F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interviews and record reviews the facility failed to follow their Activities of Daily Living policy to
provide necessary care such as bathing, dressing, and grooming, and failed to develop and implement
interventions in accordance with the needs and goals related to care for one [R1] of three residents
reviewed for improper nursing care.Findings include: R1's clinical record indicates the following in part:
Medical diagnosis cerebral ischemia, hypertension, type II diabetes, essential hypertension, arthritis,
constipation, and unspecified psychosis. Minimum Data Set, dated [DATE], indicated R1 scored [15] and is
cognitive intact.Reviewed R1's Care plan, no documentation of non-compliance with care or adverse
behaviors.On 12/13/25 at 9:25 AM V3 [Restorative Aide] and surveyor observed R1 sitting on the side of
the bed with open hoodie, no shirt, blue pants covered in different colors of stains, one sock on, shoes were
on but not tied, with a strong foul odor.On 12/13/25 at 9:28 AM, R1 stated, I'm wearing only one sock,
because all I ever had was one. The clothes I have on, is all I have. I take showers, but no one offered me a
shower, it's been a long time since I had a shower. Earlier this month I went to my heart doctor, with these
same clothes on. The people in the office were upset that I had on dirty clothes. I explained I did not have
any other clothes or two socks to put on. I do not have a coat, only this hoodie that I am wearing.On
12/13/25 at 9:30 AM, V3 stated, R1 has an odor, and needs a shower, but I think he refuses. V3 and
surveyor looked in R1's closet. V3 stated, R1 does not have any clothes, but I can go to the basement and
get some clothing out of the donation pile.On 12/13/25 at 10:00AM, V5 [Certified Nurse Assistant] stated, I
am R1's certified nurse assistant today. R1 always refuse to get a shower and change his clothes. R1 do
not have any clothes. I can go get him some clean donated clothes out the basement. Usually R1 refuses,
so I did not go get any clothes for him this morning. R1 usually has on one sock. I think he takes off the
other sock on purpose.On 12/13/25 at 11:22 PM, V6 [Registered Nurse] stated, I am R1's nurse today and
on 12/4/25, R1 was scheduled for a medical appointment for his heart. V8 [Certified Nurse Assistant] told
me R1 was refusing to get dressed and did not want to go to the appointment. I went and explained to R1
the importance of him going. R1 agreed to get dress and go to medical appointment. V8 never came back
to notify me R1 refused to shower or change into clean clothes. Later, I received a phone call from the
physician office, and they told me R1 was not dressed appropriately. I notified V2 [Director of Nursing]. I did
not see how R1 was dressed before he left the facility.12/13/25 at 12:27 PM, V2 [Director of Nursing]
stated, V6 [Registered Nurse] made me aware the hospital called the facility and said R1 was not dressed
appropriately for the weather. Upon R1's return I met him at the door. R1 had on two layers of clothing, no
coat or hat. V8 [Certified Nurse Assistant] said R1 refused to change his clothes so she placed another
layer of clothing on top. R1 was not outside in the cold. Our transportation dropped R1 off at the door and
picked R1 up. R1 has a history of refusing showers and changing clothes. I am not sure why his
non-compliance is not documented in R1's care plan. I will
Residents Affected - Few
(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:
145828
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
145828
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Kenwood Vlge Nrsg and Rhb Ctr
4505 South Drexel
Chicago, IL 60653
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 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
make sure R1 received some new clothes of his own, and R1's care plan is updated with interventions to
assess with non-compliance behaviors. The nursing staff should have canceled the medical appointment
and notified R1's physician for orders. R1 should not been allowed to leave the facility without a coat,
wearing one sock and unbathed, due to the weather and self-dignity could have potentially been
compromised. Policy documented in part:Activities Of Daily Living Policy dated 2/2025.In accordance with
the comprehensive assessment, together with respect for individual resident needs and choices, our facility
provides care and services for the following activities:Hygiene, bathing, dressing, grooming and oral
care.Will recognize and evaluate an inability to perform ADL or risk for decline in any ability to perform
ADL's.Resident Rights dated 10/25:All residents have the right to be treated with respect and dignity.
Event ID:
Facility ID:
145828
If continuation sheet
Page 2 of 2
