Inspection·August 15, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete said, I was told about it. The staff member opened the door. V4 was asked if he spoke to R3. V4 replied, I did not talk to R3. V4 said it was the nurse on duty who informed him (V4). V4 again reiterate that he did not talk to R3. And that he (V4) did not know how R3 felt about the incident. V4 said, I did not know she felt violated during that time. V4 was made aware that there was no privacy curtain to all three (3) shower areas in the shower room. V4 stated that as far as he knows there are curtains. There is no curtain, the curtain needs to be place because it will help in providing privacy. V4 stated that there were no notes about the incident because he thinks it was just a misunderstanding. V4 stated that there was a grievance documented about what happened but there were no notes or other documentation related to the incident. On 08/14/2025 at 10:07 AM, with V4 went to the shower room upon entering the door near resident's room the three (3) shower areas do not have privacy curtain. It does not have a pole to place the curtain. Both left and right shower areas are visible upon opening the door through the hallway. V4 said, You are right there is no privacy curtain. It may be because this shower room is newly renovated. V4 stated that all residents are using the same shower room without privacy curtain. When door was open will be visually exposed to any person on the hallway. Then V4 went to other shower room near resident's room. Inside shower room construction ongoing, power tools on the floor, ceiling taken off, lot of construction materials. V4 stated that this shower room is not being use by resident. And all residents in this floor male and female uses the shower room without privacy curtain. V4 stated that he will address this concern right away. On 08/14/2025 at 10:21 AM, V2 (Director of Nursing) stated that shower room needs privacy curtain for privacy. V2 stated that she addressed this concern with R3. V2 stated that R3 heard something came to the door and called for help. V2 was asked about any documentation related to incident. V2 replied, That's not an incident to me it is something that needs to be addressed but not an incident. To me I addressed. To my knowledge it affected her, when I explained to her it makes her safe. V2 stated that what happened need to be addressed but not documented. V2 said, everything does not need to be documented. V2 confirmed that V12 (Former Certified Nursing Assistant) was the staff who opened the door with R7. And V13 (Licensed Practical Nurse) was the nurse on duty during that day whom R3 spoke to about what happened in the shower room. On 08/14/2025 at 12:03 PM V13 (Licensed Practical Nurse) confirmed that the incident happened on Sunday, 07/27/2025. V13 stated that R3 told her that somebody opened the door while she was in the shower. I (V13) went in the shower room, I did see that shower room have no curtain, I did see that. On 08/14/2025 at 1:04 PM V1 (Administrator) was made aware about the privacy curtain. V1 stated that she was told about the problem regarding privacy curtain. V1 said, I understand that part about the privacy curtain that it will help. V1 was made aware that shower room was left unsecure earlier when R3 was able to push open the door without use of the key. Any person may enter shower room when a resident is performing shower. And without privacy curtain, person showering is right away visible to any person entering shower room or opening the door. Requested to facility for policy and procedure related to privacy and/or resident rights. V1 presented part of admission packet which serves as a contract between facility and residents; it reads: Resident have the right of privacy over your persona. The facility must care for residents in a manner and environment that enhances or promotes your quality of life. The facility will treat residents with dignity and respect in full recognition of resident's individuality. Event ID: Facility ID: 145914 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 145914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southpoint Nursing & Rehab Center 1010 West 95th Street Chicago, IL 60643 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and review or records the facility failed to maintain complete and accurate resident record for 1 out of 4 residents (R3). These failures affected 1 resident (R3) who felt exposed during shower without documentation as to interventions done to address concerns. Findings include: R3 is [AGE] years old, with initial admission date of 04/16/2021. R3's primary medical diagnosis acute kidney failure. R3's BIMS score dated 07/22/2025 was 14 which indicates that R3 cognition is intact and without impairment. On 08/14/2025 at 08:33 AM, R3 was seen in her room alert, able to express her thoughts clearly and within topic. R3 stated that it happened on Sunday, 07/27/2025 in the shower. I hear someone at the door. I yelled out, Hello! Hello! The next thing I know I saw a man. I don't know who it was. I told the nurse on duty. She was a female nurse. I reported the incident to her. R3 stated that shower room does not have any privacy curtain. Anyone taking shower is exposed when door was open, or a person comes in. R3 states that she complained before of people not knocking when they get in my room. R3 said, No one knocks on the door. I complaint to higher staff members. Yes, I complaint to V4 (Social Service Director). R3 said that during the time she was taking shower it was locked. And one of the staff opened the door. R3 stated that it happened around 08:30 AM to 09:00 AM. The man (R7) was able to go in the door went to the opposite door across all shower areas and went back to the door where he came in. R3 said, I felt exposed, violated, my privacy was violated, I wasn't secure, my security was violated, and I was unprotected. Left vulnerable and exposed! On 08/14/2025 at 9:30 AM, V4 (Social Service Director) denies having knowledge about any recent privacy concern with R3. V4 said, I can't remember R3 has concern about privacy. V4 stated that the proper procedure for facility staff when entering resident's room is to knock first, say your name, wait for respond before going in. For shower rooms V4 said, it does not always work that way. Even if staff knock, resident may not hear you. V4 stated that there are two (2) shower rooms on the first floor. One is under construction, so all residents in this floor uses the same shower room. Again, V4 was asked if there were resident with concern on privacy on shower room? V4 replied, I did not get any report about people coming in while resident is taking a shower. After informing V4 about the incident related to R3. V4 said, I was told about it. The staff member opened the door. V4 was asked if he spoke to R3. V4 replied, I did not talk to R3. V4 said it was the nurse on duty who informed him (V4). V4 again reiterate that he did not talk to R3. And that he (V4) did not know how R3 felt about the incident. V4 said, I did not know she felt violated during that time. V4 was made aware that there was no privacy curtain to all three (3) shower areas in the shower room. V4 stated that as far as he knows there are curtains. And if there is no curtain, the curtain needs to be place because it will help in providing privacy. V4 stated that there were no notes about the incident because he thinks it was just a misunderstanding. V4 stated that there was a grievance documented about what happened but there were no notes or other documentation related to the incident. On 08/14/2025 at 10:21 AM, V2 (Director of Nursing) was asked about any documentation related to incident. V2 replied, That's not an incident to me it is something that needs to be addressed but not an incident. To me I addressed. To my knowledge it affected her, when I explained to her it makes her safe. V2 stated that what happened need to be addressed but not documented. V2 said, everything does not need to be documented. V2 confirmed that V12 (Former Certified Nursing Assistant) was the staff who opened the door with R7. And V13 (Licensed Practical Nurse) was the nurse on duty during that day whom R3 spoke to about what happened in the shower room. On 08/14/2025 at 12:03 PM V13 (Licensed Practical Nurse) confirmed that the incident happened on Sunday, 07/27/2025. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145914 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 145914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southpoint Nursing & Rehab Center 1010 West 95th Street Chicago, IL 60643 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete V13 stated that R3 told her that somebody opened the door while she was in the shower. I (V13) went in the shower room, I did see that shower room have no curtain, I did see that. V13 stated that when she talks to R3 she was initially upset, then she said OK, and she got her pass, and she left. I was under the impression that R3 was okay that why I did not write any notes. On 08/14/2025 at 1:04 PM V1 (Administrator) was made aware that there is no documentation on R3's resident record related to incident. Concern form by V2 (Director of Nursing) was provided by facility dated 07/29/2025 related to R3 regarding shower room. Concern form is not documented on R3's resident record or part of R3's resident record. In-service was also provided by V2 dated 07/29/2025 related to shower room safety. And does not address concerns related to privacy which is the concern of R3. Event ID: Facility ID: 145914 If continuation sheet Page 4 of 4