Based on interview and record review, the facility failed to follow advanced directives for 1 of 3 (R5) residents reviewed for advanced directives in a sample of 16. This failure resulted in an Immediate Jeopardy on [DATE] when staff performed unnecessary chest compressions, respiratory ventilation for 20 plus minutes, and intubation on R5 against his advanced directive status. On [DATE] at 9:22 AM V1, Administrator was notified of the Immediate Jeopardy. The Surveyor confirmed by observation, interview and record review, the Immediate Jeopardy was removed on [DATE], after abatement reviews dated [DATE] at 7:35 AM and [DATE] at 3:07 PM but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-servicing training and policies and… …
F578 citations in Illinois
Advance directives · Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Illinois cites F578 less often than its own record predicts
0.60 times the national share — cited less often here than elsewhere.
Of every deficiency written in Illinois in 2025, this is the portion that was F578.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Illinois surveyors wrote
F578 findings written in Illinois, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on interview and record review the facility failed to formulate a desired advanced directive for one resident (R2) of three residents reviewed for Advanced Directives. This failure resulted in R2 receiving CPR (Cardiopulmonary Resuscitation) when he did not wish to. This past non-compliance occurred [DATE] through [DATE].The Facility's Advanced Directives policy dated [DATE] documents At the time of admission each resident will be asked if they have made advanced directives and provided educational information regarding state and federal law. The resident, the legal representative, or the individual who has been authorized as the resident's health care representative will be asked if an Advanced Directive, as recognized under the state law, has been executed. …
Based on interview and record review the Facility failed to prevent, assess and identify triggers that caused emotional distress during a shower, that required a new medication for emotional suffering for one of five Residents (R1) reviewed for trauma in a sample of five.Findings include:The Facility Trauma Informed Care Policy, undated, documents: guide staff in appropriate and compassionate care specific to individuals who have experienced trauma; provide in-service training about trauma, impact on health and it's context of the healthcare setting; staff are guided in evidence-based organizational and interpersonal strategies that support trauma informed care; the facility supports a culture of emotional well-being and physical safety for staff and residents; caregivers are taught… …
The short window
Recent years
| Year | Share of Illinois citations | vs expected |
|---|---|---|
| 2023 | 0.90% | 0.84× |
| 2024 | 0.92% | 0.94× |
| 2025 | 0.57% | 0.60× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Illinois surveyors cite →
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