Based on Observation, Interview and Record Review, the facility failed to ensure a resident with known bowel incontinence was provided dignified incontinence care for one of four residents (R1) reviewed for incontinence care assistance in the sample of seven. This failure resulted in R1 experiencing mental anguish and feeling embarrassed and ashamed of the lack of control of R1 bowels and the need for daily assistance with hygiene. Findings include:The facility's Dignity policy, dated 8/2019, documents Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be treated with dignity and respect at all times. …
F677 citations in Illinois
ADL care for dependent residents · Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Illinois cites F677 more often than its own record predicts
1.55 times the share F677 takes of citations nationally.
Of every deficiency written in Illinois in 2025, this is the portion that was F677.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Illinois surveyors wrote
F677 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 observation, interview, and record review, the facility failed to ensure that necessary services were provided to maintain personal hygiene and continence care for 1 of 3 sampled dependent residents (R2) who was unable to perform activities of daily living (ADLs) independently. Findings include:R2's face sheet documents R2 is a [AGE] year old admitted to the facility with diagnoses including, but not limited to: Hyperlipidemia, unspecified (too many fats or lipids circulating in blood), Essential (primary) hypertension (high blood pressure that has no single, identifiable medical cause), Gastro-esophageal reflux disease without esophagitis (chronic acid reflux symptoms, without physical damage, sores, or inflammation in esophagus) and Benign prostatic hyperplasia with lower… …
Based on observation, interview and record review the facility failed to assist residents identified as needing assistance with grooming and nail care. This applies to 8 of 8 residents (R8, R19, R62, R94, R116, R151, R159, and R184) reviewed for ADL (activities of daily living) assistance in the sample of 35. The findings include: 1. R8's EMR (Electronic Medical Record) shows her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R8's MDS (Minimum Data Set) and care plan dated October 6, 2021 shows R8 has severe cognitive impairment which prevents her from answering questions appropriately and R8 requires one staff physical assistance with personal hygiene. On November 15 and 16, 2021 intermittent observations were made of R8 with several long chin hairs. 2. …
The short window
Recent years
| Year | Share of Illinois citations | vs expected |
|---|---|---|
| 2023 | 4.49% | 1.62× |
| 2024 | 4.00% | 1.65× |
| 2025 | 3.51% | 1.55× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Illinois surveyors cite →
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