Based on interviews and record reviews the facility staff [A] failed to have the necessary skills and competencies to meet one [R1] resident health care needs [B] failed to keep the head of bed elevated, and [C] failed to provide 1:1 feeding assistance. These failures resulted in R1 experiencing an acute change of condition and subsequently expiring on 3/3/24 in the facility. Findings Include: R1's clinical record indicated in part; R1 was admitted to the facility on [DATE] with medical diagnosis of pneumonitis due to inhalation of food and vomit, dysphagia, cerebral infarction due to thrombosis of right middle cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, visuospatial deficit and spatial neglect, memory deficit, ,… …
F741 citations in Illinois
Quality of Life and Care Deficiencies
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Illinois cites F741 less often than its own record predicts
0.31 times the national share — cited less often here than elsewhere.
Of every deficiency written in Illinois in 2025, this is the portion that was F741.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Illinois surveyors wrote
F741 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 employ a qualified Psychiatric Rehabilitation Services Director (PRSD). This failure affects one resident (R74) out of one reviewed for behavioral health services on the sample list of 39.Findings include:On 1/20/26 at 3:29 PM, R74 was in his room on the facility's locked unit reserved for residents with serious mental illness and behavioral health needs.On 1/20/26 at 3:29 PM, R74 stated facility staff wanted to kick him out of the facility and that he wanted to speak with the Administrator (V1) to get the situation clarified.R74's Diagnoses List printed 1/23/26 documents R74 has medical diagnoses including Borderline Personality Disorder, Suicidal Ideation, Anxiety, Bipolar Disorder, Major Recurrent Depression,… …
The short window
Recent years
| Year | Share of Illinois citations | vs expected |
|---|---|---|
| 2023 | 0.03% | 0.65× |
| 2024 | 0.07% | 1.39× |
| 2025 | 0.01% | 0.31× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Illinois surveyors cite →
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