Aperion Care West Chicago

Inspectors wroteBased on interview and record review, the facility failed to protect a resident's right to be free from mental and physical abuse by a facility resident. This failure resulted in R4 experiencing psychosocial harm including flashbacks of prior abuse, sadness/crying, panic, fear of individuals walking into her room, and shame. This applies to 1 of 4 residents (R4) reviewed for abuse in a sample of 4.

Inspectors wroteBased on interviews and record reviews the facility failed to report resident allegations of abuse. This applies to 1 of 4 residents (R4) reviewed for abuse in a sample of 4.

Inspectors wroteBased on interviews and record reviews the facility failed to investigate resident allegations of abuse. This applies to 1 of 4 residents (R4) reviewed for abuse in a sample of 4.

Inspectors wroteBased on interview and record review, the facility failed to keep residents free from verbal and mental abuse. This failure applies to 2 of 6 residents (R1 and R2) reviewed for abuse in a sample of 8 residents.

Inspectors wroteBased on interview and record review, the facility failed to report an incident of abuse to the State Agency. This failure applies to 2 of 6 residents (R1 and R2) reviewed for abuse in a sample of 8 residents.

Inspectors wroteBased on interviews and record review, the facility failed to investigate an incident of verbal and mental abuse. This failure applies to 2 of 6 residents (R1 and R2) reviewed for abuse in the sample of 8.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect a resident's right to be free from resident-to-resident physical abuse. This failure resulted in a resident experiencing severe shoulder pain with a possible fracture, and subsequent psychosocial harm. This applies to 1 of 2 residents (R131) reviewed for abuse in a sample of 38.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve meals at palatable temperatures. This applies to all residents who receive food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to store refrigerated resident food safely in the refrigerators on the units. This has the potential to apply to all 211 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer and record individualized supplemental nutritional interventions for residents being treated for weight loss. This applies to 4 of 4 (R51, R8, R10, and R121) residents reviewed for nutrition in a sample of 38.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor, identify, and document side effects of medications, and failed to monitor for the therapeutic blood level of a medication. This applies to 4 of 5 (R82, R93, R182, and R51) residents reviewed for medications in a sample of 38.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have thermometers, keep temperature logs, remove expired items, and maintain resident refrigerators. This applies to 5 of 5 residents (R66, R118, R119, R168, R207) reviewed for refrigerators in a sample of 38.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light system was working in resident rooms. This applies to 28 of 28 (R102, R6, R156, R103, R77, R47, R202, R4, R206, R13, R209, R171, R96, R108, R177, R52, R24, R25, R31, R44, R8, R19, R109, R183, R10, R90, R113, and R210) residents reviewed for call lights. On 1/27/2026 at 10:05 AM, R113 was in bed. R113 said he was extremely upset because his call light had not worked since yesterday. R113 said the facility reported they fixed the call system problem, but it frequently continued to malfunction, causing the call lights for his entire hall to stop working for extended periods of time. R113 pressed his call light, but it was not sending a call signal outside his door and to the nurses' station main panel. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor a resident's wishes to have food warmed in a microwave at their preferred time. This applies to 1 resident (R37) reviewed for accommodation of needs. On 01/27/2026 at 12:43 PM, R37 stated there use to be a microwave available for residents' use, but it was taken away. The only microwave available is at the nursing station and is not accessible to the residents. R37 stated if residents want any food reheated, they must request the facility staff do it for them, but the time for reheating food is limited. If he wants any food reheated after 9:30 PM, staff will not heat his food. On 01/28/2026 at 4:10 PM, V8 RN (Registered Nurse) stated residents are not allowed behind the nursing station to use the microwave. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify abuse, investigate an incident of resident-to-resident abuse, implement interventions to prevent further recurrence, and report the incident. This applies to 2 of 2 residents (R131 and R200) reviewed for abuse in a sample of 38.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct a thorough investigation of physical abuse between 2 residents. This applies to 2 of 2 residents (R131 and R200) reviewed for abuse in a sample of 38.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pain assessment and management was provided for a resident's new onset of pain. This applies to 1of 1 resident (R131) reviewed for pain management in a sample of 38.

Inspectors wroteBased on interview and record review, the facility failed to provide physical therapy that was ordered by the physician. This applies to 1 of 1 resident (R151) reviewed for rehab services in a sample of 38. Findings Include:R151's diagnosis list includes Parkinsonism, idiopathic progressive neuropathy, recurrent major depressive disorder, and drug-induced subacute dyskinesia. R151's current care plan includes limited range of motion in bilateral upper and lower extremities related to pain and limited mobility; interventions include to demonstrate exercises and have resident return-demonstrate the exercises. On 01/27/2026 at 11:02 AM, R151 stated for two years he's had numbness and tingling in both legs and his fingers. R151 stated his Neurologist wrote orders for him to have PT (Physical Therapy) that was never set up for him. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain hot water temperatures at a comfortable range for residents in bathrooms and showers. This applies to all 206 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to report an abuse allegation. This applies to 1 of 3 (R1) residents reviewed for reporting abuse allegations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a comfortable, homelike environment for residents. This applies to 2 of 3 residents (R1 and R2) reviewed for inadequate cooling in the sample of 3.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide visitation rights to 2 residents, both sisters, who reside at the facility. This applies to 2 of 6 residents (R1 and R2) reviewed for right to receive visitors in the sample of 6.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse. This applies to 2 of 3 residents (R1 and R3) reviewed for resident-to-resident physical abuse.

Inspectors wroteBased on interview and record review, the facility failed to notify the facility Abuse Coordinator and the State Agency of an allegation of physical abuse. This applies to 2 of 4 residents (R2 and R3) reviewed for physical abuse in a sample of 4.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was supervised to prevent the resident from leaving the grounds of the facility, and failed to ensure nursing staff were aware R1 was out of the building resulting in a 6 hour delay in identifying R1 was missing. This failure resulted in R1 leaving the facility grounds at 5:57 PM on [DATE], and being found deceased about 600 feet from the facility's main entrance at 7:50AM on [DATE]. The Immediate Jeopardy began on [DATE] when R1 signed out of the facility, left unsupervised, and failed to return at the expected time. The receptionist failed to notify the nurse R1 had not returned to the facility by the 8:00 PM curfew and nursing staff was therefore unaware R1 was not in the facility until after 11:00 PM, when police were finally notified. [...]

Inspectors wroteBased of interview and record review, the facility failed to ensure the the pharmacy was completing monthly MRR (Medication Regimen Review) for residents residing in the facility. The facility failed to provide documentation that showed residents identified as having irregularities on their monthly MRR were addressed by the physician. This applies to 4 of 5 residents (R54, R64, R70, R122) reviewed for monthly MRR (Medication Regimen Review) in the sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's dignity was maintained while in the dining room during meal service. This applies to 1 of 2 (R70) residents reviewed for dignity in the sample of 35. R70's EMR (Electronic Medical Record) showed R70 was [AGE] years old and had been admitted to the facility on [DATE]. R70 was admitted with multiple diagnoses including schizoaffective disorder, bipolar disorder, other abnormalities of gait and mobility, generalized anxiety disorder, abnormal posture, and chronic peripheral venous insufficiency. R70's MDS (Minimum Data Set). dated October 21, 2024, showed R70 was cognitively intact, and required assistance with ADL's (Activities of Daily Living) including substantial assistance with bathing and supervision/touching assistance with dressing. R70's care plan. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor R196's decision to observe a vegan diet. This applies to 1 of 1 residents (R196) reviewed for self determination in the sample 35.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement their policy regarding care and management of implanted central venous catheter to prevent infection. This applies to 1 of 1 (R26) reviewed for central venous catheter in the sample of 35.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident assessment was documented upon return to the facility after dialysis. This applies to 1 of 1 (R109) residents reviewed for dialysis services in the sample of 35. R109's EMR (Electronic Medical Record) showed R109 was [AGE] years old and admitted to the facility on [DATE]. R109 had multiple diagnoses including end stage renal disease with dependence on hemodialysis, chronic obstructive pulmonary disease, unspecified asthma, schizophrenia, unspecified, history of falling, and essential hypertension. R109's care plan, dated November 5, 2024, showed R109 receives hemodialysis at the local dialysis center on Monday, Wednesday, and Friday. R109's care plan for dialysis was initiated on November 26, 2019, upon his admission to the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were obtained from the pharmacy in a timely manner to prevent residents from missing medication doses as ordered by the physician. This applies to 1 of 1 resident (R412) reviewed for pharmacy services in the sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and follow a vegan and dairy free diet for a resident who adhered to a vegan diet and who was allergic to dairy. This applied 1 of 1 (R196) reviewed for vegan diet menus in the sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to eliminate a known dairy allergen from a resident's diet at the facility. This applies to 1 of 2 residents (R196) reviewed for food allergies in the sample of 35.

Inspectors wroteBased on interview and record review, the facility failed to reassess and update R1's capacity for sexual consent after a significant decline in her cognition, failed to timely report an incident of sexual abuse as per facility guidance This failure resulted in the sexually inappropriate behavior between R1 and R2 in a public area. R1 is not able to consent to sexual activity due to her severe impairment in cognition and diagnosis of Dementia, and a reasonable person would not want to perform sexual acts without consent. This applies to 1 of 4 residents (R1) reviewed for sexual assault in the sample of 5. The Immediate Jeopardy began on June 25, 2024, when the facility failed to update the Capacity for Sexual Consent form when R1 was assessed to be severely impaired in cognition, and therefore unable to consent to sexual activity. [...]

Inspectors wroteBased on interview and record review, the facility failed to timely report an incident of sexual abuse as per facility guidance shown in their policy and procedure for sexual abuse. This applies to 1 of 6 residents (R1) reviewed for sexual abuse in the sample of 10.

Inspectors wroteBased on interview and record review, the facility failed to promptly conduct a thorough investigation of an incident of sexual abuse. This applies to 1 of 6 residents (R1) reviewed for sexual abuse in the sample of 10.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update and revise a care plan after a resident's change in cognitive status and inability to consent to sexual activity. This applies to 1 of 6 residents (R1) reviewed for sexual abuse in the sample of 10.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' rights to be free from acts of physical abuse by their peers. This included 10 of 10 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10) reviewed for abuse.

Inspectors wroteBased on interview and record review the facility failed to report allegations of abuse to the IDPH (Illinois Department of Public Health) Regional Office within two hours of the notification of the allegation of abuse. This applies to 10 of 10 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10) reviewed for allegations of abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who required supervision and safe swallowing strategies while eating was provided supervision while eating. This failure resulted in R1 eating alone in her room and experiencing a choking incident requiring the Heimlich maneuver and CPR (Cardio-Pulmonary Resuscitation). R1was transported via emergency response and expired. The facility also failed to have a system in place to identify residents who require supervision with eating and ensure Speech Therapy recommendations are implemented. This applies to 48 of 48 residents (R1, R3, R4, R5, R6, R7, R8, R11-R51) reviewed for supervision while eating in the sample of 51. The Immediate Jeopardy began on January 18, 2024 when V12 (BA-Behavioral Aide) served a meal tray to R1 in her room, and left R1 unattended with the meal tray. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect when the facility failed to provide services to support safe eating environment for R1 who was identified to need direct supervision and safe swallowing strategies to prevent choking and aspiration. The facility neglected to develop and implement a care plan with interventions for R1 to include the recommended eating plan and the facility neglected to train direct care staff on the services R1 needed to prevent aspiration. The facility also neglected to have a system in place to identify other residents with eating and swallowing precautions and train direct care staff on monitoring and supervising these residents and following speech therapy recommendations. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient staff to care for residents. This has the potential to affect all 206 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident with a healed pressure ulcer on the coccyx area received care to prevent the development of another pressure ulcer. This applies to 1 of 3 residents (R2) reviewed for pressure ulcers in the sample of 51.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from physical abuse. This failure resulted in R108 receiving sutures after R304 hit him in the face two times. This applies to 2 of 35 residents (R108 & R304) reviewed for abuse in the sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to submerge a food processor container for 60 seconds to ensure sanitation. This applies to 6 of 6 (R99, R36, R81, R120, R51, R192) residents reviewed for puree diets in the sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure COVID 19 positive residents remained isolated in their rooms, and failed to ensure doors were kept closed on COVID 19 positive residents for 5 of 35 residents (R175, R1, R151, 154, and R60) reviewed for infection control in the sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who requires extensive assist was provided ADL (activities of daily) care. This applies to 1 of 35 residents (R74) reviewed for ADL's in the sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's blood glucose value was monitored for a resident with a diagnosis of diabetes, and failed to ensure a resident's sutures were removed who sustained a laceration to his eyebrow/forehead. This applies to 2 of 35 residents (R53 and R108) reviewed for quality of care in the sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident had hearing aids that were in working order to maintain a resident's hearing for 1 of 35 residents (R127) reviewed for hearing and vision services in the sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to supervise a resident in the shower (R16), and the facility failed to ensure a resident was transferred in a safe manner (R126). These failures apply to 2 of 35 (R16, R126) residents reviewed for safety and supervision in the sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's pain was managed who has a history of chronic pain. This applies to 1 of 35 residents (R196) reviewed for pain management in the sample of 35.

Inspectors wroteBased on interview and record review, the facility failed to order a medication after a resident was hospitalized for 1 of 35 residents (R138) reviewed for pharmacy services in the sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications at ordered times and in ordered dosage. There were 26 opportunities with 6 errors resulting in a 23.08% error rate. This applies to 2 of 3 residents (R73 & R185) observed in the medication pass.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received the prescribed dose of insulin. This applies to 1 of 3 residents (R73) reviewed for medication administration in the sample of 35.