Health inspection·December 21, 2024

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 Page 1 of 3 145829 145829 12/21/2024 Kensington Place Nrsg & Rehab 3405 South Michigan Avenue Chicago, IL 60616

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 145829 Page 2 of 3 145829 12/21/2024 Kensington Place Nrsg & Rehab 3405 South Michigan Avenue Chicago, IL 60616

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. 145829 Page 3 of 3