Kenwood Village Nursing: Resident Threatened, Felt Unsafe - IL
She said it wasn't the first time.
The man, identified in inspection records only as R2, had been at the facility since January 2025. His care plan, dated March 17, documented that he had verbal behavioral symptoms directed toward others, including threatening, screaming, and cursing. Staff had recorded incidents going back to February. On April 6, he was documented as verbally abusive toward others. The pattern was not new, and it was not hidden in his file. It was written down, formally, in a plan that was supposed to guide how staff managed his behavior.
On September 29, a progress note recorded what R2 said after he claimed another resident had called him a name. He told staff he would punch her in the face and kill her. That note was written at 10:35 in the morning by a staff member identified as V10. It sat in his record.
The woman, identified as R1, eventually told a social worker what had been happening. R2 had called her "boy" as he wheeled past her room. When she responded, he 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. When asked why she hadn't told staff sooner, she said she just didn't.
She was asked if she felt safe. She said she did not.
A follow-up progress note dated October 2 — three days after R2 had explicitly told staff he would punch a peer in the face and kill her — shows the social worker returning to R1's room and finding the situation unchanged. R1 said he was still making comments. Still calling her that name. She told the social worker she was getting tired of it 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, the note said, would continue to follow up.
What happened next, according to the inspection record, was that R2's room was changed. The move is documented in a progress note from October 10. He was placed in a different room. He remained on the same floor as R1.
The facility's own abuse prevention policy, which carries no date, states that a resident who allegedly abused another resident will be removed from the immediate area while an investigation is underway, and that a determination will be made about what contact, if any, the accused resident should have with others during that process. The policy also says the accused resident's condition will be immediately evaluated to determine the most suitable care approaches and placement, with the safety of other residents considered.
R2 is cognitively intact. His most recent Minimum Data Set assessment shows a Brief Interview for Mental Status score of 15, the maximum, meaning his cognitive function is not impaired. He is wheelchair-dependent, having lost both legs below the knee, and is able to wheel himself with supervision. He knew what he was saying. He said it more than once. Staff documented it.
The facility did not report the situation to the Illinois Department of Public Health until October 17. The inspection that captured these findings took place on October 18, one day later. The initial investigation and reporting to IDPH, provided by a staff member identified as V4, was sent at 1:37 in the afternoon on October 17.
The inspection report does not say when the facility first became aware that R1 felt unsafe, or when it determined that a formal investigation was required. What it shows is a documented threat on September 29, a resident still reporting ongoing harassment on October 2, a room change on October 10 that kept R2 on the same floor, and a report to state authorities on October 17.
That is eighteen days between the documented threat and the report to IDPH.
The facility's own policy requires a complete written investigation report to be sent to the Department of Public Health within five working days of a reported occurrence.
R1 told the social worker during that October 2 visit that she was tired of the situation. She had been sitting with it, not telling staff, trying to manage it herself, until she couldn't anymore. When she finally did say something, the person she told wrote a note and said she would talk to someone in administration.
R2's care plan had identified his pattern of verbal aggression toward others since at least March. It named threatening others as a documented behavior. It recorded a specific incident of verbal aggression toward staff in February. By September, he was threatening to punch a peer in the face. By October, he was still on the same floor as the woman he had threatened to kill.
The inspection was filed as a complaint investigation. The level of harm was recorded as actual harm. The number of residents affected was listed as few.
R1 told the social worker she did not feel safe. That was the last thing the inspection record captures her saying on the subject.
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.
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 8, 2026 · Our methodology
KENWOOD VLGE NRSG AND RHB CTR in CHICAGO, IL was cited for violations during a health inspection on October 18, 2025.
She said it wasn't the first time.
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.