Little Village NRSG & RHB CTR

In the surveyor’s words

From the most serious findings on record at Little Village NRSG & RHB CTR, in the surveyor’s own words.

• Actual harm, patternF600May 16, 2024

  Based on interview and record review, the facility failed to ensure that residents were free from physical abuse. These failures affected R2, R3, R5, R7 and R9 as a result of R2 who was physically hit in the head with a chair by R1, causing R2 harm of pain and a facial laceration by the right eye; R7 who was physically hit in the face by R8, causing R7 psychosocial harm by feeling unsafe as a legally blind and wheelchair dependent resident in the facility; R5 who was physically pushed by R6, causing a right hand scratch; R9 who was physically hit in the face by R2; and R3 who was physically hit by R4 in the sample of 14 residents reviewed. […]

• Actual harm, isolatedF600Jun 5, 2026

  Based on interviews and reviews, the facility failed to ensure a resident (R1) remained free from sexual abuse by another resident in a sample of five reviewed. Findings include:R1's medical diagnosis in current face sheet includes but not limited to: Type 2 diabetes mellitus with other specified complication, other psychotic disorder not due to a substance or known physiological condition, bipolar disorder, current episode depressed, severe, with psychotic features. Minimum Data Set (MDS) Section C-Cognitive Patterns dated 05/24/2026 documents R1's Brief Interview for Mental Status (BIMS) as 12/15, indicating R1 has moderate cognitive impairment. On 06.04.2026 at 12:07PM, R1 was observed sitting outside her room in the hallway near the nursing station. […]

• Actual harm, isolatedF600Mar 11, 2026

  Based on interview, and record review, the facility failed to ensure a resident (R4) was free from physical abuse and verbal abuse. These failures caused R4 to suffer humiliation and emotional distress due to derogatory language used by staff, and staff forcefully pulling multiple braided strands of hair from R4's scalp, resulting in removal of approximately six braids from the crown of R4's head causing pain and injury.R4 has a diagnosis which include but are not limited to: chronic obstructive pulmonary disease, bipolar disorder, suicidal ideations, hypertensive heart disease without heart failure, viral hepatitis c, schizoaffective disorder, alcohol abuse.R4's Brief Interview for Mental Status (BIMS) dated 2/3/26 shows a score of 15 which indicated that R4 is cognitively intact. […]

• Actual harm, isolatedF689Mar 11, 2026

  Based on interview and record review, the facility failed to ensure staff followed a resident's assessed transfer status, which required the use of a mechanical lift for transfers. This failure affected one out of three residents reviewed for falls and caused R3 to be sent to the local hospital due to R3 sustaining a fracture of the distal femoral shaft, which requires R3 to use a left leg brace.Findings include: R3's diagnosis include but are not limited to: fracture of unspecified part of neck of right femur subsequent encounter for closed fracture with routine healing.R3's Brief Interview for Mental Status (BIMS) dated 2/24/26 shows a score of 5 which indicated that R3 has moderate cognitive deficits. […]

• Actual harm, isolatedF600Mar 13, 2025

  Based on interview and record review the facility failed to ensure that 4 of 4 residents (R1, R2, R5, and R6) were free from physical abuse. This failure affected R1, R2, R5, and R6 who had verbal altercation that resulted in R1 injury and bleeding to mouth and R6 injuries resulting in stitches to eyebrow and injury to forehead. This has the potential to affect all 103 residents residing in the facility. Findings include: On 02/27/25 at 12:44pm, R1 observed in the room sitting on the bed. The surveyor asked R1 about the incident of 01/25/25. R1 stated that I (R1) can't remember what happened, but (R2) and I (R1) had a misunderstanding. I (R1) did not steal anything from (R2). (R2) hit me and punched me in my face and my mouth. I (R1) was bleeding from my mouth. […]