Inspection·September 29, 2024

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. Based on interview and record review, the facility failed to prevent an incident of resident to resident physical aggression. This affected two of three residents (R1, R2) reviewed for physical abuse. This failure resulted in R2 kicking R1 in the leg and R1 sustaining a 7 cm skin tear. Findings Include: Facility Reported Incident reviewed, and reads in part: On 9/2/24 at 2:20PM, R1 was in the common area when R1 began talking in a loud voice at a R3 who was trying to push a table over. R2 approached R1 while R1 was speaking to the R3 and kicked R1 in the left lower leg, resulting in a skin tear. R1 has a diagnosis of Dementia and Restlessness and Agitation. R1's most recent BIMs score conducted on 8/16/2024 was 03/15 indicating severe impairment. R1 has diagnosis of Dementia, R1 exhibits poor safety awareness and poor impulse control. R1 also has a care planned behavior of becoming verbally agitated, which has caused peers to become agitated. R2 has a diagnosis of Dementia and Generalized Anxiety Disorder. R2's most recent BIMs score conducted on 07/02/2024 was 03/15 indicating severe impairment. R2 has a care planned behavior of exhibiting poor impulse control as well as having difficulty with interpreting her environment related to her Dementia. After thorough investigation of residents and staff, it was determined that due to R1's behavior of speaking in a loud manner at R3, R2 was frustrated with R1 and wanted R1 to stop talking and because R2 exhibits poor impulse control related to R2's advanced dementia R2 kicked R1 in response. Both residents were immediately separated and R1's skin tear to R1's left lower leg was immediately treated. On 9/28/24 at 11:40AM, V3 (Nurse on 9/2/24) stated that someone yelled to V3 to come over here, R2 kicked R1 and R1 was bleeding. V3 went and R1 was in the wheelchair located in the common area in front of the nurse's station, noted bleeding on the lower leg. V6 (RN) put pressure on the area of the wound. R1 was wearing short pants, and I could see the lower leg. Noted on left lower leg, shin area has a skin tear over 7cm in size, bleeding continuously. V6 and V3 brought R1 by the treatment cart. R2 was separated from R1, R2 was in the west corridor area after the incident. On 9/28/24 at V4 (CNA) stated V4 was passing by the common area, observed R3 shaking the table, R1 was behind R3 and telling R3 stop doing this, stop it. Stop it. R1 was saying this loud, R1 is hard of hearing, and R1 always talks loud. Suddenly I saw R2 propelling R2's wheelchair towards R1. As R2 was heading to R1, R2 was not saying anything at all. And then suddenly, V4 just passed the common area when V4 heard R1 yelling, She kicked me, she kicked me. And as V4 returned to the common area, V4 saw R2 propelling back close to the window, R2's usual spot. V4 went to check on R1 and then saw blood on R1's leg. V4 removed R1 out of the common area, V4 told the nurse and then 2 nurses assisted with R1's wound. (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: 145724 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 145724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Addolorata Villa 555 McHenry Road Wheeling, IL 60090 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)