Based on observation, interview, and record review, the facility failed to provide sufficient nursing staff and failed to follow their medication policy to ensure residents received essential medications to treat their medical conditions as ordered by their physician. There was no nurse on duty to pass medications in the entire facility and as a result, 37 residents (R1- R37) did not receive their scheduled medications on 06/05/2023 and 06/06/2023 on the evening shift (3:00 PM - 11:00 PM). These failures have the potential to cause negative medical outcomes for all 37 residents. This was identified as an Immediate Jeopardy situation which began on 06/05/2023. On 07/28/2023 at 10:00 am, the Administrator was notified of the Immediate Jeopardy. …
F725 citations in Illinois
Sufficient nursing staff · Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Illinois cites F725 more often than its own record predicts
1.68 times the share F725 takes of citations nationally.
Of every deficiency written in Illinois in 2025, this is the portion that was F725.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Illinois surveyors wrote
F725 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 sufficient nursing staff were available to meet the needs of residents. This failure has the potential to affect all 85 residents residing in the facility.Findings include:The facility's Call Light policy revised 1/2022 documents resident call lights will be answered in a timely manner. All staff should assist in answering call lights. Nursing Staff members shall go into the resident's room to respond to call system and promptly cancel the call light when the room is entered. Bathroom lights should be viewed as emergencies and immediate attention will be given. Requests shall be responded to in a professional and courteous manner. …
Based on observation, interview and record review, the facility failed to provide a sufficient amount of staff to meet the needs of the residents in a timely manner. These failures have the potential to affect all 93 residents living in the facility. Findings include: 1. R72's admission Record documents an admission date of 11/26/24 with included diagnoses of abnormalities of gait and mobility, repeated falls, unsteadiness on feet, and muscle wasting and atrophy. R72's MDS (Minimum Data Set) documents a BIMS (Brief Interview of Mental Status) of 12, indicating moderately impaired cognition. Section GG documents under Functional Abilities that R72 is substantial/maximal assistance for showering/bathing assistance. …
The short window
Recent years
| Year | Share of Illinois citations | vs expected |
|---|---|---|
| 2023 | 1.26% | 1.56× |
| 2024 | 1.10% | 1.38× |
| 2025 | 1.30% | 1.68× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Illinois surveyors cite →
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