Health inspection·January 3, 2025

F 0689 hospital nurse called informing her that R1 has been admitted with closed right hip fracture that needs surgery. Level of Harm - Actual harm Per Incident Report of the facility related to R1 fall incident, it documents as follows: Residents Affected - Few During R1's admission to the hospital (12/02/2024), the facility received a call from the hospital that R1 will be undergoing right hip surgery due to fracture and that the R1 said she fell in the facility. On 01/02/2025, at 9:57 AM, V2 (Director of Nursing) stated that a nurse tried to tell her that R1 was supposed to use the walker but did not and got up. When asked who was the nurse that told her? V2 said that she was not sure. She (the nurse) may have mixed R1 from other residents. After reviewing R1's printed progress notes, V2 said (reading the notes), On 11/28/2024, she (R1) was limping when ambulating in the hallway. V2 then said, Yes, she (R1) was allowed to ambulate. V2 was asked about the current status of R1 after the incident? V2 stated that R1 is now chair or bed bound when R1 came back from the hospital after the incident. V2 after review of R1's care plan noted that R1 needs extensive assist during transfer. R1 requires a gait belt. R1 needs to be assessed and evaluated before transfer, and to prompt R1 to stand, pivot and transfer to chair or wheelchair. V2 stated that those questions can be best answered by V12 (MDS Coordinator / Licensed Practical Nurse). V2 stated that she only knew that R1 was verbalizing that she fell when the hospital called and informed her that R1 said she fell here in the facility. V2 was made aware that per V5 (Medical Doctor) physician notes dated 12/02/2024, it was documented that R1 verbalized to V5 that she may have fall. V2 said, I was not aware that R1 verbalizing to V5 that she (R1) may have fall. On 01/02/2025, at 11:16 AM, V12 (MDS Coordinator / Licensed Practical Nurse) stated that R1 ambulates by herself without using any equipment like walker. After review of R1 fall care plan, V12 stated that R1's fall care plan was not reviewed since 2022. V12 stated, Yes, the care plan should be reviewed quarterly. V12 was asked how can R1's fall care plan reflects her current fall prevention needs when it was not reviewed since 2022? V12 stated, I know what you mean. That it needs to be updated. V12 was also asked that R1 has a care plan for extensive assist, to use a gait belt, and assess when being transferred. R1 was also identified in her care plan for decline in physical ability. V12 stated that restorative has their own scope. A He (V12) does not know about R1's decline on physical ability. Currently, the facility does not have restorative nurse. Per R1's care plan it provides as follows: R1 is unable to transfer independently and requires assistance to supervision as evidenced by R1's medical diagnosis. The goal is for R1 to be able to transfer safely from bed to chair/wheelchair with extensive assist. Intervention for R1 includes application of gait belt, evaluation, or assessment of R1's sitting and standing ability prior to transfer, and prompt R1 to stand, pivot, and transfer to chair/wheelchair. R1 has decline in physical ability that will affect her (R1's) activity pursuit daily. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146191 If continuation sheet Page 2 of 3 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 01/03/2025 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 R1 is at risk for decreased upper and lower extremities strengthening and range of motion as evidence by R1's medical diagnosis that includes mild cognitive impairment, bipolar disorder, and lack of coordination. Level of Harm - Actual harm Residents Affected - Few R1 assessment reveals a reasonable risk for falls secondary to difficulty of walking, unsteadiness on their feet, and generalized weakness. R1 was observed with weakness in the legs three (3) to four (4) times a week. R1 is observed and is at risk for fall. Fall care plan for R1 was initiated on 03/08/2022 and was last reviewed/revised on 06/01/2022. After 06/01/2022 there was no record of review/revised of R1's fall care plan. MDS (Minimum Data Set) comparison between assessments dated 10/15/2024 annual assessment (prior to fall) and 12/11/2024 significant change (after the fall). R1's functional abilities substantially declined from able to walk/ambulation to dependent or chair bound due to the fall. Hospital documentation are as follows: Dated 12/02/2024, documents, R1 chief complaint: I fell and hurt my hip. R1 sustained a mechanical fall from standing. X-Ray of the right hip reviewed. R1 has a displaced femoral neck fracture. Right hip surgery was done on 12/03/2024. Facility provided Post - Fall Protocol policy and procedure dated 09/01/2023, that focus on guidance related to resident after the fall. After request for policy and procedure of the facility prior to fall or fall prevention. V2 (Director of Nursing) stated that the facility has only post fall policy and procedure that was already provided. V11 (Director of Operation) stated that although facility has no specific policy for fall prevention. The facility has training and in-service related to fall prevention. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146191 If continuation sheet Page 3 of 3