Kenwood Village Nursing: Resident Threatened With Death - IL
The resident, identified in inspection records as R1, is a transgender woman. She is cognitively intact, uses a wheelchair, and has lived at the facility since May 2025. According to progress notes reviewed by federal inspectors, a male peer had been rolling past her room and calling her "white boy" repeatedly in the weeks before the September incident. She hadn't reported it. She told the social worker she just brushed it off.
On September 29, she stopped brushing it off. After she muttered "asshole" under her breath at him, he told her he would punch her in the face or kill her.
A nurse documented the exchange at 12:21 that afternoon. Social services was notified. A progress note entered at 12:55 PM that same day recorded what happened when a social worker sat down with R1 to hear her account directly. The resident said the other man, identified as R2, had called her "boy" and told her that if she said anything else to him, he would kill her. She told the social worker this was not the first time he had said something like that to her.
The social worker asked why she hadn't told staff before. She said she just didn't.
The social worker encouraged her to speak up any time someone made her feel uncomfortable. Then came the question that produced the clearest answer in the entire record: the social worker asked R1 if she felt safe. She said she did not.
R2 is also cognitively intact, with a BIMS score of 15, the maximum possible. He uses a wheelchair. He has been at the facility since January 2025, and his own care plan, written in March, documented that he had a history of verbal behavioral symptoms directed toward others, including threatening others, screaming at others, and cursing at others. The care plan noted he had displayed verbal aggression toward staff on February 4 and verbally abusive behavior toward others on April 6. The pattern was not new. It was written into his file.
R2's own account of the September 29 incident, recorded in a progress note at 10:35 that morning, was that his peer had called him an asshole and that he had told her he would punch her in the face and kill her. He did not deny it.
Three days passed. On October 2, the social worker followed up with R1 in her room. The resident said the problems had not stopped. R2 was still making comments to her. He was still calling her "boy." She told the social worker she was getting tired of the situation and that something had to be done. The social worker told her she would speak to someone in administration to make them aware of the continuing issues.
Social services will continue to follow up, the note said.
Eight more days passed. On October 10, a progress note documented that R2's room had been changed. He remained on the same floor as R1.
That was the facility's response to a resident who said she did not feel safe, to a peer who had threatened to kill her twice, to a documented history of verbal aggression that predated the incident by months. They moved him to a different room on the same floor.
The facility's own abuse prevention policy, reviewed by inspectors, stated that a resident who allegedly abused another resident would be removed from the immediate area and that a determination would be made about what contact, if any, the accused resident should have with others while an investigation was underway. The policy said the accused resident's condition would be immediately evaluated to determine the most suitable care and placement, considering the safety of other residents.
The investigation took eleven days to produce a room change that left R2 forty feet away, or sixty, or however far one room is from another on the same floor of a nursing home where both residents use wheelchairs and move independently.
R1's diagnosis list includes major depressive disorder. She is also identified in the records as having a gender identity disorder diagnosis, the older clinical terminology that appears in her admission paperwork. The repeated use of "boy" by R2, a cognitively intact man who knew her name and chose not to use it, was documented by staff without any notation that the language was being treated as a form of gender-based harassment rather than a generic verbal altercation between two residents.
The social worker's notes refer to R1 with female pronouns throughout. The nurse's initial note does as well. The facility's staff understood who R1 was. The question inspectors were examining was whether the facility protected her.
The inspection was a complaint investigation, meaning someone, the records do not say who, had contacted authorities before the October 18 survey date. Inspectors arrived and reviewed the clinical records, the progress notes, the care plans, and the facility's own written policies. What they found was a gap between what the policy said would happen and what actually happened, measured in days and in distance.
The deficiency was cited at a level of actual harm, affecting a few residents. That language, actual harm, is a specific regulatory finding. It means inspectors determined that the failure to act caused real injury, not merely the risk of it. R1 was not physically struck. But she told staff she did not feel safe. She told them the situation was continuing. She told them something had to be done. She said all of this out loud, to social workers who wrote it down, and the facility's answer across eleven days was a room reassignment that kept her aggressor on the same floor.
Kenwood Village Nursing and Rehabilitation Center is located at 4505 South Drexel in Chicago's Kenwood neighborhood on the South Side.
On October 2, when R1 told the social worker she was tired of the situation, the social worker's note ended with a plan. Social services will continue to follow up. Eight days later, on October 10, the follow-up was a new room number for the man who had threatened to kill her. R1's room did not change. Her floor did not change. The person she had told staff she was afraid of was still within wheelchair distance.
The record does not reflect that anyone asked R1, after October 2, whether she felt safe.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Kenwood Vlge Nrsg and Rhb Ctr from 2025-10-18 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 5, 2026 · Our methodology
KENWOOD VLGE NRSG AND RHB CTR in CHICAGO, IL was cited for violations during a health inspection on October 18, 2025.
The resident, identified in inspection records as R1, is a transgender woman.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.