Inspection·June 21, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the right of the resident to be free from physical abuse in 1 (R1) of 3 residents reviewed for abuse in a sample of 8. The findings include: R1 is a [AGE] year old male with a diagnosis including COPD, Dementia, Major depressive disorder and History of falling. R1 has a BIMS (Brief Interview for Mental Status) score of 13/15. R1 ambulates independently by wheelchair. R1 is care planned for being a potential risk for Abuse/Neglect. R1 was first admitted to the facility on [DATE]. Facility Incident Report Form dated 6/6/25 includes statement that on 6/4/25 corporate staff were reviewing video recording that shows V3 ( Housekeeper) moves R1's wheelchair unnecessarily and forcefully. R1 places his foot on the ground appearing to be non verbally communicating that he does not want to move. Despite this V3 lifts the front wheels of the wheelchair and moves R1 whose feet are visibly hanging. On 6/20/25 at 10:39AM R1 stated yes I remember when V3 (Housekeeper) spun my wheelchair and moved me from area when I came out of the elevator. He tilted my wheelchair back because I tried to put my feet down to stop him. Nothing else happened. I am fine and I feel safe in the building. I don't see that housekeeper anymore. On 6/20/25 at 9:55AM V1 (Administrator) stated on 6/4/25 V2 (corporate staff ) reported to me he witnessed abuse to a resident while reviewing facility security camera footage. V2 showed me the camera footage. At around 7:30 AM on 6/4/25 V3 (Housekeeper) was mopping the floor and R1 was coming out of the elevator. R1 went on the floor that V3 was mopping. V3 spun the resident around aggressively. R1 was resisting by putting his foot down on the floor. V3 tilted the chair backwards and moved resident from area. I suspended V3 and terminated him after my investigation. R1 was not physically abused but R1 was mentally abused as concluded by the investigation. I followed the facility abuse prevention policy. This investigation and termination was reported to corporate. There were no other witnesses to this event. On 6/20/25 at 10:25 AM Surveyor and V1 (Administrator) observed the 6/4/25 incident surveillance footage on V1's laptop. V3 (Housekeeper) was mopping the 1st floor immediately outside the elevator on the first floor. Three residents were standing in front of elevator. The elevator door opened. The three residents entered the elevator. R1 exited the elevator and rolled his wheelchair next to the wet caution sign. V3 put his mop in the bucket and grabbed the back of R1's wheelchair. V3 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 146191 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 06/21/2025 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)