Inspection·March 13, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to follow their policy on resident rights by not ensuring a package delivered to the resident was unopened. This failure applied to one (R1) of three residents reviewed for resident rights. Findings include: 03/13/2025 10:02 AM V3 (Office Manager) stated when packages are delivered to the facility they are brought to the front desk, and she then has the activities aides deliver them unopened to the residents. V3 stated packages are never opened before delivering them to the residents. R1 is a [AGE] year-old male with a diagnoses history of Partial Paralysis due to Stroke, Hypertensive Heart Disease, and Presence of Cardiac Implant who was admitted to the facility 03/09/2023. On 03/13/2025 at 10:09 AM Observed R1 in his room lying in his bed. R1 stated on 03/10/2025 the morning nurse provided him with an opened Amazon package and pointed out the open package sitting in his drawer to the surveyor. Observed a partially opened amazon package with an Amazon symbol on the outside labeled with R1's name containing pills inside. R1 stated the nurse admitted opening the package and stated she thought it was for her. R1 stated the package was cod liver oil pills. On 03/13/2025 at 11:47 AM V4 (Licensed Practical Nurse) stated she delivered R1 a package containing pills. V4 stated she did open the package because she believed it to be pills, and apologized to R1 explaining to him she thought it was medicine. V4 stated normally medication is delivered in brown paper packages. V4 stated medications are normally delivered to the front desk and the staff have them come and pick it up. V4 stated she was told there was a package for R1, and it was in a brown package like the one medication normally arrives in. V4 stated she believes staff thought R1's package was medications and that's why they handed it to her to deliver. On 03/13/2025 at 11:57 AM V5 (Business Office/Admissions Director) stated it is not appropriate for resident's mail to be opened by the facility. On 03/13/2025 at 2:25 V6 (Director of Nursing) stated the medication packages do not necessarily look the same as Amazon Packages and smaller Amazon packages are usually identifiable with an Amazon symbol. V7 (Licensed Practical Nurse/Nurse Supervisor) stated medications come in brown paper bags or a white sealed bag. V7 stated some medications do come in packages like the Amazon packages. V7 stated packages should be labeled. V7 stated everyone should be reading the label on the packages before opening them because they go to different units. V7 stated normally, Amazon packages are delivered (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: 145879 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 145879 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tri-State Village Nrsg & Rhb 2500 East 175th Street Lansing, IL 60438 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)