Health inspection·June 27, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent resident to resident physical abuse for one of four residents (R2) reviewed for abuse in a total sample of nine residents. Findings include: R1's Face sheet documents R1 is a [AGE] year-old admitted to the facility on 2.12.2013, with diagnoses including but not limited to: Cerebral palsy, Schizoaffective disorders, Hypertensive Heart disease without Heart failure, and Gastro-Esophageal Reflux disease without Esophagitis. R1's MDS *-Minimum Data Set (MDS) dated 5.6.2025 documents R1 is cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. R2's Face sheet documents R2 is a [AGE] year-old admitted to the facility on 2.6.2024, with diagnoses including but not limited to: Type 2 Diabetes Mellitus with unspecified complications, Dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, Psychotic disturbance, Mood disturbance, Anxiety; Hypertensive Heart disease with Heart failure, and Chronic Obstructive Pulmonary disease. R2's MDS *-Minimum Data Set (MDS) dated 3.31.2025 documents R2 is moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 9 out of 15. The Illinois Department of Public Health Final Investigation report completed on 4.25.2025, documents in part, on 3.19.2025 (4.19.2025) staff observed R1 tap R2's face. R2 stated while he was waiting for the smoke break, he was sitting quietly in the basement dining room. R1 approached him and hit him without provocation. He denied any precipitating factors. R1 reported to staff that R2 called him an inappropriate name. Body assessment of both residents was conducted. R2 was observed with superficial scratch under his eye which healed with no complications. (Local police department) was contacted. R1 was sent to (local hospital) for psychiatric evaluation. On 6.25.2025, at 2:41 PM, R1 said, R2 swore at me a lot. I got angry, and I hit him in the face with my right fist. I went to the hospital for fighting, they (facility) sent me. It happened in the basement dining room. Now, I would tell a worker if someone was swearing at me, I wouldn't hit them. On 6.26.2025, at 10:15 AM, V4 (CNA-Certified Nursing Assistant) said, I was up on the first floor. I was alerted by a housekeeper that R1 and R2 were fighting. When I got to the basement, I saw R1 hitting R2 in the face. We separated the residents. R2 went back to his unit, and we kept R1 downstairs for approximately 10 minutes. R1 said R2 was messing with me and calling me b*****s. (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 06/27/2025 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)