Based on interview and record review, the facility failed to ensure new admission Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures resulted in R1 not receiving diabetic monitoring or medically necessary insulin which resulted in R1 vomiting, becoming unresponsive with absence of pulse and respirations, requiring CPR (cardiopulmonary resuscitation) initiation, transferring to the local hospital, and subsequently expiring. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at Severity Level 2 while the facility is in the process of educating, auditing and monitoring all new admissions for clarification of all admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . …
F635 citations in Illinois
Resident Assessment and Care Planning Deficiencies
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Illinois cites F635 less often than its own record predicts
0.54 times the national share — cited less often here than elsewhere.
Of every deficiency written in Illinois in 2025, this is the portion that was F635.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Illinois surveyors wrote
F635 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 record review and interview, the facility failed to ensure physician orders were clarified upon admission to provide cares for 2 of 7 (R3, R6) residents reviewed for orders. This failure resulted in R3 and R6 receiving care without verified admission orders from their attending physician in the sample of 18. Findings include: 1. R3 was admitted to the facility on [DATE] with diagnoses of cerebral vascular accident (stroke), cognitive impairment, and had acute respiratory failure which required a tracheostomy (an opening in the neck into the windpipe to help air and oxygen reach the lungs). On 12/11/23, R3's Order Summary Report noted to provide tracheostomy cleaning every evening and on an as needed basis. …
Based on interviews and record review, the facility failed to not follow their Facilities Physician Orders Policy to ensure all resident/patient medications, treatment and plan of care must be in accordance to the licensed physician's order and failed to ensure to follow physician orders as it is written in the POS (physician order summary). This failure affected 1 resident (R8) out of 3 residents (R4 and R9) reviewed for Quality of Care/Treatment.Based on interviews and record review, the facility failed to not follow their Facilities Physician Orders Policy to ensure all resident/patient medications, treatment and plan of care must be in accordance to the licensed physician's order and failed to ensure to follow physician orders as it is written in the POS (physician order summary). …
The short window
Recent years
| Year | Share of Illinois citations | vs expected |
|---|---|---|
| 2023 | 0.02% | 0.25× |
| 2024 | 0.02% | 0.48× |
| 2025 | 0.03% | 0.54× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Illinois surveyors cite →
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