Inspection·September 23, 2024

F 0602 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few for the cabinet where I keep (R1)'s and other resident's wallet. I and (V1 - Administrator) have access to the wallet. We both have keys. When (R1) needs his wallet, I don't take the wallet out of the manila envelope. I give the whole manila envelope to (V5- PRSC). When they (R1 and V5) bring the manila envelope back, I don't look if (R1)'s debit and credit cards are there. Only (V5) takes the manila envelope from me. (V5) was in charge of 3rd and 4th floors, so whenever (R1) goes to store it falls on (V5) to take him. (V11- PRSC) is now assigned to 4th floor and (V5) continues to still go with (R1) to the store and it is also (V5) who would bring the whole manila envelope back to me. I did not check to make sure everything is in the wallet when the manila envelope was returned to me and when I gave it to (V5), I did not show (V5) what was in the wallet. I should have made a binder, so they sign what they take to avoid any theft, honestly to avoid theft of residents' items. I never took (R1)'s wallet and made ATM withdrawals. It is possible the debit card was not in the wallet when it was returned to me because I did not check the contents of (R1)'s wallet. On 09/04/2024 at 3:22pm, this surveyor showed V5 (PRSC Psychiatric Rehabilitation Services Coordinator) R1's Release of Responsibility For Leave Of Absence Forms, dated 02/2024 to 08/2024, and inquired if (V5) recognized the signature/staff on the space provided for PATIENT OR NEAREST RELATIVE. V5 stated that's me. This surveyor requested V5 to review the PRSC notes on 03/07/2024. V5 stated these (items) are something that we (V5 and R1) got from R***. We (V5 and R1) went out on that day. Some of them were returned because it was too big or not his style. I can't recall how many were returned. On 09/04/2024 at 3:35pm, V5 stated (R1) made withdrawals mostly at (R1's bank). I never recall any withdrawals outside of (R1's bank). I always keep an eye on (R1) because he did not have a steady gait and I don't want (R1) to fall. When I went out with (R1), there was never a time (R1) withdrew money from outside of (R1's bank). I was with (R1) all the time. I am probably 5 feet away from (R1). (R1) would put the money in his wallet, then inside the manila envelope. I don't know how much (R1) takes from the ATM. This surveyor showed V5 R1's bank statement and pointed out to V5 the transaction that was done on 03/07/2024 at (non R1's Bank) ATM withdrawal in the amount of $244.80 and asked if (V5) could explain the transaction. V5 stated I have no explanation for that, I don't know. This surveyor inquired if V5 has knowingly purchased any items using R1's debit card. V5 stated No. This surveyor inquired if he threatened a resident to get what he needed from the resident. V5 stated I am a very nice guy. R1's admission Record documented that R1's diagnoses include but not limited to bipolar disorder, essential hypertension, and depression. R1's untitled (complaint) form, dated 03/25/2024, documented, in part Person sharing the concern: (V14, R1's family member). Nature and description of the concern: (R1)'s bank account has some unexplain(ed) activity. Description of investigation: Bank was called (to) investigate and replace(d) most of the funding. R1's State Initial Reportable, dated 09/03/2024, documented, in part It was reported by state surveyor that resident's family member reported unusual activity on bank account. R1's State Final Reportable, dated 09/09/2024, documented, in part Investigation revealed that electronic payment method/debit card was used for what appear to be unauthorized charges. R1's A***** Order Details, dated 03/06/2024, documented, in part Shipping Address. (V5 and non-facility address) Payment method. (R1)'s bank account number ending in (last 4 numbers). Of note, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146191 If continuation sheet Page 2 of 12 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 09/23/2024 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 0602 shipping address was not of the facility. Level of Harm - Immediate jeopardy to resident health or safety On 09/05/2024 at 11:26am, V15 (PRSD Psychiatric Rehabilitation Services Director) stated not sure if R1 has an A***** account. PRSC's ordering for residents online, the shipping address should be the facility's address and not the PRSC address. Why ship stuff to the PRSC address if we are open for 24 hours. The expectation is everything should be shipped to this building (facility). Residents Affected - Few On 09/17/2024 1:18pm, V15 (PRSD (Psychiatric Rehabilitation Services Director) stated I know for sure (R1) has no A***** account. (R1) is not that tech savvy. He refused to use the smart phone provided by 'T****y. R1's Bank statement, dated 01/27/2024 - 02/27/2024, is marked with a handwritten note documenting PIN # (4-digit number). R1's Bank statement, dated 02/28/2024 - 03/26/2024, documented the following, in part. Deposit and Addition: 03/07 Purchase Returns (bank card last 4 digits) in the amount of $252.29 3/14 ATM Cash deposit in the amount of $400.00. 3/19 Card Purchase Return (bank card last 4 digits) in the amount of $15.24 3/26 Reversal: (Pet Store) in the amount of $119.06. The total amount returned was $786.59. ATM and Debit card withdrawals: 1. (12x) Non-(Bank) ATM withdrawals (bank card last 4 digits) with a total amount of $2,881.05. 2. (2x) ATM Withdrawals (bank card last 4 digits) with a total amount of $400.00. 3. (6x) Online food orders on 03/10/24, 03/12/24, 03/14/24, and 03/18/24 (bank card last 4 digits) with a total amount of $367.44. 4. (2x) W****** purchases (bank card last 4 digits) with a total amount of $187.33. 5. (2x) C**part purchases (bank card last 4 digits) with a total amount of $264.84. 6. (1x) T***** purchase + cash back (bank card last 4 digits) with a total amount of $67.98. 7. (11x) A***** purchases (bank card last 4 digits) with a total amount of $413.97. 8. (1x) Card purchase with pin (Pet Store) (bank card last 4 digits) in the amount of $119.06. Of note, the total amount of purchases and withdrawals without receipts = $4701.67. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146191 If continuation sheet Page 3 of 12 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 09/23/2024 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 0602 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 9. (7x) purchases (bank card last 4 digits) with receipts provided by the facility with a total amount of $4,483.60. The (09/06/2024) email correspondence with V1 in response to the inquiry of this surveyor Do you have additional receipts for (R1) aside from the 03/07/24 and 03/11/2024 R*** Receipts; 3/7/24 U****n A** hardware receipt; 03/11/24 (x2) E** L*** CEMETERY RECEIPTS; 03/07/24 (x2) and 03/25/24 A****n receipts? V1 wrote in response No I gave you everything we have. On 09/17/2024 1:18pm, V15 (PRSD (Psychiatric Rehabilitation Services Director) stated (R1) has no car and has no pet. The R*** receipt dated 03/07/2024 at 10:46am, documented 19 sold items. The R*** receipt dated 03/07/2024 at 1:52pm, documents 16 returned items. The R*** receipt dated 03/07/2024 at 2:12pm, documents 6 sold items. Of note, 9 items were retained by R1. R1's Additional Items (Patient's Clothes and Personal Belongings) list, dated 03/12/2024, documented in part Clothing Retained by Patient: Shoes x 2 and 1 magic shine sponge. Of note, 6 items were missing. R1's Personal Belonging list, dated 09/05/2024, documented in part 2 trousers and 1 Polo. Of note, no additional belonging list after 03/12/2024 and before 09/05/2024 was provided by the facility to this surveyor. The Daily Staffing dated 03/10/24, 03/12/24, 03/14/24, and 03/18/24, documented that V12 (Administrator Assistant/Front Desk), V19 (Security/Front Desk), V20 (Security/Front Desk) and V21 (Security/Front Desk) worked on these days either the 8am - 4pm shift or the 4pm-12pm shift or 12am - 8am shift. On 09/05/2024 at 9:49am, V12 stated I started in October 2022, I work Monday thru Friday, 7am-4pm. Part of my job is to call up the floor and tell the resident to pick up food order. I never had any circumstance calling (R1) to pick up his food. On 09/06/2024 at 11:57am, V19 (Security/Front Desk) stated I have been working at the facility for 27 years as security or front desk staff. I work different shifts; 8am-4pm, 4pm-12am, and 12am-8pm shifts. I know (R1). I never received any online food order from G*****b for (R1). On 09/06/2024 at 4:43pm, V22 (Security/Front Desk) stated I started here in 2021 or 2022. I am familiar with (R1). I never received any food order from G*****b or any A***** packages for him (R1). On 09/17/2024 at 4:12pm, V21 (Security/Front Desk) stated I have never received any online food order or any A***** packages for (R1). On 09/03/2024 at 3:34pm, V1 (Administrator) stated I called (V14 - R1's family member). V14 said it would take the bank 8-10 weeks before he could hear from them. I would be mad if I were not able to touch my money for that long. On 09/05/2024 at 11:54am, V1 (Administrator) stated no one should be stealing the resident's money. I am the Administrator; I have the key to (V4)'s office. There was never a time I took (R1)'s wallet from (V4)'s office. I spoke with him (V14 - R1's family member) and he said he will not hear from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146191 If continuation sheet Page 4 of 12 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 09/23/2024 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 0602 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the bank for 8-10 weeks. This surveyor inquired how would V1 feel not having access to her money in the bank for 8-10 weeks. V1 stated, I would be mad. On 09/05/2024 at 12:02pm, reading the charges on R1's March 2024 bank statement, this surveyor inquired if V1 could explain the withdrawals in the statement, V1 stated I cannot explain them. On 09/16/2024 at 11:03am, V1 (Administrator) stated I hired an outside team of Private Investigator to check on the situation, on anything that has to do with financial abuse. On 09/16/2024 at 11:27am, V25 (President - (Private Investigator's) Group) stated they (V1) did searches of (V5)'s office, and they saw (R1)'s bank statement with a PIN written on it. On 09/16/2024 at 2:38pm, V1 (Administrator) stated I have to search (V5)'s office regardless. I ended up searching his whole office. There was a bank statement for R1. I know it is a PIN number because it has word PIN written on it. The (09/18/2024) email correspondence with V1 (Administrator) documented, in part Here is the list of residents' items retrieved from (V5)'s office. (R1) Assurance wireless notice, bank statement dating January 27th thru February 27th. 2. On 09/16/2024 at 11:27am, V25 (President-(Private Investigator's) Group) stated another resident (R6) gave her debit card to (V5) who told her he will take care of her finances for her. On 09/16/2024 at 2:48pm, R6 stated I have about $2000 on my bank card. I gave my bank card to (V5) probably in December of last year. (V5) is keeping my bank card in case I need something from the store. (V5) did not tell me I could have (V4) keep the bank card for me. (V5) said let me have your bank card and I will take care of your financial stuff. (V5) knew I have a bank card because whenever I need stuff from the store, I would give him my bank card. I never received my bank statement here because I don't want these people to know my finances. I called the bank today and they said I have a dollar in my account. Surveyor inquired how R6 felt about her missing bank card and having a dollar in her (R6) account. R6 stated, I am so pissed I can pee. It means I am very mad; (V5) took all my money. This surveyor inquired who was sending money to R6. R6 stated I get a pension every month. I wrote my PIN on a piece of paper and handed it to (V5). On 09/17/2024 at 1:20pm, V15 stated I have never seen the card; but (R6) is not going to say falsely about it. I know from time to time (V5) would go to the store to buy whatever miscellaneous things (R6) needs. When I asked (R6) does anybody have access to your card? (R6) said yes, (V5) has access and he knows the pin to the card. I asked why and (R6) said because (V5) is going to take care of my finances for me. At that point, I told (R6) Stop we are going down to (V1)'s office. In (V1)'s office, I made (V1) aware of the situation and called (R6)'s bank. We (V1, V15, and R6) canceled the card and we asked for 90 days' worth of bank statements. I asked for the last 10 transactions. Most of them occurred on 09/03/2024. (R6) was shocked because she had a deposit made on 09/03. The customer service mentioned that some of the transactions were (Person to Person mobile payment application), there were at least 2 transactions of $200. It appeared, whoever is doing it, is just cleaning out the account, emptying the bank account. There were couple A***** transactions. (R6) said she did not consent to those transactions. While (R6) was listening to this, she was so shocked. (R6) was saying Oh, my God! Oh, my God! Oh, my God! It is not expected of PRSC or staff, per se, to take the card with them without the resident present. (V5) was trying to help (R6) out but he has too much access to resident information like the resident's PIN number. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146191 If continuation sheet Page 5 of 12 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 09/23/2024 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 0602 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On 09/23/2024 at 2:29pm, V15 stated we just received (R6)'s bank statement. V15 showed this surveyor the transactions on R6's (07/2024- 09/2024) bank account. V15 stated (R6) has $750 deposit on 09/03. On the same day (09/03) there were multiple (Person to Person mobile payment application) transactions to K*****h C****. According to (V1), K*****h is (V5's) middle name. There were 9 transactions on 9/03 and 1 transaction on 09/04. (R6) will not make those transactions because she had not realized that she has that money yet on the 09/03. Obviously, (R6) is getting $750 at the beginning of the month. I don't think (R6) has (Online Music Streaming Service). That is an online streaming app for music. I can guarantee you, (R6) did not have a (Online Music Streaming Service). R6's Bank statement dated 07/10/24, documented, in part Deposits and credits: 7/01 benefit payment deposit - $750. Checks and other debits: 7/01- (Online Music Streaming Service) $10.99. Checking account Summary and Detail: ending balance: $65.29. R6's Bank statement dated 08/09/24, documented, in part Deposits and credits: 8/01 benefit payment deposit - $750. Checks and other debits: 8/01 - ATM W/D Card # $408.00. 8/08 (Online Music Streaming Service) - $11.99. Checking account Summary and Detail: ending balance: $60.13. R6's (09/10/24) bank statement documented, in part Deposits and credits: 9/03 benefit payment deposit $750. Checks and other debits: 9/03 Cash App * K*****h C**** - $15.00. 9/03 (Person to Person mobile payment application), K*****h C**** $80.00. 9/03 (Person to Person mobile payment application), K*****h C**** $200.00. 9/03 (Person to Person mobile payment application), K*****h C**** $200.00. 9/03 (Delivery and Ride Service Subscription) $96.00. Checking account Summary and Detail: ending balance: $1.85. R6 admission Record documented that R6's diagnoses include but not limited to chronic obstructive pulmonary disease, unspecified; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R6's census list documented that R6 was moved to the 6th floor on 11/29/2023. R6's Minimum Data Set, dated [DATE], documented, in part Section C0500. BIMS (Brief Interview for mental status) Summary Score: 14. Indicating R6's mental status as cognitively intact. Section GG. GG0170. Mobility. J. Walk 50 feet with two turns: 88 - not attempted due to medical condition or safety concerns. R6's State initial reportable dated 09/10/2024, documented, in part Resident reported that her bank card is missing. R6's State Final reportable dated 09/17/2024, documented, in part The following is a response to an incident that occurred on 09/10/24 whereby a resident (R6) reported that her bank card was missing. (R6) stated last person that had (the bank card) was (V5). Investigation revealed that electronic payment method/debit card was used for what appear to be unauthorized charges. R6's PRSC Progress note dated 12/25/2023 at 9:16, documented, in part Resident present with a history of frivolous money management. PRSC will educate resident on setting goals to handle finances, savings, possible investing. R6's Care plan dated 09/16/2024, documented, in part Resident is at increased risk or has experienced financial abuse secondary to psychological and/or medical diagnosis. Will be free of any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146191 If continuation sheet Page 6 of 12 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 09/23/2024 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 0602 financial abuse occurrences. Assist resident with addressing financial situations with business office. Level of Harm - Immediate jeopardy to resident health or safety The (09/06/2024) email correspondence with V1 (Administrator) in response to the inquiry of this surveyor Do you have Ethics policy and procedure in reference to receiving gifts (monetary/kinds/goods) from residents? If you do not have a policy, what are your expectations? V1 wrote in response In our employee handbook it is said that no personnel or persons associated with the facility will accept gifts of money or goods of material value, favors remuneration or other compensation from any client. Residents Affected - Few The CNA Supervisor job Description dated 4/21/23, documented, in part Ensure that Resident Belonging is completed upon admission and as needed and up to date. The PRSC (Psychiatric Rehabilitation Services Coordinator) Job Description (Undated) documented, in part Summary: In keeping with our organization's goal of improving the lives of the Guests we serve, the PRSC is responsible for the overall administration, coordination, and evaluation of the social services function to meet and maintain the mental and psychosocial well-being for (of) each Guest. Essential Functions: Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 4. Coordinates the inspection of guests belongings to ensure they are properly labeled and inventoried. The Front desk/Security Job Description dated 1/26/2024, documented, in part Summary: The front desk/security staff attend to visitors by greeting, welcoming, and directing them appropriately; notifies company personnel of visitor arrival; maintains security and telecommunications system. Essential Responsibilities: 5. Monitor entrance and departure of employees. This includes overseeing the log-in and log-out books. Ensure staff and responsible party are signing resident out when leaving the facility. The Personal Property Policy and Procedure dated 01/24/2024-4163, documented, in part It is the policy of the (Facility) to permit residents to retain personal property items as long as they do not infringe upon the rights of other residents or affect the safety and well-being of the residents. Procedure. 5. The belonging list shall be updated as needed upon receiving new item. The Signing Patients Out When Leaving the Building policy dated 01/01/2024, documented, in part Intent: Signing patients out when staff are taking residents out of the building. Procedure: This policy ensures that when any resident is taken out of the building by a staff member, that staff member is to sign the patient in and out at the front desk with a date and time. The Ordering Items for Residents policy dated 01/01/2024, documented, in part This policy ensures that items ordered for residents by staff in the facility are done properly and complies with any (Facility) Healthcare policies. Procedure: If staff orders items online for the residents, they are to be shipped and received to the facility. The Abuse Policy dated 1/4/24, documented, in part It is the policy of the facility that each resident will be free from abuse. Abuse can include misappropriation of resident property and exploitation. Additionally, residents will be protected from abuse while they are residing at the facility. No abuse or harm of any type will be tolerated. The facility presented a removal plan on 09/16/2024 at 3:18pm and was not approved. A revised (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146191 If continuation sheet Page 7 of 12 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 09/23/2024 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 0602 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Removal Plan was submitted on 09/17/2024 at 12:26pm and was not approved. A revised Removal Plan was submitted on 09/18/2024 at 2:52pm and was not approved. A revised Removal Plan was submitted on 09/18/2024 at 3:36pm and was approved. On 09/19/2024 at 12:37pm, further review of the revised Removal Plan that was submitted on 09/18/2024 at 3:36pm documented no in-services for abuse and resident's belonging which was previously noted on the revised Removal Plan submitted on 09/17/2024 at 12:26pm. On 09/19/2024 at 2:58pm, V1 was informed of the discrepancies on the removal plan provided to this surveyor. V1 stated I don't know what happened let me ask (V29 - Management Consultant). A revised removal plan was submitted on 09/20/2024 at 9:26am and was not approved. A revised removal plan was submitted on 09/20/2024 at 3:20pm and was approved. The Immediate Jeopardy that began on 03/25/2024 was removed and the deficiency remains at a level 2 on 09/23/2024. On 09/23/2024 at 4:29pm, V1 (Administrator) stated I initiated in-services again, and still ongoing about abuse and resident's belongings when you first came here on 09/03/2024. Surveyor confirmed the following: The (09/03/2024) Abuse in-service was reviewed with no issue noted. Attached documents 7signs of nursing home abuse, how to prevent abuse, and abuse policy and procedure. The (09/03/2024) Resident Belongings in-service was reviewed with no issue noted. Attached Resident belonging documented, in part No one is allowed to hold any resident's wallet, cards, or money. On 09/19/2024, V26 (Activities Aide), V30 (Maintenance Assistant), V31 (Maintenance Director), V32 (CNA), V33 (PRSC (Psychiatric Rehabilitation Services Coordinator), V34 (Housekeeping/Maintenance), V35 (Housekeeping/Laundry Supervisor), and V36 (Dietary Supervisor) all affirmed in-services were received in the month of September about abuse and resident belongings. The (revised 09/04/2024 and 09/09/2024) personal property policy and procedure, The (09/16/2024) new employee health care worker background check, and the (09/19/2024) Online Purchase for Resident were reviewed and appropriate revisions were made that were included in the removal plan. V1 Removed V5 from the facility on September 4, 2024, suspended without pay pending investigation as part of actions to mitigate risks to R1 and any other resident. Suspension status will remain until investigation concludes. If facts are founded, V5 will be terminated immediately with appropriate reporting to Health Care Worker Registry. On 09/19/2024 at 9:54am, V1 (Administrator) stated V5's time sheet and the write up are my proofs that he is not at the facility at this time. It still an ongoing investigation and we get outside help to make sure we thoroughly go through the situation, and it does not happen again and to find out who did it. V5's Employee Disciplinary Action dated 09/04/2024, documented, in part Type of offense: Possible fraudulent activities in multiple occasions. PRSC (V5) has taken resident out to the bank multiple (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146191 If continuation sheet Page 8 of 12 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 09/23/2024 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 0602 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few times and on all these dates there are suspicious activities in which the patient (R1) states that he does not recognize. (V5) is suspended pending investigation. V5's Timecard from 09/01/2024-09/19/2024 indicated no entry since 09/05/2024. On September 4, 2024, V1 implemented a revised personal items log to account for resident personal items such as debit, credit, ID, and wallet. (see attached Exhibit F Personal Items Log which includes the date, personal items requested, resident name, employee name, date/time of personal item given to resident, date/time of personal item returned from resident, as well as the purpose of the request). The Resident In and out log (Debit card, ID, and Wallet), (undated), was reviewed with no issue noted. R7's Resident in and out log (Debit Card, ID, and Wallet) dated 09/12/24 and 09/16/24, provided date, employee name, resident name, out, in and purpose with attached [NAME] and bank withdrawal receipts. On 09/19/2024 at 11:44am, V4 unlocked the office on the 5th floor with a key. Inside the room, V4 showed her desk with 3 drawers on the left side. The 2nd drawer was locked. V4 stated only the administrator and myself have the key to the second drawer. V4 attempted to open the drawer with no luck. Unable to open the drawer by just pulling the door handle of the drawer. V4 opened the drawer using a key and showed this surveyor R1's and R6's valuables. On September 4, V1 Revised the resident personal property policy to include the following language regarding investigating misappropriation of resident funds/property (see attached Exhibit G - (Facility) Personal Property Policy and Procedure) In the event a claim is made regarding misappropriated funds or property, the Administrator will be made aware immediately and any potentially involved employees will be removed immediately from the building with an immediate independent investigation conducted to mitigate any potential risks to residents. All other prudent measures will be taken to mitigate risks including canceling accounts with questionable charges until investigations are complete. The revised personal items log in addition to the requirements of the new policy requiring witnesses and receipts, and a detailed log of community visits including the staff members who accompanied the resident, date and time will address concerns regarding not only accounting for resident and staff going out on community pass but also Accounting for resident belongings and safeguarding against theft. In addition, the revised policy includes that once the investigation is complete, the facility will assist the resident in retrieving any loss of value owed to the resident. The actions address a system of investigating the potential misappropriation of resident funds. The Personal Property policy and procedure dated 09/04/2024, documented, in part 9. In the event a claim is made regarding misappropriated funds or property, the Administrator will be made aware immediately and any potentially involved employees will be removed immediately from the building with an immediate independent investigation conducted to mitigate any potential risks to residents. once the investigation is complete, the facility will assist the resident in retrieving any loss of value owed to the resident. The actions address a system of investigating the potential misappropriation of resident funds. 10. All other prudent measures will be taken to mitigate risks including canceling (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146191 If continuation sheet Page 9 of 12 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 09/23/2024 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 0602 accounts with questionable charges until investigations are complete. Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146191 If continuation sheet Page 10 of 12 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 09/23/2024 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to follow their own policy to conduct a complete background check of employees prior to working with residents. This failure has the potential to affect all the residents at the facility. Residents Affected - Many Findings include: The (Effective as of 08/29/2024) untitled document indicated that V5 (PRSC) was hired on 07/31/2023, V7 (CNA Supervisor) was hired on 04/01/2024, V8 (Certified Nursing Assistant) was hired on 06/27/2024, V9 (CNA) was hired on 08/01/2024, V10 (CNA) was hired on 04/30/2024, and V11 (PRSC) was hired on 03/31/2024. The (09/06/2024) email correspondence with V1 (Administrator) documented that V5 works on the 3rd floor, V7 works on all the floors, V8 works on any floor, V9 works on the 2nd and 3rd floor, V10 works on the 3rd floor, and V11 works on the 4th floor. On 09/04/2024 at 10:33am, V4 (Office Manager/HR Director) stated the purpose of the healthcare worker background check is to see if staff are eligible to work in a nursing home facility. To make sure the correct kind of people with good character are working here at the facility to prevent abuse. When applicants come to fill out the application form, I do the background check. Our policy is to do it after I receive the application. Before hiring, to know if they are eligible or not, to work at the facility to prevent abuse to our residents. If they are hired today, healthcare background should be done today. Applicants can't be hired until background check is in good standing. On 09/04/2024 from 10:35am -10:50am, during the review of V5, V7, V8, V9, V10, and V11 personnel file, this surveyor inquired for the result of V5's, V7's, V8's, V9's, V10's, and V11's Illinois Sex Offender, Department of Corrections Sex Offender, Department of Corrections Inmate Search, Department of Corrections Wanted Fugitive, and Health and Human Services Office of Inspector General registries. V4 stated I don't have them. When I got the position, I was taught to check in IDPH worker registry. I was not taught to check employees on those registries that you mentioned. I am not completely checking the background of the employees and it put residents at risk to anything that the staff may have on their background that I don't know of because I did not check staff on those registries. Review of V5's personnel file indicated that background check was initiated on 09/03/2024. Of note, no results provided for (State) Sex Offender, Department of Corrections Sex Offender, Department of Corrections Inmate Search, Department of Corrections Wanted Fugitive, and Health and Human Services Office of Inspector General registries. Review of V7's personnel file indicated that background check was initiated on 09/03/2024. Of note, no results provided for Illinois Sex Offender, Department of Corrections Sex Offender, Department of Corrections Inmate Search, Department of Corrections Wanted Fugitive, and Health and Human Services Office of Inspector General registries. Review of V8's personnel file indicated that background check was initiated on 06/27/2024. Of note, no results provided for (State) Sex Offender, Department of Corrections Sex Offender, Department of Corrections Inmate Search, Department of Corrections Wanted Fugitive, and Health and Human Services Office of Inspector General registries. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146191 If continuation sheet Page 11 of 12 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 09/23/2024 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of V9's personnel file indicated that background check was initiated on 08/01/2024. Of note, no results provided for (State) Sex Offender, Department of Corrections Sex Offender, Department of Corrections Inmate Search, Department of Corrections Wanted Fugitive, and Health and Human Services Office of Inspector General registries. Review of V10's personnel file indicated that background check was initiated on 03/26/2024. Of note, no results provided for (State) Sex Offender, Department of Corrections Sex Offender, Department of Corrections Inmate Search, Department of Corrections Wanted Fugitive, and Health and Human Services Office of Inspector General registries. Review of V11's personnel file indicated that background check was initiated but date could not be determined due to printing. Of note, no results provided for (Sate) Sex Offender, Department of Corrections Sex Offender, Department of Corrections Inmate Search, Department of Corrections Wanted Fugitive, and Health and Human Services Office of Inspector General registries. The (undated) Business Office Manager/Payroll Specialist documented, in part As business office manager/payroll specialist you will operate as the first line of assistance to employee within the facility; supporting operations, department heads and employees alike. Responsible for monitoring and processing facility payroll, including: maintains employee personnel files. Completes background checks. The Abuse Policy, dated 1/4/24, documented, in part It is the policy of the facility that each resident will be free from abuse. Abuse can include misappropriation of resident property and exploitation. Additionally, residents will be protected from abuse while they are residing at the facility. No abuse or harm of any type will be tolerated. Overview of Seven Components. A. Screening. Abuse policy requirements: it is the policy of this facility to screen employees prior to working with residents. Screening components include criminal background check. Procedure: 1. Employee screening and training. The facility will not hire an employee who was found guilty of abuse, exploitation or misappropriation of property by a court of law; or who has a finding in the state nurse aid registry concerning abuse, exploitation, or misappropriation of resident property. For prospective employees, reviewing documentation of status and any disciplinary actions from other registries. A. Nurse aides: the facility will not employ an individual who has a finding entered in the state nurse aid registry concerning abuse, exploitation, or misappropriation of residence property. C. A criminal background check will be conducted on all prospective employees as provided by the facilities policy on criminal background checks. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146191 If continuation sheet Page 12 of 12