F657 in Illinois. Pick another state for the same tag.
Against expectation — 2025
Illinois cites F657 less often than its own record predicts
Versus expected share0.45×
0.45 times the national share — cited less often here than elsewhere.
Share of Illinois citations0.84%
Of every deficiency written in Illinois in 2025, this is the portion that was F657.
Illinois0.84%
National1.87%
Share of all citations that were F657.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Illinois surveyors wrote
F657 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, isolatedJanuary 31, 2024
Based on interview and record review the facility failed to review and revise a resident's (R2) plan of care, after the resident exhibited hypersexual behaviors. This failure resulted in R2 sexually abusing R1 on January 5, 2024, resulting in R2's arrest by the local police and charged with two counts of domestic battery. This applies to 1 of 4 residents (R2) reviewed for behavioral care plans in the sample of 6.
The findings include:
R2 was admitted to the facility on [DATE]. R2 had multiple diagnoses including schizophrenia, schizoaffective disorder, bipolar disorder, restlessness and agitation, violent behavior, psychosis not due to a substance or known physiological condition, based on the face sheet. …
D · No harm, potential for more than minimal, isolatedAugust 18, 2026
Based on interview, observation and record review the facility failed to ensure a care plan intervention for falls risk was communicated for one (R11) of three residents reviewed for accidents in the sample list 24.Findings Include: On 8/12/2026 at 9:55 a.m. R11 observed sitting in room up in wheelchair with anti-tip devices attached on back of the wheelchair. On 8/12/2026 at 11:55 a.m. V18, Certified Nursing Assistant (CNA) presented a binder that is located at nurses' station labeled South CNA Binder that has handwritten care planned interventions in place for the residents. R11 has an intervention noted for anti-roll backs on wheelchair that was last updated on 7/22/2026. On 8/12/2026 at 12:31 p.m. …
B · No harm, potential for minimal, patternFebruary 7, 2019
Based on observation, interview and record review, the facility failed to revised care plans related to falls for four residents (R7, R16, R88, R102) in a sample of 36, reviewed for falls.
Findings includes:
R7 had a fall on the following dates; 5/19/18, 9/7/18, and no new goals or interventions were care planned with measurable goals toward preventing R7 from further falls. On 2/4/19 at 10:09AM R7 self propelling in wheelchair without shoes being in use at this time.
Facility records indicate R16 having falls on the following dates; 4/4/18, 6/30/18, 9/19/18 and no new goals or interventions were care planned with measurable goals toward preventing R16 from further falls. …
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