Health inspection·May 4, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a bowel movement, R1 does not wipe his buttocks after the bowel movement. I was going to shower R1 because he just finished having a bowel movement and he did not wipe his buttocks. After I handed R1 the towel, I told him to go to the shower room and I told him that I'm coming. I had to go and attend to another resident who could not walk. I was with the other resident about 8 to 10 minutes and then I went to the shower room to meet R1, but R1 was not in the shower room. I went to R1's room, I observed R1 sitting on the floor with his legs straight. R1 was wearing pants and gym shoes while R1 was sitting on the floor. When I walked out of R1's room to check on another resident, R1 was sitting on the bed. When I returned to R1's room, R1 was sitting on the floor. I asked R1 why he was still in his room. R1 told me that he is suffering from his right arm. I grabbed R1's pants from the back and I got him up. R1 stood up. When R1 stood up, I pulled R1's pants and diaper down and R1 was full of poop. R1 said that he is not going to shower because R1's right arm hurts too much. I cleaned R1 up while R1 was standing up. After I changed R1, I told R1 to sit on the bed. R1 eats downstairs, so I told R1 to go and eat downstairs. R1 said that R1 does not want to go because his arm is in too much pain. When R1 told me that he's not going to go eat downstairs, I told my nurse. I told the nurse on duty, V7 (licensed practical nurse), that R1 cannot go downstairs to eat and that R1 broke his arm. I went downstairs and brought R1 his tray. I asked R1 what he was doing on the floor, but he did not respond to me, so I asked him what he was still doing in his room. He said that his right arm hurts. R1 did not tell me how he fell. I would always go and supervise R1 in the shower room because R1 would go and wet the towel and pretend that he was taking the shower. R1 is needs supervision in the shower room. Normally I go with R1, but I needed to mop the floor because another resident peed in the hallway. When I see the resident on the floor, I am not supposed to pick up the resident from the floor without a nursing assessment. Picking up R1 from the floor was the mistake I made. I informed the nurse that R1 had a fall after R1 was already in bed and after R1 told me that R1 is going to stay in bed for breakfast due to his right arm pain. When a resident has a fall, the policy is to inform the nurse right away, which I did not do. After I informed the nurse that R1 had a fall and that R1's arm was hurting, V7 went to assess the resident. R1 was sent to the hospital. The mistakes I made is that I transferred R1 post fall without informing the nurses and without the nurse's assessment. R1 slipped off the bed and fell on his right arm. I never stretched is arm and never pulled on his shoulder when I was getting R1 up. I just pulled R1 by his pants. I did not ask for assistance from other staff to transfer R1 to bed post fall, I lifted him by myself. On 05/03/2025, at 2:41 PM, V1 (administrator) stated, I investigated the incident that occurred on 04/21/2025. I got a call from the hospital that R1 was claiming that R1 was physically abused by the staff. I immediately initiated the investigation. V3 (S1/certified nursing assistant) was the certified nursing assistant that was assigned to R1. V3 was immediately suspended and sent home, pending investigation. R1 was not in the building at the time that the investigation was started, R1 was in the hospital. Then I got another call around 4:30 PM from R1's V12 (primary physician). He verbalized what the resident was claiming about the incident. I explained to the physician that I initiated the investigation and the physician shared that he had spoken to the emergency room doctor. The emergency room doctor had concluded that R1's right arm fracture was not as a result of physician abuse. V12 recommended that we in-service nursing staff and certified nursing assistants on proper transfer techniques. We spoke to the physical therapist to initiate the in-services. The resident was readmitted to the facility later that day. The following day on 04/22/25, I interviewed R1. R1 shared that he was on the floor and V3 lifted him up from the back. His hand gave out when the C.N.A. lifted him up. When he was asked if he feels it was an intentional physical aggression, R1 said no, it was not intentional. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146191 If continuation sheet Page 2 of 4 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 05/04/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R1 was re-interviewed by me. He stated that he was sitting on the edge of the bed and the C.N.A tried to lift him up by his arm and that's how R1 sustained the fracture. He again said that he doesn't think it was intentional. We interviewed other residents and residents never accused this particular C.N.A. of being abusive or aggressive towards the resident. Staff were interviewed on abuse and reporting of abuse. All the staff in the facility receive abuse prevention training monthly and as needed. A C.N.A should not pick up a resident after a resident sustained a fall because it can cause injury without a nursing assessment. V3 should have first notified the nurse on duty to assess R1 when R1 fell. Based on the recommendation from the nurse, we can get then get the resident up from the floor. It is never ok for a C.N.A to pick up a resident from the floor post fall without notifying the nurse and without nursing assessment. On 05/03/25, at 3:03 PM, V2 (director of nursing) stated, After interviewing V3 (S1/certified nursing assistant), we educated V3 about proper transfers. V3 says that R1 was sitting on the floor, however, V3 and other staff should never assist a resident from the floor alone without notification of the nurse. The nurse must complete an assessment first to see if it is safe to transfer the resident from the floor post fall. We educated V3 on never assisting a resident post fall alone, without other staff assistance. All the nursing staff were educated about proper transfers and therapy demonstrated proper and safe transfers. On 05/03/2025, at 3:12 PM, V13 (restorative director) stated, R1 transfers independently with stand-by supervision. R1 requires stand-by assistance for showers. R1 is moderate assistance with shower. R1 requires staff encouragement for showers. R1 did not have any prior falls, prior to 04/21/2025. R1 did not tell me that he had a fall. I asked R1 if he had a fall, but R1 did not confirm that R1 fell. R1 just told me that he went to the hospital. On 05/03/2025, at 3:34 PM, V7 (licensed practical nurse) stated, On 04/21/2025, I was working on the 4th and 5th floor. While I was on the 5th floor, V3 (S1/certified nursing assistant) alerted me that a resident is hurt. I went to assess R1. R1 was sleeping in his bed. I opened the resident's chart to see if he has any pain medications. I see that R1 has a prescription for pain medications for shoulder pain. I got the pain cream and I went to R1's room to apply the cream. That's when R1 told me that the shoulder that the cream is prescribed for is not what was causing the pain. I was not told that the resident had a fall. I was told by V3 that R1 is having pain. When the resident told me that his right arm is hurting, that's when I did the assessment. While I was assessing R1, that's when R1 alleged that V3 twisted his arm. I was still not informed about a fall; I was only informed by the resident that the C.N.A twisted R1's arm. R1's right arm was visibly swollen. R1 was not able to do range of motion and move his arm due to excruciating pain. I asked R1 how long R1 was having this pain. R1 told me that he was having pain since this morning. I followed the facility protocol and if there is an alleged abuse allegation, we report it to the abuse coordinator who is the administrator. From there the administrator will give me the directives on what to do next. The whole time during R1's assessment, I was not informed at all that a had had taken place. R1 only reported an alleged abuse allegation that V3 twisted his arm, but the C.N.A never told me that a fall occurred. V3 only told me that R1 is having difficulty moving his arm. R1's Progress Note (dated 04/21/2025) documents, Resident complained of right arm swelling. Assessment done. Swelling noted on said arm. He admits to excruciating pain. Range of motion is limited. Resident cannot abduct right arm. Physician notified and responded with order to send resident to community hospital for medical evaluation. Nurse to nurse report given and an estimated time of arrival of 30 min obtained from ambulance. Resident left the facility accompanied by 2 EMT (emergency medical transport) staff without incident. Family member notified via voice mail. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146191 If continuation sheet Page 3 of 4 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 05/04/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R1's Progress Note (dated 04/21/2025) documents, Follow up call made to community hospital regarding patient's status. Spoke with the nurse. That resident will be returning to facility. That patient will be on a sling. Incoming to follow up with return. R1's Progress Note (dated 04/21/2025) documents, Resident returned back to the facility via medical transport. Arrived with 2-person assist on a stretcher. Received alert and oriented at baseline. emergency room discharge documentation confirmed fracture to the right arm with sling in place. Assessment of swelling noted around the scapula region, resident denies pain at this time. No facial grimacing observed. Discharge order for resident is to schedule an appointment with physician (Orthopedic surgery). Physician notified of resident's return, new order for Tylenol 325mg; take 2 tabs by mouth every six hours hours as needed for pain. Order received and carried out. Director of nursing notified. Message left for emergency contact (daughter). Monitoring in place. Vitals stable. R1's Emergency Record (dated 04/21/2025) documents that R1's diagnosis was closed fracture of right shoulder. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146191 If continuation sheet Page 4 of 4