West Chicago Living and Rehab Center

In the surveyor’s words

From the most serious findings on record at West Chicago Living and Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, patternF684Nov 12, 2024

  Based on interview and record review, the facility failed to have a system or any policies in place to identify services needed to meet the intimacy rights of mentally ill female residents of child-bearing age. This failure resulted in one female resident (R1) becoming pregnant by another resident and experiencing psycho-social harm when she was hospitalized and per the hospital Psychiatrist, is now in a catastrophic situation. This failure resulted in an Immediate Jeopardy. […]

• Immediate jeopardy, isolatedF600Jan 31, 2024

  Based on interview and record review, the facility failed to protect a resident's (R1) right to be free from sexual abuse from another resident (R2) with known history of sexual behaviors. This failure resulted in R1 being sexually abused by R2. This applies to 1 of 6 residents (R1) reviewed for sexual abuse in the sample of 6. This resulted in Immediate Jeopardy. The Immediate Jeopardy began on January 4, 2024, when R2 was identified by the facility to be more hypersexual and no interventions were put in place to protect other residents, resulting in R1 being sexually abused. V1 (Administrator), V2 (Director of Nursing), V3 (Assistant Director of Nursing) and V13 (Human Resource) were notified of the Immediate Jeopardy on January 23, 2024, at 4:27 PM. […]

• Immediate jeopardy, isolatedF600Mar 18, 2022

  Based on observation, interview and record review, the facility failed to protect a resident from sexual abuse by a facility staff member. This applies to 1 of 3 residents (R1) reviewed for abuse. As a result of this failure, R1 was exposed to sexually abusive behaviors from V11 (CNA- Certified Nurse Aide). The findings include: On 3/15/22 at 2:40 PM, V4 CNA (Certified Nursing Assistant) said R2 reported to her last week V11 CNA was always coming to their room, and R2 saw V11 trying to kiss R1. V4 said she immediately reported it to V5, Lead CNA. On 3/15/22 at 1:32 PM, V5 CNA said last week V4 informed her R2 told her V11 was always in their room and was hugging and kissing R1. […]

• Actual harm, isolatedF657Jan 31, 2024

  Based on interview and record review the facility failed to review and revise a resident's (R2) plan of care, after the resident exhibited hypersexual behaviors. This failure resulted in R2 sexually abusing R1 on January 5, 2024, resulting in R2's arrest by the local police and charged with two counts of domestic battery. This applies to 1 of 4 residents (R2) reviewed for behavioral care plans in the sample of 6. The findings include: R2 was admitted to the facility on [DATE]. R2 had multiple diagnoses including schizophrenia, schizoaffective disorder, bipolar disorder, restlessness and agitation, violent behavior, psychosis not due to a substance or known physiological condition, based on the face sheet. […]

• No harm, potential for more than minimal, widespreadF812May 22, 2025

  Based on observation, interview and record review, the facility failed to ensure that the dishes are sanitized during dish washing procedure and failed to ensure that dented cans were separated from the in-use cans. This applies to all 88 residents that received foods prepared in the facility kitchen. The findings include: Facility's CMS Application Form for Medicare/Medicaid dated May 19, 2025, showed that the facility census was 88 residents. Facility provided information that there are no residents on NPO (nothing by mouth) status. On May 19, 2025, at 9:24 AM, the initial tour of the facility's kitchen was conducted in presence of V4 (Dietary Manager). The dry storage area had 3 cans (6 pounds, 6 ounce each) of Salsa Para Enchiladas that were dented at the seams. […]