Crestwood Terrace: Resident Raped by Fellow Resident - IL
That is how it began, according to a federal inspection report filed after a December 26 complaint at Crestwood Terrace, a long-term care facility in Crestwood, Illinois. The woman, identified in inspection records only as R3, was in the shower when another resident, R2, pulled back the curtain and began kissing her. She told him she didn't want him. He continued. She was screaming. When it was over, she was burning, she said, and in pain and bleeding.
The inspection, conducted December 27, 2025, found that what happened to R3 constituted sexual abuse resulting in actual harm. The violation affected few residents, in the language of the report, meaning the inspectors identified this as an isolated incident rather than a pattern. For R3, that distinction means very little.
A registered nurse identified in the report as V3 was in the middle of medication pass on A wing when someone told her to go see R3. She went. R3 told her that a resident had forced himself on her while she was taking a shower, that she had been screaming at the time. V3 gave her a clean towel and told her to wipe from front to back. There was blood on the towel. Staff then contacted the administrator, called 911, and notified the doctor.
That sequence, the towel, the instruction, the phone calls, is the entirety of what the report describes as the immediate staff response to a resident who had just been raped.
By early afternoon, a psychiatric mental health nurse practitioner identified as V12 had evaluated R3. The report records what V12 said at 3:04 p.m. on December 26: "At this time, she appears to be doing well. She stated that she just wants to move on with my life now. She also stated that it doesn't feel good, and that she was given several STD medications and is moving forward. I am going to prescribe some medications because she is experiencing nightmares. I will meet with her once a week to process these experiences with her so that she can work through them and continue to heal."
She was given several STD medications. She is experiencing nightmares. She just wants to move on with her life.
These are not the words of a woman who is doing well. They are the words of a woman who is trying to survive something that happened to her inside a building where she was supposed to be safe.
The inspection report includes the facility's own written abuse policy, dated March 2021, which states that the facility "affirms the right of our residents to be free from verbal, physical, sexual, mental abuse, neglect, exploitation, misappropriation of property, involuntary seclusion, or mistreatment." The policy defines sexual abuse to include sexual assault. It states that the facility has "attempted to establish a resident sensitive and resident secure environment." It states that all instances of abuse, even those involving residents in a coma, cause physical harm, pain, or mental anguish.
The policy existed. It did not prevent what happened to R3.
The facility also distributed a pamphlet to residents titled "Residents' Rights for People in Long-Term Care Facilities," revised in November 2018. The pamphlet tells residents: "You must not be abused, neglected, or exploited by anyone, financially, physically, verbally, mentally, or sexually." It tells them their facility must be safe, clean, comfortable, and homelike. It tells them their facility must treat them with dignity and respect.
R3 had that pamphlet, or access to it. She had the rights it described. She was screaming in the shower, and another resident walked through the curtain anyway.
The inspection report does not describe what relationship, if any, existed between R3 and R2 before December 26. It does not describe R2's diagnosis, cognitive status, or history. It does not say whether R2 had access to R3's shower area because of a supervision gap, a staffing shortage, a facility layout problem, or something else entirely. It does not say whether anyone had previously observed concerning behavior from R2 toward R3 or toward other residents. The report does not contain that information, or if inspectors gathered it, they did not include it in what was made public.
What the report does contain is R3's own account, delivered to inspectors with what they described as "a tearful sound in her voice, as if she was trying to fight back the tears."
She told them she recognized his shoes when he came to her curtain. She told them she said she didn't want him. She told them he continued and raped her. She told them she was burning and in pain and bleeding.
She told inspectors all of this, apparently, on the day after it happened, while she was still in the facility where it occurred.
The psychiatric nurse practitioner's plan, as recorded in the inspection report, is to meet with R3 once a week to help her process these experiences and continue to heal. The word "experiences" is doing considerable work in that sentence. What R3 experienced was a rape. She experienced it inside a nursing home. She experienced it while screaming. She experienced it in a shower, one of the most physically vulnerable situations a person can be in, in a place that had published a policy and distributed a pamphlet promising her it would not happen.
The nurse practitioner noted that R3 stated she just wants to move on with her life now. That is a thing people say when they are exhausted and in shock and when the people around them are asking them to describe the worst thing that has ever happened to them. It is not a clinical finding. It is not evidence of recovery. The same nurse practitioner, in the same conversation, noted the nightmares had already started, less than 24 hours after the assault.
The inspection report was filed as a complaint investigation, meaning someone reported what happened and triggered an outside review. The visit took place the following day, December 27. The violation was cited at a level of actual harm.
Crestwood Terrace's written policy says the facility has attempted to establish a resident secure environment. R3 was not secure. She was in the shower, and she was screaming, and the facility's response when it was over was to hand her a towel.
She is experiencing nightmares now. She was prescribed medications for them. A psychiatric nurse practitioner will meet with her once a week.
She told the nurse practitioner it doesn't feel good.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Crestwood Terrace from 2025-12-27 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: August 17, 2026 · Our methodology
CRESTWOOD TERRACE in CRESTWOOD, IL was cited for violations during a health inspection on December 27, 2025.
The woman, identified in inspection records only as R3, was in the shower when another resident, R2, pulled back the curtain and began kissing her.
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.