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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure that residents remain free of abuse for one of three
residents (R5) reviewed for abuse in the sample of eight.
Findings include:
Facility's final incident report dated (3/21/2025) documents in part, on 3/16/2025, staff observed (R4) acted
inappropriately towards (R5). Staff immediately intervened and both residents were separated. (R5)
indicated (R4) walked up in a conversation he was having with another peer at the end of the 3rd floor
hallway. (R5) alleged that (R4) began to use profanity towards him and touched him inappropriately across
his eyes with an open hand. Peer (R6) that was speaking to (R5) indicated that (R4) walked up and stated,
I'm tired of your stuff and acted inappropriately towards R5. He (R6) stated it was unprovoked.
On 4/16/2025, at 10:26 AM, V4 (Assistant Director of Social Service) said it was reported that R4 and R5
were in the long hall on third floor. R5 said R4 walked up to R5 while R4 was having conversation with
another peer. R4 started using profanity, then with his hand, went across R5's eyes with an open hand.
On 4/16/2025, at 10:33 AM, R6 said I was talking to R5. R4 walked up to R5 and hit R5 in the face. He (R4)
hit him (R5) the face real hard. It was unprovoked.
On 4/16/2025, at 10:38 AM, R4 said R5 jumped me. He (R5) got out of his wheelchair and punched me in
the back, then I hit him in the face. They sent me out to the hospital. I was gone for three days.
On 4/16/2025, at 2:54 PM, R5 said I was talking to R6 in the hallway. R4 came out of his room and said I'm
gonna f*** you up. I said to R4, would you hit a man in a wheelchair; he (R4) hit me across the face with an
open hand. I never touched him. There were no staff that witnessed the incident.
On 4/17/2025, at 10:17 AM, V2 (DON-Director of Nursing) said, it was reported to me that they (R4 and R5)
had an altercation. I was told that R4 hit R5. R4 was sent out for psychiatric evaluation. He's never done
that before.
R4's medical record documents R4 was dmitted to the facility on [DATE], with diagnoses including but not
limited to: Hypertensive heart disease with heart failure, Psychotic disorder, Left bundle-branch block, and
Thrombocytopenia. R4's MDS (Minimum Data Set of 3/30/25) documents a BIMS (Brief Interview for
Mental Status) as 13 denoting the resident is cognitively intact.
(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
04/18/2025
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
R5's medical record documents R4 was admitted to the facility on [DATE] with diagnoses including but not
limited to: Chronic obstructive pulmonary disease, Inflammatory and immune myopathies, Opioid
dependence, Effusion, right kneeR4's MDS (Minimum Data Set of 3/30/2025) documents a BIMS (Brief
Interview for Mental Status) as 15 denoting the resident is cognitively intact.
Residents Affected - Few
Abuse Policy (Reviewed 1.18.2024) documents,
POLICY
This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of
proper, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse,
neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the
facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this
policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse,
neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and
mistreatment of residents.
Definitions
Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by
accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or
punishment with resulting in physical harm, pain, or mental anguish to a resident. The term willful in the
definition of abuse means the individual must have acted deliberately, not that the individual must have
intended to inflict injury or harm.
Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and
derogatory terms to residents or families, or within their hearing distance, regardless of an individuals' age,
ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of
harm, saying things to frighten a resident, such as telling a resident that he/she will never to be able to see
his/her family again.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145829
If continuation sheet
Page 2 of 2
