Inspection·December 7, 2023

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed provide ADL (Activities of Daily Living) to one resident (R28) reviewed for ADL's in the sample of 44. Residents Affected - Few Findings include: R28 has a diagnosis of but not limited to Pneumonia, Moderate Protein-Calorie Malnutrition, Epilepsy, Schizoaffective Disorder, Allergic Contact Dermatitis and Chronic Obstructive Pulmonary Disease. R28 has a Brief Interview for Mental Status score of 11. On 12/4/2023 at 11:17 am, surveyor observed R28's fingernails to be long on both hands. R28 stated that his nails are too long for a man and would like them to be trimmed. On 12/5/2023 at 2:42 pm, surveyor observed R28's fingernails to be long on both hands. On 12/05/2023 at 2:46 pm, V16 (CNA) stated resident's fingernails are trimmed every time she notices that they are dirty and or long and nail care is provided with showers. On 12/06/2023 at 12:34 pm, V1 (Administrator) stated staff are expected to provide nail care when providing ADL care, during showers and as needed. Activities of Daily Living Policy dated 1/4/2023 documents, in part, the facility will provide care and services for the following activities of daily living: hygiene-nail care. Care plan focus for ADL self care dated 5/31/2023 documents, in part, check nail length and trim and clean on bath day and as necessary. Job Description titled Nursing Assistant with an updated date of 1/4/2023 documents, in part, provides personal care, trim nails. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146191 If continuation sheet Page 2 of 11 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 12/07/2023 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)

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, interviews, and record review the facility failed to provide supervision while shaving for one resident (R5), reviewed in a sample of 44. Findings include: R5 is [AGE] year old with diagnosis including but not limited to: Schizoaffective Disorder, Schizophrenia, Chronic Obstructive Pulmonary Disease, Age-related Osteoporosis and Cataract Extraction. On 12/5/23 at 10:04 AM, R5 was observed in bathroom located in day room on the fifth floor. The bathroom door was cracked and Surveyor observed R5 inside of the bathroom shaving with a manual cartridge razor. No staff members were observed in or near the bathroom with R5. On 12/5/23 at 10:10 AM, Surveyor observed V10 (Certified Nurse Assistant /CNA) enter the bathroom with R5 to retrieve the razor. On 12/06/2023 V1, (Administrator) said, The residents cannot shave themselves. We (staff) have to shave them (residents) or stand near and supervise them while they are shaving for safety reasons. There are no orders for shaving. Everyone has the right to shave as long as they are supervised. On 12/5/23 at 10:10 AM, V10 (CNA) said, Usually I am with R5 while he shaves, but I (V10) went to the restroom. He (R5) can shave himself, but he just needs supervision while shaving for safety. R5's care plan with target date of 2/21/2024 documents, Focus: resident (R5) has a history of self-harm; R5 presents with altered thought processes evidenced by hallucination, delusions, exaggerated responses related to inability to process and synthesize information, inability to evaluate reality. R5's Minimal Data Set, Functional Status dated August 29, 2023 documents R5 requires limited assistance (staff provide guided maneuvering of limbs or other non- weight bearing assistance) and One person physical assist with personal hygiene including shaving. R5's Minimal Data Set, Functional Abilities and Goals dated November 21, 2023 documents R5 requires Supervision or touching assistance with personal hygiene including shaving. Facility Policy titled Activities of Daily Living documents, the facility will provide care and services for the following activities of daily living: Hygiene- bathing, dressing, grooming including shaving, oral care, and fingernail care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146191 If continuation sheet Page 3 of 11 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 12/07/2023 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)

F 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure the Daily Nurse Staffing was conspicuously posted in a prominent place readily accessible to residents and visitors. This failure has the potential to affect all 120 residents residing in the facility. Residents Affected - Many Findings include: On 12/04/2023, V1 (Administrator) presented a facility census of 120 residents. On 12/04/2023 at 9:10 am, surveyors enter the facility and did not observe the Daily Nurse Staffing that included the facility name, date, residents census and hours worked per shift for licensed and unlicensed staff responsible for resident care posted visibly in a prominent place in the facility. On 12/04/23 at 1:08 pm, Surveyor requested V1 (Administrator) to locate the daily staff posting for the facility and V1 stated, We (referring to the facility) don't have one. When V1 was asked the importance of the Daily Staff Posting for the facility V1 stated So everyone knows how many staff are in the building. V1 explained that a schedule is kept at the receptionist desk however there is no posting for visitors or residents to see daily nurse staffing in the building each day. V1 stated no staff is assigned to post the daily nurse staffing in the facility and that V1 would make sure the nurse staffing is posting in the facility moving forward. The (Rev. 208; Issued:10-21-22; Effective: 10-21-22; Implementation:10-24-22) State Operations Manual documented, in part §483.35(g) Nurse Staffing Information. §483.35(g)(1) Data requirements. The facility must post the following information on a daily basis: (iv) Resident census. §483.35(g)(2) Posting requirements. (i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift. (ii) Data must be posted as follows: (A) Clear and readable format. (B) In a prominent place readily accessible to residents and visitors. GUIDANCE §483.35(g) The facility's staffing data document may be a form or spreadsheet, as long as all the required information is displayed clearly and in a visible place. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146191 If continuation sheet Page 4 of 11 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 12/07/2023 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)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure a medication administration error rate of less than 5 percent for 2 of 7 residents (R119, R3) reviewed for medication administration. There were 33 opportunities and 3 errors resulting in a 9.09% medication administration error rate. Residents Affected - Few Findings include: R3's diagnosis includes but are not limited to chronic obstructive pulmonary disease, unspecified, difficulty in walking, not elsewhere classified, unsteadiness on feet, other abnormalities of gait and mobility, abnormal posture, unspecified lack of coordination, hyperlipidemia, unspecified, anemia, unspecified, bipolar disorder, unspecified, pure hypercholesterolemia, unspecified, essential (primary) hypertension, history of falling, vitamin deficiency, unspecified, osteoarthritis of hip, unspecified , unspecified asthma, uncomplicated, schizophrenia, unspecified, muscle weakness (generalized), and altered mental status, unspecified. R3's Brief Interview for Mental Status (BIMS) dated 10/31/2023 documents R3 has a BIMS score of 13 which indicates R3's cognition is intact. R119's diagnosis includes but are not limited to other fracture of right lower leg, subsequent encounter for closed fracture with routine healing, bronchitis, not specified as acute or chronic, unsteadiness on feet, schizophrenia, unspecified, unspecified convulsions and pain in right ankle and joints of right foot. R119's Brief Interview for Mental Status (BIMS) dated 10/31/2023 documents R119 has a BIMS score of 12 which indicates R119's cognition is moderately impaired. On 12/5/2023 at 8:50 am, V6 (LPN/Licensed Practical Nurse) started dispensing the following medications for R119: Clozaril (Clozapine) Oral Tablet 50mg (milligrams)-Give one tablet by mouth two times a day. Valproic Acid Oral Capsule 250mg (milligrams)-Give two capsules by mouth every 12 hours. On 12/5/2023 at 8:55 am, V6 (LPN/Licensed Practical Nurse) stated R119 does not have a medication package with Clozaril Oral Tablet 50mg available for 12/5/2023 at 9:00 am. V6 was not able to administer R119 the scheduled 9am dose of Clozaril Oral Tablet 50mg. On 12/5/2023 at 9:05 am, V6 (LPN/Licensed Practical Nurse) made a call to the pharmacy to inquire about R119's missing Clozaril 50mg tablet for 12/5/2023 scheduled to be given at 9:00 am. V6 stated the pharmacy representative stated the Clozaril 50mg Tablet for 12/5/2023 to be given at 9:00 am was sent to the facility. On 12/5/2023 at 9:25am, V6 (LPN) notified V2 (DON/Director of Nursing) of the missing dose of Clozaril 50mg Tablet for R119's 9:00am scheduled dose. On 12/5/2023 at 9:30 am, V6 (LPN/Licensed Practical Nurse) started dispensing the following medications for R3: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146191 If continuation sheet Page 5 of 11 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 12/07/2023 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)

F 0759 Multivitamin Oral Tablet-Give one tablet by mouth one time a day. Level of Harm - Minimal harm or potential for actual harm Lithium Carbonate Capsule 300mg-Give one capsule by mouth two times a day. Residents Affected - Few On 12/5/2023 at 9:35 am, V6 (LPN) stated R3 does not have a medication package with a Multivitamin Oral Tablet and a Lithium Carbonate Capsule 300mg available for 12/5/2023 at 9:00 am. V6 was not able to administer R3 the scheduled 9am doses of Multivitamin Oral Tablet and Lithium Carbonate Capsule 300mg. On 12/5/2023 at 9:40 am, V6 (LPN) made a call to the pharmacy to inquire about R3's missing Multivitamin Oral Tablet and Lithium Carbonate Capsule 300mg scheduled to be given at 9:00 am on 12/5/2023. V6 stated the pharmacy representative stated the Multivitamin Oral Tablet and Lithium Carbonate Capsule 300mg to be given at 9:00 am was sent to the facility. On 12/5/2023 at 9:45 am, V6 (LPN) notified V2 (DON/Director of Nursing) of the missing doses of Multivitamin Oral Tablet and Lithium Carbonate Capsule 300mg for R3's 9:00am scheduled dose. On 12/5/2023 at 2:19 pm, V6 (LPN/Licensed Practical Nurse) stated the nursing supervisor is responsible for making sure all residents medications are here at the facility on time. V6 stated it is my expectation that the medication is available for the residents when the medication is scheduled to be given to the resident. V6 stated the night nurse is to check to make sure the times on the resident's medication packages match the resident's medication administration record. On 12/5/2023 at 3:08 pm, V2 (DON/Director of Nursing) stated the medication cycle starts every Monday, the pharmacy delivers the medication to the facility every Monday. V2 stated the Multivitamin Oral Tablet (scheduled for administration at 9am) and Lithium Carbonate Capsule 300mg (scheduled for administration at 9am ) for R3 and the Clozaril Oral Tablet 50mg for R119 (scheduled to be administered at 9:00am) were delivered by the pharmacy. V2 stated the pharmacy delivered the medication packages with 6:00am printed on the package instead of 9:00 am for this medication cycle. On 12/5/2023 at 3:30 pm, reviewed R3's nursing progress note dated 12/05/2023 14:44 by V2 (DON/Director of Nursing) which documents in part, Writer made aware by NOD (nurse on duty) regarding discrepancy in time for Lithium. Pharmacy contacted secondary to discrepancy in time for lithium medication administration which did not match with time in MAR (medication administration record) and as ordered. Medication was being packed for 6am administration but order states to be given at 9am. Pharmacy stated that it was their mistake and that it would be corrected for next distribution/cycle. Dr.(doctor) made aware and stated to change administration time to 6am. Pharmacy made aware. Administrator notified. On 12/5/2023 at 3:35 pm, reviewed R119's nursing progress note dated 12/05/2023 at 15:15 by V2 (DON/Director of Nursing) which documents in part, Writer made aware by NOD (nurse on duty) regarding discrepancy in time for Clozapine. Pharmacy contacted secondary to discrepancy in time for Clozapine medication administration which did not match with time in MAR (medication administration record) and as ordered. Medication was being packed for 6am administration but order states to be given at 9am. Pharmacy stated that it was their mistake and that it would be corrected for next distribution/cycle. Dr.(doctor) made aware and stated to change administration time to 6am. Pharmacy made aware. Administrator, notified. On 12/6/2023 at 2:21 pm, V2 (DON/Director of Nursing) stated the facility nurses are responsible (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146191 If continuation sheet Page 6 of 11 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 12/07/2023 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)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete for following the rights of medication administration. V2 stated the nurses are to make sure the medication is administered to the right patient, at the right time, that it is the right medication, right amount/dosage and the medication is being administered by the right route. V2 stated the nurse administering the medication should be looking at the medication administration record before administering a resident's medication. On 12/6/2023 reviewed the facility's Policy and Procedure dated 1/4/2023, Subject: Medication Errors/Missing Medications documents in part, it is the policy of facility that all its residents will be free from medication errors that may cause discomfort and jeopardize the resident's health and safety. Underneath Procedure: Missing Dose, In the event of a missing dose the nurse has to notify the physician for further order if a resident takes less than 100% of the dosage, or if you withhold it for some reason, document in the MAR (medication administration record) or nurse's note and notify the physician. Event ID: Facility ID: 146191 If continuation sheet Page 7 of 11 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 12/07/2023 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure that expired eye medication was removed from the medication cart for one resident (R54) from a sample of 44. Findings include: R54 is [AGE] year old with diagnosis including but not limited to: Primary Open- Angle Glaucoma, Chronic Obstructive Pulmonary Disease, Hyperlipidemia, and Schizoaffective Disorder. On [DATE] during investigation, Surveyor observed an expired eye medication on the third floor medication cart. The expired eye medication was Latanoprost .005% and was labeled with R54's name. The Latanoprost medication had a sticker on the bottle that documented, use by [DATE]. On [DATE] at 10:50 AM, V12 (Licensed Practical Nurse/ LPN) said, The medication (eye drops) expired on [DATE]. I (V12) will discard this and reorder a new one. Surveyor inquired about the possible outcomes of a resident using expired eye medication. On [DATE] at 10:50 AM, V12 (LPN) said, The expired medication may cause adverse (unfavorable) effects for the patient. On [DATE] at 2:56 PM, V30 (Pharmacist) said, When we (Pharmacy) send eye drop medication to the facility, it will come with a sticker. The sticker will indicate the expiration date once opened. The Latanoprost is good for around 42 days after opened. If the medication is used after expiration date, it reduces the effectiveness of the medication. The medication won't work. R54's Physician Order Sheet documents includes the following active order: Latanoprost Emulsion 0.005% instill one drop in both eyes at bedtime. Facility Policy titled Eye Drop Medications documents: It is the policy of the facility to ensure eye drop medications are discarded after their expiration date based on the pharmacy recommendations. Facility Policy titled Medication Storage documents: The Director of Nursing and or designee conducts random inspections of all nursing care units or other areas of the Nursing Home where medications are dispensed, administered, or stored; the pharmaceutical vendor checks medication carts, treatment cart and medication rooms to make sure all drugs are current and available. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146191 If continuation sheet Page 8 of 11 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 12/07/2023 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. These failures have the potential to affect all residents who consume food prepared by the facility. Findings include: On 12/04/23 at 10:06 AM, the food service area toured. Floor of food service area has ceramic floor tiles missing and cracked in front of the dishwasher and steam table. Grout between tiles throughout food service area are heavily soiled from black encrustation and not easily cleanable. The entrance/interior of walk in cooler has ceramic tiles missing and cracked on the floor. The floor is not easily cleanable. On 12/04/23 at 10:10 AM, The dietary hand sink located next to coffee machine has cleaned silverware under coffee machine on shelf. The silverware and coffee machine are subject to splash from the handwashing sink when in use. Staff were observed using the handwashing sink during this observation. On 12/4/23 at 10:08 AM, the dry food storage room was observed with two plastic bulk containers. One container had a 25 pound opened bag of sugar. The container was not labeled with content description. The opened bag of sugar did not have package delivered date attached. The other plastic container had a 25 pound bag of flour opened with no delivered date attached. The container was not labeled with content description. On 12/6/23 at 12:10 PM, V3 (Food Service Supervisor) stated we have limited space in the food service area and we will have to relocate the coffee machine and shelf system. V3 stated I am aware of the bulk food containers in dry food storage room with no label and package delivered dates. They were labeled and dated. The facility failed to follow its policy. Policy titled Food Date and Labeling (December 2023) Policy includes It is the policy of this facility to label & date all foods not stored in its original packaging. It is also the policy of this facility to date all food in its original packaging upon delivery to the facility. Policy titled Dietary Infection Control Policy (December 2023) states including, It is the policy of this facility Dietary Department to follow proper infection control procedures to help prevent the transmission of infectious diseases. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146191 If continuation sheet Page 9 of 11 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 12/07/2023 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)

F 0914 Provide bedrooms that don't allow residents to see each other when privacy is needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure three residents had a privacy curtain which extended around the bed. This failure affected three residents (R110, R421, R4) (residing in the same room) in a sample of 44 residents. Residents Affected - Few Findings include: R110's diagnosis includes but are not limited to other drug induced secondary parkinsonism, supraventricular tachycardia, unspecified, extrapyramidal and movement disorder, unspecified, gastro-esophageal reflux disease without esophagitis, vitamin D deficiency, unspecified, schizoaffective disorder, unspecified, disorder of teeth and supporting structures, unspecified, acquired absence of left great toe, acquired absence of other left toe(s), bipolar disorder, unspecified, essential (primary) hypertension, cognitive communication deficit, other lack of coordination, history of falling, thrombocytopenia, unspecified. R110's Brief Interview for Mental Status (BIMS) dated 11/06/2023 documents R110 has a BIMS score of 12 which indicates R110 has some moderate cognitive impairment. R4's diagnosis includes but are not limited to gastro-esophageal reflux disease without esophagitis, unspecified osteoarthritis, unspecified site, chronic obstructive pulmonary disease, unspecified, type 2 diabetes mellitus without complications, essential (primary) hypertension, pure hypercholesterolemia, unspecified, schizophrenia, unspecified, hyperlipidemia, unspecified, insomnia, unspecified. R4's Brief Interview for Mental Status (BIMS) dated 11/02/2023 documents R4 has a BIMS score of 13 which indicates R4's cognition is intact. R421's diagnosis includes but are not limited to multiple fractures of ribs, left side, subsequent encounter for fracture with routine healing, heart failure, unspecified, gastro-esophageal reflux disease without esophagitis, benign prostatic hyperplasia without lower urinary tract symptom, non-pressure chronic ulcer of other part of right lower leg with unspecified severity, wedge compression fracture of T7-T8 vertebra, subsequent encounter for fracture with routine healing, chronic kidney disease, stage 3 unspecified, extrapyramidal and movement disorder, unspecified, hypothyroidism, unspecified, schizophrenia, unspecified, vitamin D deficiency, unspecified, polyneuropathy, unspecified, hyperlipidemia, unspecified, essential (primary) hypertension, peripheral vascular disease, unspecified, chronic obstructive pulmonary disease, unspecified, constipation, unspecified, bipolar disorder, unspecified , liver disease, unspecified, history of falling, and difficulty in walking, not elsewhere classified. R421's Brief Interview for Mental Status (BIMS) dated 11/14/2023 documents R421 has a BIMS score of 15 which indicates R421's cognition is intact. On 12/04/2023 at 11:30 am, surveyor observed three beds in the same room. No privacy curtains were observed hanging from the ceiling for each of the three beds. On 12/04/2023 at 11:50 am, R110 stated I never had a privacy curtain in the room, I don't need a curtain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146191 If continuation sheet Page 10 of 11 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 12/07/2023 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)

F 0914 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 12/06/2023 at 1:42 pm, V23 (Maintenance Director) stated the curtains were placed in the room on Monday December 4, 2023. V23 stated I took the privacy curtains down to wash them, but I forgot to put the privacy curtains back up. V23 stated the privacy curtains are used to provide privacy for each resident in the room. On 12/06/2023 reviewed the Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities Policy (Rev. 11/18) presented to the surveyor by facility which documents in part, You have a right to privacy and confidentiality of your personal and medical records. Your medical and personal care are private. Facility staff must respect your privacy when you are being examined or given care. Event ID: Facility ID: 146191 If continuation sheet Page 11 of 11