Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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 prevent and protect residents from resident-to-resident
physical and verbal abuse. This failure affects two (R2, R4) residents out of five residents reviewed for
abuse in a total sample of five. As a result of this failure, R1 pushed R2 on 04/6/25. R1 punched and yelled
derogatory words to R4 on 04/29/25.
Findings include:
Facility reported incident/FRI dated 04/06/2025, documents the facility reported an altercation between R1
and R2. FRI documents R1 made alleged contact with R2. Staff intervened and separated R1 and R2.
Facility reported incident/FRI dated 04/29/2025, documents the facility reported an altercation between R1
and R4. FRI documents R1 made alleged contact with R4. Staff intervened and separated R1 and R4.
1. On 05/07/2025, at 2:15 PM, R2 was laying on his bed, easily aroused, and in no apparent distress. R2
stated he got a minor scrape on his right elbow during the incident that had to do with R1. R2 reports he
and R1 argued because R2 told R1 to move because R1 was standing in front of R2, in the hallway, outside
of R2's room. R2 stated he was going to walk out of R2's room. R2 stated R1 was not his roommate. R2
stated that is when he told R1 to move. R1 didn't want to move and R1 then turned around and pushed R2.
R2's elbow hit something. R2 stated he feels safe right now.
R2's current face sheet document R2 is an [AGE] year-old individual admitted to the facility on [DATE], and
has diagnoses not limited to parkinsonism, weakness, cognitive communication deficit.
R2's MDS/Minimum Data Set, dated [DATE], documents R2 has a BIMS/Brief Interview for Mental Status
score of 09/15, indicating R2 has moderate cognitive impairment.
R2's nurse's note dated 04/06/2025, at 2:54 AM, writer was informed alleged inappropriate contact was
made, involving co- peer. Both parties immediately separated and assessed. Resident was assessed by
clinical team with skin alteration to left elbow. Resident states he feels safe in the facility and denies pain at
this time.
On 05/06/2025, at 1:51 PM, via telephone V11 (Certified Nursing Assistant) stated the incident regarding
R1 and R2 occurred on the third floor and V11 was in a different resident's room. V11, I (V11) just got done
doing patient care, and I heard a small sound like if someone bumped the wall; like
(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
05/08/2025
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)
F 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
if someone opens the door too hard. I came out of the patient's room and R2 was standing in the doorway
hallway. V11 reported he assumed R2 pushed the door and V11 told the nurse regarding the noise V11
heard. V11 reports he saw R1 standing in the hallway. V11 stated when he asked R2 if he was ok, R2
responded 'yes, I am fine', and R2 walked off.
2. On 05/07/25, at 11:16 AM, R4 sitting on his bed, wearing his own clothes, in no apparent distress. R4
noted with yellow/bluish discoloration to right eye. R4 stated last week when R1 punched him. R1 was
playing the television loud, late at night around 3:00 AM. R4 stated R4 asked R1 to lower the volume and
R1 swore at R4, F*** you! R4 stated R1 came out of nowhere and punched him on his right eye. R4 stated
before, R1 was quiet. I think R1 was off his medications or something. R4 stated R1 punched R4 just once
and denied any other physical altercation. R4 stated R4 denied hitting R1. R4 reported the nurse came in
the room and R1 started swinging on her. R4 stated he denied for police to take his report. R4 stated he is
fine, and it didn't hurt him. R4 stated, I think they took (R1) away.
R4's current face sheet document R4 is a [AGE] year-old individual admitted to the facility on [DATE] and
has diagnoses not limited to chronic systolic (congestive) heart failure, other abnormalities of gait and
mobility, weakness, essential (primary) hypertension.
R4's MDS/Minimum Data Set, dated [DATE], documents R4 has a BIMS/Brief Interview for Mental Status
score of 14/15, indicating R4 has intact cognition.
R4's nursing progress note dated 04/29/2025, at 5:30 AM, documents in part, resident (R4) co peer was
alleged inappropriate towards him. Code purple initiated with both parties separated. Resident (R4)
declined police notification and states he feels safe in the facility. No mental or emotional distress noted.
On 05/07/2025, at 9:50 AM, via telephone V12 (Licensed Practical Nurse) stated she was the nurse on duty
the night shift the incident between R1 and R4 occurred. V12 reported it was early in the morning. V12
stated, I (V12) was in the nurse's station and the patient (R4) screamed for help. V12 stated R1 and R4
were roommates in a four-bed room. V12 stated when she arrived at the residents' room, V12 saw R1
standing in front of R4's bed. V12 stated she asked what happened and R4 said to her, he hit me, he hit
me. V12 stated she tried to redirect R1 to step out of the room and R1 said R1 was not going to move out of
the room and threatened to punch R4 again and told R4 you b****. V12 stated she yelled out for help and
asked V18 (Certified Nursing Assistant) for help. V12 stated she kept telling R1 to step back and then R1
punched V12 on the shoulder and continued to threaten to punch V12 and R4. V12 stated when she asked
R4 what happened. V12 reported R4 informed her R4 asked R1 to lower the loud music on the phone and
then R1 got up and punched R4. V12 stated when R1 was in the dining room, V18 called V12 (Licensed
Practical Nurse) and told V12 R1 was heading back to the room. V12 stated R1 remained on 1:1
monitoring. V12 stated she notified V2 (Director of Nursing) and V1 (Administrator). V12 stated R1 refused
to leave the room despite staff's attempt to redirect R1. R1 refused any medication. V12 stated R4 was in
the room and V12 stated R1 threatened to punch R4 once more. V12 reported V12 called 911 and began
the petition for R1 to be sent out. When the ambulance arrived, V12 stated she assessed R4 and noted
right eye area with redness and a bump. No bleeding noted. V12 stated R4 denied having the police
involved and R4 denied any other injuries.
On 05/08/2025, at 3:16 PM, V18 (Certified Nursing Assistant) stated she remembers V18 heard one of the
residents, I don't know which one, yelling, V12 (Licensed Practical Nurse) walked over there. I ended up
coming there too because I heard more hollering, when I (V18) got there. V18 reports R1 was
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145654
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
145654
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
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)
F 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
yelling in V12's face and pointing at V12's face. V18 states she denies witnessing any physical altercation
between R1 and R4. V18 stated V12 and V18 were trying to get R1 to back away from V12. V18 stated R1
was also yelling at R4. V18 stated, Basically cursing at him (R4), calling him (R4) out of his name. V18
stated she was monitoring R1 one to one in the dining area until R1 didn't want to sit anymore in the dining
area and went back to R1's room. V18 stated her shift ended soon after, but she found out R1 was sent out
to the hospital. V18 reports V1 (Administrator) is the abuse coordinator. V18 stated physical, mental, verbal,
taking things from residents are types of abuses.
R1's face sheet documents R1 is a [AGE] year-old individual admitted to the facility on [DATE], and has
diagnoses not limited to major depressive disorder, recurrent, unspecified, aphasia, other abnormalities of
gait and mobility, cerebral infarction, unspecified, hemiplegia, unspecified affecting unspecified side.
R1's trauma screening assessment dated [DATE], documents in part R1 is at risk for abuse due to an
allegation of resident (R1) having inappropriate boundaries with peer 4/6/25 and was hospitalized .
R1's MDS/Minimum Data Set, dated [DATE], documents R1 has a BIMS/Brief Interview for Mental Status
score of 12/15, indicating R1 has moderate cognitive impairment.
R1's petition for involuntary form dated 04/06/25, documents in part R1 is displaying increased aggression
towards peers/staff not easily redirected.
R1's petition for involuntary form dated 4/29/25, documents in part R1 display harm to others, not easily
redirected, refused PRN (as needed) medication, 911 notified for assist.
R1's care plan documents in part resident (R1) presented with socially inappropriate behavior of playing
loud music/videos, notedly disturbing roommates/others. Intervention includes teach/model socially
appropriate behaviors specifically r/t playing music/videos at ss reasonable volume in areas shared by
others. provide redirection/education as indicated to promote goal compliance. encourage the use of
headphones.
R1's care plan documents in part resident (R1) is susceptible to abuse due to resident's depressive
symptoms as well as his diagnosis upon admission, resident is also a young adult in a nursing home.
Resident may lack insight into symptoms of his altered mental status/psychosis symptoms which may
impact his interpersonal interactions. Resident also at risk for abuse due to an allegation of resident having
inappropriate boundaries with peer 4/29/25. 4/07/25 Resident involved in altercation r/t (related to)
exercising impaired reasoning/judgment AEB (as evidenced by) extreme reaction to a co peers
pushing/touching of chair.
Facility document dated 03/01/21, titled abuse prevention program documents in part, it is the policy of this
facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of
resident property. Verbal Abuse: Any use of oral, written, or gestured language includes disparaging and
derogatory terms to residents or their families, or within their hearing distance, to describe residents,
regardless of their age, ability to comprehend or disability. Physical Abuse: Hitting, slapping, pinching,
kicking, etc. It also includes controlling behavior through corporal punishment.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145654
If continuation sheet
Page 3 of 3
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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 May 8, 2025 survey of Landmark of Lincoln Park Rehabilitation and Nursin?
This was a inspection survey of Landmark of Lincoln Park Rehabilitation and Nursin on May 8, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Landmark of Lincoln Park Rehabilitation and Nursin on May 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
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.