F656 in Illinois. Pick another state for the same tag.
Against expectation — 2025
Illinois cites F656 less often than its own record predicts
Versus expected share0.25×
0.25 times the national share — cited less often here than elsewhere.
Share of Illinois citations0.87%
Of every deficiency written in Illinois in 2025, this is the portion that was F656.
Illinois0.87%
National3.44%
Share of all citations that were F656.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Illinois surveyors wrote
F656 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.
G · Actual harm, isolatedDecember 7, 2025
Based on interview and record review, the facility failed to implement care plan interventions during ambulation and transfer which affected one resident (R1) that required hospital transfer. This failure resulted in staff's inability to prevent a fall and R1 sustaining a hip fracture.Findings include:R1 is an [AGE] year-old, originally admitted on [DATE] with medical diagnosis that include and are not limited to: Parkinson's Disease, Dementia and Obstructive and Reflux Uropathy, according to Minimum Data Set (MDS), R1 has a Brief Interview for Mental Status (BIMS) score of 3/15, indicating severe cognitive impairment. …
E · No harm, potential for more than minimal, patternAugust 11, 2026
Based on interviews and review of records, the facility failed to provide interventions related to incidents involving aggressive behavior towards other residents for 5 out of 9 residents (R1, R2, R4, R5 and R6) for a total of 9 residents in the sample. These failures have the potential to affect 5 residents (R1, R2, R4, R5 and R6) due to lack of interventions that may prevent recurrent of similar incidents.Findings include: After full care plan review, the following identified concerns related to resident's behavior were not addressed in the care plan: Incident dated 07/30/2026 involving R1 and R2, per staff statements V15 (Licensed Practical Nurse) on 08/04/2026 at 12:46 PM, V7 (Certified Nursing Assistant) on 08/04/2026 at 08/04/2026, V8 (Certified Nursing Assistant) on 08/04/2026. …
C · No harm, potential for minimal, widespreadMarch 10, 2023
Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives or goals and interventions to meet the residents' needs for 6 (R90, R103, R52, R22, R85, R134) residents reviewed for advance directives. This has the potential to affect all 142 residents per the census on [DATE].
Findings include:
On [DATE] at 2:38 PM R90's health record reviewed and documented that R90's admitted was on [DATE] with diagnoses not limited to asthma, schizophrenia, post-traumatic stress disorder, and bipolar disorder. R90's Physician Order Sheet (POS) for ,d+[DATE] documented in part: Advance Directive - FULL CODE. …
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