Inspection·May 11, 2023

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from physical and verbal abuse. This failure resulted in R1 experiencing a corneal abrasion following physical abuse by R2. This applies to 2 of 3 residents (R1 and R2) reviewed for abuse in the sample of 8. The findings include: 1. On May 8, 2023, at 3:37 PM, R1 was in his wheelchair in the dining room. R1 had an eyepatch over his right eye. R1 said, [R2] punched me and hurt my eye. R1's EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE], with multiple diagnoses including: chronic obstructive pulmonary disease, Crohn's disease, heart failure, dementia, and anxiety. R1's MDS (Minimum Data Set) dated April 12, 2023, shows R1 has moderate cognitive impairment. The MDS continues to show R1 requires limited assistance from facility staff for bed mobility, transfers, dressing, toilet use, personal hygiene, and walking in room. R1's abuse care plan revised on May 12, 2022, shows, [R1] is at risk for abuse related to: has a history of dementia. The facility's final report to the State Agency dated May 5, 2023, shows, On 04/29/23 at approximately 6:00 PM, the nurse witnessed both resident's (R1 and R2) arguing and had physical contact . On April 30, 2023, at 9:58 AM, V12 (emergency room Physician) documented, Presenting status post being physically assaulted by another member of his nursing facility. Patient states that a gentleman came up and punched him in the face breaking his glasses yesterday, says he was also struck several times in the right shoulder. Denies any other injuries during the assault, denies fall, denies head strike loss of consciousness other than where he was punched. Primary reason for presenting today is that he has some mild pain in the right eye and says that his vision is slightly blurry. Says he had difficulty sleeping last night because the pain. The documentation continues to show R1 was diagnosed with a corneal abrasion on his right eye in the Emergency Room. On May 9, 2023, at 2:25 PM, V7 (RN/Registered Nurse) said, I was the nurse on April 29, 2023. I was in the dining room and I heard a commotion by the washroom, and I went over there. [R1] was in the doorway in the washroom, and the scene that I saw was [R2] hitting [R1]. [R1] was covering his face like a boxer and waving his head side to side. I saw [R2] hitting [R1]'s arms. [R2] was making (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 6 Event ID: 145379 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 145379 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Valley Ridge Rehab & Hcc 275 East Army Trail Road Bloomingdale, IL 60108 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)