Health inspection·December 18, 2025

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. Based on interview, and record review, the facility failed to protect the resident's right to be free from abuse for two (R51, R92) in a sample of 21 residents. Findings include: Facilities incident report form (11/11/2025 at 5:45 PM) documents in part: R51 and R92 had an altercation in their room. R51 stated R92 hit him in the stomach. R92 stated R51 took his belongings, placed his profile picture on his television, and was blowing kisses at him. R51 has a medical history of schizoaffective disorder, bipolar disorder, and a brief interview for mental status (BIMS) score of 14, which means R51 is cognitively intact. R92 has a medical history of bipolar disorder, and schizophrenia and a BIMS score of 12, which means R92 is moderately impaired. On 12/15/2025 at 11:12 AM, Surveyor observed R92 laying on his bed while watching television. R92 seems comfortable and free of pain. R92 stated he had an altercation with his roommate R51. R92 stated the altercation started because he caught his roommate stealing his clothes. R92 stated he got into a physical and verbal altercation due to that reason. Surveyor asked R92 if he can describe the physical altercation in detail. R92 stated he cannot remember all the details of the altercation, but he does remember it became into a physical and verbal altercation. On 12/16/2025 at 9:25 AM, R51 stated he had an altercation with R92 a few weeks ago. R51 stated when R92 was not in the room he went through his personal belongings. R51 stated he took some Kool-Aid from R92's bedside drawer. R51 stated he made a cup of Kool-Aid and went back to his bed. R51 stated when R92 came back to the room, he noticed that R51 had gone through R92' s personal belongings. R51 stated R92 became very angry and started yelling. R51 stated R92 walked up to him while he was laying down on the bed and punched him in the stomach. R51 stated he was sent to the hospital for further evaluation. R51 stated a police report was made on that day due to the incident. R51 stated he returned from the hospital 1-2 days later, he was free of any injuries. R51 stated he was moved to another room across the facility and has not had any contact with R92 ever since the altercation. On 12/16/2025 12:15 PM, V1 (Administrator) stated she is part of the abuse prevention program in the facility. V1 was called to come to the first floor, the D hallway on the day of the incident. V1 stated the second shift nurse on duty informed her of an altercation that was taking place between R51 and R92. V1 stated R92 admitted to hitting R51 in the stomach because he was upset that R51 was going through his belongings. V1 stated R92 was also upset that R51 was blowing kisses at him, hung a profile picture of himself on R92 television, and took some of his Kool-Aid. V1 stated R51 admitted to taking R92's Kool-Aid, denied hanging up his profile picture of himself on R92's television and denied blowing kisses to R92. V1 stated the ambulance was called, and R51 was sent to the emergency department for further evaluation, he had no injuries. V1 stated we had a room ready for him as soon as he came back. V1 stated the new room is located across the other side of the facility in the H hallway. V1 stated it took a while to calm R92 down, he was very upset and wanted to leave the facility against medical advice (AMA). V1 stated the psychiatrist ordered a one-time order of Haldol 5 mg intramuscular, and a Haldol 5 mg every 6 hours by (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: 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 12/18/2025 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)