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 and procedure to prevent R1 from being
physically abused by R2. This failure affected 1 (R1) of 4 residents reviewed for abuse.
Findings include:
R1 is a [AGE] year old male with a diagnosis including Cerebral infarction, Hemiplegia affecting left
dominant side, Chronic kidney disease, Mood disorder, Difficulty in walking, Diabetes 2, Opiod abuse,
Heart failure and Kidney failure. R1 was first admitted to the facility on [DATE]. R1 has a BIMS (Brief
interview for mental status) score of 13/15. R1 is care planned for including Behavior, may demonstrate
behavioral distress. 10/19/24.
R2 is a [AGE] year old male with a diagnosis including Heart failure, Chronic kidney disease, Bipolar
disorder, Alcohol dependence with alcohol-induced persisting dementia and Alcoholic cirrhosis of liver. R2
was first admitted to the facility on [DATE]. R2 has a BIMS (Brief Interview for Mental Status) score of
14/15.
On 1/4/25 at 1:35PM R1 stated around Christmas R2 came into my room. He asked where his lighter was
and I told him to get out. He pushed me to the floor and was on me. He left. I had to go to the hospital. I
have a fractured back and fractured ribs. I haven't had any other issues with him since. He was moved to a
different floor but I am afraid of him .
On 1/4/25 at 1:49PM R2 stated I went into R1's room to talk to his roommate (R3) around Christmas time.
R1 was acting goofy and told me to get out of his room. He got up out of the chair and pushed me on my
chest. I pushed him back with one hand on his chest. He went back a step and that was it. I turned around
and left. That was it. I haven't seen him or had any other issues with him since.
On 1/7/25 at 12:08PM R3 (R1's roommate) stated I was sleeping. I heard a commotion. I looked and R1
was on the floor. I did not see anything happen. I was sleeping. The nurse came in and looked at R1. That
was it.
On 1/7/24 at 11:23AM V8 (LPN per phone) stated I went into R1's room. R2 was not in R1's room at this
time. R1 stated to me that R2 pushed him down to the floor and his back hurt. I talked to R2 and both their
stories were conflicting. R2 stated he did not push R1 down to the floor. I assessed R1 and he had a small
skin tear on his heel. This would have had nothing to do with any altercation. I notified the doctor and R1
was sent to the hospital for evaluation. R2 was sent to hospital for evaluation. The administrator was also
notified. I talked to R1's roommate. He said he heard a commotion
(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:
145914
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
145914
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Southpoint Nursing & Rehab Center
1010 West 95th Street
Chicago, IL 60643
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
but didn't see R1 and R2 pushing each other. R1 returned from from the hospital with no injury. R2 was
moved to another floor.
Hospital record dated 12/18/24 shows R1 X Rays indicate no fracture or dislocation of shoulder. CT scan of
chest abdomen and pelvis was negative for acute abnormality. No injuries.
Residents Affected - Few
Facility initial incident report dated 12/19/24 shows R1 and R2 were involved in an alleged dispute in R1's
room. Nursing staff observed R1 on floor upon assessment complained of back pain.
Facility final incident report dated 12/25/24 shows R2 stated that he entered the room of R1 to request a
lighter from roommate. At this time it is reported that R1 became verbally aggressive and began to argue
with R2. R2 then pushed R1. R1 was educated on not entering peers rooms without permission prior to
entering. Both residents were sent out for evaluation.
Facility abuse prevention program policy (undated) documented in part: It is the policy of this facility to
prevent resident abuse, neglect, mistreatment. The facility will not tolerate resident abuse or mistreatment
by anyone, including staff members or other residents. Abuse: the willful infliction of injury.
Facility residents rights policy (undated) documented in part: Be free from abuse and neglect. You have the
right to be free from verbal, sexual, physical and mental abuse.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145914
If continuation sheet
Page 2 of 2
