Kenwood Vlge Nrsg And Rhb Ctr

F 0600 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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. Resident R2's MDS dated [DATE REDACTED] shows a BIMS score of 15 which means Resident R2 is cognitively intact. Resident R2 uses a wheelchair and able to wheel himself with supervision. Resident R2's comprehensive care plan dated 3/17/25 documents in part: Resident R2 has verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others). [Resident R2] displayed verbal aggression towards staff on 2/4/2025. On 4/6/25 resident exhibited verbally abusive behavior toward others. Resident R2's progress notes dated 9/29/25 at 10:35 AM, documented by V10 documents in part: Resident [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. Resident R2's progress notes dated 10/10/25 at 3:17 PM documented by V7 revealed Resident R2's room was changed but remained on the same floor as Resident 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Kenwood Vlge Nrsg and Rhb Ctr

4505 South Drexel Chicago, IL 60653

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

residents' [Resident R1] room, and she told resident that she continues to have problems with co-peer. Resident [Resident R1] stated that he continues to make comments to her and to call her [NAME] Boy. Resident [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.Resident 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. Resident R2's MDS dated [DATE REDACTED] shows a BIMS score of 15 which means Resident R2 is cognitively intact. Resident R2 uses a wheelchair and able to wheel himself with supervision. Resident R2's comprehensive care plan dated 3/17/25 documents in part: Resident R2 has verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others). [Resident R2] displayed verbal aggression towards staff on 2/4/2025. On 4/6/25 resident exhibited verbally abusive behavior toward others. Resident R2's progress notes dated 9/29/25 at 10:35 AM, documented by V10 documents in part: Resident [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. Resident R2's progress notes dated 10/10/25 at 3:17 PM documented by V7 revealed Resident R2's room was changed but remained on the same floor as Resident 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Kenwood Vlge Nrsg and Rhb Ctr

4505 South Drexel Chicago, IL 60653

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 0610 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

10/10/25 at 3:17 PM documented by V7 revealed Resident R2's room was changed but remained on the same floor as Resident 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.

Event ID:

Facility ID:

If continuation sheet