Inspection·August 13, 2024

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 protect the resident's right to be free from physical abuse by another resident which applies to 5 of 5 residents (R1, R2, R3, R4, R5) reviewed for abuse in a sample of 7. This failure resulted in R1 sustaining a right hip fracture. The findings include: 1. R1's Facesheet printed on 8/12/24 showed R1 to be a [AGE] year-old male admitted to the facility with diagnoses which include: metabolic encephalopathy, hemiplegia (right sided), vascular dementia, cerebral infarction. R2's Facesheet printed on 8/12/24 showed R2 to be an [AGE] year-old male admitted to the facility with diagnoses which include: dementia and Alzheimer's disease. The facility's Final Incident Report dated 8/4/24 showed R1 and another male (R2) had an altercation on 7/31/24. It is noted R1 and R2 have dementia and cognitive deficits. R1 approached R2 who was sitting in a chair. R1 attempted to get R2 to move from the chair. R2 stood up and struck R1 in the face. R1 them fell back onto the floor. On 8/12/24 at 1:00 PM, R6 stated, A few of us (residents) were in the dining room area before breakfast time. (R2) was sitting in (R1's) spot. (R1) gets upset when other residents are sitting in his chair. (R1) nudged (R2), waved his hands to (R2) to get away. (R2) stood up and punched (R1) in the face. (R1) fell back on the floor. On 8/12/24 at 2:00 PM, R7 stated, When (R1) walked into the dining room (R1) got upset. We (residents) do not have assigned seats, but (R1) has his chair he sits in all the time. (R1) walked up to (R2), (R1) tapped (R2) on the arm, and (R2) punched (R1) in the face. (R1) fell back on the floor and landed on his butt. On 8/13/24 at 11:00 AM, V3 (Assistant Director of Nursing) stated R1 initially had no signs of injury. After the incident R1 was placed in a wheelchair at the table for breakfast. At the end of breakfast V10 (Certified Nursing Assistant/CNA) came and asked me to look at R1. V3 stated R1 usually ambulates by himself with no assistance. At that time R1 was having difficulty standing up and bearing weight on his right leg. V3 stated when R1's leg was moved R1 winced in pain. V3 stated R1 was sent out to the hospital. R1's Hospital Records showed he was admitted on [DATE] with a right hip fracture after having an (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 3 Event ID: 145434 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 145434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claridge Healthcare Center 700 Jenkisson Lake Bluff, IL 60044 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)