Inspection·February 18, 2024

F 0689 - 01/21/2024 R1 was observed sitting on the floor. Level of Harm - Actual harm Resident Verbalized: Resident stated I worked all day and as I was walking home, I got tired and just sat on the floor. Residents Affected - Few Intervention: Implement interventions to manage and cope with dementia-related behaviors. R1's fall assessment dated [DATE] indicated: R1 is a high fall risk due to past falls, impaired transfers, can not walk unassisted, and impaired mental status. Scored 75.0 indicates R1 is a high fall risk. R1's facility reported final report dated 1/12/24 documents in part: On 1/8/24 at 6:50 PM, R1 was observed by staff lying on his left side on the floor near the doorway. During investigation, staff were interviewed, all claimed R1 was confused and disoriented and hard to redirect. R1's CT scan revealed small subarachnoid bleeding on the left fissure. Based on the information and interviewed, R1 is lacking safety awareness due to progression of disease process. Interviews: On 2/17/24 at 12:52 PM, V4 [Licensed Practical Nurse] stated, I am familiar with R1. He has cancer that has spread to the bones and goes to cancer treatments. R1 can state his needs at the moment, but he has dementia with aggressive behaviors at times and impulsive. R1 needs continuous monitoring, supervision and re-direction. I was R1 nurse on 12/7/23 when he had a fall. I was the end of the hallway completed blood sugar checks and staff told me R1 was on the floor. I observed R1 next to his bed on the floor with no clothes on. During the body assessment I noted a laceration above his eyebrow. R1 was sent to the hospital and received sutures. On 1/8/24, R1 was re-admitted back to facility from having stomach pains. The ambulance transporters placed R1 into bed, I completed his body assessment and noticed R1 was very confused, trying to remove his clothing and kept trying to get up from bed. I called V3 [Director of Nursing] and asked if R1 could be moved closer to the nursing station, V3 told me she would move R1 closer. I was at the nursing station completing R1's admission paperwork when I heard R1's roommate yelled out for help. R1 had a fall and was only back in the facility for an hour. I observed R1 lying on the floor next to his bed without any clothes on. I completed body assessment and R1 was placed back into bed. I notified V3, physician and state guardian of the fall. R1 fall interventions is to keep his room free of clutter and move R1 closer to the nursing station. I cannot remember if the bed was in low position, there was no floor mats on the floor next to R1's bed. After his falls on 1/8/24, when R1 returned to the facility on 1/14/24, I would put R1 in his wheelchair and push him with me from room to room to complete my medication pass. To ensure he did not fall, while I was down the hall. R1 needs one to one monitoring to prevent falls. On 2/17/24 at 1:23 PM, V3 [Director of Nursing] stated, R1 has cancer to the bones, he is not easy redirected, R1 like to be naked and takes his clothes off and is very aggressive. R1 has been in and out the hospital. 12/7/23, R1 trying to get out of bed, and fell trying to get to wheelchair, impulsive behavior. The intervention was to implement fall prevention measures, encourage the use of mobility aids, and collaborate with physical therapy for strengthening exercise. On 01/08/2024 at 15:07 R1 was observed naked sitting on the floor by his bed side. Intervention was to provide regular mobility assistance to the resident to prevent independent attempts at transferring. On 01/08/2024 at 19:13 R1 was observed by staff lying on the floor. Resident was lying at the entrance of his room on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145796 If continuation sheet Page 2 of 4 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 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral 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 0689 Level of Harm - Actual harm Residents Affected - Few his left side. R1's x-ray showing bleeding at the arachnoid. The intervention was physical therapy and occupational therapy referral. On 01/21/2024, R1 was observed sitting on the floor. The intervention was to implement interventions to manage and cope with dementia-related behaviors. After every fall there should be a nursing intervention in place specific to the resident to prevent another potential fall. Our minimum data set coordinator [MDS] places fall interventions in the care plan. The nursing team discus our options and MDS coordinator places in the care plan. R1 interventions are not specific as they should have been. Some specific care plans would be low bed, call light in reach, or place floor mats next to the bed. I do not know why R1 do not have those interventions in his care plan or specific interventions. The nursing staff should know what basic fall intervention are to implement. Some nurses take R1 with them during their medication pass. There is no reason why the nurse should not take the R1 with them while passing medications, its part of the nurse job, if the CNAs are busy. On 2/17/24 at 3:10 PM, V5 [Social Service Director] V5 stated, R1 is declined significantly since admission due to spreading cancer, very confused restless and compulsive. R1 need continuous monitoring and cues. R1 has state guardian as of January 2024. There are times when R1 behavior and cognition goes up and down not all the time sometimes when he needs 1:1 sitting. On 2/17/24 at 6:00 PM, V6 [Agency Licensed Practical Nurse] stated, R1 was alert he tell you the basic things, like bathroom, and hungry at times. R1 was very confused on 1/8/24. I received report from V4 that R1 had a fall around 3PM, and he was moved to another room closer to the nursing station. R1 need very close monitoring and supervision. When I checked on R1, he was in bed sleeping. V8 [Certified Nurse Assistant] told me he took R1 his food tray and R1 did not eat any of his food. V8 and I went to R1's room to warmed up his food, and positioned R1 in a sitting up position so he could eat dinner. V8 went to help another resident, and I went down the hall to look for a wheelchair. On my back down the hallway, near his room I observed R1 lying on the floor in front of his bedroom door in the hallway. I completed a body assessment, check R1's vital signs, completed range of motion. I did not see any apparent injuries. I called R1's physician I received an order to send R1 back to the hospital, because he had two falls upon with in hours of R1 being re-admitted back to the hospital. V8 or I could not stay with R1 continuously, we have to care and tend to other residents on the floor. R1 has another fall on 01/21/2024. Nursing staff observed R1 on the floor. R1 said he was tired after getting off the floor then sat down. I completed head to toe assessment, no apparent injury. V9 [R1's Facility Physician] order x-rays they were negative for fracture. I was taking care of other residents and R1 got out of bed. R1 need to have one to one monitoring. On 2/17/24 at 6:35PM, V8 [Certified Nurse Assistant] stated, R1 is confused and needs a lot of monitoring. R1 was sleeping for a while and did not wake up to eat dinner. V6 and I went to R1's room and woke him up to position up in bed so he can eat. I warmed up his dinner and R1 started to eat. I left out R 1's room to assist another resident. I heard the V6 call out for assistance. I observed R1 lying on the floor outside his doorway. R1 told me he was trying to go watch the football game. I kept monitoring R1, but R1 got up so fast when I was down the hall. On 2/18/24 at 10:01 AM, V9 [R1's Facility Physician] stated, I was notified on 1/8/24 that R1 was re-admitted back to the facility and had fallen twice with in a few hours, I gave an order to send R1 back to the hospital for further evaluation. R1 medically and cognitively declined when his cancer had spread to the bone and possible brain. The nursing staff should take into consideration that R1 needs close monitoring and supervision to help prevent falls. R1 fall could have been prevent only if he had one to one supervision, the facility is not capable to provide one to one supervision all the time. Administration maybe consider R1 needs a facility that is capable to provide very close (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145796 If continuation sheet Page 3 of 4 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 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral 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 0689 monitoring. Level of Harm - Actual harm On 2/18/24 at 10:15 AM, V1 [Administrator] stated, V3 completed the fall investigations, and (State Survey Agency) report. I read over the report, I am familiar with R1 and his falls. R1 had a declined secondary to cancer now to the bones. There were times R1 was one to one and staff stayed in the room, there is no order for one to one or any intervention. The nursing staff are all aware that R1 is a high fall risk and need close monitoring, the staff has done their best. The hospital should have sent him back to the facility unstable. Residents Affected - Few Policy: Documents in part: Fall [No Date] -To ensure that all incidents that occur with residents are identified, reported, investigated and care plans reviewed, to provide appropriate medical interventions with residents involved in fall incidents as deemed necessary by the health care providers, to study fall causations and to provide corrective actions to prevent reoccurrence when possible. -Resident's care plans will be reviewed and updated as necessary by the interdisciplinary FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145796 If continuation sheet Page 4 of 4