Based on interview and record review the facility failed to monitor a resident's blood glucose levels for a resident with history of critical blood glucose levels and recent diabetic medication changes for 1 of 13 residents (R2) reviewed for Quality of Care in the sample of 13. This failure resulted in R2's blood sugar becoming critically low then R2's heart stopped.The Immediate Jeopardy began on ([DATE]) when R2's critical low blood sugar was not reported to the physician; the facility failed to develop a treatment plan with R2's physician for the critical low blood sugar. V1 Administrator was notified of the Immediate Jeopardy on [DATE] at 3:38PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on [DATE]. …
F684 citations in Illinois
Quality of care · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Illinois cites F684 more often than its own record predicts
1.31 times the share F684 takes of citations nationally.
Of every deficiency written in Illinois in 2025, this is the portion that was F684.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Illinois surveyors wrote
F684 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 follow physicians orders for weight monitoring and reporting of weight gain for a resident with Congested Heart Failure for 1 of 2 resident (R51) reviewed for respiratory care in sample of 54. This failure resulted in R51 being sent to the hospital for weight gain, wheezing, shortness of breath, with 11 lbs of excess fluid. Findings include:R51's admission record documents an admission date 03/30/23 with diagnoses including: chronic obstructive pulmonary disease (COPD), heart failure, type 2 diabetes mellitus, benign neoplasm of cranial nerves, chronic respiratory failure with hypoxia, venous insufficiency, chronic respiratory failure with hypercapnia, morbid obesity due to excess calories, anxiety disorder, polyosteoarthritis,… …
Based on interview and record review, the facility failed to ensure that residents medications were given as ordered by the physician based on the facility's policy and procedure regarding drug administration. This applies to 2 of 3 residents (R2 and R3) reviewed for medications in the sample of 14.The findings include:1. R3 had multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, anoxic brain damage, neuralgia and neuritis, chronic embolism and thrombosis, based on the face sheet.R3's quarterly MDS (Minimum Data Set) dated June 2, 2026 showed that R3 was cognitively intact.On August 26, 2026 at 2:32 PM, R3 stated that on August 15, 2026, V4 (agency RN, Registered Nurse) gave her morning medications late at around 2:00… …
The short window
Recent years
| Year | Share of Illinois citations | vs expected |
|---|---|---|
| 2023 | 4.74% | 1.31× |
| 2024 | 5.06% | 1.27× |
| 2025 | 5.62% | 1.31× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Illinois surveyors cite →
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