Based on interview and record review, the facility failed to ensure competency of the Professional Nursing staff for 1 of 6 (R5) reviewed for Professional Standards in the sample of 50. This failure has the potential to affect all 128 Residents residing in the facility.The immediate jeopardy began on 9/10/25, when V6, Registered Nurse (RN), failed to appropriately respond to an emergent medical event, when R5 displayed symptoms of medical distress and presented with a blood glucose level of 33. V6 failed to follow physician's order of administering Baqsimi (Glucagon) for low blood sugar, and instead disassembled prefilled Epinephrine and Narcan cartridges, combining pieces of both medication cartridges, and administered Epinephrine injection nasally. …
F658 citations in Illinois
Professional standards of care · Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Illinois cites F658 less often than its own record predicts
0.33 times the national share — cited less often here than elsewhere.
Of every deficiency written in Illinois in 2025, this is the portion that was F658.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Illinois surveyors wrote
F658 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 provide care in accordance with professional standards of quality by failing to develop and implement a care plan for a resident with documented history of dysphagia, despite recommendations from speech therapy that resident should have swallowing precautions in place; and by failing to follow policy and guidelines in performing emergency procedures during life-threatening situations. These deficiencies affected one (R1) of four residents reviewed for accidents and supervision and resulted in R1 experiencing a choking episode and subsequently died in route to the hospital for emergency care. …
Based on interview and record review facility failed to ensure provider and clinical staff's documentation was accurate for one of three (R3) residents reviewed for professional standards.Findings include:R3 was admitted to facility on [DATE] with diagnoses that included mitral valve insufficiency, heart failure, difficulty walking, dysphagia, type two diabetes, acute respiratory failure, chronic obstructive pulmonary disease, hypertension, myocardial infarction, peripheral vascular disease, atherosclerotic heart disease, chronic kidney disease, atrial fibrillation, gastroesophageal reflux, obesity, enterocolitis due to clostridium difficile.Minimum Data Set (MDS) dated [DATE] included Brief interview of Mental Status (BIMS) of thirteen indicating R3 was cognitively intact. …
The short window
Recent years
| Year | Share of Illinois citations | vs expected |
|---|---|---|
| 2023 | 0.58% | 0.36× |
| 2024 | 0.50% | 0.30× |
| 2025 | 0.58% | 0.33× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Illinois surveyors cite →
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