Aperion Care West Chicago

In the surveyor’s words

From the most serious findings on record at Aperion Care West Chicago, in the surveyor’s own words.

• Immediate jeopardy, patternF689Feb 8, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF689Jan 23, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF600Jul 18, 2024

  Based 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. […]

• Actual harm, isolatedF600Jun 17, 2026

  Based 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. The findings include:Care plan, provided 6/17/26, showed R4's diagnoses included major depression, anxiety, bipolar disorder, depression, dissociative and conversion disorder, The care plan showed R4 was at risk for abuse due to a history of abuse, poor insight and judgement. […]

• Actual harm, isolatedF600Jan 31, 2026

  Based 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. The findings include: R131's Electronic Medical Record (EMR) indicated that progress notes, dated 1/18/2026, documents at approximately 10:15 PM, R131 was suddenly attacked by another male resident (R200) without provocation when R200 attempted to place his arm around R131's neck. […]