Based on interview and record review, the facility failed to provide physician ordered gastrostomy care including cleansing, laboratory monitoring, flushes, residual checks and tube insertion site assessments for a resident with an internal percutaneous endoscopic gastrostomy (PEG) tube for nutritional support for one of three residents (R9) reviewed for gastrostomy tubes (G-tube) in the sample of 16. This failure resulted in R9 transferring to the emergency room and being admitted to the hospital with fever, abdominal pain, diarrhea, nausea and vomiting, toxic appearance and a diagnosis of sepsis from multiple suspected sources including a g-tube site infection with pus filled drainage.These failures resulted in an Immediate Jeopardy. …
F693 citations in Illinois
Tube feeding · Quality of Life and Care Deficiencies
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Illinois cites F693 more often than its own record predicts
1.32 times the share F693 takes of citations nationally.
Of every deficiency written in Illinois in 2025, this is the portion that was F693.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Illinois surveyors wrote
F693 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 an enteral feeding was administered as ordered 1 of 3 residents (R1) reviewed for enteral feedings in the sample of 3. This failure resulted in R1's admission to the acute care hospital for treatment of aspiration pneumonia.The findings include:R1's face sheet showed she was admitted to the facility 9/24/2020 with diagnoses to include hypokalemia, dysphagia, gastrostomy status, gastrointestinal hemorrhage, chronic obstructive pulmonary disease, major depressive disorder, and anxiety disorder. …
Based on observation, interview and record review the Facility failed to discontinue enteral feeding tube orders after an enteral gastrostomy feeding tube was removed and failed to assess, document and treat drainage and redness around a gastrostomy site for one of two Residents (R1) reviewed for gastrostomy care in a sample of three.Findings include:The Facility Gastrostomy Tube-Feeding and Care Policy, dated 8/2020, documents: to provide nutrients, fluids and medications per physician orders to residents requiring feeding through an artificial opening in the stomach; licensed nurse will review physician orders for type of formula, concentration, rate of flow and method of administration; inspect the surrounding skin for redness, tenderness, swelling, irritation, purulent drainage or… …
The short window
Recent years
| Year | Share of Illinois citations | vs expected |
|---|---|---|
| 2023 | 1.22% | 1.63× |
| 2024 | 0.98% | 1.39× |
| 2025 | 0.93% | 1.32× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Illinois surveyors cite →
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