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 document review the facility failed to ensure resident the right to be free from abuse in 2 of 4
residents included in a total sample of 8 residents.
Findings include:
R2 is a [AGE] year old female with a diagnosis including Emphysema, Hypothyroidism and Liver disease.
R2 was first admitted to the facility on [DATE]. R2's BIMS (Brief Interview of Mental Status) score is 15/15.
R2 care plans include conflictual, difficult behavior with other persons. Symptoms are manifested by
covert/open conflict with of repeated criticism of staff. Behavior is manifested by unprovoked expressions of
anger towards staff and peers. Behaviors of false allegations, initiates false reports and allegations of
mistreatment perpetrated by others. History of aggression, accused of being inconsiderate to her
roommates feelings as well as being discourteous. R2 is also care planned for being susceptible to abuse.
R3 is a [AGE] year old male with a diagnosis including Vertebra fracture, Neurogenic bowel, Anxiety
disorder, Depressive disorder, and Angina pectoris. R3 was first admitted to the facility on [DATE]. R3 has a
BIMS (Brief Interview of Mental Status) score of 15/15. R3's care plan includes R3 is susceptible to abuse
due to his past trauma and current physical limitations. Displays socially inappropriate & maladaptive
behavior as evidenced by being involved in a verbal disagreement with a peer, as evidenced by playing his
radio/music at a high volume despite redirection. Demonstrates behavioral distress related to ineffective
coping mechanisms. Problems manifested by use of profanity demeaning statements, verbal threats and
yelling at others.
Facility Abuse prevention investigation dated 5/14/25, shows that on 5/8/25, R2 and R3 had a verbal
encounter, and R3 spilled water on R2. This prompted investigation into the incident which was found to
have caused no harm to either party. Both residents received psychiatric services with respect to behaviors.
R3 is on a medication to help manage anxiety and agitation. After R2 had provided a signed statement that
she feels safe and that nothing detrimental had occurred, CPD (Chicago Police Department) was notified.
No further action was taken by CPD. R2 was satisfied with the outcome and voiced no other concerns. The
facility verified that there was no harm to either R2 and R3 and both residents expressing feeling safe and
having experienced no mental/emotional harm. R2 and R3 attested they have not experienced any type of
abuse at the facility. Both residents refused a room change. Other residents were interviewed, and they
raised no safety concerns. Family and MD's will be notified of the outcome of the investigation.
R2's progress note dated 05/05/2025, states nurse (V4) observed resident and peer having a verbal
(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 2
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
05/29/2025
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
disagreement. Residents were separated and kept safe. Psych made of aware of behaviors. Resident was
able to be redirected and remain calm and cooperative. Resident alert, oriented. Resident offered a room
change in which resident refuse. Resident prefers to stay in room. Social worker to follow up.
On 5/27/25, at 1:20 PM, V4 (LPN) stated, I heard commotion. I was at the nurses station I heard R2 say
'you poured water on me'. Then I heard R3 say now who is the wetback. I separated them and reported to
V5 (Last administrator/abuse prevention coordinator). R2 called police and they arrived. That is all I know
about the incident. R2 and R3's room were next to each other. R2 had an issue with R3's music being too
loud. R3 was moved a few rooms down and now there are no issues between the both of them.
On 5/27/25, at 11:55 AM, R2 stated, Yes R3 threw water at me in the corridor when we got into a verbal
altercation. It got me wet but didn't hurt me. I called the police, and they came. I was in the room next to
him. He played his radio too loud, so I called police on him. We got into a verbal altercation where he called
me a lot of bad names. I moved to a new room, and I don't hear the loud radio anymore. I feel safe now, but
he did assault me with the water.
On 5/27/25, at 1:00 PM, R3 stated Yes, I threw water at R2 from my water cup. She called me a wetback
mother------. She is a real problem since she came from another floor. I play my TV and radio and she
keeps complaining that it's too loud. She called the police on me several times. I actually apologized to her
for the water incident, but she keeps complaining about me.
Facility policy titled Abuse Prevention Program Policy includes: It is the policy of this facility to prohibit and
prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a
crime against a resident in the facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145654
If continuation sheet
Page 2 of 2
