Inspection·March 28, 2025

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review it was determined that the facility failed to provide an effective pest control program. This failure has the potential to affect 201 residents residing in the facility. Residents Affected - Many Findings Include: On 03/26/25 at 09:35 V6 (R3's Family Member) stated The facility has mice and R3 has seen the mice in her room. The mice sometimes get caught in the bathroom and in the roommate's clothing. A mouse was in R3's bed. R3 saw a mouse the day before yesterday. On 03/26/25 at 10:42 AM Per telephone interview V5 (Anonymous) stated R2 has been in the facility since December. R2 was sent to the hospital and when R2 returned he (R2) was in a room on the third floor. The bed that R2 was in had mouse dropping on the bed frame. R2 was in the room, it was dark and when I turned on the light a mouse ran across the floor. On 03/26/25 at 10:10 AM V1 (Administrator) stated the pest control company were coming out weekly and I upped it to twice a week. There is work being done on the building to make a better sealing of the building. We do have an issue with mice, I have not seen any, but staff have seen them. On 03/26/25 at 11:46 AM R5 was observed sitting on the bed eating lunch. A white cardboard sticky mouse trap and a black corner mouse trap were observed near the corner of the room under the corner of the radiator. R5 stated I saw a mouse this morning. It was a medium size mouse in the corner by the mouse trap. I have been here a week and saw a mouse twice the day before yesterday. I told my roommate but didn't tell anyone else. On 03/26/25 at 11:50 AM V7 (Certified Nurse Assistant) stated I saw a mouse this morning when I was getting the resident in room [ROOM NUMBER] ready for his appointment. I think it shot out of the bathroom. I see them (mice) often. On 03/26/25 at 11:53 AM R4 was observed sitting in a chair in the dining room eating ice cream. Surveyor asked R4 had he seen any mice. R4 began laughing and said are you serious, today on the right side of my bed. He (the mouse) has come to see me plenty of times like we are family. I had my bookbag on the floor and it went in my bag. I talked to the certified nurse assistant and licensed practical nurse. I have seen the mice every day. It was one in the dining room today and I have seen dropping in my bed this morning, on the radiator and floor. On 03/26/25 at 11:59 AM V8 (Licensed Practical Nurse) stated I have worked here since March 12th. I saw mice two Fridays ago in orientation. I was charting and one came out at the nurse station. (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 3 Event ID: 145828 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 145828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kenwood Vlge Nrsg and Rhb Ctr 4505 South Drexel Chicago, IL 60653 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)