Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0600
Level of Harm - Minimal harm
or potential for actual harm
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 protects a resident's right to be free from physical
abuse. This failure affected one (R1) resident reviewed for abuse in a total sample of 3 residents.
Residents Affected - Few
Findings include:
R1 and R2's (12/05/2024) Initial reportable documented, in part Description of occurrence. On 12/05/2024,
R2 was observed to engage in an altercation with R1. R1's (12/05/2024) Witness Statement documented,
in part (R2) slapped me in the face. She did not tell me why she hit me. R2's (12/05/2024) Witness
Statement documented, in part When asked reason for hitting (R1), resident stated 'who is (R1)? V5
(Certified Nursing Assistant) (12/05/2024) Witness Statement documented, in part (R2) was in the hallway
and just walked up and slapped (R1). V7 (Licensed Practice Nurse) (12/05/2024) Witness Statement
documented, in part (R2) walked up, slapped (R1), laughed and kept walking. (R2) slapped (R1) on her
right cheek.
On 12/20/2024 at 11:09am, with V5 (Certified Nursing Assistant) present, R1 stated (R2) hit me on my
head.
On 12/20/2024 at 11:04am, V5 (Certified Nursing Assistant) stated I was working on that day when (R2)
smacked (R1) on her face. (R1) was upset because she was slapped on her face. It was in the morning,
after breakfast, she (R1) was facing the dayroom and (R2) was coming out of her room, walked towards the
dayroom, and smacked (R1) on the face with open hand, and walked off. It happened so fast. (R2) is like a
toddler goes around and hits people.
On 12/20/2024 at 11:30am, V7 (Licensed Practice Nurse) stated I started working at the facility on
11/19/2024. (R2) is busy. Meaning, hard to redirect; it takes multiple redirections and constantly coaching.
(R2) was touchy. I was the nurse working on that day when the incident between her and (R1) happened.
We were cleaning the table after breakfast. I was standing by the elevator and nurse's station, and she (R2)
came around the corner and (R1) was facing the nurse's station storeroom. (R2) just slapped (R1) on her
face with her open hand and (R2) just walked away. She never broke stride and kept walking and we never
had time to intervene.
ON 12/20/2024 at 11:37am, V7 stated I assessed (R1) and there was no bruising, no hand marks, no
apparent injury but the mere fact that (R1) was slapped, I have to report it. That was the first time I
witnessed (R2) doing that, and nobody told me (R2) would do that.
On 12/20/2024 at 12:03pm, V8 (Director of Social Services) stated (R2) has a psych diagnosis of
(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:
145829
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
145829
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/21/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Kensington Place Nrsg & Rehab
3405 South Michigan Avenue
Chicago, IL 60616
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
Residents Affected - Few
schizophrenia with quite a few extensive histories of mental illness. V8 said, R2 is very unpredictable and
impulsive. R2 is unpredictable because she would walk fast, and she would reach out and touch you or
grab you without any signs or notice of intention. V8 said, R2 is impulsive because when it comes to
redirection she would have excessive babbling.
On 12/20/2024 at 12:07pm, V8 stated (R2) does not respect boundaries. We redirect, talk to her, do
consultation, and try to get her to understand that her behavior is not appropriate. Sometimes we were
successful but not all the time, and she would get back to inappropriate behavior. (R2) has short-lived
retention of information. The approaches on her careplan were updated. Our approaches are not successful
because the behavior continues. The expectation of the staff is to make sure (R2) is not acting
inappropriately by redirecting her prior to a behavior. The goal is for the staff to anticipate and redirect any
behavior before she acted on the behavior.
On 12/20/2024 at 2:24pm, V3 (Assistant Administrator) stated It is not expected of a resident to be slapped
while they are residing here. The resident should not be slapped, even though the slap is not hard, on the
face without their permission, that can be construed as an abuse. When we admit a resident, we are
indicating that we are able to meet their needs including their behavior.
R1's Facesheet documented that R1's Diagnoses: (include but not limited to) dementia, hypertensive heart
disease, and Type 2 Diabetes.
R1's (10/14/2024) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS
(Brief Interview for Mental Status) Summary Score: 12. Indicating R1's mental status as moderately
impaired.
R1's (12/05/2024) Progress note documented, in part (R1) was struck by another resident on the right side
of her face. Authored by: V7.
R1's (Problem Start Date: 01/19/2024, Edited: 12/05/2024) care plan documented, in part Problem:
potentially at risk for abuse. Goal: will have absence of instances of abuse.
R2's Facesheet documented that R2's Diagnoses: (include but not limited to) schizoaffective disorder,
psychosis, and strange and inexplicable behavior.
R2's (10/16/2024) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS
(Brief Interview for Mental Status) Summary Score: 13. Indicating R2's mental status as cognitively intact.
R2's (12/05/2024) Progress Note documented, in part Writer (V7) observed (R2) walked up to another
resident and struck her across the face.
R2's (edited: 08/05/2024 by: V9 Assistant Director of Social Service) Care plan documented, in part has
history in engaging in aggressive behaviors that is often directed towards other. She exhibited aggressive
bx (behaviors) towards 2 of her peers. Will have reduced episodes of physical aggression towards other.
Anticipate resident's needs in order to decrease physical behavioral symptoms. Separate resident from
others as needed.
R2's (edited: 12/05/2024 by V9) care plan documented, in part has a history in engaging in aggressive
behaviors that is often directed towards other. Recently, she was involved in an alleged incident
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145829
If continuation sheet
Page 2 of 3
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
145829
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/21/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Kensington Place Nrsg & Rehab
3405 South Michigan Avenue
Chicago, IL 60616
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
Residents Affected - Few
in which she exhibited inappropriate behavior towards peer. Approach: Anticipate needs in order to
decrease physical behavioral symptoms.
The (undated) Residents' Rights for People in Long-Term Care Facilities documented, in part As a
long-term care resident in the State, you are guaranteed certain rights, protections and privileges according
to State and Federal laws. Your rights to safety. You must not be abused. Your facility must provide services
to keep your physical health at their highest practicable levels. Your facility must be safe.
The (1/18/2024) Abuse Policy documented, in part Policy. This facility affirms the right of our resident to be
free from abuse. This facility therefore prohibits abuse. In order to do so, the facility has attempted to
establish a resident sensitive and resident secure environment. This will be done by: establishing an
environment that promotes resident sensitivity, resident security and prevention of mistreatment; identifying
occurrences and patterns of potential mistreatment. This facility is committed to protecting our residents
from abuse by anyone including other residents. Physical abuse include: hitting, slapping. Resident
Assessment. Through care planning process, staff will identify any problem goals and approaches which
would reduce the chances of abuse. Staff supervision: Supervisors will monitor the ability of the staff to
meet the needs of residents, including that assigned staff have knowledge of individual resident care
needs.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145829
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
FAQ · About this visit
Common questions about this visit
What happened during the December 21, 2024 survey of KENSINGTON PLACE NRSG & REHAB?
This was a inspection survey of KENSINGTON PLACE NRSG & REHAB on December 21, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at KENSINGTON PLACE NRSG & REHAB on December 21, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect b..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.