Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aperion Care West Chicago during CMS and state inspections, most recent first.
Failure to Prevent Verbal Abuse Between Residents: Two residents were involved in an altercation after one resident teased another resident and mispronounced a third resident’s name. The exchange escalated into profane name-calling, threats to kill, and an attempted physical attack that staff had to block. One resident had a history of verbal aggression and poor impulse control, and multiple witnesses, including an aide and psychosocial staff, confirmed the threatening behavior.
Failure to report resident-to-resident abuse allegation: Two residents became involved in a dining room altercation that included verbal threats, profanity, and an attempted physical attack. One resident with a history of verbal aggression and poor impulse control was reported to have used derogatory language and threatened to kill the other resident, while multiple witnesses and staff described the event as escalating behavior requiring intervention. The administrator interviewed staff but did not report the incident to the State Agency, and the abuse investigation logs did not include the event.
A facility failed to investigate an alleged verbal and mental abuse incident between two residents. Staff and resident interviews described one resident using profane, threatening language, including a threat to kill the other resident, and attempting to attack him while staff blocked the approach. The abuse logs did not include the incident, despite the facility policy requiring documentation of all incidents and a proper investigation of any abuse allegation.
A resident with intact cognition was suddenly attacked from behind by another resident, who placed his arms around the resident’s upper torso and neck in a headlock until staff and another resident intervened. The incident was described by staff as unprovoked physical abuse, and video review confirmed the aggressor’s physical contact. After the assault, the resident developed new, severe left shoulder pain unrelieved by current analgesics, with nursing assessments documenting high pain scores and limited ROM; imaging later showed an acute or subacute glenoid fracture. The resident also reported increased anxiety, hypervigilance, sleep disturbance, depressed mood, and fear of using common areas after hearing the aggressor state he was “here for murder,” and a psychiatric NP noted these symptoms were not consistent with the resident’s baseline and reflected an acute traumatic response.
The facility failed to maintain safe and palatable food temperatures for all residents receiving meals from the kitchen. Several residents reported that their meals were not served hot, and one resident stated that staff would not reheat her food or obtain a new tray, leaving her to eat it cold. During observation, hot food items such as broccoli, sweet and sour pork, rice, and grilled cheese were found held well below 135°F, while some pureed items and carrots were at 120°F. A test tray with chili, carrots, cornbread, and cookies was served on a Styrofoam plate. The Dietary Director reported that, due to budget constraints, meals are served on Styrofoam, there is no plate warmer, and delivery carts are not insulated, all of which affect temperature maintenance, and also noted that trays sometimes sit on units up to 20 minutes before being passed. Facility policy requires hot foods to be held at 135°F or above.
Unsafe storage of resident food in unit refrigerators was identified when a supplement refrigerator and a shared refrigerator had no thermometer or temperature log and contained opened, unlabeled, undated, and expired food items, including spoiled food with a sour smell. Staff interviews showed confusion about who was responsible for cleaning the refrigerators, labeling and dating food, and maintaining temperature logs, and the DON and Administrator could not provide the last 12 months of refrigerator temperature logs.
The facility failed to maintain a functional call light system for an entire hall, affecting 28 residents whose room call lights were not activating signals at the nurses’ station or outside their doors. Cognitively intact residents who required moderate to substantial assistance with ADLs reported that their call lights had not worked since the prior day and that this was a recurrent issue, forcing them to yell or bang on walls to obtain help, including for toileting. A visually impaired resident with cognitive impairment and needing moderate to maximal ADL assistance was observed repeatedly yelling for help with hydration without staff response. A CNA confirmed that the hall’s call lights were not working at the start of her shift and that she received no instructions on alternative monitoring. Maintenance staff and the Maintenance Director reported recurrent wiring problems with the main call light panel, acknowledged that some rooms’ call lights had stopped working multiple times in the past month, and indicated there were no work order logs for these issues, while facility documentation of rounding was limited and nonspecific.
A facility failed to administer and record individualized oral nutritional supplements for four residents being treated for weight loss. The residents were thin and frail, with histories including significant weight loss, dementia, dysphagia, mental health disorders, and pressure injuries. Staff reported giving house stock supplements in a standard cup, but the EMARs did not show the amount administered or consumed, and the care plans did not consistently reflect the ordered supplement interventions.
Failure to monitor psychotropic side effects and antiseizure drug levels. A resident receiving Clozapine was repeatedly observed with excessive drooling, and two other residents on psychotropic regimens were also observed drooling, yet the TARs documented no side effects despite orders and care plans to monitor for them. In addition, a resident with a seizure disorder had a subtherapeutic Dilantin level, the MD ordered a dose increase and repeat level, and the follow-up blood level was not completed as ordered.
Resident room refrigerators were found without thermometers, without daily temperature logs, and with expired food left inside. One resident’s refrigerator was dirty, and another had ice buildup and a broken door hinge that had been reported but not repaired. Facility staff stated thermometers, temperature logs, and refrigerator cleaning were supposed to be in place per policy.
Two residents were involved in a resident-to-resident physical altercation in which one resident placed the other in a headlock, resulting in severe shoulder pain and later psychosocial distress for the affected resident. The Administrator/Abuse Coordinator viewed security footage confirming the event but did not initially classify it as abuse or report it to the state agency within the time frames required by facility policy, and an internal investigation with staff statements and incident documentation was not promptly completed. Neither resident’s EMR or care plan was updated at the time of the incident to include new interventions, protections, or behavior-related approaches, despite one resident’s psychiatric diagnoses and the other’s ongoing pain and distress, and abuse- and behavior-related care plan sections were only added during the survey.
Two residents were involved in a physical altercation in which one resident reportedly charged at another, grabbed him, and placed him in a headlock, after which the affected resident complained of severe shoulder pain. The Administrator/Abuse Coordinator reviewed security camera footage and was aware of the incident the same day but did not immediately report it to the state agency or initiate a thorough abuse investigation as required by facility policy. The incident was reported to the state and an investigation was initiated only several days later, contrary to the facility’s abuse reporting and investigation procedures.
A resident developed new, sharp, severe left shoulder pain after an altercation, with pain scores frequently in the 7–10/10 range and compromised shoulder ROM, despite receiving PRN acetaminophen-codeine and acetaminophen. The resident repeatedly reported that existing pain medications were ineffective and requested further evaluation, yet staff did not promptly initiate a comprehensive pain assessment or timely revise the pain management plan as required by the facility’s pain management policy, resulting in prolonged unrelieved pain until imaging later identified a left glenoid fracture.
Resident food reheating was limited to posted time windows, and a resident reported that a microwave previously available to residents had been removed. Staff confirmed residents could not access the microwave behind the nursing station and that food would only be reheated during specified morning and evening periods, with no reheating after bedtime. The ADM stated there was no facility policy specifying when food may be reheated.
Failure to Provide Ordered PT: A resident with Parkinsonism, idiopathic progressive neuropathy, recurrent major depressive disorder, and drug-induced subacute dyskinesia reported numbness and tingling in both legs and fingers and said his neurologist ordered PT that was never set up. Staff interviews and record review showed the RN had not recently provided PT, the scheduler believed the referral had been sent to the PT director, and the PT director stated the resident had not been seen by PT since 2022. The neurologist’s AVS included a PT referral to evaluate and treat sensory ataxia, but the facility had no documentation that the ordered PT services were provided.
The facility did not maintain hot water temperatures within the required range in bathrooms and showers, resulting in cold or tepid water for all residents over an extended period. Multiple residents reported discomfort and avoided bathing, while staff and maintenance logs documented ongoing complaints. Water temperature checks confirmed readings well below policy standards, and maintenance staff acknowledged delayed and insufficient monitoring and response.
A resident with multiple medical conditions reported pain and rough treatment during care by a CNA, leading to distress and complaints to staff. Several staff members observed the resident's distress, reported the incident, and wrote statements, but the administrator did not report the abuse allegation to the Department of Public Health as required by facility policy.
Two residents with multiple medical conditions experienced excessive heat in their room due to a malfunctioning air conditioner that was not promptly repaired. Despite reports from the residents and high heat index readings, staff did not monitor the room temperature as required by facility policy, resulting in prolonged exposure to uncomfortable and potentially unsafe conditions.
Two cognitively intact sisters residing in different units were denied the right to visit each other, despite repeated requests and no behavioral issues. Staff failed to address or document their visitation rights in care plans, and ignored or dismissed the requests until the issue was raised during a survey. This was not in accordance with the facility's policy, which allows 24-hour access for immediate family.
Two residents experienced unprovoked physical abuse from another resident with a history of aggression and cognitive impairment. The aggressor struck both individuals with a closed fist, causing significant pain but no visible injuries. The incidents were reported to staff and confirmed through interviews and record review, highlighting a failure to protect residents from physical abuse.
Two residents with intact cognition reported being physically abused by another resident, with one incident witnessed by CNAs and reported to psychiatric rehabilitation staff. Despite these reports, the allegations were not communicated to the Abuse Coordinator or State Agency as required by facility policy, resulting in a failure to initiate timely investigation.
A resident with psychiatric conditions left the facility unsupervised and was found deceased the next morning. The resident signed out with a red pass, which allowed unsupervised outings, but did not return as expected. The receptionist failed to notify the nursing staff, leading to a delay in recognizing the resident's absence. The nursing staff was unaware until after 11:00 PM, and the resident was found deceased the following morning.
The facility failed to ensure monthly Medication Regimen Reviews (MRR) were conducted for several residents, as required by their policies. This deficiency was identified through interviews and record reviews, revealing missing MRRs for multiple residents with various medical conditions. The facility could not provide documentation of pharmacy recommendations or follow-up actions, despite the consulting pharmacist's responsibility to complete and email the MRRs.
A resident was observed in the dining room wearing an improperly closed gown, exposing her skin and undergarments, which compromised her dignity. Despite being cognitively intact and having clothing available, the resident was not assisted to dress appropriately, contrary to the facility's dignity policy.
A resident with intact cognition and a long-standing vegan diet was not provided with adequate vegan protein sources at the facility, leading to allergic reactions from consuming dairy products. Despite multiple discussions with staff, the facility failed to document or accommodate her dietary preferences, resulting in meals lacking protein and a care plan that did not address her vegan diet.
A resident with multiple health conditions had an exposed central venous catheter due to a missing end cap, which was not promptly addressed by the facility's staff. The Infection Control Nurse and the assigned RN failed to apply a sterile barrier, contrary to the facility's policy, leaving the catheter exposed for two days until a suitable end cap was found.
A facility failed to document a resident's assessment after dialysis sessions, despite the resident's dependence on hemodialysis and multiple diagnoses. The resident's care plan required assessments, including vital signs and fistula site condition, which were not documented until late November. Additionally, there was a lack of consistent communication regarding the avoidance of taking blood pressure from the resident's right arm, where a fistula was located.
A resident did not receive pregabalin for several days after admission due to a failure in submitting a prescription to the pharmacy. The medication was supposed to start shortly after admission, but was delayed until the issue was identified and addressed by the staff. The facility's policy requires a valid prescription for controlled substances, which was not followed.
A resident with a vegan diet and dairy allergy was not provided with appropriate meals at the facility. Despite her dietary needs being communicated, she was forced to consume dairy products due to a lack of alternative protein sources, leading to allergic reactions. The facility's dietitian and food service director acknowledged the issue, but the resident's clinical record lacked documentation of her dietary preferences and allergy.
A resident with a documented dairy allergy and preference for a vegan diet was repeatedly provided with dairy products as protein sources, leading to allergic reactions. Despite the resident's complaints and discussions with the facility's dietitian and food service director, the facility failed to offer adequate vegan protein options or document the resident's dietary needs, resulting in continued exposure to allergens.
A facility failed to reassess a resident's capacity for sexual consent after a cognitive decline, leading to an inappropriate incident with another resident. Despite severe dementia, staff initially believed the interaction was consensual. The incident was not reported promptly, violating facility policies.
A facility failed to timely report a sexual abuse incident involving two residents, one of whom had severe cognitive impairment. Staff intervened and separated the residents, but the facility did not immediately report the incident to authorities, believing it was consensual based on outdated assessments. Further evaluations revealed the resident's inability to consent, leading to a delayed report to the Illinois Department of Public Health and local law enforcement.
A facility failed to promptly investigate a sexual abuse incident involving two residents in a secure behavioral unit. Despite initial reports of consensual interaction, witnesses described inappropriate behavior, and one resident's cognitive impairment indicated she could not consent. The facility delayed reporting the incident to authorities, relying on outdated assessments, and did not follow its abuse prevention policy.
A facility failed to update a care plan after a resident's cognitive status declined, affecting her ability to consent to sexual activity. Initially assessed as capable, the resident's BIMS score later indicated severe impairment, but the care plan lacked specific interventions to address this change, leaving her at risk for sexual abuse.
The facility failed to protect residents from physical abuse by their peers, as multiple incidents involving ten residents were not reported to the Illinois Department of Public Health. The administrator believed only incidents causing emotional distress or physical injury needed reporting, following a directive from corporate. Incidents included physical altercations between residents with various mental health diagnoses, such as schizophrenia and bipolar disorder, which were not documented as required by the facility's policy.
The facility failed to report multiple allegations of abuse to the Illinois Department of Public Health within the required two-hour timeframe. Incidents involving residents with psychiatric and cognitive impairments, such as physical altercations and aggressive behaviors, were documented but not reported as mandated by the facility's policy. This deficiency was identified for all residents reviewed for abuse allegations.
Failure to Prevent Verbal Abuse Between Residents
Penalty
Summary
The facility failed to keep residents free from verbal and mental abuse. The deficiency involved 2 of 6 residents reviewed for abuse in a sample of 8 residents. Resident 1 was a male with diagnoses including a single episode of major depressive disorder, alcohol dependence in remission, insomnia, and peripheral vascular disease, and his care plan noted a history of verbal aggression and poor impulse control. Resident 2 was a male with diagnoses including anxiety disorder and problems related to social environment. On May 14, 2026, an altercation occurred in the dining room/first floor common area between Resident 1 and Resident 2 after Resident 1 was teasing Resident 5 and mispronouncing his name. Resident 2 asked Resident 1 to stop, and the interaction escalated into yelling and threats. Resident 2 stated Resident 1 called him a profane derogatory name, threatened to kill him, and attempted to attack him, causing him to shake and move away. Resident 1 stated he lunged toward Resident 2, went after him to throw a punch, and yelled profanities and threats. Resident 6, the restorative aide, and psychosocial services staff all reported hearing Resident 1 threaten Resident 2 and observed staff physically block Resident 1 from reaching him. The facility policy defined verbal abuse as oral or gestured language that includes disparaging or derogatory terms, threats of harm, or statements meant to frighten a resident.
Failure to Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an incident of abuse to the State Agency after an altercation between two residents. One resident had diagnoses including a single episode of major depressive disorder, alcohol dependence in remission, insomnia, and peripheral vascular disease, and his care plan noted a history of verbal aggression and poor impulse control. Another resident had diagnoses including anxiety disorder and problems related to social environment. During the incident in the dining room, the two residents argued after one resident was teasing another resident by mispronouncing his name, and the interaction escalated into verbal threats and an attempted physical attack. Statements obtained during interviews described the incident as involving profanity, threats, and aggressive behavior. One resident said the other became angry, used a profane derogatory name, stood up, and headed toward him to attack him. The other resident said he was going after the first resident and admitted he was out of line and had gone after him to throw a punch. A restorative aide said he held the resident back from approaching the other resident and heard, "I'll kill you." Another resident said she heard a threat to kill the other resident. Staff members also described the event as a code yellow behavior incident in which one resident was verbally aggressive and attempting to get through staff to reach the other resident. The administrator stated he interviewed several staff members about the disagreement, but the facility abuse investigation logs and reports for the month did not include a report of the altercation. The administrator also stated he did not report the incident to the State Agency. The facility policy stated that any allegation of abuse would be reported to the Illinois Department of Public Health immediately, but not more than two hours after the allegation of abuse, and that any incident not involving abuse and not resulting in serious bodily injury would be reported within 24 hours.
Failure to Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to investigate an incident of verbal and mental abuse involving two residents. One resident had diagnoses including a single episode of major depressive disorder, alcohol dependence in remission, insomnia, and peripheral vascular disease, and his care plan noted a history of verbal aggression and poor impulse control. Another resident had diagnoses including anxiety disorder and problems related to social environment. Interviews with staff and residents described an altercation in the dining/common area in which one resident became verbally aggressive toward the other, used profane and derogatory language, threatened to kill him, and attempted to physically approach or attack him while staff had to block him. The other resident reported feeling shaken and moving away during the incident, and a witness stated the resident threatened to kill the other resident. The facility’s abuse investigation logs for the month did not include an investigation of this altercation. The administrator stated staff reported a disagreement and that one resident became more escalated than the other, but he did not type up interviews. The facility policy stated that all incidents would be documented, whether or not abuse, and that any incident or allegation involving abuse would result in a proper investigation.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Shoulder Fracture and Psychosocial Harm
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident from resident-to-resident physical abuse. Late in the evening, one resident was suddenly attacked by another male resident who approached from behind while the victim was standing at the ice machine holding a cup. The aggressor placed both arms around the resident’s upper torso and neck area, putting him in a headlock. Staff and another resident intervened to separate them. Multiple staff, including an RN and a CNA, as well as the resident’s roommate, described the event as an unprovoked physical attack or physical abuse. The Administrator, who serves as the Abuse Coordinator, reviewed security camera footage and confirmed that the aggressor made physical contact and had his arms around the resident from behind. Following the incident, the resident reported new, severe left shoulder pain that began after the attack, distinct from his pre-existing chronic cervical and back pain from a decades-old accident. He consistently rated his shoulder pain as 8–10/10, described it as severe and unbearable, and reported that it was not relieved by his current pain medications. Nursing documentation reflected ongoing high pain scores and limited range of motion in the left shoulder. An X-ray later showed an acute or subacute inferior glenoid fracture fragment of the left shoulder, and the resident continued to experience significant pain with shoulder movement. The resident stated he had repeatedly requested an X-ray and to be sent to the hospital to assess the injury. The resident also experienced psychosocial distress after the assault. He reported feeling on edge, anxious, fearful of encountering the aggressor again, and hesitant to use common areas where the abuse occurred. He described intrusive recollection of the aggressor’s statement, “I’m here for murder,” which he heard during the altercation and which replayed in his mind, causing fear and distress. He reported difficulty sleeping, frequent nighttime awakenings, feeling more depressed and withdrawn, and no longer feeling safe in the facility. A psychiatric NP noted that the resident’s reported symptoms of heightened anxiety, hypervigilance, disrupted sleep, and worsening mood were not consistent with his baseline and were characteristic of an acute traumatic response. Both the in-house NP and psychiatric NP emphasized that pain and psychological distress are subjective experiences that must be taken seriously regardless of mental or psychiatric status. The facility’s own abuse policy affirms residents’ rights to be free from abuse and defines abuse as the willful infliction of injury or intimidation resulting in physical harm, pain, or mental anguish.
Failure to Maintain Safe and Palatable Food Temperatures
Penalty
Summary
The facility failed to ensure that food and drink were served at palatable and safe temperatures for all residents receiving meals from the kitchen. Multiple residents reported that their meals were not served hot, with one resident stating the food is not always served hot, another stating the food is usually barely warm, and another stating the meals are usually not served hot. One resident reported that when she requested staff to reheat her food, she was told they could not do so and would not obtain a new tray from the kitchen, leaving her to eat the food cold. The DON confirmed that all residents in the facility at the time of the survey received services from the Dietary department. During a meal service observation with the Dietary Director and a cook, several hot food items were found to be held below the facility’s stated standard of 135°F, including broccoli at 100°F, sweet and sour pork (carbohydrate-controlled, low concentrated sweets) at 95°F, plain rice at 100°F, and grilled cheese sandwiches at 90°F, while some pureed items and carrots were at 120°F. A test tray contained chili, carrots, crumbly cornbread, and cookies served on a Styrofoam plate. The Dietary Director stated that due to budget constraints, the facility uses Styrofoam instead of real plates, acknowledged that Styrofoam affects the maintenance of food temperatures, and reported there is no plate warmer and the delivery carts are not insulated. He also stated that there have been occasions when meal trays remained unpassed on the units for up to 20 minutes after leaving the kitchen. The facility’s undated policy stated that foods meant to be held for a long time require elevated temperatures and should be held at 135°F or above.
Unsafe Storage of Resident Food in Unit Refrigerators
Penalty
Summary
The facility failed to store refrigerated resident food safely in the refrigerators on the units. On 01/29/2026, the second-floor small refrigerator identified by CNAs as the supplement refrigerator had no thermometer or temperature log and contained opened beverages, a bun wrapped in a paper towel with white crystal powdered substance, a green apple with bite marks, a cup of vanilla pudding without a date or label, and a 32 oz carton of nutritional supplement without an open or use-by date. The larger shared refrigerator on the same floor also had no thermometer or temperature log and contained multiple expired, unlabeled, or undated food items, including expired chicken noodle soup, dried-up blueberries, unlabeled containers of rice and meat, noodle dish, vegetable pizza, asparagus, bread with fettuccini and shrimp, an expired smoothie, and an unlabeled pizza in a zippered bag. One container of bread, fettuccini, and shrimp had a strong sour spoiled smell. Staff interviews showed confusion about responsibility for refrigerator cleaning, labeling, dating, and temperature monitoring. A CNA stated she did not know who was responsible for maintaining the refrigerator log or throwing out expired spoiled food items, while another CNA stated the staff member receiving the food was responsible for labeling and dating it and that maintenance was responsible for updating the temperature log. The Maintenance Director stated everyone using the refrigerator was responsible for keeping it clean but did not know who monitored the refrigerator or log or where completed logs were kept. The DON stated nursing staff were responsible for the unit refrigerators, including labeling and dating food items and completing the temperature log, and said temperatures could not be logged without a thermometer. The Administrator and DON were unable to provide the last twelve months of refrigerator temperature logs for the unit refrigerators.
Failure to Maintain Functional Call Light System for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure a functioning call light system for all residents on one hall, affecting 28 residents whose rooms were connected to a faulty call light panel. Multiple residents reported that their call lights had not worked since the previous day and that this was a recurrent problem over the past month. One cognitively intact resident who required moderate to maximal assistance with ADLs demonstrated that pressing his call light did not activate a signal outside his door or at the nurses’ station and stated he had no way to get assistance or help in an emergency. Another cognitively intact resident who required touch to substantial assistance with ADLs reported significant difficulty obtaining toileting assistance due to the nonfunctioning call light and described having to yell or bang on the wall to get staff attention. A visually impaired resident with cognitive impairment and needing moderate to maximal ADL assistance was observed yelling repeatedly for help with hydration without staff response. Staff interviews confirmed that the call lights for the unit had stopped working the previous afternoon and that this had occurred multiple times in the prior month. A CNA assigned to the affected hall stated that when she started her morning shift, the room call lights were not working and that she had not been given instructions on how residents would be monitored while the system was down. Maintenance staff reported that the main call light panel at the nurses’ station had a missing wiring connection, that they had just rewired it, and that the wiring problem had recurred at least three times in the past month. The Maintenance Director acknowledged that some rooms’ call lights had stopped working, that an outside vendor had been called previously, and that there were no work order logs for the call light issues. An untitled facility document showed 30‑minute rounding for a limited time period on one date but did not specify which residents were rounded on, what type of rounds were done, or any entries covering the time from when the call lights again stopped working through the following morning, despite the facility’s policy requiring prompt reporting of call bell system defects and room checks until repair.
Failure to document and individualize oral nutritional supplements for residents with weight loss
Penalty
Summary
The facility failed to administer and record individualized supplemental nutritional interventions for residents being treated for weight loss. Four residents reviewed for nutrition—R51, R8, R10, and R121—had active orders for house stock oral nutritional supplements, but the January 2026 EMARs did not document the total amount administered and consumed for any of them. The facility’s dietitian and nursing staff stated that the supplements were ordered as a serving, but the order did not specify the amount because the product could change, and nurses were using the facility’s house stock supplement container for administration. R51 was described as thin and frail, with a history of significant weight loss, dementia with mental health illness, and dysphagia. He was observed multiple times with poor intake, including skipping breakfast or eating less than 50% of a meal. A CNA reported his refusal of meals to the LPN, and the LPN stated she gave him the ordered nutritional supplement using a 5-oz medication cup, while also giving the same measured amount to R8, R10, and R121. R51’s care plan included monitoring intake and recording it, along with providing supplements as ordered, but the EMAR did not show the amount administered and consumed. R8, R10, and R121 were also described as thin and frail, with histories of significant weight loss and other conditions including mental health disorders, dementia, and dysphagia. R8’s nutrition note called for a daily supplement, R10’s note called for supplements three times a day, and R121’s note called for additional nutritional support related to pressure injuries and wound healing. Their care plans included supplement-related interventions, but the EMARs did not document the amount administered and consumed. The facility policy stated that residents receiving supplements should have individualized nutritional interventions written in the MAR and that the resident’s tolerance of the supplement would be monitored and data collected in the medical record.
Failure to Monitor Psychotropic Side Effects and Antiseizure Drug Levels
Penalty
Summary
The facility failed to monitor, identify, and document side effects of medications for residents receiving psychotropic drugs. R82, who had diagnoses including anxiety disorder, psychosis, schizophrenia, depression, and extrapyramidal and movement disorder, was observed on multiple occasions with excessive drooling while talking, repeatedly wiping his mouth, and showing moisture marks on his shirt below his mouth. He stated that he could not control the drooling and felt embarrassed by it. His POS showed he was receiving Clozapine 50 mg, three tablets in the morning and five tablets at bedtime, and an order to monitor for side effects of antipsychotic medication was documented. However, the TAR for January 2026 showed no side effects documented for the month, despite the observations and staff statements that drooling is a common side effect of antipsychotic medication. R93, who had diagnoses including dementia, depressive disorder, severe intellectual disabilities, and schizoaffective disorder, bipolar type, was observed pacing, repeatedly stating he was going to the gas station and asking what he needed to buy, while also drooling excessively with moisture marks on his shirt. On additional observations, he was standing near the nurse's station and drooling excessively. His POS showed he received Clozapine 50 mg at bedtime, Olanzapine 20 mg half tablet twice daily, and Benztropine Mesylate 0.5 mg twice daily for drug-induced extrapyramidal symptoms, with an order to monitor for side effects of antipsychotic medication. His care plan directed staff to monitor for side effects and effectiveness every shift, but the TAR documented no side effects for the month reviewed. R182, who had diagnoses including depressive disorder, anxiety disorder, extrapyramidal and movement disorder, schizophrenia, and schizoaffective disorder, was also observed with excessive drooling while standing by his doorway and constantly wiping his mouth while talking. He said he was embarrassed by the drooling and that his appearance mattered to him. His POS showed he received Clozapine 100 mg every morning and 200 mg at bedtime, along with Benztropine Mesylate 1 mg twice daily, and an order to monitor for side effects of antipsychotic medication. His care plan also required monitoring for side effects and effectiveness every shift, but the TAR again showed no side effects documented for the month reviewed. In addition, R51, who had a seizure disorder and history of convulsions, was receiving Dilantin for seizure management. His last Dilantin blood level was 4.0, below the reference range of 10.0 to 20.0, and the physician ordered a dosage increase and a repeat blood level in two weeks. The repeat level was not completed as ordered, and the EMR showed the lab order remained incomplete as of the survey date.
Resident Room Refrigerators Lacked Thermometers, Logs, and Proper Maintenance
Penalty
Summary
The facility failed to maintain resident room refrigerators in accordance with its policy for foods brought in by family and other visitors. During observation, 5 of 5 reviewed residents with refrigerators had issues including missing thermometers, no temperature logs available, expired food items left inside, and refrigerators that were dirty or not functioning properly. R119 and R207 each had refrigerators without thermometers, and R207’s refrigerator contained chicken salad and applesauce. R118’s refrigerator also had no thermometer and contained multiple half-pints of milk with best-by dates of 1/21/26 and 1/26/26. R66’s refrigerator was heavily stained and dirty inside, and no temperature logs were available for any of these residents’ refrigerators. R168’s refrigerator had ice built up in the freezer and a broken door hinge that made it difficult to open and close, and the resident stated the condition had been present for some time and had been reported to staff without repair. Facility staff identified that thermometers were supposed to be in resident refrigerators, Social Services was supposed to check with residents regarding the refrigerators, and housekeeping was responsible for cleaning them. The facility policy required each refrigerator to have an inside thermometer and a daily temperature log, for food past its use-by date to be discarded, and for housekeeping to clean and sanitize refrigerators at least monthly.
Failure to Identify, Investigate, and Report Resident-to-Resident Abuse and Update Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify, investigate, protect, and report an incident of resident-to-resident abuse, and to implement care plan interventions afterward. One resident reported severe left shoulder pain that began after another resident suddenly charged at him, grabbed him from behind, and placed both arms around his upper torso in a headlock. During observation, the resident was seen in bed holding his left shoulder and wincing in pain, and later verbalized psychosocial distress related to the incident. The Administrator/Abuse Coordinator acknowledged reviewing security camera footage the night of the incident, which showed the aggressor resident approaching from behind and placing both arms around the other resident’s upper torso. Despite this, the Administrator did not consider the event to meet the facility’s definition of abuse at that time and did not report it to the state agency until nine days later, contrary to the facility’s policy requiring immediate or timely reporting of allegations and incidents. The facility did not conduct an internal investigation of the incident in a timely manner and was unable to provide staff statements, interviews, incident reports, or other related documentation during the survey. Review of the injured resident’s EMR showed no new care plan interventions or protective measures were initiated following the incident to address his severe shoulder pain or psychosocial distress, and his care plan was not updated until during the survey. The other resident involved had diagnoses including anxiety disorder, insomnia, schizophrenia, and schizoaffective disorder, yet his care plan was also not updated after the incident. Care plan sections addressing abuse, behaviors, mood triggers, and physical and verbal aggression for both residents were only added during the survey, indicating that the facility did not promptly implement or document interventions or protections following the reported abuse, as required by its Abuse and Retaliation Prevention and Reporting policy.
Failure to Timely Report and Investigate Resident-on-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to promptly report and thoroughly investigate an allegation of physical abuse between two residents. On 1/27/2026 at 10:37 AM, one resident (R131) was observed sitting in bed, holding his left shoulder and wincing in pain, and reported experiencing severe left shoulder pain that began on 1/18/2026 after being physically attacked by another resident (R200). R131 stated that R200 suddenly charged at him, grabbed him, and placed both arms around his upper torso, putting him in a headlock. The facility’s Administrator/Abuse Coordinator (V1) acknowledged that he had reviewed security camera footage from 1/18/2026 and was aware of the incident that same night. Despite this awareness, V1 stated he did not report the incident to the Illinois Department of Public Health (IDPH) at that time because he did not believe it met the definition of abuse, citing the absence of serious injury, bodily harm, or psychosocial effects. The incident was not reported to IDPH until 1/27/2026, as confirmed by a fax confirmation sheet showing the initial report was sent at 2:59 PM with a documented occurrence date of 1/18/2026 and categorized as resident abuse. The report also indicated that a thorough investigation was to be conducted, demonstrating that the investigation was initiated nine days after the incident. This delay and failure to immediately initiate an investigation conflicted with the facility’s Abuse and Retaliation Prevention and Reporting policy, which requires that all incidents be documented and that any incident or allegation involving abuse result in an investigation initiated by the administrator or designee upon learning of the report, including interviews of the reporter, individuals with direct knowledge, and the resident, as well as review of written statements and pertinent medical records or documents.
Failure to Adequately Assess and Manage New Onset Severe Shoulder Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate assessment and management for a resident’s new onset of severe left shoulder pain following a physical altercation with another resident. The resident, who had previously reported only mild, occasional pain that did not affect sleep and had intact cognition and no upper extremity ROM limitations per the MDS, began experiencing sharp, non-radiating left anterior shoulder pain rated 8–10/10 after the incident. The N Adv – Long Term Care Evaluation identified this as a new issue, with documented severe pain and facial expressions consistent with pain. Despite this, the resident reported that his existing pain medication regimen, which predated the incident, was not relieving the new shoulder pain, and he repeatedly requested an X-ray and hospital evaluation. Medication records showed that after the incident, the resident received PRN Acetaminophen-Codeine 300-30 mg and Tylenol Extra Strength 500 mg on multiple occasions, yet pain assessments documented ongoing moderate to severe pain levels (4–10/10) on numerous days. The resident consistently reported severe, unrelieved left shoulder pain, including during surveyor interviews, and described worsening pain with shoulder movement. Nursing documentation and interviews confirmed that the resident’s pain remained severe and that his left shoulder ROM was compromised, indicating a change in condition and ineffective pain control. However, there was no evidence that the pain management plan was promptly reassessed or modified in response to the resident’s persistent high pain scores and reports of inadequate relief. The facility’s own Pain Management Program policy required initiation of a pain assessment protocol whenever there is a change in condition requiring pain control or a change in the identification of pain, recognition of pain as the fifth vital sign, ongoing monitoring, and review and updating of care plans when pain management is ineffective. Interviews with the in-house NP and psychiatric NP emphasized that pain is subjective and must be taken seriously regardless of psychiatric status, and that uncontrolled pain can exacerbate psychological symptoms. Despite these expectations and the DON’s stated requirement that pain rated above 6/10 necessitates immediate action, the resident’s severe, ongoing pain after the new injury was not adequately assessed or managed in a timely manner, and the pain management plan was not effectively adjusted in accordance with facility policy until much later, when imaging ultimately revealed a left glenoid fracture.
Resident Food Reheating Restricted to Set Times
Penalty
Summary
The facility failed to honor a resident's wish to have food warmed in a microwave at the resident's preferred time. R37 stated that a microwave had previously been available for resident use but was removed, and the only microwave now available is located at the nursing station and is not accessible to residents. R37 reported that if food needs to be reheated, staff must do it, but only during limited posted times, and that food would not be heated after 9:30 PM. Staff confirmed that residents are not allowed behind the nursing station to use the microwave and that reheating is restricted to posted time frames of 8:30 AM to 9:30 AM and 8:45 PM to 9:15 PM. An RN stated the restriction was intended to prevent residents from interrupting staff while they work and because residents need to go to sleep at night, adding that without a cutoff time residents would stay up all night heating food. Behavioral aides and a CNA also stated they only reheat resident food during the specified times and not after bedtime. The Administrator stated there are set times for reheating food so staff are not reheating food all day, and also stated there is no facility policy specifying times when food may be reheated.
Failure to Provide Ordered Physical Therapy
Penalty
Summary
The facility failed to provide physical therapy that was ordered by the physician for R151. R151’s diagnoses included Parkinsonism, idiopathic progressive neuropathy, recurrent major depressive disorder, and drug-induced subacute dyskinesia. His care plan addressed limited range of motion in both upper and lower extremities related to pain and limited mobility, with interventions to demonstrate exercises and have the resident return-demonstrate them. During interview, R151 stated he had numbness and tingling in both legs and fingers for two years and reported that his neurologist had written orders for PT that were never set up. He also stated he gave the after-visit summary from the doctor’s office to the floor nurse and to the scheduler. Record review and staff interviews showed the resident was not receiving the ordered therapy. An RN stated R151 had not recently received PT services. The scheduler stated she arranges follow-up appointments and referrals and said R151 had been followed by the in-house PT department, with the referral given to the PT director. The PT director stated the department was not seeing R151 and had not seen him since 2022; his last PT evaluation was 8/8/22, and he received eight sessions before discharge. The DON stated that when a resident returns from a community physician visit with a PT referral, the PT director is notified during the morning meeting, or the DON is notified directly if the floor nurse provides the referral, but she did not know how the therapy order was overlooked. The neurologist’s after-visit summary dated 4/23/25 included a referral for PT to evaluate and treat sensory ataxia, and the facility had no documentation that the ordered PT services were provided.
Failure to Maintain Safe and Comfortable Hot Water Temperatures
Penalty
Summary
The facility failed to maintain hot water temperatures within a comfortable and safe range for residents in bathrooms and showers, affecting all 206 residents. Multiple residents reported that the water had been cold or freezing for at least one to three weeks, making showering uncomfortable and leading some to avoid bathing altogether. Residents consistently documented their complaints in maintenance logs and voiced their concerns to staff, including the resident council president, who highlighted the issue multiple times. Staff interviews confirmed that complaints had been ongoing, and maintenance logs reflected repeated reports of inadequate hot water. Direct observations and water temperature testing conducted by the Maintenance Director and other staff on various dates revealed that hot water temperatures in resident bathrooms and shower rooms ranged from 65.2 to 84 degrees Fahrenheit, well below the facility's policy requirement of 100-110 degrees Fahrenheit. The Maintenance Director acknowledged awareness of the issue and stated that water temperatures were only being checked twice a week, and that he did not take further action initially, opting to wait and see if the mixing valve would resolve the problem. Maintenance logs and resident council meeting minutes further documented ongoing concerns about insufficient hot water. Staff, including CNAs and RNs, confirmed that they had received numerous complaints from residents about the lack of hot water and had communicated these concerns to maintenance. Despite these reports, the issue persisted for an extended period, with maintenance staff only beginning to address the problem in the days immediately preceding the survey. The facility's own policy required staff to ensure water was at a comfortable and safe temperature before bathing residents, but this standard was not met during the period in question.
Failure to Report Abuse Allegation as Required
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident who was cognitively intact and dependent on staff for bathing and showers. The resident, who had multiple diagnoses including hemiplegia, major depressive disorder, seizures, osteoarthritis, contractures, and schizophrenia, reported experiencing pain during care, specifically when being changed and showered by a particular CNA. The resident expressed to staff that she did not want this CNA to care for her anymore due to the pain caused during these interactions. Multiple staff members, including CNAs and a nurse, observed or were informed of the resident's distress and complaints of rough care, including being pulled and having cold water put on her during a shower. On the day of the incident, the nurse on duty heard the resident crying and, upon inquiry, was told by the resident that the CNA had been rough during the shower. The nurse reported the incident to the supervisor, who then sent the CNA home pending investigation. Several staff members wrote statements about the incident and placed them in the administrator's mailbox, as per facility protocol. The Director of Nursing was notified and instructed that an assessment be completed to check for bodily injury, and a grievance form was filled out. The administrator was also notified but did not respond to the allegation until after the weekend. Despite the facility's policy requiring immediate reporting of abuse allegations to the Department of Public Health and documentation of all incidents, the administrator did not report the incident to the Illinois Department of Public Health. There was also uncertainty among staff regarding the status and handling of the investigation, with some staff not being interviewed and the Director of Nursing stating she had not received any written statements. The failure to report the abuse allegation as required by policy and regulation constitutes the deficiency.
Failure to Maintain Safe and Comfortable Room Temperatures During Extreme Heat
Penalty
Summary
The facility failed to provide a comfortable, homelike environment for two residents who experienced inadequate cooling in their shared room. Both residents, who were cognitively intact and had multiple medical diagnoses including major depressive disorder, hypertension, and type 2 diabetes mellitus, reported that their room felt warm and that the air conditioning was not functioning properly. One resident stated that he had reported the issue on a Friday, but the air conditioner had not been fixed, leading him to leave his room early in the morning due to discomfort. The other resident confirmed that the air conditioning had not been working for a long time and that the air coming from the unit was not cold, despite the windows being closed. Temperature readings taken in the room showed a heat index above the recommended maximum, with the highest recorded at 84.8 degrees Fahrenheit and humidity at 69%. Maintenance staff acknowledged that attempts to repair the air conditioner were unsuccessful and that temperature monitoring was not conducted in the affected room as required by the facility's extreme weather policy. Instead, temperatures were only taken in facility hallways and in one location on each floor, with no documentation showing that temperatures were monitored every two hours in the residents' room during the period of extreme heat. The facility's policy requires maintaining room temperatures between 71 and 81 degrees Fahrenheit and monitoring every two hours during extreme weather, but these procedures were not followed in this case.
Failure to Honor Visitation Rights Between Family Members
Penalty
Summary
The facility failed to provide visitation rights to two cognitively intact sisters, both residents, who wished to visit each other. One sister resided on a secured third-floor unit and the other on the first floor. Despite both residents having no behavioral issues and care plans that encouraged socialization and family involvement, there were no interventions or documentation in their care plans addressing their right to visit each other. The sister on the third floor repeatedly expressed her desire to visit her twin to both nursing and social services staff, but her requests were ignored or dismissed, and she was not allowed to visit her sister for an extended period. During the survey, the resident again requested to see her sister and voiced her frustration about being denied visitation, especially when other residents were allowed visitors. Staff responses were inadequate, with one staff member deflecting responsibility and another ignoring the request. Only after the resident insisted during a group meeting with surveyors and staff was she finally allowed to visit her sister. The facility's own policy states that residents have the right to receive visitors of their choosing, including immediate family, at any time, yet this policy was not followed in the case of these two residents.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by two incidents involving a resident with a history of aggression and cognitive impairment. On the morning of 4/16/2025, a resident with diagnoses including paranoid schizophrenia, dementia with anxiety, and major depressive disorder, who was known to be short-tempered and had a documented history of physical and verbal aggression, struck her roommate on the right side of the face and head with a closed fist. The attack was unprovoked, and the victim reported pain rated 6 out of 10, though no physical injury was sustained. The aggressor then left the room and struck another cognitively intact resident at the nurses' station, also with a closed fist, causing pain rated 7 out of 10 but no visible injury. Both victims reported the incidents to staff, and the events were confirmed through interviews and record review. The aggressive resident's care plan had previously documented her tendency to become physically and verbally aggressive due to medication noncompliance, poor coping skills, and mental illness. Prior incidents of aggression toward peers were also noted in her records. Staff interviews confirmed that the incidents were reported to facility administration and that the facility's abuse policy defines abuse as any physical or mental injury inflicted upon a resident, including deliberate actions by cognitively impaired individuals. The facility's failure to prevent these incidents resulted in residents experiencing pain and emotional distress.
Failure to Report Alleged Physical Abuse to Abuse Coordinator and State Agency
Penalty
Summary
The facility failed to notify the Abuse Coordinator and the State Agency of allegations of physical abuse involving two residents with intact cognition. One resident reported being hit on the head and face by another resident, though she could not recall the exact date. Another resident stated she was hit on the head four times by the same resident, resulting in a headache for two days. This incident was witnessed by two CNAs, and the resident reported it to two Psychiatric Rehabilitation Services Coordinators. Despite these reports, the allegations were not communicated to the Abuse Coordinator as required by facility policy. Staff interviews revealed that while some staff believed they had reported the incidents to appropriate personnel, the Abuse Coordinator and the State Agency were not notified. The facility's guidelines require immediate reporting of any suspected abuse to the administrator or an immediate supervisor, who must then inform the administrator. However, the chain of command was not followed, and the required notifications and investigations were not initiated in a timely manner.
Resident Found Deceased After Leaving Facility Unsupervised
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring of a resident, leading to the resident leaving the facility grounds unsupervised and not returning at the expected time. The resident, who had a history of schizophrenia, delusional disorders, and other psychiatric conditions, was allowed to leave the facility with a red pass, which permitted unsupervised outings for up to two hours. On the day of the incident, the resident signed out at 5:57 PM but did not return, and the receptionist failed to notify the nursing staff of the resident's absence. The nursing staff was unaware of the resident's absence until after 11:00 PM, resulting in a significant delay in initiating a search. The resident's nurse, who was on duty from 3:00 PM to 11:00 PM, did not receive a report from the receptionist about the resident's failure to return. The nurse only realized the resident was missing during the evening medication pass and did not call a code pink or notify the police until much later. The resident was eventually found deceased the following morning, approximately 600 feet from the facility's main entrance. Interviews with staff and other residents revealed a lack of understanding and communication regarding the facility's sign-out and pass privilege protocols. The receptionist, who was relatively new, did not follow the protocol of notifying the nurse when a resident did not return. Additionally, there was confusion among the staff about the resident's pass level and the supervision required, contributing to the oversight and delay in recognizing the resident's absence.
Removal Plan
- R1 is no longer a resident at the facility.
- All Community survival risk assessments were reviewed for accuracy, updated accordingly and all Care plans were reviewed to validate they match. Assessments were reviewed by IDT team composed of Administrator, DON, and Social Service designee.
- All staff have been re-educated on the facilities therapeutic leave of absence policy. Any staff on leave or unavailable staff were educated via phone and again before next scheduled shift. Administrator, Assistant Administrator, DON, and Assistant Director of Nursing/ADON conducted the training. Policy details that all residents leaving the premises should be signed out, establish an agreed upon time frame for return to the facility, sign back in upon return to the facility, and what to do if a resident does not return at the agreed upon time. All new hires and agency staff (if utilized in the future) will be educated on this policy prior to working their first shift.
- Facility receptionists were educated by their supervisor on the pass return protocol; Protocol states Only residents with green pass can leave the facility unsupervised, all residents leaving must sign out and establish an agreed upon time for return. Residents must sign back in upon return from pass. If resident fails to return at the agreed upon time, the 1st floor nurses station will be notified before their next scheduled shift.
- No resident goes out on independent pass without having a current Community survival/elopement risk assessment completed and CP updated.
- The pass privilege list was reviewed by the facility IDT composed of Administrator, DON, and Social Service designee, and compared to the response report of current elopement risk/community survival assessments.
- All residents identified as having exit seeking behaviors were reviewed by a Social Service designee and care plans were updated as appropriate.
- All residents with a history of suicidal ideation/suicidal attempts have their independent pass privilege assessment signed by a physician/provider.
- Updated Medical director on event and details. Medical director notified of incident by the facility DON and reviewed the facility's immediate action plan. He agreed with the immediate action plan.
- Administrator and/or designee will audit 5 residents' 2X per week for 6 months to ensure resident's community skills assessment and care plan are accurate.
- Director of Nursing and/or designee will audit the resident sign in/out log daily for 3 months then 2X per week for 3 months to ensure that all residents are accounted for.
- Community pass policy reviewed with IDT and medical director.
- QAPI review with Medical Director to review incident and plan of action. IDT conducts assigned regular rounds during shift to ensure visual monitoring and staff supervision. Action plan will be reviewed monthly at QAPI meeting.
Failure to Conduct Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed monthly Medication Regimen Reviews (MRR) for residents, as required by their policies and procedures. This deficiency was identified through interviews and record reviews, revealing that the pharmacy did not complete monthly MRRs for several residents. Specifically, the facility could not provide documentation showing that residents identified with irregularities in their MRRs were addressed by a physician. The report highlights several cases where the facility did not comply with the monthly MRR requirement. One resident, with multiple diagnoses including chronic obstructive pulmonary disorder and schizoaffective disorder, was missing an MRR for April 2024. Another resident, with conditions such as toxic encephalopathy and bipolar disorder, did not have MRRs for February and April 2024, and the facility failed to provide documentation of pharmacy recommendations or follow-up actions. Additionally, two other residents with various medical conditions also lacked MRRs for the same months. Interviews with facility staff, including the Director of Nursing and the Psychotropic Nurse, revealed that the consulting pharmacist was responsible for completing the MRRs and emailing the recommendations to the facility. However, the facility was unable to provide the necessary documentation to demonstrate compliance with their policy, which mandates regular and reliable consultant pharmacist services and the retention of records.
Resident Dignity Not Maintained During Meal Service
Penalty
Summary
The facility failed to maintain a resident's dignity during meal service in the dining room. A resident, identified as R70, was observed seated at a dining room table wearing a gown that was not properly closed, exposing her skin and undergarments from the bottom of her left armpit to mid-thigh. This exposure was visible from the door of the dining room, where there were six tables of residents and three staff members present. Earlier that day, R70 was also seen walking in the hallway wearing only a gown and bare feet, accompanied by staff. R70's electronic medical record indicated she was cognitively intact and required assistance with activities of daily living, including dressing. Her care plan noted the need for supervision and assistance with dressing but did not address concerns about wearing clothing. A registered nurse, identified as V14, stated that R70 only wears clothing when leaving her room and confirmed that clothing was available in R70's closet. The facility's policy on dignity emphasized encouraging residents to dress in their own clothes rather than hospital-type gowns, which was not adhered to in this instance.
Failure to Honor Resident's Vegan Diet Preference
Penalty
Summary
The facility failed to honor a resident's decision to observe a vegan diet, which was a significant aspect of her self-determination and personal choice. The resident, who had intact cognition, had been vegan for many years prior to her admission to the facility. Despite her clear communication of dietary preferences and allergies, the facility did not provide adequate vegan protein sources, forcing her to consume dairy products to meet her nutritional needs. This led to allergic reactions, including rashes and nasal congestion, as the resident was allergic to cow's milk. The resident had multiple discussions with the facility's staff, including the administrator and corporate dietitian, about her dietary needs. However, these discussions were not documented in her clinical record, and no adjustments were made to accommodate her vegan diet. The facility's menu did not include a vegan option, and the resident was often served meals lacking in protein, contrary to her dietary requirements. The facility's failure to provide alternative protein sources, such as beans or veggie burgers, further exacerbated the issue. The facility's procedures for menu planning and food preferences were not followed, as evidenced by the lack of documentation and failure to address the resident's dietary needs in her care plan. Despite the resident's repeated requests and the facility's acknowledgment of her dietary preferences, the facility did not take appropriate steps to ensure her nutritional needs were met in accordance with her vegan diet. This oversight highlights a significant deficiency in honoring resident choice and ensuring adequate nutrition.
Failure to Maintain Sterile Barrier on Central Venous Catheter
Penalty
Summary
The facility failed to implement its policy regarding the care and management of an implanted central venous catheter, leading to a potential risk of infection for a resident. The resident, who has a medical history including type 2 diabetes mellitus, foot ulcer, osteomyelitis, peripheral vascular disease, Parkinson's Disease, and Schizophrenia, was observed with an exposed central venous catheter. The catheter, implanted in the resident's right upper chest, was missing an end cap, which is crucial for preventing contamination. The Infection Control Nurse, identified as V3, acknowledged the missing end cap but failed to apply a sterile barrier while searching for a replacement, leaving the catheter exposed. Further investigation revealed that the Registered Nurse assigned to the resident, V4, also noticed the missing end cap at the beginning of her shift but did not take action to cover the exposed catheter with sterile gauze. The facility's policy, dated February 2009, mandates that a sterile end cap must be placed on the end of intermittent tubing between administrations to prevent infections. Despite this policy, the resident's catheter remained exposed until an appropriate end cap was found two days later, as confirmed by the Director of Nursing, V2.
Failure to Document Dialysis Assessment
Penalty
Summary
The facility failed to document a resident assessment upon return from dialysis for a resident with multiple diagnoses, including end-stage renal disease, chronic obstructive pulmonary disease, and schizophrenia. The resident, who was dependent on hemodialysis, had a care plan indicating dialysis sessions on Monday, Wednesday, and Friday. However, a review of the resident's progress notes from early November to early December revealed no documentation of assessments upon return from dialysis. The Director of Nursing confirmed that the assessment, including vital signs and the condition of the fistula site, should be documented on the Medication Administration Record (MAR), but this was not done until late November. Additionally, the facility's policy required monitoring and documentation of the presence or absence of bruit and thrill at the fistula site each shift, which was not added to the record until late November. A Registered Nurse stated that the resident had a fistula in the right forearm, and staff should avoid taking blood pressure from that arm. However, there was no consistent communication or signage to inform all staff of this requirement. The nurse also expressed uncertainty about where to document the after-dialysis assessment, indicating a lack of clarity and adherence to the facility's policy on dialysis monitoring and observation.
Failure to Provide Timely Medication Delivery
Penalty
Summary
The facility failed to ensure timely delivery of medications from the pharmacy, resulting in a resident missing doses of pregabalin as ordered by the physician. The resident, who was admitted with multiple diagnoses including major depressive disorder and anxiety disorder, did not receive pregabalin from the time of admission until several days later. The EMR indicated that the medication was supposed to start on November 28, 2024, but was not available or administered until December 4, 2024. Interviews with facility staff revealed that the medication was not delivered because a prescription had not been submitted to the pharmacy. The LPN acknowledged the delay and contacted the pharmacy and physician only after the issue was identified. The Director of Nursing stated that medications should be received within 24 hours of admission and that the nurses should have addressed the unavailability of the medication sooner. The facility's policy requires a valid prescription for controlled substances to be received by the pharmacy before dispensing, which was not adhered to in this case.
Failure to Provide Vegan and Dairy-Free Diet for Resident
Penalty
Summary
The facility failed to prepare and follow a vegan and dairy-free diet for a resident who adhered to a vegan diet and was allergic to dairy. The resident, identified as R196, had a physician order sheet indicating a general diet with regular texture and consistency, and an allergy to dairy products. Despite this, the resident reported being made to drink milk due to a lack of other protein sources, which led to allergic reactions such as rashes and nasal congestion. The resident had been vegan for many years and had communicated her dietary needs to the facility's corporate dietitian and administrator, but her requests for vegan protein options like veggie burgers were not fulfilled. Observations and interviews revealed that the resident's meals typically lacked adequate protein sources, forcing her to consume dairy products despite her allergy. The resident's lunch trays often consisted of items like plain noodles, green beans, and salads without protein, and she reported not receiving requested items such as potato salad. The facility's food service staff indicated that they could not accommodate individual requests for items like beans due to bulk purchasing practices. The resident's clinical record lacked documentation of her dietary preferences, allergy, or any discussions about providing alternative protein sources. The facility's corporate dietitian and food service director acknowledged the resident's dietary preferences and allergy but failed to ensure that her nutritional needs were met. The dietitian admitted that the resident's intolerance was listed as an allergy in the clinical record and that she should not have been receiving dairy products. However, there was no official diet order for a vegan diet, and the facility did not have a pre-planned vegetarian menu. The facility's planned menu spreadsheets showed no vegan diet was planned or served, and the resident's care plan did not address her dietary needs or allergy.
Failure to Accommodate Resident's Dairy Allergy and Dietary Preferences
Penalty
Summary
The facility failed to eliminate a known dairy allergen from a resident's diet, despite the resident's documented allergy to dairy products. The resident, who has a history of major depressive disorder and suicidal ideations, was provided with lactose-free milk and cheese as protein sources, despite reporting allergic reactions such as rashes and nasal congestion. The resident expressed dissatisfaction with the lack of alternative protein sources and felt compelled to consume dairy products due to inadequate vegan protein options provided by the facility. The resident's care plan clearly documented the dairy allergy and instructed staff to ensure the allergy was noted on various records, including the Medication Administration Record and tray care. However, the facility's dietary management failed to adhere to these instructions. The resident's clinical records lacked documentation of any discussions regarding the dairy allergy or the provision of vegan protein options, despite the resident's repeated complaints and discussions with the corporate dietitian and food service director. The facility's planned menus did not include pre-planned vegan diets, and the resident's lunch trays consistently lacked protein items. The corporate dietitian and food service director were aware of the resident's dietary preferences and allergy but did not take appropriate action to accommodate these needs. The facility's failure to document and address the resident's dietary requirements resulted in the continued provision of dairy products, contrary to the resident's allergy and ethical dietary preferences.
Failure to Reassess Capacity for Sexual Consent Leads to Incident
Penalty
Summary
The facility failed to reassess and update a resident's capacity for sexual consent after a significant decline in her cognitive abilities. This oversight led to an incident of sexually inappropriate behavior between two residents in a public area. The resident in question, who was diagnosed with severe dementia, was initially assessed to have the capacity to consent to sexual activities. However, a subsequent assessment revealed a severe cognitive impairment, indicating that she could no longer provide consent. The incident occurred when the resident engaged in sexual acts with another resident in the dining room, witnessed by other residents. Despite the resident's severe cognitive impairment, staff initially believed the interaction was consensual. The facility's policy required reassessment of a resident's capacity to consent following any significant cognitive changes, which was not done in a timely manner. Interviews with staff and other residents revealed that the incident was not immediately reported or addressed according to the facility's abuse prevention and reporting policies. The failure to update the resident's capacity for sexual consent and the delay in reporting the incident contributed to the deficiency identified by the surveyors.
Removal Plan
- R1 has an updated capacity to consent for sex assessment completed.
- R2 has been sent out to the hospital for a psychiatric evaluation.
- An emergency Quality Assurance meeting has been conducted with facility medical director and IDT to review the incident and action plan.
- Residents that have been identified being at risk from sexual exploitation have had their care plans updated to reflect interventions to prevent abuse.
- All residents have been reassessed for capacity for sexual consent.
- Residents that have been identified for being at risk from sexual exploitation were interviewed if they have been taken advantaged of or manipulated to perform sexual acts. None of them responded yes.
- Residents who are identified as at risk to potentially be the perpetrator for sexual abuse or exploitation will be reassessed and placed closer to the nurse's station for increased monitoring, and have their care plans updated to reflect.
- The capacity to consent policy has been revised and updated.
- Social Service staff received an Inservice on updating the capacity for consent assessment whenever a significant change in a resident's cognition is noted.
- Facility wide Inservice, initiated and ongoing. Information included: How to recognize sexual abuse and the facility's abuse protocol to prevent it from happening to other residents. The Abuse prevention reporting policy, specifically the definition of abuse, sexual abuse, sexual assault and internal reporting requirements and identification of allegation and protection of residents. All staff were re-educated prior to their next scheduled shift including staff that are on leave and are on vacation. Staff acknowledged information via signature or via phone call. Administrator and Assistant administrator are conducting the training. Administrator/Managers will continue to monitor all staff for compliance by a competency questionnaire.
- Facility administrator and/or designee will interview 5 staff members to ensure staff is aware of the facility policy related to sexual abuse. (Audit Tool included).
- Facility Administrator and/or designee will interview 5 residents to ensure they are free from abuse.(Audit Tool included).
Failure to Timely Report Sexual Abuse Incident
Penalty
Summary
The facility failed to timely report an incident of sexual abuse as per their policy and procedure for sexual abuse. The incident involved two residents, R1 and R2, who were observed engaging in a sexual act in the dining room. Staff intervened and separated the residents, and both stated the interaction was consensual. However, the facility did not immediately report the incident to the Illinois Department of Public Health (IDPH) or local law enforcement, as required by their policy. The incident was initially reported by a resident witness, R5, who informed the staff about the inappropriate behavior. The Registered Nurse, V4, assessed R1 and reported the incident to the Administrator, V1, who reviewed R1's capacity to consent based on a previous assessment. Despite concerns about R1's cognitive impairment and the age gap between R1 and R2, the facility did not conduct an immediate investigation or report the incident, as they believed it was consensual based on outdated information. Further assessments revealed that R1 had severe cognitive impairment and lacked the capacity to consent to sexual activity. The facility's Social Service Director, V3, confirmed that R1's cognitive status had deteriorated since the initial assessment. The facility eventually reported the incident to IDPH and local law enforcement after consulting with a psychiatrist and reassessing R1's capacity to consent. The delay in reporting and investigating the incident constituted a failure to adhere to the facility's abuse prevention and reporting policy.
Failure to Investigate Sexual Abuse Incident Promptly
Penalty
Summary
The facility failed to promptly conduct a thorough investigation of an incident of sexual abuse involving two residents, R1 and R2, in the secure behavioral unit. On July 9, 2024, staff reported an interaction between R1 and R2 in the dining room, which was initially described as consensual by both residents. However, R1's electronic medical records indicated socially inappropriate behavior, and witnesses, including R5 and R6, described the incident as inappropriate and public. Despite these observations, the facility did not immediately investigate the incident or interview witnesses. The facility's initial response was inadequate, as staff did not verify R1's capacity to consent, despite concerns about her cognitive impairment. R1's BIMS score had decreased from moderate to severe cognitive impairment, indicating she could not provide consent. The facility's Social Service Director confirmed that R1 was reassessed on June 25, 2024, and found to have severe cognitive impairment, which should have identified her as at risk for sexual abuse. Despite this, the facility relied on an outdated assessment from April 2024, which incorrectly suggested R1 could consent. The facility's policy on abuse prevention and reporting was not followed, as the incident was not promptly reported to the Illinois Department of Public Health (IDPH) or the police. The Administrator, V1, delayed reporting the incident, believing it was consensual based on outdated information. It was only after consulting with a psychiatrist and reassessing R1's capacity that the facility reported the incident to IDPH and the police. This delay in investigation and reporting highlights a failure to adhere to the facility's policy and procedures for abuse prevention and reporting.
Failure to Update Care Plan After Change in Cognitive Status
Penalty
Summary
The facility failed to update and revise a care plan following a significant change in a resident's cognitive status, which affected her ability to consent to sexual activity. The resident, a female with a history of dementia and other mental health conditions, was initially assessed as having the capacity to consent to sexual activity. However, a subsequent assessment revealed severe cognitive impairment, indicating that she could no longer provide consent. Despite this change, the care plan was not updated with specific interventions to address her inability to consent, leaving her at risk for sexual abuse. The deficiency was identified during a review of the resident's electronic medical records and interviews with facility staff. The resident's BIMS score, which measures cognitive function, decreased from 11/15 to 5/15, indicating a severe cognitive decline. The facility's policy requires that care plans be updated when there is a change in a resident's cognitive status, but this was not done in a timely manner. The lack of updated interventions in the care plan was a critical oversight, as acknowledged by the facility's Social Service Director, who stated that the care plan should have been revised to reflect the resident's new cognitive status and associated risks.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by their peers, as evidenced by multiple incidents involving ten residents. The administrator, identified as V1, did not report these incidents to the Illinois Department of Public Health (IDPH) because he believed that only incidents causing emotional distress or physical injury needed to be reported. This directive was reportedly given by corporate. The incidents included physical altercations between residents, such as one where a resident was pushed to the floor in an elevator after a verbal dispute. The report details specific incidents involving residents with various mental health diagnoses, including schizophrenia, bipolar disorder, and dementia. For example, one resident with major depressive disorder and schizophrenia was involved in a verbal and physical altercation with another resident in an elevator. Another incident involved a resident with schizoaffective disorder who was bitten by a roommate, resulting in slight redness on the heel. These incidents were not reported to the state, despite the facility's policy requiring such reports. The facility's failure to report these incidents is a significant deficiency, as it violates residents' rights to be free from abuse. The facility's policy on abuse prevention and reporting was not followed, as evidenced by the unreported incidents. The report highlights the need for proper documentation and reporting of all incidents of abuse, regardless of the perceived severity, to ensure the safety and well-being of all residents.
Failure to Report Abuse Allegations Timely
Penalty
Summary
The facility failed to report allegations of abuse to the Illinois Department of Public Health (IDPH) Regional Office within the required two-hour timeframe after being notified of the allegations. This deficiency was identified for all ten residents reviewed for allegations of abuse. The facility's administrator, V1, stated that he was instructed by the facility's corporation that allegations not causing emotional distress or physical injury did not need to be reported, which led to the failure to report several incidents. The report details multiple incidents involving residents with various psychiatric and cognitive impairments, including schizophrenia, bipolar disorder, and schizoaffective disorder. For instance, an altercation between two residents, R3 and R6, on May 5, 2024, was not reported to the IDPH. R3 claimed that R6 punched her, and in response, she scratched R6's face. Despite the incident being documented in progress notes, no report was submitted to the IDPH Regional Office. Similar reporting failures occurred with incidents involving other residents, such as R1 and R2, R3 and R4, and R7 and R8, where physical altercations and aggressive behaviors were documented but not reported as required. The facility's policy, titled 'Abuse Prevention and Reporting- Illinois,' mandates that any allegation of abuse or incident resulting in serious bodily injury be reported to the Department of Public Health immediately, but not more than two hours after the allegation. However, the facility did not adhere to this policy, as evidenced by the administrator's failure to submit reports for several incidents involving resident-to-resident altercations. This systemic issue highlights a significant deficiency in the facility's compliance with state reporting requirements for abuse allegations.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near West Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| West Chicago Living And Rehab Center | 3 mi | ★★★★★ | 4 | 0 |
| Covenant Living - Windsor Park | 3 mi | ★★★★★ | 0 | 0 |
| Ahva Care Of Winfield | 3.6 mi | ★★★★★ | 0 | 0 |
| Wynscape Health & Rehab | 4.1 mi | ★★★★★ | 3 | 0 |
| Dupage Care Center | 4.3 mi | ★★★★★ | 13 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.