Aperion Care West Chicago
APERION CARE WEST CHICAGO in WEST CHICAGO, IL — inspection on January 31, 2026.
Found 6 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
During the interview, R131 was observed pacing back and forth in his room, appearing restless and visibly tense when recounting the event. He stated his pain and fear made it difficult for him to sleep, he had been waking frequently at night, and he felt more depressed and withdrawn than usual. R131 reported he no longer felt safe in the facility and expressed concern a similar incident could happen again. On 1/29/2026 at 10:46 AM, an interview was conducted with V14 (In-house NP - Nurse Practitioner), and on 1/30/2026 at 9:37 AM, an interview was conducted with V34 (Psychiatric NP).
Both stated pain is a subjective experience, meaning it is based on the resident's personal perception and report rather than solely on observable or objective findings.
They emphasized regardless of a resident's mental or psychiatric status, if a resident reports pain, it must be taken seriously, appropriately assessed, and treated as real pain. V34 further explained that the symptoms reported to her regarding R131 following the 1/18/2026 altercation - including heightened anxiety, hypervigilance, disrupted sleep, and worsening mood - were not consistent with his baseline presentation. V34 explained that these symptoms are characteristic of an acute traumatic response to a threatening event, particularly when the resident continues to experience ongoing physical pain and fear of recurrence. V34 stated such a response can manifest as rumination about the incident, avoidance of common areas, sleep disturbance, emotional withdrawal, and increased distress, and may warrant additional psychiatric support, monitoring, or interventions. V34 further emphasized psychological distress, like pain, is a subjective experience, and clinicians must take a resident's report of distress seriously rather than discount it based solely on objective findings. On 1/28/2026 at 3:12 PM, V1 (Administrator) stated he reviewed the facility's security camera footage from 1/18/2026 and observed R200 making contact with R131.
Per V1, the video showed R200 with his arms around R131 after approaching him from behind. V1 also confirmed he is the facility's Abuse Coordinator, and he was made aware of the incident on the night it occurred. V1 stated if a staff member had attacked a resident in the same manner as R200 attacked R131, he would consider that to be physical abuse and a reportable event.
The facility's policy titled Abuse and Retaliation Prevention and Reporting (effective 1/8/2026) states, The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment.
This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents The policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish to a resident.
The policy also showed Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment
145830 01/31/2026
Aperion Care West Chicago 201 West North Avenue West Chicago, IL 60185
According to R131, R200 suddenly charged at him, grabbed him, and placed both arms around his upper torso, putting him in a headlock. On 1/28/2026 at 3:12 PM, V1 (Administrator/Abuse Coordinator) stated he had reviewed the facility's security camera footage from 1/18/2026 and confirmed he was made aware of the incident that night.
V1 described the footage showed R200 approaching R131 from behind and placing both arms around his upper torso. V1 stated he did not report the incident to the Illinois Department of Public Health (IDPH) at that time because he did not believe it met the facility's definition of abuse, reasoning there was no serious injury, bodily harm, or psychosocial effects. V1 further acknowledged the incident was not reported to IDPH until 1/27/2026, nine days later. He indicated an internal investigation had not yet been conducted but would be initiated.
Requests for staff statements, interviews and/or any other documentation related to the incident (including incident reports), had been made; however, the facility was not able to provide any of these records prior to the end of the survey.
Review of R131's EMR (Electronic Medical Record) shows following the 1/18/2026 incident, R131 did not have new care plan interventions or protective measures initiated to address the outcomes of the incident, including severe left shoulder pain and psychosocial distress (which he verbalized experiencing on 1/29/2026 at 12:45 PM). R131's care plan had not been updated following the incident.
Care plan sections related to abuse (created 1/29/2026) and psychosocial wellbeing, including mood triggers (created 1/27/2026), were added only during the survey.
Review of R200's EMR shows diagnoses including anxiety disorder, insomnia, schizophrenia, and schizoaffective disorder. R200's care plan had not been updated after the incident involving R131.
Care plan sections related to mood triggers (created 1/30/2026), abuse (created 1/28/2026), behaviors (created 1/28/2026), and physical and verbal aggression (created 1/28/2026) were added during the survey.
The facility's policy titled Abuse and Retaliation Prevention and Reporting (effective 1/8/2026) states The purpose of this policy is to ensure that the facility is doing all that is within its control to prevent occurrences of abuse.and mistreatment of residents This will be done by: identifying occurrences and patterns of potential mistreatment immediately protecting residents involved in identified reports of possible abuse .implementing systems to promptly and aggressively investigate all reports and allegations of abuse .and making necessary changes to prevent future occurrences .filing accurate and timely investigative reports The policy further states: Any allegation of abuse, retaliation, or any accident resulting in serious bodily injury be reported to IDPH immediately, but no more than two hours after the allegation, [and that] any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours.
Residents who allegedly abused another resident shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement considering his or her safety, as well as the safety of other residents and employees of the facility. In addition, the facility shall take all steps necessary to ensure the safety of residents.
145830 01/31/2026
Aperion Care West Chicago 201 West North Avenue West Chicago, IL 60185
According to R131, R200 suddenly charged at him, grabbed him, and placed both arms around his upper torso, putting him in a headlock. On 1/28/2026 at 3:12 PM, V1 (Administrator/Abuse Coordinator) stated he reviewed security camera footage from 1/18/2026 and confirmed awareness of the incident that night. V1 stated he did not report the incident to IDPH (Illinois Department of Public Health) at that time because he did not believe it met the definition of abuse, reasoning there was no serious injury, bodily harm, or psychosocial effects. V1 further acknowledged the incident was not reported to IDPH until 1/27/2026.
Review of V1's Initial Report to IDPH regarding the physical altercation involving R131 and R200 included a fax confirmation sheet indicating it was sent on 1/27/2026 at 2:59 PM.
The report confirmed a date of occurrence of 1/18/2026 and stated the incident category as Resident Abuse.
The reported also stated, Facility will conduct a thorough investigation with complete report to follow, indicating an investigation had been initiated 9 days later.
The facility's policy titled Abuse and Retaliation Prevention and Reporting (effective 1/8/2026) states, The purpose of this policy is to ensure that the facility is doing all that is within its control to prevent occurrences of abuse.and mistreatment of residents.
The policy also states: All incidents will be documented, whether or not abuse, neglect.was alleged or suspected as any incident or allegation involving abuse. will result in an investigation and that upon learning of the report, the administrator or designee shall initiate an incident investigation.
Investigation Procedures: The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident, and the resident, if interviewable.
Any written statements that have been submitted will be reviewed, along with any pertinent medical record or other documents.
145830 01/31/2026
Aperion Care West Chicago 201 West North Avenue West Chicago, IL 60185
further stated any pain rated above 6 out of 10 on the pain scale is considered severe and requires
policy titled Pain Management Program (Revised 7/6/2018) states the purpose of the policy is to
unrelieved pain and to develop an optimal pain management plan to enhance healing and promote physiological and psychological wellness.
The policy further outlines that the pain management program includes the following components:Documentation of pain assessment and ongoing monitoring;Informed resident participation in care decisions, including decisions related to pain management;Recognition of pain as the fifth vital sign, along with temperature, pulse, respiration, and blood pressure.
The facility's policy also specifies that the pain assessment protocol must be initiated whenever there is a change in the resident's condition that requires pain control or when there is a change in the identification of pain.
Per policy, care plans must be reviewed and updated whenever the resident's pain management plan is found to be ineffective and at least during each quarterly care conference.
Lastly, the policy requires documentation of the resident's response to the pain management plan to ensure ongoing evaluation and effectiveness.
145830 01/31/2026
Aperion Care West Chicago 201 West North Avenue West Chicago, IL 60185
CMS (Centers for Medicare and Medicaid Services) shows the survey start date of 1/27/26 and a
residents residing in the facility at the time of survey start on 01/27/26 receive services from the Dietary department.On 01/27/2026 at 12:19 PM during the dining observation, R118 stated the food isn't always served to them while it is hot.R207 stated the food served is usually barely warm.R100 stated the meals are usually not served hot.On 01/27/2026 at 12:51 PM, R40 stated the food isn't usually served hot. R40 stated she will request staff to reheat her food, but she is told they can't reheat if for her. R40 stated staff will not get her a new tray from the kitchen, so she must eat it cold.On 01/28/2026 at 12:23 PM, food holding temperatures were done with V4, Dietary Director and V39 Cook.
The following foods were noted held in degrees Fahrenheit (F): Broccoli- 100 degrees FSweet and Sour Pork carbohydrate-controlled Low Concentrated Sweets- 95 degrees FPlain Rice- 100 degrees FGrilled Cheese Sandwiches- 90 degrees FPureed Grilled Cheese- 120 degrees FCarrots- 120 degrees FPureed Broccoli- 120 degrees F On 01/27/2026 at 1:05 PM, the test tray sent to the conference room had two cookies, chili in a bowl, carrots, and crumbly corn bread on a Styrofoam plate.On 01/28/2026 at 12:23 PM, V4, Dietary Director, stated because of budget constraints, he is unable to purchase real plates, so the residents' meals are served on Styrofoam. V4 stated Styrofoam impacts how food temperatures are maintained. V4 stated there is no plate warmer and the delivery carts are not insulated, which also makes it difficult to maintain food temperatures. V4 stated there have been occasions he has gone to the units and meal trays are left unpassed up 20 minutes after being sent from the kitchen.The facility provided an undated policy which stated foods that are meant to be served and displayed for a long time require elevated temperatures for storage.
Foods are held at 135 degrees F or above to stop the growth of harmful microorganisms and preserve food safety
145830 01/31/2026
Aperion Care West Chicago 201 West North Avenue West Chicago, IL 60185
Daily Census report, dated 1/27/2026, showed R102, R6, R156, R103, R77, R47, R202, R4, R206, R13,
2/2/2018, said the facility was to respond to residents' requests and needs in a timely and courteous
reach of the permanent call light when needed.
Call bell system defects will be reported promptly to the Maintenance Department for servicing, and room checks will be done until the system is repaired.