Based on interview and record review the facility failed to ensure a resident was free from the use of unnecessary psychotropic medications, including polypharmacy for 1 of 3 residents (R1) reviewed for chemical restraints in a sample of 8. This failure caused R1 to develop extrapyramidal symptoms (involuntary movements) and lethargy which contributed to a severe weight loss, the development of pressure ulcers, and overall decline in health. R1 was hospitalized on [DATE] and admitted to the Intensive Care Unit with diagnoses of Septic Shock, Dehydration, Hypernatremia, Transaminitis, Hypoxia, Elevated Troponin, Failure to Thrive, Acute Kidney Injury, Elevated Lactic Acid, Elevated Brain Natriuretic Peptide (BNP), Acute Respiratory Failure, and Multi-Organ Failure. …
F605 citations in Illinois
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Illinois cites F605 less often than its own record predicts
0.79 times the national share — cited less often here than elsewhere.
Of every deficiency written in Illinois in 2025, this is the portion that was F605.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Illinois surveyors wrote
F605 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 observation, interview, and record review the facility failed to ensure a resident was free from chemical restraints, failed to implement and document individualized non-pharmacological interventions prior to psychotropic medication administration, and failed to administer medications according to physician's orders for one of three residents (R1) reviewed for unnecessary medications in the sample list of 20. This failure resulted in R1 sustaining a fall resulting in an acute subdural hematoma.Findings include:On 6/30/26 at 1:06 PM, R1 was lying in bed on R1's right side. …
Based on interview and record review the facility failed to document behaviors to justify the use of psychotropic medications and document nonpharmacological interventions attempted for two (R49, R66) of five residents reviewed for unnecessary medications in the sample list of 44 residents. Findings include: The facility's Behavior Monitoring policy dated 5/6/26 documents behaviors and interventions will be monitored. The facility's Use of Psychotropics policy dated 5/6/26 documents: The policy is to ensure residents only receive psychotropic medications when nonpharmacological interventions are contraindicated, and these medications should only be used to treat symptoms and not for staff convenience. …
The short window
Recent years
| Year | Share of Illinois citations | vs expected |
|---|---|---|
| 2024 | 0.02% | 1.13× |
| 2025 | 0.55% | 0.79× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Illinois surveyors cite →
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