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 verbal abuse for two (R1
and R2) out of four residents reviewed for resident-to-resident abuse. The findings include:R1's face sheet
showed R1's admission date was on 1/6/25 with diagnoses not limited to Asthma, Bipolar disorder,
Hypertensive heart disease without heart failure, Delusional disorders, Other psychoactive substance use,
Other chronic pain, Anxiety disorder, Insomnia. MDS (Minimum Data Set) dated 7/9/25 showed R1's
cognition was intact.R2's face sheet showed R2's admission date was on 5/30/25 with diagnoses not
limited to Hemiplegia, unspecified affecting left dominant side, Bipolar disorder, Chronic obstructive
pulmonary disease, Type 2 diabetes mellitus, Myelodysplastic syndrome, Pathological fracture left ankle,
Spinal stenosis cervical region, Hypertensive heart disease without heart failure, Chronic kidney disease,
Generalized anxiety disorder, Schizoaffective disorder, Personal history of transient ischemic attack (TIA),
and cerebral infarction, Nicotine dependence. MDS dated [DATE] showed R2's cognition was moderately
impaired.On 8/24/25 At 10:05AM observed R1 ambulating with a walker with steady gait, alert, oriented x 3,
and verbally responsive. R1 said about a couple of weekends ago, R2 threatened/harassed her. She said
R2 was going to attack me or hit me. R2 was shouting at me. R1 further stated that R2 cursed her and
stated, B****, get out of my way. F*** you. I will beat you're a** out. On 8/24/25 at 10:24am R2 observed
sitting up in a wheelchair by his bedside, alert and oriented x 3, verbally responsive. He said about a couple
of weekends ago, R1 called him N***R. R2 said R1 is mad at him whenever she saw him. He said R1
cursed him and called out names whenever he is coming. R2 stated R1 yelled/screamed at him saying F***
you, F*** off. R2 said he cursed back at R1 and stated leave me alone, CRAZY or I will knock on your a**
out, F*** you. R2 said he yelled/screamed/cursed R1 too. On 8/24/25 At 10:53AM V3 (Licensed Practical
Nurse/LPN) said had worked with R1. Surveyor reviewed R1's EHR (electronic health record) with V3 and
he stated he wrote progress notes for R1 on 8/10/25. V3 said there was incident between R1 and R2 on
8/10/25. He said R1 was verbally aggressive with R2, there was a lot of back and forth between R1 and R2
but did not hear specific words that they (R1 and R2) were saying to each other. V3 said both R1 and R2
were raising voices/yelling at each other. V3 said he could hear upset voices from R1 and R2 but was not
able to hear specific words. He said staff separated R1 and R2. V3 said it was reported to him that that R1
was harassing R2 with yelling profanities or using swear words probably F*** words. V3 said R1 and R2
were using not appropriate language - more of aggressive words but can't say specific words or appropriate
language that were used by R1 and R2. R1's Progress Note dated 8/10/25 by V3 (LPN) showed in part: R1
has been verbally aggressive with various staff/peers. Staff received complaints from peers/staff that R1
was agitating other clients unprovoked by yelling profanities at them.R1's Care plan dated 1/6/25 showed in
part: R1 is at risk for abuse due to residing at a long-term care facility. Resident will be free of abuse/neglect
daily.On 8/24/25 At 11:07AM V9 (Certified
(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:
146149
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
146149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/25/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Westwood Vlge Nrsg and Rhb Ctr
2444 West Touhy Avenue
Chicago, IL 60645
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
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Nursing Assistant/CNA) stated she had worked with R2 but not with R1. Stated she knew R1. V9 said there
was an encounter between R1 and R2 about couple of weekends ago, both R1 and R2 were
yelling/screaming/cursing at each other. V9 stated R1 said to R2 shut the f*** then R2 cursed back to R1
stating, get the f*** out of my way. V9 said both R1 and R2 were exchanging F words to each other. She
said both residents were separated. V9 said it was verbal abuse between R1 and R2 because they were
yelling/screaming and cursing at each other. Stated she thought the administrator was aware of it because
there were nurses who heard or witness the verbal abuse at that time. On 8/24/25 At 12:08PM V12 (CNA)
stated had seen R1 and R2 yelling and screaming at each other and staff need to break up and control the
situation. V12 said it happened about a couple of weekends ago when R1 and R2 passed or saw each
other. V12 said R2 cursed at R1, stated F*** you. I am tired of this shit. I want the f*** out of here. I am tired
of that b****. V12 said R1 did cursed back to R2 and stated F*** you, F*** off. V12 said it was a verbal
abuse between R1 and R2 and he thought the Administrator knew about it. On 8/24/25 At 1:25PM V13
(LPN) stated she had been working with R2. She said R2 is alert and oriented x 3, Easily agitated, cursing,
yelling and screaming to staff. Surveyor reviewed R2's EHR with V13 and stated that R2 had a verbal
altercation with R1 on 8/10/25. V13 said R1 and R2 were going back and forth. She said R1 and R2's
voices were raised or were yelling at each other. V13 said R2 yelled at R1, R2 stated leave me the F***
alone. V13 said R1 was threatening R2 to call the police on him and R1 will put R2 in jail. V13 said R1
called R2 N***R. She said R1 does not like R2. V13 said she heard R1 cursing but could not identify or
remember the words R1 said to R2. V13 said they separated both residents (R1 and R2). She said the
Administrator was informed about the incident. V13 said the incident between R1 and R2 could be viewed
as verbal abuse to each other due to raising of voices/yelling and threatening. R2's Progress Note by V13
(LPN) dated 8/10/2025 showed in part: R2 was involved in a verbal altercation with peer. This resident was
in his room when he was approached by a peer. Peer called this resident a N***r and stated she was going
to call the state and the police and have this resident arrested. Peer threatened to have this resident placed
in (County jail). R2 then stated leave me the f*** alone I am not bothering you. Peer continued to make
inappropriate statements to R2. Residents were separated at this time.On 8/24/25 At 1:54PM V15 (CNA)
stated she had worked with R2 but did not work with R1, but she knows R1. V15 said R2 could be verbally
and physical abusive with staff, would try to hit staff. V15 said R1 and R2 screamed or yelled at each other.
She said R1 does not want to be around R2. V15 said did not hear R1 or R2 cursing each other. Stated she
could not recall the specific words/cursed words used by R1 and R2.On 8/24/25 At 2:16PM V2 (Director of
Nursing/DON) she said an example of Verbal abuse is belittling, name calling, cursing, screaming/yelling at
each other. She said resident in the facility should be free from abuse. On 8/24/25 At 2:29PM V1
(Administrator) stated she has been working in the facility for 32 years and she is the Abuse coordinator.
Stated Types of abuse are Physical, verbal, mental, sexual, exploitation, inv seclusion, neglect, chemical
restraint. V1 said example of verbal abuse is screaming/yelling, cursing, calling out their names,
demeaning/belittling resident. V1 said the goal is for all residents to be free of any abuse in the facility.
Facility's abuse prevention program policy dated 2/2017 showed in part: The facility affirms the right of our
residents to be free from abuse. Verbal abuse is the use of oral language that willfully includes disparaging
and derogatory terms to residents within their hearing distance, regardless of an individuals' age, ability to
comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, saying
things to frighten a resident. Facility's residents' rights policy dated 11/18 showed in part: You must be
abused, neglected, or exploited by anyone - financially, physically, verbally, mentally or sexually.
Event ID:
Facility ID:
146149
If continuation sheet
Page 2 of 2