Little Village Nrsg & Rhb Ctr

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 protect the rights of the resident and allow one (R2) resident to go out on a community pass after a ninety-day restriction without performing a reassessment. R2's Minimum Data Set (MDS) dated [DATE] shows R2 is cognitively intact.R2's was admitted to the facility on [DATE] with diagnoses including but not limited to other bipolar, major depressive disorder recurrent, severe with psychotic symptoms, generalized anxiety disorder, and other psychoactive substance abuse. On 8/19/25 at 10:58 AM, R2 received in room, stated he has been in the facility since October 2023. He went out to the community on independent pass on 2/28/25, he came back to the facility intoxicated with drug-marijuana, and he was given a ninety-day community pass restriction on 3/3/25.

His ninety-day community restriction officially ended in June 2025, but he is still not being allowed to leave the facility despite multiple requests voiced to the facility V7 (Social Service Director), and the facility is violating his rights.On 8/19/25 at 3:10 PM, V7 (Social Service Director) stated that he has been in the facility for one year, the residents have the right to go out on pass based on safety community assessment.

The resident could go out for two hours, four hours, or eight hours, when the resident violates the contract, the resident will be restricted as ordered and complete a new community access observation assessment to determine if the resident is qualified to go out to the community independently or with supervision. R2 had repeated violations of constant alcohol/drug overdose whenever he goes out independently, on 2/28/25 he overdosed with some drug, and the physician placed him on ninety-day community restriction until 6/1/25. V7 stated that, R2 should have been reassessed since 6/1/25 to determine if he is qualified to go out to the community independently or with supervision, but he was not reassessed until surveyor walked into the facility on 8/19/25.On 8/21/25 at 12:20 PM, V1 (Administrator) stated that she has been in the facility for twenty years, the residents have the right to go out to the community. R2 should have been reassessed after the end of the ninety-day community pass restriction on 6/1/25 because that is his right.

She will ensure V5 takes care of this situation right away.R2's physician order dated 3/3/25 documents in part; Restricted community pass for 90 days until 6/1/25.R2's community access observation assessment dated [DATE].

Residents Rights dated 10/2027 documents in part: residents are entitled to exercise their rights and privileges to the fullest extent possible.

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.

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