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 ensure that residents were free from physical
abuse from fellow residents. This failure affected two residents R3(who was physically abused by R2) and
R5(who was physically abused by R4), that were reviewed for resident versus resident physical abuse.
Findings include:
R2's diagnoses include but are not limited to Schizophrenia, Delusional Disorders, Schizoaffective
Disorders, Psychotic Disorder with Delusions, and Anxiety. BIMS (Basic Interview for Mental Status) score
dated 10/7/24 is 15(Cognitively Intact).
R3's diagnoses include but are not limited to Schizophrenia and Bipolar disorder. BIMS score dated
11/14/24 is 10(Moderate Cognitive Impairment).
R4's diagnoses include but are not limited to Bipolar Disorder, Schizophrenia, Depressive Disorders,
Psychotic Disorder, Obsessive Compulsive Disorder, Manic Episodes, and Violent Behavior. BIMS score
dated 12/31/24 is 15(Cognitively Intact).
R5's diagnoses include but are not limited To Schizophrenia, Psychotic Disturbance, Mood Disturbance,
and Anxiety. BIMS score dated 1/25/25 is 15(Cognitively Intact).
1. On 1/27/25 at 2:45pm, R3 stated She (R2) hit me from behind at the back of my head, I didn't do nothing
to her. I don't know why. No pain, I feel safe. R3 added that R2 doesn't live here no more.
On 1/27/25 at 1:04pm, V10 (LPN/Licensed Practical Nurse) stated It was on the third floor. I saw (R2) hitting
(R3) with a closed fist and staff immediately pulled her (R2) away. She (R2) was sent to the hospital.
In a statement dated 1/8/25 written by V23 (LPN), V23 stated that R2 ran up on R3 and started hitting R3
and verbalizing paranoia and sexual statements. V23 added We quickly separated her (R2) from (R3) and
monitored her in a room one to one.
Facility's report that was sent to the state agency on 1/8/25 states that R2 was going down the hallway in
his wheelchair when R2 grabbed R3 several times in the head.
During this investigation, R2 was no longer at the facility, and could not be interviewed.
(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:
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
02/06/2025
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
2. On 1/27/25 at 10:57am, R4 stated Yes, I hit her (R5) with a magazine because she (R5) made me upset.
I don't want to talk about it no more. It's over with.
On 1/27/25 at 11:22am, R5 stated She (R4) hit me on the head with the magazine, and I didn't do nothing
to her. R5 was asked about feeling safe and stated that she feels safe and does not see R4 again.
Residents Affected - Few
On 1/27/25 at 12:42pm, V9 (Activity Aide) stated It was during activity in the basement dining area. (R4)
usually wanted to get in everyone's conversation. I saw (R4) was sitting in her chair when she (R4) used
her magazine to swat (R5) on the head and (R5) did not do anything in return. (R5) was in the wheelchair
and (R4) was in her chair. Staff came immediately and separated them.
Facility's report that was sent to the state agency on 12/27/24 states that R5 told R4 to stop jumping into
her conversation, and R4 became upset, exchanged words with R5, and swatted R5 with a magazine twice
on the head. R4 was sent to the hospital for psychiatric evaluation where she was admitted .
On 1/28/25 at 2:19pm, V3 (Social Services Director) stated When a resident attacks or hits or strikes other
residents, that is physical abuse. When they make physical contact, that is abuse. With the population that
we serve, they(residents) can have hallucination or delusions at any time, but we try to be proactive. We try
to redirect the one that is able to listen and use de-escalation techniques.
On 1/28/25 at 10:00am, V1 (Abuse Coordinator/Assistant Administrator) stated When 2 residents have
physical altercation, it's a form of physical abuse. We will notify the doctor and the family and send the
aggressor to the hospital. If they live in the same hallway, I will transfer the aggressor to another room in
another hallway or another floor.
Facility's Abuse Policy with latest revision 1/18/2024, states in part: This facility affirms the right of our
residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods
and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation This
facility is committed to protecting our residents from abuse, neglect, exploitation . This policy further states
that the definition of abuse is Any physical or mental injury or sexual assault inflicted upon a resident other
than by accidental means. Abuse is the willful infliction of injury, physical harm, pain
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145829
If continuation sheet
Page 2 of 2
