F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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
interview and record review, the facility failed to notify the facility Abuse Coordinator and the State Agency
of an allegation of physical abuse.
This applies to 2 of 4 residents (R2 and R3) reviewed for physical abuse in a sample of 4.
The findings include:
R3 is a [AGE] year-old-female admitted on [DATE], having cognition intact as per the MDS (Minimum Data
Set), dated 4/7/25.
On 4/22/25 at 12:30 PM, R3 stated, (R4) hit me on my head and face. But I don't remember the day exactly.
It happened in my room, and nobody saw it.
R2 is a [AGE] year-old female admitted on [DATE], with cognition intact, as per the MDS, dated [DATE].
On 4/22/25 at 11:40 AM, R2 stated, One of the residents (R4) hit me on my head four times last week. I
had a headache after that for two days. The incident happened in front of the nurse's station and (V7,
Certified Nursing Assistant/CNA) and (V8, CNA) witnessed the incident. I reported the incident directly to
(V9, Psychiatric Rehabilitation Services Coordinator/PRSC) and (V10, PRSC).
On 4/33/25 at 11:00 AM, V7 (Certified nursing assistant/CNA) stated, (R2) told me that (R4) hit her three
times to her head. I am pretty sure I reported it to the nurse. I thought the nurse would inform the Abuse
Coordinator (V1).
On 4/22/25 at 12:20 PM, V8 (CNA) stated, I remember (R4) hit me on that day (4/16/25). (R2) told me that
(R4) hit her, but I didn't see (R4) hit (R2). (R3) also told me that (R4) hit her. I didn't report it to the Abuse
Coordinator.
On 4/22/25 at 12:32 PM, V9 stated, I personally didn't see the incident that (R4) hits (R2) on her head. I
know (R4) had a really bad day and was going off. I told the incident to my boss (V11, Psychiatric
Rehabilitation Service Director/PRSD). Also, (R3's) daughter was here and told me that (R4) hit her mother.
I told the Administrator about (R3's) daughter's concern. It happened on Wednesday (4/16/25), and it was
my late day and I start at 11:00 AM on Wednesday.
On 4/23/25 at 3:00 PM, V11 stated, The physical abuse allegation between (R2) and (R4) was not
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
145830
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145830
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aperion Care West Chicago
201 West North Avenue
West Chicago, IL 60185
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
reported to me. As per the chain of command, (V9) was supposed to report the allegation to me or the
Abuse Coordinator. We will provide in-service to staff to report the abuse allegation to the Abuse
Coordinator.
On 4/22/25 at 12:35 PM, V10 (PRSC) stated, I heard about the incident between (R3) and (R4) last
Wednesday (4/16/25). I heard (R4) had behavior issues, and she hurt other residents. When (R3's)
daughter reported that (R4) hit her mom, they moved (R4) to another room. I didn't report it to the Abuse
Coordinator as I didn't see the incident.
On 4/22/25 at 2:00 PM, V2 (Assistant Administrator) stated, Our staff are supposed to report any abuse
allegation to our Administrator, who is our Abuse Coordinator. If our Administrator is unavailable, they can
report the abuse allegations to me. The abuse allegations should have been reported to us for investigation.
We are going to discipline (V8) for not reporting abuse allegations, and we will initiate an abuse
investigation.
On 4/23/25 at 11:30 AM, V1 stated, The abuse allegations from (R4) to (R2) and (R3) were not reported to
me. I talked to my staff including (V8) to report any kind of abuse allegation to myself immediately. We
started an in-service to educate staff to report abuse allegations immediately to the Abuse Coordinator.
A review of the facility provided Abuse Prevention and Reporting Guidelines, revised on 10/24/22,
documents: Employees are required to report any incident, allegation, or suspicion of potential abuse,
neglect, exploitation, mistreatment, or misappropriation of resident property they observe, hear about, or
suspect to the administrator immediately, or to an immediate supervisor who must then immediately report
it to the administrator.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145830
If continuation sheet
Page 2 of 2
