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Complaint Investigation

Kenwood Vlge Nrsg And Rhb Ctr

October 18, 2025 · Chicago, IL · 4505 South Drexel
Citations 3
CMS Rating 1/5
Beds 155
Provider ID 145828
Healthcare Facility
Kenwood Vlge Nrsg And Rhb Ctr
Chicago, IL  ·  View full profile →
Inspection Summary

KENWOOD VLGE NRSG AND RHB CTR in CHICAGO, IL — inspection on October 18, 2025.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0600
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Actual Harm

diagnoses but not limited to hypertensive heart and chronic kidney disease with heart failure and stage 5 chronic kidney disease, acquired absence of left leg below knee, and acquired absence of right leg below knee. R2's MDS dated [DATE] shows a BIMS score of 15 which means R2 is cognitively intact. R2 uses a wheelchair and able to wheel himself with supervision. R2's comprehensive care plan dated 3/17/25 documents in part: R2 has verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others). [R2] displayed verbal aggression towards staff on 2/4/2025. On 4/6/25 resident exhibited verbally abusive behavior toward others. R2's progress notes dated 9/29/25 at 10:35 AM, documented by V10 documents in part: Resident [R2] stated that his peer called him an as***le and he stated that he will punch her in the face and kill her. R2's progress notes dated 10/10/25 at 3:17 PM documented by V7 revealed R2's room was changed but remained on the same floor as R1.

The facility's Abuse Prevention Program policy and procedures (no date) documents in part: The facility will take steps to prevent potential abuse while the investigation is underway.

Consumers who allegedly abused another consumer will be removed from the immediate area and a determination made as to contact, if any, with other consumers during the course of the investigation.

The accused consumer's condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other consumers and employees of the facility.The facility's Resident Rights Guideline (no date) documents in part: Our residents have certain rights and protections under Federal law that help ensure appropriate care and services are provided.

The right to a safe, clean, and comfortable, and home-like environment that allows independence as possible.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/18/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Kenwood Vlge Nrsg and Rhb Ctr

4505 South Drexel Chicago, IL 60653

SUMMARY STATEMENT OF DEFICIENCIES

residents' [R1] room, and she told resident that she continues to have problems with co-peer.

Resident [R1] stated that he continues to make comments to her and to call her [NAME] Boy.

Resident [R1] stated she is getting tired of the situation, and something has to be done.

Writer informed her that she would talk to someone in Administration to make them aware of the continuing issues between her and her peer.

Social services will continue to follow up.R2's clinical records show an admission date of 1/10/25 with included diagnoses but not limited to hypertensive heart and chronic kidney disease with heart failure and stage 5 chronic kidney disease, acquired absence of left leg below knee, and acquired absence of right leg below knee. R2's MDS dated [DATE] shows a BIMS score of 15 which means R2 is cognitively intact. R2 uses a wheelchair and able to wheel himself with supervision. R2's comprehensive care plan dated 3/17/25 documents in part: R2 has verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others). [R2] displayed verbal aggression towards staff on 2/4/2025. On 4/6/25 resident exhibited verbally abusive behavior toward others. R2's progress notes dated 9/29/25 at 10:35 AM, documented by V10 documents in part: Resident [R2] stated that his peer called him an as***le and he stated that he will punch her in the face and kill her. R2's progress notes dated 10/10/25 at 3:17 PM documented by V7 revealed R2's room was changed but remained on the same floor as R1. V4 provided a copy of the initial investigation and reporting sent to IDPH dated 10/17/25 at 1:37 PM.

The facility's Abuse Prevention Program policy and procedures (no date) documents in part: All incidents will be documented, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of consumer property occurred, was alleged or suspected.

Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of consumer property will result in an investigation.

The investigator will report the conclusions of the investigation in writing to the Executive Director or designee within five working days of the reported incident.

Public Health shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment or misappropriation of consumer property has been reported and is being investigated.

Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/18/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Kenwood Vlge Nrsg and Rhb Ctr

4505 South Drexel Chicago, IL 60653

SUMMARY STATEMENT OF DEFICIENCIES

10/10/25 at 3:17 PM documented by V7 revealed R2's room was changed but remained on the same floor as R1. V4 provided a copy of the initial investigation and reporting sent to IDPH dated 10/17/25 at 1:37 PM.

The facility's Abuse Prevention Program policy and procedures (no date) documents in part: The facility will take steps to prevent potential abuse while the investigation is underway.

Consumers who allegedly abused another consumer will be removed from the immediate area and a determination made as to contact, if any, with other consumers during the course of the investigation.

The accused consumer's condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other consumers and employees of the facility.

All incidents will be documented, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of consumer property occurred, was alleged or suspected.

Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of consumer property will result in an investigation.

The investigator will report the conclusions of the investigation in writing to the Executive Director or designee within five working days of the reported incident.

Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in CHICAGO, IL, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from KENWOOD VLGE NRSG AND RHB CTR or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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