Based on interview and record review, the facility failed to implement and follow their Abuse Prevention Policy and Procedures by failing to protect a resident (R1) from physical and verbal abuse, failed to immediately report allegations of abuse to the state agency, failed to initiate a timely investigation, and failed to take immediate actions to ensure resident safety. These failures resulted in psychosocial harm of R1 who is fearful and scared of another altercation with V5 and fearful he will be abused again. Failure of the facility not following their abuse policy puts all 147 residents at risk of being abused.The Immediate Jeopardy began on 07/05/2026 when R1 and V5 were involved in a physical altercation in the facility. …
F607 citations in Illinois
Abuse-prevention policies · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Illinois cites F607 more often than its own record predicts
1.20 times the share F607 takes of citations nationally.
Of every deficiency written in Illinois in 2025, this is the portion that was F607.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Illinois surveyors wrote
F607 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 implement and follow its Abuse Prevention Policy and Procedures by failing to protect a resident (R4) from physical and verbal abuse, failed to protect a resident from misappropriation of property (R6), and failed to take immediate actions to ensure resident's safety. These failures resulted in psychological harm for R4 who feared for his life when a staff he accused of physically abusing him came back to his room a day or two later, and R6 who lost a family heirloom that she intended to pass on to another family member.Findings include:1.) R4 was admitted to the facility on [DATE], face sheet listed the following past medical history in part: Chronic inflammatory demyelinating polyneuritis, primary osteoarthritis, type 2… …
Based on observation, interview, and record review, the facility failed to follow their abuse policy to ensure all residents are free from abuse for 2 (R1, R2) of 4 residents reviewed for abuse in a sample of 4.Findings include: 1. R1's Undated Face Sheet documents he was initially admitted to the facility on [DATE] and diagnoses including dementia, depression, hemiplegia and hemiparesis. R1's admission Minimum Data Set (MDS) dated [DATE] documents he is cognitively intact, wheelchair dependent and no behaviors exhibited. …
The short window
Recent years
| Year | Share of Illinois citations | vs expected |
|---|---|---|
| 2023 | 0.48% | 0.65× |
| 2024 | 0.86% | 1.14× |
| 2025 | 0.79% | 1.20× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Illinois surveyors cite →
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