Health inspection·November 26, 2025

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 observations, interviews and record reviews, the facility failed to provide wheelchairs to residents that were in safe and working condition to 3 (R12, R13 and R14) of 3 residents reviewed for concerns on properly functioning wheelchairs. This failure had the potential to result in accidents and safety hazards. Findings Include:R12's Face Sheet documents that R12 was admitted to the facility on [DATE] with a diagnosis of nontraumatic intracerebral hemorrhage, traumatic subdural hemorrhage epileptic seizures related to external causes, chronic kidney disease, and hypertensive heart disease without heart failure aneurysm of the descending thoracic aorta.R12's last quarterly Minimum Data Sheet (MDS) documents a Brief Interview for Mental Status (BIMS) score of 14 indicating cognitively intact with little to no impairment. R12's MDS dated [DATE] shows impairments to both R12's upper and lower extremities and requires substantial to maximum assistance in all activities of daily living (ADL) categories except eating and oral hygiene in which R12 requires supervision.R13's Face Sheet documents that R13 was admitted to the facility on [DATE] with a diagnosis of unspecified injury at unspecified level of cervical spinal cord, subsequent encounter, hemiplegia, unspecified affecting left nondominant side, and may use wheelchair for mobility.R13's last quarterly Minimum Data Sheet (MDS) documents a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact with little to no impairment. R13's MDS dated [DATE] shows impairments to both R13's upper and lower extremities and requires substantial to maximum assistance in all activities of daily living (ADL) categories except eating and oral hygiene in which R13 requires supervision.R14's Face Sheet documents that R14 was admitted to the facility on [DATE] with a diagnosis of weakness, cerebral infarction affecting right dominant side, hemiplegia and hemiparesis, and chronic respiratory failure with hypoxia.R14's last quarterly Minimum Data Sheet (MDS) documents a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact with little to no impairment. R14's MDS dated [DATE] indicates R14 needing moderate assistance to supervision.On 11/24/2025 at 11:49AM, R12 was dressed and sitting in R12's room in R12's wheelchair. R12 stated that R12's wheelchair is not working because it is hard for the wheels to move.On 11/24/2025 at 11:56 AM, V33 (Licensed Practical Nurse) stated that R12 had complained to V33 that R12's wheelchair was hard and when V33 asked, What do you mean by hard, R12 responds that it is just f-ing hard. V33 stated that V33 reported the wheelchair issue to maintenance for repair and that it was fixed. V33 added that R12 still complained that the wheelchair's wheels were hard to move.On 11/24/2025 at 12:35 PM, R13 was sitting near the nurse's station outside of R13's door. R13 said that the strap/seat belt of R13's wheelchair was broken due to R13's fall. R13 pointed to the right side of the chair near R13's lower back. R13's buckle strap was broken.On 11/24/2025 at 12:40 PM, R14 wheeled up to the nurse's station and when asked, R14 stated that R14's wheelchair was broken. R14 said that R14's brakes were not working and the rubber parts of R14's wheels kept coming off.On 11/24/2025 at 3:03PM, V28 (Restorative Aide) stated that a month ago R12 complained to V28 about R12's wheelchair and V28 Residents Affected - Few Note: The nursing home is disputing this citation. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145796 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 11/26/2025 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)