Health inspection·December 12, 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 observation, interview and record review, facility failed to protect a resident from physical abuse. This failure affected one resident (R9) of 10 residents reviewed for abuse. This failure resulted in R10 hitting R9 on the face in the dining room, resulting in R9 sustaining superficial scratches to R9's face.Findings Include: R9's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Cerebrovascular disease, type 2 diabetes mellitus without complications, idiopathic peripheral autonomic neuropathy, chronic obstructive pulmonary disease, unspecified, hyperlipidemia, hypertensive heart disease without heart failure, gastro-esophageal reflux disease without esophagitis, history of falling, benign prostatic hyperplasia without lower urinary tract symptoms. Minimum Data Set Section (MDS) section C (dated Sep.10, 2025) documents that R9 has an Interview for Mental Status (BIMS) score of 12, indicating that R9's cognition is intact. Care plan (dated 07/02/2025) documents that R9 is potentially at risk for abuse/neglect secondary to moderate physical deficits and soft-spoken communication. Recently, he was involved in an incident where he was not the aggressor. R9 is alert and able to verbalize needs.R10's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Parkinson's disease without dyskinesia, without mention of fluctuations, schizoaffective disorders, chronic obstructive pulmonary disease, unspecified, bipolar disorder, Hypertensive heart disease with heart failure. Minimum Data Set Section (MDS) section C (dated 10/22/2025) documents that R10 has an Interview for Mental Status (BIMS) score of 13, indicating that R10's cognition is intact. Facility Final Incident Investigation Report (dated 07/08/2025) documents in part: On 07/02/2025 at approximately 3:20PM, R10 was observed to strike R9 while in the basement dining area. Staff intervened and immediately separated the residents. Body assessments conducted for R9 and R10. R10 reported no pain and injury. R9 denied pain but was observed with 2 superficial scratches on face. Emergency contacts for R9 and R10 notified. R9 alleged R10 got out of his wheelchair and became aggressive towards him. R9 alleged he was stationary in the basement dining area when R10 came towards him, stood up from the wheelchair and came at him. R9 denied any precipitating factors. Residents who witnessed the incident indicated that R10 became aggressive towards R9. A resident alleged observing R10 trying to get past in between R9 and another peer who were sitting at the table in the basement dining area. R10 stood up and became aggressive towards R9. Abuse Prevention Policy (revised 10/2022) 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, misappropriation of property, and mistreatment of residents. 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 physical harm, pain, or mental anguish to a resident. Resident Rights Policy Page 1 of 3 145829 145829 12/12/2025 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 (revised 11/2018) states in part: Your rights to safety- You must not be abused, neglected, or exploited by anyone- financially, physically, verbally, mentally or sexually. On 09/30/2025, surveyor was conducting a facility reported incident related to resident-to-resident abuse, that occurred on 07/02/2025. On 9/30/25 at 2:42 PM, R9 observed sitting in his motorized wheelchair in his room. Surveyor conducted an interview with R9. R9 stated, R10 hit me because R10 was trying to get by. R10 and I were in the cafeteria. I was in my wheelchair. R10 was in his wheelchair. It was not enough space for R10 to get by. R10 put his hand on my chair. I went to move R10's hand. R10 stood up and struck me in the face. I was not injured and R10 was not injured. I did not go to the hospital. R10 went to the hospital for psychiatric evaluation. I feel safe in the facility.On 9/30/25 at 2:34 PM, surveyor conducted an interview with resident, R10. R10 stated, I ain't been fighting with nobody. Ain't nobody hit me. I ain't hit nobody. I stay in my room watching television. I feel safe in the facility.On 12/10/2025 at 10:55AM, V1 (administrator) stated, On 07/02/2025, it was reported that at 3:20PM, R10 was observed hitting R9 in the face, in the dining room. Staff intervened immediately and separated R10 from R9. The nurses completed body assessment on both residents. R10 had no pain or injury. R9 had a superficial scratch on his face. Both R9 and R10's physicians and emergency contacts were made aware of the incident. The police were called, and a report was filed. R10 was petitioned and sent out to the hospital for psychiatric evaluation. R9 was provided first aide for the scratch on his face. The issue started because both residents are in wheelchairs. R10 was trying to get by and could not, and that's how the incident started. R10 became frustrated because he could not get by and struck R9 in the face. R9 and R10 have not had any incidents prior to the physical altercation. R9 and 10 did not have other incidents after the altercation. R9 and R10 both feel safe in the facility.On 12/11/2025 at 9:48AM, V18 (psychiatric rehabilitation services coordinator) stated, On 07/02/2025, I was coming out of the office in the basement, and I heard a commotion coming from the big dining room. I went inside the dining room to see what the commotion was, and I saw that the certified nursing assistants already separated R9 and R10. R10 became furious and he was saying that R9 needs to get out of his way. Where they were sitting, there is a lot of residents in wheelchairs and R10 was trying to get by but couldn't. R10 became frustrated and R10 hit R9 in the face. I saw R9 with a scratch on his face, which was a result of being struck in the face by R10. R9 did not attempt to strike R10 back. R10 was placed on 1 to 1 supervision and R10 was sent out to the hospital for psychiatric evaluation.R9's Progress Note (dated 07/02/25) documents, It was reported that resident had an unprovoked altercation with one of his peers. Resident has 2 scratches to his lower right cheek. Resident stated that the other resident scratched him in the face for no reason. The scratches cleansed with normal saline and left open to air, no bleeding noted. Physician notified. No new orders given. V/S 98.1-78-18-132/77, O2 sat 98% on room air. Will continue to monitor.R9's Progress Note (dated 07/02/25) documents, 1:1 VISIT TOPIC: Well-being Check. Writer met with resident in an effort to process event and to assess resident's mood/behavior. Educated the resident on importance of verbalizing any concerns immediately to staff for intervention/support. Processed with resident event; he reported no additional concerns and presented with adequate mood and stated feeling okay but verbalized feeling somewhat upset by event. Feelings/concerns were validated, resident reported no concerns. Resident was alert and oriented x3. PLAN: Continue to be available to resident as appropriate.R10's Progress Note (dated 07/02/2025) documents, It was reported by social service that resident had and altercation with another resident and the other resident sustained scratches to his face. Resident received delusional and uncooperative with social services as to what led up to the altercation. Physician called and order given to send resident to community hospital emergency room with a 145829 Page 2 of 3 145829 12/12/2025 Kensington Place Nrsg & Rehab 3405 South Michigan Avenue Chicago, IL 60616

F 0600 Level of Harm - Minimal harm or potential for actual harm petition.R10's Progress Note (dated 07/02/2025) documents, Ambulance called for transport with ETA (estimated time of arrival) 30-40 minutes. Nursing report given to registered nurse at community hospital emergency room. Sister of resident was notified that resident will be sent to community hospital. Resident remains on the unit at this time.R10's Progress Note (dated 07/03/2025) documents, Resident has been admitted DX (diagnoses): aggressive behavior. Residents Affected - Few 145829 Page 3 of 3