Based on interview and record review the facility failed to monitor and supervise 1 of 3 residents (R2) reviewed for elopement. This failure resulted in R2, a cognitively impaired resident, identified as being at risk for elopement, exiting the facility unsupervised on [DATE]. R2 was found at a public laundromat unattended and confused.This was identified as an Immediate Jeopardy.V1 (Administrator), V2 (Director of Nursing) and V65 (Regional Director of Operations) were presented with the immediate jeopardy template on [DATE] at 4:00 PM. The immediate jeopardy began on [DATE] when R2 left the building unattended by staff.The facility presented a plan to remove the immediacy on [DATE]. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. …
F689 citations in Illinois
Accidents and supervision · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Illinois cites F689 more often than its own record predicts
1.81 times the share F689 takes of citations nationally.
Of every deficiency written in Illinois in 2025, this is the portion that was F689.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Illinois surveyors wrote
F689 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 ensure safety was provided for a resident when given hot coffee. This failure resulted in R1 sustaining a second degree burn to her arm from hot coffee on 8/1/26. This is for 1 of 2 residents (R1) reviewed for safety and supervision in the sample of 8.The findings include:The Incident Report dated 8/1/26 for R1 showed under the notes section; R1 sustained a thermal burn to her right forearm after accidentally spilling hot coffee. The certified nursing assistant (CNA) delivered the breakfast tray with meal set up and notified this nurse that she had spilled coffee. Upon immediate assessment, a burn measuring 13 centimeters (cm) x 5.3 cm was noted to the right forearm. …
Based on observation, interview, and record review the facility failed to ensure safe transfers were provided for residents for 2 of 4 residents (R1 & R4) reviewed for safety and supervision in the sample of 6.The findings include:1. The Incident Report dated 8/19/26 for R1 showed: This nurse was notified by R1 that she had bruising to the left big toe that had developed the night before. Assessed the area to the skin and noted bruising to the left big toe with slight redness. R1 stated during transportation the night before her left big toe hit the wall. The interdisciplinary team met to discuss R1's bruising to the left great toe likely due to bumping during a transfer.On 8/30/26 at 11:04 AM V4 CNA stated R1 had a bruise to her toe and said that somebody rammed it into something. …
The short window
Recent years
| Year | Share of Illinois citations | vs expected |
|---|---|---|
| 2023 | 8.29% | 1.68× |
| 2024 | 9.46% | 1.76× |
| 2025 | 10.02% | 1.81× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Illinois surveyors cite →
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