't remember what size the wheelchair was When the wheelchair wheel broke, they couldn't get R2 out, so they had to call 911 for assistance. My presumption is the wheelchair did not support R2's weight or they did not have R2 strapped in correctly. They had to bring another wheelchair because the wheelchair was broken, and they did not have another wheelchair available. I did a report, and we did incorrect stuff. I did not do an incident report, and I don't have anything documented. When called, the nurse should have made documentation, informed the director of nursing and medical doctor. I will take total accountability. There should have been risk management, interview the staff and anyone involved including 6 interviews, R2 should have been assessed when he got back in the building, assessed for 72 hours, a wheelchair should have been ordered in the proper size, a root cause analysis should have been done, restorative and the interdisciplinary team should have gotten involved. The Root cause is R2 needed a bigger (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146167 If continuation sheet Page 5 of 6 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 12/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Foster Health & Rehab Center 2840 West Foster Avenue Chicago, IL 60625 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete wheelchair. How V6 reported the incident was so vague, I did not speak to anyone. We rescheduled the appointment. On 12/24/25 at 09:15 AM V3 (Director of Nursing) stated the wheelchair that broke, R2 had it for a long and it was a regular wheelchair in weight. Policy:Titled Accident Incident/Fall Reporting Policy revised 01/01/25 document in part: Any accident/incident will be reported immediately to the nurse or appropriate person designated to be in charge. A written report will be completed for anu individual (resident) involved in an accident or an incident while residing in the facility. Purpose: To ensure that accidents and incidents that occur with residents is identified, reported, investigated, and resolved. To provide a database to study the cause of accidents/incidents and to provide assistant in implementing corrective actions to prevent reoccurrence when possible. Procedure: 1. If a resident is involved in and accident/incident an immediate assessment of the resident will be completed. 2. The nurse responsible for the oversite and care of the resident will complete an incident/accident report. When possible, a descriptive statement will be obtained from the resident and any witnesses. (Utilize the witness statement form). 3. The nurse will notify the resident's attending physician/nurse practitioner. Any actions/communications are to be documented in the resident's medical record. 4. The surrogate or authorized representative is to be notified of the accident/incident. 5. Any accident/incident report, which has occurred, shall be reported to the nurse's manager on duty or designee. 6. An accident/incident report will be completed as soon as information is obtained. The report is to be completed as fully as possible before the nurse ends the shift. An exact description of the circumstances surrounding the incident/accident will be provided. Only facts will be documented. 7 The occurrence will be documented in the resident's medical record. Documentation in the medical record should include the following: Description of the occurrence, Physical and mental status of the resident, Time of physician notification and physician response/orders, Time of notification of the resident's family, guardian, or responsible party. 8. A complete incident/accident report will be submitted to the Director of Nurses or designee. 10. Documentation of the resident's physical and mental status will be completed each shift following the incident for a minimum of 72 hours or until the condition symptoms improve. Neuro-checks will be completed according to policy. 11. The occurrence is to be communicated shift to shift as part of the unit report until the resident is stabilized. 13. A thorough investigation will be completed within 5 business days. 14. Based on the results of the investigation, the resident care plan is revised as necessary to prevent or minimize further accidents/incidents when possible. 15. A complete investigation tool and other written information will be maintained with the incident report. Event ID: Facility ID: 146167 If continuation sheet Page 6 of 6