Addison Heights Health And Rehabilitation Center

Review of the admission Minimum Data Set assessment dated [DATE] identified Resident #27 was rarely or never understood by staff.

Review of the plan of care dated 08/07/25 revealed Resident #27 was at risk for falls related to confusion, and unawareness of safety needs.

Interventions included providing the resident with activities that were appropriate for the resident (tablet, foam blocks, stuffed animals, nerf basketball).

Review of the witness statement written by Certified Nursing Assistant (CNA) #348 and dated 09/30/25 revealed CNA #348 witnessed Licensed Practical Nurse (LPN) #489 continuously snatch Resident #27's stuffed animal away from him. LPN #489 told Resident #27 he could not have his stuffed animal back unless he sat down or went to his room.

Review of the witness statement written by LPN #484 and dated 09/30/25 revealed a CNA reported a nurse was taking away Resident #27's toys, snatching them from him, telling the resident his toy was in jail, and telling the resident he was bad. LPN #484 then observed LPN #489 snatch Resident #27's stuffed dog. Resident #27 became very upset and was yelling for the nurse to give the stuffed animal back. LPN #484 attempted to intervene and told LPN #489 to give Resident #27 their toy back. LPN #489 stated Resident #27 was bad and the toy was going to dog jail. LPN #484 informed LPN #489 she could not take Resident #27's toy away. LPN #484 went and called Unit Manager #844 to report what had occurred. In the meantime, a CNA came and reported LPN #489 had been grabbing Resident #27's toy away from him again.

Review of facility Self-Reported Incidents revealed the facility did not report the allegation of staff-to-resident abuse toward Resident #27 to the State Survey Agency on 10/02/25.

During an interview on 10/09/25 at 12:02 P.M., LPN #484 reported that on the evening of 09/30/25, LPN #489 took Resident #27's stuffed animal and refused to return it to the resident unless the resident put his soft helmet on. LPN #484 reported this caused Resident #27 to become upset and aggravated. LPN #484 stated she reported this to Unit Manager #844 immediately.

During an interview on 10/14/25 at 2:03 P.M., the Administrator verified the allegation of staff-to-resident abuse involving Resident #27 had occurred on 09/30/25 and was not reported to the State until 10/02/25.

Review of the undated facility policy titled Residents Right To Freedom From Abuse, Neglect, and Exploitation Policy and Procedure revealed when the facility has identified abuse, the facility would report the alleged violation and investigation within required timeframes.

This deficiency represents non-compliance investigated under Complaint Number 2637192.

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

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