Aliya of Oak Lawn: Sexual Assault of Resident - IL
Staff came running toward the yelling. A third resident entered the room and began shouting at the aggressor to stop.
By then, the damage was done.
The assault happened on the morning of August 18, 2025. Federal inspectors documented what happened in a complaint inspection completed August 26. What the records show is not a single failure of supervision, but a sequence of ignored warnings stretching back more than a month, each one documented, each one insufficient to stop what came next.
A nursing note from July 17 recorded that a registered nurse, identified in inspection records as V5, had observed the aggressor, referred to as R2, repeatedly entering another resident's room and attempting to touch him, telling him he loved him. V5 said she was already aware R2 had a history of inappropriate touching of other residents. She said R1, the man who would later be assaulted, had reported to her that R2 had touched his anus.
That was five weeks before the assault.
On the morning of August 18, a nurse identified as V7 heard a resident yelling "help, help, help." Staff started running. They found R1 on his back in bed, R2 standing beside him, reaching under his gown. R1's adult brief was loose. R1 told staff he didn't know what R2 was doing to him. He has no feeling below the waist.
A certified nursing assistant, V8, said she heard another resident, R3, already in the room telling R2 to get out. V8 described R1's condition to inspectors: contracted hands stuck behind his head, legs contracted and open, entirely dependent on staff for all assistance. R2, she noted, was a known wanderer. He should not have been in R1's room.
R2 was petitioned to the hospital that day for inappropriate sexual behavior toward a peer. The petition was the facility's response. It was not the end of the matter for R1.
The nurse practitioner, V3, saw R1 the following day, August 19. R1 told her that R2 had lifted his gown and grabbed his penis. R1 told her he can't get an erection because he is paralyzed. R1 said he was not gay. He was crying. V3 suggested he go to the hospital.
Hospital records from August 19 document the emergency department visit. The admitting diagnosis: sexual assault of adult. Emergency department notes state R1 was manually groped by another resident, allegedly witnessed by a third resident. A case manager who spoke with R1 on August 21 found him alert and oriented, and refusing discharge back to long-term care. R1 told the case manager he had just left a facility where he was molested.
He would not go back.
The police report from August 19 fills in what R1 told officers. He was lying in bed alone. R2 entered in a wheelchair, rolled up beside the bed, then stood up and opened R1's diaper. R2 placed his right hand inside and began to groan. R1, who has no sensation below the waist, did not know exactly what R2 was doing to his genitals. He began calling for a nurse. R3 entered and shouted at R2 to stop.
The social worker, V2, told inspectors she learned about what happened during the morning meeting on August 18. She said she was informed R2 had opened R1's adult brief and had his hand inside it. R1 told her he felt uncomfortable because he was not homosexual.
The restorative aide, V10, was instructed to move R1 to a different room after the assault. R1 asked her to stay with him. He told her he was scared. She said she had been informed he was inappropriately touched by R2.
A CNA identified as V11 saw R1 crying and asked if he was okay. R1 told her: please don't leave him. V11 told inspectors R1 was scared to be left alone. She described him as contracted and entirely dependent on staff for assistance.
The woman identified as R2's power of attorney, V12, spoke with inspectors on August 26, the day of the inspection. She said R2 has dementia and a history of same-sex relationships. She said the facility had called her before the August 18 incident, about prior episodes of R2 touching other residents inappropriately. She said the facility had been patient with R2. Then she said something that reframed the entire sequence of events.
"The facility is acting like they do not have any patience with R2, like they can't tolerate R2 anymore," she told inspectors. "R2 will do the same thing at any facility."
She was not wrong that R2's behavior was driven by dementia. She was also, in that sentence, describing a man whose pattern of behavior was known to everyone, documented in nursing notes going back to July, communicated to his own family representative in prior phone calls, and still not stopped before he assaulted a paralyzed man in his bed.
The facility had found a new placement for R2 before the August 18 assault. That facility refused to accept him after the incident.
The inspection report cites the facility's own abuse policy, dated October 2022, which states that residents have the right to be free from abuse and that sexual abuse includes non-consensual sexual activity and sexual assault.
The policy existed. The documentation existed. The July 17 nursing note existed. The prior calls to R2's power of attorney existed.
R1 lay in a hospital bed on August 21, alert and oriented, and told a case manager he would not return to a long-term care facility. He said he had just been molested in one.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aliya of Oak Lawn from 2025-08-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 4, 2026 · Our methodology
ALIYA OF OAK LAWN in OAK LAWN, IL was cited for violations during a health inspection on August 26, 2025.
Staff came running toward the yelling.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.