Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0600
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment,
and neglect by anybody.
Level of Harm - Actual harm
Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to prevent incident of resident-to-resident
physical assault. This affected three of three residents (R1-R3) reviewed for physical abuse/assault. This
failure resulted in R1 physically assaulting R2 and R3, however as a result of the assault, R1 sustained
bilateral nasal bone fracture and blunt abdominal trauma. The findings include:On entry to the facility R1
had been hospitalized on [DATE]. According to progress notes, R1 returned to the facility on 8/7/25 at
approximately 8:00PM. On 8/8/25 at 9:44AM R1 on patio, sitting, smoking. R1 looking down, away from
surveyor, not making eye contact, did not interact or greet surveyor. R1 kept looking away. Observed under
eyes swollen, light purple crescent shape under each eye, flat scratches/abrasions on right side of nose
along bridge. R1 would not speak to surveyor.On 8/8/25 at 10:55AM R1 her room, no visible injury on
hands or face. Ambulates freely. R1 said I was sitting outside having a smoke and that lady (R1) came up to
me, got in my face and tried to hit, I hit her back. R2 said I'm not hurt. R1 said she not my friend I don't
know why she wanted to fight me. R1 said yeah, we were fighting. R1 said V2 (Social Service Aide) was
there she saw it. R1 said then R1 got in a fight with another lady; I just came inside. R2 said we was outside
on the smoking patio.R1's diagnosis includes but are not limited to Anxiety Disorder, Cognitive
Communication Deficit, and Unspecified Psychosis. R1's cognitive assessment dated [DATE] identifies she
is cognitively intact. R1's behavior assessment dated [DATE] identifies delusions for potential indicators of
psychosis.Witness statement with R1's name with no signature or date states I ran up to (R3) and
attempted to hit (R3) and she hit (back). I got in (R2's) face and (was) trying to fight her.Witness statement
with R3's name and signature states (R1) hit me and (I) hit her back and we started fighting.Witness
statement with R2's name and signature states (R1) came in my face and R1 hit me, and I defended
myself. I hit, grabbed her hair, and kicked her.On 8/7/25 at 11:22 V2 (Social Service Aide) said R1, R2, and
R3 were outside on the smoking patio. V2 said V2 was inside, and one monitor was outside. V2 said V2
heard arguing and walked out, and saw staff try breaking up the fight. R1 and R2 were yelling at each other,
and they were swinging at each other. R1 hit R2 first. R2 was sitting and R1 was standing over R2. V2 saw
that R1 and R2 were getting separated. V2 said during that time R1 got away and hit R3, and then they
start fighting. V2 said V2 saw R3 swinging at R1. V2 said as we were walking away, I saw R1 had blood on
her nose. V2 said R1 came out, she looked frustrated and mad when she came outside, that is usual for
her. At 2:11PM V2 said when R1 came down, V2 told her she could not go outside. V2 said I kept
redirecting her and R1 took it upon herself to go outside anyway. V2 said V2 did not give her a cigarette. V2
said R4 said R1 woke up mad and irritated. V2 said when a resident is on restriction, Social Service Staff
will give us the list, I was told the day before that R1 was on restriction. V2 said V2 told R1 she could not go
out, she continued to walk past me, she said she wanted to go out. V2 said when R1 got out there, they
started arguing. V2 said it was
(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:
145639
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
145639
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Chicago Ridge Snf
10602 Southwest Highway
Chicago Ridge, IL 60415
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 0600
Level of Harm - Actual harm
Residents Affected - Few
not reported to anyone that R1 was on the patio until after the fight had occurred.V2's witness statement
signed and dated 8/5/25 states R1 went out the door and (V2) heard arguing. I saw V5 (Social Service
Assistant) was trying to break up a fight between R2 and R1. I went to help and R1 ran to R3 and hit her,
then they started fighting.On 8/7/25 at 12:23PM V3 (Licensed Practical Nurse/LPN) stated R1 was brought
to the unit and V3 was notified she had been in altercation with another resident. V3 said V3 assessed her
and cleansed her nose. V3 said V3 put an ice pack on her nose. V3 said she was not aware if R1 was on a
smoking restriction.On 8/7/25 at 12:47PM R4 said on 8/5/25 R4 was on the patio smoking with R1. R4 said
R1 was upset because the smoke girl had told her she can't come out and smoke the rest of the day. R4
said the other lady, lives on the first floor (R3) told her to mind her business. R4 said that made R1 mad and
I told R1 to stay here, finish your smoke, be good, and then come back in. R4 said I came inside to talk to
the smoke monitor inside. R4 said then I saw V2 run outside, and I just knew it was R1. R4 said when R1
came inside I saw blood on her nose and her cheek. R4 said R1 said she got in a fight. R4 said I spoke to
R1 on the phone today, she said they were checking her out because she had blood on the brain.On 8/7/25
at 1:32PM V5 (Social Service Assistant) said R1 and R2 were arguing and then R1 hit R2. They were
fighting. V5 said V2 (Social Service Aide) came to help me break up the fight. Then R1 went and hit R3. V5
said I was outside on the patio when the fight happened. V5 said R2 was sitting on the bench near where I
was and then R1 walked up to R2, and they were arguing and then they were hitting (each other). V5 said
R1 and R2 exchanged some words and R1 was mad. R1 had an attitude the whole time she was there. V5
said I sensed she was angry when she came out. V5 said R1 was on smoke restriction and was not
supposed to be on the smoking patio.On 8/7/25 at 1:55PM V1 (Social Services) said R1 was on smoking
restriction because she had got caught smoking in her room. V1 said R1 was on restriction for 30 days. V1
said R1 can go outside for fresh air but she can't be out there for smoking time. V1 said R1 wasn't
supposed to be down there on 8/5/25. V1 said the V2 (Social Service Aide) should have stopped R1. V1
said V2 was trying to stop her from going out. On 8/7/25 at 2:24PM V6 (Director of Nursing) said R1
became aggressive with one resident and another resident jumped in and separated them. V6 said R1 had
scratches on her face, and she was the aggressor. She tried to beat up 2 people at the same time. V6 said
if a resident is on restrictions, they should not be on the patio with the smokers. V6 said we need to be
vigilant to make sure to not allow the person to be outside. The surveyor asked V6 if not smoking can cause
a smoker to be cranky. V6 replied absolutely can be cranky. V6 said for nicotine withdrawal we can offer
them something else. V6 said I am not sure if R1 was offered something. V6 said I did not know R1 was on
restriction until after the incident happened. V6 said R1 was not even supposed to be down there, on the
smoking patio. V6 said if the smoke monitors cannot redirect the resident, they should call the nurse and
social services for direction to ensure R1 did not violate her restriction. V6 said the staff did not tell anyone
R1 was outside.Review of R1 progress notes include screaming and cursing at staff and punch and choke
staff on 1/30/25. On 5/12/25 progress notes states R1 presented verbal inappropriate behavior with
obscene language to the writer.On 8/8/25 at 1:17PM V7 (Physician) said I was notified that R1 was
attacked by 3 others. V7 said I know I got a call about R1 having been attached by 3 other residents. V7
said I was told she was bleeding, but not from where. I told them to send her out for an evaluation. V7 said
they're supposed to have a staff on the balcony (smoking area) watching the residents. V7 said the purpose
for them to be watching is for safety. V7 said nasal fractures and blunt abdominal trauma can be a result of
trauma or impact. V7 said they didn't tell me where she was hit when they called me.R1's Screening
Assessment for Indicators of Aggressive and/or Harmful Behaviors dated 6/7/25 states history or recent
episode of
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145639
If continuation sheet
Page 2 of 3
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
145639
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Chicago Ridge Snf
10602 Southwest Highway
Chicago Ridge, IL 60415
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 0600
Level of Harm - Actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
aggressive/agitated behavior is substantial or significant problem. It was reported R1 was allegedly involved
in inappropriate interaction with peer. assessment dated [DATE] states R1 has history of
aggression.Smoking Risk review dated 7/24/25 documents R1 was smoking in room with peer. R1
presented with verbal inappropriate behavior. Smoking Risk review dated 4/24/25 documents R1 smoking
in hall bathroom. R1 refused to sign smoke contract and not receptive. Smoking Risk review dated 4/22/25
documents R1smoking in peer's room. R1 counseled on facility policy and safe smoking. R1 not receptive.
R1 smoking contract dated 7/24/25 states verbalized to resident, R1 refused to sign.R1's care plan dated
7/24/25 states R1 demonstrates non-compliance with safe smoking regulations by smoking in rooms,
bathrooms, halls, stairways, elevators, and other non-designated areas. Smoking at non designated times.
Interventions include explaining the safe smoking policy and policy for non-compliance. R1's care plan
dated 8/5/25 (revised date) states history of aggressive, inappropriate behavior, includes
conflicts/altercations with others, threatening behavior, verbal or physical aggression. Intervention includes
intervene when inappropriate behavior is observed.R1's progress notes dated 8/5/25 states involved in
social inappropriate interaction. R1 in altercation on patio during smoke break. Skin tear to her face,
redness near right side of her face and bridge of her nose. R1 sent to hospital for evaluation.Progress notes
dated 8/6/25 state R1 transferred to hospital with diagnosis of Assault & Fracture Nasal bones.R1's facility
obtained medical records dated 8/7/25 stated schedule this patient for follow up in plastic surgery clinic to
discuss her recent bilateral nasal bone fractures. Hospital discharge diagnosis includes Abdominal pain,
Blunt Abdominal Trauma.R3's diagnosis includes anxiety disorder and Psychoactive Substance Abuse.
R3's cognitive assessment dated [DATE] identifies cognitive intact. Behavior assessment dated [DATE]
identifies no potential indicators of psychosis.Progress notes 8/5/25 document R3 involved in social
inappropriate interaction with peer. R3 sent to hospital for psych evaluation. (R3 remained hospitalized upon
exit of survey.)R3's care plan includes history of aggression, inappropriate behavior, conflicts/altercations
with others, verbal or physical aggression. R3 has severe, chronic persistent mental illness. At times shows
aggression. Physically abusive behavior when agitated.R2's diagnosis includes but are not limited to
Schizoaffective Disorder, Altered Mental Status, Violent Behavior, and bipolar disorder. R2's cognitive
assessment dated [DATE] identifies she is cognitively intact. R2's Behavior assessment dated [DATE]
identifies delusions for potential indicators of psychosis.Progress notes dated 8/5/25 states R2 involved in
social inappropriate interaction with peer. R3 said another resident approached and attempted to make
contact with her and she defended herself. Progress noted dated 8/5/25 at 1:14PM states R1 has been
arrested two times for domestic battery.The facility behavior management policy and procedure dated 11/22
states it is the policy of the nursing department to determine the cause of behaviors when possible and
initiate interventions to reduce control or prevent identified behaviors. In the event the behavior cannot be
managed staff will implement protocols to prevent the residents from harming self or others. The purpose is
to prevent the residents from harming self or others. Procedure: notify social service of any behaviors as
soon as possible initiate behavior monitoring and recording to provide pattern of behaviors and response to
planned interventions when applicable. Targeted behavior agitated behavior which represents a danger to
self and others. Preventative measure observe residence for behavior escalation of anxiety aggression
such as loud voice tone handwringing swear and yelling and other irritability. Removed from problem area.
Allow time for the resident to voice feelings and frustration.
Event ID:
Facility ID:
145639
If continuation sheet
Page 3 of 3
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
FAQ · About this visit
Common questions about this visit
What happened during the August 8, 2025 survey of CHICAGO RIDGE SNF?
This was a inspection survey of CHICAGO RIDGE SNF on August 8, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CHICAGO RIDGE SNF on August 8, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect b..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.