Based on observation, interview and record review, the facility failed to ensure one of 21 residents (R10) was free from involuntary seclusion, failed to ensure criteria was met for admission to the Secured Dementia Unit and failed to follow physician's guidance for resident's wellbeing to prevent a change in condition reviewed in a sample of 41.These failures resulted in R10, a cognitively intact resident with admitting diagnoses of Post-Traumatic Stress Disorder and Generalized Anxiety, to be admitted to the Secured Dementia Unit on 1/30/26 and remained in the unit until 2/26/26.These failures resulted in Immediate Jeopardy.The Immediate Jeopardy was noted to begin on 1/30/26, when the facility failed to ensure a resident was free from Involuntary Seclusion when a cognitively intact… …
F603 citations in Illinois
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Illinois cites F603 less often than its own record predicts
0.33 times the national share — cited less often here than elsewhere.
Of every deficiency written in Illinois in 2025, this is the portion that was F603.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Illinois surveyors wrote
F603 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 ensure that residents were kept free from involuntary seclusion when staff tethered a bedsheet from the resident's room door handle to a hallway handrail, physically trapping the resident inside the room. This deficient practice affected one of four residents (R1) reviewed for abuse. A reasonable person reviewing these actions would conclude that tying a door shut with a bedsheet is a punitive, non-therapeutic mechanism used to involuntarily confine a resident.A reasonably prudent caregiver would recognize that blocking an exit in this manner completely strips the resident of their freedom of movement, creates an immediate fire and entrapment hazard, and serves strictly as a measure of staff convenience to manage the resident's… …
Based on interview and record review, the facility failed to follow their abuse policy by involuntarily holding a resident in their room by blocking or holding the door closed with the use of a garbage bag. This failure affected 1 (R2) of 6 residents reviewed. Findings Include: R2 is a [AGE] year-old male. R2's Minimum Data Set (MDS) dated [DATE] shows R2 is severely cognitively impaired and has a diagnosis of Unspecified Dementia, with other behavioral disturbance, other disorders of brain, Alzheimer's disease, Cognitive communication deficit, Type 2 diabetes mellitus, Essential hypertension, other abnormalities of gait and mobility, and need for assistance with personal care. On 12/10/24 at 11:54 AM, R2 was observed pacing in R2's room. R2 appeared to be confused. …
The short window
Recent years
| Year | Share of Illinois citations | vs expected |
|---|---|---|
| 2023 | 0.03% | 1.64× |
| 2024 | 0.05% | 0.91× |
| 2025 | 0.01% | 0.33× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Illinois surveyors cite →
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