Health inspection·February 6, 2025

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. Page 1 of 2 145829 145829 02/06/2025 Kensington Place Nrsg & Rehab 3405 South Michigan Avenue Chicago, IL 60616

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 145829 Page 2 of 2