Inspection·December 20, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy to ensure a resident is free from abuse. This failure affected 1 (R2) out of 3 residents reviewed for abuse. The findings include: R2's admission record showed admission date on 10/16/2023 with diagnoses not limited to Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, Cerebral infarction, Chronic respiratory failure, Unspecified convulsions, Psychotic disorder with delusions due to known physiological condition, Alcohol abuse, Bipolar disorder, Major depressive disorder, Anxiety disorder, Essential (primary) hypertension. MDS (minimum data set) dated 9/25/2024 showed R2's cognition was moderately impaired. On 12/17/24 at 12:40 PM Surveyor observed R2 sitting up on the side of the bed, alert, and oriented x 3, verbally responsive. R2 stated he is ambulatory with walker / rollator. R2 was able to remember the incident that happened on 11/30/24 and stated he was coming off the 1st floor elevator when R1 punched him at the back for no reason at all. R2 said, R1 hit me at the back forcefully. R2 said, I feel abused, R1 punched me in the back. R2 stated he did not fight back and kept his cool. R2 asked R1, What are you doing? Why did you hit me? R2 stated staff separated them. R2 said he was hurt a little bit, there was no swelling / redness / bruising. R2 stated there were residents and staff who witnessed the incident but could not remember their names. R2 stated he feels safe in the facility. On 12/17/24 at 2:41 PM V38 (LPN / Licensed Practical Nurse) stated has been working in the facility for a month. V38 stated, she did not witness the incident on 11/30/24 between R1 and R2, there was a Code PURPLE (behavior code in the building) called by the receptionist. V38 went down to 1st floor right away. V38 said, R1 was sitting up on wheelchair very agitated and wanted to go outside the building to smoke and was assisted by staff. V38 said, V49 (Receptionist) informed her that R1 punched / hit R2. V38 said, full body assessment was done for R1 and R2, no redness, no bruising, no swelling noted, denied pain. V38 said R1 was transferred to the hospital for psychiatric evaluation. On 12/18/24 at 11:19 AM V6 (Social Service Director/ SSD) stated, V6 has been working in the facility since February 2024. V6 said had been informed about the incident on 11/30/24 between R1 and R2. They had a verbal altercation / disagreement. R1 was sent out to hospital with a petition for psychiatric evaluation. V6 said, stated potentially residents could be vulnerable for abuse living in the facility. V6 said, abuse care plans should be developed for all residents. Surveyor reviewed R1's care plan with V6 and abuse care plan was not found. (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: 145654 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 145654 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Landmark of Lincoln Park Rehabilitation and Nursin 735 West Diversey Chicago, IL 60614 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)