F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to provide comfortable and safe temperature
levels for the residents by not following their policy to maintain consistent temperatures at 71 degrees or
greater. This failure affected all 147 residents that reside at the facility.Findings include:On 01/20/26 at
11:05am, R7 stated that it has been cold in the facility for a few days. R7 stated that a guy came and put
plastic on his window, but he was still cold. R7 stated that he has 4 blankets covering him. Surveyor
observed R7 with 4 blankets. On 01/20/26 at 11:14am, the surveyor observed V3 (Maintenance Supervisor)
use a handheld infrared thermometer to check random room temperatures in multiple areas. Observed
thermometer readings of 55.4 degrees Fahrenheit in room [ROOM NUMBER]xx, 58.8 degrees Fahrenheit
in room [ROOM NUMBER]yy, 62 degrees Fahrenheit in room [ROOM NUMBER]zz. On 01/20/26 at
11:14am, V3 (Maintenance Supervisor) stated that he was first informed about the facility being cold on
Sunday 01/18/26. V3 stated that he came to the facility on [DATE] and placed plastic on some of the
resident windows. V3 stated that he did not do temperature checks on Sunday when he came into the
facility. V3 stated that he came back to the facility on Monday 01/19/26 and began placing plastic on the
remaining windows. V3 stated that the temperature in the building should be at least 71 degrees
Fahrenheit. V3 stated that it is not okay for the residents to be cold. V3 stated that he made a call to the
service company on Monday 01/19/26 and did not hear back from them. V3 stated that he informed the
administrator on Monday 01/19/26 that the building was cold. V3 stated that on Tuesday 01/20/26, the
administrator authorized him to place an emergency call to the boiler service company. On 01/20/26 at
11:33am, the surveyor entered the 2nd floor nursing unit and instantly felt a cold chill. Surveyor observed
V3 (Maintenance Supervisor) use handheld infrared thermometer to check random room temperatures in
multiple areas of the 2nd floor nursing unit. Observed thermometer readings of 68.2 degrees Fahrenheit in
the 2nd floor long hallway, 63.9 degrees Fahrenheit in room [ROOM NUMBER]xx, 59.7 degrees Fahrenheit
in room [ROOM NUMBER]yy.On 01/20/26 at 12:57pm R3 stated that he has been cold for two days. R3
stated that he is uncomfortable and would like the room temperature to be warm.On 01/20/26 at 1:02pm R1
stated that the facility has been cold for a few days, and the facility is not doing anything about the cold. On
01/20/26 at 1:11pm V10 (Registered Nurse/RN) observed sitting at the 3rd floor nurse's station with a
winter coat and hat on. V10 stated that he is cold. V10 stated that he first felt the cold temperature in the
building on Monday 01/19/26. V10 stated that he did not inform anyone when he felt the cold temperatures
and he just gave his residents extra blankets. V10 stated that the residents still complained about being
cold, so he had them to put on hoodies and jackets and provided more blankets for those residents that
were still complaining about the cold temperature.On 01/20/26 at 1:56pm V8 (Refrigeration Technician)
stated that for the facility to achieve the desired temperature of 71 degrees, the facility would have to have
an additional heat source.On 01/20/26 at
(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
01/22/2026
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 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
2:14pm surveyor observed V3 (Maintenance Supervisor) use handheld infrared thermometer to check
random room temperatures in multiple areas of the 1st floor nursing unit. Observed thermometer readings
of 68.5 degrees Fahrenheit in room [ROOM NUMBER]xx, and 67.1 degrees Fahrenheit in room [ROOM
NUMBER]yy.On 01/20/26 at 2:41pm V1 (Administrator) stated that she was first notified of the building
being cold on Tuesday 01/20/26. V3 stated that she informed maintenance to contact the service company
to check the boiler. V1 stated that she told the DON (Director of Nursing) to make sure that all the windows
were closed and that the plastic placed on the windows were still up. On 01/21/26 at 10:45am surveyor
observed V3 (Maintenance Supervisor) use handheld infrared thermometer to check random room
temperatures in multiple areas of the 1st, 2nd and 3rd floor nursing units. Observed thermometer readings
of 64.9 degrees Fahrenheit on 3rd floor long hallway, 64.9 degrees Fahrenheit in room [ROOM
NUMBER]ww, 64.0 degrees Fahrenheit in room [ROOM NUMBER]tt, 66.7 degrees Fahrenheit in room
[ROOM NUMBER]zz, 63.9 degrees Fahrenheit in room [ROOM NUMBER]yy, 66.9 degrees Fahrenheit in
room [ROOM NUMBER]xx, 65.7 degrees Fahrenheit in room [ROOM NUMBER]ww.On 01/21/26 11:40am
V7 (DON) stated that she was first made aware of the facility being cold on Sunday 01/18/26. V7 stated that
she received a phone call from V15 (Licensed Practical Nurse/LPN) stating that it was cold in the building.
V7 stated that she informed V1 (Administrator) of the phone call from V15 (LPN). V7 stated that she does
not know what action was taken after she informed V1 (Administrator). V7 stated that she instructed her
staff to make sure that all the windows were closed and to hand out extra blankets to any resident that was
complaining of being cold. V7 stated that she does not know what the temperature of the building should
be. On 01/21/26 at 12:55pm V2 (Assistant Administrator) stated that she was first made aware of the
building being cold on Monday 01/19/26. V2 stated that she did not have an actual temperature gun to
check the temperature of the facility, that she just felt the coldness in the air. V2stated that they are trying to
figure out what else they can do to decrease the cold temperature in the building. V2 stated that V3
(Maintenance Supervisor) was instructed to put plastic over the air conditioning (A/C) units and to place
blankets over the windows.On 01/21/26 at 2:41pm surveyor observed V2 (Assistant Administrator) use
handheld infrared thermometer to randomly check temperatures throughout the building. Observed
thermometer readings of 68 degrees Fahrenheit in room [ROOM NUMBER]ss, 67 degrees Fahrenheit in
room [ROOM NUMBER]ww, 66.5 degrees Fahrenheit in room [ROOM NUMBER]rr, 69 degrees Fahrenheit
in room [ROOM NUMBER]zz, 66 degrees Fahrenheit in room [ROOM NUMBER]yy, and 67-degrees
Fahrenheit in room [ROOM NUMBER]pp. Surveyor observed plastic coverings to windows and A/C wall
units.Facility's undated policy titled Residents' Rights for People in Long-Term Care Facilities documents in
part, Your rights to safety: . Your facility must be safe, clean, comfortable and homelike. Your rights as a
citizen and a facility resident: . You have the right to complain to your facility and to get a prompt
response.Facility's undated policy titled Extreme Weather Temperature Policy documents in part, Policy: it is
the policy of this facility to maintain indoor temperatures in the range of 71 to 81 degrees Fahrenheit.
Interventions will be promptly implemented to protect residents' health and safety when temperatures
fluctuate outside the accepted range.
Event ID:
Facility ID:
145829
If continuation sheet
Page 2 of 3
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
01/22/2026
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review the facility failed to distribute and serve food to two residents (R1
and R6) in accordance with professional standards for satisfactory food consumption. This failure affected
two residents reviewed for dietary services.Findings include:R1's medical diagnoses include but are not
limited to type 2 diabetes mellitus, lymphedema, acquired absence of left leg below knee, acquired
absence of right leg below knee.R1's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for
Mental Status score of 15, indicating R1's cognition is intact.R6's medical diagnoses include but are not
limited to chronic obstructive pulmonary disease, hypertensive heart disease without heart failure, mild
cognitive impairment of uncertain or unknown etiology.R6's MDS dated [DATE] has a BIMS score of 14,
indicating R6's cognition is intact.On 01/20/26 at 12:29pm observed R1 and R6's lunch trays delivered to
their bedside.On 01/20/26 at 12:30pm observed V12 (Dietary Manager) take temperature of R1' and R6's
lunch meal tray. R1 and R6's pork shoulder meat temperature 96.6 degrees Fahrenheit. On 01/20/26 at
12:33pm V12 (Dietary Manager) stated that the food temperature should be at least 145 degrees
Fahrenheit. V12 stated that she has been informed by the residents that they receive cold food. V12 stated
that she has had to come to the nursing units to assure that the resident meal trays were passed out in a
timely fashion. V12 stated that no one wants to eat cold food unless the food is supposed to be served cold.
V12 stated that she confirms that the resident trays that were tempted were cold.On 01/20/26 at 12:44pm
V11 (Certified Nursing Assistant/CNA) stated that residents have complained about receiving cold food.
V11 stated that if the resident complains about their food being cold, she warms their food in the
microwave. V11 stated that she also informs the dietary staff that the resident food was cold. V11 stated
that residents are still upset after she warm their food up in the microwave because they want the food to
already be hot. V11 stated that they are now trying to pass the meal trays in the dining area and the
resident rooms at the same time so that none of the meal trays are cold.On 01/20/26 at 1:02pm R1 stated
that the food he receives is served cold. R1 stated that the facility tells him to have the CNA (Certified
Nursing Assistant) to warm up his food, and he feels that the food should be served hot and he should not
have to have it warmed up. On 01/21/26 at 11:40am V7 (Director of Nursing/DON) stated that dietary did
speak to her about having her staff to pass the meal trays as soon as they come up to the unit.V7 stated
that they have come up with a system so that someone is in the dining area passing out meal trays and
someone is also passing trays to resident rooms at the same time.Facility's policy titled Food Preparation
and Service review dated 07/2025 documents in part, Policy statement: Food service employees shall
prepare and serve food in a manner that complies with safe food handling practices. Policy Interpretation
and Implementation: Food Preparation, Cooking and Holding Temperatures and Times: 1. The dander zone:
for food temperatures is between 41 degrees Fahrenheit and 135 degrees Fahrenheit. This temperature
range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. 2. Potentially
hazardous foods include meats, poultry, seafood, cut melon, eggs, milk, yogurt and cottage cheese. 3. The
longer foods remain in the danger zone the greater the risk for growth of harmful pathogens. Therefore,
PHF (potentially hazardous foods) must be maintained below 41 degrees Fahrenheit or above 135 degrees
Fahrenheit. 6. Previously cooked food must be reheated to an internal temperature of 165 degrees
Fahrenheit for at least 15 seconds.
Event ID:
Facility ID:
145829
If continuation sheet
Page 3 of 3