Based on observations, interviews, and record reviews, the facility failed to follow their policy by not completing a comprehensive assessment after a resident's change in medical condition and when adding new diagnoses' to residents' plan of care. This failure applied to one of one (R93) residents reviewed for comprehensive assessment and has resulted in R93 being deemed unfit to make decisions without thorough documentation that the physician verified or reconsider underlying causes of cognitive impairment (including recent urinary tract infection, known to cause [CONDITION(S)]) and/or failing to include diagnostic tests and collaboration with other physician specialists (such as neurology) when giving the resident a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Findings… …
F637 citations in Illinois
Assessment after a significant change · Resident Assessment and Care Planning Deficiencies
Assess the resident when there is a significant change in condition
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Illinois cites F637 less often than its own record predicts
0.13 times the national share — cited less often here than elsewhere.
Of every deficiency written in Illinois in 2025, this is the portion that was F637.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Illinois surveyors wrote
F637 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 perform a significant change comprehensive assessment after residents exhibited an increase in behaviors, were diagnosed with new psychiatric conditions, and were prescribed new ant-psychotics medications for two of two residents (R3 and R16) reviewed for signification change in condition in the sample of 30. The Centers for Medicare and Medicaid Services (CMS) (Resident Assessment Instrument) RAI 3.0 Manual dated 10/2025 documents a resident with MI or ID/DD must have a Resident Review conducted when there is a significant change in the resident's physical or mental condition. …
The short window
Recent years
| Year | Share of Illinois citations | vs expected |
|---|---|---|
| 2023 | 0.06% | 0.21× |
| 2024 | 0.02% | 0.10× |
| 2025 | 0.03% | 0.13× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Illinois surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction