Health inspection·October 3, 2024

F 0914 Provide bedrooms that don't allow residents to see each other when privacy is needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure that residents have privacy curtains which extend around the bed. This failure affected Four residents (R8, R9, R10, and R14) reviewed for residents' privacy. Residents Affected - Some Findings include: On 9/30/24 at 10:59 am, Surveyor observed that the privacy curtains that are supposed to extend around the beds for R8, R9, R10, and R14 were not there. On 10/2/24 at 11:15am, the surveyor observed again that the privacy curtains were still missing. At this time, the surveyor called the attention of V10(CNA/Certified Nurse Assistant). V10 stated that each resident usually has a curtain around the bed for when they need privacy. On 10/2/24 at 11:30 am, V7 (Maintenance Director) stated All residents have privacy curtains. The surveyor then toured around with V7 and found that the privacy curtains for all of the 4 residents were missing. V7 stated I will put up the privacy curtains when they are available. The facility's policy titled Quality of Life - Dignity with revision date August 2009 states: each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. #10 states: Staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 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: 146018 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 146018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Little Village Nrsg & Rhb Ctr 2320 South Lawndale Chicago, IL 60623 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)