Kenwood Vlge Nrsg and Rhb Ctr

Inspectors wroteBased on interviews and record review, the facility failed to ensure that a nurse and CNA (Certified Nursing Assistant, CNA) maintained a current CPR (Cardiopulmonary Resuscitation) certification card while working in the facility which has the potential to affect all 149 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to a.) offer coronavirus disease 2019 (COVID-19) vaccinations and b.) adequately document COVID-19 vaccination status for four (R25, R52, R103, R132) out of five residents reviewed for immunizations in a total sample of 28 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect residents from physical abuse. This failure affects two of three residents (R2 and R3) reviewed for abuse in a total sample of five residents.

Inspectors wroteBased on review of records and interview, the facility failed to acquire preadmission screening and resident review due to being outstanding for three (R1, R2, and R3) out of three residents in a total sample of three resident reviewed. These failures affect three residents (R1, R2, and R3) in determining correct care settings for residents with serious mental illness.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that four residents (R4, R6, R8 and R10) were free from abuse. This failure has affected four of seven residents reviewed for abuse.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that one non-ambulatory resident (R1) with dementia was sent to the hospital and evaluated after being found on the floor. This failure resulted in R1 being diagnosed with a clavicle fracture one day after an unwitnessed fall.

Inspectors wroteBased on observation, interview and record review the facility failed to protect one resident (R1) from physical and emotional abuse from V8 (Licensed Practical Nurse-LPN). This failure affected one resident (R1) of 3 reviewed for abuse. This failure resulted in R1 reporting she was hurt in her arms and neck. X-Ray of right and left elbows, forearm, wrist, and hand reveals mild soft tissue swelling.

Inspectors wroteBased on observation, interviews and record reviews the facility failed to follow their Activities of Daily Living policy to provide necessary care such as bathing, dressing, and grooming, and failed to develop and implement interventions in accordance with the needs and goals related to care for one [R1] of three residents reviewed for improper nursing care.

Inspectors wroteBased on interviews and record reviews, the facility failed to affirm the right of their residents to be free from verbal and mental abuse and failed to prevent potential further abuse by failing to remove the alleged perpetrator (R2) from interacting with R1. These failures affected two (R1, R2) out of four residents reviewed for abuse. These failures resulted in R1 feeling unsafe and scared for her safety, was unable to sleep, and felt like no one was doing something to protect her. Findings Include: On 10/17/25 at 9:39 AM, Surveyor observed R1 sitting by the side of her bed alert and oriented to time, place, and situation. R1 stated, There is one gentleman his name is [R2]. He [R2] lives on the same floor as me. He [R2] is two rooms down from my room. He [R2] is black. He [R2] has prosthetics on both legs. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to thoroughly investigate allegations of abuse and failed to prevent potential further abuse by failing to remove the alleged perpetrator (R2) from interacting with R1. These failures affected two (R1, R2) out of four residents reviewed for abuse. These failures resulted in R1 feeling unsafe and scared for her safety, was unable to sleep, and felt like no one was doing something to protect her. Findings Include: On 10/17/25 at 9:39 AM, Surveyor observed R1 sitting by the side of her bed alert and oriented to time, place, and situation. R1 stated, There is one gentleman his name is [R2]. He [R2] lives on the same floor as me. He [R2] is two rooms down from my room. He [R2] is black. He [R2] has prosthetics on both legs. He [R2] uses his wheelchair and continues to pass by my room and harasses and threatens me almost every day. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to send the initial and final reports of abuse allegations to Illinois Department of Public Health (IDPH) for two (R1, R2) out of four residents reviewed for abuse. Findings Include: On 10/17/25 at 9:39 AM, Surveyor observed R1 sitting by the side of her bed alert and oriented to time, place, and situation. R1 stated, There is one gentleman his name is [R2]. He [R2] lives on the same floor as me. He [R2] is two rooms down from my room. He [R2] is black. He [R2] has prosthetics on both legs. He [R2] uses his wheelchair and continues to pass by my room and harasses and threatens me almost every day. This started a month ago. I have everything written down. It started on 9/14/25 at 6:15 PM, I came back from the hospital. I was in the hospital for multiple seizures. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to evaluate and address a resident's continued poor appetite for adequate nutrition and hydration, failed to follow the dietary's recommendation, and failed to consistently implement interventions, monitor the effectiveness of interventions and revising them as necessary for one (R1) out of four residents reviewed for nutritional services. These failures resulted in R1 being hospitalized due to hypovolemic shock, malnutrition, and dehydration. Findings Include:R1's clinical records revealed R1 was admitted in the facility on 6/23/25 and was discharged home on 7/9/25. R1's listed diagnoses include but not limited to cerebral infarction, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, unspecified severe protein-calorie malnutrition, dysphagia pharyngoesophageal phase, and major depressive disorder. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to follow their policy and procedure to develop a baseline care plan that included individualized information to ensure that the resident's immediate care needs are met and maintained for 1 (R1) out of 4 residents reviewed for baseline care plans. Findings Include:R1's clinical records revealed R1 was admitted in the facility on 6/23/25 and was discharged home on 7/9/25. R1's listed diagnoses include but not limited to cerebral infarction, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, unspecified severe protein-calorie malnutrition, dysphagia pharyngoesophageal phase, and major depressive disorder. [...]

Inspectors wroteBased on observations, interview, and record review it was determined that the facility failed to provide an effective pest control program. This failure has the potential to affect 201 residents residing in the facility. Findings Include: On 03/26/25 at 09:35 V6 (R3's Family Member) stated The facility has mice and R3 has seen the mice in her room. The mice sometimes get caught in the bathroom and in the roommate's clothing. A mouse was in R3's bed. R3 saw a mouse the day before yesterday. On 03/26/25 at 10:42 AM Per telephone interview V5 (Anonymous) stated R2 has been in the facility since December. R2 was sent to the hospital and when R2 returned he (R2) was in a room on the third floor. The bed that R2 was in had mouse dropping on the bed frame. R2 was in the room, it was dark and when I turned on the light a mouse ran across the floor. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that one resident (R2) was free from abuse from two residents (R1 and R8) in a sample of 6 residents reviewed for abuse. These failures resulted in R1, an ambulatory resident, physically punching R2, a wheelchair resident, in the face causing a facial skin tear, periorbital contusion and nasal fracture, and R8, an ambulatory resident, physically hitting R2 in the back of the head.

Inspectors wroteBased on interview and record review, the facility failed to provide facility staff supervision of a resident (R1) in the basement dining room in a sample of 6 residents reviewed for improper nursing care. This failure resulted in R2, a wheelchair resident, being punched in the face two times by R1, an ambulatory resident with verbal and physical aggressive behaviors, causing R2 to sustain a facial skin tear, periorbital contusion and nasal fracture.

Inspectors wroteBased on interview and record review, the facility failed to revise and review a resident's behavioral health care plan that has not been effective and develop individualized interventions which affected one resident (R1) out of three residents (R1, R2, R6) reviewed for quality of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to discard expired foods, failed to ensure the freezers/refrigerators was monitored and maintained at the appropriate safe temperatures, failed to ensure an accurate documentation on the dishwasher temperatures log, failed to ensure the dishwasher was working properly. These failures affected all residents in the facility receiving an oral diet from dietary services.

Inspectors wroteBased upon observation, interview, and record review the facility failed to ensure that the 2nd and 3rd floor medication carts were locked while unattended. This failure has the potential to affect 99 residents (51 residents on the 2nd floor and 48 residents on the 3rd floor).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to properly label and date oxygen equipment (humidifier bottled, and nasal cannula) and failed to properly contain oxygen equipment (Continuous Positive Airway Pressure CPAP mask, and nasal cannula) per the facility's policy. These failures affected four residents (R15, R51, R70 and R99) reviewed for respiratory care in a sample of 58 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two licensed personnel conducted a physical inventory of controlled substances on the 3rd floor at each change of shift. This failure has the potential to affect all 48 residents on the 3rd floor.

Inspectors wroteBased on observation, interview, and record review the facility failed to discard an expired opened multi dose vial. This failure has the potential to affect all 48 residents on the 3rd floor reviewed for labeling and storage of drugs and biologicals.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the container of the multi blood glucose test strips were labeled with the open date. These failures have the potential to affect 4 residents (R4, R34, R60 and R80) who receive blood glucose monitoring tests on the third floor.

Inspectors wroteBased on observation and record review facility failed to 1. ensure proper hand hygiene in between resident care when passing meal trays; 2. [NAME] Personal Protective Equipment when providing care to residents on Contact Precautions; 3. Failed to ensure Personal Protective Equipment and garbage cans are available and accessible and failed to prevent the urinary catheter drainage bag from touching the floor. These failures affected 8 residents (R6, R27, R36, R58, R77, R88, R95, R106) in a sample of 58 residents reviewed. Findings Include: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the handrail was firmly secured to the wall. This failure has the potential to affect all 51 residents on the second floor.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure call device was within reach for one resident (R74). This failure had the potential to affect the 58 residents in the sample.

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain a doctor's order for an advance directive which affected one resident (R58) reviewed for advanced directive in the sample of 58 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure electronic health records were kept in a private manner. This failure has the potential to affect 2 residents (R63 and R44) in a sample of 58 residents reviewed for confidentiality of records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the closet drawers were not missing in effort to provide a homelike environment. This failure affected 4(R75, R80, R7, and R1) residents reviewed for homelike environment in the total sample of 58 residents.

Inspectors wroteBased on observation interview and record review, the facility failed to complete a new pre-admission screening and resident review (PASSR) when a new mental health diagnosis is identified. This failure affects 1 resident (R69) out of a sample of 58.

Inspectors wroteBased on observation, interview, and record review, facility failed to provide the necessary treatment to promote healing and failed to assess accurate site to a resident with a skin impairment. These failures affected 1 (R105) of 1 resident reviewed for wound care. Findings Include: R105 has a medical diagnosis of but not limited to hemiplegia and hemiparesis following cerebral infarction, affecting right dominant side, Congestive Heart Failure, Aphasia and Osteoarthritis. The Minimum Data Set (MDS) dated [DATE] shows R105's cognition is impaired, with a four out of fifteen points required on the Brief Interview for Mental Status (BIMS). R105 Physician Order Sheet dated 1/22/2025 documents right posterior thigh: Cleanse with Normal Saline Solution, skin prep to peri wound, apply hydrocolloid dressing. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the low air loss mattress was not layered with multiple linens for 1 resident (R78). This failure affected 1 resident reviewed for pressure ulcer/injury prevention and treatment in a sample size of 58. R78 has a diagnosis of but not limited to Sequelae of Infarction, Schizophrenia, Dementia, Palliative Care, and Cellulitis. R78 has a Brief Interview of Mental Status Score of 7, which indicates that R78 is cognitively impaired. R78's order from hospice company dated 12/24/2024 documents, in part, new air mattress and air mattress for hospital bed. R78's care plan focus Pressure Ulcer/Injury dated 7/24/2023 documents, in part, use low air loss mattress in bed. R78's Minimum Data Sheet section GG dated 11/26/2024 documents, in part, Functional Limitation in Range of Motion: for upper and lower extremities: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that an adaptive device (splint/palm grip) was in place of a contracted hand which affected one resident (R61) in the total sample of 58 residents when reviewed for limited mobility.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly log refrigerator temperatures for 2 residents' (R7 and R16) with personal refrigerators in their rooms. This failure has the potential to affect all 58 residents in the sample.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents received the education addressing the benefits and risk or had the opportunity to receive the Influenza and Pneumonia vaccines. This failure affected three residents (R50,58, R119) out of five residents reviewed for immunizations.

Inspectors wroteBased on interview and record review the facility failed to ensure that one resident (R2) was free from resident-to-resident physical abuse. This failure affected one resident (R2) in a total sample size of three residents (R1, R2, and R3) reviewed for physical abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to post the daily nursing staffing. This failure has the potential to affect all 109 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the resident environment remain free of accident hazard and failed to ensure that treatment cart was locked when not in visual proximity of the nurse and not in use to prevent tampering and accidental hazard for one resident (R7) in the sample and the. This failure has a potential to affect R7 whose oxygen tank was stored on the bare floor in the room and inhaler was left on the bedside table visible to hallway. This as the potential to affect all the residents on the 1st and 3rd floor of the facility.

Inspectors wroteBased on interview, and record review the facility failed to ensure that one resident (R2) was free of abuse (theft). This failure affected R2 whose money and debit card were stolen with activities of withdrawal from their funds and has the potential to affect all the 100-resident residing at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the breakfast menu was followed. This failure affected 100 residents in the facility who were receiving an oral diet. Findings Include: On 2/4/24 at approximately 7:55 AM, first floor breakfast food cart was inspected. Surveyor noted no seasonal fruit on the residents' trays. Noted R3's tray consisted of a toast, scrambled egg, chopped up meat, coffee, and juice. R3's meal ticket shows double portion, NCS (No Concentrated Sweet)/NAS (No Added Salt) mechanical soft diet. R4's tray consisted of cereal, two sausages, one boiled egg, coffee, and juice. R4's meal ticket shows low fat diet regular. At 8:12 AM, R5 was just finished eating breakfast in the 2nd floor dining room. R5 stated R5 got two sausages, orange juice, coffee, toast, a boiled egg, jelly, and sugar. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's personal belongings were recorded on admission and failed to provide proper storage and access to personal items. This failure affected one resident(R2) out of four residents reviewed personal property.

Inspectors wroteBased on observation, interview and record review the facility failed to a) store and label food items in accordance with professional standards for food service safety and b) follow proper sanitation for cleaning dishes. This failure has the potential to affect 99 residents that eat food from the kitchen.

Inspectors wroteBased on observation, interview and record review the facility failed to properly contain waste in dumpsters and failed to ensure dumpster lids were securely closed.

Inspectors wroteBased on observations, interviews, and review of records the facility failed to follow storage of medications policy for 1 out of 3 medication carts for a total of 3 medication carts reviewed. These failures includes opened vial of insulin that are expired, and house stock medications that are not kept with cover. Failures have the potential to affect 16 residents that are on the same floor that may receive insulin and medications that are not in the right container exposed to environment.

Inspectors wroteBased on observations, interview and records review, the facility failed to follow their policy on dignity by failing to provide privacy bag for indwelling urinary catheter for one (R6) of two residents reviewed in a sample of 21.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide grooming care for three (R23, R31, R47) dependent residents reviewed for Activities of Daily Living/ADL care.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure low air loss mattress devices were in the correct settings for two (R32 and R53) residents using a low air loss mattress.

Inspectors wroteBased on observation, interviews, and review of records the facility failed to follow enteral tube medication administration policy related to proper tube placement prior to administering medication via gastronomy tube. These failures apply to 1 resident (R47) out of 7 residents observed during medication administration review.

Inspectors wroteBased on observation, interview and review of records, the facility failed to administer the right dose of medication as ordered. There were 26 opportunities with 3 errors resulting to 11.54% (percent) error rate. These failures applies to 2 residents (R104 and R57) out of 7 residents observed for medication administration.

Inspectors wroteBased on observation, interview and record review the facility failed to follow the recommended menu for three residents (R67, R68 and R112) that receive a puree diet.

Inspectors wroteBased on observation, interview, and review of records the facility failed to follow the policy of infection control aseptic techniques by stacking five medication cups containing medication that were exposed to high touch areas and then administered the medication via a gastronomy tube. The facility also failed to follow Enhanced Barrier Precautions by not wearing required personal protective equipment during medication administration via gastronomy tube. These failures apply to 1 resident (R47) out of 7 residents observed during medication administration review.

Inspectors wroteBased on interview and record review the facility failed to offer pneumonia vaccines to eligible residents residing in the facility. This failure affects four of five residents (R25, R31, R40, R47) reviewed for pneumonia vaccines in the sample of 21.

Inspectors wroteBased observations, interviews, and review of records the facility failed to provide privacy curtain for a resident that has daily treatment order on perennial area for 1 out of 1 resident (R77) for a total sample 21 residents. This failure affects 1 resident (R77) privacy during scheduled treatment.

Inspectors wroteBased on interview and record review, the facility failed to update the Facility Assessment on an annual basis. This failure has the potential to affect all 101 residents residing in the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed follow their policy on hand washing by staff not washing hands after handling dirty dishes and before handling clean dishes. These failures have the potential to affect all 103 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observations interviews and records review, the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents. This failure has the potential to affect all 105 residents residing in the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the 3-lid outside dumpster was closed at all times and failed to ensure the 3-lid outside dumpster was not overflowing with trash in an effort to prevent pest and rodent migration. These failures have the potential to affect all residents residing at the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a home like environment for 6 (R5, R6, R7, R8, R9, and R10) residents reviewed for safe, clean, comfortable, and home like environment in a total sample of 11 residents.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of physical abuse to the local state agency. This failure affected one resident (R4) out of four residents reviewed for physical abuse.

Inspectors wroteBased on interview, and record review, the facility failed to adequately supervise a resident and failed to implement individualized fall prevention interventions for a resident operating a motorized wheelchair to avoid a fall for one resident (R4) who was identified at risk for falls. This failure affected one resident (R4) out of 4 residents reviewed for fall injury prevention interventions.

Inspectors wroteBased on observation, interview and record review the facility failed to address significant, unplanned weight loss, and failed follow Registered Dietitian's recommendation to start oral nutritional supplements. The facility also failed notify the physician of a significant, unplanned weight loss. This resulted in a continued weight loss including a significant weight loss (>5% change over a span of 1 month and >7.5% change over a span of 3-month period) for 1 (R63) of 7 residents reviewed for nutrition for a total of 25 residents in the final sample.

Inspectors wroteBased on observations, interviews ,and record review the facility failed to maintain a clean environment in multiple areas. The dry storage room was seen with dirt and dropping like particles. The dishwashing room and food preparation area large fans have dirt and accumulation of particles. Multiple kind of breads were not dated when received. The facility also failed to take food temperature before placing on the plate for consumption. These failures have the potential to affect 112 residents in the facility who are receiving oral diet.

Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain accurate records of usage and accountability, for 5 residents (R15, R26, R50, R93, and R214) receiving controlled substances on 2 of 5 medication carts reviewed for medication storage and labeling.

Inspectors wroteBased on observation, interview and record review the facility failed to label individual resident's insulin [NAME] with an open date, failed follow their policy to discard expired insulin and house stock medications, and failed follow pharmaceutical storage instructions to refrigerate unopened insulin in 2 of 5 medication carts reviewed for medication storage and labeling for 4 residents (R15, R57, R82, R213) in a sample of 43 residents.

Inspectors wroteBased on observations, interviews, and record review the facility failed to date and store respiratory supplies per facility's policy for 6 (R7, R63, R71, R94, R100, and R163) of 6 residents reviewed and failed to ensure a urinary catheter storage bag was stored properly for 1 (R14) out of 1 resident reviewed for infection control and prevention. These failures have the potential to affect 7 residents (R7, R14, R63, R71, R94, R100, and R163) in minimizing risk of infections for a total of 25 residents in the final sample.

Inspectors wroteBased on observation, interviews, and record review the facility failed to follow their policy to care plan a resident to self-administer an inhaler. Resident verbalized taking the medication more than what was ordered by physician. Failures include 1 out of 1 resident (R71) reviewed for self-administration of medication for a total of 25 residents in the final sample.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to follow a resident's (R86) preferences for getting out of bed for 1 out of a total sample of 25 residents.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide transfer assistance and repositioning to a dependent resident (R86) for 1 out of a total sample of 25 residents.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to apply a resident's (R41) ordered splints/orthotics for 1 of 3 residents reviewed for splints/orthotics in a total sample of 25 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a functioning walker, failed to assess for fall risk and failed to care plan a resident for fall. These failures affected 1 out of 3 residents (R31) reviewed for accidents and hazards in a total of 25 residents in the final sample.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide food in the appropriate form as prescribed by the physician's diet order for 1 resident (R110) out of 7 residents reviewed for nutrition for a total of 25 residents in the final sample.