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
observation, interview, and record review the facility failed to protect a resident (R1) from physical abuse by
another resident (R2). This applies to 2 of 5 residents (R1, R2) reviewed for physical abuse in the sample of
5.
The findings include:
R1's Facesheet shows that R1 has diagnoses that include, but are not limited to, dementia and insomnia.
R2's Facesheet shows that R2 has diagnoses that include, but are not limited to, psychosis, major
depressive disorder, and insomnia.
R1's Minimum Data Set (MDS) Section C dated 11/17/24 shows R1 scored a five out of fifteen on his brief
interview for mental status (BIMS), indicating severe cognitive impairment.
On 12/31/24 at 9:10 AM, R1 was in R1's room, lying in bed half asleep and half watching the television. R1
stated he was not in pain and that he did not have bruising on his torso area. R1 was unable to recall the
12/23/24 incident but appeared pleasant and had his needs met.
On 12/31/24 at 9:50 AM, R3 stated that R2 typically eats his breakfast and returns to R2's room when
finished. R3 also said that this was the first time that R2 has ever shown any signs of aggression towards
staff or residents. On 12/23/24, just after breakfast in the dining room on the second floor, R3 noticed R2
was pacing from his table to another table in the dining room, and out and down the hallway and back. R3
stated that as R1 entered the dining room through the main entrance, that's when R2 ran towards R1,
kicked R1 to the ground, and kicked him approximately five times to R1's torso. R3 and staff shouted at R2
to stop and R2 stopped kicking R1 and returned to R2's table.
On 12/31/24 at 10:00 AM, V6 (Housekeeping) stated she was in the hallway just outside of the second-floor
dining room when the incident occurred. V6 stated she witnessed R2 shove R1 to the ground and started
kicking R1. V6 yelled at the residents to stop and yelled for staff to come help. V6 stated V3 (Assistant
Director of Nursing) came down the hall and when V6 arrived, R2 had already stopped kicking R1.
On 12/31/24 at 8:30 AM, V3 stated R1 and R2 were separated immediately and both were assessed by
staff. V3 personally assessed R1 and stated he had no injuries, no bruising, and R1 could not recall what
had happened. For precautions, V3 moved R1 to the third floor approximately 30 minutes after the
(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:
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
12/31/2024
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)
F 0600
Level of Harm - Minimal harm
or potential for actual harm
incident. R2 was difficult to redirect after being separated and was eventually discharged to a behavioral
health hospital on [DATE] and as of 12/31/24, R2 was still at the behavioral health hospital.
R2's monthly Psychiatrist Physician Notes with dates of 12/3/24, 11/5/24, and 10/8/24, all show that R2 had
no previous signs of irritability or aggressive behaviors towards others.
Residents Affected - Few
On 12/31/24 at 8:51 AM, V4 (Social Services) said that she has not known R2 to be aggressive towards
staff or residents prior to the incident on 12/23/24.
On 12/31/24 at 12:26 PM, V9 (Medical Director) stated it is his expectation that residents are to be free
from physical abuse within the facility. V9 stated that there was no physical harm done to R1 from the
reports received by staff at the facility.
Facility Abuse Prevention Program Facility Policy states, This facility affirms the right of our residents to be
free from abuse, neglect, misappropriate of resident property, corporal punishment, and involuntary
seclusion. This facility therefore prohibits mistreatment, neglect or abuse of its residents, and has attempted
to establish a resident sensitive and resident secure environment.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 2 of 2
