Wentworth Rehab & Hcc
WENTWORTH REHAB & HCC in CHICAGO, IL — inspection on November 25, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
of dementia.
When a person's dementia is progressing, there may be behavioral issues such as psychotic symptoms and delusions because some parts of the brain is damaged. At a stage 5 dementia, a person may not know where they are and are not in reality. It is obvious that they cannot consent to medical procedures, psychotropic medication, or make financial decisions on their own regarding paying bills.
They would need a more in depth assessment on their decision- making abilities.On 11/24/25 at 2:25 pm, V1 (Administrator) stated the following, We do not have Sexual Assessment forms that I know of.On 11/24/25 at 2:50 pm, V2 (DON/ Director of Nursing) stated the following, R14 has not had any neuro psychiatric evaluations as far as I know while he was here. We don't have an assessment to measure a resident's capability to consent to sex.
Yes, a patient's care plan should be updated after observed having sexual intercourse in his room with a male visitor.Facility Staff schedule dated 11/01/25 documents, V19 CNA (Certified Nurse Assistant) working the 3pm- 11pm shift on the third floor.
The Initial Investigation report was faxed to IDPH on 11/19/25 at 2:24 pm and documents an allegation of sexual abuse involving R14 and V20.The Initial Investigation report was faxed to IDPH on 11/20/25 at 5:49 pm and documents an allegation of financial abuse involving R14 and V20.R14's Memory Care Initial assessment dated [DATE] documents the following; R14 is only oriented to person (knows self); R14 is not oriented to place, time or situation (does not know where he is, does not know why he is here, and does not know the current day/ month); R14 has short-term and long-term memory problems; R14's FAST (Functional Assessment Staging Tool for Dementia) scale is Stage five of Seven. R14's Care Plan dated 10/03/25 documents, R14 is at risk for abuse related to cognitive impairment and diagnosis of dementia; R14 has an ADL (Activity of Daily Living) Functional deficit related to dementia, impaired cognition, incomplete performances and periods of confusion.Facility Abuse policy documents the following: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion; the facility will report reasonable suspicion of a crime; the purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents.
This is done by immediately protecting residents involved in identifying reports possible abuse; implementing systems to investigate all reports and allegations of mistreatment promptly and aggressively, and making the necessary changes to prevent future occurrences; filing accurate and timely investigative reports.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/25/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Wentworth Rehab & Hcc
201 West 69th Street Chicago, IL 60621
SUMMARY STATEMENT OF DEFICIENCIES
Investigation report was faxed to IDPH on 11/19/25 at 2:24 pm and documents an allegation of sexual abuse involving R14 and V20.The Initial Investigation report was faxed to IDPH on 11/20/25 at 5:49 pm and documents an allegation of financial abuse involving R14 and V20.R14's Physician Order Sheet, Care Plan, Face sheet, and Medical Record exclude any orders regarding V20's visitation restrictions.Facility Abuse policy documents the following: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion; the facility will report reasonable suspicion of a crime; the purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents.
This is done by immediately protecting residents involved in identifying reports possible abuse; implementing systems to investigate all reports and allegations of mistreatment promptly and aggressively, and making the necessary changes to prevent future occurrences.Facility Abuse policy excludes verbiage related to assessing the sexual activity or capacity for sexual consent in residents with cognitive impairment.
Facility Visitation policy documents, the facility permits visitation at all times and will not restrict visitation without a reasonable clinical necessity or safety restriction.Facility Visitation policy excludes any protocol or required documentation regarding visitors' restrictions and abuse.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/25/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Wentworth Rehab & Hcc
201 West 69th Street Chicago, IL 60621
SUMMARY STATEMENT OF DEFICIENCIES
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to report allegations of sexual and financial abuse involving one resident R14.
This failure has the potential to affect 191 residents that reside at the facility.Based on interviews and record review, the facility failed to report allegations of sexual and financial abuse involving one resident R14.
This failure has the potential to affect 191 residents that reside at the facility.Findings include:R14 is [AGE] year old with diagnosis including but not limited to: Alzheimer's disease, moderate dementia, essential hypertension, type 2 diabetes mellitus without complications and benign prostatic hyperplasia with lower urinary tract symptoms. R14's BIMS (Brief Interview for Mental Status) dated 10/3/25 resulted in a score of 7, which indicates severe cognitive impairment. On 11/19/25 at 11:14 am, V1 (Administrator) stated the following, V18 (Memory Care Director) informed me that a CNA (Certified Nurse Assistant) had reported to her (V18), that R14 was observed in his room with his visitor (V20) without clothes and engaging in sexual intercourse sometime last month. We did our investigation by asking R14 if he consented to the sexual act and he said yes.
Just because he (R14) has dementia doesn't mean that he lost his desire to have sex.
However, we have banned V20 from visiting R14 at this time per R14's family request. V23 (R14's family) did not want V20 visiting R14 because she felt that there was some financial abuse going on. On 11/19/25 at 1:50 pm, V18 (Memory Care Director) stated the following, After the alleged sexual act, I assessed to see if (R14) was in distress. I also asked R14 about what happened and he (R14) stated that it was consensual sex. I notified V1 via telephone about the sexual incident, also that R14's family (V23) was concerned about possible financial abuse. R14's family had made me aware on 11/1/25, that she was concerned with V20 possibly taking advantage of R14 and receiving money from him.
V20 was restricted from visiting R14.
The block was for safety reasons, for possible financial abuse. I (V18) didn't document that V20 was banned, I just added him to the list at the front desk. I didn't document the sexual incident that occurred on 11/1/25, but I had planned to document and forgot.On 11/24/25 at 2:25 pm, V1 (Administrator) stated the following, I did not report the incident between R14 and his friend (V20) because he (R14) stated that the sex was consensual. I didn't report the suspected financial abuse because V20's visiting privileges were banned.R14's Care Plan dated 10/03/25 documents, R14 is at risk for abuse related to cognitive impairment and diagnosis of dementia; R14 has an ADL (Activity of Daily Living) Functional deficit related to dementia, impaired cognition, incomplete performances and periods of confusion.
The Initial Investigation report was faxed to IDPH on 11/19/25 at 2:24 pm and documents an allegation of sexual abuse involving R14 and V20.The Initial Investigation report was faxed to IDPH on 11/20/25 at 5:49 pm and documents an allegation of financial abuse involving R14 and V20.Facility Census dated 11/17/25 documents 191 residents.Facility Abuse policy documents the following: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion; the facility will report reasonable suspicion of a crime; the purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents.
This is done by immediately protecting residents involved in identifying reports possible abuse; implementing systems to investigate all reports and allegations of mistreatment promptly and aggressively, and making the necessary changes to prevent future occurrences; filing accurate and timely investigative reports.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/25/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Wentworth Rehab & Hcc
201 West 69th Street Chicago, IL 60621
SUMMARY STATEMENT OF DEFICIENCIES
Respond appropriately to all alleged violations.
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to conduct investigations for allegations of financial and sexual abuse for one resident R14 in a sample of five reviewed for abuse.
This failure has the potential to affect 191 residents that reside at the facility.Findings include:R14 is [AGE] year-old with diagnosis including but not limited to: Alzheimer's disease, moderate dementia, essential hypertension, type 2 diabetes mellitus without complications and benign prostatic hyperplasia with lower urinary tract symptoms.
R14's BIMS (Brief Interview for Mental Status) dated 9/26/25 resulted in a score of 6, which indicates severe cognitive impairment. R14's BIMS (Brief Interview for Mental Status) dated 10/3/25 resulted in a score of 7, which indicates severe cognitive impairment. On 11/19/25 at 11:14 am, V1 (Administrator) stated the following, V18 (Memory Care Director) informed me that a CNA (Certified Nurse Assistant) had reported to her (V18), that R14 was observed in his room with his visitor (V20) without clothes and engaging in sexual intercourse sometime last month. We did our investigation by asking R14 if he consented to the sexual act and he said yes.
Just because he (R14) has dementia doesn't mean that he lost his desire to have sex.
However, we have banned V20 from visiting R14 at this time per R14's family's request. V23 (R14's family) did not want V20 visiting R14 because she felt that there was some financial abuse going on. On 11/19/25 at 1:50 pm, V18 (Memory Care Director) stated the following, After the alleged sexual act, I assessed to see if (R14) was in distress. I also asked R14 about what happened and he (R14) stated that it was consensual sex. I notified V1 via telephone about the sexual incident, also that R14's family (V23) was concerned about possible financial abuse. R14's family had made me aware on 11/1/25, that she was concerned with V20 possibly taking advantage of R14 and receiving money from him.
V20 was restricted from visiting R14.
The block was for safety reasons, for possible financial abuse. I (V18) didn't document that V20 was banned, I just added him to the list at the front desk. I didn't document the sexual incident that occurred on 11/1/25, but I had planned to document and forgot.On 11/24/25 at 2:25 pm, V1 (Administrator) stated the following, Investigations should be documented via progress note or incident report in order to keep a written documentation of keeping track of what transpired. I would expect for the sexual act between R14 and V20 to be documented.R14's Care Plan dated 10/03/25 documents, R14 is at risk for abuse related to cognitive impairment and diagnosis of dementia; R14 has an ADL (Activity of Daily Living) Functional deficit related to dementia, impaired cognition, incomplete performances and periods of confusion. R14's Medical Record excludes any investigation or documentation regarding the sexual incident on 11/1/25.The Initial Investigation report was faxed to IDPH on 11/19/25 at 2:24 pm and documents an allegation of sexual abuse involving R14 and V20.The Initial Investigation report was faxed to IDPH on 11/20/25 at 5:49 pm and documents an allegation of financial abuse involving R14 and V20.Facility Census dated 11/17/25 documents 191 residents.Facility Abuse policy documents the following: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion; the purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents.
This is done by immediately protecting residents involved in identifying reports possible abuse; implementing systems to investigate all reports and allegations of mistreatment promptly and aggressively, and making the necessary changes to prevent future occurrences; employees are required to immediately report any occurrences of potential mistreatment they observe, hear about, or suspect to a supervisor or administrator; upon learning of the report, the administrator or designee shall initiate and incident investigation.
Facility ID: