Inspection·October 2, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement their fall protocol by failing to re-assess a resident after a fall and failed to implement care plan interventions for one (R1) of three residents reviewed for falls. Findings include: R1's medical record (Face Sheet) documents R1 is a [AGE] year-old female admitted to the facility on 5.25.2022 with diagnoses including but not limited to: Epilepsy, Bipolar Disorder, Paranoid Schizophrenia, Lack of Coordination, and Difficulty in Walking. R1's MDS (Minimum Data Set of 7-7-2023) documents R1 is moderately cognitively impaired and experiences hallucinations and exhibits delusions. On 9-30-2023 at 12:05 PM, R1 was observed awake and alert sitting on the side of her bed eating lunch. A soft helmet was noted on R1's head; a CAM (controlled ankle movement) boot was noted on R1's left lower extremity. There were no floor mats noted on the floor in front of resident's bed. On 9-30-2023 at 3:55 PM, V8 (Restorative Supervisor) said, fall assessments should be completed upon admission, quarterly, after a fall incident, and when there is a significant change in condition. A fall assessment was not completed after R1's fall (in August). On 9-30-2023 at 5:05 PM, V8 (Restorative Supervisor) said, R1's floor mats should be in place when she is lying in or sitting on R1's bed. On 9-30-2023 at 5:59 PM, V1 (Administrator) said, R1 does have a history of falls; all falls were related to seizure activity. We monitor her every 15 minutes, placed her in a low bed, encouraged her to call for assistance. After the fall, we put a leaf on her headboard (to alert staff she is a fall risk), moved her closer to the Nurses Station, placed mat on floor. The mat should be in place when she is in bed or sitting on bed. Fall risk assessments should be completed upon admission, quarterly, after a fall, and when there is a change in condition. R1's care plan: Resident has had multiple falls and is deemed a high fall risk due to diagnosis of seizures without clear warning signs or ability to verbalize when seizures may occur secondary to psych diagnosis (revised 9-16-2023) documents the following intervention: Floor mats to be placed around bed. Restorative Fall Protocol and Policy (1-1-2023) documents: The following protocol/policy is to (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 3 Event ID: 146191 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 146191 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mado Healthcare - Uptown 4621 North Racine Avenue Chicago, IL 60640 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)