F659 in Illinois. Pick another state for the same tag.
Against expectation — 2025
Illinois cites F659 more often than its own record predicts
Versus expected share3.09×
3.09 times the share F659 takes of citations nationally.
Share of Illinois citations0.12%
Of every deficiency written in Illinois in 2025, this is the portion that was F659.
Illinois0.12%
National0.04%
Share of all citations that were F659.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Illinois surveyors wrote
F659 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.
J · Immediate jeopardy, isolatedNovember 20, 2025
Based on interview and record review, the Facility failed to ensure staff were knowledgeable and competent to provide emergent tracheostomy reinsertion for 1 of 1 resident (R2) in the sample of 1. This failure resulted in R2 being transported via EMS (Emergency Medical Services) for reinsertion of a trach after dislodgement after nursing staff on duty failed to attempt to reinsert the trach because they weren't properly trained and didn't feel comfortable/confident in doing so. R2 remains in the Intensive Care Unit following trach reinsertion. This has the potential to affect current and new admissions that require tracheostomy care. …
Based on interview, and record review the facility failed to provide documentation showing staff was qualified to replace a gastrostomy tube (g-tube) per standards of practice for 1 of 4 residents (R1) reviewed for staff qualifications in the sample of 4. This failure resulted in R1's g-tube migrating into the small intestines leading to complications requiring hospitalization.Findings Include: On 4/13/26 at 12:10 PM, V1 (Administrator) said she did not know if V2 had any certification or training on changing a urinary catheter g-tube and to ask V2 directly. On 4/13/26 at 12:16 PM, V2 (Director of Nursing/DON) said she was not sure what prompted R1's urinary catheter g-tube to be changed, the nurse approached her and said the family wanted her to change it. …
D · No harm, potential for more than minimal, isolatedApril 23, 2026
Based on interview and record review the facility failed to implement physician's orders for one of three residents (R1) reviewed for following plans of care on the sample list of nine. Findings Include:R1's Medical Diagnoses List dated April 2026 documents Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Hypertension, Atrial Fibrillation, and Type II Diabetes Mellitus.R1's Minimum Data Set, dated [DATE] documents R1 is cognitively intact. R1's Physician Medication Order Sheet dated April 2026 documents a physician order for nursing to wrap R1's bilateral legs with elastic compression bandages from dorsum feet to below the knee every morning and remove at bedtime. …
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