Health inspection·November 20, 2024

F 0584 (slats) on the floor. Level of Harm - Minimal harm or potential for actual harm On 11/17/2024 at 10:38 AM, V12 (Certified Nursing Assistant) checked R91's window blinds and stated there's a lot of missing panels. I don't see panels on the floor. Residents Affected - Some On 11/17/2024 at 10:41 AM, V12 checked R74's window blinds and stated the vertical window blind has missing panels/slats. No panels on the floor. On 11/17/2024 at 10:46 AM, V12 checked R76's window blinds and stated the window blinds has no panels/slats at all. I don't see any panels/slats on the floor. ON 11/17/2024 between 10:52am and 11:11am, V13 (Maintenance Supervisor) checked R74's, R76's, R82's, and R91's window blinds and corroborated the observations done by this surveyor with V12. On 11/17/2024 at 11:11 AM, V13 (Maintenance Supervisor) stated we are expected to provide a homelike environment to our residents. If something is broken in my home, I will fix it right away. I knew about the missing panels (slats) on the window blinds about two months ago now. I have a lot of work to do and it is just me and the Maintenance Director. Every day, I have to fix something; like a broken toilet, leaking water, and clogged drain. I never get the chance to fix all the window blinds that are broken or with missing panels. On 11/18/2024 at 11:16am, V2 (Director of Nursing) stated we are not providing a homelike environment if there are missing panels on the window blinds. Window blinds are used for privacy. If missing, we are not providing coverage or privacy to the residents. R74's (Active Order as Of: 11/18/2024) Order Summary Report documented, in part Diagnoses: (include but not limited to) bipolar disorder, major depressive disorder, copd (chronic obstructive pulmonary disease). R74's (Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R74's mental status as cognitively intact. R76's (Active Order as Of: 11/18/2024) Order Summary Report documented, in part Diagnoses: (include but not limited to) dysphagia and gastrostomy status. R76's (08/23/2024) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 00. Indicating R74's mental status as severely impaired. R82's (Active Order as Of: 11/18/2024) Order Summary Report documented, in part Diagnoses: (include but not limited to) Type 2 Diabetes Mellitus, essential hypertension. R82's (10/01/2024) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R82's mental status as cognitively intact. R91's (Active Order as Of: 11/18/2024) Order Summary Report documented, in part Diagnoses: (include but not limited to) Obsessive Compulsive disorder and epilepsy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146191 If continuation sheet Page 2 of 13 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 11/20/2024 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R91's (10/22/2024) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R91's mental status as cognitively intact. The (undated) Residents' rights for people in Long-term Care Facilities documented, in part As a long-term care resident in the State, you are guaranteed certain rights, protections, and privileges according to state and federal laws. Your rights to safety. Your facility must be safe, clean, comfortable, and homelike. The Resident Right - Safe/clean/comfortable/Homelike dated 01/01/2024 documented, in part Intent: It is the policy of the facility to provide a safe, clean, comfortable homelike environment in such a manner to acknowledge and respect resident rights. Procedure: 1. The resident has a right to a safe, clean, comfortable, and homelike environment. 2. The facility must provide a safe, clean, comfortable, and homelike environment. 3. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146191 If continuation sheet Page 3 of 13 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 11/20/2024 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 0659 Provide care by qualified persons according to each resident's written plan of care. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to have a qualified licensed nurse oversee the facility's restorative nursing program. The failure has the potential to affect all 120 residents that receive restorative programming. Residents Affected - Many Findings include: On 11/17/24 at 10:25 AM, V5 (Restorative Director) stated that V5 is the restorative director and that V5 is a COTA (Certified Occupational Therapist Assistant). On 11/18/24 at 9:55 AM, V1 (Administrator) stated that V5 supervises the restorative programming in the facility. On 11/18/24 at 12:22 PM, V5 stated that V5 creates and evaluates all restorative programs in the facility. V5 explained that V5 is responsible for assessing residents for restorative need and creating a restorative care plan. V5 stated that all restorative certified nursing assistant aides report to and are supervised by V5 and V5 completes all the training on restorative for staff members. V5 stated that V5 was qualified to supervise the restorative nursing program because V5 had taken a course on restorative nursing. On 11/19/24 at 10:09 AM, V2 (Director of Nursing) stated that the facility does not have a restorative nurse. V2 affirmed that V5 oversees the restorative nursing program. V2 stated that V2 isn't familiar with restorative nursing services so V2 does not provide supervision to V5. V2 stated that V2 was unsure if a restorative nursing program could be supervised by a staff member that was not a licensed nurse. On 11/19/24 at 10:27 AM, V1 stated that V5 oversees and supervises the restorative nursing program in addition to assessing and completing restorative assessments. V1 affirmed that V5 was a COTA and not a licensed nurse. V1 affirmed that V5 is qualified to supervise the restorative nursing program because V5 has taken a class in restorative nursing. V1 affirmed that the facility uses the RAI (Resident Assessment Instrument) to guide resident assessment and care. Record review of list of residents on restorative program documents in part that 120 residents receive restorative nursing programming. Record review of job description titled, Restorative Director (dated 1/21/24) documents in part . the Restorative Director plays a critical role in providing superior customer service and nursing care to all residents. The Restorative director implements and directs the facility's restorative nursing program with the goal of helping residents reach and maintain their full mobility potential. Essential Functions -Develops, implements directs and evaluates the facility's Restorative Nursing Program. -Meets and consults with the facility's interdisciplinary team on a regular basis to develop and maintain restorative care standards. Ensures restorative nursing program complies with applicable laws, regulations, and national restorative nursing standards and requirements . Record review of CMS's RAI Version 3.0 Manual Chapter 3 MDS Items [O] (10/2024) Page O-51 documents in part, .A registered nurse or a licensed practical (vocational) nurse must supervise the activities in a restorative nursing program. Sometimes, under licensed nurse supervision, other staff and volunteers will be assigned to work with specific residents . Although therapists may participate, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146191 If continuation sheet Page 4 of 13 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 11/20/2024 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 0659 members of the nursing staff are still responsible for overall coordination and supervision of restorative nursing programs. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146191 If continuation sheet Page 5 of 13 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 11/20/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm R86's face sheet shows that R86 has a diagnosis which includes but not limited chronic obstructive pulmonary disease, vitamin D deficiency, bipolar disorder, disorder of bone, and history falling. Residents Affected - Some R86's Brief Interview for Mental Status (BIMS) dated 09/24/24 shows a BIMS score of 15 which indicates that R86 is cognitively intact. On 11/17/24 at 10:40 am, R86's room was observed with a nasal cannula (NC) concentrator that had NC oxygen tubing undated, and uncontained next to R86's bed. R86's Physicians Order Sheet (POS) dated 03/15/2024 shows that R86 has orders for Oxygen (2 L) (2 liters) per minute via nasal cannula as needed for Shortness of breath. R93's face sheet shows that R93 has a diagnosis which includes but not limited chronic obstructive pulmonary disease (COPD), unspecified asthma, osteoarthritis of knee, pure hypercholesterolemia, paranoid schizophrenia, essential primary hypertension, atherosclerotic heart disease, and urinary incontinence. R93's Brief Interview for Mental Status (BIMS) dated 10/15/24 shows a BIMS score of 15 which indicates that R93 is cognitively intact. On 11/17/24 at 10:48 am, R93's room was observed with a NC concentrator that had oxygen tubing undated, and uncontained next to R93's bed. R93 stated that R93 uses oxygen as need for shortness of breath every day at the facility. When R93 was asked how often R93's oxygen tubing is changed R93 stated, Whenever It (referring to R3's humidifier bottle) gets empty. R93's Physicians Order Sheet (POS) dated 10/09/2024 shows that R93 has orders for Oxygen (2 L) (2 liters) per minute via nasal cannula as needed for Shortness of breath d/t (due to) COPD. On 11/18/24 at 2:11 pm, V2 (Director of Nursing, DON) was asked regarding oxygen tubing and V2 stated, Oxygen tubing is changed daily. It should be dated with a date and placed in a plastic bag when not in use. When V2 was asked regarding the importance of labeling oxygen tubing with a date and placing the oxygen tubing in a bag when not in use and V2 stated, For infection control. The facility's document dated 01/04/2024 and titled Oxygen Storage documents, in part: Procedure: 1. When the Oxygen is at bedside, not in use, tubings (tubing) must be contained in a clear plastic bag. 2. Tubing must be discarded and replace every 72 hours and prn (as needed). 5. Label all tubings and bubble humidifier with a date and nurses initials. Based on interview and record review, the facility failed to ensure oxygen signs were placed on the resident's door and failed to properly label and date oxygen tubing. This failure affects 3 residents (R86, R93, R25) and has the potential to affect all 25 residents that reside on the 5th floor. Findings include: On 11/17/24 at 10:47 AM, R25 was observed lying in bed with nasal cannula in R25's nostrils. R25 had an oxygen concentrator on next to R25's bed, delivering oxygen to R25. No oxygen in use signage was observed on the resident's door or in any place of high visibility on the unit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146191 If continuation sheet Page 6 of 13 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 11/20/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 11/17/24 at 10:52 AM, V10 (Agency Licensed Practical Nurse) affirmed that there was no sign on R25's door. V10 stated that V10 was unsure if there is supposed to be oxygen signage on the door to alert others to R25's oxygen use. V10 stated that oxygen is flammable and can combust if exposed to flames. On 11/19/24 at 10:27 AM, V1 (Administrator) stated when residents are undergoing oxygen therapy, the facility standard is that the resident should have a sign on their door stating that oxygen is in use. V1 affirmed that 25 residents reside on the 5th floor. R25's physician orders document in part an order for 2 liters of oxygen via nasal cannula as needed for shortness of breath. Facility policy titled OXYGEN Storage (updated 1/4/2024) documents in part, .7. And Sign should post on resident door when use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146191 If continuation sheet Page 7 of 13 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 11/20/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review the facility failed to ensure that the controlled drugs-count record form was not prematurely signed by in and outgoing nurses. These failures have the potential to affect all residents on the second, fourth, fifth, and six floors receiving medications. Findings Include: On 11/17/24 at 12:40 pm, on the second floor the controlled drugs- count record sheet was prematurely signed for the outgoing nurse. On 11/17/24 at 12:41 pm, surveyor inquired to V9 LPN (License Practical Nurse) why is the controlled drugs- count sheet prematurely sign for the outgoing nurse? V9 stated, I always sign for outgoing when I sign for incoming because there are no medications in there. Surveyor inquired to V9 if it is checked with the incoming nurse at the beginning and ending of each shift. V9 stated, that's how I do it, I sign both when I come in because nothing is in there. On 11/17/24 at 1:45 pm, surveyor requested the controlled drug-count records for all resident floors. V2 DON (Director of Nursing) gave the third, fourth, fifth and six floor's sheets. The fourth, fifth and six floors were all prematurely signed for the outgoing nurse. On 11/19/24 10:48 am, V2 (DON) stated, The narcotic sheet should be sign when the nurses come in and when they go out. They (Nurses) should not sign the sheet before the end of their shift. The nurses should look in the narcotic box even if nothing is there. They should not sign before their shift is over because they still need to confirm that there is nothing in the box and to also make sure the count is right if there is something there. Facility's policy (2/21/24) titled Medication and Narcotic Storage documented in part, Procedure: 10. Narcotic count will be done every shift with in and outgoing nurse and sign by the nurses. Facility's policy (1/21/24) titled Medication Narcotic Count Policy documented in part, Narcotic count will be done every shift with in and outgoing nurse and sign by the nurses. In the event that there's no narcotic on that floor nurses still have to sign that there's none. Facility's (undated) job description titled Registered Nurse, RN documents in part, Essential Duties and Responsibilities: 2. Ensure that the written policies and procedures that govern the day-to-day functions of the nursing department are followed by all nursing personal assigned . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146191 If continuation sheet Page 8 of 13 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 11/20/2024 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 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. Based on observation, interview, and record review the facility failed to discard an expired medication. This failure has a potential to affect one resident (R74) in a sample size of 57 residents. Findings Include: On 11/17/24 at 12:20 pm, the third-floor medication cart had R74's Breo Ellipta (Fluticasone Furoate-Vilanterol Inhalation Aerosol Powder Breath) that was labeled to use by 11/14/24. R74's admission diagnosis includes but not limited to asthma, COPD (Chronic Obstructive Pulmonary Disease), and congestive heart failure. R74's active orders as of 11/18/24 documents in part, Fluticasone Furoate-Vilanterol Inhalation Aerosol Powder Breath Activated 200-25 MCG/ACT 1 puff inhale orally one time a day for Antiasthma. R74's MAR (Medication Administration Record) documented in part, (Fluticasone Furoate-Vilanterol Inhalation Aerosol Powder Breath) had a check mark indicating administered on 11/15/24, 11/16/24 and 11/17/24. On 11/17/24 at 12:21 pm, V15 RN (Registered Nurse) stated, I cleaned the cart and missed that. Observed V15 take the inhaler out of the medication cart. On 11/19/24 10:48 am, V2 DON (Director of Nursing) stated that expired medications should not be in the medication cart. The nurse on duty should take the medication out of the cart. Facility's policy dated 1/21/24 and titled Medication Discard and Labeling documented in part, Expired medications will be removed from the cart or refrigerator and returned to the pharmacy. Nurse on duty or supervisor will re-order expired meds as needed. Facility's (undated) job description titled Register Nurse, RN documents in part, Essential Duties and Responsibilities: 10. Prepare and administer medications as ordered by the physician. 11. Order prescribed medications, supplies, and equipment as necessary, and in accordance with our established policies. Facility's (undated) job description titled Licensed Practical Nurse documents in part, Characteristic Duties: 10. Order prescribed medications, supplies, and equipment as necessary, and in accordance with our established policies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146191 If continuation sheet Page 9 of 13 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 11/20/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure an Enhanced Barrier precaution (EBP) sign is posted for a resident on EBP and failed to ensure a PPE (personal protective equipment) bin is available for resident on EBP. These failures affected 1 (R76) resident reviewed for infection control. Residents Affected - Few Findings include: On 11/17/2024 at 10:25 AM on 3rd floor, there was an EBP sign posted by the door with R76's room identifier. A PPE bin was also available outside of the room with R76's room identifier. The room was located at the end of the hallway. This surveyor knocked on the door. No one was in the room. On 11/17/2024 at 10:46 AM, R76 was in a room located right across the 3rd floor's nurse's station in the middle of the hallway. The room identifier did not indicate R76 was residing in that room. There was no EBP sign nor PPE bin on site. ON 11/17/2024 at 11:36 am, on the end hallway on 3rd floor with V15 (Agency Registered Nurse) this surveyor pointed to the EBP sign posted on the door and the PPE bin outside of the room and inquired who was the resident on EBP. V15, looking at the name identifiers on the door frame, stated the only resident I could think of on EBP is (R76) because she has a g-tube. But she was moved to a new room. I don't know when. ON 11/17/24 at 11:39 AM, by room right across the nurse's station where R76 was observed, this surveyor requested V15 to check for EBP sign and PPE bin. V15 stated there was no EBP sign posted and no PPE bin outside of (R76)'s room. When she moved to a different room, the EBP sign and the PPE bin should move with her so the staff would know the precautions. Anyone caring for her and in contact with her g-tube will take precautions. The main purpose is prevention of infection. ON 11/19/2024 at 12:22 pm, V13 (Maintenance Supervisor) stated we have to paint her (R76) room that's why we moved her (R76) last Friday (11/15/2024) and moved her back last Sunday (11/17/2024) around 5pm. On 11/18/2024 at 11:19 am, V2 (Director of Nursing) stated I think they were doing something in her (R76) room that's why they had to move her. The policy is to move the EBP sign and PPE bin with her. The purpose of moving the EBP sign and the PPE bin is to make the staff aware that the resident is on precautions; so, anyone who is taking care of the resident is taking precautions. Main purpose of moving the EBP sign and the PPE bin with her is for infection control. R76's (Active Order as Of: 11/18/2024) Order Summary Report documented, in part Diagnoses: (include but not limited to) dysphagia and gastrostomy status. Order Summary: Feeding formula six times a day. 1 can per feeding PGT (per gtube). Active. Order Date: 08/20/2024. Enhance(d) Barrier Precautions to be observed and utilized when providing high-contact resident care activities to prevent spread of infectious germs secondary to risk colonization due to resident having indwelling devices. Order Date: 08/10/2024. PEG tube flush with 250ml Q6 (every 6) hours for routine order. Order Date: 08/19/2024. R76's (08/23/2024) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 00. Indicating R74's mental status as severely (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146191 If continuation sheet Page 10 of 13 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 11/20/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few impaired. Section GG. Functional Abilities and Goals. GG0130. A. Eating -1 dependent. E. Shower - 1 dependent. F. upper body dressing - 1 dependent, G. Lower body dressing - 1 dependent. I. personal hygiene - 1 dependent. R76's (08/10/2024) care plan documented, in part Focus: at an increased risk for spreading possible multi-drug resistant organism (MDRO) secondary to indwelling medical devise regardless of MDRO colonization status. Goal: will decrease risk of spreading possible MDRO to other staff or residents through use of recommended precautions and PPE (personal protective equipment). Interventions: ensure proper signage to inform staff of precautions. The (11/17/2024) Residents on Enhance(d) Barrier Precautions indicated R76 was on the list. Of note, the room listed for R76 was not where R76 was observed on 11/17/24. The (undated) Enhanced Barrier Precautions from CDC (Centers for Disease Control and Prevention) documented, in part Providers and staff must: wear gloves and a gown for the following High-Contact Resident Care Activities: Device care or use: feeding tube. The Enhanced Barrier Precautions (EBP) policy and procedure dated 2/12/2024 documented, in part the purpose of enhanced barrier precautions is to prevent opportunities for transfer of MDRO's (multi drug resistant organism) to employees' hands and clothing during cares, beyond situations in which staff anticipate exposure to blood or bod fluids. Policy: it is the policy of this facility that enhanced barrier precautions, in addition to Standard And Contact Precautions will be implemented during high contact resident activities when caring for resident with indwelling medical devices. High Contact Resident Care Activities include: Device care or use: feeding tube. When initiating EBP: post EBP signage at the door. Ensure PPE and disinfectant are present, ordered, and restocked routinely and placed at the entrance of room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146191 If continuation sheet Page 11 of 13 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 11/20/2024 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to provide functioning call device for residents requiring assistance from staff. This failure affected 2 (R91, R98) residents reviewed for resident call system in the total sample of 57 residents. Residents Affected - Few Findings include: On 11/17/2024 at 10:40 AM, V12 (Certified Nursing Assistant) checked R91's call device and stated the call light is broken; the call light box is not lit to indicate it is working. On 11/17/2024 at 10:49 AM, V12 checked R98's call device and stated the call light box is not lit to indicate it is working. ON 11/17/2024 between 10:52am and 11:05am, V13 (Maintenance Supervisor) checked R91's and R98's call devices and corroborated the observations done by this surveyor with V12. On 11/17/2024 at 11:09 AM, V13 stated it is expected to have a properly functioning call light to let the nursing staff know the resident needs assistance. How can they ask for assistance if the call light is broken. On 11/18/2024 at 11:23am, V2 (Director of Nursing) stated we should provide a functioning call device to the resident. Call device is a lifeline to our residents, and it must remain functional at all times. Anything could have happened if the call device is not functioning, including death. I am just stating the worst-case scenario. On 11/19/2024 at 2:53pm, V1 (Administrator) stated we don't have call light assessment. R91's (Active Order as Of: 11/18/2024) Order Summary Report documented, in part Diagnoses: (include but not limited to) Obsessive Compulsive disorder and epilepsy. R91's (10/22/2024) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R91's mental status as cognitively intact. R91's (Target date: 01/10/2025) care plan documented, in part Focus: Alteration in ADL's r/t (related to) medical and psych (conditions). Requires assistance with dressing, grooming, mobility, bathing, toileting & personal hygiene. Goals: All ADL's will be met on a daily basis, with the resident doing as much as possible for self within limits of medical and psych conditions. Interventions: Anticipate resident needs while giving routine care. Answer call light as quickly as possible. Ensure safety at all times. Keep call light within reach and instruct the resident in the proper use of call light. R98'S (Active Order as Of: 11/19/2024) Order Summary Report documented, in part Diagnoses: (include but not limited to) essential hypertension, extrapyramidal and movement disorder, unsteadiness on feet. R98's (10/17/24) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 10. Indicating R98's mental status as moderately (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146191 If continuation sheet Page 12 of 13 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 11/20/2024 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 0919 impaired. Section GG. Functional Abilities. GG0130. C. toileting hygiene: 1 - dependent. Level of Harm - Minimal harm or potential for actual harm R98's (Target date: 11/20/2024) care plan documented, in part Focus: Alteration in ADL's r/t (related to) medical condition(s). Requires assistance with grooming & personal hygiene, transfers, mobility, toileting, and eating. Goals: All ADL's will be met on a daily basis, with the resident doing as much as possible for self within limits of medical condition. Interventions: Anticipate resident needs while giving routine care. Answer call light as quickly as possible. Ensure safety at all times. Keep call light within reach and instruct the resident in the proper use of call light. Residents Affected - Few The Call Light Policy dated 1/1/2024 documented, in part When call light system is not working, all nursing staff will implement 30-minute rounds to ensure all resident are provided care as needed. When call light system is not working, maintenance needs to be notified immediately. The (9/21/2024) untitled facility provided document reads as follows the purpose of a functioning call light system is to enable residents to ask for assistance. Safety and satisfaction: the system should enhance patient safety by enabling quick response and quick access to assistance, and reducing the risk of unattended emergencies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146191 If continuation sheet Page 13 of 13