F 0609
Level of Harm - Minimal harm
or potential for actual harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
Based on interview and record review, the facility failed to report an allegation of mental abuse (bullying) to
the state survey agency. This failure affects 1 resident (R1) sampled for abuse reporting.
Residents Affected - Few
Findings include:
On 5/20/2025 at 11:00 AM, V1 (Administrator) explained that when R1 was admitted to the hospital, V1 was
notified by V9 (Licensed Practical Nurse) that the hospital told V9 that R1 was being bullied by R1's
roommate (R4). V1 could not recall the actual date of the allegation. V1 stated that V1 investigated the
allegation by interviewing other staff and R4. V1 said that the facility could not substantiate the bullying
allegation but kept R1 and R4 separated after the allegation was made. V1 denied that the allegation was
reported to the state survey agency. V1 affirmed that bullying can be mental abuse and that the allegation
should have been reported.
On 5/21/2025 at 12:11 PM, V9 (Licensed Practical Nurse) could not recall the exact date, but could recall
that during R1's last hospitalization, a social worker from the hospital had called and asked to speak with a
nurse. V9 stated that the social worker was inquiring about the relations between R1/R4 (R1's Roommate)
and said that R1 reported being bullied by R4 to hospital staff. V9 stated that V1 is the abuse prevention
coordinator, and immediately notified V1 of the allegation.
Record review of facility witness statement collected from R4 dated 4/24/25 documents in part that R4 was
accused of bullying R1.
Facility policy titled, Abuse (Reviewed 1/18/2024) documents in part .When an allegation of abuse,
exploitation, neglect, mistreatment, or misappropriation of resident property has been made, the
administrator, or designee, shall notify the Department of Public Health's regional office immidiately by
phone or fax. Public health shall be informed that an occurance of potential abuse, exploitation, neglect,
mistreatment, or misappropriation of resident property has been reported to the administrator and is being
investigated.
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:
146018
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
146018
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/21/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Little Village Nrsg & Rhb Ctr
2320 South Lawndale
Chicago, IL 60623
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 0610
Respond appropriately to all alleged violations.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, the facility failed to complete a thorough investigation of
verbal/mental abuse after an allegation of bullying was made. This failure affects 1 resident (R1) sampled
for abuse.
Residents Affected - Few
Findings include:
R1's Minimum Data Set (3/20/25) documents in part a brief interview of mental status (BIMS) summary
score of 15, indicating R1 is cognitively intact.
On 5/20/2025 at 10:32 AM, R1 stated that R1 was being bullied/harrased by R2 and R3. R1 did not name
R4 as a resident that was harassing R1. R1 stated that R2 and R3 have formed a clique and call R1 a dirty
pol** whenever R1 walks past R2/R3. R1 explained that R2/R3 calling him names makes him feel worthless
and that the harassment had been going on for over a year. R1 affirmed R1 told the hospital about the
bullying during R1's last hospital stay in April.
On 5/20/2025 at 11:00 AM, V1 (Administrator) explained that when R1 was admitted to the hospital, V1 was
notified by V9 (Licensed Practical Nurse) that the hospital called and told V9 that R1 was being bullied by
R1's roommate (R4). V1 could not recall the actual date of the allegation. V1 stated that V1 investigated the
allegation by interviewing R4. V1 said that the facility could not substantiate the bullying allegation but kept
R1 and R4 separated after the allegation was made. V1 affirmed that R1 was not interviewed after the
allegation was made. V1 was not aware that the allegation was about R2 or R3. Surveyor requested the
investigative documents related to the allegation and V1 stated, I (V1) didn't write any of it down. V1
affirmed that V1 only had a statement from R4. No further investigative documentation was provided from
V1 prior to the exit of the survey.
Record review of signed facility witness statement collected from R4 by V1 (Administrator) dated 4/24/25
documents in part that R4 was accused of bullying R1 and that R4 would no longer be roommates with R1.
On 5/21/2025 at 12:11 PM, V9 (Licensed Practical Nurse) could not recall the exact date, but could recall
that during R1's last hospitalization, a social worker from the hospital had called and asked to speak with a
nurse. V9 stated that the social worker was inquiring about the relations between R1/R4 (R1's Roommate)
and said that R1 reported being bullied by R4 to hospital staff. V9 stated that V1 is the abuse prevention
coordinator, and immidiately notified V1 of the allegation.
Facility policy titled, Abuse Policy (1/18/2024) documents in part, The purpose of this policy is to assure that
the facility is doing all that is within its control to prevent occurances of abuse . This will be done by: .
implementing systems to promptly and aggressively investigate all reports and allegations of abuse . Verbal
abuse is the use of oral written or gestured language that willfully includes disparaging and derogatory
terms to residents . Mental abuse includes but is not limited to humiliation, harassment, threats of
punishment . Reports will be documented and a record kept of the documentation . All incidents will be
documented whether or not abuse, neglect, mistreatment or misappropriation of resident property occurred,
was alleged or suspected . 4. Investigation procedures. The appointed investigator will, at a minimum,
attempt to interview the person who reported the incident , anyone likely to have direct knowledge of the
incient, and the resident, if interviewable . Residents to whom the accused has provided care and
employees whom the accused has regularly worked, will be interviewed .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146018
If continuation sheet
Page 2 of 2
